Pedaitric Dentistry 1 [PDF]

Zitiervorschau

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Cairo University

Faculty of Dentistry

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Pediatric Dentistry and Dental Public Health Department

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Pediatric Dentistry

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Dedication

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To the memory of Professor Doctor Nawal Soliman, for her outstanding achievements and efforts in the field of Pediatric Dentistry; to whom we extend our deepest gratitude, love and respect. Department Staff members October 2021

Index

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Intended learning outcomes 1 Introduction 3 Morphological differences between primary and permanent teeth 9 Normal occlusion in children 13 Management of child behavior 16 I- Psychological management 17 II-Pharmacological management 30 The child’s first dental visit 38 Local anesthesia for dental child patient 43 Restoration of primary teeth 47 Management of deep carious lesions in children 60 Rampant caries 78 Early childhood caries 80 Stainless steel crown 85 Extraction of teeth in children 89 Management of traumatic dental injuries in children 93 Management of space maintenance problems in children 108 Gingival and periodontal problems in children 122 Dental management of handicapped children 137 Nutrition and dental health 153 Child Abuse and Neglect 167

a- Knowledge and understanding:

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Intended Learning Outcomes for Pediatric Dentistry

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a1- Recognize the aims and benefits of Pediatric dentistry for child, dentist and nation. a2- State the importance of primary teeth. a3-Describe the factors that influence the child behavior in dental office and the different psychological management approaches. a4-Describe the need for and types of premedication and their application in clinical practice (pharmacological management). a5-Recognize and illustrate the morphological differences between primary and permanent dentition and their significance in clinical practice. a6-Describe the normal occlusion of pediatric patients at different ages of life. a7- Recognize the different methods and techniques of pain control for children. a8- Identify the different restorative techniques and materials for children. a9- Describe the different types of pulp therapy. a10- Recognize the etiology, clinical picture and management of early childhood caries. a11-Classify traumatic injuries and select the appropriate management for each class. a12-Describe different methods of space analysis and state the possible management for different cases of space problems in both primary and mixed dentitions. a13-Memorize the different types of periodontal diseases and their differential diagnosis. a14-Recognize different treatment modalities for handicapped patients. a15-Recognize the effect of nutrition on dental health.

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b- Intellectual skills:

b1- Make decisions regarding management of deep caries in both primary and permanent dentitions. b2- Integrate personal, medical and dental history together with clinical and radiographic findings to manage both immediate and delayed effects of traumatic injuries.

c- Professional and practical skills: c1- Clinically treat uncomplicated cases regarding cavity preparation and pulp therapy c2- Differentiate clinically between primary and permanent teeth. c3- Perform appropriate cavity preparations and pulp therapy procedures in artificial and extracted teeth. 1

d- General and transferable skills:

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d1- Communicate with children and their families using appropriate communication skills. d2- Show merciful attitude towards children& their parents and respectful attitude towards dental staff. d3- Adhere to health and safety regulations as they greatly affect dental practice and environment.

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INTRODUCTION

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Define pediatric dentistry. List the aims and benefits of pediatric dentistry. List the importance of primary teeth. Recognize the eruption of primary teeth and teething problems. Identify the chronology of primary and permanent teeth as well as the sequence of eruption for both dentitions.

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By the end of this chapter, the student must be able to:

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INTRODUCTION

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Pediatric dentistry is that branch of dental science, which deals with the guidance of the primary and young permanent dentition in growth and development as well as the prevention and treatment of pathologic oral conditions, which may occur during childhood.

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According to the American Association of Pediatric Dentistry: Pediatric Dentistry is an age defined specialty that provides preventive and therapeutic care for infants and children through adolescence including those with special health care needs. Scope 1. It encompasses a variety of disciplines, techniques, procedures and skills that share common basis with other specialties but are modified to the special needs of children. 2. Age specific not technique specific. 3. Deals with patients in their formative years. 4. Fulfill the needs of special children. 5. Its goal is mainly prevention.

Aims and benefits of pediatric dentistry

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I- For the child patient: 1- The child will have a better masticatory apparatus that provides good masticatory function, which is essential for the child's optimal growth, better health and better look. Any defect in the masticatory apparatus such as dental caries, premature loss of teeth or malocclusion will result in impaired masticatory function. This in turn may lead to malnutrition and subnormal general growth. 2- The child will have fewer dental diseases in his adulthood as prevention is the most important aim of pediatric dentistry. 3- He will have less psychological trauma from dentistry as he is properly managed and treated. 4- From the economical point of view, pediatric dentistry is far less expensive to the individual because it reduces much of the dental work later in his adulthood. II- For the dentist: He will learn more skills and abilities in the different fields of dentistry as well as learning many techniques, which are unique to children. 4

Importance of primary teeth:

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III- For the nation: Pediatric dentistry helps to ensure optimal state of growth and development for the child; therefore, it will provide the nation with better healthy citizens.

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All the primary teeth are in use from age 2 to 7 years; some of the primary teeth are in use from age 2 till 12 years. 1- Preparation of the child's food for digestion and assimilation during active periods of growth and development.

2- Maintenance of space in the dental arches for the permanent teeth. With the premature loss of the primary teeth, severe dental irregularities may develop.

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3- Development of speech: Ability to use the teeth for pronunciation is acquired with the aid of the primary dentition. Early and accidental loss of the primary anterior teeth may lead to difficulty in pronouncing the sounds f, v, s, z and th. 4- Cosmetic function: Improving the appearance of the child. If a child accidentally loses his primary anterior teeth, his appearance will be affected, he will find himself different from the other children in his same age and accordingly this affects him from the psychological point of view.

Eruption of primary teeth

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Definition:

Tooth eruption is the movement of a tooth from its site of development (bony crypt) within the alveolar bone to its functional position in the oral cavity. - The primary teeth begin to form at 7 w.i.u. Calcification of the central incisor starts at 4 m.i.u. The sequence of calcification of the primary teeth is central incisors, first molars, lateral incisors, canines and second molars. - At the time of birth, there are no functioning teeth in the mouth, but radiographs of the infant's jaws show calcification of: * Five-sixths of the crown of the central incisors. 5

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* Two-thirds of the crown of the lateral incisors. * The incisal tip of the canine. * Isolated cusps of the first and second primary molars. * Occasionally calcification of the first permanent molar and the incisal edge of the permanent central incisor. Teething in children: Eruption of the primary dentition begins in the fifth or sixth month of a child's life. Eruption of primary teeth is preceded by increased salivation. Teething is a normal physiologic process. It doesn’t increase the incidence of fever, infection or diarrhea but it causes restlessness and increased thumb sucking or gum rubbing.

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The signs of teething may be manifested locally and/or systemically: Local: - Redness or swelling of gingiva over erupting tooth. - Patches of erythema on the cheeks. -Child wants to put the hands or fingers into the mouth - Increased salivation and drooling. Systemic: - High fever. - General irritability and crying. - Loss of appetite. - Diarrhea. - Increased thirst. -Circumoral rash. Most studies refer to these symptoms (fever and diarrhea) as coincidental with teething.

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Treatment: Local: - Teething toys: . A variety of teething rings rattles and keys are available. . The baby may obtain relief from soreness by the pressure of biting. . Only well-made and smooth toys should be used. -Teething foods: . Hard rusk or biscuit preparations are used in the same way as teething toys. . They should contain no sugar. -Topical medications: . Various types of ointment and gel are available for topical application to gingiva. Common ingredients include Salicylates, which have anti-inflammatory, analgesic and anti-pyretic effects. e.g.: Dentinox. 6

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Systemic: Analgesics: Sugar free - paracetamol preparations Dosage: up to 1 year: 5ml at bedtime 1-5 years: 10 ml at bedtime. Do not give any injections such as vitamin D and calcium to enhance teething because these prescriptions if not needed may damage the kidneys. Systemic conditions influencing eruption of teeth: There are some conditions that cause delay in development and eruption of teeth as: - Down’s syndrome. - Cleido-cranial dysplasia. - Hypothyroidism. - Hypopituitarism.

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Chronology of primary and permanent dentition Chronology of primary dentition: Maxillary primary teeth Mandibular primary teeth

A 7-8 M A 6-7 M

Sequence of eruption:

B 8-9 M B 7-8 M

C 18 M C 16 M

D 14 M D 12 M

E 24 M E 20 M

A-B-D-C-E

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▪ Mandibular teeth erupt earlier than maxillary teeth by 1-2 months. ▪ Teeth of girls erupt earlier than teeth of boys. ▪ Roots of primary teeth are completely formed 1-1.5 yrs following eruption. Roots of primary teeth persist without resorption for 1.5 years. ▪ Beginning of root resorption in primary teeth occurs after complete crown calcification of their permanent successors. ▪ Crowns of permanent teeth are completely formed 3 years before eruption. ▪ Shedding of deciduous teeth coincides with dates of eruption of their permanent successors (at this stage 2/3 of the root of the permanent successor is formed). ▪ Roots of permanent teeth are completely formed 3 years following eruption. ▪ In some children deciduous teeth may not erupt till the age of about 12 7

Eruption dates of permanent teeth: Mandibular teeth 1 6-7 years 2 7-8 years 3 9-10 years 4 10-11 years 5 11-12 years 6 6 years 7 12-13 years 8 17-21 years

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Maxillary teeth 1 7-8 years 2 8-9 years 3 11-12 years 4 10-11 years 5 10-12 years 6 6 years 7 12-13 years 8 18-21 years

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■ Sequence of eruption of maxillary teeth: 6-1-2-4-5-3-7-8

■ Sequence of eruption of mandibular teeth: 6-1-2-3-4-5-7-8

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months. This could be considered normal if the child is free from any hereditary or systemic diseases.

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MORPHOLOGICAL DIFFERENCES BETWEEN PRIMARY AND PERMANENT TEETH By the end of this chapter, the student must be able to:

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1- Recognize and illustrate the morphological differences between primary and permanent teeth. 2- Define the clinical significance in cavity preparation for both primary and permanent dentitions.

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MORPHOLOGICAL DIFFERENCES BETWEEN PRIMARY AND PERMANENT TEETH

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There are twenty primary teeth: a central incisor, a lateral incisor, a canine, a first molar and a second molar in each quadrant. These teeth are exfoliated and replaced by the permanent central and lateral incisors, canines and first and second premolars. Considerable morphological differences exist between the primary and permanent teeth both in size and color of the teeth and in their general external and internal morphology. I- Size: 1- Primary teeth are smaller in all dimensions than the corresponding permanent teeth.

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2- The mesiodistal width of primary incisors and canines is less than their permanent successors, while the mesiodistal width of primary molars is wider than their successors (premolars). 3- The thickness of enamel and dentine in primary teeth is approximately half its thickness in permanent teeth. Therefore, an occlusal cavity must be shallower than in permanent teeth to avoid pulp exposures. II- Color: The color of primary teeth is bluish white, while that of permanent teeth ranges from grayish white to yellowish white.

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III- Crown: 1- The crowns of primary teeth are wider in their mesiodistal diameter in relation to their cervico-occlusal height than those of permanent teeth. This gives the primary anterior teeth a cup shaped appearance and the primary molars a squat shape. 2- The crowns of primary molars are bulbous due to their markedly constricted necks and pronounced cervical ridges on the buccal aspect especially in the first primary molar. This bulbous shape and the pronounced cervical bulge in primary molars make it difficult to apply the matrix band. The constriction at the neck calls for special care in the placement of the gingival seat during class II cavity preparation. 10

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3- The buccal and lingual surfaces of primary molars, converge sharply toward the occlusal surface, forming a narrow occlusal table. This characteristic is especially evident in the first primary molar, making the isthmus portion of a class II amalgam filling very narrow and liable to fracture.

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4- The buccal and lingual inclines in primary molars are relatively flatter above the cervical bulge than those in permanent molars. 5- The enamel cap in primary teeth is thinner and has nearly a constant depth throughout the crown.

6- The enamel cap in primary molars ends abruptly at the cementoenamel junction, while in permanent teeth it tapers off to a feather edge.

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7- The enamel rods at the cervix slope occlusally in primary teeth instead of being oriented gingivally as in permanent teeth. This characteristic does not necessitate beveling of the gingival floor in class II cavity preparations in primary molars. 8- The interproximal contact between primary molars is not a small round area as in permanent molars but tends to be a large ellipsoid and flattened area. IV- Roots: 1- The roots of the primary anterior teeth are narrower mesiodistally than permanent anterior. 2- The roots of primary teeth are longer and more slender in comparison to the crown size than in permanent teeth.

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3- The roots of primary molars flare out near the cervix leaving no root trunk. 4- The roots of primary molars diverge and bulge as they reach the apex to envelope the underlying permanent teeth buds. Special care must be employed in the extraction of primary molars with unresorbed root to avoid the permanent buds being removed at the same time. V- Pulp: 1- The pulp outline follows the dentinoenamel junction more closely in primary than in permanent teeth.

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2- The pulp horns are higher in primary molars, especially the mesial pulp horn. The pulp chambers are proportionately larger than permanent teeth, hence there is less tooth structure protecting the pulp in primary teeth which requires special attention when establishing the depth of cavities in primary teeth.

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3- The root canals of primary molars show more lateral branchings and apical ramifications than permanent molars. This characteristic makes it impossible to remove all pulp tissue in the root canals during root canal therapy.

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4- The apical foramina in primary teeth are relatively wider than in permanent teeth.

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NORMAL OCCLUSION IN CHILDREN

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By the end of this chapter, the student must be able to:

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1- Describe the normal occlusion of pediatric patients at different ages of life.

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NORMAL OCCLUSION IN CHILDREN

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Occlusion at 3 years of age: 1- The relationship between the distal surfaces of opposing second primary molars may be one of the following: A- Straight or flush terminal plane: In which the distal surfaces of opposing second primary molars are in the same coronal plane. B- Mesial step terminal plane: In which the distal surface of the lower second primary molar is mesial to the distal surface of the maxillary second primary molar. C- Distal step terminal plane: In which the distal surface of the lower second primary molar is distal to the distal surface of the maxillary second primary molar. The flush terminal plane is most frequently seen at three years of age.

2- Presence of spacing between primary teeth: a. Incisor spacing to accommodate for the larger size of permanent incisors. b. Primate spaces which are mesial to upper C and distal to lower C. These spaces are greater in the mandible than the maxilla. c. Spacing between primary molars.

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3- Normal overbite.

Occlusion at 6 years of age: 1- At the age of 6 years, spacing persists between the primary anterior teeth. 2- As a result of attrition and increase in width of maxilla compared to mandible, the mandible assumes a forward position to maxilla i.e., edge-to-edge relationship. 3- At the age of 6 years, a mesial step terminal plane is present where the distal surface of lower E is about 2 mm mesial to that of upper E. This is due to: A. Bodily forward movement of mandible to maxilla. B. Closure of spacing between primary teeth especially the primate spaces which are greater in the mandible than maxilla as a result of eruption of first 14

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permanent molars at 6 years of age. This allows the lower E to move more forward than upper E producing a mesial step terminal plane. 4- At 6 years of age the first permanent molars are clinically visible and may assume one of the following relations: a- Class I molar relationship: mesiobuccal cusp of upper 6 is at or near the buccal groove of lower 6. b- Class II molar relationship: mesiobuccal cusp of upper 6 is mesial to buccal groove of lower 6. c- Class III molar relationship: mesiobuccal cusp of upper 6 is distal to buccal groove of lower 6. The most desirable occlusion in the permanent dentition is Class I interdigitation.

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Occlusion at 8 to 9 years: 1. With the eruption of the upper and lower permanent incisors there is an increase in depth of overbite due to their greater height in comparison to the reduced vertical dimension in the primary molar area. This is corrected by the eruption of premolars. 2. Presence of diastema between upper permanent central incisors, which is normal for this age (ugly duckling stage). This is corrected by the eruption of the permanent canines when pressure exerted by those teeth is transferred from the roots to the crowns of permanent incisors.

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Occlusion at 10 to12 years: 1- Diastema between upper central incisors is closed by the eruption of permanent canines. 2- With the eruption of premolars, the vertical dimension is increased which corrects the deep overbite. 3- Closure of Leeway spaces (difference between combined mesiodistal width of C, D & E (larger) and 3, 4 &5 (smaller). This space is greater in the mandible (1.7 mm) than in maxilla (0.9 mm) which allows the lower first permanent molar to move more forward than the upper first permanent molar and assume a normal relationship.

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MANAGEMENT OF CHILD BEHAVIOUR

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Define and classify child behaviour management. Identify the difference between treating children and adults. Recognize the psychological management of child behaviour. Identify different types of fear. Classify child behaviour. Describe the different techniques for behaviour management. Recognize the pharmacological management of child behaviour.

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By the end of this chapter, the student must be able to:

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MANAGEMENT OF CHILD BEHAVIOUR

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The successful outcome of all procedures in Pediatric dentistry depends on the ability of the dentist to manage the child.

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Behaviour Management: it is the means by which the dental health team effectively performs treatment for a child and at the same time instills a positive dental attitude in the child patient towards future dental treatment. Classification of behaviour management: I – Psychological management (nonpharmacological). II – Pharmacological management (sedation and general anesthesia).

I-PSYCHOLOGICAL MANAGEMENT OF CHILD BEHAVIOUR (NON-PHARMACOLOGICAL)

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Why does treatment of children differ from treatment of adults? 1- The child is either faced with a new situation that he has no experience with or has had an unpleasant past dental experience. 2- Treatment of adults involves a one-to-one relationship (dentist-patient relationship), while treatment of a child involves a one to two relationship (dentist-child and parent relationship). So, the child’s behaviour could be influenced by his parents’ attitudes, fear and anxiety.

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Child patient

Parent

Dentist

Pediatric patient triangle

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a- Main Factors

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1- Psychological growth of the child:

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Factors which influence child behaviour in the dental office: a- Main factors. b- Co-factors.

A child grows physically as well as emotionally. A dentist who is aware of children’s abilities at various ages can use this information to communicate at the child’s level.

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* The Newborn (before 2 years): - Has a fairly elaborate (uncomplicated) emotional equipment. - Has the ability to express fear, anger and joy. - Grows emotionally by exploring the boundaries of the environment around him. * Two years old: - Will cry when put into a new situation e.g., dental situation. - As long as he cries quietly the dentist can continue his work. - Has a short attention span. - Too young to be reached with words, so → Way of communication is emotional (Show gentleness and kindness). Sometimes reached through his mother. - Fears sudden movements, so → Work skillfully with no jerky movements (the dental chair must be moved slowly). - He depends on his mother, so → No need to separate them. He can stay in his mother’s lap.

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* Three years old (Me-too-age): - Enters a period of semi-independence (can do some things for himself). - Can form sentences, so → can be reached by words. - Likes to be praised. - Likes to please (to have a reward for his good behaviour). - Likes to imitate (me-too-age). - Feels more secure with parent, although you can separate them after some time. * Four years old (How and why stage): - One of the most pleasant children the dentist can have in his office. - Becomes more independent. - He is a great talker, very inquisitive, always asking about things (how and why 18

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stage). - Very proud of his possessions and likes to show off. - Likes to be praised. - Can be very cooperative and responds well to verbal directions. - Very imaginative so a peak of fear is reached at that age (fear of unknown) but fear from strangers becomes less.

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* Five or six years old: - Fear declines because he has grown mentally and can evaluate fear producing situations. - Can be reached through simple explanation. - Never lie to him because he is old enough to distinguish true from false. - Likes to be praised, very proud of his hobbies, accomplishments, clothes and appearance. - By this age, the child has entered school and has friends so he may develop subjective fear from misleading stories at school.

2- Parental influence: Parents have great influence on their children’s behaviour. Sometimes parents and not the child constitute a problem in dental office. Normal behaviour of parents: Children need from their parents love and affection but at the same time they need firm guidance (they must know what is permissible and what is not permissible). Extreme parental attitudes:

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1- Over affection “over love”: Causes: - Only child - Only boy

- youngest in family - Late marriages

Features: - This child is inadequately prepared to face life. - He is shy, timid, cries easily and hides behind his mother.

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Causes: Previous accident or present difficulty.

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2- Over protection: - Child is protected more than he should be. - Mother interferes in his life and assists him in every minute task. - His play is restricted. - He is not permitted to make decisions.

Features: In dental office: This child is shy, fearful, displays temper tantrum (resists the dentist).

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3- Over indulgence: - Parents are yielding to all the child’s needs; he is not denied any wish or desire. Features: - This child is spoilt, selfish and stubborn. - In dental office: He is resistant, defiant and screams without tears. 4- Over anxiety: * Usually associated with over affection, over protection and overindulgence. - There is extra concern about the child. - He is kept from school or dental appointment for any minor illness.

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Causes: - Previous illness. - Previous accident e.g., death of his brother. Features: - In dental office: He is timid, shy and fearful.

5- Over authority: - Parents are critical and nagging. - Parents demand from the child excessive responsibilities more than his chronological age. - Compare him with older children.

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6- Under affection: - Parents have little time for their child because of: - Social or economical reasons. - Incompatibility or jealousy between parents.

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Features: - In dental office: He shows physical tenseness and restlessness.

Features: - Child feels insecure, uncertain, may develop bad habits as nail biting or thumb sucking. - In dental office: He is shy, timid and cries easily.

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7- Rejection: - Extremely abnormal behaviour which may be due to: - Immature parents. - Financial burdens. - Wrong sex.

Features: - Child is selfish, restless, disobedient, may be lying or stealing. - In dental office: Displays temper tantrum (defiant and resistant). 3- Physical condition of child:

a- The sick child “Chronically ill”:

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Negative influence → if the child has been sick for long periods and given special attention →he displays symptoms of overindulgence. Positive influence → if the child has undergone treatment in a hospital, he will develop a spirit of “I can take it too” and usually obeys orders. b- Nutrition: Deficiency of some vitamins and minerals may result in irritability, fatigue and restlessness. c- Physical and mental fatigue: - Lack of sleep or exhaustion results in poor behaviour in dental office. - Morning hours or after naptime are choice appointments for child dental patient. 21

4- School:

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Positive influence: - If the child has gone to a nursery or preschool, he has gained experience and is more cooperative in dental office. - He has the opportunity to mix with other children and his teachers. - He has learnt to obey orders. - He is less likely to fear strangers than a child who has been confined to home. * High school provides children with proper dental instructions.

Negative influence: Child may develop subjective fear from misleading stories about dentistry from his friends at school.

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5- Fear: Fear is one of the primary emotions acquired soon after birth. - At first the child is unaware of the nature of the stimulus producing fear. - As he grows, he becomes aware of the stimuli producing fear.

Value of fear: Should not be eradicated but directed for protection of child against danger, e.g., the child should be taught not to be afraid of dentist but of caries. Types of fear:

A- Real or true fear:

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1) Objective fear: - Responses produced as a result of direct physical stimulation of sense organs with stimuli which are unpleasant in nature i.e., results from personal exposure to pain or discomfort. e.g., a child who was poorly managed by dentist will develop fear from future dental treatment. -Objective fear may be associative in nature. e.g., a child who was poorly managed by persons wearing white uniforms will develop fear from similar uniforms on dentist or his assistant. 2) Subjective fear: - Responses based on feelings and attitudes that have been suggested to the child by others without the child having the experience personally. 22

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e.g. -hearing of a painful dental experience from one of his friends or his mother. -observing fear in his mother while undergoing dental treatment → the child will imitate her (mother transmits her fear to her child).

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-Why is subjective fear the worst type of fear? The mental picture producing fear is retained in the child’s mind & by his vivid imagination this picture becomes magnified. The longer subjective fear remains in mind, the more it becomes magnified. Subjective fear is not circumscribed by a personal experience so there is no limit for the intensity of fear that can be produced. 3)Needle pain fear: If the child was subjected to previous therapeutic injections or vaccinations.

B- Emphasized or not true fear:

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1) Fear of unknown: - An instinct present in every person. - Any unknown situation is fearful until experienced. - We can overcome this fear by familiarizing the child with the dental office, personnel and equipment. 2) Fear of strangers (dentist or his assistant). 3) Fear of separation from parents.

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b- Co-factors

1- Decoration & cleanliness of dental office. 2- Kindness & smile of dental personal. 3- Showing the child around dental office to get familiarized. 4- Knowledge about patient (calling him by his nick name, show interest in his hobbies, pets, brothers or sisters ………) 5- Time & length of appointment (15 – 20 minutes). 6- Skill & speed of dentist. 7- Avoid fear promoting words. 8- Praising good behaviour. 9- Giving gifts at end of visits. 10- Never lose your temper if child behaves badly. 23

Classification of child behaviour

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Many systems have been developed to classify child behaviour in dental office. These include Wright's clinical classification, Frankel behaviour rating scale and Lampshire's classification.

He divided children into 3 categories:

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Wright's clinical classification:

1- Children with cooperative behaviour: - Child is relaxed and shows minimal apprehension. - He displays a reasonable level of cooperation which allows the dentist to function efficiently.

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2- Children lacking cooperative behaviour: a- Very young children (less than 2.5 years). b- Mentally handicapped children. - The dentist cannot establish communication with them → Sedation or general anesthesia.

3- Potentially uncooperative behaviour: - i.e., child with a behavioral problem but has the ability to perform cooperatively if properly managed.

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- This category includes: a- Timid, shy or bashful child. b- Defiant (resistant) child. c- Fearful child. a- Timid, shy or bashful child:

Behaviour: - Child tries to hide behind his mother. - Looks down to floor when addressed. - Usually does not respond or responds in few words.

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b- Defiant "resistant" child:

Child defies dentist to do anything. Refuses to open his mouth. May fight or kick. Does not cry but screams loudly without tears. Says: "I won't open my mouth." "I don't care if my teeth have caries or not."

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Behaviour: -

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Management: 1- Take a child for a tour in dental office to familiarize him with dental personnel, equipment and office. 2- Calling him with his nick name to feel that he is at home, show interest in his hobbies, pets, brothers, sisters……. 3- Treat him with kindness. 4- Sometimes reached through his mother.

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Management: 1- Order the child with a firm tone of voice to sit calmly and open his mouth. 2- Use body control e.g., put your fingers on his sternum. 3- If he refuses to respond, perform "emotional shock therapy" or "hand over mouth technique" by putting your hand suddenly over the child's mouth (and sometimes his nose) for a few seconds, while talking calmly in his ear telling him to sit quietly because the work is going to be completed no matter how his behaviour is. Then tell him that you will remove your hand if he stops screaming. If he nods his head, remove hand immediately. If he starts screaming again, repeat procedure. Usually, the child is calm after two times. After that show kindness and praise good behaviour. c- Fearful child:

Behaviour: - He is apprehensive. - His heart beats fast. - Looks pale. - May cry with a lot of tears but without any sound. - He may resist a little but usually obeys.

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Management: 1- Analyze the child's fear by making a conversation with him to know the cause of fear. He usually expresses fear from a certain dental procedure e.g., extraction, drilling (objective fear) or says that he has heard something about dentistry that has frightened him (subjective fear). 2- Overcome his fear by demonstration and explanation. 3- In the first appointment: a. Start with simple non painful procedures e.g., fluoride application, prophylaxis, examination, taking x-rays……. b. Explain to child what you are doing (Tell, Show, Do). 4- Use voice control if needed (firm but kind). 5- Give the child a signal to use e.g., raising his left hand if he feels uncomfortable and wants you to stop working. 6- Never use force (aversive techniques) with fearful child to avoid psychological trauma.

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N.B. In case of emergency e.g., avulsed tooth, you can use physical restraint to prove to child that the procedure is easy and not as what he thought.

Techniques of behaviour management

A) Non – Aversive techniques:

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1- Pre appointment preparation: - It involves taking the child for a tour around the dental office to get oriented. - The child should be aware that nothing would be done on that day. - The child meets the receptionist, dental assistant & dentist. - Certain dental equipment can be shown & explained in child's language e.g., Mr. Wind & Mr. Water for chip syringe. - This helps to remove unfavorable thoughts in child’s imagination. 2- Behaviour shaping: - A procedure by which the desired behaviour is instilled in the child. This is done by a planned introduction of treatment procedures, so that the child is gradually trained to accept treatment in a relaxed and cooperative manner. - Easy and painless treatment procedures are carried out first, and then gradually proceed to difficult and long procedures.

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Steps: 1- Examination and prophylaxis. 2- Topical fluoride application and fissure sealant. 3- Small occlusal cavity not requiring anesthesia. 4- Larger cavities or pulp capping with anesthesia. 5- Pulpotomy, pulpectomy and extraction.

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3- Tell- Show- Do: It involves: a. Verbal explanation of the procedure in words the child can understand (tell). b. Demonstrate for the child the visual, auditory and tactile aspects of the procedure (show). c. Without deviating, complete the procedure (do). N.B. Explanations should not be detailed so as not to confuse the child. e.g., When introducing a child to prophylaxis: - TELL the child that his teeth will be brushed using a special brush. - SHOW the child how the brush revolves in the hand piece (you can even try that on his fingernail). - DO → brush the child’s teeth.

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4- Positive reinforcement: - Positive behaviours of the child should be reinforced repeatedly while negative ones should be ignored. - Reinforcement could be through: 1- Material reinforcers e.g., toys and stickers. 2- Social reinforcers e.g., praise, facial expressions, nearness and physical contact. 3- Activity reinforcers e.g., allow child to adjust dental chair, dental light or hold an instrument. 5- Permitting the child a sense of control: The child can be given a signal to use when he feels discomfort e.g., raising his hand. This makes the child feels that he has some control (secure) especially because he cannot communicate verbally when there is so much in his mouth. Dentist has to stop working immediately when the child uses this signal. 6- Voice control: - It is controlled alteration of voice volume and tone to influence child behaviour. - Tone of voice must be firm but kind. 27

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7- Distraction: - The technique of diverting the child's attention from an unpleasant procedure. e.g., local anesthetic injection. - The most popular distraction technique is audio-analgesia e.g., music, audiotaped stories or videotaped cartoons.

02

8- Modeling: - Done by making the child observe individuals (models) who demonstrate appropriate behaviour during dental treatment. i.e., good example. - The child will usually imitate the model. - Models may be: - Live (parent or another child). - Videotapes. B) Aversive techniques (for the difficult, defiant and resistant child):

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1- Hand-Over-Mouth exercise: - To help the hysterical child regain self control. - This is done by putting your hand (may be wrapped with a towel) suddenly over the child's mouth for a few seconds, while talking calmly in his ear telling him to sit quietly because the work is going to be completed no matter how his behaviour is. Then tell him that you will remove your hand if he stops screaming. If he nods his head, remove hand immediately. If he starts screaming again, repeat the procedure. Usually, the child is calm after two times. After that show kindness and praise good behaviour. - Indications: 1- Hysterical, defiant child. 2- 3-6 years old children (preschool age). - Contraindications: 1- Child with an airway obstruction. 2- Very young children (under 3 years) and very old children. 3- Mentally handicapped children who are unable to verbally communicate or understand. 4- Fearful child. 2- Physical restraint: Can be performed by dentist, staff or guardian or with the use of restraining device. Parents must be informed, and the dentist obtains a consent before using restraints. 28

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- Types of restraints: * Mouth (to keep mouth opened) e.g., tongue blades, mouth props, bite blocks. * Head: head positioner. * Extremities: straps. * Body: papoose board, Pedi wrap, safety belts. - Indications: 1- Child who requires emergency treatment or limited treatment and cannot cooperate. 2- Extremely resistant child. 3- Physically handicapped child e.g., children who perform involuntary movements (to protect child and practitioner). - Contraindications: 1- Fearful child. 2- Children who cannot be restrained due to medical condition e.g., heart disease.

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II- PHARMACOLOGICAL MANAGEMENT OF CHILD BEHAVIOUR

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The great majority of children introduced to dentistry by various approaches of behavior management become relaxed and cooperative. Unfortunately, a minority remain uncooperative. The most common reason for lack of cooperation is fear and anxiety. If fear persists despite carefully conducted introductory treatment, some form of sedation may be helpful.

I) Conscious sedation 1.

Definition: “A minimally depressed level of consciousness in which the patient’s ability to maintain a patent airway independently and continuously and respond appropriately to physical simulation and or verbal command is retained” Indications: a- For nervous and apprehensive children. b- A potentially uncooperative child who wishes to be helped.

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2.

Contraindications: a. Severely uncooperative child b. Hypersensitivity to the agent

4.

Objectives of conscious sedation: - Provide comfortable high quality dental service. - Control inappropriate behaviour of patient. - Produce in patient a positive psychological attitude towards future dental care.

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3.

Routes of administration: - Oral. - Intramuscular. - Intravenous. - Subcutaneous. - Rectal. - Intranasal. - Inhalation (nitrous oxide).

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Oral route: - The oral route is the most commonly employed route of drug administration for pediatric dentistry. - The drug may be given at home or at the office. Giving the drug in the office has advantage of supervision (to be certain that the proper dose is given at the appropriate time). - Clinical effectiveness after 30 minutes and peak drug effect may require 1 hour or more. - The duration of action is relatively prolonged after 4 to 6 hours. - Since absorption of drugs occur in the stomach, instructions should be given to the parents that no solid foods should be taken after midnight before the sedation appointment, this includes milk, since it becomes solid once introduced to the acidic environment of the stomach. These recommendations are for two reasons: 1. Drug uptake is maximized when the stomach is empty. 2. Prevent vomiting. Advantages of oral route: 1- Universally acceptable. 2- Ease of Administration. 3- Decreased incidence of allergic reaction. Disadvantages of oral route: 1- Patient (parental) compliance. 2- Prolonged onset of action. 3- Prolonged duration of action. 4- Erratic absorption.

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Intravenous route: - Represents the most efficient method of ensuring predictable and adequate sedation. - Children selected for intravenous sedation must be cooperative and prepared to accept intravenous injection. - The dose required to produce satisfactory sedation is about 0.1 mg/kg body weight, this is injected slowly over a period of 1-2 minutes during which time the child is spoken to in a relaxing and reassuring manner. - Sedation is deepest immediately following the injection and for the next 10 minutes, during this period injection of local anesthesia is given and treatment is started. 31

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- Among drugs, most commonly used are →Diazepam. - Duration of sedation is about one hour.

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Advantages of intravenous route: 1- Very rapid effect. 2- Because the drug is injected directly into the blood stream absorption is not a complicating factor.

Disadvantages of intravenous route: 1- The intravenous route carries an increased potential for complications. e.g., hematoma or allergic reactions. 2- Not recommended for very young children (below 6 years of age). 3- The need for a period of postoperative recovery and subsequent restrictions of activities.

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Intramuscular route: - This method is used to produce deep sedation in very uncooperative young patients who cannot be adequately sedated by oral or intravenous methods. Advantages of intramuscular route: 1- Faster absorption than oral route. 2- Does not require patient cooperation.

Disadvantages of intramuscular route: 1- Delayed absorption. 2- Possibility of tissue trauma at the injection site.

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Subcutaneous route: - Injection of the drug beneath the skin into the subcutaneous tissue. - Slow rate of absorption is noticed following the subcutaneous route, which limits the effectiveness of this route in dentistry. Rectal route: - This method is most appropriate for very young children and as an alternative for those who refuse oral administration and for those who intensely dislike injection. - This method is used for reduction of mild anxiety.

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Agents or drugs commonly used for sedation: 1. Gases --- Nitrous oxide and oxygen combination. 2. Antihistamines --- Hydroxyzine, Promethazine. 3. Benzodiazepines--- Diazepam (Valium), Midazolam (Dormicum). 4. Barbiturates --- Short acting such as Seconal, Pentobarbital. 5. Chloral hydrate. 6. Narcotics --- Meperidine. 7. Propophol --- (Deprivan).

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Factors influencing Dosage: 1. Age 2. Body Weight 3. Emotional state and activity: Extremely anxious or defiant child will require more premedication than will the mildly apprehensive child. 4. Route of administration: Drugs given I.V. will act more rapidly and are given in lower dose, whereas a drug given orally acts more slowly and dosage requirements are higher. Intramuscular administration of drugs results in intermediate onset of action and dosage requirements. 5. Time of the day: Dosage may sometimes be reduced if given during the time when the child usually takes a nap. Conversely dosages may have to be elevated if the drug is administered during the time when the child is usually engaged in active play. Inhalation Analgesia (Nitrous oxide): For production of conscious sedation, the inhalation route is limited to nitrous oxide.

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Characteristics of nitrous oxide: a- Colorless, odorless gas that is neither explosive nor flammable but supports combustion as well as oxygen. b- It is quickly absorbed from the lungs into the blood stream, and it is transported to the brain and other tissue in the serum. c- It is excreted unchanged through the lungs. Indications: 1. In children with mild anxiety (fearful and anxious) who wish to receive dental treatment and have the capacity to be compliant and follow instructions.

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2. Children with short attention span, since it changes the patient’s perception of passage of time. 3. A cooperative child undergoing a lengthy dental procedure. 4. A patient whose gag reflex interferes with dental treatment.

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5. A patient for whom profound local anesthesia cannot be obtained.

6. Helps to raise the pain threshold so it may be used to lessen the discomfort during a local anesthetic injection. However, nitrous oxide will not eliminate the need for local anesthetic injection.

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Contraindications: a) Upper Respiratory tract infection. b) Pulmonary diseases (bronchitis, emphysema and tuberculosis) c) Nasal obstruction due to any cause if it prevents easy breathing through the nose. d) Children with certain psychiatric disorders. e) Children with a history of motion sickness, who may experience vomiting when given nitrous oxide. f) Pregnant females. g) Patients with otitis media as nitrous oxide increases pressure in air filled cavities.

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Equipment: 1) Nitrous oxide machine consisting of a flowmeter that measures the delivered oxygen and nitrous oxide. 2) Fail-safe valve that cuts off flow of nitrous oxide when oxygen level drops below 3 liter/minute. 3) Reservoir Bag. 4) Nasal inhaler (mask). 5) Oxygen and nitrous oxide tanks. 6) Proper scavenger system. Techniques: Two techniques have been described: a. Slow induction technique. b. Rapid induction or ‘surge’ technique. 34

Slow induction technique:

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1- Describe to the patient in language he understands what nitrous oxide is and how it will make him feel (e.g., it will make him feel happy and kind of like he is floating in air). 2- Introduce nasal inhaler and encourage the child to breathe through the nose. 3- The delivery of nitrous oxide / oxygen should begin with 100 % oxygen for 3-5 minutes 4- Then the concentration of nitrous oxide may gradually be increased 5 - 10% every 3-5 minutes till it reaches final concentration of 70% oxygen and 30% nitrous oxide.

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The state of analgesia is reached when: * The child feels tingling sensation in fingers and toes. * Sagging of eyelids. * He smiles and will follow simple instructions. * His mouth stays open easily. * When this state is reached local anesthesia is given.

Recovery from analgesia: By inhalation of 100% oxygen for 5 minutes, the child will regain his normal state of consciousness. Rapid induction technique:

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1. Initiation is done by administering equal parts of nitrous oxide and oxygen for 10-15 minutes. 2. This is followed by maintenance phase where the nitrous oxide is reduced by half for 40 minutes. 3. Withdrawal is by administering oxygen only. 4. Oxygen is used to prevent anoxia, which is produced if nitrous oxide is used alone.

Adverse side effects: 1.

Acute effect (on the patient): • Hypoxia. • Bone marrow depression due to prolonged use in long term sedation of chronic pain. • Neurotoxicity. 35

Safety recommendations: 1. 2. 3. 4.

3

Chronic effect (dentist and assistants): • Reduced fertility. • Spontaneous abortion. • Neurological defects. • Increased incidence of liver disease. • Malignancy.

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2.

Use the minimum effective dose. Use scavenging equipment. Vent exhausts gases to outside. Check delivery system for leakage monthly.

II) General Anesthesia

Indications:

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If the child’s behavior is unacceptable following psychological and pharmacological behavior management, one should consider hospitalizing the patient to provide treatment under general anesthesia.

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• Severe dental diseases in physically, mentally or medically handicapped children. • Documented allergy to local anesthesia. • Extensive facial trauma. • Multiple carious and abscessed teeth in very young children. Pre-anesthetic assessment

• The anesthetist should be consulted. Operating theatre environment: • Children should be allowed to wear their own clothes. • Local anesthetic cream should be placed on the back of the hand to allow painless insertion of the canola. • Allowing the parent to be with the child during induction minimizes anxiety. • Parents should be called into the recovery ward once the child has woken and is stable. 36

Fasting instructions:

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Children under six years of age: • No solids for 6 hours pre-operation. • No breast milk for 4 hours pre-operation. • No clear fluids for 2 hours pre-operation.

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• Normal day-stay recovery is a minimum of 2 hours after the operation.

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Children older than six years of age: • No solids or liquids for 6 hours pre-operation.

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THE CHILD'S FIRST DENTAL VISIT

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By the end of this chapter, the student must be able to:

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1- Recognize the aims of the first dental visit. 2- Recognize how to prepare the child and his parents for the first dental visit.

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THE CHILD'S FIRST DENTAL VISIT

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Preparation of the child and his parents before the first dental visit will result in a better behavior pattern in the dental office.

02

The aims of the first dental visit are as follows: 1- To establish good communication with the child and parent. 2- To obtain important background information (i.e., the child's social, dental and medical history). 3- To examine the child and to obtain radiographs if required. 4- To perform a simple dental procedure. 5- To explain treatment aims to the child and parent.

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Preappointment communication with parents: The dentist must communicate with the parents before the first dental visit to: 1- Ask parents to prepare their child for the first visit. Simply inform the child as casual as possible that you are taking him to the dentist to look at his teeth. 2- Lower the parent's anxiety. 3- Inform the parents for his plans for the first visit. The first visit is only for acquaintance & to gain the child's confidence, obtaining background information about the child, examining the child and if possible, do a simple procedure.

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Dental environment, appointment time and reception area: - The receptionist should greet the child in a friendly and cheerful manner. - The assistant must be nicely dressed, smiling and kindly guide the child and his parents to the reception area. - The dentist should appear relaxed and establish friendly communication with the child and his parents. - Appointment: o Time → Avoid interference with nap times. →Early morning appointments or after nap times should be set. o Length → First visit should be short (15 to 20 minutes). - Reception area: o Should be comfortable and attractive, simple furniture, nice colors, nice pictures on the walls, simple toys, children's books. o Should be far from operating room. 39

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Obtaining information (history taking): - The assistant escorts the child and his parents to the dentist's consultation room (not the operating room). - The dentist should establish friendly communication with the child and his parents. - Ask parents about their main concern (chief complaint). - Answer any questions for the child and his parents. - The dentist obtains patient's history which is divided into three parts: social, dental and medical history. • Personal (social) history: Name, date of birth, address, school, brothers and sisters, pets, hobbies, mother's occupation, father's occupation. • Dental history: Past dental history (type of any previous treatment, regularity of visits, changing dentists) all this gives an impression about the attitudes of child and parents towards dental treatment. Ask the child about his chief complaint using simple words with no reference to pain. • Medical history: Systemic diseases, mental problems, any previous operations or serious illness, also family history of serious illness.

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Accompanying the child into the dental operatory: - The dentist accompanies the child into the dental operatory. - The parent is allowed to accompany the child into the dental operatory during the first visit for moral support. - At subsequent visits the dentist must decide whether to keep the parent or not based on: 1- The child's age (very young usually needs moral support). 2- Child's behaviour. 3- Parent's character. Examination and recording: 1- A good approach is to ask the child "how many teeth has he got and to ask him to count them". 2- Proceed with counting. In this way the child will realize that there is nothing traumatic about treatment. 40

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3- If the child refuses to sit in the dental chair, he can sit in his parent's lap with head supported by right parent's arm. 4- This first examination may not be detailed. However, in successive visits further details may be obtained. 5- During examination: a. Avoid the sight of a sharp instrument or careless use of a probe. b. Avoid fear promoting words. c. Avoid sudden jerky movements.

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Introductory treatment: 1- After the examination, if the child is not presenting with pain, only simple non painful procedures are carried out in the first visit. e.g., → Polishing teeth with a soft brush. a. Taking x-rays. b. Fluoride treatment. 2- Use Tell-Show-Do technique and positive reinforcement. 3- Injections and cavity preparations should be avoided during the first visit until the dentist gains the child's confidence.

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Termination of visit and parent's involvement: 1- At the end of first visit the dentist can assess →Child behaviour. →Parent's reactions. 2- Praise child for good behaviour and ignore bad behaviour. 3- Prepare child for next visit by telling him in a simple way what is going to be accomplished in the second visit. 4- Parent's involvement: a. Before the child is dismissed explain the intended treatment plan to the parents. b. Tell them roughly the number of visits required. c. Discuss the fees. d. Stress on importance of preventive measures. e. Request the child’s toothbrush on the second appointment. Treatment planning: a- With a good history and examination, an accurate diagnosis and treatment plan can be made. b- Consider first the patient's chief complaint. c- Then proceed in a systematic manner with the more important to the less important. 41

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Recall visits: If the child has been properly managed during the first visit, the recall visits will proceed smoothly.

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LOCAL ANESTHESIA FOR DENTAL CHILD PATIENT

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By the end of this chapter, the student must be able to:

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02

1- Recognize the different methods and techniques of pain control for children.

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LOCAL ANESTHESIA FOR DENTAL CHILD PATIENT

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Topical anesthesia or surface anesthesia: Applied to injection site to make needle insertion painless.

3

Local anesthesia is the most common method of pain control in dentistry. However, this method of eliminating pain is painful itself and can be very distressing to the child patient.

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Forms of topical anesthesia: a. Paste (ointment, cream, gel). b. Solution (spray in pressurized container). c. Cotton pellets. d. Adhesive discs. Use of topical paste is better than spray because the spray splatters and reaches the soft palate causing gagging sensation. Requirements of an acceptable topical anesthesia: 1- Of pleasant taste. 2- Fast acting and effective. 3- Causes no irritation. Steps for administration of local anesthesia:

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1- Preparation of the child patient: - He is told that his tooth is going to be "put to sleep". - At first "a paste" will be applied to put the gum to sleep, and then it will be “washed away". - Parents should not interfere or comment. 2- Application of topical anesthesia: - Should be applied to dried mucous membrane. - Use one end of cotton wool roll to dry site of insertion and other end to apply the paste. In nerve block injection the child may hold the cotton wool roll between teeth to localize topical anesthetic paste. - Wait for about 2 minutes before giving the injection to allow topical anesthesia to work.

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3- Injecting local anesthetic solution: 1. Warm local anesthetic carpule between hands before use. 2. Apply pressure to injection site using your finger before injection. 3. Stretch the tissues before insertion of needle to facilitate penetration. 4. Concealment of the syringe from the child. The assistant gives you the syringe in working position before injection and receives it when injection is complete. Pass the syringe below the child's chin and out of his field of vision. 5. Distract child's attention at moment of needle insertion. 6. Inject the first drop on penetration wait for a moment, then inject slowly. 7. After completing the local anesthetic injection tell the child what he is going to feel (numbness, feels big or fat…….). 8. About 1 ml of the 1.8 ml carpule produces profound anesthesia in children under 10 years of age. 9. Allow enough time before starting any procedure. 10.Use fine gauge needle (gauge 27 for aspirating and gauge 30 for nonaspirating). Local Anesthetic techniques:

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Upper jaw and lower anterior teeth (Infiltration anesthesia): - All the maxillary and lower anterior teeth can be anesthetized by infiltration anesthesia using a short needle. - In case of extraction in upper jaw avoid palatal injection because it is very painful for the child patient. - As an alternative give intrapapillary injection. How? Wait for buccal infiltration to have its effect and then inject into the palatal aspect of interdental papillae from the buccal side distal and mesial to the tooth to be extracted with the needle perpendicular to the gingiva. Lower posterior teeth (Nerve block anesthesia): - Used for all mandibular molars. - Used to anesthetize large area with fewer injections. - Used when there is localized infection in area of infiltration site.

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N.B.: * Lower primary molars in the very young child (before eruption of first permanent molar) can be anesthetized by infiltration anesthesia for any procedure. * For extractions use buccal infiltration and lingual infiltration (you can use intrapapillary injection instead of lingual infiltration).

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* Nerve block injection is made in children slightly lower and more posteriorly than in adults because the mandibular foramen is situated at a lower level than occlusal plane of primary teeth and the size of mandible is smaller.

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RESTORATION OF PRIMARY TEETH

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Identify the different restorative techniques. Explain the basic principles in the preparation of cavities in primary teeth. Explain the recent concepts in restorative dentistry. Identify the different restorative materials.

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1234-

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By the end of this chapter, the student must be able to:

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RESTORATION OF PRIMARY TEETH

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Of all the many services the dentist provides for his child patients, the restoration and preservation of carious teeth is of major importance, for if these teeth are lost prematurely by caries, not only will the child be handicapped for the present but significant impairment of his normal masticatory function may affect him for his entire lifetime. In this respect, restorative dentistry is preventive as well as corrective. Isolation:

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The maintenance of dry operating field during cavity preparation and placement of the restorative material is important. This could be accomplished using rubber dam.

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The rubber dam offers the following advantages: 1-Saves time: Elimination of rinsing, spitting and talking of child allows quick operative work to be done.

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2-Aids management: Uncooperative or apprehensive children can be better controlled with a rubber dam in place since rubber dam controls movement of tongue and lips.

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3-Controls saliva: • Minute pulp exposures can be easily detected when the tooth is isolated. • Extent of exposure, amount and type of hemorrhage from pulp tissue can be easily detected. • Prevents foreign materials from contacting oral structures. e.g., floor of mouth or tongue which will stimulate salivary flow and interfere with operative procedures. 4-Using a rubber dam prevents aspiration or swallowing of foreign objects by the child who is in a semi-reclining position on the dental chair. Basic principles in the preparation of cavities in primary teeth: In preparing cavities for restoring primary teeth, although the basic principles of cavity preparation are applied, there are certain modifications done in cavity design for primary teeth related to the morphologic difference between primary and permanent molars.

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Class I cavities in primary molars:

1. The outline form should include all pits, fissures and grooves into which a sharp explorer can penetrate.

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Flat pulpal floor

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2. A flat pulpal floor is generally advocated, although some prefer to make the pulpal floor slightly concave throughout to allow for greater depth of the filling material, for better distribution of stress in the restoration and to avoid endangering the high pulpal horns.

Concave pulpal floor

3. The depth of pulpal floor should be established just beneath the dentinoenamel junction (0.5 mm) to avoid pulp exposure due to the reduced thickness of enamel and dentin.

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4. All the internal line angles should be rounded to avoid stress concentration.

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5. The side walls should slightly converge towards occlusal so that the preparation will follow the outer form of the crown to aid in retention of restoration.

6. Spot preparations in primary molars: * Beside the regular class I cavity preparations done in primary molars; occlusal spot preparations have been recommended. In such preparations, only the carious pit or groove is prepared, and the tooth is restored in the usual manner. These preparations are applicable in any of the primary molars with exception of the lower second primary molars in which 50

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extension for prevention including all deep pits and fissures is recommended.

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* From the clinical experience it has been found that interproximal caries in primary molars usually occurs in pairs. Proximal spot preparations have been recommended for such situations. For example, if an incipient proximal carious cavity is present in the mesial surface of a second primary molar, while the adjacent first primary molar has a proximal lesion on its distal surface, a proximal spot preparation in the mesial surface of second primary molar and a regular occluso-distal cavity in the neighboring first primary molar can be done. This spot preparation should be small, not undermining the marginal ridge and can be done only in patients with low caries index. Class II cavities in primary molars:

1. These preparations include an occlusal, an isthmus and proximal portion. The

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outline form of the occlusal step should be dovetail-shaped to avoid lateral displacement of restoration including all carious pits, fissures, and developmental grooves.

2. The side walls of the occlusal step should converge from the pulpal floor to the occlusal surface.

3. The pulpal floor should be established just beneath the dentinoenamel junction.

4. Angles between the side walls and the pulpal floor should be gently rounded.

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5. Since primary molars are characterized by having a narrow occlusal table, the

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area of the isthmus should be made as wide as possible buccolingually without weakening the cuspal areas or endangering the pulp in order to prevent fracture of amalgam restorations in this area. It has been suggested that the optimum average width of the isthmus area in primary molars should be approximately one-half of the intercuspal dimension of the tooth.

6. The axio-pulpal line angle should be beveled or grooved to reduce the

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concentration of stresses and provide greater bulk of material in the isthmus area, which is liable to fracture.

7. The greater constriction of the necks of primary molars calls for special

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attention when establishing the gingival seat of the proximal box. The further the gingival seat is carried down gingivally, the deeper pulpally must be the axial wall to maintain the proper 1 mm width, which can endanger the pulp. Therefore, the gingival seat of the proximal box should be established just beneath the free margin of the interproximal gingival tissue at a higher level (occlusally) than in permanent teeth and should be of sufficient depth to break contact with the adjacent tooth (approximately 1mm). It is unnecessary to bevel the enamel of gingival seat since the enamel rods at the cervix slope occlusally.

8. The proximal box line angles and walls should converge towards the occlusal, following the buccal and lingual surfaces of the tooth. This provides

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for increased retention, carries the preparation into self-cleansable areas, and avoids undermining the adjacent cusps.

9. An axiobuccal and axiolingual retentive groove may be included in the

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preparation. These grooves will aid in the retention of restoration.

10. If extensive proximal lesions are present, excessive flaring of the proximal

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surfaces will result in fragile unsupported tooth structure. Therefore, covering the tooth with a stainless-steel crown will result in a more serviceable restoration.

11. The usual matrices such as ivory, Tofflemire, and Wagner should not be

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used when condensing amalgam in class II cavities in primary molars, as they will not produce a desirable finished restoration since the primary molars have prominent buccocervical ridge, marked constriction of the crown in the cervical region, and sharply converging buccal and lingual surfaces towards the occlusal. A spot-welded band or T-band matrix can be successfully used producing a well contoured restoration.

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Class III cavity preparation:

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1. In these cavities caries involves proximal surfaces of anterior teeth without involving the incisal angle.

2. If removal of the caries will not involve or weaken the incisal angle, a small

02

conventional class III cavity may be prepared, and the tooth restored with composite.

3. If the caries is more extensive a dove tail preparation can be made, the dove

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tail can be prepared on the lingual or the labial surface of the tooth. This is particularly important when restoring caries on distal surface of primary canine due to the broad contact between its distal surface and the mesial surface of first primary molar and the height of interproximal gingival tissues which necessitates the use of a modified class III cavity preparation utilizing a dovetail.

4. Cavity preparations are more conservative nowadays and an adhesive fluoride

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releasing restorative material can be used for such cavities.

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Class IV cavity preparation:

teeth.

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1. In these cavities, caries involves the inciso-proximal angle of the anterior 2. If caries is not extensive, disking by sandpaper disc is performed to remove

02

the decay, and then fluoride is applied topically.

3. In regular class IV cavity preparations, composite resin material can be used for restoration.

4. If caries is extensive, anterior chrome steel crowns with facing or acrylic jacket can be used. Class V cavity preparations:

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1. Caries involves the gingival ⅓ of buccal & lingual surfaces. 2. Outline form includes all caries.

3. Depth of preparation is only 0.5 mm in dentin.

4. Retention of material is obtained from convergence of walls of preparation. Glass ionomer cement could be used for restoring these cavities.

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Recent concepts in restorative dentistry: Until recently restorative dentistry was based on G.V. Black’s principles. This is now opposed by a conservative approach based upon preservation of tooth structure. Recent advances in preventive measures and the arrival of ADHESIVE DENTISTRY have greatly reduced the size of cavity preparation. Guiding principles for adhesive cavity design: The following table shows principles of cavity design according to G.V. Black in comparison with adhesive cavity design.

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2- Outline form

G.V. Black

Adhesive cavity design

- Gaining access to cavity. - Prepare cavity to standard outline. - Remove any remaining caries. - Includes all deep fissures even those, which are not carious.

- Gaining access to caries. - Remove caries. - Plan the final outline according to the material used. - Involves carious fissures while sound deep fissures may be covered with sealant. - Prevention of extension i.e., no need to extend the preparation into self-cleansing areas or to remove affected dentin in deep portions. The approach focuses on healing instead of removal of demineralized tissues. - Remove loose and fragile enamel rods at C.S.A., which are directly exposed to occlusal load while other unsupported tooth structure may be conserved and reinforced by the bonded restoration. - Preservation of marginal ridges in case of early proximal caries by utilizing spot preparations. - Micromechanical retention, which includes current etching and bonding procedures. - Beveling which increases the potential surface area for retention. - Cleanliness of adhesive surfaces to ensure optimal bonding. Adhesive restorative material

- Extension for prevention i.e. extend the preparation into self-cleansing areas.

4- Resistance

-Removal of all undermined and unsupported tooth structure.

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3- Extension

3

Principles of cavity design 1- Access

5- Retention

6- Cleanliness

7- Materials used

- Macromechanical retention: * Convergence of walls. * Dovetail. * Undercuts. * Axial grooves. - Finishing the walls and toilet of the cavity. Non-adhesive restorative material

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New caries classification: Based on principles of adhesive dentistry, MOUNT & HUME in 1997 advocated a new classification for caries called Sites Stages classification (Si / Sta). Principles of Si/Sta:

1-Tooth structure saving: - Preservation of sound caries susceptible tooth structure. - Preservation of marginal ridges by using spot preparations. - Removal of loose and fragile enamel rods only if directly exposed to occlusal load, while other unsupported tooth structure may be conserved and reinforced by the bonded restoration.

56

3

- Preservation of demineralized dentin in the deep portions near the pulp chamber to protect the pulp tissue from direct operative trauma.

02

2- Utilization of modern adhesion technology benefits: i. Mechanical benefits: strengthening of tooth/ restoration compound through micro retention effect. ii. Biological benefits: provision of proper marginal seal at tooth restoration interface which protects the pulp tissue and enhances its reparative power by preventing microleakage.

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3- Biointegration: which involves: a- Preservation of function and esthetics. b- Prevention of recurrent caries.

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1- Amalgam: Most commonly used restorative material for primary teeth.

02

Advantages: 1 – Requires simple procedures. 2 – Durable (high strength properties). 3 – Used where moisture control is a problem.

3

Restorative materials for primary teeth

Disadvantages: 1 – Has no adhesive properties so requires undue cavity preparation. 2 – Environmental and occupational hazards (mercury). 3 – No esthetic properties.

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2- Composite Tooth colored restorative material for anterior teeth Advantages: 1 – High strength properties (inorganic filler). 2 – High esthetic properties.

Disadvantages: 1 – Requires acid etching (requires patient cooperation). 2 – Polymerization shrinkage 3 - Discoloration.

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3-Glass ionomer Tooth colored restorative material for anterior teeth and simple occlusal cavities in posterior teeth. Advantages: 1 – High adhesive properties (chemical bond to enamel and dentin). 2 – Fluoride leaching properties (used in patients with high caries index). 3 – Used as filling material – cement – base – core. Disadvantages: 1 – Low esthetic properties. 2 – Brittle (not used in stress bearing areas). 58

3

4- Resin modified Glass ionomer Glass ionomer + resin component.

02

Advantages: 1 – High strength (used in stress bearing areas). 2 – High adhesive properties. 3 – Fluoride leaching properties (used in children with high caries index). 4 – High esthetics. 5 – Light cured (finished immediately). 6 – Its coefficient of thermal expansion is very close to that of the tooth.

5- Compomer To have advantages of both composite and glass ionomer, in terms of fluoride release, strength and esthetics.

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Advantages: 1 – High esthetics. 2 – High strength. 3 – Adhesive properties. 4 – Fluoride release. 5 – Can be used as a restorative material and fissure sealant.

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6- Stainless steel crown: Indications: 1- Badly decayed or broken-down teeth. 2- Pulpotomized teeth. 3- Restoration of teeth affected by developmental problems e.g., enamel hypoplasia. 4- As an abutment for space maintainers. 5- In patients with high caries susceptibility or in patients where routine oral hygiene measures cannot be performed (handicapped patients).

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3

MANAGEMENT OF DEEP CARIOUS LESIONS IN CHILDREN By the end of this chapter, the student must be able to:

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02

Identify the diagnostic aids for vital pulp therapy. Know the different techniques for vital pulp therapy. Know the different techniques for non vital pulp therapy. Identify the reaction of pulp to commonly used capping materials. Recognize the cause of failure following vital pulp therapy. Know the different techniques of pulp therapy for young permanent teeth.

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123456-

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3

MANAGEMENT OF DEEP CARIOUS LESIONS IN CHILDREN

02

Pulp exposure is caused most commonly by caries but may also occur during cavity preparation or by fracture of the crown. Pulp exposures caused by caries occur more frequently in primary than in permanent teeth because primary teeth have relatively large pulp chambers, more prominent pulp horns and thinner enamel and dentine. In primary molars with proximal cavities, pulp involvement occurs in about 85% of those with broken marginal ridges.

Diagnostic aids in selection of teeth for vital pulp therapy

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1-History of pain: The dentist should distinguish between two types of pain: provoked and spontaneous pain (unprovoked). Provoked pain: is precipitated by stimulus (thermal, chemical or mechanical) and disappears after removal of stimulus. For example: • Pain associated with eating is due to pressure from accumulated food within the carious lesion and chemical irritation to the vital pulp protected by a thin layer of dentine (good prognosis). • Pain due to cold or hot food or drinks may indicate hyperemia or pulpitis.

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Spontaneous pain: is a throbbing constant pain that may keep the patient awake at night. It indicates advanced pulp damage (poor prognosis). 2-Clinical signs and symptoms:

A. Abnormal tooth mobility indicates severely diseased pulp or involvement of periodontal ligament. B. Sensitivity to percussion indicates apical or periodontal inflammation or both. C. Presence of swelling, sinus, draining fistula or chronic abscess indicates a non vital pulp. 61

3

D. Size of exposure and amount of pulpal bleeding are the most valuable observations in diagnosing the condition of the primary pulp: - Small pin-point exposure surrounded by sound dentine indicates favorable condition for vital pulp therapy.

02

- Large exposure with watery exudate or pus indicates unfavorable condition for vital pulp therapy. - Small controllable amount of bleeding during and or following pulp amputation is a favorable condition for pulp therapy. - Excessive uncontrollable bleeding during and or following pulp amputation is an unfavorable condition for pulp therapy.

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3-Radiographic interpretation:

Periapical and bitewings radiographs are used to examine periapical area and supporting bone. Pulp exposure cannot be accurately detected from an x-ray film. Radiographic interpretation in children is more difficult than adults due to: a. Young permanent teeth with incompletely formed root ends give the impression of periapical radiolucency. b. The roots of primary molars undergoing normal physiologic resorption may suggest a pathologic change.

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c. Permanent teeth are superimposed on the primary teeth. Radiographs are valuable for determining the following: a) Periapical changes such as widening of periodontal membrane space. b) Rarefaction in supporting bone. c) Calcified masses within pulp chamber and root canals. d) Periapical and interradicular radiolucencies of bone.

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4-Vitality tests:

3

Either thermal or electrical. Thermal pulp vitality tests:

02

• Application of heat (hot gutta percha or hot instrument). • Application of cold (ethyl chloride or ice cone).

• The reaction of a normal tooth is tested first (pain on application of stimulus which disappears after removal of stimulus). • If pain persists, this indicates hyperemia or pulpitis.

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• If tooth does not respond, this indicates a non-vital pulp. Electric pulp tester:

• Record the reading of a normal tooth first.

• If the affected tooth responds at a lower reading than normal, this indicates hyperemia or pulpitis.

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• If the affected tooth responds at a higher reading, this indicates pulp degeneration.

Disadvantages of electric pulp tester: a) Child may become apprehensive and gives a false positive response. b) Pulp tester may give false positive response when content of pulp is liquid (liquefaction necrosis).

5-Physical condition of patient:

Seriously ill children e.g., heart disease, nephritis, leukemia or tumors should not be subjected to the possibility of an acute infection resulting from pulp 63

Vital Pulp Therapy

02

Pulp Capping

3

therapy. Moreover, the pulp might not possess normal regenerative power. Extraction of the involved tooth after proper premedication with antibiotics is the treatment of choice in such conditions.

The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing either directly on the exposed pulp (direct pulp capping) or on a thin residual layer of soft dentine at the base of the cavity (indirect pulp capping). Indirect Pulp Capping Definition:

Indications:

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It is the procedure in which only the gross caries is removed from the lesion, while the remaining carious dentine which if removed would result in pulp exposure is covered with a material which promotes healing.

Teeth with deep carious lesions approximating the pulp, free of any clinical or radiographic signs of pulp disease. Technique:

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First visit:

1- Administer local anesthesia and isolate tooth with rubber dam. 2- Gross caries is excavated from the carious lesion, while the leathery dentine in the deepest portion is left and covered with calcium hydroxide paste and a reinforced temporary dressing. 3- Tooth should not be re-entered for 6-8 weeks. During that period the carious process in the deep layer will be arrested and calcium hydroxide will stimulate the formation of secondary dentine and the remaining microorganisms will be destroyed by bactericidal action of calcium hydroxide. 64

Second visit:

02

3

The tooth is re-entered, and any remaining carious dentin is carefully removed. Sound dentin is apparent which protects the pulp. Apply calcium hydroxide dressing and restore the tooth in usual manner. If a small exposure is encountered a different type of treatment is provided. N.B., Recently the need for the second visit (i.e., re-entering the tooth) is questioned. Proper case selection and adequate sealing with a durable restorative material ensures success. If no adverse signs or symptoms develop, there will be no need for re-entry.

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By the end of pulp capping, treatment is judged successful if there is: 1- No sensitivity to percussion. 2- No history of pain following treatment. 3- No radiographic evidence of periapical pathosis or root resorption. 4- No clinical evidence of pulp exposure if the tooth was re-entered.

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Fig. (l) Deep caries approximating pulp with no signs of actual pulpal inflammation.

Fig. (2) The deepest layer of carious dentine is left over the pulp.

Fig. (3) Cover exposed dentine with zinc oxide-eugenol.

Fig. (4) After 6-8 weeks, all caries is removed and the tooth is restored as usual. 65

Direct Pulp Capping

3

Definition:

Indications:

02

It is the procedure of covering the exposed vital pulp with a material which promotes healing.

1) Small pinpoint exposure surrounded by sound dentin, produced accidentally during cavity preparation or due to trauma. 2) Absence of pain with the exception of pain during eating. 3) Normal vital pulp.

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4) No bleeding at exposure site or an amount that would be considered normal. 5) Normal radiographic findings. Technique:

1- Administer local anesthesia and isolate tooth with rubber dam. 2- When pulp is exposed during the last stages of caries removal, carious dentin chips will be pushed into the pulp tissue which becomes contaminated resulting in pulpitis.

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3- So, enlarging the exposure site is needed to wash away carious and non carious fragments and allow direct contact of capping material with pulp tissues. 4- Flush the exposure site with normal saline to clean the area and keep the pulp moist while a clot is forming. 5- Cap the pulp with calcium hydroxide followed by reinforced cement and the permanent restoration.

N.B. Direct pulp capping is not encouraging in primary teeth because pulp tissue ages early and less active undifferentiated mesenchymal cells are available 66

3

which can be induced to transform into odontoblasts and lay down secondary dentin. Moreover, during process of root resorption, some cells may transform to odontoclasts causing internal resorption. Pulpotomy

02

Definition:

It is the removal of coronal pulp tissue till the level of entrance of pulp canals and capping the radicular pulp tissue to keep it in a good condition. Indications:

1. In primary and young permanent teeth with wide pulp exposures when the tissues adjacent to exposure site show slight evidence of inflammation.

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2. Slight amount of bleeding at exposure site which is considered within normal. 3. Normal vital pulp.

4. Normal clinical and radiographic signs.

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Technique: 1. Administer local anesthesia and isolate the tooth with rubber dam. 2. Establish outline form to ensure access to the pulp chamber. 3. Remove all carious dentin with round bur and spoon excavator, this ensures a clean operating field. 4. Remove the roof of pulp chamber using a fissure bur. 5. Remove any overhanging ledges of dentin as pulp tissue under ledges may not be easy to remove. 6. Amputate the coronal pulp tissue with a large spoon excavator or with a large round bur in low-speed handpiece carefully to avoid perforation of the floor of the pulp chamber. 7. Wash and flush the pulp chamber with sterile water or saline solution. 8. Dry and control bleeding with sterile cotton pellets for about 4 minutes. If bleeding continues, look for remnants of coronal pulp still adhering to the walls of the pulp chamber and remove them. 9. Apply capping material.

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Types of pulpotomy according to the capping material used:

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3

1- Calcium Hydroxide Pulpotomy: It is indicated in young permanent teeth with exposed vital pulp and incomplete root formation. Under calcium hydroxide, the pulp is able to maintain its vitality; it organizes an odontoblastic layer to lay down reparative dentin and gives the chance to the root to complete its apical growth. After pulpotomy is completed and formation of healthy clot a layer of Ca (OH) 2 is applied then reinforced cement and the permanent restoration is inserted. This procedure gives 61 % success.

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2- Formocresol Pulpotomy: It is recommended for primary teeth with carious exposure. The formocresol used is Buckley’s formocresol which is composed of 19 % formalin and 35 % cresol in a vehicle of glycerin and distilled water. Formocresol solution releases formaldehyde, which diffuse through the pulp and by combining with cellular protein fixes the pulp tissues. Formocresol, as supplied, can be diluted to 1:5 concentration using 3 parts of glycerin and one-part distilled water. Success rates up to 96% have been reported using formocresol pulpotomy in vital primary teeth. Pulpotomy is performed in a single visit: 1- After amputation of the coronal pulp, control of bleeding and formation of a blood clot, apply a cotton pellet moistened with formocresol and blotted on a sterile cotton roll to remove the excess over the radicular pulp stumps for 4-5 minutes. Pulp stumps appear dark brown.

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2- Prepare a paste of reinforced zinc oxide-eugenol. Remove the cotton pellet moistened with formocresol and place enough paste to cover the radicular pulp stumps. Pressure should be avoided on radicular pulp tissues. 3. Fill the pulp chamber with temporary cement and prepare the tooth for a stainless-steel crown. In case of non-vital pulp and difficulty in performing a one visit pulpotomy two-visits may be advocated: If there is any sign of hyperemia following amputation of coronal pulp (pain or excessive hemorrhage) indicating that inflammation is present in the tissues beyond the coronal portion of the pulp, two visits formocresol pulpotomy, partial pulpectomy or even extraction of the tooth is indicated. 68

3

1- After coronal pulp amputation, a cotton pellet moistened with formocresol is placed over the radicular pulp stumps and covered with temporary dressing.

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02

2- In the second visit after 2-3 days, isolate tooth with rubber dam without local anesthesia, remove the dressing and pellet and complete the procedure as one visit technique. N.B.: A stainless steel crown is the ideal restoration after pulpotomy because the crown of the tooth is brittle and may fracture.

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Fig. (1) Remove infected carious before entering pulp horn.

Fig. (2) Enter pulp chamber through dentine exposure site or at area of the pulp chamber.

Fig. (3) Remove roof of the pulp chamber and expose coronal pulp tissue.

Fig. (4) Amputate coronal pulp tissue with a sharp excavator to the level of the orifice of the canals.

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3 02 Fig. (6) Hemorrhage is controlled and pulp stumps are visible.

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Fig. (5) Apply a cotton pellet to pulp stumps. This should control hemorrhage within 1-2 minutes if the pulp involvement does not extend into the root canal portion of the tooth.

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Fig. (7) For Ca (OH) 2 pulpotomy in a young permanent tooth place a 2mm layer of calcium hydroxide over pulp stumps.

Fig. (9) After medicament is placed over pulp stumps. Seal tooth with zinc oxide-eugenol. This may also used to fill the tooth provided the tooth will be restored with a permanent restoration soon.

Fig. (8) For formocresol pulpotomy place a moistened formocresol pellet that has been blotted on pulp stumps and leave in contact for 5 minutes.

Fig. (10) Stainless steel crown should be used as final restoration for primary molars that have undergone pulp treatment. These teeth become brittle when the internal blood supply is removed and may fracture at a later time from the force of mastication. 70

Partial pulpectomy:

3

Definition:

It is the removal of coronal pulp tissue and as much as possible of the contents of root canals without interfering deeply into the apical portion.

02

Indications:

1- It is indicated in primary molars as it is impractical to perform complete pulpectomy in such teeth because of difficulty to obtain adequate access to the root canals in the small mouth of children and due to the complexity in morphology of root canals having lateral branchings and apical ramifications where removal of all radicular pulp content is impossible.

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2- When the coronal and radicular pulp tissue are vital but show clinical evidence of hyperemia. 3- The tooth may or may not have a history of pain. 4- No evidence of necrosis (tooth is vital).

5- Normal radiographic findings (no evidence of widening of periodontal membrane space or periapical pathosis).

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Technique: The technique is completed in one appointment: 1- Remove the coronal pulp tissue (same steps in pulpotomy). 2- Remove as much as possible from the content of root canals with a serrated broach. Care should be taken not to penetrate the apex. 3- No widening of the root canals is done. 4- Irrigation of the canals with normal saline. 5- Dry the canals with sterile paper points. 6- The root canals may be filled with zinc oxide-eugenol (a resorbable material which will be resorbed as normal root resorption occurs). Filling the root canals: • A thin mix of zinc oxide-eugenol paste may be prepared, and paper points covered with the material are used to coat the root canal walls. 71

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• A thick mix of the zinc oxide-eugenol should be prepared, rolled into a point and carried into the root canal. • Root canal plugger may be used to condense the material into the canal. • Zinc phosphate is put as a base and the tooth should be restored with chrome steel crown.

Fig. (1) Extirpate pulp with barbed broach. If canal is narrow, use a file.

Fig. (2) Filling the canal with zinc oxide -eugenol.

Non-vital pulp therapy

Complete pulpectomy [endodontic treatment] Definition:

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It is the complete removal of coronal and radicular pulp tissue.

Indications:

- In non-vital primary anterior teeth where the root canals are accessible. - The canals may be prepared with the help of a radiograph. Care should be taken not to traumatize the apical region. - The root canals are filled with a resorbable material such as zinc oxide eugenol, or premixed calcium hydroxide paste (vitapex) which is composed of iodoform and calcium hydroxide

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3

Treatment of non-vital primary molars:

Technique of non-vital pulpotomy: First visit:

02

Ideally a non-vital tooth should be treated by pulpectomy and root canal filling. However, complete pulpectomy in primary molars is extremely difficult and often impractical. A non-vital pulpotomy method is advocated.

1- Necrotic coronal pulp tissue is removed (as pulpotomy).

Second visit:

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2- Seal a cotton pellet moistened with formocresol or camphorated monochlorophenol into the pulp chamber for 7-10 days. The strong antiseptic action of these materials combats infection in radicular pulp.

1- Remove cotton pellet and place antiseptic paste composed of zinc oxide and eugenol. 2- Press antiseptic paste into root canals with a cotton pellet. Pressure forces the paste down the root canals. 3- Restore the tooth in usual manner.

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N.B: This technique could be used in the presence of sinus, abscess or some degree of tooth mobility. A sinus is expected to disappear following control of infection and a mobile tooth becomes firm as periapical bone reforms.

Reaction of the pulp to commonly used capping materials: Pulp capping agents have developed along three main lines: 1- Devitalization. 2- Preservation. 3- Regeneration.

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02

3

1- Devitalization: This procedure is based on complete fixation of underlying radicular pulp tissue thereby avoiding infection and internal resorption. This is achieved by using formocresol. - Formocresol: Formaldehyde in formocresol is a strong tissue fixative and has an antimicrobial action. Tissue fixation is achieved by chemical binding of formaldehyde with proteins in pulp cells, while its bactericidal effect is achieved by chemical binding to proteins of microorganisms. Histologically, formocresol produces progressive fixation of pulp tissue with ultimate fibrosis of the entire pulp.

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2- Preservation: This procedure produces only minimal insult to underlying pulp tissue without initiating an inductive process, thereby preserving maximum vital radicular pulp tissue. This is achieved by using glutaraldehyde and ferric sulphate. - Glutaraldehyde: Similar to formaldehyde, glutaraldehyde fixes proteins of pulp cells. However, molecules of glutaraldehyde are larger than formaldehyde which limits its penetration into the underlying pulp tissue. Moreover, binding of glutaraldehyde to proteins of pulp cells is stronger and irreversible. Histologically, when glutaraldehyde is placed over vital pulp tissue it produces an initial zone of fixation which does not migrate apically. The tissues underlying this fixed zone have cellular details of normal pulp which suggests that the vitality of the remaining pulp is maintained. The material is used as 2 % or 5 % buffered glutaraldehyde solution for pulpotomy technique in primary teeth.

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- Ferric sulphate: It is a non – aldehyde chemical which is used as a 15.5 % solution for pulpotomy technique in primary teeth based on its hemostatic and coagulative properties. Histologically, when ferric sulphate is applied to amputated pulp tissue, blood reacts with ferric and sulphate ions which cause agglutination of blood proteins. These agglutinated proteins form plugs to occlude the capillary orifices which produce chemical sealing of the cut blood vessels. 3- Regeneration: This procedure is based on induction of reparative dentin formation by the pulp capping agent, thereby leaving the underlying radicular pulp tissue vital and 74

02

3

healthy. This could be achieved by using calcium hydroxide and mineral trioxide aggregate. - Calcium hydroxide: It is a highly alkaline material with pH 12. It consists mainly of calcium and hydroxyl ions. The calcium ions stimulate cellular proliferation in pulp tissue. The hydroxyl ions maintain a state of alkalinity important for cell proliferation and produce an antiseptic effect. It is used in pulpotomy technique in young permanent teeth. Histologically, the pulp tissue underneath the calcium hydroxide remains vital and organizes an odontoblastic layer to lay down reparative dentin which gives a chance for the root to complete its apical growth. One month after the capping procedure, a calcified bridge is evident radiographically. This bridge increases in thickness during the next 12 months. The pulp beneath the calcified bridge remains vital and free from inflammatory cells.

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- Mineral trioxide aggregate: A pulp capping agent with excellent sealing ability. It is highly biocompatible with potent antimicrobial properties due to its high alkalinity (pH 12.5). The material has the ability to stimulate dentin bridge formation adjacent to dental pulp. N.B.: Electrosurgery pulpotomy: It is known as non – chemical devitalization. Its mechanism of action is cauterization of pulp tissue.

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Laser pulpotomy: It produces superficial zone of coagulation necrosis which remains compatible with underlying tissues and isolates the pulp from vigorous effects of external stimuli. Failures following vital pulp therapy: 1-Internal resorption:

• Occurs within pulp canals several months following pulpotomy. • It is a destructive process due to osteoclastic activity. • Pulp canals become widened, walls become thin, and perforation may occur.

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Etiology:

2-Alveolar abscess:

02

3

1- A true carious pulp exposure is usually associated with some degree of inflammation. This inflammation may be limited to coronal pulp tissue or may extend to the entrance of pulp canals. Osteoclasts may become attracted to the area and initiate resorption. 2- All capping materials are irritating and produce some degree of inflammation, inflammatory cells in the area of inflammation may attract osteoclasts which initiate internal resorption. 3- Because the roots of primary teeth are undergoing normal physiological resorption there is osteoclastic activity in the area which may predispose the tooth to internal resorption.

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- Develops several months following pulp therapy. - Infection may be present in bone around root apex or more commonly in bifurcation area. - May be associated with fistula in chronic conditions. - Primary teeth which develop an alveolar abscess should be removed, while permanent teeth can be treated with endodontic treatment.

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General contraindications for pulp treatment of primary teeth: 1- A patient from family having unfavorable attitude towards dental health and conservation of the teeth. 2- A tooth, with gross breakdown that restoration would be impossible following pulp treatment. 3- A tooth with caries penetrating the floor of pulp chamber. 4- A tooth close to natural exfoliation. 5- A patient with poor general health. Pulp therapy for young permanent teeth Apexogenesis [vital pulpotomy]: Indications:

Vital permanent teeth with immature root development having large carious or traumatic exposures. The tooth should have normal clinical and radiographic signs. 76

Aim:

02

Apexification [ root end closure in non-vital teeth]:

3

Maintain the radicular pulp vital to allow complete root development. Calcium hydroxide placed over radicular pulp stumps stimulates the formation of a calcific bridge and successful root closure.

Indications:

In young permanent teeth with pulp necrosis and incompletely formed apices. Aim:

Technique:

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To promote root elongation and or calcific root closure. Even though the pulp is necrotic, epithelial root sheath of Hertwig persists and allows regeneration.

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The entire pulp is removed, and calcium hydroxide is used to fill the root canals and is replaced every 3-4 months until apical closure occurs. The tooth is then treated with root canal therapy.

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RAMPANT DENTAL CARIES

3

By the end of this chapter, the student must be able to:

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1- Define rampant caries. 2- Identify the characteristics and etiology of rampant caries.

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RAMPANT DENTAL CARIES

3

Definition:

02

Rampant caries has been defined by Massler as a suddenly appearing, widespread, rapidly burrowing type of caries resulting in early involvement of the pulp and affecting those teeth usually regarded as immune to ordinary decay.

Characteristics of rampant caries are:

1- The involvement of proximal surfaces of the lower anterior teeth 2- Development of cervical type of cavities. 3- The caries process is accelerated to the extent that it becomes uncontrollable.

Rate:

Etiology:

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The term rampant caries should be applied to a caries rate of 10 or more new lesions/year.

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1- Emotional disturbances: An emotional disturbance may initiate an unusual craving for sweets or the habit of snacking, which might in turn influence the incidence of dental caries. Salivary deficiency is common in tense, nervous or disturbed persons. 2- Sucrose is more likely to cause rampant multisurface cavitation this is related to high molecular weight dextrans that are formed during the metabolism of sucrose by streptococcus mutans.

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Early Childhood Caries

3

By the end of this chapter, the student must be able to:

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02

1- Define early childhood caries. 2- Identify the etiology and mechanism of early childhood caries. 3- Know the clinical picture and developmental stages of early childhood caries. 4- Identify the management of early childhood caries.

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Early Childhood Caries

3

Terminology: The most commonly used name is "Nursing-Bottle Caries". Other names mentioned in the literature are Baby-bottle caries, Nursing bottle syndrome, Babybottle tooth decay, Nursing caries and recently Early Childhood Caries.

02

Definition: It is a specific pattern of rampant caries affecting the primary teeth of an infant during the first three years of age. According to the American Association of Pediatric Dentistry: ECC 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.

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Etiology: This disorder results from: 1. Inappropriate nursing habits, involving breast or bottle – feeding at bedtime or during the night. 2. The regular use of a sweetened comforter (a bottle containing sweet beverages) at bedtime or during the day. 3. Breast-feeding beyond the normal age for weaning. 4. Falling asleep with pacifier covered with honey or jam. 5. The regular use of syrups for therapeutic reasons during chronic or recurrent illnesses.

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Mechanism: • When the child falls asleep, the milk or the sweetened liquid becomes pooled around the maxillary anterior teeth. • The carbohydrate containing liquid provides an excellent media for acidogenic bacteria (S. mutans and Lactobacilli). • As salivary flow is decreased during sleep, the clearance of the liquid from the oral cavity is slowed. • The lactose content of the milk (Human or bovine) can be cariogenic as the milk is allowed to stagnate on the teeth for long time.

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3

Clinical picture: 1- Teeth affected: • The four maxillary incisors are most affected. • The four mandibular incisors usually remain sound. • Because the tongue lies over the lower teeth during sucking. • The other primary teeth, the canines, first molars and the second molars may exhibit caries involvement depending upon how long the carious process remains active. 2- Clinical pattern: • The maxillary incisors develop a band of dull white demineralization along the gum line that goes undetected by parents. • Then the white lesions develop into cavities that circle the necks of teeth with a brown or black collar.

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• In advanced cases the crowns of the four maxillary incisors may be destroyed completely leaving decayed brownish black root stumps. Developmental stages: I- Initial stage: *Cervical opaque, chalky white demineralization of the tooth substances. *Pain is not felt at this stage.

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II. Damaged stage: *The carious lesion extends into the dentin and shows marked discoloration. *Parents can spot the condition at this stage due to the discoloration of the teeth and the child complains when cold foods are ingested. III. Deep lesion stage: *Lesions in the maxillary incisors are larger and the first primary molars are all affected. *Complaints of pain during tooth brushing or eating. *Pulpal problems in the maxillary incisors can occur. IV. Traumatic stage: *Maxillary incisors become so weakened by caries that relatively small forces suffice to fracture them.

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V. Arrested caries: *In all the previous stages arrested caries might occur, when the cause of the dental caries is eliminated. The lesions might get a dark brown to black appearance.

02

Management of Early Childhood Caries: Management of Early Childhood Caries can be divided into two main categories A. Prevention. B. Treatment. A. Prevention of Early Childhood Caries:

1- National community-based educational programs for mothers and caregivers to influence their dietary and oral hygiene habits as well as those of their infants.

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2- Parents counseling and education: a- From birth, the infant should be held while feeding. b- The child who falls asleep while nursing should be burped and then placed in bed. c- The mother should wean the child as soon as he can drink from a cup at approximately 12-15 months of age. d- Parents should be cautioned about prolonged and frequent infant feeding habits. e- Oral hygiene measures. 3- Early dental examination at or before the age of 1 year (as recommended by AAPD).

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4- Professional application of topical fluoride varnishes and fissure sealant. B. Treatment of Early Childhood Caries: I.

II.

Cessation of bad feeding habits. Sealing all caries-free pits arid fissures.

III.

Fluoride application.

IV.

Gross excavation of carious lesions and filling of the cavities with reinforced zinc oxide-eugenol or glass-ionomer cement. This will arrest the caries process and prevent its rapid progression to the dental pulp. 83

Pulp therapy and buildups of restorable teeth. This may involve Compomer, Composite filling and stainless-steel crowns.

VI.

Treatment under general anesthesia is often required for small children with extensive carious lesions.

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02

3

V.

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STAINLESS STEEL CROWN

3

By the end of this chapter, the student must be able to:

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02

1- Identify the indications of stainless-steel crown. 2- Recognize the clinical procedure for stainless steel crown. 3- Recognize the causes of stainless-steel crown failure.

85

STAINLESS STEEL CROWN

3

Stainless steel (preformed) crowns are prefabricated crown forms, which can be adapted to individual primary molars and cemented in place to provide a definitive restoration. They are considered the most durable and reliable restoration.

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Indications: Stainless steel crowns are the restoration of choice in the following situations: 1- Restoration of primary or permanent teeth with extensive carious lesions (more than two surfaces affected). 2- Following pulpotomy or pulpectomy procedures (teeth become brittle after removal of pulp content and may fracture if not protected). 3- Restoration of teeth affected by developmental problems (e.g., enamel hypoplasia, amelogenesis and dentinogenesis imperfecta). 4- As an abutment for certain appliances, such as space maintainers. 5- In patients with high caries susceptibility or where routine oral hygiene measures cannot be performed (handicapped patients). Clinical procedures: 1- Appropriate local anesthesia should be obtained, and the tooth should be isolated, preferably with rubber dam. 2- Caries removal and appropriate pulp treatment should be completed if necessary.

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Tooth preparation: 1- Proximal reduction to open the contact using tapered diamond stone. 2- Occlusal reduction (l-1.5mm) to avoid occlusal prematurity using wheel stone. 3- Buccal and lingual preparation is not always necessary except where there is a large buccal bulge. 4- The preparation should finish with a smooth feather edge cervically with no step or shoulder. Crown selection: - The selected crown must fit to the prepared tooth with a tight snap. - Choosing the correct size is assisted by measuring the mesiodistal dimension of the tooth using a divider. 86

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Crown adaptation: 1- Try the crown on the tooth, place the crown on the lingual side and rotate it toward the buccal side. The crown should extend 1mm beneath the gingiva. 2- Most commercially available crowns are anatomically trimmed and contoured cervically and require little or no modification. 3- If the gingival extension is too long, using a crown and bridge scissors cut around the gingival margin of the crown/then contour it with a ball and socket plier.

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Crown cementation: - The status of the pulp influence selection of the cementing material. - A cavity varnish must be applied before cementing a crown to a vital tooth. - There are several options for the cementing media e.g., zinc phosphate cement, zinc oxide eugenol cement, reinforced zinc oxide eugenol cement, polycarboxylate cement and glass ionomer cement. - Zinc phosphate cement is commonly used for cementation of stainless-steel crowns. Causes of stainless-steel crown failures: 1- Poor tooth preparation. 2- Poor crown adaptation and subsequent poor retention. 3- Improper cementation and presence of open margins. 4- Recurrent caries. 5- Crown abrasion through the occlusal surface.

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Recent advances: 1- Stainless steel crowns may be esthetically improved by placement of composite resin in a buccal window cut into the labial face of the crown. 2- Crowns with prefabricated tooth-colored buccal facings are available. 3- Crowns with bonded resin veneers for primary incisors were developed to serve as a convenient, durable, reliable and esthetic solution for restoring severely destructed primary incisors.

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Preparation of the tooth for stainless steel crown

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EXTRACTION OF TEETH IN CHILDREN

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Identify the indications and contraindications for extraction of primary teeth. Identify the indications for extraction of permanent first molar. Recognize the techniques of removal of primary teeth. Recognize the postoperative instructions for the child and his parents.

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By the end of this chapter, the student must be able to:

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EXTRACTION OF TEETH IN CHILDREN

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The general principles of oral surgery remain the same whether applied to the adults or to children. However, there are some factors to be considered in oral surgery for children as compared to adults:

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1. The oral cavity is small and there is greater difficulty in gaining access to the field of operation. 2. The jaws are in the process of growth and development and the dentition is in a continuous state of change with eruption and resorption of primary teeth and eruption of permanent teeth. Any premature extraction of primary teeth may lead to irregularities in the permanent teeth.

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3. The bone structure of a child contains higher percentage of organic material, which makes it more pliable than adult bone and not as likely to fracture. Indications for extraction of primary teeth: 1. Teeth decayed beyond possible repair. 2. Infection of the periapical or inter - radicular area which cannot be eradicated by other means. 3. Acute dento - alveolar abscess with cellulitis. 4. Teeth interfering with normal eruption of succeeding permanent teeth. 5. Submerged teeth.

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Contraindications to extraction of primary teeth: Many of these contraindications are relative and may be overcomed with special precautions and premedication. 1. Acute infectious stomatitis, acute ulcerative gingivitis or acute herpetic gingivostomatitis. The acute phase should be controlled before extraction. 2. Blood disorders: These render the patient susceptible to postoperative infection and hemorrhage. Extractions should be performed only after consultation with hematologist and proper preparation of the patient. 3. Rheumatic heart disease, congenital heart disease and congenital kidney disease require proper antibiotic coverage. 4. Acute systemic infections of childhood, because of lowered body resistance. Malignancy, if suspected, on the other hand, extractions is strongly indicated if the orofacial areas are to receive irradiation. 5. Teeth which have remained in irradiated bone. 90

6. Diabetes mellitus: Extraction can be done after the condition is controlled.

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Indications for extraction of permanent first molars: - If a permanent first molar is removed before the permanent second molar has erupted through the gingiva, the chances that the second molar will move mesially and occupy the space of the extracted first molars are very good. - When two first molars are diseased beyond repair, they should be removed. - But if three first molars are diseased beyond repair, all four molars should be removed with the expectation that a more symmetrical dentition will result.

Preoperative preparation: As the extraction of a tooth can be emotionally upsetting to the child and the parents, some preparations are necessary.

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a) Parent’s preparation: - A parental consent is important before extraction. - Any possible medical condition that may require special precaution should be discussed. b) Child preparation: - Avoid the use of technical words and words suggesting fear or pain. - Explain to the child what sensation may be experienced. - The child should realize the difference between pressure and pain.

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Techniques for the removal of primary teeth: Although extraction of a deciduous tooth with completely resorbed roots is a simple task, removal of some of the deciduous teeth with all or part of the roots present can be challenging. - Armamentarium for extraction procedures is much the same as for adult, but as all anatomic structures are smaller, special forceps are available for primary teeth. - Fracture of a slender root is common, especially when there is uneven resorption. These roots should be removed using a small elevator or even a large spoon excavator or universal scaler. - When removing young permanent teeth, the young elastic bone structures, and incomplete root development usually facilitate the extraction.

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Extraction of anterior teeth: Anterior teeth should be luxated to the labial during the extraction procedure due to the lingual position of the permanent teeth buds then rotated slightly and delivered labially.

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Extraction of maxillary primary molars: - Because the palatal root is curved, it indicates the direction of the removal, and the initial direction of force is slightly to the palatal. - Slight force is emphasized in order not to fracture the curved palatal root then in a single sustained force to the buccal until the tooth is loosened. - A counterclockwise motion delivers the tooth out of the socket.

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Extraction of mandibular primary molars: - The cross-section of the mandibular first primary molar roots is flat mesiodistally and elliptical, therefore, any rotary motion is contra- indicated. - The initial force is slightly to the lingual; then a single sustained force to the buccal until the tooth is loosened. - A counterclockwise rotation delivers the tooth from the socket. - During extraction, the mandible is supported with the non-extraction hand to protect TMJ against any possible injury. Postoperative instructions:

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1. For the child: 1. The child should not be dismissed until a blood clot has formed; the child is instructed to hold between his lips a small cotton roll until his lips "wake up". 2. The child may return to school or go out and play once the numbness has gone. 3. A child should be reassured that he will get a new tooth in the place of the one that was removed. 2. For the Parents: - Tell the parents why the cotton roll is used and that they should not be concerned if there is slight oozing or blood from the socket. - Light meal with no hard food is recommended. - The parents are instructed not to continuously ask the child how painful the area is. - Simple written instructions can be helpful.

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MANAGEMENT OF TRAUMATIC DENTAL INJURIES IN CHILDREN By the end of this chapter, the student must be able to:

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1- Classify traumatic dental injuries. 2- Know how to diagnose traumatic dental injuries. 3- Identify treatment of traumatic dental injuries in both permanent and primary teeth. 4- Know the different reactions of tooth to trauma.

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MANAGEMENT OF TRAUMATIC DENTAL INJURIES IN CHILDREN

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Injury to both the primary and permanent teeth and the supporting structures is one of the most common dental problems seen in children. Besides physical trauma it also has a great psychological impact on both the parents and the child.

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Epidemiology: - The international association of dental traumatology reports that one out of every two children sustain a dental injury most often between the ages of 812. - In Egypt, 9.8% of school children suffer traumatic dental injuries in the permanent dentition. - The majority of injuries occur to the anterior teeth in particular the maxillary central incisors of both primary and permanent dentition. Classification of trauma to anterior teeth: Several classifications have been advocated by several authors. 1- Descriptive classification: a- Fractures of teeth: 1- Uncomplicated crown fracture (without pulp involvement). 2- Complicated crown fracture (with pulp involvement). 3- Crown-root fracture. 4- Root fracture.

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b- Injuries involving the whole tooth: • Concussion: sensitivity of the tooth due to mild blow without abnormal loosening or mobility. The tooth may be sensitive to percussion. • Subluxation: loosening of the tooth without displacement, due to a more severe blow resulting in injury to periodontal ligament. • Displacement: ➢ Intrusion: displacement of a tooth in an apical direction. Tooth is pushed into the socket, causing fracture of the bone at the floor of the socket in most of the cases. ➢ Extrusion: displacement of a tooth in a coronal direction. Tooth is seen extruded partially out of the socket. ➢ Labial/lingual/palatal: displacement of a tooth in a labial or lingual direction. 94

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➢ Lateral: displacement of a tooth in a mesial or distal direction. • Avulsion: loss of tooth, where the entire tooth is out of the socket. c- Trauma to the supporting bone: Involves alveolar bone fractures.

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2- Ellis and Davey classification: Class 1: simple crown fracture with little or no dentin. Class 2: extensive crown fracture involving considerable amount of dentine without pulp exposure. Class 3: extensive crown fracture involving considerable amount of dentine with pulp exposure. Class 4: non-vital traumatized tooth with or without loss of crown structure. Class 5: loss of the tooth. Class 6: root fracture with or without crown fracture. Class 7: tooth displacement without crown or root fracture. Class 8: fracture of crown en-mass. Class 9: traumatic injuries of deciduous teeth.

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3- Modified Ellis and Davey classification: A modification of Ellis and Davey classification of crown fracture is useful in recording the extent of damage involving young permanent incisors. Class I: Traumatized teeth with fracture involving enamel only or enamel and little dentine. Class II: Traumatized teeth with fracture of enamel and considerable amount of dentine. Class III: Traumatized teeth with fracture of enamel and dentine with pulp exposure. Class IV: Traumatized teeth where amputation of the crown en-mass occurs. Class V: Traumatized teeth where there is root fracture accompanied with or without crown fracture.

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Class I

Class III

Class IV

Class V

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Diagnosis: I. History: 1. Personal History: It should include the patient's name, age, sex, address and source of referral if any. 2. Medical History: Routine data on the patient’s general health should be obtained particularly those relevant to dental management e.g., cardiac diseases or bleeding disorders. 3. Dental History: • Previous dental history: Information can be obtained on the frequency of dental visits, type of treatment performed such as extraction or conservative procedures. The type of anesthesia used for the procedures and the co-operation of the child can be determined.

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• History of trauma: When, Where, and How?

When did the accident occur? - In cases of oral trauma with damage to the teeth, time elapsed since trauma is very important. - If there is an avulsed tooth which needs to be repositioned, or a fractured crown with pulp involvement, the shorter the time between accident and treatment the better the prognosis.

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Where did the accident occur? If the accident occurred in a dirty environment, prophylactic tetanus treatment is indicated.

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How did the injury happen? A direct blow under the chin may cause a fracture in the condyle and fracture of crowns of molars and premolars. For young children, when there is a marked discrepancy in clinical findings and the history given, child abuse should be suspected.

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II. Clinical Examination: 1. Extra-oral Examination: 1- Lacerations, abrasions, and contusions on the face, head, neck and exposed limbs can be noted visually. 2- Any asymmetries including any deviation in mandibular path during mouth opening. Extra-oral wounds should be inspected for foreign bodies. 2. Intraoral Examination: It includes: (1) the soft tissues, (2) the hard tissues. 1. Soft-tissue Examination: - Note any lacerations of the tongue, gingiva, labial and buccal mucosa or penetrating wounds. - The presence of embedded tooth fragments should always be suspected in this case. - A hematoma in the floor of the mouth indicates mandibular fracture. 2. Hard-tissue Examination: a-Displacement: Teeth may suffer labial, lingual, palatal, or lateral displacement as well as intrusion, extrusion or avulsion. Visually determine and note any displacement. b-Mobility: If two or more teeth are seen to move, an alveolar fracture should be suspected. c-Tooth fracture: Observe the amount of lost tooth structure and look for evidence of pulp exposure. d-Color change: Non-vital teeth often appear discolored with varying degrees from gray brown to black.

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III. Vitality test: A-Electric pulp tester:

B-Thermal test:

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- If injured tooth responds at a lower reading than normal tooth this indicates pulp hyperemia. - If injured tooth responds at a higher reading than normal tooth this indicates pulpitis. - If there is no response this indicates pulp necrosis.

- Failure of tooth to respond to thermal test indicates pulp necrosis. - A more painful reaction to cold application which does not subside removal of the stimulus indicates a pathologic condition in the pulp.

after

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Failure of a recently traumatized tooth to respond to pulp testing may indicate pulp necrosis but may also indicate that the tooth is in a state of shock which may last for ten days up to 2 weeks. In such a case provide emergency treatment only and the tooth is retested after 2 weeks. If at the end of 2 weeks, the tooth does not respond this indicates pulp necrosis. IV-Radiographic examination:

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- Irregularities in the size of pulp chamber or root canals as compared with adjacent teeth indicates previous injury. - The stage of apical development dictates the line of treatment. - The proximity of coronal pulp to the area of fracture also dictates the line of treatment. - Root fractures can be easily detected. - The radiograph provides a record for the tooth immediately after injury. - Other findings seen in X-ray are pulp calcifications, periapical radiolucencies, widening of periodontal membrane space and displacement (intrusion or extrusion). - If a jaw fracture is suspected extra-oral radiographs are indicated (panoramic and lateral oblique views).

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Treatment of Traumatic Dental Injuries (Permanent Dentition) I. Soft tissue injuries: a. Determination of child immunization status: - If the child had received primary immunization the antibody forming mechanism may be activated with booster injection of tetanus toxoid. - Un-immunized child can be protected through passive immunization with tetanus antitoxin (tetanus immunoglobulin). b. Debridement, suturing and/or haemorrhage control of open soft tissue wounds, and when indicated refer the child to a physician. II. Concussion: - A mild blow to the tooth resulting in mild sensitivity requires little or no treatment. - Examination with regular vitality testing at subsequent visits is required. III. Subluxation: - With mobility of the tooth but no displacement, there is often hemorrhage around the gingival margin of the tooth, and the tooth may be sensitive to percussion. - The treatment is similar to that of the concussed tooth. - If mobility is extensive, splint the tooth using the acid-etch splinting technique. - Periodic reviews every 3 to 4 weeks are essential to monitor for abscess formation and loss of vitality. IV. Tooth Fracture: Class I: *A crack or craze of the enamel without loss of tooth structure: - Does not require treatment. - Vitality testing should be performed at regular intervals. *Fracture of enamel only: - No treatment is needed except smoothening down any sharp edges to prevent irritation of the lips or tongue and topical application of fluoride. - The patient should be re-examined at 2 weeks, again at 1 month and then continually observed. Class II: Aim of treatment: 1- Protect the pulp from chemical or thermal insult and bacterial contamination. 2- Restore esthetics and function. 3- Maintain the integrity of the arch by restoring normal contact with adjacent teeth. 99

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Emergency treatment: - Cover the exposed dentine by a layer of` hard-setting calcium hydroxide to encourage reparative dentine formation and reduce the possibility of further trauma to the pulp followed by a protective covering of acid-etch composite resin. - It may not be advisable to restore an extensive crown fracture with a finished esthetic resin restoration on the day of the injury to avoid excessive tooth manipulation. - After an adequate recovery period (at least 4 weeks), a permanent esthetic resin restoration may be completed.

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Fragment Restoration (Reattachment of Tooth Fragment) - It is a procedure of reattaching the fragment of a fractured tooth using resin and bonding techniques. - This procedure is atraumatic since the tooth requires no mechanical preparation. - If no dentine is exposed, the fragment and the fractured tooth enamel are etched and reattached with a resin or glass ionomer bonding material. - If considerable dentine is exposed or a direct pulp cap is indicated, a thin protective dressing of calcium hydroxide should remain over the exposed dentine and pulp of the tooth. - The removal of a small amount of the remaining dentine on the inner surface of the fragment must be done carefully leaving the outer enamel margins undisturbed to provide guidance for the exact repositioning of the fragment on the fractured tooth.

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Class III: The treatment depends on many factors such as: 1- Vitality of the exposed pulp (Vital or Non vital). 2- Size of the exposure (Small or Large). 3- Time elapsed since the exposure (Early, within 6 hours or late). 4- Degree of root maturation (Open apex or close apex). 5- Restorability of the fractured crown (Restorable or not). 6- Physical condition of the patient (Medically compromised or not). The main objective of treatment is to retain the tooth and maintain its vitality. The following procedures may be adopted: - Direct Pulp capping. - Calcium hydroxide pulpotomy. - Apexification. - Pulpectomy. 100

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-In case of small minute exposure, patient reported immediately, tooth is vital with closed or open apex, treatment is direct pulp capping using calcium hydroxide. -In case of small minute exposure, patient reported late, or a large exposure and patient reported immediately, tooth is vital and open apex, treatment is vital pulpotomy using calcium hydroxide. -In case of large exposure, patient reported late, tooth is vital or non-vital and open apex, treatment is apexification using calcium hydroxide as filling material for root canals [to promote completion of root and apical closure]. -In all cases with complete roots and closed apex whether the tooth is vital or not, treatment is root canal therapy.

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Class IV: - Treatment involves removing the loose fragment which is often held in a close position to the rest of the tooth by the periodontal ligament fibers. - Then it can be decided if the remaining part of the tooth can be extruded orthodontically or whether a surgical approach will be required to gain access to it prior to pulp therapy and placement of post and core restoration. Class V: - In the permanent dentition root fractures mainly affect the maxillary central incisors with closed apices. - Below 11 years of age, the root is in its formative stage and more resilient to the effects of trauma. - Fracture may occur in the cervical third, middle third or apical third of root.

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* Apical third root fracture: - No treatment is needed. - Follow up with X-ray should be continued up to 6 weeks. - Usually healing takes place without treatment with bony [osteocementum] or fibrous union between the fractured ends. * Middle third root fracture: - With this type of fracture there will be displacement of the fractured crown-root segment, usually palataly or lingually. - Under local anesthesia, achieve reduction into position by digital pressure, and stabilize the tooth or teeth in this position by splinting (4-6 weeks). - Splinting is done because repair only takes place when the fractured ends are stabilized and maintained in position. 101

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Types of splints: 1. Acid-etched resin composite splint. 2. Orthodontic brackets and wire splint. 3. Arch wire and resin splint. 4. Acrylic splint.

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* Coronal (Cervical) third root fracture: - Remove the coronal segment. - If the fracture is 1-2mm infra-bony an osteoplasty to expose the root or orthodontic root extrusion may be required. - Root canal treatment with post and crown restoration can be accomplished, otherwise extraction is the treatment of choice.

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V. Displacement of permanent anterior teeth: - Intrusion: An intruded permanent tooth can be treated in one of three ways: 1. In case of intruded tooth with incomplete root formation, the tooth will erupt spontaneously. 2. In case of intruded mature teeth immediate surgical repositioning, splinting, and endodontic therapy is done. 3. Orthodontic extrusion and repositioning. Complications such as external root resorption and loss of marginal bony support do occur in surgically repositioned teeth. A far better success rate has been achieved with orthodontic repositioning which occurs slowly over 3 to 4 weeks. Endodontic therapy can be performed when there is adequate crown available.

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- Extrusion: Reposition an extruded tooth by digital pressure and maintain its position by splinting. - Avulsion: In the permanent dentition avulsion of the maxillary central incisors is most common in the age of 7 to 10 years. There are three important factors to be considered in cases of avulsion: 1- Time interval between injury and treatment. 2- Conditions under which the tooth or teeth have been stored. 3- Stage of root development: revascularization is better in case of open apex. The treatment of choice, for permanent teeth, is immediate re-plantation within 30-60 minutes of injury. 102

Storage media may be: Saliva, normal saline, cold milk, HBSS or water.

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The tooth must be kept moist to prevent irreversible damage to the periodontal membrane, if it cannot be replanted immediately.

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In many cases the initial patient/dentist contact is by phone. It is essential to advise the parent to follow these procedures: 1. The tooth should be handled by the crown only. 2. The tooth should be rinsed under running tap water. 3. Insert the tooth back into its socket if possible. 4. Let the child gently occlude on a gauze or handkerchief for stability and present to the dental office as soon as possible. 5. If re-plantation is not possible, the tooth should be placed in a suitable storage medium. 6. If no storage medium is available, the tooth should be placed in the mouth between cheek and gum or under the tongue. 7. Come to the dental office immediately.

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Technique of replantation: - The tooth is held from the crown and cleaned with normal saline. - Avoid using any brush or sharp instrument on the root surface as it might remove remnants of periodontal fibers. - Remove any coagulated tissue from the socket using a curette and irrigate the socket with normal saline. - Place the tooth in the socket using gentle pressure and check occlusion. - Apply a flexible splint for up to 1-2 weeks (open apex) and for 2 weeks (closed apex). - Administer systemic antibiotics. - Initiate root canal treatment 7 to 10 days after replantation and before splint removal and use calcium hydroxide as an intra-canal medicament for up to one month followed by root canal filling with an acceptable material. - In case of closed apex and extra-oral dry time more than 60 minutes stabilize the tooth for 4 weeks using a flexible splint and initiate root canal treatment before replantation.

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Patient instructions: • Soft diet for up to two weeks. • Brush teeth with a soft toothbrush after each meal. • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week

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Follow-up schedule: Replanted teeth should be monitored clinically and radiographically during the first year (once a week during the first month, 3, 6, and 12 months) and then yearly thereafter. Treatment of Traumatic Dental Injuries in the primary dentition: Primary teeth are more likely to be displaced than fractured because of: - The thinner and more elastic alveolar bone. - Physiological resorption, which reduces the root length.

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The effect of injury in the deciduous dentition falls into two categories: Immediate effect on the primary teeth: Displacement: Intrusion, extrusion or avulsion. Fracture: Crown-root fracture (very rare). Indirect effect on the unerupted permanent teeth: Hypoplasia: Turner’s hypoplasia. Hypomineralization Dilaceration

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Treatment of fractured primary teeth: - Enamel fractures: smooth sharp edges. - Enamel and dentin fractures: acid etch composite restorations. - Fractures involving pulp: pulp therapy or extraction. - Traumatized anterior teeth that have become non-vital: no treatment is required unless there are signs of a pathological condition (i.e., pain, abscess and fistula). Treatment can be either pulpectomy then filling with resorbable paste or extraction. - Fractures of root of primary teeth: extraction.

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Treatment of displaced primary teeth:

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Intrusion: - Most intruded primary teeth will re-erupt over a period of few months. - If the intruded tooth is in contact with the underlying successor removal of the intruded tooth is indicated. - Infection of the intruded primary tooth e.g., periapical abscess necessitates its extraction. Extrusion: - The extruded primary tooth is usually extracted if severely loose. - Repositioning such tooth may result in damage to the underlying permanent successor. - In addition, providing adequate splint to support the repositioned tooth may be difficult in a very young child.

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Avulsion: - Avulsed primary teeth are not replanted to avoid injury to the underlying permanent successor. - The tooth should be discarded. Reaction of tooth to trauma:

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Pulpal hyperemia: - Occurs following minor trauma where there is congestion of blood vessels in pulp chamber which may eventually result in pulp necrosis. - The hyperemic tooth appears reddish in color as compared to adjacent teeth. - The hyperemic tooth may undergo resolution or necrosis and is treated with root canal therapy. Internal hemorrhage: - Occurs following trauma which results in hyperemia and increased blood pressure in the pulp which leads to rupture of capillaries and escape of RBCs with subsequent breakdown and pigment formation. - Discoloration may be temporary in mild cases where reabsorption of RBCs occurs before reaching the dentinal tubules. - Discoloration may be permanent in severe cases due to pigment formation in dentinal tubules. Pulp calcification:

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- It is a rapid physiologic repair response of the pulp to trauma which may continue until the pulp is completely replaced by calcified tissue. - The clinical crowns of such teeth appear opaque yellow in color and show no response to various pulp tests. - Primary teeth will undergo normal physiologic resorption, while permanent teeth will be indefinitely retained.

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Internal resorption: - It is a destructive process caused by osteoclastic activity which may be seen radiographically in pulp chamber or root canals a few weeks following trauma. - It may lead to perforation of the root or the crown which appears with a “pink spot” where the vascular pulp tissue shines through the remaining thin shell of the crown. - If internal resorption is detected early, the pulp tissue is extirpated, and Ca (OH)2 is placed in the canal to create an environment unfavourable for root resorption. Repeated applications of Ca (OH)2 may be necessary until radiographs confirm cessation of the process. Gutta percha is placed as the final filling material. External root resorption: - Occurs following trauma associated with damage to the periodontal structures or when trauma causes tooth displacement. - The process usually continues until gross areas of the root are destroyed.

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Pulpal necrosis: - Occurs following severe blow to a tooth which causes severance of apical vessels and decreased blood supply to the pulp. - A necrosed tooth can be treated with root canal therapy. Ankylosis: - Trauma which causes injury and inflammation to periodontal membrane is associated with osteoclastic activity which may result in external root resorption. This process may be followed by repair. If repair occurs at a higher rate than resorption, this may lead to fusion of alveolar bone and root surface. - Radiographically there is interruption in periodontal membrane space of ankylosed tooth and continuity of dentin and alveolar bone. - Clinically there is difference in the incisal plane of ankylosed tooth and adjacent teeth (submerged). 106

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- In ankylosed primary anterior teeth, extraction is done followed by a space maintainer. - In ankylosed permanent anterior teeth, the tooth can be covered by a jacket crown.

MANAGEMENT OF SPACE MAINTENANCE PROBLEMS IN CHILDREN 107

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Define arch length analysis. Know different techniques for arch length analysis. Identify the indications and contraindications for space maintainers. Identify the factors affecting construction of space maintainers. Know the different space maintainers for primary and permanent dentition. Identify the classification of space maintainers.

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By the end of this chapter, the student must be able to:

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MANAGEMENT OF SPACE MAINTENANCE PROBLEMS IN CHILDREN

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Whenever primary or permanent teeth are lost prematurely loss of space and arch length may result. Migration of primary and/or permanent teeth can occur, and the available space may be reduced by an amount sufficient to cause some degree of crowding in the permanent dentition.

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Arch length analysis: Definition: Arch length analysis (ALA) are methods by which orthodontist can estimate and predict tooth size/jaw size relationship. Early determination of future crowding has an important role in diagnosis and treatment planning in mixed dentition stage. Mixed dentition analysis (MDA) is helpful in the prediction whether there is sufficient space for the unerupted canines and premolars or not. Since malaligned and crowded teeth usually result from lack of space, this analysis is primarily of space within the arches. Space analysis requires a comparison between the amount of space available for the alignment of the teeth and the amount of space required to align them properly. Classification: Numerous methods have been proposed for arch length analysis. These methods could be classified as follows:

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I- Classification according to the method of tooth size estimation: 1. Methods, which depend on the measurements from radiographs. 2. Prediction based upon the correlation between the mesiodistal dimensions of the erupted and non erupted teeth. 3. Combination of these methods. ll- Classification according to the developmental stage of dentition: 1. Methods used in mixed dentition stage. 2. Methods used in permanent dentition stage.

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Mixed dentition arch length analysis techniques:

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1- Nance Analysis: Aims:

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Nance aims from his analysis to determine whether the dental arch will accommodate the permanent teeth or not, i.e., to predict the adequacy or inadequacy of the arch length.

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Conclusions: 1- Nance concluded that the length of the dental arch from the mesial surface of the first permanent molar on one side to the mesial surface of the first permanent molar on the other side of the arch is always decreased during the transition from the mixed dentition to the permanent dentition. 2- He observed that in the average patient a lee-way space in the mandibular arch of 1.7 mm per side exists which is the difference between the combined mesiodistal widths of the primary mandibular canine and first and second primary molars and the mesiodistal widths of their permanent successors (3, 4, 5), the primary teeth being larger. 3- This difference between the combined mesiodistal widths of the previously mentioned three primary teeth in the maxillary arch compared with their three permanent successors is only 0.9 mm per side.

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Materials needed for analysis: 1- Sharp divider. 2- A set of periapical films. 3- Millimeter ruler. 4- Brass wire of 0.026 inch (0.65mm). 5- Card for recording measurements. 6- A set of study models.

Procedure: 1- The actual width of the erupted four mandibular permanent incisors is first measured, from the stone model using a sharp divider. The individual measurements are recorded. 2- The width of the unerupted mandibular canines and first and second premolars on the radiographs should next be measured. 3- The combination of the previous two measurements will give an indication of the space needed to accommodate all the permanent teeth anterior to the first permanent molar. 110

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4- Determine the amount of space available for the permanent teeth from the study models (arch length in mixed dentition period). A piece of 0.026-inch brass ligature wire, contoured to arch form, is placed on the lower model extending from the mesial surface of the first permanent molar on one side of the arch to the mesial surface of the first permanent molar on the opposite side. The wire should pass over the buccal cusps of the posterior teeth and the incisal edge of the anterior teeth. 5- From this measurement subtract 3.4 mm in the lower arch (or 1.8 mm in the upper arch), which is the space the arch length may be expected to decrease as a result of the mesial drifting of the first permanent molars (lee-way space). 6- Thus, by comparing the two measurements (available and needed space), the dentist can predict with a fair degree of accuracy the adequacy of the arch circumference. Required space

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Available space

Space excess

No space problem Space deficiency

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2-Moyer’s Mixed-Dentition Analysis:

Advantages: 1- It can be completed in the mouth as well as on casts. 2- It may be used for both arches. Based on: 1- Correlation of tooth size, i.e., one may measure a tooth or a group of teeth and predict accurately the size of the other teeth in the same mouth. 2- Moyer developed a predictograph to predict the mesiodistal width of unerupted canines and premolars. 111

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3- The mandibular incisors, since they erupt early in the mixed dentition and may be measured accurately, have been chosen for measuring, to predict the size of the upper and lower canines and premolars from his predictograph. 3-Tanaka and Johnston Analysis:

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- It is a variation of Moyer’s analysis. - The estimated widths of the unerupted canines and premolars correspond to the 75% level of probability in Moyer’s prediction table.

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Procedure: 1- The sum of the widths of the mandibular permanent incisors is measured and divided by 2. 2- For the lower arch, add 10.5 mm to the result and for the upper arch, add 11 mm to the result to obtain the total estimated widths of the canines and premolars. 3- For example, if the width of the lower incisors was 23 mm, divide by 2 and add 10.5 mm for the lower arch. The result is 22 mm which is the estimated width of lower canines and premolars.

Space Maintainers:

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Indications: 1- Premature loss of primary molars to prevent the migration of the adjacent teeth. 2- Loss of a primary canine to prevent midline deviation and/or loss of arch length. 3- Premature loss of primary incisors does not usually require space maintenance because mesial movement of the adjacent teeth is not generally expected. Contraindications: 1- If there is sufficient amount of space present to allow for eruption of permanent teeth. 2- If severe crowding exists, which requires orthodontic intervention. 3- If the succedaneous tooth will be erupting soon.

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Factors affecting construction of space maintainers:

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Requirements of an ideal Space maintainer: 1- Maintains mesio-distal and vertical dimensions of the space. 2- Does not interfere with tooth eruption. 3- Allows individual functional movement of teeth. 4- Does not interfere with mesio-distal space opening through natural growth. 5- Provides esthetics in case of anterior tooth loss.

1. The time factor: - If space closure is to occur, it will usually take place during the 6 months period following extraction, so maintain space as soon as possible. - If space closure has occurred, construct an active space maintainer (space regainer) to regain the lost space before maintaining the space.

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2. Age: - The chronological age is not as important as the developmental one. The average eruption dates must not influence decisions regarding the construction of a space maintainer. - The dentist must depend upon x-ray to provide useful information to when the tooth is going to erupt (developmental age) instead of the eruption tables (chronological age).

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3. Amount of bone covering the unerupted tooth: - This provides important information regarding the eruption time. - If there is an amount of bone covering the crown of the permanent successor as seen in x-ray, this indicates that many months are expected before this tooth erupts, so a space maintainer is indicated. - If the overlying bone is destroyed, for example, by an alveolar abscess related to the primary predecessor, the tooth may erupt before its eruption date written in the eruption table. 4. Degree of development of permanent successor: - It has been proven that the developing tooth does not move in its crypt until complete calcification of the crown and the beginning of root formation. - At the time of extraction of the deciduous tooth, if the crown of the permanent successor is not fully formed, there might be a great chance of complete wound healing with bone formation, and thus a delay in the eruption of the permanent successor up to one year. 113

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- On the other hand, if the extraction of the deciduous tooth happened after the beginning of root formation of the permanent successor the tooth might erupt earlier by 6 months.

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5. Sequence of the eruption of teeth: - The dentist should observe the relationship of the developing and erupting teeth to the teeth adjacent to the space created by the premature loss of primary tooth. - For example, if a second primary molar has been lost prematurely and the second permanent molar is ahead of the second premolar in eruption, there is a possibility that the second permanent molar will exert a strong force on the first permanent molar causing it to drift mesially and occupy some of the space required for the second premolar.

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6. Delayed eruption of the permanent tooth: - Individual permanent teeth are often, observed to be delayed in their development, partially impacted or a deviated from their normal path of eruption. - This will result in abnormally delayed eruption of these teeth. - In such case extract the primary tooth, construct a space maintainer and allow the permanent tooth to erupt and assume its normal position.

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I- Space maintenance for the first Primary molar area: - If the first primary molar is lost during active eruption of first permanent molar, a strong forward force will be exerted on the second primary molar which tips into the space required for the eruption of the first premolar. - If the loss occurs during active eruption of permanent lateral incisors, distal drifting of primary canine may occur. - Shifting in the midline towards the space created by the premature loss, falling in of anterior segment on the affected side and increased overbite may occur. 1- Band and Loop Maintainer:

Classification: Fixed, passive and non-functional.

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Advantages: 1- Easy to construct. 2- Low cost of materials. 3- Gives room for erupting permanent teeth. 4- Does not need patient compliance. 5- Can be used for very young patients.

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Indications: In case of unilateral single tooth loss; usually the first primary molar or the second primary molar after the eruption of first permanent molar. The band is adapted on the tooth distal to the space.

Disadvantages: 5- Does not restore masticatory function. 6- Does not prevent over eruption of opposing teeth.

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2- Stainless steel crown and loop maintainer: Classification: Fixed, passive and non-functional.

Indications: Indicated if posterior abutment tooth has extensive caries or vital pulp therapy. N.B.: The loop may be cut off and the crown is left to serve as a restoration for the abutment tooth when there is no longer need for the space maintainer.

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II- Space maintenance for the second primary molar area: Premature loss of second primary molar leads to mesial drifting of first permanent molar and impaction of second premolar. A- After eruption of first permanent molar: - Band and loop maintainer is used. - Stainless steel crown and loop maintainer is used. - The first permanent molar is used as abutment tooth.

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B- Before eruption of first permanent molar: - Mesial drifting and migration of first permanent molar will occur during its eruption. So, a space maintainer is needed that will guide the first permanent molar during its eruption into normal position. - This may be: • Crown and loop maintainer with distal shoe extension (fixed, passive and non-functional). • Band and loop maintainer with distal shoe extension (fixed, passive and non-functional). The distal shoe extension extends into the alveolus of distal root of the prematurely lost second primary molar. - The first primary molar is used as the abutment tooth.

Band and loop space maintainer

crown and loop space maintainer

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Distal shoe space maintainer

III- Space maintenance for the primary canine area: - If loss of primary canine occurs before eruption of permanent lateral incisor, the latter will drift distally during its eruption, there will be a shift in midline and space closure. - So, maintain space with: • Band and loop space maintainer (fixed, passive and nonfunctional). • Crown and loop space maintainer (fixed, passive and nonfunctional). - The first primary molar is used as abutment tooth. 116

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1. Removable partial denture: Classification: Removable, passive and functional.

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IV- Space maintenance for primary incisor area: If there is incisor spacing, no drifting of adjacent teeth is expected to occur. If anterior primary teeth were in contact before the loss or if there is arch length inadequacy in anterior region, this may cause a collapse in the dental arch and primary canines may drift mesially.

Advantages: 1- Improves esthetics. 2- Re-establishes function. 3- Prevents abnormal speech and tongue habits. 4- Maintains vertical dimension and prevents over eruption of opposing teeth.

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Disadvantages: 1- Can be lost or broken. 2- Needs patient compliance. 3- Requires supervision and adjustment.

Contraindications: 1- Children with high caries index and poor oral hygiene. 2- Uncooperative children who may lose or break it.

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2. Modified Fixed partial denture: Bands are adapted on last molars and an arch wire is soldered to the lingual surfaces of the bands passes over the crest of the ridge of the edentulous area with an acrylic base engulfing the wire and carrying the missing teeth. V- Space Maintenance for the permanent incisor area: - Loss of anterior permanent teeth requires immediate treatment by space maintainer since space loss in this area is very rapid. - If space closure has occurred, space should be regained first before construction of space maintainer using partial denture working appliance. In this appliance cervical clasps are adapted to the first permanent molars to aid in retention and finger springs are contoured to the teeth to be repositioned. Finger springs are adjusted 0.5 mm every 2-3 weeks until the lost space is regained. A temporary tooth replacement may be added to the appliance to improve the child's appearance. 117

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- After the space has been regained, the space maintainer used is a removable partial denture. - If a maxillary permanent central incisor is lost prior to the eruption of the lateral incisor, the lateral incisor is expected to drift mesially during its eruption. Therefore, an acrylic extension into the alveolus of the maxillary permanent central incisor will be successful in guiding the unerupted lateral incisor into its normal position (acrylic root guide). VI- Space maintenance for area of multiple loss of teeth: 1-Acrylic partial denture: Classification: Removable, passive and functional.

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Indications: Indicated in case of bilateral loss of more than one tooth. Advantages: 1- Easily adjusted to allow for the eruption of teeth. 2- Restores masticatory function.

Disadvantages: 1- Easily broken. 2- Changes in the denture base will occur if removed from the mouth even for few days. 3- New carious lesions may develop unless proper cleaning of teeth and denture is performed.

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N.B.: To aid in retention stainless steel wire clasps are contoured for the canines. If the loss of one or both second primary molars occurs a short time before the eruption of the first permanent molars, the acrylic partial denture may be preferable than the distal shoe maintainer. An accentuated post dam which approximates the mesial surface of unerupted first permanent molar may influence the first permanent molar favorably in its eruption. 2- Passive lingual arch: Classification: Fixed, passive and non-functional.

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Indications: Indicated in case of bilateral loss of mandibular primary teeth, when the lower first permanent molars and lower permanent incisors are fully erupted.

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Advantages: 1- Does not need patient cooperation. 2- No breakage problem. 3- No problem of increased caries activity. Bands are cemented on the lower first permanent molars and an arch wire (0.8mm) is soldered to the middle third of the lingual surfaces of the molar bands and extends forward making contact with the cingulum of lower permanent incisors near the gingival margin.

Passive lingual arch

3- Active lingual arch: Classification: Semifixed, active and nonfunctional.

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Indications: Indicated in case of bilateral loss of mandibular primary teeth followed by loss of space in older children where the lower first permanent molars and lower permanent incisors are fully erupted. The arch wire which is soldered to the posterior bands on the lower first permanent molars is constructed with U loops which are activated before insertion of the space maintainer to distalize the first permanent molars. 4- Passive transpalatal bar: Classification: Fixed, passive and non-functional.

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Indications: Indicated in case of bilateral loss of maxillary primary teeth when the upper first permanent molars and upper permanent incisors are fully erupted.

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Bands are adapted to the maxillary first permanent molars and a bar adapted to the palate is soldered to the bands, thus preventing the maxillary first permanent molars from mesial movement as they rotate around their palatal root.

Transpalatal bar

5- Active transpalatal bar: Classification: Semifixed, active and non-functional.

Indications: Indicated in case of bilateral loss of maxillary primary teeth when the upper first permanent molars and upper permanent incisors are fully erupted and mesial movement of the maxillary first permanent molars with rotation has occurred.

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In this case U loop is constructed in the palatal bar and is activated before insertion of space maintainer to distalize and regain the position of the maxillary molars. 6- Full dentures for children: Classification: Removable, passive and functional. Indications: Used in children who have lost all their teeth due to widespread oral infection or extensive decay or in case of complete anodontia.

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VII- Space maintenance for the first permanent molar area:

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1- After eruption of second permanent molar: - If the space is to be maintained, a band or stainless-steel crown and loop space maintainer can be constructed. The second permanent molar is used as abutment tooth. - A modified fixed bridge can also be used although gingival recession will continue, and margin of restoration may be exposed. It can be replaced with another bridge after completion of growth. - Sometimes the orthodontist may decide to move the second permanent molar bodily to occupy the space of the prematurely lost first permanent molar.

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2- Before the eruption of second permanent molar: - If the space is to be maintained, a band and loop or stainless-steel crown and loop space maintainer with distal shoe extension which extends into the alveolus of distal root of the lost first permanent molar can be constructed. The second premolar is used as abutment tooth. - If the first permanent molar is extracted a long time before eruption of second permanent molar, there is a good chance that the second permanent molar may drift mesially to occupy the place of the prematurely lost first permanent molar. This can be guided by an orthodontist, provided that the x-ray shows the presence of a third molar of normal size.

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Classification of space maintainers: According to restoring function: a) Functional, e.g., partial denture. b) Non-functional, e.g., band and loop space maintainer. According to activity: a) Active, e.g., active lingual arch. b) Passive, e.g., passive lingual arch. According to retention: a) Fixed, e.g., band and loop space maintainer. b) Semifixed, e.g., active lingual arch. c) Removable, e.g., partial denture.

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GINGIVAL AND PERIODONTAL PROBLEMS IN CHILDREN By the end of this chapter, the student must be able to:

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1- Classify the gingival and periodontal diseases in children. 2- Identify treatment modalities for gingival and periodontal diseases in children.

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GINGIVAL AND PERIODONTAL PROBLEMS IN CHILDREN The gingiva is the mucous membrane that extends from the cervical portion of the tooth to the mucobuccal fold. The gingiva is divided into:

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1- Papillary portion: occupying the interdental space (interdental papilla). 2- Marginal portion: forming a collar of free gingiva around the neck of each tooth. 3- Attached portion: attached to the underlying alveolar bone by dense fibrous tissue.

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During adulthood: 1- The gingiva is pale pink in color. 2- Firmly bound to the alveolar bone. 3- Stippling varies from fine to coarsely grained appearance. 4- Gingival margin has a sharp knife-like edge.

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During childhood: A) Gingiva: 1- More reddish: because of thinner and less hornified epithelium and great vascularity. 2- Lack of stippling: because of the shorter and flatter connective tissue papillae of the lamina propria. 3- Flabbier, associated with decreased density of the connective tissue of lamina propria. 4- Rounded and rolled margins, related to hyperemia and edema that accompany eruption. 5- Greater sulcular depth, relative to ease of gingival retraction. B) Cementum: Thinner and less dense. C) Periodontal membrane: 1- Wider. 2- Fiber bundles are less dense with less fibers. 3- Increased hydration, greater blood supply. D) Alveolar bone: 1- Thinner lamina dura (radiographically). 2- Fewer trabeculations. 3- Wider marrow spaces. 123

Gingivitis in Children

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4- Decreased degree of mineralization. 5- Greater blood supply. 6- Flatter alveolar crest associated with primary teeth.

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Classification: Gingival and periodontal diseases in children can be classified as follows: I- Acute Lesions: 1- Eruption Cyst or Eruption Hematoma. 2- Acute Gingival Problems Associated with Eruption of Teeth. a) Eruption gingivitis b) Pericoronitis 3- Acute Gingival Problems Associated with Exfoliation of Primary Teeth. 4- Acute Herpetic Infection. 5- Recurrent Aphthous Stomatitis. 6- Acute Necrotizing Ulcerative Gingivostomatitis (ANUG). 7- Acute Oral Moniliasis (Candidiasis or Thrush). 8- Acute Bacterial Gingivitis. II- Chronic Gingivitis in Children. III-Conditioned Gingival Enlargement. I-Acute lesions

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1-Eruption cyst or eruption hematoma: Definition: A type of dentigerous cyst associated with erupting primary teeth. Occurs in all ages including newborn. Etiology: Unknown or due to mechanical trauma resulting in hemorrhage and accumulation of blood in the dilated space above the crown of an erupting tooth. Clinical features: Bluish fluctuant swelling over an erupting tooth. Treatment: Usually unnecessary but if cyst is causing undue delayed eruption or if parents are excessively worried, surgical excision can be done to expose the crown. 124

2- Gingivitis during tooth eruption:

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A- Eruption gingivitis: Definition: Localized inflammation at the site of an erupting tooth which subsides after the tooth emerges into the oral cavity.

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Treatment: Topical anesthesia e.g., Xylocaine ointment before meals to relief pain.

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B- Pericoronitis: Definition: Acute inflammation of gingiva surrounding an erupting tooth, most commonly the mandibular third molar. In children it is related to an erupting lower second primary molar or a lower first permanent molar. Etiology: Accumulation of food debris and bacteria under the gingival operculum of the erupting tooth. Clinical features: 1) The gingival operculum becomes red, swollen and painful. 2) With gentle pressure, a purulent exudate is discharged. 3) Swollen operculum may be further traumatized by the opposing teeth. 4) In severe cases, there may be regional lymphadenopathy, fever and general malaise.

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Treatment: 1) Gentle debridement under the inflamed operculum with a curette to: a) Remove the debris. b) Permit discharge of the purulent exudate which usually relieves some of the acute symptoms. 2) Warm saline mouth rinses are prescribed. 3) Antibiotics may be necessary in the presence of fever and lymphadenopathy. 4) Once the acute symptoms subside, surgically remove the operculum if it was found creating a retention area. 5) The condition improves when the tooth reaches functional occlusion.

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3-Gingivitis associated with tooth exfoliation: Etiology: The sharp, uneven, partially resorbed root ends of primary teeth may cause mechanical irritation to the underlying tissues. This results in loss of function on this side, accumulation of deposits, gingival enlargement, bleeding and discomfort.

4-Acute Herpetic infection:

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Treatment: Extraction of primary tooth eliminates the pathologic condition and encourages eruption of permanent successor.

A-Primary Herpetic Gingivostomatitis: Etiology: Caused by Herpes simplex virus.

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Types: 1- Primary: • 99 % of primary infections are of the subclinical type. • 1 % of all primary infections is of the clinical type. 2- Secondary (Recurrent Herpes Labialis) Duration: 1- Disease is self limiting. 2- Its course is about 10–14 days.

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Age: - Primary infection rarely affects children under the age of one year due to the presence of maternal antibodies - It occurs before five years of age, before the formation of neutralizing antibodies. - It reaches its peak at the age of 3 years. Transmission: Contagious disease and spreads by direct contact.

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Clinical picture: 1- Systemic findings: - Appear before the oral signs. - Usually severe and include high fever, irritability, headache, anorexia, malaise and submaxillary gland involvement. 2- Oral findings: Fiery red diffuse inflammation of the gingiva and alveolar mucosa associated with multiple small vesicles filled with yellowish fluid, which rupture leaving shallow painful ulcers with inflamed borders 1-3 mm in diameter anywhere in the mouth except the tips of interdental papillae. Oral lesions usually heal in 5 to 6 days without scar formation.

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Treatment: - It is mainly supportive and palliative to relief acute symptoms. - Soft diet with high fluid intake because the high body temperature and discomfort in taking fluids results in dehydration. - Avoid sour, spicy or rough food. - Vitamin supplements. - Topical anesthetic before mealtime e.g., xylocaine ointment to enable the child to eat. - Bed rest and isolation from other children in the family because the disease is contagious. - Analgesics to relief pain. - Secondary infection of ulcers may be reduced by chlorohexidine mouth wash or spray. - Oral oxytetracycline used as mouth wash controls secondary infection and shortens the duration of disease (avoid other tetracyclines to prevent staining of developing teeth). B-Recurrent Herpes Labialis: Following primary infection with herpes simplex virus, the disease may recur in the form of small lesions outside the mouth usually on the lips. Etiology: May be related to emotional stress, lowered tissue resistance or excessive exposure to sunlight. Treatment: Zovirax cream (antiviral) may be used five times daily for five days. 127

Age: In school aged children and in adults.

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5-Recurrent aphthous ulcer (recurrent aphthous stomatitis): Recurrent ulceration of oral mucous membrane.

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Etiology: Unknown or may be due to autoimmune reaction of oral epithelium, trauma, stress, nutritional deficiencies or gastrointestinal disorders. Clinical picture: Prodromal symptoms of burning and tingling sensation are experienced by patient 24 to 48 hours preceding the ulcerations.

Treatment:

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1- Ulcers may be single or multiple and start as small, localized erosions of the oral epithelium which are not preceded by vesicles. 2- Within 2 to 3 days, ulcers increase in size to reach 1 to 10 mm, with a grayish centre and raised reddened margins. 3- Pain & discomfort are striking clinical features. 4- Healing occurs without scaring in 10 to 14 days

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1- Mild cases: require no treatment. 2- Severe cases: - Surface anesthetic ointment, 4 – 5 times daily. - Oral achromycin 250 mg suspension used as mouth wash 4 times daily after meals for 5 – 7 days to shorten the course of the disease. - Topical paste e.g., Aphthasol applied four times daily. - Antimicrobial mouthwash e.g., Listerine twice daily. - More recently, carbon dioxide laser application.

6-Acute necrotizing ulcerative gingivitis (ANUG or Vincent infection): Etiology: Bacterial infection caused by Borrelia Vincenti and fusiform bacilli. Predisposing factors: Mal nourished children with history of debilitating disease e.g., viral infections (measles and chicken pox). 128

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Age: - In developed countries acute necrotizing ulcerative gingivitis is primarily limited to adolescents. - In the less developed countries, it affects young children. - The disease was seen in 18 months old children.

Transmission: The disease is not contagious.

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Duration: 1- Disease is not self limiting. 2- In neglected malnourished children, the intraoral necrotic process may spread extraorally resulting in Noma or cancrumoris.

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Clinical picture: - Rapid destruction of interdental papillae with pain and bleeding. - Gingival margin is covered by pseudomembranous necrotic covering. - Punched out interdental papillae with an erythematous line below the necrosed tissue. - Characteristic foul odour and excessive salivation. - In severe cases fever, malaise, anorexia and lymphadenopathy may occur.

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Treatment: 1- Removal of local irritating factors. 2- Subgingival curettage and debridement of necrotic tissue. 3- Use mild oxidizing mouth rinse after meals e.g., Hydrogen peroxide to remove debris and necrotic material. 4- In severe cases with massive necrosis, fever or lymphadenopathy, antibiotics are indicated e.g., penicillin. 5- Gingivoplasty can be done to correct gingival deformity after relief of acute symptoms. Recurrence: A difficulty in coping with this disease is the frequency of recurrence. This recurrence may be the result of: a) An immunological phenomenon. b) Persistent gingival deformity. c) Failure to eliminate local factors. d) After cessation of the acute symptoms, the patient may not return for definitive treatment. 129

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7-Acute candidiasis: (moniliasis or thrush) Etiology:

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Fungal infection caused by yeast like fungus called monilia albicans which is a common inhabitant of oral cavity. 1- Monilia albicans may multiply and cause a pathologic condition when: c- Tissue resistance is lowered. d- The equilibrium between oral micro-organisms (bacteria and fungi) is altered following the excessive prolonged use of broad-spectrum antibiotics. 2- Usually occurs in premature, debilitated or malnourished children. 3- Common in institutions where there is crowding. 4- Mothers with monilial vaginitis may transmit the infection to their newborns (neonatal candidiasis).

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Clinical picture: - Elevated bluish white adherent patches anywhere on the oral mucosa (sometimes extending to circumoral mucosa) which when removed leave a raw painful bleeding surface. - Any mucosal surface in mouth may be involved. Treatment: - Stop antibiotics. - Give 1 ml of antifungal mycostatin (Nystatin) suspension 100,000 units/ ml to be dropped and held in mouth before swallowing for local action four times a day.

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8-Acute streptococcal gingivitis: Very rare type of gingivitis which is difficult to diagnose without laboratory tests. Clinical picture: Gingiva is red, painful and bleeds easily. Treatment: 1- Broad spectrum antibiotics (if bacterial in origin). 2- Improve oral hygiene.

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II-Chronic non-specific gingivitis Age: In children during the preteenage and teenage period.

Clinical picture:

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Etiology: may be: Local factors e.g., Plaque, calculus, malocclusion, sharp irritating tooth margins, over hanging restorations, mouth breathing. Systemic predisposing factors e.g., nutritional deficiency, hormonal disturbances and diabetes mellitus.

Treatment:

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- Gingivitis may be localized to anterior region or generalized. - Gingival margin is red, swollen with loss of stippling and bleeds on slightest touch or on eating moderately rough food. - Pseudo pockets are formed due to gingival enlargement.

- Correct predisposing factors (local and systemic). - Improve oral hygiene. III-Conditioned Gingival Enlargement

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1-Puberty Gingival Enlargement: Age: Gingival enlargement which occurs in children during the prepubertal and pubertal periods. Etiology: - Hormonal changes occurring during the prepubertal and pubertal periods. - Subclinical nutritional deficiencies as a result of faulty dietary habits during these periods e.g., quick meals. Clinical characteristics: - Gingival enlargement confined to anterior segment. - Interdental papillae are bulbous and prominent. - The gingival margin is red and bleeds on slightest touch. - Tooth brushing is usually avoided by those patients due to excessive bleeding. 131

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Treatment: - Encourage proper oral hygiene. - Removal of local irritating factors such as plaque and calculus. - Dietary recommendations to ensure adequate nutrition. - Oral administration of ascorbic acid. - Usually, the gingival enlargement will regress after puberty (above 18 years). - In severe persistent cases gingivoplasty may be required. 2-Gingival Fibromatosis: Etiology: A rare type of gingival enlargement which has been referred to as elephantiasis gingivae. It may be due to: a) Idiopathic (of unknown cause). b) May follow a familial pattern.

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Clinical characteristics: - Gingival enlargement involves the free and attached gingiva. - The enlarged gingiva is painless, firm and dense (feels like bone). - Color is slightly paler than normal gingiva with coarse stippling. - Enlargement may be localized or generalized. - At birth the gingival tissues appear normal but begin to enlarge with the eruption of primary teeth. This enlargement continues with the eruption of permanent teeth until the enlarged tissues cover the clinical crowns of teeth. - The enlarged fibrous tissues may delay the eruption of teeth or cause displacement of teeth and malocclusion. - During mastication the enlarged tissues may become traumatized resulting in secondary inflammation. Treatment: - Gingivectomy in several stages, although it may be followed by recurrence. - Recurrence has not been reported following removal of teeth and construction of dentures. 3-Dilantin gingival hyperplasia: Etiology: Dilantin is a widely used anti-convulsant drug in the treatment of epilepsy. This drug causes gingival enlargement in 50% of patients which develops a few weeks following therapy. Children and young adults show more hyperplasia than adults. 132

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Clinical characteristics: - Hyperplasia is generalized. - It appears first in the interdental papillae which appear lobulated, granular and stippled. - The lobules coalesce together such that the entire occlusal surfaces of the teeth are covered. - The enlarged tissues may delay the eruption of teeth. - The enlarged tissues become traumatized during mastication which results in secondary inflammation.

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Treatment: - Encourage proper oral hygiene measures. - Removal of local irritating factors and oral prophylaxis. - Gingivectomy in severe cases. - Antihistaminic drugs, corticosteroids, folic acid and ascorbic acid have been used with limited success. - Cooperation with physician to change the drug. - More recently folic acid therapy has been used (oral rinsing twice daily with topical folic acid solution gives better results than systemic folic acid). 4-Scorbutic Gingivitis: Etiology: Gingivitis due to vitamin C deficiency. The chief function of ascorbic acid is the formation of cementing substance in capillary epithelium. Deficiency of vitamin C results in defects in the integrity of capillary walls resulting in capillary fragility and bleeding.

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Clinical characteristics: - Mild cases of vitamin C deficiency are more common than severe cases. - Mild cases may be manifested by impaired wound healing, petechiae, tendency for hematoma and chronic gingivitis. - In mild cases, the interdental papillae and marginal gingiva are swollen and bleed easily on slightest touch. - Severe cases of vitamin C deficiency are rare in children nowadays. Treatment: - No therapeutic administration of vitamin C is indicated unless laboratory findings suggest scurvy. - Improvement of oral hygiene. 133

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- Correction of diet. - Therapeutic dose of vitamin C is 100-300 mg/day in divided doses. - Polyvitamin preparations can be used to correct other vitamin deficiencies.

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Periodontitis: - Periodontitis is an inflammatory disease of the gingival and deeper tissues of the periodontium, which is characterized by: - Pocket formation - Destruction of the supporting alveolar bone - There are different forms of periodontitis: I. Chronic Periodontitis II. Aggressive Periodontitis - III. Periodontitis associated with genetic disorders I. Chronic Periodontitis - Chronic periodontitis is more common in adults but can occur in children and adolescents. - It can be localized (less than 30% of dentition affected) or generalized (more than 30% of dentition affected). Characterized by a slow to moderate rate of progression that may include periods of rapid destruction. A horizontal pattern of bone loss is most common and the degree of bone loss is related to oral hygiene. - Can be further classified according to severity into: - mild (1-2 mm clinical attachment loss) - moderate (3-4 mm clinical attachment loss) - severe ( >5 mm clinical attachment loss) - Treatment: - Thorough prophylaxis - Maintain excellent oral hygiene. - II. Aggressive Periodontitis - Aggressive periodontitis may be more common in children and adolescents. The primary features include rapid attachment and bone loss with familial aggregation. It can be localized or generalized. - Localized aggressive periodontitis (LAgP) - Common in children and adolescents. Patients have interproximal attachment loss on at least two permanent first molars and incisors, with attachment loss no more than two teeth other than first molars and incisors. Occurs without clinical evidence of systemic disease and is characterized by severe loss of 134

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alveolar bone around permanent teeth. Alveolar bone around primary teeth can be an early finding in the disease. Functional neutrophil defects are common and include anomalies of chemotaxis, phagosytosis and bactericidal activity. Generalized aggressive periodontitis (GAgP) Common in adolescents and young adults. Begin at any age and affects the entire dentition. Patients have generalized interproximal attachment loss including at least three teeth other than permanent first molars and incisors. They also exhibit marked periodontal inflammation and heavy accumulations of plaque and calculus. Neutorphilis exhibit suppressed chemotaxis. Treatment of aggressive periodontitis: it depends on early diagnosis, a combination of surgical or non-surgical root debridement in conjunction with antibiotic (tetracycline prescribed sequentially with metronidazole, or metronidazole in conjunction with amoxicillin) therapy is recommended. III. Periodontitis associated with genetic disorders

Papillon LeFevre syndrome: Etiology: A rare inherited disease (autosomal recessive). In many cases there is evidence of parental consanguinity.

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Clinical characteristic: - Severe gingival inflammation with alveolar bone loss and exfoliation of both primary and permanent dentition. - Hyperkeratosis of palms of hands and soles of feet. - Periodontal and alveolar bone destruction starts between two to three years of age and progresses rapidly. - By 4-5 years of age all primary teeth are lost. The inflammation subsides after loss of teeth. - The same cycle accompanies permanent teeth. - Radiographic examination reveals severe horizontal bone resorption. Treatment: - Prognosis is poor. Complete dentures are inserted at an early age.

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Acute Lesions in Children

Pericoronitis

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Eruption Cyst

Aphthous Stomatitis

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ANUG

Candidiasis

Dilantin gingival hyperplasia

Gingival Fibromatosis 136

DENTAL MANAGEMENT OF HANDICAPPED CHILDREN

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[CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)]

By the end of this chapter, the student must be able to:

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1- Define handicapped children. 2- Identify the classification for children with special health care needs. 3- Identify the management of children with special health care needs.

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DENTAL MANAGEMENT OF HANDICAPPED CHILDREN

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[CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)]

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Definition: Handicapped children are those having certain physical, mental, social and dental conditions that prevent them from achieving full potential when compared with other children. The term Children with Special Health Care Needs (CSHCN) could replace some terminologies which were given to those children as: handicapped or disabled.

Classification:

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(CSHCN) could be classified into three main categories according to the type of handicapping condition into: I- Dental handicapping conditions as: - Cleft lip and palate. - Amelogenesis imperfecta. - Dentinogenesis imperfecta.

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II- Medical (physical) handicapping conditions as: 1- Cardiovascular disorders either congenital or acquired. 2- Bleeding disorders e.g.: Hemophilia. 3- Neuromuscular disorders e.g.: Epilepsy, Cerebral palsy. 4- Sensory disorders e.g.: Hearing and visual impairments (deafness and blindness). 5- Mental handicapping conditions e.g.: Down’s syndrome. Management of (CSHCN)

1- General considerations should be followed with all disabled children.

2- Specific management for each condition.

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1- General considerations

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- First dental visit: It usually runs and follows the same guidelines of the first dental visit of a normal child. Objectives of the first dental visit:

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a- To establish good communication with the child and his parents.

b- To obtain background information about the child regarding → Social, dental and medical history. c- Examination of the child: - Extra-oral examination to evaluate general appearance. - Intra-oral examination to detect any abnormality in the teeth.

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d- Taking radiographs: - To detect any abnormalities in the developing dentition. - To detect specific problems. - To detect dental caries. N.B.: * Stabilization of the film should be done. * Reverse bitewing technique: Some disabled children cannot control gagging reflex. Therefore, bitewing film could be put in the vestibule rather than the floor of the mouth, and the x-ray tube is put below the lower border of mandible on the opposite side.

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e- Introduce the child to a simple treatment procedure e.g., → Fluoride application. f- Explain the treatment objectives to the child (if possible) and his parents. E.g. - Length and number of treatment visits. - Importance of oral hygiene measures and disease prevention. g- Preventive measures: All (CSHCN) are at high risk to develop oral and dental diseases, so the dentist should design a preventive dental program for them and follow its implementation with the parents.

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Among these preventive measures:

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1- Home dental care:

It is the prime responsibility of the parents to establish good oral hygiene to their disabled child.

2- Diet counseling:

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Home dental care should be performed for: - Infants → The dentist should instruct the parents to clean the child’s teeth with a piece of soft cloth. - For an older child → - The parents should brush the child’s teeth using the scrubbing technique. - Certain modifications are found in the toothbrushes used to help children with poor motor and neuromuscular skills.

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- Diet history analysis should be evaluated by the dentist, and diet modifications should be listed and given to the parents. - Certain drugs as sedatives, hypnotics and anticonvulsants not only contain sugars, but also reduce salivary flow rate and thereby reduce the protective effect of saliva against dental caries. - With certain neuromuscular disorders the masticatory function of the child is so compromised, and they are fed soft diet, which is highly cariogenic.

3- Fluoride application:

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The level of fluoride in drinking water should be evaluated at first. - If between 0.7-1 ppm → no need for fluoride supplements. - If less than that → fluoride supplements are needed either systemically or topically applied.

4- Preventive restorations:

Such as: -Fissure sealants are highly indicated for those children who at high risk. -Stainless steel crowns are highly indicated for patients with severe bruxism. -ART (Atraumatic Restorative Treatment) is also indicated.

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5- Regular professional supervision:

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Recall dental visits every 3 months are very important for those children to re-examine and re-evaluate the oral and dental conditions and to apply fluoride if needed.

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h- Physical (body) restraints: Body restraints or immobilization is indicated (to prevent involuntary or risky movements of the child). *Indications: - Lack of the child’s cooperation due to physical or mental disability. - Lack of the child’s cooperation (resistant child) and failure of all behaviour shaping techniques performed by the dentist. - If the safety of the child or the dentist is at high risk without the use of body restraints. *Contraindications: - With cooperative child. - If there is an underlying medical or systemic problem e.g., cardiac children. - Shouldn’t be used as a punishment. - Shouldn’t be used in the first visit. Restraining Devices

Intra-oral to keep the mouth open

Extra-oral for body control

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Intra-oral restraining devices: - Mouth prop. - Rubber bite blocks.

Extra-oral (body control) restraining devices: - Safety belt. - Pedi-wrap restraints. Head stabilizing devices: - Head positioner. - Extra assistants.

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Devices to stabilize the head

N.B.:

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The choice of G.A. (treatment under general anesthesia) for disabled child should be kept in mind if the dentist fails to treat him under local anesthesia.

2- Specific Management of CSHCN

Rheumatic Heart Disease:

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1- Cardiac diseases

Definition: It is a serious inflammatory disease of the heart characterized by deformity or damage of the heart valves. Children with rheumatic heart are susceptible to subacute bacterial endocarditis (infection of endocardium with streptococcus viridans). This may occur due to bacteremia following dental procedures.

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Streptococcus viridans introduced into the blood stream following any dental procedure which may initiate bacteremia will colonize on Endocardium at or near damaged heart valves resulting in subacute bacterial endocarditis. Dental management:

1-Consult the patient's cardiologist.

2-In apprehensive patients prescribe sedative after medical consultation. 3-If general anesthesia is indicated hospitalize the patient.

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4-Pulp therapy in primary teeth is not recommended due to possibility of resulting infection. 5-Endodontic treatment in permanent teeth can be done after careful selection. Permanent teeth with poor prognosis should be removed. 6-If extraction is indicated give prophylactic antibiotic to reduce the incidence of subacute bacterial endocarditis.

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According to the American Heart Association the following can be given:

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1- Amoxicillin (Unasyn or Augmentin) → for children 50 mg/kg given orally one hour before dental treatment. e.g.: a child weight 20 kg x 50 mg =1000 mg (i.e., one gm).

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2- In patients who are unable to take oral medication: Ampicillin 50 mg/kg IM injection 30 minutes before treatment.

3- In patients allergic to penicillin: Clindamycin e.g.: Dalacin- C. Or Erythromycin orally one hour before treatment.

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* Dental procedures requiring prophylactic antibiotic: Any dental procedure which could induce bleeding as: - Extraction of a tooth. - Scaling and root planning. - Endodontic treatment and instrumentation beyond the apex. - Placement of orthodontic bands. - Intraligamentary local anesthesia. - Dental implants.

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* Dental procedures not requiring prophylactic antibiotic: - Filling and restoration. - Local anesthesia injection. - Placement of rubber dam. - Impressions. - Removal of sutures. - Shedding of primary teeth. - Placement of orthodontic brackets. - Taking radiographs.

2- Bleeding disorders

Hemophilia:

Definition: It is a blood coagulation disorder due to deficiency of one or more of clotting factors which results in severe bleeding. Hemophilia A is the most common bleeding disorder which results from deficiency of factor VIII 143

Oral manifestations:

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1- Spontaneous bleeding from oral mucous membranes.

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(antihemophilic factor). The disease occurs in males while females act as carriers (sex linked recessive trait) transmitting the disease to males from one generation to another. Bleeding time is normal (1 to 3 minutes), while coagulation time is prolonged (30 minutes or more).

2- Poor oral hygiene due to irregular tooth brushing out of fear from excessive bleeding. 3- High dental caries due to inability to eat hard fibrous food. Dental management:

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1- Consult patient’s hematologist to know the severity of bleeding (mild, moderate, severe). 2- Local anesthesia: ▪ Nerve block anesthesia is contraindicated as it may lead to hematoma due to puncturing large vessels and bleeding into pharyngeal spaces leading to respiratory obstruction. ▪ Infiltration anesthesia containing vasoconstrictor is recommended using finest gauge needle. ▪ General anesthesia can be used for extensive dental procedures.

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3- Restorative treatment: - Rubber dam should be used to isolate the operating field and to protect the cheeks, lips and tongue. Care should be taken during placement of rubber dam clamps, wedges and matrices. - Precautions should be taken during preparation of the teeth for crowns, while cavity preparation can be done safely. - For taking an impression the periphery of the tray should be lined with wax to prevent injury of soft tissue. 4- Pulp therapy: - Pulpotomy and pulpectomy are preferred over extraction and indirect pulp capping is preferred over Pulpotomy. 144

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- If vital pulp is exposed an intrapulpal injection should be given to control pain. Bleeding from the pulp chamber doesn’t present a significant problem and could be controlled by pressure with cotton pellets.

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5- Periodontal therapy: - Gingivitis can predispose to spontaneous gingival bleeding so instructions for brushing cannot be overlooked. - Supragingival calculus can be removed atraumatically with ultrasonic scaler or hand instrument. - Subgingival scaling and root planning could be performed only after factor replacement therapy.

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6- Oral surgery: - For patients undergoing dental surgeries or even extractions, consultation with the hematologist for preoperative evaluation and postoperative management is mandatory. - Before oral surgery the patient should receive whole blood, transfusion or should be infused with the missing factor. - Simple extractions can be done by 40% factor replacement one hour before dental procedure. - Extraction should be atraumatic as much as possible. - Bleeding can be controlled by local measures e.g., pressure packs and hemostatic agents such as thrombin or surgicel. - Avoid using sutures unless it enhances healing. - Prescribe antibiotics for infected cases to reduce postoperative infection. - Avoid disturbing clot by finger, tongue or by rinsing. - Patient should receive liquid diet for 72 hours postoperative and then a soft pureed diet for another 10 days because hard food may disturb the formed blood clot. - Analgesics for pain may be prescribed e.g., Tylenol. Avoid salicylates e.g., aspirin and anti-inflammatory drugs as they may alter platelet function and increase the risk of bleeding. - Normal exfoliation of primary teeth does not require factor replacement and bleeding could be controlled by direct finger pressure and gauze with topical application of local hemostatic agent.

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3- Neuromuscular disorders

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a- Epilepsy:

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Definition: It is a disease characterized by repeated attacks of unconsciousness which may last for a moment or for a period of minutes. This loss of consciousness may or may not be accompanied by muscular contractions or convulsions. Etiology: - Idiopathic: Genetic or acquired. - Post traumatic – post infectious. - Post toxic (lead or arsenic poisoning). - Or secondary to brain injury. Types:

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Petit mal: characterized by loss of consciousness only for a few seconds, there is no evidence of muscle spasm, and the condition presents no difficulty during dental treatment. Grand mal: characterized by prolonged loss of consciousness, generalized convulsions and severe muscular spasm. This may lead to: • Slipping of patient from dental chair. • Hitting himself against any object.

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• Severe tongue biting.

• Sudden closure of the mouth due to contraction of jaw muscles.

Oral manifestations: 1. Tooth fractures, dental arch fractures and avulsion of teeth due to frequent falls. 2. Gingival hyperplasia which occurs in 32-84% of epileptic patients due to Dilantin used to suppress seizures in those patients.

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Dental management:

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Management of the gingival hyperplasia: 1. Proper oral hygiene measures should be stressed, and gingival curettage can be done. 2. Gingivectomy to return the gingiva to its normal anatomy. 3. After surgery: Follow up by the dentist is important to prevent the recurrence of gingival hyperplasia. Chlorohexidine mouth wash may be beneficial in prevention of recurrence of the condition.

1- Give antianxiety drug if needed before dental treatment e.g., valium.

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2- Keep the dental atmosphere relaxed. Dentist should avoid the precipitating factors that may lead to convulsions as: a) Operating light (should not be focused on the patient’s eyes). b) Loud noise and high music. c) Insufficient sleeping hours before dental appointments. 3- If an attack occurs, lower the dental chair and put the patient in a supine position with his head tilted to one side to facilitate the exit of saliva or vomitus. 4- Use suction for suctioning any secretions to prevent aspiration. 5- Use wrapped tongue blades to prevent tongue biting.

6- Floss is attached to small objects introduced in the mouth to facilitate quick withdrawal in case an attack occurs.

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b- Cerebral Palsy:

Definition: It is a collection of neuromuscular disorders as a result of permanent brain damage in the prenatal and perinatal periods during which time the CNS is still maturing. The condition is usually associated with mental retardation. Etiology: Brain damage which may result from: • Congenital brain defect. • Trauma to the head. • Infections of the brain. 147

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• Anoxia (decreased oxygenation). • Premature birth.

Oral manifestations:

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General manifestations: • Mental retardation in 60 % of the cases. • Seizure disorders and hyperirritability. • Sometimes sensory disorders are presented as hearing or visual impairments. • Speech disorders as the patient cannot articulate because of lack of control of speech muscles. • Abnormal limb position and limited control of the neck muscles.

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1- Periodontal diseases due to: a) Eating soft diet as the patient cannot chew food as a result of poor muscular coordination. b) Neglection of the oral hygiene and tooth brushing due to lack of manual dexterity. c) Patients taking anticonvulsants (dilantin) show a degree of gingival hyperplasia.

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2- Dental caries due to: a) Poor oral hygiene. b) Impaired chewing and swallowing will lead to poor eating habits as soft diet. c) Patients show higher incidence of enamel hypoplasia. 3- Malocclusion: a) Protrusion of maxillary anterior teeth. b) Excessive overbite and overjet. c) Open bite. d) Unilateral crossbite. The most important causative factor of malocclusion may be: 1. Disharmony between intraoral and perioral muscles. 2. Uncoordinated and uncontrolled movement of the jaws, lips and tongue.

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5- Trauma to maxillary anterior teeth due to: a) Repeated fall accidents. b) Protrusion of maxillary teeth.

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4- Bruxism which results in: a) Severe attrition of primary and permanent teeth. b) Loss of the vertical dimensions. c) TMJ disorders.

6- Tongue thrust and mouth breathing.

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Dental management: 1- Cough reflex is delayed which increases chances of aspiration of foreign objects, so: • Use rubber dam. • A piece of floss is attached to small objects e.g., files and clamps, to facilitate withdrawal. 2- Involuntary body movements so use restraining devices such as: • Pedi wrap which controls all the limbs. • Safety belts to maintain patient in dental chair.

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3- Involuntary jaw movements which may result in sudden closure of mouth. So, stabilize jaws opened by using: • Molt mouth prop. • McKesson rubber bite blocks. • Several wrapped tongue blades. 4- Stabilizing the head by plastic head positioner to avoid sudden movements. 5- Treat patient while sitting in his wheelchair. 6- During dental treatment maintain patient's body in middle of dental chair with his limbs as close as possible to his body. 7- Elevate the back of the dental chair slightly due to difficulty in swallowing. 8- Avoid sudden jerky movements to reduce startle reflex.

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9- Introduce oral stimuli slowly to avoid gag reflex. N.B.: General anesthesia is preferred for those patients.

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10- Prevention: a) Stress on home dental care e.g., tooth brushing. Horizontal scrub method could be used, and electric toothbrushes give good results. b) Diet and nutrition: - Survey the diet with parents. - Replace solid forms of sugar with soluble forms. - Avoid sugary snacks. c) Fluoride exposure: Suggest the use of systemic fluorides, topical fluorides and fluoride containing toothpastes. d) Preventive restorations: - Use pit and fissure sealants. - Use long withstanding restorations e.g., amalgam. - Use chrome steel crowns for badly broken teeth and large restorations. e) Regular dental visits: every two to four months.

4- Sensory handicapping conditions

A- Deafness and hearing impairments. B- Blindness and visual impairments.

A- Dental management of patients with hearing impairment:

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* Oral manifestations: Sometimes deafness is accompanied by: 1. Bruxism. 2. Poor oral hygiene due to inability to learn adequately oral hygiene instructions. * Dental management: 1- In the first appointment determine how the child desires to communicate e.g.: - With lip reading. - With sign language. - Writing notes or combination of these. 2- Face the patient and maintain visual contact with him.

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3- Employ Show – Do approach and allow the patient to use other sensations as taste or touch to communicate. 4- If the child is wearing a hearing aid, it should be turned off before dental procedure, as those children are very sensitive to vibrations coming from the handpiece. 5- Keep smiling, be calm and communicate kindly.

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B- Dental management of patients with visual impairment (Blindness): * Oral manifestations: 1- Poor oral hygiene due to visual impairment. 2- Hypoplastic teeth. 3- Higher incidence of traumatic injuries than normal children. 4- Early childhood caries due to prolonged bottle-feeding.

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* Dental management: 1- Describe the dental office to the child in details. 2- Sit close to the patient and maintain physical contact with the child e.g., holding his hand. 3- Allow the patient to ask questions about the treatment. 4- Utilize Tell- Do approach and allow the patient to touch, taste and smell for explaining the treatment. 5- Maintain a relaxed atmosphere and limit the patient’s dental care to one dentist.

6- Mental handicapping conditions Down’s syndrome

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(Mongolism, Trisomy 21)

Definition:

Down’s syndrome is the leading cause of mental retardation. It occurs in about 1 of every 660 births. It is associated with an extra chromosome 21, so each cell contains “three” number 21 chromosome rather than “two”, i.e., trisomy of 21st chromosome. This syndrome is most common among first born infants of women over 35 years of age. Oral manifestations: 1- Prognathic class III relationship, which lead to open bite. 2- Mouth breathing and xerostomia. 151

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Protruded scrotal tongue. Delayed teeth eruption and exfoliation. Microdontia and partial anodontia. The roots of the teeth tend to be small and conical. Rapid destructive periodontal diseases. Lower caries index. Hypotonia: decreased muscle tone of the lips and cheeks which may lead to inefficient chewing.

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Dental management: - Many children with Down’s syndrome are affectionate and cooperative, and dental procedures can be provided without compromise if the dentist works at a slightly slower rate. - Light sedation and immobilization may be indicated in those children who are moderately apprehensive. - Severely resistant patients may require general anesthesia.

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NUTRITION AND DENTAL HEALTH

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Define nutrition. Explain the basic rules for feeding children. Identify the adequate diet and its constituents. Recognize the importance of vitamins.

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By the end of this chapter, the student must be able to:

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NUTRITION AND DENTAL HEALTH

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What is meant by nutrition? Nutrition is that science which deals with food and nutrients, and their role in attaining and maintaining health. Food:

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Is anything solid or liquid which when swallowed provides the body with materials necessary to produce energy, to maintain optimum growth, repair and reproduction and to maintain metabolic functions, tissue integrity and tissue function.

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Nutrients (nutriments): Are chemical components, which enable food to perform its function. They are classified into six major groups: Proteins, Carbohydrates, Lipids, Vitamins, Minerals and Water. e.g., meat is a food containing protein.

Adequate diet: A diet adequate in quantity and quality and contains all essential nutrients in favourable proportions.

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Well balanced diet: Is attained by including the four basic food groups: - Meat group. - Milk group. - Bread and cereal group. - Vegetables and fruit group.

Importance of the child’s first dental visit: If the child’s first dental visit occurs at the recommended age of approximately 3 years, one can find that the dental practitioner has a wonderful opportunity to observe the child during one of the most dynamic periods of growth. It is recognized that early malnutrition causes retarded physical growth and may impair learning and behaviour of children.

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Assessment of nutritional status:

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1- Clinical evaluation: - Although a complete physical examination of the patient is not within the scope of the dentist, many things can be learned about the patient just by observing the physical appearance and by asking the parents a few wellchosen questions concerning eating, sleeping, and hygiene habits. - Healthy, normal children should have a fairly regular pattern of eating and sleeping. - If parent mentions that the child does not rest well or is nervous and emotional, one could suspect that the child may have a feeding problem as well. - Observation of the skin, hair, nails, and muscular tone, for example, can provide clues to determine whether the child is well nourished.

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2- Diet survey: The use of a diet survey is valuable for providing information regarding eating habits and their relation to dental caries and also may show a deficiency of nutrient intake which may result in a substandard level of nutrition.

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Basic Rules for Feeding Children Satisfactorily: 1.Avoid forced feeding because it leads to dislike for eating at mealtimes and increases eating between meals. 2.Discourage between meals eating so that good eating habits are established and to reduce the incidence of dental caries. 3.Avoid discussion that attaches any undue importance to a particular food. 4.Avoid excessive milk intake because milk is bulky and satisfies hunger. 5.Avoid excessive intake of refined carbohydrates. 6.Make mealtime a pleasant family social event to encourage the child to eat properly at mealtime. What is meant by an Adequate Diet? A diet adequate in quantity and quality and contains all essential nutrients in favourable proportions (proteins, carbohydrates, lipids, vitamins, minerals and water).

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Constituents of an adequate Diet: Proteins:

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Functions of proteins: Proteins are nutrients, required by the body for growth, tissue repair, and synthesis of many constituents of the body such as antibodies, hormones and enzymes.

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Structure of proteins: There are twenty-two amino acids that, in varying proportions and combinations, form the proteins. 1- Those that cannot be synthesized in the body to meet daily requirements → Indispensable. 2- Those that can be formed by the degradation of an indispensable amino acid, such as tyrosine from phenylalanine → Semi dispensable. 3- Those amino acids that are synthesized in the body in amounts sufficient to meet daily requirements → Dispensable. It has been shown that to promote optimum protein synthesis, all amino acids should be present in favorable ratios. To accomplish this, it is much more efficient to obtain the amino acids through a well-chosen, adequate diet.

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Classification of proteins: According to their biological value: 1- Complete → containing all amino acids in favourable proportions. 2- Incomplete → deficient in some amino acids. According to their source: 1- Animal proteins (in meat, eggs, fish, milk and other dairy products). 2- Plant proteins (grains e.g., wheat and legumes e.g., soybeans). In general, animal proteins are more complete and of higher biologic value than are plant proteins. Requirements for proteins: The requirement for protein varies according to the condition present. - During early growth periods, the requirements for protein may be as high as 4 to 5 grams / kg body weight per day.

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Carbohydrates:

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Significance of Protein Deficiency in Dental Surgery: 1- Delayed wound healing. 2- Prolonged period of convalescence. 3- Increased secondary infection.

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Effects of Protein Deficiency: 1- Retarded growth. 2- Decreased mental and physical function. 3- Decreased resistance to infection.

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Functions of carbohydrates: - Regardless of the role some carbohydrates have in the etiology of dental caries, the importance of carbohydrates in nutrition is great. - The major function of carbohydrates is to provide energy for the chemical work of the body.

Sources of carbohydrates: Carbohydrates are present in all foods in varying amount, but the major sources are considered to be: - Grains and the products made from them (such as cereals, bread, crackers). - Starchy plants (such as potatoes, corn, peas, and beans). - A considerable amount of carbohydrate in the form of lactose is obtained from milk.

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Requirements of carbohydrates: * 40- 60 % of the total daily calories. * The quality or source of the carbohydrates is of greater importance than the amount consumed. Fats:

Functions of fats: 1. Supply energy in a fairly condensed form. One gram of protein or carbohydrate furnishes only about four calories, while one gram of fat furnishes nine calories. 2. Fats supply the essential fatty acids that are needed by the body for optimum growth and maintenance of tissue. 3. Fats also serve as vehicles for the fat-soluble vitamins that are obtained naturally in foods. 157

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4. Retard the secretion of gastric juice and tend to delay gastric emptying and delay the sensation of hunger. It reduces the desire for frequent in-between meal snacks.

Vitamins: 1. Fat soluble vitamins:

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Dental implication of an adequate fat intake: An adequate fat intake at breakfast and lunch decreases the need for between meal snacks. Oils and some fats tend to form a film over the surfaces of teeth. A fatty film helps to protect the enamel surface from acids produced in the mouth.

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Vitamin A: Functions of vitamin A: - It is associated with the tissues of epithelial origin such as the skin, hair, eyes, and mucosal epithelium. Deficiency of vitamin A results in dry scaly skin, brittle hair, xerophthalmia and night blindness. - It is an important vitamin in tooth formation because of the epithelial origin of the enamel organ. - It is known as anti-infection vitamin because of its role in maintaining the integrity of ciliated epithelium in respiratory tract. Sources of vitamin A: Vitamin A occurs in milk, eggs, and meat, especially liver. In the yellow - pigmented vegetables such as carrots, spinach, cantaloupe.

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Requirements of vitamin A: During the first year → 1500 IU obtained from milk. Above one year → 2000 – 4500 IU obtained from previously mentioned sources. Dental and oral effect of vitamin A deficiency: Up to the age of seven years, vitamin A deficiency may cause disturbances in the developing tooth germ. When a prolonged vitamin A deficiency is present during enamel formation the function of ameloblasts is affected resulting in enamel hypoplasia.

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Vitamin D: Functions of vitamin D: Is necessary for normal calcification of osseous tissues and is important in the development of healthy bones and teeth. A deficiency of vitamin D in children is one of the causes of rickets. Known as antirachitic vitamin. A precursor of vitamin D is found in the skin. It is acted upon by sunlight to produce active form of vitamin D. Daily requirements of vitamin D: - Depends on the amount of exposure to sunlight. - Under ordinary conditions 400 I.U./ day satisfies the requirements. - When outdoor activities are restricted for a prolonged period 800 - 1200 IU/ day are needed.

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Sources of vitamin D: - Vitamin D fortified milk, vitamin D drops, skin, cod liver oil, butter and eggs. Dental effects of vitamin D deficiency: 1. Deficient calcification of teeth. 2. Delayed eruption.

Vitamin D and dental caries: It seems to decrease dental caries if the vitamin is given during development of the teeth.

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Vitamin E: Functions of vitamin E: - Is important as an antioxidant. It thus protects vitamin A, which is easily destroyed by oxidation. -The antioxidant properties of vitamin E may also prevent the hemolysis of erythrocytes, that is why vitamin E is used in treatment of hemolytic anemia in premature babies. Sources of vitamin E: - The best sources of vitamin E are the seed grain oils such as wheat germ oil. - Oysters and eggs are also sources of this vitamin.

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Vitamin K: Functions of vitamin K: - Is known as antihemorrhagic vitamin, because of its role in the bloodclotting mechanism. In deficiency of vitamin K, plasma prothrombin activity is decreased, which in turn, increases the clotting time of the blood. Therefore, serious hemorrhages may occur in vitamin K deficiency. Sources of vitamin K: - Vitamin K is obtained naturally in several ways. Bacterial synthesis in the large intestine normally supplies an adequate amount in humans. - In food, vitamin K is obtained from green leafy vegetables. - Liver is an excellent source.

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2. Water soluble vitamins: Thiamine (B1): Deficiency: - Its deficiency results in a disorder known as beriberi which is characterized by degenerative changes in the nervous system. Clinically, three different types of thiamine deficiency may be recognized: (1) “Dry-Beri-Beri” in which a multiple peripheral neuritis is the main feature. (2) “Wet beriberi” in which edema, changes in tendon reflexes, paresthesia, and muscle cramps are common. (3) “Cardiac” type, which rapidly progresses to acute heart failure. Sources: Good sources of thiamine are liver, yeast, whole grains, enriched flour and cereals, and fresh green vegetables.

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Oral manifestation of thiamin deficiency: 1. Increases the predisposition of oral mucous membrane to herpetic lesions. 2. Recurrent aphthae under the tongue, on mucobuccal fold and oral surface of lower lip. Riboflavin (B2): Function: It is the vitamin found in several coenzymes, the flavoproteins, which are essential in oxidation-reduction reactions of metabolism.

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Sources: The best sources of riboflavin are dairy products and meat.

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Deficiency: The clinical signs of riboflavin deficiency include eye lesions, angular stomatitis glossitis and dermatitis around the nose.

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Niacin: Deficiency: - Is known as the antipellagra vitamin. -Pellagra is a deficiency syndrome, which is characterized in the early stages by weakness, lassitude, anorexia, and gastric upset. - Later this is followed by the classical “three Ds”-dermatitis, diarrhea, and dementia. In addition, glossitis and stomatitis are common features.

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Sources: Good sources of niacin are all types of high-quality protein such as meat, fish, eggs and milk. Oral manifestation of niacin deficiency: - One of the earliest signs of niacin deficiency is fiery red glossitis, the tongue becomes swollen and fissured. - In acute niacin deficiency there may be generalized stomatitis and inflammation of the gingiva.

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Pyridoxine (B6): Functions: - Is a vitamin that functions as a coenzyme in those reactions involving decarboxylation and transamination of amino acids. Deficiency: - A deficiency results in dermatitis about the eyes, in the eyebrows, and at the angles of the mouth. - Because pyridoxine is distributed widely among various foodstuffs, a deficiency of this vitamin is not likely to occur unless the diet is extremely poor.

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Pantothenic acid:

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Sources: Is widely distributed in natural foodstuffs. The name of the vitamin itself reflects this property-pantothenos means universal occurrence.

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Functions: Pantothenic acid is vitally important in metabolism, where it functions as a part of coenzyme, involved in the release of energy from carbohydrates and is needed for the synthesis of fatty acids and steroid hormones.

Deficiency: Results in fatigue, malaise, headache, disturbance of sleep, nausea, vomiting, paresthesia of extremities and muscle cramps.

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Folic acid: Is also known as folacin. Functions: - In intracellular synthesis of purines and pyrimidines which are necessary in formation of DNA and RNA which carry genetic material of the cells. - For division and maturation of RBCs.

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Deficiency: Maturation arrest of bone marrow. Glossitis. Gastrointestinal disturbances. Megaloblastic anemia (size of RBC’s and their hemoglobin content larger than normal). N.B.: Megaloblastic anemia may occur in cases of: 1- During pregnancy due to dietary lack of folic acid, insufficient absorption caused by vomiting and increased demand for folic acid by the fetus. 2- In individuals with malabsorption syndromes due to diseases of small intestine. 3- Extremely poor diet. Sources: 1- Synthesized by intestinal flora. 2- In diet e.g., liver, green vegetables and cheese. 162

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Vitamin B12: Source: 1- Bound to animal proteins. 2- Little vitamin B12 in vegetables.

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Deficiency: - Results in megaloblastic anemia (macrocytic hyperchromic anemia). - Neurological symptoms because vitamin B12 is essential for metabolism of myelin sheath of nerves.

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Causes of deficiency: An intrinsic factor secreted by stomach is necessary for absorption of vitamin B12 . Deficiency can occur due to: 1- Absence of intrinsic factor due to genetic causes or due to total or subtotal gastrectomy. 2- In vegetarians. 3- Parasitic infections. 4- Malabsorption syndromes. Requirements: In normal individuals, about 1.5 ug / day will maintain and meet the biochemical needs of the body.

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Biotin: Functions: - Is necessary in the enzyme systems of bacteria, animals, and probably man. - It is required in carboxylation and decarboxylation reactions associated with carbohydrate, lipid, and protein synthesis. Sources: - Biotin is found in a wide variety of foods. - Intestinal synthesis by bacteria is an important source of this vitamin. Causes of deficiency: A protein in raw egg white (avidin) combines with biotin and prevents absorption of the vitamin by the intestine.

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Ascorbic acid (vitamin C): Functions: 1-Essential for tissues of mesenchymal origin, fibrous tissues, teeth, developing bones, and blood vessels. 2- Important in development of odontoblasts and other specialized cells (collagen and cartilage). 3- Maintenance of strength and integrity of blood vessels.

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Deficiency: - Results in scurvy. Clinical scurvy is rare, but many cases of vitamin C deficiency exist on subclinical basis. - Scurvy may be observed occasionally in infants whose milk formula is unfortified and who refuse fruit juice. - The classical signs of ascorbic acid deficiency include weakness easy fatigue, shortness of breath, pain in bone, joints, and muscles, dry rough skin, petechial hemorrhages or ecchymoses, swollen, spongy, inflamed gingiva, and extremely mobile teeth. Sources: Citrous fruits. Fresh vegetables e.g., tomatoes, spinach. Liver.

Requirements: 35 – 50 mg/day for infants and growing children. 60 mg/day for adults

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Minerals: The fifth class of nutrients is the minerals.

Calcium: The skeletal tissues of the body contain over 99%of the total body calcium and 70% to 80 % of the total body phosphorus. Functions: - Vital role in skeletal tissues. - Calcium is necessary to maintain acid-base equilibrium. - Helps control muscle tone. - Regulation of heart beats. - Normal blood-clotting mechanism. 164

Requirements: 800 mg/day.

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Sources: Milk and dairy products.

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Absorption: Is increased when: → Adequate vitamin D is available. → Gastric acidity is low.

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Phosphorus: Functions: 1- An important bone mineral. 2- Plays a primary role in energy transformation. Phosphate compounds in the form of adenosine diphosphates and triphosphate (ADP and ATP) plus other compounds containing a high-energy phosphate bond are essential to provide energy for biochemical reactions. 3- Many co-enzymes have phosphate radicals for example, thiamine pyrophosphate. Iron: Functions: - Is an essential mineral for the body. - It is present in hemoglobin (in RBCs), myoglobin (in muscles) and in several enzymes.

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Need for iron: Is increased during periods of increased demand such as growth in infants and young children, pregnancy and hemorrhage. Absorption of iron is increased by: 1- Gastric acidity which reduces iron from ferric to ferrous state which is more readily absorbed. 2- When vitamin C is available in the diet because it changes iron from ferric to ferrous state which initiates its absorption.

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Deficiency: - A deficiency of iron results in hypochromic microcytic anemia (size of RBCs is smaller than normal and their Hb content is less than normal). - The frequency of occurrence of this type of anemia is greatest among infants and children who are fed milk only as milk is poor in iron and in women during years of menstruation and rarely in males except when blood loss occurs e.g., ulcers. Sources: Good sources of iron are meat, shellfish, egg yolk, and legumes. Fair sources are green leafy vegetables, whole grains and enriched cereal products.

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Dental implications of dietary and medicinal forms: Iron in fluid form causes a generalized black staining of the teeth due to deposition of iron sulphide. Iron sulphide due to its low pH causes excessive decalcification of the teeth.

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Requirements: About 18 mg/day.

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CHILD ABUSE & NEGLECT (CAN) An overview for dentists

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INTRODUCTION: Childhood should have a care-free time filled with love, and the joy of discovering new things and experiences. However, it is a dream for many children. Child abuse and neglect is an increasing social problem. The effects of child abuse and neglect are not limited to childhood but cascade throughout life, with significant consequences for victims (on all aspects of human functioning), their families, and society.

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DEFINITION: Child abuse and neglect (CAN) is defined by World Health Organization (WHO) as, “Any kind of physical, sexual, emotional abuse, neglect or negligent treatment, commercial or other exploitation resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.” PREDISPOSING FACTORS: I. PARENTAL CHARACTERISTICS II. CHILD CHARACTERISTCS III. ENVIRONMENTAL CHARACTERISTICS

I. PARENTAL CHARACTERISTICS Violence, poverty, parental history of abuse, socially isolated, Low self-esteem, less adequate and maternal functioning.

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II. CHILD CHARACTERISTCS Unwanted or unplanned child, no. of children in the family, child's temperament, position in the family, additional physical needs if ill or disabled, and activity level or degree of sensitivity to parental needs III. ENVIRONMENTAL CHARACTERISTICS Chronic stress, problem of divorce, poverty, unemployment, poor housing, frequent relocation, alcoholism, and drug addiction.

TYPES OF ABUSE: I. Physical abuse II. Sexual abuse III. Emotional abuse IV. Child Neglect

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I. Physical abuse: Shaking, hitting, burning/ scalding, female genital mutilation, fabricated and induced illness, drowning and suffocating Clinical findings: • Bruises, marks, burns, lacerations and abrasions • fractures and dislocations • mutilation injuries II. Sexual abuse: Drug dependence, alcohol dependence, major depression, and general anxiety disorder

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III. Emotional abuse: •Verbal abuse, •Excessive demands on a child’s performance •Discouraging caregiver and child attachment •Penalizing a child for positive, normal behaviour

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IV. Child Neglect: Types: a) Physical b) Medical c) Inadequate supervision d) Educational e) Emotional Oral findings of Physical Child Abuse: Lips: •Bruises, lacerations, scars from persistent trauma •Burns caused by hot food or cigarettes •Bruising, scarring or erosion at corners of mouth (gag trauma)

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Teeth: •Fractured, displaced, mobile, or avulsed •Non-vital and darkened •Unaccountable malocclusion

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The oral cavity: •Tears of labial or lingual frenum caused by either a blow to the mouth, forced feeding or forced oral sex •Burns or lacerations of gingiva, tongue, palate or floor of the mouth caused by hot utensils of food

Maxilla/ Mandible: • Signs of past or present fracture of bones, condyles, ramus or symphysis, • Unusual malocclusion resulting from previous trauma.

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Signs of Child Neglect: •Untreated rampant caries •Untreated pain, infection, bleeding or trauma affecting orofacial region •History of lack of continuity of care in the presence of identified dental pathology

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Identification of CAN • Doctors of Medicine are expected to practice: – Recognize – Record – Report – Refer • Clinician should be able to recognize the specificities of oral and dental status, since it could be the first indications of abuse. • All members of dental team: Administrators, Assistants, Nurses, Hygienists etc play an important role in recognition and prevention of abuse. Egyptian children Helpline =16000 The prevention and diagnosis of child abuse is usually undertaken by a Paediatrician. The dental team has an important role to play however as the head and neck are the areas most often targeted.

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Cairo University

Faculty of Dentistry

Pediatric Dentistry and Dental Public Health Department

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Dental Public Health And Preventive Dentistry

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Dedication

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To the memory of Professor Doctor Nawal Soliman for her outstanding achievements and efforts in the field of Pediatric Dentistry; to whom we extend our deepest gratitude, love and respect. Department Staff members October 2021

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Index Intended learning outcomes

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2 3 7 31 36 39 42 44 46

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Dental Public Health and Preventive Dentistry Introduction Prevention of Dental caries Prevention of Periodontal Diseases Prevention of Occlusal Abnormalities Prevention and treatment of Oral Habits Prevention of Traumatic Dental Injuries Role of Dental Profession in Prevention of Oral Cancer Prevention of Communicable Diseases

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Epidemiology Introduction Epidemiology of Dental Caries Epidemiology of Periodontal Diseases Dental Needs and Demands Organization of Dental Care Group Practice and Teamwork

53 54 57 64 74 77 82

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a- Knowledge and understanding:

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Intended Learning Outcomes for Dental Public Health

b- Intellectual skills:

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a16-Enumerate different levels of prevention. a17-memorize factors affecting prevalence of dental diseases. a18-Recognize different methods of prevention of dental diseases. a19-Classify caries and periodontal indices. a20-Discuss the scientific principles of sterilization, disinfection and antisepsis. a21-Identify factors affecting dental needs and demands. a22-Identify the concept of group practice and team work. a23- Enumerate duties of dental auxiliaries. b4-Identify individuals at high risk to dental diseases. b5- Select the appropriate preventive measure for every individual.

c- Professional and practical skills:

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c3- Detect and quantify caries using different caries indices. c4- Detect and quantify inflammatory periodontal diseases using different periodontal indices.

d- General and transferable skills:

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d4- Provide children with proper oral hygiene measures. d5- Provide children and their parents with proper dietary recommendations and advice.

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DENTAL PUBLIC HEALTH AND PREVENTIVE DENTISTRY By the end of this section, the student should be able to understand and comprehend:

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Dental public health and its characteristics. Preventive dentistry and its objectives. The three main levels of prevention. Preventive measures for dental caries. Preventive measures for periodontal diseases. Prevention of some occlusal abnormalities. Prevention and treatment of oral habits. Prevention of traumatic dental injuries. Prevention of oral cancer. Prevention of communicable disease.

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INTRODUCTION

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DENTAL PUBLIC HEALTH Definition:

Characteristics of public health:

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Dental public health was defined by the American Dental Association as the science and art of preventing dental diseases and promoting dental health through organized community efforts, i.e. it serves the community, as a patient rather than the individual.

1. It must be done in areas where group responsibility is recognized. e. g. success in controlling many contagious & communicable diseases in an area depends upon the presence of group responsibility.

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2. Public health methods depend on team work; this is due partly to the necessity of efficient handling of large groups of people and partly that many processes involved in prevention are better applied through team work. 3. Public health work should deal with all parts of problem; involving the host population and the environment.

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4. Prevention is considered a major objective of public health programs. This is because: a) Prevention of a disease is greater good in life than its cure. b) Prevention can be better performed on mass population through public health. c) Prevention is cheaper than cure. 5. Public health methods must depend on biostatistics, which helps in arithmetic measurements of a disease in large population. 6. Public health deals with healthy and apparently healthy as well as with diseased people 7. Education of the public and adaptation of public health programs to the community.

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Objectives of dental public health:

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1- It gives an accurate indication about dental diseases. 2- It takes into consideration the current social changes in the community that influence the prevalence of dental diseases. 3- It provides the dentist with specialized skill and knowledge to plan dental health programs for large populations. 4- It stresses the importance of prevention in the minds of the public.

PREVENTIVE DENTISTRY Definition:

It is a philosophy of dentistry. It comprises the various procedures used by dentists, dental hygienists, physicians, nurses, teachers, and others to develop scientific oral health knowledge and habits.

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Objectives of Preventive Dentistry: It aims to prevent: 1- Factors which predispose to disease. 2- The disease itself. 3- Factors which evoke more severe manifestations of diseases. 4- Factors which tend to maintain disease in a chronic state. 5- Complications & sequelae of disease. 6- Factors which maintain disability resulting from disease. 7- Factors which interfere with rehabilitation.

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Dental practice is nowadays shifting towards the various levels of prevention. These levels extend through from the prepathogenic period of the disease to the period of the rehabilitation after the disease itself has gone by. True or primary prevention occurs in the prepathogenic period and involves first health promotion and then specific protection. Secondary type of prevention occurs in the early period of pathogenesis. This involves early diagnosis and prompt treatment. Later in the period of pathogenesis comes tertiary prevention. This includes disability limitation and rehabilitation. Most of the measures noted in the following table are specific for dental caries.

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Levels of prevention Period of Pre-pathogenesis Primary level of Prevention Health promotion - Health education in oral hygiene. - Good standard of nutrition. - Diet planning. - Periodic inspection.

Specific protection - Good oral hygiene. - Fluoridation of public water supplies. - Topical fluoride application. - Avoidance of sticky foods, particularly between meals. - Tooth brushing after eating. - Dental prophylaxis. - Treatment of highly susceptible but uninvolved areas in highly susceptible persons. - Prevention orthodontics.

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Period of Pathogenesis Secondary level of prevention Early Diagnosis and prompt treatment - Periodic detailed oral examination with x-ray. - Prompt treatment of incipient lesions. - Extension for prevention. - Attention to developmental defects. - Compulsory examination of school children.

Tertiary level of Prevention Disability Limitation

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- Treatment of well developed lesions. - Pulp capping. - Root canal therapy. - Restoration of natural teeth. - Extraction. - Orthodontic treatment.

Rehabilitation

- Replacement of lost tooth structure by appliances (bridges, partial dentures, implants…)

PREVENTION OF DENTAL CARIES

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Dental caries continues to be number one problem in dentistry. It should receive the major attention not only from the standpoint of restorative procedures, but more important from the standpoint of preventive procedures designed to reduce the problem.

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The most accepted theory for the etiology of dental caries is Miller’s chemicoparasitic or acidogenic theory on which most of the preventive measures are based. According to this theory, the oral bacteria present in the dental plaque attached to teeth surfaces act on the carbohydrates, particularly freely fermentable type (sucrose) producing acid. This acid attacks the calcified tooth material dissolving it producing dental caries.

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From the above it can be concluded that the susceptibility of the tooth surface to acid attack, the dental plaque attached to the tooth surface, the bacterial activity in the plaque and the carbohydrate ingested into the plaque are the factors involved in initiation and progress of dental caries. Bacteria + sucrose (in the plaque) → Acid Acid + susceptible tooth surface → Dental caries

The elimination of any one of these factors would diminish or prevent dental caries.

I- Dietary control of dental caries

Diet has a great influence on oral health; it can affect the teeth in two ways:

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Pre-eruptive effect: i.e. before eruption, while the tooth is still forming . 1-Before birth through placental circulation from mother to fetus, which provides calcium and vitamin D for proper development of teeth. 2-After birth through general nutrition where the essential nutrients are carried by the blood stream from the digestive tract. Post-eruptive effect: i.e. after tooth has erupted into the mouth , the diet has a local effect by controlling the lodgment of freely fermentable carbohydrates which accumulate around the teeth. 6

Preventive dietary measures:

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1-Reduction of the frequency of carbohydrate intake: a. Oral clearance of carbohydrates: some forms of carbohydrates take a longer time to be cleared from the mouth e.g: sticky candies and biscuits. Caries activity increases with increase in clearance time. This is because carbohydrates stay for a longer time in contact with teeth surfaces. b. Time of consumption of carbohydrates: caries activity increases when carbohydrates are consumed between meals. c. Amount and frequency of consuming carbohydrates: caries activity increases with increasing the amount and frequency of consuming carbohydrates. Dietary recommendations: Carbohydrates should not be completely restricted from the diet, but dietary recommendations can be given. These are: 1- No more than half the daily caloric intake be from carbohydrates.

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2- Select more soluble forms of carbohydrates which clear quickly from the mouth e.g. leafy green or yellow vegetables are good carbohydrates sources with low retention. Avoid sticky candies and biscuits. 3- Consume carbohydrates at meals and avoid between meal snacks. Substitute sticky sweets with raw fruit or vegetables or nuts for in between meal snacks. 4- Cheese is recommended as a caries preventive food because it causes: a. Strong stimulation of salivary flow. b. Raises calcium concentration in plaque. c. Raises oral pH to 7.5 within 3 minutes following ingestion which favours remineralization.

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2-Sucrose substitutes: 1- Replacing sucrose, glucose and fructose with artificial sweetening agents such as: aspartum, mannitol and saccharin reduce the cariogenicity of food. 2- Sorbitol sweetened chewing gum and candies are much less cariogenic than those containing sucrose.

3- Xylitol is used nowadays in confectionary and toothpaste because: - It is less cariogenic than sucrose and sorbitol. - It inhibits certain strains of streptococci. 7

3-Addition of caries inhibiting agents:

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a-Fluorides: Addition of fluoride to foods e.g. salt, milk, bread and flour. However, individual consumption of those foods varies considerably.

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b-Inorganic and organic phosphates: Act primarily by forming a protective layer on the enamel surface. c-Dextranase: Reduces the adherence of bacteria to tooth surface.

Diet History Analysis Aim:

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Determination of individual eating habits when vague reports from patients make it impossible to determine whether an adequate diet is being obtained. Importance: 1- Helps the dentist to define to the patient his dental and dietary problem and to discuss solutions. 2- Enables the dentist to give good dietary recommendations to change his patient's dietary habits. 3- Helps as a guide to improve the general nutritional level of patient.

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4- Makes the parents actively involved in the problem by recording the diet history of their child. Technique: 1- Ask the parents to record on a diet sheet the exact food intake of their child for a period of 3 –7 days (at meals and between meals). 2- Analyze the report for calories, carbohydrates, proteins, fats and important minerals and vitamins. 3- Compare the results with the recommended dietary allowances and the desirable distribution of food among the four basic food groups. 8

4- Determine the total amount and type of carbohydrates consumed and the time of consumption (at meals or between meals).

Caries activity tests

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5- Accordingly, give dietary recommendations to improve the patient’s dietary habits.

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Definition: Number of tests which aim at predicting caries activity in an individual.

Aims: 1- To identify individuals with a higher probability to develop dental caries. 2- To identify individuals in need for caries control measures. 3- To induce patient cooperation (by illustrating acid production).

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A- The lactobacillus count test: - This test is based on the assumption that caries is a process whereby fermentable carbohydrate debris in the mouth is broken down into acids by oral microorganisms such as lactobacilli and streptococci. - There is generally a correlation between the number of lactobacilli and dental caries activity, so the lactobacillus count test has as its objective to find the number of lactobacilli present in a patient's mouth in order to predict his caries susceptibility.

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Technique: 1- In this test a specimen of saliva is collected by the patient chewing on a cube of paraffin wax first thing after getting up in the morning and spitting into a sterile bottle. 2- The saliva is diluted & spread on tomato agar plates (pH5) and incubated for 96 hours. 3- The colonies are counted and the number of lactobacilli per ml of the original saliva is calculated. 4- Patients with: - A count over 10,000 have moderate to marked caries activity. - Between 1000 and 10,000 slight to moderate activity. - And below 1000 very slight or no caries activity. B- Methyl red test: This method uses water soluble methyl red pH indicator for disclosing areas of the tooth surface that develop pH below 5.2 (Enamel dissolves at pH 5.2) 9

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Technique: Methyl red (0.216%) is a chemical indicator that changes from yellow at pH 6 or above to deep red at pH 5. 1- Apply the solution which is yellow is to all the teeth and after 30 seconds, some areas of red coloration appear indicating acid formation. The change in colour to red will appear in the active carious areas in proportion to their caries activities.

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2- Rinsing with 1% sugar solution and after few minutes apply Methyl red solution another time. Further change in color to red is noted. Red areas which are not already showing caries may suggest the sites of future caries (increased concentration of acids).

Benefits: This test is a convenient method to demonstrate to parents the role of freely fermentable carbohydrates in the caries process and the value of immediate brushing and rinsing after the ingestion of carbohydrates.

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C- The Snyder test: This test measures the ability of oral microorganisms to form acid from carbohydrates. Technique: 1- A sample of 0.2ml of the saliva specimen obtained by asking the patient to chew on a cube of paraffin wax first thing after getting up in the morning and spit into sterile tube. 2- The sample is inoculated into a glucose agar medium with indicator Bromocresol green. 3- This is incubated along with a control without saliva. 4- The change in colour to yellow indicates a fall in pH or acid formation. 10

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If the change occurs: - Within 24 hours------it indicates Marked caries activity. - Within 48 hours------it indicates Moderate activity. - Within 72 hours------it indicates Slight caries activity. - Above 72 hours------it indicates No caries activity.

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D- Alban test (Modified Snyder test): - Alban test is introduced as a simplified substitute for the Snyder test. - It uses Snyder's media but with less agar.

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Technique: 1. 5ml of semi-solid agar in a tube is used for the test. 2. Ask the patient to expectorate directly (unstimulated saliva) in the tube containing the media. 3. The tube is labeled and incubated for 4 days & then observed for: - Changes in color from green to yellow. - The depth in the medium to which the change in color has occurred from top to bottom. Alban suggested the following scale from 0 to 4 for scoring: • A zero score indicates → no color change • Score 1→ is a color change to yellow in the top 1/4 of the tube. • Score 2 → is to the halfway mark. • Score 3 → is to the 3/4 mark. • Score 4 → is when the entire length of the agar column has changed to yellow. Benefits: 1- Ideal for patient's education motivation and cooperation. 2- Can be easily used in dental office.

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E- Dip slide method: The dip slide test is a practical method to quantitate lactobacilli or streptococci. 1- Dip-slide method for lactobacillus count: Technique: 1- A special plastic slide is coated with lactobacilli selective agar. 2- Undiluted, paraffin-stimulated saliva is flowed over the agar surface. 3- The slide is then placed into sterile tube, which is tightly closed and incubated at 37oC for 4 days. It is then removed. 4- The colony density is determined by comparing it with a model chart. Reading of more than 10.000 colonies/ml of saliva is high. 11

Reading of less than 1000 colonies \ml of saliva is low. Reading between 1000 -10.000 colonies\ml of saliva is medium.

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2-Dip-slide method for S. mutans count: Technique: 1- A special plastic slide is coated with Mitis Salivarius Agar, containing 20% sucrose. 2- Undiluted, paraffin- stimulated saliva is poured on it. 3- The slide is then tightly screwed into covered tube and incubated at 37°C for 48 hours. 4- The density of Streptococcus Mutans colonies is evaluated as follows: 1 = Low when the colonies are discrete less than 200 colony. 2 = Medium when the colonies are more than 200 colony. 3 = High when the colonies are tiny and uncountable.

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Benefits: 1. The dip slide method is simple, practical and inexpensive. 2. Can be used in a private dental office.

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F- Dentobuff test strips: Chair side method to test buffer capacity of saliva. Strip contains acid and pH indicator. Technique: 1. Collect the saliva sample 2. Using a small pipette, take a drop and put it on the test strip 3. Wait 5 minutes. The color indicator will reflect the pH of saliva.

The color indicator will reflect the pH. After five minutes, compare the color of the test pad with the chart supplied by the manufacturer. Yellow color indicating-------------pH of 4 or less (saliva fails to buffer acid). Green color indicating--------------moderate buffer capacity. Blue color indicating ---------------favorable buffer capacity.

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II- Oral Hygiene Measures 1- Tooth brushing:

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A. Tooth brush design: A straight brush is the one generally preferred, it offers an overall efficiency to all parts of the mouth.

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The desirable qualities of a toothbrush are:

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1. Manmade bristles of about 0.4mm thick x 12mm long. 2. Firm and resilient bristles with rounded and polished ends. 3. Short head with flat brushing surface (2.5x0.5cm) to permit access to all surfaces of the teeth. 4. Multitufted, 2 or 3 rows of separate bundles of bristles. This allows the bristles to enter easily in the embrasures and in the depth of the fissures. 5. Able to remove plaque from teeth. Electric toothbrush: - Offers mechanical aid and less manual effort. - It is recommended in case of disabled individuals.

Ionic tooth brush: Manual tooth brush that removes the dental plaque not only mechanically, but mainly with ionic action.

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Theory of action: 1- Plaque has a positive charge, so it clings to our negatively charged teeth. 2- Ionic tooth brush changes the charge of the tooth surface from negative to positive, so the tooth will reject the plaque from its surface, which will be attracted to the bristles of the brush.

Regular Tooth brush

Ionic Tooth brush

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B. Tooth brushing methods: We have to stress that our patients clean their teeth using the toothbrush and not "washing" or "brushing" them only.

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For teaching an effective tooth brushing technique, the dentist must emphasize the following:

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1) Motivation: The nature of the plaque and its adhesion to the tooth is explained. The role of plaque in caries and periodontal disease is outlined. 2) Education: - Paint the teeth with a disclosing agent to point out the plaque to the patient. - The plaque is gently scraped off the tooth with a probe to demonstrate how easy it can be removed.

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3) Demonstration: - The patient is asked to bring the brush which up to the present has been used at home, not a new one. - Ask the patient to demonstrate his usual brushing. - Errors in brushing, areas omitted and lack of organized method are noted. - Use life-size models for toothbrush demonstration. 4) Assessment: - After demonstration, patient is asked to brush his teeth similarly. - Apply disclosing agent to indicate the amount of residual plaque overlooked. - Further training is given. Tooth brushing techniques:

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1-Rotation or roll method: 1- Divide each half jaw into 3 regions (anterior-middle-posterior) 2- Apply twisting motion on buccal and lingual surfaces of the teeth. 3- Bristles rest on the alveolar mucosa pointing away from occlusal surfaces. 4- Maintain pressure and roll across gingiva towards occlusal. 5- Repeat 10 times in each region. 6- Brush occlusal surfaces with to and fro action. 7- Hold brush vertically for lingual surfaces of upper and lower incisors.

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C- Disclosants:

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Stress that: 1- Brushing is done immediately after eating. 2- Use a systematic way of brushing. 3- Do not forget to brush the lingual surfaces of the teeth. 4- Effective brushing time is 2-4 minutes.

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2-Fone’s method: Recommended for young children. 1- Teeth are put into occlusion. 2- Apply circular motion on outer surfaces of the teeth without any twisting of the handle.

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Definition: Disclosants are water-soluble dyes used to stain the plaque and other deposits and make them obvious in order to: 1- Confirm to the patient the presence of harmful film and hence facilitate instruction on its removal. 2- Enable the dentist, during scaling and polishing procedures to confirm that the tooth surfaces are free from all deposits. Desirable qualities: a) Stain plaque selectively. b) Do not stain the rest of the oral structures. c) Does not discolour anterior teeth fillings d) Has an acceptable taste. e) Has no harmful effects if it is accidentally swallowed.

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Forms: Tablets, liquid, wafers or swabs. They may be red, blue or yellow or fluorescent disclosants. Examples of disclosing solution are: 1- Iodine. 2- Basic fuchsin.

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D-Tooth paste (Dentifrices):

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Definition: A dentifrice is a substance used with a toothbrush to remove bacterial plaque and debris from the teeth surfaces for cosmetic purposes or therapeutic purposes. Therapeutic dentifrices are those containing a drug or chemical agent added for a specific preventive or treatment action. The best so far are those containing fluorides as they can be of significant anticaries value when routinely used.

Qualities: Of acceptable taste and flavor, color and consistency, and should not be harmful with prolonged use.

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Components: • Detergent 1-2% • Cleaning and polishing agents 20-40 % • Binder (thickener) 1-2% • Humectant 20-40% • Flavoring agent 1-1.5% • Water 20-40% • Therapeutic agent 1 -2% • Preservative, sweetener and coloring agent 2-3%

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Fluoride-containing tooth pastes: - Enables the delivery of topically applied fluoride to large number of persons. - Results in reduction in caries incidence by 10-30%. - Produces greater caries inhibition on proximal surfaces than occlusal or buccolingual surfaces. Compounds most commonly used are : 1- Stannous fluoride (causes tooth discolouration) 2- Sodium fluoride e.g. Crest, Close up 3- Sodium monofluorophoshphate (MFP) e.g. Colgate, Signal 2. 4- Amino fluoride (not commercially available ) Special guidelines for young children: 1- Use pea-sized amount of toothpaste. 2- Use formulations with low fluoride concentration (500-600ppm) for children younger than 7 years. 3- Parental supervision to avoid the risk of excessive ingestion of tooth paste. 16

Special purpose toothpaste: In case of sensitive cervical areas use desensitizing pastes e.g. Sensodyne.

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E-Mouth washes: Mouth wash or mouth rinse is a product used to clean the mouth, freshen the breath, and reduce plaque & gingivitis. Its effect will be greater when it’s used after brushing.

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What are the proper steps when using mouth rinses? • Before using a mouth rinse, brush and floss teeth. • Measure the proper amount of rinse recommended on the container or by a dentist. • Close lips and keep teeth slightly apart & swish liquid around the mouth. • The suggested rinsing time is 30 seconds to one minute. • Finally, spit liquid from mouth. • Do not rinse or eat for 30 minutes after using a mouthwash in order not to decrease its effects. Dental Care Tips for Children: - Children under 6 years & who cannot rinse should not use mouthwash. - Should be used under parental supervision. - It should not be swallowed. Classification of mouthwashes:

1-Therapeutic: They contain an active ingredient that helps prevent or treat certain oral health conditions.

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2-Non therapeutic (Cosmetic): - They are available over the counter. - They temporarily freshen breath & mask mouth odour. - They aid in removing food particles. 3-Herbal: 1- Have antiseptic and antibacterial properties. 2- Have the advantage of using natural ingredients such as “chlorophyll” which is a powerful breath freshener. 3- Don’t contain stabilizers or preservatives. 4- Effective in reducing plaque, gingival inflammation and bad mouth odour. 17

2- Other cleaning devices

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A-Dental floss: It is a tool used to disorganize and remove microbial masses located below the gum margins interproximally.

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Types: 1-Waxed: It is recommended for patients with very tight proximal contacts .

2-Unwaxed: - It can slide through the contact areas easily. - It provides effective cleaning because its fibers open during work and trap the plaque. 3-Medicated floss: It is impregnated with fluoride or chlorohexidine.

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Technique of flossing: 1- Cut a suitable length of floss (15cm). 2- Hold between the thumb & index fingers. 3- Introduce the floss from the occlusal surface through contact point down to gingival crevice, wrap around curvature of tooth and scrap towards the occlusal surfaces.

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B-Toothpicks: - It removes microbial masses from areas inaccessible to toothbrush bristles e.g. cleaning buccal and lingual surfaces of third molars and cleaning periodontal pockets. - Wooden, plastic & medicated tooth picks are available. - Toothpicks are used in case of wide embrasures while dental floss is used in case of tight interproximal contact. Technique: Insert toothpick into the embrasure pointed end first, with the stick at an angle of 45▫ to long axis of the tooth. The stick is rubbed about 12 times in each space. C-Rubber tip: - Used to clean interdental spaces and for massaging the gingiva. - Located on the handle of some toothbrushes. 18

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Technique: Place tip between teeth pointing towards occlusal surface, press against the gums and vibrate the tip.

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D-Interdental brush: - It is a small conical or tapered single tufted brush designed to be inserted into a plastic reusable handle. - It is available in various sizes and shapes.

Indications: To remove plaque from interdental spaces located posteriorly and for cleaning the exposed furcation areas.

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3-Oral Rinsing: -Rinsing the mouth: By forcing water vigorously back and forth through the teeth.

Purpose: 1- To remove material loosened by floss and tooth brush. 2- To remove traces of sugar from teeth when it is not possible to brush after intake of a diet containing sugar. -Water irrigator : A device which uses a gentle forced water stream. The water flow may be continuous or intermittent to remove oral debris.

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Purpose: 1- To clean pockets. 2- To clean under bridges and orthodontic appliances.

4-Dental prophylaxis : It is the removal of hard deposits on tooth surface by scaling then smoothening and polishing the surfaces with pumice on rubber cups or brushes. Advantages: 1- Smooth surfaces are less susceptible to be stained or coated with plaque. 2- Easy detection of early carious lesions.

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III- Topical protection of teeth

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This includes all measures applied to increase the resistance of the intact outer tooth surface. Among these measures are operative dentistry, prophylactic odontotomy, prophylactic fissure filling, fissure sealants, preventive resin restoration and atraumatic dentistry (ART) are the most essential.

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1-Fissure sealants: Definition: Fissure sealants are materials used to (correct) seal deep pits and fissures of newly erupted posterior teeth and change them into non-retentive surfaces. A significant caries reduction was observed when fissure sealants were correctly applied to deep pits and fissures of newly erupted teeth.

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Types of sealant materials: These are either chemically cured or light cured (using visible light). a- BIS- GMA resin (filled or unfilled). b- Glass ionomer cement. c- Compomer.

Indications: - Newly erupted posterior teeth with deep pits and fissures. - Patients at high risk to dental caries. - Medically compromised patients for prevention against dental caries. Application of pit and fissure sealants: Steps of application are:

Remove any debris using pumice on a small brush or rubber cup. Wash the tooth with air water spray. Isolate the tooth with cotton rolls. Dry the tooth with compressed air. Etch the occlusal tooth surface with enamel etching solution or gel (37% ortho-phosphoric acid) for one minute. 6- Wash thoroughly with air water spray. 7- Dry with compressed air until chalky white enamel surface appears. 8- Apply the fissure sealant with little brush. 9- Polymerize light cure sealant for 20 seconds keeping the tip of the light gun as close to the surface as possible. 10- Check the occlusion for any high spots. 11- Check the integrity of sealant every 6 months.

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2- Preventive resin restoration: - This procedure was born of fissure sealants. - The technique is based upon restoring minimal carious lesions on occlusal surface, usually in young permanent molars, while concomitantly preventing caries by sealing other deep pits and fissures on the same surface without mechanical removal. Technique: 1- A small round bur is used for removal of any carious tissue. 2- The tooth is etched as for sealant application. 3- Pit and fissure sealant is applied to fill the small cavity and seal the deep pits and fissures on the occlusal surfaces. A composite of thin consistency may be used. 3- Atraumatic restorative treatment (ART): The two main principles of ART are: A- Removing carious tooth tissue using hand instruments only. B- Restoring the cavity with adhesive filling material currently a glass ionomer.

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Carious cavities suitable for ART should be: A- Involving the dentin with no pulpal involvement. B- Accessible to hand instruments.

The advantages of ART include: 1- Use of easily available and inexpensive procedures. 2- Permit oral health care workers to help people who otherwise never would have received any oral care; such as handicapped, villages in rural and suburban areas, homebound, institutionalized people and economically less developed countries.

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4-Prevention of Dental Caries with Fluoride: What is fluoride? Fluorine is one of the halogens. It is the most active element of this group. It is not present in the free form of the free element. Fluoride is the only proved diet substance to be of anticariogenic benefit for humans. Fluoride can be used to control dental caries either by: a) Systemic route, i.e. by ingesting fluoride. b) Topical application. Mode of Action of Fluoride: The role played by fluoride in the control of dental caries is mainly as follows: 21

1- Ionic exchange of fluoride with the hydroxyl group of calcium hydroxyapetite in the surface layers of enamel changing it into fluoroapetite, which is less soluble in acids.

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2- Enzymatic inhibition interfering with the breakdown of glucose to lactic and pyruvic acid. Both phosphatase and anulase enzymes are inhibited by fluoride.

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3- Bacterial inhibition, fluoride has a direct inhibitory effect on the bacteria of the dental plaque.

4- Fluoride has the ability to precipitate minerals from saturated solutions. As saliva is saturated by minerals, fluoride favors the precipitation of the calcium phosphate on the surface of enamel, so it aids in remineralization of partially demineralized enamel in early caries. 5- Fluoride lowers free surface energy. This will decrease the plaque accumulation on the treated enamel surface.

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6- Action on tooth size and morphology: In communities with fluoridated water supplies, there is a trend towards shallower fissures and lower cusp height and smaller tooth size. This will decrease caries susceptibility. Sources of fluoride: Humans obtain fluoride from water and food.

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From water: 1- Water from deep wells provides high natural fluoride concentration. 2- Sea water contains about 1.2 –1.4 mg/Kg fluoride. 3- River Nile water contains about 0.36 mg/Kg fluoride. 4- The recommended optimal fluoride concentration for public water supplies varies with the annual mean temperature from 0.7 - 1.2 ppm. From food: 1- Most vegetables, fruit and dairy products, meat and poultry contain little fluoride 2- Sea foods e.g. salmon, sardines, shrimp and crabs may contain up to 2.5 ppm. 3- Most drinks contain some fluorides especially tea & the fluoride content of the water used in preparation of such drinks should be considered. 4- The average diet provides 0.2-0.3 mg fluoride daily.

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Fluoride Content of Enamel: Fluoride is concentrated at the surface and decreases towards the amelodentinal junction. Its concentration in surface enamel reaches 2000 - 3000 ppm in water-fluoridated areas. Uptake of Fluoride by the Teeth: Fluoride is incorporated in enamel and dentine in two stages:

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a) Before eruption: - During Calcification, traces of fluoride are incorporated into the crystalline structure of teeth. - Further amounts of fluoride are taken up by the external enamel surface from the surrounding tissue fluids before eruption.

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b) After eruption: Enamel surface continues to pick up fluoride derived from diet, water and saliva. This continues throughout life and is directly proportional to the concentration of fluorides in food and water ingested. Toxicity of Fluoride: The severity depends upon the amount of fluoride ingested and the duration of intake. A-Acute fluoride toxicity: Cause: Ingestion of a massive single dose (4-5 gm) of fluoride. In infants fluoride toxicity results from ingesting a dose of 0.25 gm fluoride.

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Symptoms: Nausea, vomiting, muscle tetany, spasm, coma, cardiac arrhythmia and death. Treatment: - Empty stomach (gastric lavage). - Give antidote (milk). - IV 10% calcium gluconate injection to control convulsions. B-Chronic fluoride toxicity: Cause: Ingestion of high levels of fluorides for a prolonged period of time. Signs: Bone deformities, joint fixation, dental fluorosis (mottled enamel). 23

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Mottled enamel: - If fluoride was ingested during the tooth developmental period at levels injurious to the ameloblasts, mottled enamel may result with various degrees of severity. - It usually affects the permanent dentition and ranges from white spots to severe brown stains.

A. Systemic Fluoride:

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Methods of Providing Fluoride: This can be achieved either by ingesting calculated amount of fluoride to be incorporated in the developing teeth, or topically applying fluoride preparations on exposed tooth surfaces to increase their resistance to caries process.

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1. Water fluoridation: 1- There is an inverse relationship between the fluoride level in drinking water supplies and the incidence of dental caries. 2- A fluoride concentration of 1 ppm was found to be optimum regards effective anticaries effect and lower mottled enamel. 3- Fluoridation of public water is an ideal public health measure because its benefits do not depend on the co-operation of the recipients and because it is cheap. 4- Fluoride concentration in public water supplies varies from 0.7 ppm (for hot countries ) to 1.2 ppm ( for cold countries ). This depends on the daily water consumption which in hot countries is usually double or triple that of cold countries. 5- In Egypt, fluoride concentration in the River Nile is about 0.36 ppm which is considered optimum due to hot weather in Egypt which increases the daily water consumption.

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2. Fluoridation of school water supply: - Done in areas where fluoridation of public water supplies is not possible. - Higher fluoride concentration (5 ppm) is used because children benefit from fluoridation only during school hours & days. - Results in 40% caries reduction. 3. Fluoride supplements: - Given when fluoridation of pubic water supplies is not possible. - In the form of tablets, drops or syrup. - The dose is 0.5 mg/day for children up to 3 years and 1mg/day for children over 3 years 24

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- It should be continued till complete crown calcification of second permanent molar i.e.10 years. - Fluoride preparations should be kept out of reach of children to avoid over dosage. - Fluoride tablets disguised as sweets are not advised.

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4. Fluoride incorporation in various foods: E.g. salt, milk, bread and rice which are common foods. However, the consumption of these foods varies from one person to another.

B. Topically applied fluorides: The topical application of fluoride can be carried out either by the patient himself (self-applied) or by members of the dental profession (professionally applied). 1. Self administered fluoride applications: a) Fluoride tooth pastes (dentifrices): (Discussed before).

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b) Brushing or rinsing with fluoride solution: - Regular rinsing or brushing every week with 0.2% sodium fluoride reduces dental caries incidence. This is to be done after the routine tooth brushing to obtain clean tooth surface and direct access to the enamel surface. - Highly diluted solution (0.02% sodium fluoride) can be used daily for patients showing high caries susceptibility. c) Fluoride gel: - A commercially available product containing 1.23% fluoride. - It has to be loaded in a special applicator (foam tray) to hold the gel in place for about 4 minutes. With some applicators, the whole mouth can be treated at once. d) Fluoride dental floss: Dental floss (unwaxed) impregnated with fluoride will result in a significant a reduction in the colonies of microorganisms on the proximal tooth surfaces. 2-Professionally applied fluoride: It is very beneficial in reducing dental caries particularly for children who live in area with low fluoride concentration in the drinking water. a) Sodium fluoride: - The recommended procedure of 4 applications of 2% sodium fluoride solution, one week interval, between every application results in 40% reduction in dental caries. These 4 applications are considered a single application and have to be applied every year. 25

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- For those children to whom it is difficult to apply fluorides every year; it is customary to treat the teeth with topical fluorides at 3,7,10 and 13 years of age. This is to insure that all the primary teeth and most of the permanent ones receive the beneficial effect of fluorides just after their eruption. - Sodium fluoride has a good shelf life; the solution can be kept for a long period of time without deterioration.

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b) Stannous fluoride: Single annual application of 8% stannous fluoride gives about 65% reduction in caries incidence. Disadvantages: 1. Stannous fluoride solution is unstable. 2. It has a short shelf life, so it has to be prepared freshly for each application by dissolving 0.8 gm of stannous fluoride in 10 ml distilled water. 3. It has a disagreeable astringent taste. 4. It discolors decalcified enamel.

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c) Acidulated phosphate fluoride: Combination of 1.23% sodium fluoride in 0.1 M orthophosphoric acid applied topically to the teeth of children on annual basis decreases caries from 50-70%. Advantages: 1- Stable, so it does not have to be prepared freshly for every treatment as in case of stannous fluoride. 2- It does not discolor decalcified enamel.

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Procedure for applying fluorides topically; a) Stannous fluoride: 1. A thorough prophylaxis should be performed using pumice and rubber cup. It is preferable to add one drop of 8% stannous fluoride solution to the polishing paste. 2. The upper and lower teeth on one side are isolated with cotton rolls. A saliva ejector helps to keep the area dry. The teeth are then air-dried. 3. An 8% stannous fluoride solution is freshly prepared and applied to all surfaces of the dried teeth with a cotton applicator. The teeth are kept moist with the solution for 4 minutes by applying it every 15 to 30 sec. b) Acidulated phosphate fluoride: The same technique as for stannous fluoride. c) Sodium fluoride: 1. A thorough prophylaxis is performed. 26

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2. Teeth on one side are isolated as mentioned before. 3. Teeth are then dried and the 2% sodium fluoride solution is applied to all teeth surfaces with a cotton applicator. The solution is allowed to dry on the teeth for 3 to 5 minutes. 4. On 3 subsequent visits, usually one week apart, the same procedure is repeated with the exception that prophylaxis is omitted and these 4 times are considered one application.

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d) Prophylactic paste: - The routine use of prophylactic pastes containing fluoride in the dental office every six months increases the fluoride content of surface enamel and its resistance to acid attack. - The most recently available are stannous fluoride - zirconium silicate paste and an acidulated phosphate fluoride - silicone dioxide paste. e) Fluoride Varnish: Definition: It is a sticky yellowish protective coating in a resin base that is painted over the teeth surfaces to prevent dental caries or to allow remineralization of initially demineralized enamel surfaces. Advantages: 1. Easy application. 2. Accepted by patients. 3. Higher fluoride acquisition than gels and foam. 4. It has the ability to adhere to enamel for long periods and thus release fluoride slowly to the teeth. 5. Negligible amount of ingested fluoride. Application: 1- The commercially available varnishes contain either 5% Sodium fluoride or 1% Fluorosilane. 2- It is painted by brush over teeth surfaces and allowed to harden for 5-6 minutes. This application should be repeated every 3-6 months. 3- Studies reported about 18-70% reduction of smooth surface caries when using fluoride varnishes.

1- Areas of demineralized enamel on the primary incisors.

2- Teeth are dried with gauze square. 27

5- Three months later.

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4- After application, a yellow film remains on the teeth.

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3- Varnish is applied to the tooth surface with a small brush.

Laser Light in preventive dentistry:

2. 3. 4. 5.

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1.

Recently, laser has been thought to be promising in caries prevention by: Increasing the resistance of dental tissues to caries by reducing the rate of demineralization. Sealing pits and fissures and homogenizes the enamel surface by melting structural elements. Laser application encourages fluoride uptake by dental tissues. Laser application to carious lesions vaporizes enamel caries and adjacent sound enamel fuses and eliminates small defects. Application of laser prior to application of fissure sealants improves its retention.

CARIES RISK ASSESSMENT Risk assessment

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Risk assessment is the identification of individuals at high risk for future disease. Caries risk assessment is to predict if new carious lesions will develop, or if early lesion will continue to grow. Importance: identify target population, evaluate effectiveness of a preventive program. It is also important to consider that risk of developing dental caries exists on a continuum and changes over time as risk factors change. Therefore, caries risk status should be re-evaluated periodically. Risk factors: social history, medical history, dietary habits, use of fluoride, plaque control, saliva clinical evidence. The AAPD developed a caries risk assessment tool to provide appropriate preventive care for children and adolescents. The caries risk assessment tool (CAT) is used to assess a child’s caries risk based on clinical conditions, environmental factors and general health conditions. 28

According to each caries risk indicator individuals are divided into Low, moderate and high risk.

Environmental

• Optimal systemic and topical fluoride • Consumption of simple sugars at mealtime • High socioeconomic status • Regular use of dental services

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General health

• Carious teeth in past 24 months • One area of enamel demineralization • Gingivitis

High Risk

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• No carious teeth in past 24 months • No enamel demineralization • No visible plaque, gingivitis

Moderate Risk

• Carious teeth in past 12 months • More than one area of enamel demineralization • Visible plaque

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Clinical Conditions

Low Risk

• Sub-optimal systemic and topical fluoride • Occasional consumption of simple sugars as snacks (1-2) • Midlevel socioeconomic status • Irregular use of dental services

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Caries Risk Indicator

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• Sub-optimal topical fluoride • Frequent consumption of simple sugars as snacks (3 or more) • Low level socioeconomic status • No source of dental services • Active caries in mother • Children with special health care needs • Conditions impairing salivary flow or composition

ADA Caries risk assessment form

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Contributing conditions: Fluoride, sugar, parents’ caries experience, General health condition: SHCN, eating disorders. Clinical condition: Cavitation, missing teeth, visible plaque.

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PREVENTION OF PERIODONTAL DISEASE

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Three areas can be distinguished in gingiva 1- Interdental papillae. 2- Gingival margin. 3- Attached gingiva.

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What is periodontal disease? ➢ It is the affection of periodontium or supporting tissues of the teeth. ➢ It may range from mild inflammation of gingiva to severe destruction of periodontal ligament and bone.

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Characters of normal gingiva: 1- Pink 2- Firm 3- Stippled 4- Well-formed papillae 5- Gingival sulcus shallow in depth

When gingiva is inflamed : 1- Change in color to red (due to hyperemia) 2- Swelling of gingival margin & interdental papillae. 3- Loss of stippling 4- Bleeding: on tooth brushing or spontaneous 5- In more advanced cases: • Destruction of periodontal ligament • Bone destruction • Pocket formation • Looseness of teeth

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Causes of Periodontal Disease: These may be divided into local and systemic factors. a) Local factors:

1. The consistency of the diet: - Important on the basis of functional stimulation derived from mastication which is essential for the normal metabolic activity of the gingiva and underlying tissues. - Soft foods are detrimental to the periodontium: 1- First, because they do not afford functional stimulation. 31

2- Second, they faster accumulation of irritating food debris at the gingival margin. Bacterial activity in the food debris can cause gingivitis.

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2. Calculus: Although important in the adult is hardly an etiological factor in children.

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3. The process of shedding of deciduous teeth and eruption of permanent teeth: - Cause gingivitis during the mixed dentition period. - The child will avoid chewing on a loose or painful tooth allowing deposits to be left on and around the affected site.

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4. Untreated caries: - Cervical and interproximal cavities cause food impaction & gingival irritation, whereas an open occlusal cavity causes decreased function and food accumulation on the affected side. - Poorly contoured restorations and overhanging cervical margins are also a cause of periodontal disease.

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5. Occlusal abnormalities: - Crowding of teeth, open bite, proclined maxillary incisors, and incompetent lips, are common cause of gingivitis by: 1- Interfering with normal function. 2- Allowing food stagnation. - Early extraction of a first permanent molar will: 1- Prevent the normal cleansing effect of mastication. 2- Allow food stagnation around the tooth opposite the space. 6. Prosthetic and orthodontic appliances when poorly fitting or incorrectly designed. b) Systemic factors: i. Endocrinal disorders: - Diabetes which causes gingival diseases particularly if there is neglected oral hygiene. - At puberty there are often hormonal changes which alter the gingival condition where the gingiva becomes swollen & hemorrhage. ii. Drugs: The anticonvulsant drug "Dilantin" causes characteristic gingival hyperplasia starting at the interdental papillae and spreading over other areas & occasionally completely covering the teeth. 32

iv. Blood dyscrasias: Such as leukemia exhibit gingival changes.

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iii. During acute fevers: Such as typhoid and measles, deterioration of the gingivae may occur due to the concomitant poor oral hygiene but an improvement occurs on recovery.

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v. Avitaminosis: May affect the gingiva; particularly the lack of vitamin C, which gives rise to scurvy.

Preventive Measures

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1- Dental prophylaxis: - It is more important in the control of periodontal diseases than it is in the control of dental caries. - Patients with tendency for gingivitis should be: • Closely observed to know in how many months calculus accumulation will pass beyond home care control. • Should receive dental prophylaxis every 3 to 4 months if required. • Dentists should use posterior bitewing x-rays annually to observe any alveolar bone loss. • Check tooth brushing habits.

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2- Good oral hygiene: • Should be stressed at an early age. • Encourage children to eat hard fibrous food. • Stress on care of gingiva during toothbrushing.

3- Toothbrushing: - There are several methods of toothbrushing. - None of them is superior to the others. - The thoroughness of plaque and debris removal depends upon the correct application of any brushing method rather than the method itself.

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➢ Roll technique mentioned before can be used. ➢ For patients with periodontal disease recommend the following tooth brushing methods:

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• Charter's method: End of bristles contact enamel and gingiva with the bristles pointing occlusally at 45 degree angle. Maintain lateral vibration in a mesiodistal direction and downward pressure (towards the occlusal surface).

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• Stillman's method: End of bristles rest on attached gingiva and cervical areas of teeth with the bristles pointing away from the occlusal surface. Maintain lateral vibration in a mesiodistal direction & downward pressure (towards the occlusal surface).

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* This lateral vibratory motion during toothbrushing is important for : 1- Forces the bristles between teeth so cleans the interproximal surfaces. 2- Massages the interdental gingival tissues. * As a final step brush dorsum of the tongue to increase the circulation and to remove bacteria and waste products which result in foetid oris. 4- Other devices: E.g. dental floss, tooth picks, rubber tips to massage gingival tissues and clean interproximal spaces. (The uses of these devices are discussed before) 5- Oral irrigation : (discussed before)

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6- Early treatment of carious cavities: - Caries should be treated as soon as a cavity is spotted. - Use bite-wing films for early detection of interproximal lesions. - New restorations should be carefully inserted, contoured and polished. - Old restorations should be checked for improper contact, overhanging margins and defect at the tooth restoration interphase. 7- Disorders of occlusion: Early diagnosis of occlusal disorders and early treatment by preventive or interceptive measures will save the gingiva. 8-Correction of mouth breathing: 34

This should be treated either by clearing the oro-nasal passages surgically or by orthodontic means as oral screen.

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9- In the presence of prosthetic or orthodontic appliances: • The patient must be warned to perform good oral hygiene to prevent food accumulation. • Be sure that the appliance is properly fitting. • Clean removable appliances outside the mouth. • Relief tissues by leaving dentures outside mouth at night.

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10- In the presence of systemic diseases : • Refer patient to medical attention. • Remove local irritating factors. • Give dietary recommendations in case of vitamin deficiency. • Stress on good oral hygiene.

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PREVENTION OF OCCLUSAL ABNORMALITIES

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Definition: Preventive orthodontics is that division of dentistry, which deals with the recognition, prevention, treatment and elimination of the factors involved in the production of oral and dento-facial abnormalities.

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During the regular examination of the child, the dentist should be able to: • Understand normal dentofacial growth and development. • Recognize early deviation from normal, for example, delayed eruption of permanent maxillary incisors due to the presence of supernumerary tooth. • Understand the various etiological factors in malocclusion. • Record the possible harmful oral habits such as thumb sucking, tongue thrusting, lip habits. • Recognize the cases which need early intervention, for example, extraction of retained primary incisors to prevent palatal or lingual eruption of the permanent incisors. • Recognize when it is better to wait and delay orthodontic treatment and when to consult an orthodontist. The following may be considered as being within the scope of preventive attention:

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1. Retained deciduous teeth: An ankylosed tooth may cause malalignment of the permanent successor and may cause lack of development of the alveolar process. 2. Poor restorative attention, loss of contacts due to caries or inadequately contoured fillings may lead to loss of space posteriorly. 3. Premature loss of deciduous posterior teeth may lead to loss of space required for the eruption of permanent successors. Attention should be paid to the necessity for provision of a space. 4. Crossbites in wholly deciduous arches do not require orthodontic interference as the permanent arches are not usually corrected by this early treatment. 36

5. Unerupted or erupted supernumerary teeth may cause malalignment of teeth.

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6. Individual teeth in cross bite with their opponents may be corrected by simple bite-plane appliance.

Age: 5- 6 years. Sex: boys more than girls.

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7. Ectopic eruption of the first permanent molars. The mesially positioned first permanent molar may cause premature resorption and exfoliation of the second primary molar. The problem occurs in approximately 3% of the population.

Site: It may occur in more than one quadrant in the same mouth. Maxillary molars are most frequently involved.

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Diagnosis: full mouth radiographs at 5 or 6 years of age are essential for early diagnosis. Complications: Child may complain of neuralgic pain in the area of impaction of first permanent molar resulting from the resorption of the distal portion of the second primary molar, break in the epithelial attachment that allows the ingress of oral fluids and resultant pulpal inflammation. If this occurs, the primary tooth must be removed.

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Treatment: - Although the problem is self-limiting in two thirds of cases, one third require correction. - When the first permanent molar is partially erupted a brass separating wire provides the simplest form of treatment. Technique: 1- Anesthetize the gingiva buccal & palatal to the tooth. 2- A brass wire (0.5 to 0.6 mm) is passed under the contact point between the upper first permanent molar and upper second primary molar from buccal to palatal side. Twist the ends together over the contact point.

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3- Cut off the ends leaving 5 mm and tuck in neatly to avoid cheek injury. Retighten the wire every 2 to 3 days.

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4- The wire will cause disto-occlusal movement of the first permanent molar. If the contact opens during treatment to the degree that the wire can no longer be retained a thicker wire should be used.

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5- If the second primary molar is severely damaged extract the tooth and construct an active appliance to distalise the first permanent molar into its proper position before placing a passive space maintainer.

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PREVENTION AND TREATMENT OF ORAL HABITS

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Definition of habit: "A habit is a fixed practice produced by constant repetition of an act".

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1-Digit sucking: 1. One of the most common oral activities of infants and young children are thumb and finger sucking which are generally termed ''digit sucking''. 2. Thumb sucking is more prevalent than finger sucking.

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Etiology: 1- Physiological: the infant sucks any object brought into contact with the lips. This reflex behavior lasts for the first several months of postnatal life. 2- Imitation of other children. 3- Feeding problems: rapid feeding or rapid transition from liquid to solid feeding. 4- Emotional disturbances or social problems. Classification: Phase I: In infancy (birth to 2 years). It is a normal activity, which may be ignored in infancy. Phase II: In the preschool child (2 to 5years) mild sucking before retiring or when fatigued is normal. This results in temporary malformation of the jaws or displacement of the teeth. Phase III: In the school child (6 to 12 years). It is usually a manifestation of emotional & social immaturity. This is active thumb sucking resulting in malocclusion.

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Malocclusion from thumb sucking: 1- Anterior open bite. 2- Proclination of upper incisors and retroclination of the lower incisors. 3- Tongue thrust: anterior open bite favors the forward positioning of the tongue. 4- Posterior cross bite due to over activity of buccinator muscle compressing the maxilla. Control of thumb or finger sucking: I- Physiological: Direct conversation with child or reward system. II- Chemical means: bitter-flavored preparations or distasteful agents that are applied to the fingers or thumbs. 39

2- Bruxism:

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Definition: Non functional grinding on teeth during sleep

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III- Mechanical: 1- Application of adhesive tape to thumb or finger. 2- Hawley appliance with a palatal bar may be fitted as a habit reminder. 3- Active oral screen: corrects the habit and corrects the protruded incisors.

Etiology: may be due to: 1- Emotional disturbance. 2- Cuspal interference (high restorations). 3- Handicapped children e.g. epilepsy, cerebral palsy. Effect:

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1- Traumatic occlusion. 2- T.M.J. troubles. 3- Abrasion (decreased vertical dimension).

Treatment: 1- Elimination of cuspal interference. 2- Tranquilizers. 3- Stainless steel crowns on primary molars to correct the vertical dimension. 4- Night guard (soft rubber splint or acrylic splint to wear at night). 5- Refer to psychiatrist. 3- Mouth breathing:

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Etiology: 1) Respiratory obstructions e.g. adenoids, deviated nasal septum, enlarged tonsils. 2) Habitual mouth breathing. Effect: 1- Protrusion of upper incisors. 2- High arched palate. 3- Chronic gingivitis. Treatment: 1- Treatment of the cause either surgically or orthodontically. 40

2- Passive oral screen in case of habitual type. 3- Active oral screen in case of protruded incisors.

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Etiology: 1- Stress and psychological disturbances. 2- Excessive overjet. 3- Class II division I. 4- Associated with finger sucking habit.

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4- Lip biting and sucking:

Effect: 1- Proclination of upper incisor and retroclination of lower incisors. 2- Anterior open bite.

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Treatment: 1- Treatment of the cause. 2- Self-discipline not to perform the habit. 3- Habit breaking appliance (lip bumper). 4- Oral screen may be used. 5- Tongue thrusting:

Etiology: 1- Persistence of infantile type of swallowing. 2- Associated with thumb sucking. 3- Respiratory obstruction. 4- Macroglossia as in acromegaly. 5- Muscular imbalance as in cerebral palsy.

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Effect: 1- Protrusion of maxillary incisors. 2- Increased overjet and open bite. 3- Lisping & speech problems.

Treatment: 1- Learning of the new reflex. 2- Tongue guard. 3- Correction of malocclusion:i- Treatment of open bite after age of 10 years. ii- Treatment of protruded incisors with active oral screen. 41

PREVENTION OF TRAUMATIC DENTAL INJURIES

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The incidence of fractured teeth could be reduced significantly by correcting the predisposing factors:

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1- Children with proclined teeth are particularly susceptible to trauma. Early orthodontic therapy is an important preventive measure in order to reduce excessive overjet & maxillary protrusion.

2- There is high frequency of injuries to anterior teeth among those taking part in contact sports e.g. football, boxing, wrestling. Mouth guards may be effective in prevention of dental injuries in those children. Mouth protectors or mouth guards:

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Requirements: - Retentive. - Comfortable. - Provide ease of speech. - Ease of breathing. - Protect the teeth and soft tissues. - They should be made of materials which can be easily washed, cleaned and disinfected.

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Types of mouth Protectors: 1- Stock prefabricated vinyl protector. 2- Mouth formed protectors. 3- Custom made protectors.

1- Stock prefabricated vinyl protectors: • They are usually supplied in three different sizes: small, medium and large. • The appropriate size is chosen for the individual and trimmed as necessary to fit on the upper jaw. Some remolding in the mouth is possible by prior immersion in the water. • These protectors are generally considered to be unsatisfactory because they are loose & thus are not tolerated. Also they do not provide proper coverage of vulnerable areas.

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2- Mouth formed protectors: • These are usually supplied in a kit containing a plastic shell, which is matched to the upper arch and trimmed where necessary. • The fitting surface is filled with mixed soft acrylic and put to place on the maxillary teeth where the material is allowed to set while the teeth are gently closed together. • Further trimming of the margins is carried out if required.

* Advantages: 1- Reasonably quick to construct. 2- Less expensive. 3- Could be used for fluoride application.

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* Disadvantages: 1- Excess bulk. 2- Less comfort. 3- Interferes with speech. 4- Difficult to adjust. 5- Repeated tear.

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3- Custom made protectors: • This is made of semi-rigid acrylic resin material on a stone cast of the maxillary arch of the individual. • When taking impressions, all removable appliances should be removed from the mouth.

* Advantages: 1- Lack of excessive bulk. 2- Careful Coverage of vulnerable areas. 3- Do not encroach on the free way space occlusally.

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THE ROLE OF DENTAL PROFESSION IN DETECTION AND PREVENTION OF ORAL CANCER

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Total prevention of cancer before its occurrence is nearly impossible. However, it can be prevented from causing rapid destruction of tissues and death to the patient by early detection and treatment.

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This could be accomplished by: 1. Recognition of the predisposing factors to oral cancer e.g. ill- fitting dentures, broken teeth or teeth with sharp edges, excessive use of tobacco, poor diet and systemic diseases known to be predisposing to cancer. 2. In case of suspecting a lesion to be neoplastic, the dentist must consult a specialist. 3. Observe the suspected lesion over a period of time to detect changes in the size or character.

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4. Ulcers in the mouth of unclear cause and not responding to indicated treatment should not be neglected for long time. 5. Do not apply local drug or medication and caustics to an ulcer with uncertain diagnosis. 6. The dentist can apply simple tests (in case of doubt) to suspected lesions. Exfoliative cytology and oral smears provide the dentist another diagnostic measure.

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a- Oral cytology or oral exofoliative cytology: Is the study of normal and abnormal desquamated cells of the oral cavity. Cells may be scrapped from surfaces or aspirated from natural fluid and examined after special staining.

b- Toluidine blue test: Toluidine blue is an acidophilic metachromic nuclear stain, which has an affinity for areas of carcinoma in situ and invasive carcinoma but not for normal mucosa.

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Technique: 1- The patient is instructed to rinse with water. Excess saliva is removed by suction. 2- A mucolytic agent, 1% acetic acid is applied to the mucosa with a cotton applicator. 3- Toluidine blue, 1% is then applied with a cotton applicator. The dye should cover the entire lesion and clinically normal margins. 4- Excess Toluidine blue is removed by rinsing with water. 5- Lesions which retain the dye stain blue and are classified as positive. Negative lesions do not retain the dye. 6- Lesions which retain the stain should be biopsied. Negative lesions should be followed clinically for variable periods.

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PREVENTION OF COMMUNICABLE DISEASES IN DENTAL PRACTICE

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Communicable diseases are those that can be transmitted from patients to patients, dentist to patients and vice versa.

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Pathway of disease transmission: - Organisms can be directly transferred from one host to another usually by blood stream, saliva or respiratory secretions. - Entrance to the blood stream usually occurs when the skin is penetrated by a contaminated instrument or needle or when organisms seep into an open wound such as cut on the operator's hand. - During breathing, conversation coughing or sneezing organisms are sprayed into the environment producing an aerosol. - Hand pieces, air and water syringes & ultrasonic scalers can create serious aerosols. - Some organisms are able to survive on (suction tips, sinks and operatory equipment) for extended periods and provide a source of cross infection. Communicable diseases may be bacterial or viral in origin. The most important communicable diseases of concern to dentists are:

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Viral Diseases: 1. Upper respiratory tract infection. 2. Mumps- Rubella - Measles. 3. Herpes virus 4. Hepatitis virus 5. Human immunodeficiency virus (HIV) (AIDS). Among Bacterial diseases are: Tuberculosis, syphilis, Diphtheria... etc. Viral hepatitis: - Viral hepatitis is a common infection that produces inflammation and necrosis of liver cells. - Hepatitis B virus (HBV) is of major concern to the dentist. Members of the dental profession assume a risk of acquiring (HBV) three times higher than that for the general population.

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Transmission: It is transmitted from person to person by: 1- Percutaneous introduction of blood. 2- Direct contact with secretions contaminated with blood containing (HBV). 3- From inoculation of mucous membrane. 4- Wound exudate contains (HBV) and open wound to wound contact can transmit infection.

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Prevention of (HBV): 1- Barrier technique utilizing rubber gloves, masks, gowns and protective eyewear should be used when contact with blood or contaminated secretions can occur. 2- Disposable equipment should be used when blood contamination can occur. 3- Proper cleaning and sterilization of non disposable equipment. 4- Effective hepatitis B vaccine affords the dentist and his team additional protection against acquiring (HBV)) infection. A series of three doses is required; the second and third doses respectively are given 1 and 6 months after the first. Acquired Immune Deficiency Syndrome (AIDS): It is a condition caused by infection with a virus known as human immunodeficiency virus (HIV). Transmission: Contaminated blood, semen, vaginal secretions and breast milk.

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Prevention of (AIDS): 1- Avoid direct contact of skin and mucous membrane with blood or blood products, excretions & secretions of persons likely to have AIDS. 2- Gloves and careful hand washing with an effective disinfectant soap are required. 3- Gowns and protective eyewear and masks are required when direct contact with patient's secretions or blood is anticipated. 4- Contaminated operatory surfaces such as dental chairs, cart tops, bracket table should be cleaned with a freshly prepared 1:10 dilution of 5% sodium hypochlorite. 5- All reusable instruments including hand pieces should be thoroughly washed and autoclaved.

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Tuberculosis: Tuberculosis is of special concern for dental personnel since the oral cavity is one of the chief pathways of transmission. The causative organism is Mycobacterium which is resistant to many chemical disinfectants and survives well on dry surfaces.

Control of Microorganisms:

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Prevention of Tuberculosis: 1- Since this disease is transmitted by droplets (coughing, sneezing, talking) the use of facemasks is very important. 2- Strict sterilization of equipment. 3- B.C.G. vaccine is mandatory.

1- Sanitization: It is the mechanical and chemical cleaning of a surface or object to remove dust and dirt and to reduce the number of microorganisms.

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2- Disinfection: - It is the destruction of bacteria and other microorganisms by chemicals or heat. - Disinfectants are used in dentistry to reduce the number of microorganisms within the patient’s mouth or operator's hand. - Disinfectant agents that are lethal for bacteria are called bactericides. - Those that inhibit or suppress bacterial growth are described as bacteriostatics. - The chemical agent having the highest level of disinfecting ability is 2% gluteraldehyde. It is effective against mycobacterium tuberculosis and hepatitis virus after immersion for 10 hours. - Disinfection methods should be only used to control contamination on surfaces or items within the dental environment that cannot be sterilized such as hand pieces, walls, floors, counters and dental equipment. - Chemical solutions should not be used for immersion of instruments in between patients because instruments treated in this way are likely to be sources of contamination when re-used. 3- Sterilization: The highest level of disease control is sterilization. There are several methods of sterilization in dentistry such as autoclave, dry heat oven, ethylene oxide gas and chemical solutions.

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The autoclave (steam under pressure): It is used at a temperature of 121 °C (25 0°F) and pressure of 15 to 20 psi for 15 to 20 minutes.

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Advantage: The most reliable, quick and efficient method for sterilization of wide variety of materials.

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Disadvantages: a) Cannot be used for oils, greases, powders and heat sensitive materials. b) May rust metal instruments. c) May dull cutting edges.

Dry heat oven: Used at a temperature of 1600C- 1700C for 1 hour. Metal and glass equipments, oils, waxes, greases, powder, needles and other small instruments enclosed in glass or metal can be sterilized.

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Advantages: a) Large capacity b) Does not dull cutting edges. c) Only method for sterilization of oils greases and powder. d) Does not erode glass surfaces or corrode metals. e) Simple to operate.

Disadvantages: a) Requires longer time for sterilization. b) Cannot be used on some heat sensitive materials. c) Instruments must be dry before sterilization to prevent rusting.

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Ethylene oxide gas: It is used at a temperature of 120o F for 2 - 3 hours or at room temperature for 12 hours. Most dental supplies and instruments can be sterilized by ethylene oxide gas. Advantages: a) Useful for sterilization of hand pieces that cannot be autoclaved. b) Useful for heat sensitive items.

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Disadvantages: a) It causes irritation to eye and nose, so inhalation must be avoided. b) Longer sterilization time is required. c) Equipments are more expensive than other methods.

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Chemical Solution (gluteraldehyde): It is used at room temperature for 10 hours and requires optimum concentration of chemical solution. It can be used for sterilization of plastics and other heat sensitive materials that can not withstand heat sterilization. Advantages: a) Does not require heat to achieve sterilization. b) Plastics, rubber and other heat sensitive material can be sterilized. c) Good for lenses, mirrors, hand pieces. d) Is not affected by soaps and detergents.

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Disadvantages: a) Requires immersion of objects for minimum of 10 hours to achieve sterilization. b) Destruction of hepatitis virus is probable but not proven. c) May corrode carbon steel after 24 hours of immersion. Preparing instruments for sterilization:

1. Cleaning instruments: Any instrument that is to be sterilized must be prepared by thorough cleaning, rinsing and drying. The presence of blood, saliva, soap films and other organic debris not only increase the number of microorganisms that must be killed but also protects them against the destructive agent.

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2- Wrapping instruments: Unless an instrument will be used immediately after it is sterilized it should be wrapped in a paper or plastic bag. These bags are constructed of materials that can withstand the conditions of sterilization. 3- Instrument transfer: To maintain a chain of asepsis in preparing the tray for treatment, sterile supplies should be transferred to the bracket table by means of transfer forceps rather than with fingers.

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Hand scrubbing and washing: There are two levels of bacteria on the hands: 1- There is a superficial layer of transient bacteria which are on the outer layer of the skin, under the fingernails and around the nails. 2- There is also a deeper level called resident bacteria which lie deep in the cervices and folds of the skin. Scrubbing of hands is a must to dislodge these bacteria. Scrubbing should start at the finger tips and nails. An orange wooden stick can be used to clean under the nails. The washing should continue to all sides of the fingers, hands, wrists and lower arms for 6 minutes; this is followed by the use of an antiseptic solution. Specific protection: Disposable gloves: The gloves are important to give extra protection to the operator against the transmission of hepatitis and other diseases transmitted by means of blood stream

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Face Masks: Used to prevent air borne infections e.g. acute respiratory infections and to prevent dispersion of particles of debris, polishing agents, calculus and water contaminated by saliva.

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Protective eyeglasses: Eye protection during dental treatment is necessary to prevent physical injuries and infection of the eyes. The eyeglasses should have a wide coverage, smooth rounded edges, flexible, light in weight and easily disinfected. Eye infections can follow the accidental dropping of an instrument on the face or the splashing of various materials from a patient’s oral cavity into the eye.

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EPIDEMIOLOGY By the end of this section, the student should be able to understand and comprehend:

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Epidemiology, its types and objectives. The scientific pattern for an epidemiologic investigation. Indices used for measuring dental caries and periodontal diseases. Factors which affect the prevalence of dental caries and periodontal diseases. Dental needs and dental demands in the community. The need for organizing dental care. The various types of dental auxiliaries. The importance of group practice. The importance of teamwork.

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INTRODUCTION

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EPIDEMIOLOGY

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Definition: It is the science concerned with the occurrence, distribution and determination of state of health and disease in human groups and populations. It is concerned with the group rather than the individual.

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Objectives: 1- Determination of health and disease in communities or groups (community diagnosis or group diagnosis) 2- Determination of factors which influence the occurrence of a condition (etiology of disease) 3- Determination of public needs. 4- Evaluation of health care. Types of epidemiology:-

1-Descriptive epidemiology:It is concerned with observation and reporting of the distribution of disease or condition in a population. 2-Analytical epidemiology:It is used to determine the etiologic factors and mechanisms associated with the distribution of disease.

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Epidemiologic Problems in Dental Field: 1- Dental caries. 2- Periodontal diseases. 3- Dental cleanliness, stain, calculus. 4- Enamel opacities and fluorosis. 5- Malocclusions and handicapping dentofacial anomalies. 6- Oral neoplasms.

Scientific pattern for an epidemiologic investigation:Epidemiological investigation should follow the following scientific pattern:53

Establishing the objectives. Design of the investigation. Selection of the sample. Conducting the examination. Analyzing the data. Drawing the conclusions. Publishing the report.

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1-Establishing the objectives The investigator must be absolutely clear about the objectives of the investigation. The starting point of a study is the expression of a null hypothesis, for example, there is no difference in the extent of dental disease between the groups to be investigated or in cases of clinical trials, no method is better than the other in preventing or treating disease. 2-Design of the investigation

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A- Types of studies: 1- Prevalence study or cross-sectional study: The condition or disease existing at a particular point of time, i.e. the state of the population at the time of examination. It is commonly used for making comparisons between two or more populations and expressed as percentage. 2- Incidence or longitudinal study: Where the amount of new disease in a population is measured over a period of time, usually one year. It is the change in a condition over a period of time. In a progressive disease such as dental caries, it is necessary to measure the increase by the extent of the new disease. This is obtained by observing the same groups of individuals on two occasions and subtracting the extent found at the first examination from that observed at the second. It is expressed as rate (cases per population per time).

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B-Controls: 1- Control group: When investigating the effect of a factor on the incidence of a disease in a group, it is not enough to confine the examination to the group exposed to the factor, but a parallel group not exposed to the factor must also be studied in the same way. This is called the control group and it is similar as possible to the test group except in respect to the factor under investigation. 2- Placebo: In case of a clinical trial, it is important to give the control group an ineffective substance having the same appearance and ingredients as the tested material but the ingredient to be studied is absent. This is called a placebo.

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3-Selecting the sample

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C-Blind study: It is a study in which the investigator does not know whether the subject is a member of the test or control group. If the subject does not know whether he is using a test product or a placebo, this is called double blind study. This is to avoid unconscious bias.

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Definition: Sample is a part of the population which we carry the study on because it is impossible to examine every individual in the population. Advantages of sampling: 1- Saves time, effort and money. 2- Allows the study to be carried out when the available resources are limited.

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Types of sample: 1- Selected sample: It is a sample in which a criterion is set for the inclusion of individuals in the study, and each individual satisfying this criterion forms a part of the sample. 2- Random sample: Each individual has an equal chance to be included in the sample. It is done using random number tables. 3- Stratified random sample: If the condition under investigation is related to various factors e.g. age or sex, the population is first divided into these groups (strata) and a random sample is taken from each group e.g. dental caries is an age-specific disease which should be stratified by age in any survey.

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4- Cluster sample: A simple random sample which is selected from groups or clusters of individuals e.g. schools, villages. Sample size: It is determined according to: 1- The available resources, facilities and time. 2- Prevalence of the disease (the lower the prevalence, the bigger the sample) 3- Number of variables e.g. age, sex socioeconomic level. 4-Conducting the examination

To study any dental disease, we must consider the examination methods, diagnostic aids, diagnostic criteria and indices used for measuring the disease. 55

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Requirements of an Ideal Index: An ideal index should possess the following characteristics:

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Definition of index: It is defined as a numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits designed to facilitate comparison with other population classified by the same criteria and method. An index describes the prevalence of a disease in a population and also describes the severity or intensity of the condition.

1- Clarity: The criteria of scoring should be clear and easy to apply.

2- Objectivity: Each index should have a specific and clear objective.

3- Simplicity: Each index should be easy to apply even in field studies.

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4- Reliability: The index should be reliable so that when a condition in the same subject is measured repeatedly, it should give the same results. 5- Sensitivity: The index should be able to detect small differences in what is being assessed. 6- Acceptability: The index should be acceptable to the subject. In other words it should not cause pain or discomfort to the subject. 7- Amenability to evaluation: The index should be amenable to statistical evaluation.

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8- Economical: The index should be economical in field studies. 9- Not time consuming: The index should not be time consuming so that it can be used in a large number of subjects. Uses of Dental Indices: 1- To study the oral health status of population. 2- To study incidence and prevalence of oral diseases. 3- To study etiological factors responsible for oral diseases e.g. plaque & calculus. 4- For collection of data in epidemiological studies. 5- For research work. 6- For planning oral health programs. 56

EPIDEMIOLOGY OF DENTAL CARIES A- Indices used for the assessment of dental caries:

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The commonest definition for caries diagnosis states that a tooth is considered carious when a sharp explorer catches in a cavity with a detectably soft floor and/or some undermined enamel or a breakdown in the walls of a pit or fissure.

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Indices used for assessment of dental caries can be divided into: I. Indices used for permanent dentition. II. Indices used for primary dentition. III. Indices used for mixed dentition. I- Indices used for permanent dentition:

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1- Prevalence index: • Simplest index used to measure dental caries, describes if disease is present or absent. • Unit of measurement is the individual. • Useful when comparing populations with wide differences in caries experience.

Prevalence rate =

Number of affected persons in the population Total number of population

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2- Slack index (1958): A sensitive classification of the extent of carious lesions was advocated by Slack et al., (1958) where the size of the lesion is indicated on a scale running from 1 to 3. D1: The probe catches in a pit or fissure but does not penetrate to the dentin. D2: Obvious carious lesion involving the dentin, but cavitation has not proceeded to more than one quarter of the crown. D3: Cavitation has proceeded so that more than one quarter of the crown is involved. Slack index for an individual =

Total number of affected teeth scores Total number of affected teeth

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D: decayed tooth. (scores 1) M: missing tooth due to caries. (scores 1) F: filled tooth. (scores 1)

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3- DMF (1938): • Used for permanent teeth. • Unit of measurement is the tooth.

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DMF index for individual = Number of D+M+F teeth in individual DMF index for group = Number of D+M+F teeth in all individuals Number of individuals in the group

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4- DMFs index: (decayed, missing, filled surfaces index): - This is a more sensitive measure of dental caries condition per person where accurate work is done using dental x-rays. - It is very useful for measurements during clinical trials of caries preventing agents. - This index counts the number of the affected tooth surfaces where each affected tooth surface scores one. - Here the unit of measurement is not the tooth (as in DMF) but the tooth surface. DMFs index for individual = Number of D + M + F surfaces in individual. DMFs index for group=

Number of D + M + F surfaces in all individuals Number of individuals in the group

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* Examples of decayed surfaces: - Give score 2 for an occluso-distal cavity because it involves 2 surfaces. * Examples of missing surfaces: - Give score 5 for extracted posterior tooth. - Give score 4 for extracted anterior tooth. *Examples of filled surfaces: - Give score 5 for full coverage crown for posterior tooth. - Give score 4 for full coverage crown for anterior tooth. - Give score 2 for an occluso-mesial amalgam filling. II- Indices used for primary dentition: 58

1- Prevalence index: (discussed before).

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2- Slack index: (discussed before).

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3- dmf index: This index may be used to summarize the status of primary teeth. d: decayed tooth (including teeth with temporary filling and recurrent caries around filling). (scores 1) m: missed tooth due to caries. (scores 1) f: filled tooth. (scores 1) dmf index for individual = Number of d + m + f teeth in individual. dmf index for group =

Number of d +m +f teeth in all individuals Number of individuals in the group

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2- dmfs index: - This index is used to score the number of surfaces decayed, missed and filled surfaces in the primary dentition. - This index counts the number of the affected tooth surfaces where each affected tooth surface scores one. - Here the unit of measurement is not the tooth (as in dmf) but the tooth surface. dmfs index for individual = Number of d + m + f surfaces in individual. dmfs index for group = Number of d +m +f surfaces in all individuals

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Number of individuals in the group

N.B.: scores are calculated as previously mentioned in DMFs index for permanent teeth.

III- Indices used for mixed dentition: When dental caries is assessed in children during the mixed dentition stage, both def index for primary teeth and DMF index for permanent teeth are used together and each index is scored separately for the individual. 59

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def index: An index used for measuring dental caries in the primary dentition of children during the mixed dentition stage. d: decayed deciduous tooth indicated for filling. (scores 1) e: decayed deciduous tooth indicated for extraction. (scores 1) f: filled deciduous teeth. (scores 1)

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- Teeth missing for any reason are not recorded, and because of this, this index may be regarded as a measurement of observable dental caries prevalence.

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- A disadvantage of this index is that when a population of children has received widespread extraction because of dental caries they may actually show a lower def than children in another population with fewer carious lesions in primary teeth.

B- Factors affecting the epidemiology of dental caries: They are divided into three main groups: 1-Host factors. 2-Agent factors. 3-Environmental factors.

I. Host factors

1- Age:

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- It was found that the greatest caries incidence in permanent teeth occurs between 15 to 25 years of age. - Pit and fissure caries is the predominant type occurring at this period. - A pronounced decrease in caries incidence was shown between 25-35 years of age since the more susceptible tooth surfaces have already been affected by caries. - Another increase in caries incidence occurs at about 45-55 years which is the proximal type. - Over 60 years of age, root caries occurs because root surfaces become denuded by gingival recession.

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2- Sex: Although the female might be expected to show a higher caries rate due to earlier tooth eruption, a sex difference was not clearly demonstrated. No evidence that pregnancy accelerates dental caries in females has been found.

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3-Race: - In USA, studies have shown marked difference in caries experience between white and black. - Black have more caries than white people. The difference in caries experience indicates that white people receive different standards of care than black. 4- Familial and genetic pattern of caries: It is difficult to distinguish between true inheritance through the chromosomes and the dietary and oral hygiene habits in the family. However, inheritance of a characteristic tooth structure or form whether good or poor is common.

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5- Emotional disturbance: Emotional disturbance, particularly anxiety states & severe mental stress influence the incidence of dental caries. 6-Nutrition: Nutrition is considered a host factor because the individual selects specific foods from the environment available to him.

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7- Variation of caries within the mouth: A) According to the tooth surfaces attacked: a. Pit and fissure caries b. Proximal caries c. Cervical caries d. Root caries B) Frequency with which teeth are attacked: Lower incisors are the least teeth exposed to caries. C) Bilateral symmetry.

II. Agent factors

1-Bacterial factors: - At first, many workers focused on the relation between dental caries rate & the number of lactobacilli in the mouth. 61

- Attention now focuses on certain strains of streptococci which can induce plaque and cavitations.

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2- Role of carbohydrates: - Freely fermentable carbohydrates have an essential role in caries process. Also the rate of clearance from the mouth affects the rate by which bacteria may act upon carbohydrates to produce acids. - Carbohydrates with rapid oral clearance seem to be less risky in the development of dental caries than those which remain in the mouth for a longer time. III. Environmental factors:

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1. Geographic variation: A) Temperature: • Temperature acts to vary the caloric requirements as well as the water intake of human beings. • Inhabitants of colder climates eat more processed carbohydrates as carbohydrates are quick cheap source of warmth and energy. • This is associated with decrease in water intake and therefore, caries incidence increases. And the reverse occurs in areas with high temperature. B) Sunshine: As the sunshine increases, the amount of ultraviolet rays increases which supply vitamin D by mobilizing its precursor under the skin. Also, as sunshine increases, temperature increases, so there will be increased demand for water consumption, which help wash away food debris from the mouth.

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C) Rain fall: - Most crops utilize in their growth the upper thirty centimeters of soil. - As the rain fall increases leaching of the minerals from soil especially fluorides will lead to reduction of fluoride concentration in crops. In addition, rain fall is accompanied by heavy clouds which block sunlight.

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D) Humidity: As humidity rises, the DMF rises too. This is because of the decreased demand of water intake in areas with high humidity levels.

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2- Fluoride: Fluoride in the drinking water during the time of tooth formation and mineralization results in formation of fluoroapatite crystals, which are more cariesresistant. 3- Total water hardness: Measured in terms of calcium carbonate. An inverse relation was reported between DMF and the total water hardness.

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4- Trace elements: • Some are found in water but most are found in greater concentration in foodstuffs. • It has been found that there is marked increase in dental caries in areas where selenium was high both in water and food-stuffs. • On the other hand, molybdenum and vanadium have caries inhibiting influences. 5- Degree of urbanization: - Urbanization may be accompanied by an increase in dental caries. - This may be due to the type of diet in urban areas (refined and freely fermentable carbohydrates).

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6- Social factors: Good economic status and social pressure in the direction of good mouth appearance are both strong factors in creating demand for dental treatment which lowers the caries incidence.

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EPIDEMIOLOGY OF PERIODONTAL DISEASES

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Periodontal diseases are inflammatory conditions affecting the periodontium. The periodontium comprises the gingiva, the periodontal ligament, the alveolar bone and the cement covering the roots of the teeth.

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A- Indices Used For Assessment of Gingival and Periodontal Diseases:

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1. P.M.A. Index: - It is the first numerical system of recording gingival condition. - The name of this index is based on the fact that gingival inflammation starts in the interdental papillae (P) , spreads around the marginal gingiva (M) and if more severe involves the attached gingival (A). - The 3 letters stand for: P papillary (gingival papilla mesial to the tooth) M marginal A attached gingiva Criteria: Cases are called: • Mild: if 1 to 4 papillae are affected and 0 to 2 margins are affected. • Moderate: if 4 to 8 papillae are affected and 2 to 4 margins are affected. • Severe: if more than 8 papillae and more than 4 margins are affected or involvement of attached gingiva. Scoring: The number of affected PMA units are counted and considered as separate estimates for the individual. The average PMA for the group is determined by summing the number of affected gingival units and dividing by the number of cases in the study. All present teeth are examined (sometimes a quadrant). 2. The gingival Index (GI): The index was developed by Loe and Sillness. The severity of the gingival condition is indicated on a scale running from 0-3. Criteria: 0: No inflammation. 1: Mild inflammation, slight redness, slight odema, probing with a blunt probe do not result in bleeding. 64

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2: Moderate inflammation: odema, redness, glazing the marginal gingiva is swollen, probing with a blunt probe elicits bleeding. 3: Severe inflammation: marked redness and odema, spontaneous bleeding and/or ulceration. It is a partial recording system; six teeth are selected for the examination. 62 4 4 26

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Scoring: - For each of the six teeth, mesial, distal, buccal and lingual gingival units are scored independently. - The tooth scores are summed and divided by 4 which gives the gingival index of the tooth. - The scores of the 6 teeth are summed and divided by their number which gives the GI of the individual.

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3. The periodontal index (PI) Russel's Index: Criteria: The criteria of the PI index are: 0: Negative: There is neither obvious inflammation in the investing tissue nor loss of function. 1: Mild gingivitis: There is an obvious area of inflammation in the free gingiva, but this area does not circumscribe the tooth. 2: Gingivitis: inflammation completely circumscribes the tooth but there is no apparent break in the epithelial attachment. 6: Gingivitis with pocket formation: The epithelial attachment has been broken, and there is pocket formation there is no interference with normal masticatory function, the tooth is firm in its socket. 8: Advanced destruction with loss of masticatory function, the tooth may be loose, may have drifted, may have dull sound on percussion, may be depressive in its socket. Scoring: - All the present teeth are examined. - The teeth scores are summed and divided by their number; this will give the PI of the individual. - PI of a group equals to the summation of the PI scores of the individuals in the group divided by their number. Why did the author write score 6 after score 2? - If the PI score of an individual is small (i.e. 1 or 2) this indicates that this individual has gingival affection. - If it is high (6 to 8), this indicates that this individual has periodontal affection. 65

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- If the score is inbetween 2 and 6, this indicates that this individual is affected by both gingival and periodontal disease. - This index is most suitable for assessment of the gingival and periodontal condition in adult populations. Modification: Lilienthal et al. (1964) modified Russel's index by using a partial recording system to be easier with large surveys. The teeth used are:

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7 14 41 7 Here the authors take 7 instead of 6 due to the frequent loss of the latter due to caries.

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4. The oral hygiene index (OHI) and the oral hygiene index simplified (OHI-S): These indices were first developed by Greene and Vermillion 1964. The OHIS and the OHI have two components, the debris index and the calculus index. For the OHI: - Each jaw is divided into 3 segments molar, premolar and anterior segment, i.e. the canines and incisors. - Examine the whole mouth. - The worst tooth in each segment is taken as representative of the segment. - The buccal and lingual surfaces of each tooth are scored. - Therefore, the OHI comprises 12 surfaces of six teeth.

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For the OHI-S: - The examination is limited to 6 permanent tooth surfaces. - These are: the labial surface of the upper right central incisor, the labial surface of the lower left central incisors, the buccal surfaces of the upper first permanent molars and the lingual surfaces of the lower first permanent molars. - When any of these teeth are missing, a comparable adjacent tooth is substituted. - Only fully erupted teeth are scored.

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Criteria: A. Oral Debris DI: 0: No debris or extrinsic stain. 1: Soft debris covering not more than one-third of the tooth surface, or extrinsic stain without debris regardless of the surface area covered. 2: Soft debris covering more than one-third but not more than two-thirds of the exposed tooth surface. 3: Soft debris covering more than two-thirds of the exposed tooth surface.

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B. Oral calculus CI: 0: No calculus present. 1: Supra-gingival calculus covering not more than one third of the exposed tooth surface. 2: Supra-gingival calculus covering more than one third but not more than two thirds of the exposed tooth surface or individual flecks of subgingival calculus around the cervical portion of the tooth. 3: Supra-gingival calculus covering more than two thirds of the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical area of the tooth.

Measurement of debris and calculus indices

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Scoring: For determining OHI: - DI equals the summation of the DI scores of the 12 surfaces examined divided by 12. - CI equals the summation of the CI scores of the 12 surfaces examined divided by 12. - So, OHI= DI + CI. For determining OHI-S: - DI equals the summation of DI scores of 6 examined surfaces divided by 6. - CI equals the summation of CI scores of 6 examined surfaces divided by 6. - So, OHI-S = DI + CI

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6. Community Periodontal Index of Treatment Need (CPITN):

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Purpose: This index assesses periodontal treatment needs rather than periodontal status so that, appropriate oral care can be provided for populations and individuals.

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Indicators: The CPITN records treatable conditions as: 1. Periodontal pockets 2. Gingival inflammation (presence or absence of bleeding) 3. Dental calculus (supra-gingival and sub-gingival) and other plaque retentive factors. It does not record irreversible changes as gingival recession.

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Procedure: 1. The dentition is divided into six segments (sextants). The sextants are: anterior segments (canine to canine of upper and lower jaws), right and left posterior segments (premolars and molars of upper and lower jaws). A sextant must have at least two functioning teeth. 2. The worst condition observed within each sextant is recorded and given a code using the following codes and criteria.

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Criteria used to record the worst condition observed in each sextant: Code 0: Healthy periodontal tissues. Code 1: Bleeding observed during or after gentle probing. Code 2: Supra- or sub-gingival calculus or other plaque retentive factors such as ill-fitting crowns or poorly adapted edges of restorations seen or felt during probing . Code 3: Pathological pocket of 4-5 mm, that is, when the gingival margin is on the black area of the probe. Code 4: Pathological pocket of 6 mm or more, that is when the black area of the CPITN probe is not visible. Code X: When only one tooth or no teeth are present in a sextant. It is considered as missing sextant and is indicated with a diagonal line through the chart index box. 3. The CPITN probe and probing procedures: The CPITN probe (tactile probe or sensing instrument) has a thin handle of light weight. It has a ball tip end of 0.5mm diameter which allows easier detection of sub-gingival calculus and facilitates the identification of the base of the pocket, thus decreasing the tendency for false reading. The probe has a black color coded 68

part from 3.5 mm to 5.5 mm which facilitates rapid assessment of periodontal pocket depth.

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The direction of the probe during insertion is parallel to the long axis of the tooth. The sensing force of insertion should not cause pain to the patient. Sites for probing are mesial, mid lines and distal of both buccal and lingual surfaces.

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The use of the CPITN periodontal probe for determination of treatment need

TN 0: Code 0 or X (missing) indicates no need for treatment.

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4- Classification of treatment needs:

TN 1: Code 1 indicates a need for improving personal oral hygiene.

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TN 2: (a) Code 2: indicates need for professional cleaning and scaling then giving patient oral hygiene instructions. (b) Code 3: shallow to moderate pocketing (4 to 5 mm depth) indicates need for scaling and oral hygiene instructions .

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TN 3: Code 4: deep pocket (6 mm or deeper) indicates need for complex treatment which involves deep scaling, root planning and complex surgical procedures. 5- Recording of CPITN:

a- A chart index of six squares is used denoting the codes of the worst condition observed within each of the examined six sextants.

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b- Missing sextants are indicated with a diagonal line through the appropriate box.

c- Examples of CPITN for an individual:

Case 1:

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2 2 70

3

Case 2: 0 1

3 3

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3 3

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There is at least one deep pocket in the right posterior sextant (requiring deep scaling and root planning) and one moderately deep pocket in the left posterior sextant of the maxilla(requiring scaling and oral hygiene instructions) Three sextants have no pocket depths over 3 mm but do require scaling and oral hygiene instructions. One sextant is missing.

There are moderately deep pockets in all posterior sextants (require scaling and oral hygiene instructions). There is bleeding on gentle probing in the lower anterior sextant (a need of improved personal hygiene in this area) and no treatment need in the upper anterior region.

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B- Factors affecting the prevalence and incidence of periodontal diseases: I-Host factors

1- Age:

- Periodontal diseases progress steadily with age. This is due to the fact that periodontal disease is a cumulative disease & the linear increase with age reflects this feature. - Starting from the age of 13 there is an increase in the number of individuals having pockets and bone loss.

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- Gingivitis is also common in the mixed dentition stage associated with shedding and eruption of teeth.

2- Sex:

- Periodontal condition is better in females in USA and Europe due to a better status of oral hygiene. - On the contrary in developing countries, the periodontal condition is worse in females after the age of 20 as they: 71

1) Give birth to many children and suffer from recurrent gingivitis & pocket formation during pregnancy.

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2) Also, the frequent pregnancies and lactation periods deprive the mother from nutrients.

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3- Correlation with oral hygiene: There is a strong correlation between the severity of gingival and periodontal disease and the oral hygiene condition. 4- Socioeconomic status: Several surveys have demonstrated that periodontal health improves with increase in the education level and income.

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5- Effect of tobacco: There is a high correlation between the periodontal condition and smoking. Gingivitis & periodontitis with bone resorption increase with increasing consumption of tobacco. The prevalence of ulcerative gingivitis in young cigarette smokers is high. This may be due to the effect of tobacco & the heat derived during smoking. 6- Systemic disease: Diabetes: There is a significant correlation between diabetes and periodontal disease especially if the patient has poor oral hygiene. Effect of diabetes: -The increase in blood sugar level causes atherosclerosis and deposition of mucopolysaccharides in blood vessels. This leads to narrowing of the blood vessels of the gingiva decreasing the blood supply and nutrition to the gingival tissues.

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7- Nutrition: Some gingival diseases are correlated to vitamin deficiency e.g. scorbutic gingivitis occurs as a result of vitamin C deficiency. 8- Abnormalities in occlusion: Some correlation exists between gingivitis and some occlusal abnormalities. A) Crowding: Causes food accumulation and presents a difficulty in maintaining good oral hygiene at those sites.

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B) Protruded maxillary incisors: Cause incompetent lips & mouth breathing which causes dryness of gingival tissues and cracking.

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9- Race: Some studies have shown an increased prevalence of gingival diseases among Asian and African races compared to Scandinavian and White Americans. Yet, no clear difference was seen when education, dental care and oral hygiene were kept equal. II- Agent factors

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A positive correlation exists between amount of bacteria, plaque & calculus and the severity of gingival & periodontal diseases.

III- Environmental factors

1. Geographic distribution of periodontal diseases: Studies revealed that periodontal diseases are more prevalent & more severe in some Asian and African countries than in the United States. South American countries seem to fall in between.

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2. Fluoride concentration in drinking water: Gingival and periodontal status improves as the fluoride intake increases due to the decrease in the number of carious cavities especially cervical and proximal. 3. Oral environment:

a) Prosthetic appliances: Gingival inflammation, mobility & bone destruction increase in teeth adjacent to partial dentures particularly if they are improperly designed or the patient has poor oral hygiene. b) Dental caries: There is positive correlation between dental caries and periodontal disease scores. 73

DENTAL NEEDS AND DENTAL DEMANDS

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I- Dental Needs Types of Need:

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1- Normative need: A condition which a professional e.g. dentist defines as requiring treatment. E.g. presence of carious cavity. 2- Felt need: Assessed by asking people if they feel they need a dental service or not. This is inadequate because there are some asymptomatic conditions & people feel they do not need to be treated.

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3- Expressed need: Felt need turned into action. eg. a patient feels pain from a cavity and asks for treatment. 4- Comparative need: Identified in an area by comparing it with other areas regarding disease or service. E.g. if other areas have a decrease in level of disease or increase of service, therefore there is a need in the examined area. Factors which influence Dental Needs: Dental needs vary from one country to another according to: 1- Degree of Development:

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a- Underdeveloped countries: (primitive areas) Their demands are to be kept alive and free of pain. Their needs are simple & include: 1- Exodontia (extraction). 2- Little amount of dental health education. E.g. instructions in good oral hygiene and nutrition. 3- Water fluoridation may be valuable. b- Developing countries: (slightly developed) Their demands are mainly for: 1- Exodontia. 2- Prosthodontia. 74

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Their needs include: 1- Extraction of painful teeth. 2- Insertion of partial dentures or complete dentures of simple design. 3- Dental health education. 4- Prevention and early treatment of dental diseases for young generations.

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c- Well developed countries: Their needs include: 1- Restoration of serviceable teeth. 2- Replacement of missing teeth. 3- Routine dental examination for early control of dental diseases. 4- Preventive and educational measures. E.g. water fluoridation, instructions in proper oral hygiene & nutrition. This is called Comprehensive dental care.

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2- Age: - Need for treatment of traumatic injuries to anterior teeth is maximum at age of 12-14 years. - Need for fillings reaches a peak between 15-24 years. - Need for extraction, increases with age. - Need for periodontal treatment is high at middle age but reaches a peak at 40 years. - Need for crown and bridge is high in middle age (only a small group of teeth have been extracted). - Need for partial dentures follows. - Need for complete dentures, is in later years of life. - Oral cancer is in later years of life.

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3- Sex: - Need for fillings and periodontal treatment is the same in both sexes. - Need for extraction and dentures is lower in women than in men (women show more interest in their oral health to avoid cosmetic disfigurement). 4- Income: a- In developed countries: Dental needs are lower among patients with increased income due to: → better preventive measures. → better education. → more frequent visits to dentist. b- In less developed countries: People with increased income need more dental care especially young age groups. 75

Factors affecting demand:

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II- Demand for Dental Care

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5- Race: - In USA it was shown that blacks need fillings, periodontal treatment, extractions and prosthodontia more than whites. - Indian and Chinese groups have high needs for periodontal treatment than USA citizens but lower needs for caries treatment.

a- Automatic factors: Any increase in one or more of these factors is automatically associated with an increase in demand for dental care. A- Gross increase in population: The larger the community the greater the demand for dental care.

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B- Urbanization: More persons in urban than in rural areas visit the dentist more regularly. This may be due to difficulty of transportation in rural areas. C- Education: Demand for dental services increases with the increase in the level of education.

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D- Occupational changes: Persons in professional occupation visit the dentist more frequently than manual workers.

E- Income per capita: Income per capita is correlated positively with demand for dental services. b- Dentist’s efforts to stimulate demand: This includes dentist’s efforts in dental health education to make the patient recognize the sequelae of neglected oral and dental condition and to maintain the dental apparatus healthy and functioning.

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ORGANIZATION OF DENTAL CARE

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THE DENTIST AND HIS PROFESSION

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Dentistry is a specialty of medicine. The dentist practices his specialty in his private dental surgery or belongs to some sort of health care organization as a specialist beside his medical colleagues. The organization can be governmental or non- governmental.

In the past century, dentistry has become more specialized. Expensive equipment and elaborate techniques were developed for every specialty. The coordination of the services of the general dentist with the orthodontist, the oral surgeon, the pedodontist, and other specialties makes the delivery of high standard dental services easier.

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Members involved in providing dental services are: 1- The dentist: - Someone who is properly licensed and registered to practice dentistry, graduated from a recognized college or a university. - The dentist is the only member of the dental team qualified to make a diagnosis and provide treatment strategies. - Two-thirds of all dental school graduates become general practitioners. The remaining one-third becomes dental specialists.

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2- Recognized dental specialists: Once a dentist becomes a specialist, he or she must limit their practice to that specialty. The eight recognized dental specialists are: 1) Public health dentist → is a dental specialist who provides dental services mainly prevention, field studies and epidemiological studies to the community. 2) Pediatric dentist → is a dental specialist who treats children from their first dental visit through approximately age 18. 3) Orthodontist → is a dental specialist who applies dental braces, retainers and other appliances to correct dental deformities straighten the teeth and align jaw movements. 4) Periodontist → is a dental specialist who performs gingival and periodontal treatment whether surgical or non-surgical and deals with dental implants. 77

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5) Prosthodontist → is a dental specialist who replaces lost natural teeth with fixed prosthesis (crowns, bridges or implants) or removable prosthesis (full or partial dentures). 6) Endodontist → is a dental specialist who performs root canal treatment and related procedures, such as apicectomies and retrograde fillings. 7) Oral surgeon → is a specialist who extracts teeth, removes diseased tissues, surgically exposes impacted teeth; wires fractured jaws and places dental implants. A maxillofacial surgeon may also treat accident victims or diseases e.g. cancer which require reconstruction of facial features. 8) Oral pathologist → is a dental specialist who diagnoses and studies oral diseases and conducts research related to the oral cavity and its diseases. 3- Dental intern: A graduate of dental school serving a first year internship of clinical training under supervision in a teaching hospital.

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4- Dental auxiliaries: A person who is trained to give help and support to the dentist.

Types of Dental Auxiliaries

I-Non operating: A- Clinical:

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1- Dental Assistant: Duties: 1- Reception of patient. 2- Preparation of mouthwashes and napkins. 3- Sterilization and preparation of instruments, cleaning instruments and preparing new instruments for next appointment. 4- Mixing of restorative materials and impression materials. 5- Filing of patients. 6- Assistance in x-ray work, developing and processing. 7- Instructions to patient in good oral hygiene e.g. tooth brushing. 8- After care of patients with general anesthesia. 2- Chair – Side Dental Assistant: - One chair-side dental assistant, increases number of treated patients by 33%. - Two chair-side dental assistants, increase number of treated patients by 62%. - This is because dentist will work under less physical and mental strain & provides better service. 78

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- Four-handed dentistry: is the art of seating the dentist and his assistant in such a way so that both can reach easily patient's mouth, with patient in fully supine position. Duties: 1- Handling instruments and materials. 2- Retraction. 3- Aspiration.

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B- Laboratory:

II-Operating:

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Dental laboratory technician: - They are usually men. - Originally training was done in dental office which resulted in variation in quality of training. - Nowadays there are commercial dental laboratories working for a lot of dentists. This is better because: 1- Dentists do not have enough work to employ a full-time technician. 2- Technician can profit by division of labor in these laboratories e.g. expert in gold, expert in porcelain……..

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1- Dental Auxiliaries: Trained for over 2 years to perform operations of limited nature i.e. repairable procedures (can be redone or corrected). They do not prepare cavities but complete the restorative procedures. Duties: 1- Application of rubber dam. 2- Application of temporary restorations. 3- Application of matrices. 4- Condensation and carving amalgam. 5- Finishing and polishing restorations. 2- Dental Hygienist: Two ranks:

A-Public Health Dental Hygienist: Trained for one or more years in dental health education and public health beyond dental hygiene certificate. Duties: 1- Screening or examination of school children or workers in industries and refer them to the dentist for treatment. 79

2- Classroom teaching in dental health. 3- They are very efficient in public health programs.

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B-Clinical dental hygienist They receive less training than public health dental hygienist. Duties: 1- Dental prophylaxis (removal of calculus & stains). 2- Polishing restorations. 3- Topical fluoride application.

III- New auxiliary types for underdeveloped areas: In these areas there is acute dentist shortage. The WHO suggests making use of 2 types of dental auxiliaries for such situations.

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A- The Dental Licentiate: Trained for not less than 2 years in the following: Duties: 1- Dental prophylaxis. 2- Cavity preparation and filling. 3- Extractions under local anesthesia. 4- Treatment of common gingival and periodontal diseases. 5- Early diagnosis of serious conditions requiring referral. They are responsible to a dentist at national level or to the chief of the local health service. Supervision & control occur in rural areas.

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B- The Dental Aid: - Has briefer training (4-6 months) followed by a period of field training. - Performs first aid procedures for relief of pain. Duties: 1- Extraction under local anesthesia. 2- Control hemorrhage. 3- Early diagnosis of serious dental conditions requiring referral.

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A- Clinical

II- Operating

B- Laboratory

1- Dental auxiliary

1- Dental licentiate

2- School dental nurse

2- Dental aid

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1- Dental assistant

Dental laboratory technician

3- Dental therapist

2- Chairside dental assistant

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III- New auxiliaries for underdeveloped countries

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I- Non operating

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Dental Auxiliaries

4- Dental hygienist

5- Expanded function dental auxiliary

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GROUP PRACTICE

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Definition: Group practice is a term given when more than one specialist are gathered and work under one roof. The ideal size of group practice may range from 6- 12 individuals.

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The group may be independent (private) or operated by governmental or nongovernmental agency. The non-governmental group practice may be owned by the partners (with equal votes), owned by a small organization (social, charity or cooperative) or by one senior practitioner responsible for recruiting a number of associates.

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In a successful group practice, there must be at least one skilled general dentist working along with other specialists as well. A dental specialist limits his practice to a certain specialty, while the skilled general dentist can provide periodic recall, preventive services and referral to other specialists. In such group practices, patients accept a multiple dentist-patient relationship when they realize that the group operates as a team.

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Advantages of group practice:I-Advantages for the patient:a) Better care through quick and easy consultation. b) Easy referral between operators. c) Records are available for all operators d) Economical as reduction of cost is reflected on fees. e) Security: the patient feels more secure as many services of good quality are within his reach. II-Advantages for the dentist:a) Daily contact between operators and regular staff meetings improve professional knowledge. b) Emergencies and vacations can be better organized. c) Convenience: due to the presence of many services in one building. This can increase the number of patients served per year. d) Economic due to sharing common facilities e.g. one reception room, one xray unit and one sterilization system. e) Group practice gives a quicker start to a young dentist. 82

Team Work

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Disadvantages of group practice:1- Personal conflicts due to loss of individuality. 2- Some patients may find it a disadvantage being shuttled back and forth from one operator to another. 3- Location and business procedures may not please all members.

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A team is a group of individuals with different roles and functions whose combined efforts towards a mutually shared goal are required for the successful completion of a specific task. A team usually consists of professional and paraprofessional personnel.

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Applications of team work: I- At the community level: - Conducting epidemiological studies for the population e.g. survey team. - This team consists of a group of workers who come together to provide dental health services for the community. The team includes: 1. Expert epidemiologists 2. Public health worker 3. Dental hygienist 4. Statistician. II- At the patient level: 1- Cleft lip and palate team. 2- Maxillofacial team.

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The team working in such cases are different specialists who work together to treat complicated cases. The team includes: plastic surgeon, oral surgeon, pediatric dentist, orthodontist, prosthodontist, ENT specialist, speech therapist, pediatrician, nurses and social workers. The patient should be a member of this team when making decisions about his or her treatment.

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