Abnormal Musculature

·        High tongue position w/ strong mentalis muscle à may damage occlusion

·        May result in a collapse of the lower dental arch and drifting of anterior segment

Oral Habits

·        Thumb and finger habits cause abnormal forces

·        May initiate collapse after untimely tooth loss

Existing Malocclusion

·        Arch length inadequacies

·        Class II malocclusion, div. 1

·        Usually become more severe after untimely loss

Stage of Occlusal Development

·        More space loss is likely if teeth are erupting near a space left by untimely loss

Time elapsed since loss

·        Usually takes place during the first six months after extraction

·        Insert appliance ASAP when indicated

Dental age of patient

·        Chronological not as important as dental age

·        Teeth erupt when ¾ of the root is formed regardless of the chronological age (Gron study)

Amount of bone covering the unerupted tooth

·        Other predictions are inaccurate if bone is lost due to infection

·        Permanent eruption is typically accelerated in case of infection

·        If bone covers crown eruption will be delayed for several months à a space maintenance appliance is indicated

·        Erupting premolars usually require 4-5 months to move through 1 mm of bone

Sequence of the eruption of teeth

·        Observe relationship of developing and erupting teeth near space

·        IF premolar is lost and lateral incisor is erupting à result in distal movement of primary canine into space

Delayed eruption of the permanent tooth

·        Not uncommon to observe partially impacted permanent teeth or deviation in eruption

·        Extract primary tooth and make appliance to maintain space

Extraction

·        Necessary in cases of severe carious destruction and/or abscess

·        Premature extraction of primary 2^nd molar allows mesial drift of 1^st permanent molar à blocks eruption of 2^nd permanent premolar

Caries

·        Interproximal caries (untreated) allows mesial drifting of perm. 1^st molar and distal drifting of lower prim. molars during eruption of lower lateral incisors

Ectopic eruption

·        Common w/ maxillary perm. 1^st molars

·        Active appliance and space maintenance if prim. 2^nd molar is lost

Ankylosis

·        Primary molars

·        Allows mesial tipping of perm. 1^st molar and distal drifting of primary molars during eruption of lower lateral incisors

·        Treat with space maintenance appliance

Trauma

·        Most common with anterior teeth

·        Questionable if arch length is lost

·        Esthetics is main issue

·        May result in abnormal tongue position and affect speech

Appliance

Description

Band and Loop

·        Orthodontic band and SS wire

·        Indicated in unilateral space loss (max. and mand.)

·        Used in bilateral space loss in transitional dentition

Lingual Arch

·        Orthodontic band and SS wire

·        Indicated in bilateral and unilateral space loss (mand. only)

·        Wire contacts erupted lower perm. incisors just at the level o the cingula

Nance Holding Arch

·        Orthodontic band, SS wire, and acrylic palatal button

·        Indicated in bilateral or unilateral space loss in maxilla

·        Button firmly contacts palatal mucosa

Transpalatal Arch

·        Orthodontic bands and SS wire

·        Indicated in unilateral or bilateral space loss in the maxilla

·        Transverse wire lies just off palatal mucosa

Distal Shoe

·        Orthodontic band and SS wire or bar

·        Also of SS crown and SS wire or bar

·        Adjustable type (Gerber) has SS crown with adjustable distal extension used frequently in Pacific Pediatric Clinic

·        Has a blade projection that penetrates gingival

·        Position of blade must be checked radiographically first

·        Guide eruption of permanent 1^st molar

Advantages

1.       Requires minimal patient cooperation

2.     Not as easily broken as removable appliances

3.     Requires fewer adjustments than removable appliances

Disadvantages

1.       Usually does not restore occlusal function

2.     May be difficult to clean

3.     Often difficult to adjust

Advantages

1.       Same as fixed cemented

2.     Easier to adjust and repair

3.     Easier to cement bands

Disadvantages

1.       Same as fixed cemented

2.     Slightly easier to damage

Advantages

1.       Easily cleaned

2.     Easily adjusted

3.     Easily constructed

4.     Easily repaired

5.     Maintains occlusion (prevents super-eruption of teeth opposing edentulous area)

Disadvantages

1.       Requires patient cooperation

2.     Soft tissue irritation or incompatibility

3.     Relatively easily broken

4.     Potential plaque trap

Tooth

Diagnosis

Treatment

Primary incisors

·        Early loss will cause little change in dentition

·        Space maintenance is not necessary

·        Esthetics is the main concern

·        Functional concerns relate to tongue habits and speech problems

·        Removable Acrylic à appliance of choice

·        Fixed Appliances à indicated if the patient cannot manage a removable; work best when replacing only one or two teeth

Primary cuspid

·        Incisors tend to shift laterally into the space

·        Creates a midline deviation and dental asymmetry

·        Accelerated when perm. incisors begin to erupt à intervene at this time

·        Due to insufficient arch space or caries or trauma

·        No midline shift – Minimal intercuspid crowding (< 2mm) à Arch Class I occlusion
-Extract remaining canine and place lingual arch
-Prevents lingual tipping of lower anterior teeth
-Prevents shifting of midline

·        No midline shift – Significant intercuspid crowding (> 2mm) à Arch Class I occlusion
-Arch length analysis
-3-4mm discrepancy indicates orthodontics
-Extract remaining canine and place lingual arch
-Prevents lingual tipping of lower anterior teeth
-Prevents shifting of midline

·        Midline Shift
-Usually caused by severe intercuspid space deficiency and requires orthodontics

Primary first molar

·        Unlikely to lose space here

·        Space maintenance is indicated for premature loss (in both primary and mixed dentitions)

·        Lateral and posterior shift of incisors may create arch discrepancy, particularly lower 1^st molars

·        Prior to, or During, Eruption of Permanent 1^st Molar
-The most critical time for space maintenance
-Mesial force of erupting molar may cause primary 2^nd molar to move into space
-Primary canine may also shift

·        After Eruption of Permanent 1^st Molar
-NO SPACE MAINTENANCE if premolar is nearing eruption (root is 1/2 to 2/3 formed w/ little or no overlying bone)
-All other cases need space maintenance

·        Appliance Types à band and loop, lingual arch, nance holding arch, transpalatal arch, removable acrylic as indicated

Primary second molar

·        Reserves space for permanent 2^nd premolars

·        Distal root guides erupting permanent 1^st molar

·        Premature loss usually results in mesial drift of permanent 1^st molar

·        Space maintaining device is needed to guide eruption of permanent 1^st molar

·        Caused by caries, extraction, ectopic eruption, and ankylosis

·        Prior to, or During, the Eruption of the Permanent 1^st Molar
-Distal Shoe à preferred in most cases; allows maximum control; contraindicated in medically compromised pts
-Removable Acrylic w/ Gingival Extension à in cases of multiple loss or medical situations; gingival extensions do not penetrate the gingival but exert pressure just mesial to mesial marginal ridge of unerupted perm. 1^st molar

·        After the Eruption of the Permanent 1^st Molar
-Determine status of succeeding bicuspid
-NO SPACE MAINTENANCE required if tooth is near eruption; otherwise yes
-Band and Loop, Lingual Arch, Nance Holding Appliance, Transpalatal Arch, Removable Acrylic as indicated

Child’s Perception

Previous Dental Experiences or Perception

Cognitive development

Fear/Anxiety

Age

Socialization and Peer Influence

Dental Management techniques

Emotional State

Familial influence

Strategy Developed

All above information is integrated into developing a behavioral strategy

Action

Either Acceptable or Unacceptable

General Characteristic

Behavior Management

Strong imagination

Can be used for distraction

Strong sense of trust

Honesty with patient is very important

Perceptions of others independent of overt appearances

You won’t fool children

Be yourself and be sincere

Children act on their emotions with less inhibition than adults

Expect immediate reaction to stimulus

Group

Age

Characteristics

Behavior Management

Infant

0 à 15 mo.

-Teething, chewing on anything

-Maternal antibody protection waning

-Stranger anxiety evident

-Cooperative behavior lacking

-Dental intervention usually informative or preventative (off bottle by 1 year)

-May be seen for trauma or pathology

General anesthesia in hospital an option for moderate to major dental needs

Toddler

15 mo. à 2 yrs

-Rapidly developing cognitive, verbal, and motor skills

-Cooperative behavior lacking

-No sense of cause and effect

-Unable to understand necessity of dental procedures

-Dental examination

-Usually done with child in parents lap or knee-to-knee

-Prophy/fluoride

-Opportunity to build trust; expediency and gentle touch essential

-Minor Dental Caries

-Can sometimes be done w/o local anesthesia

-Major Dental Caries

-Conscious sedation or general anesthesia

-Minor Oral Surgery

-Conscious sedation or general anesthesia

Preschooler

2 à 6 yrs

-Distinct personality developing

-Skilled in use of words and symbols

-Can be effective in interpersonal communication

-Behavior still influenced by immediate environment

-Play behavior involves significant role playing

-Dramatic fantasies

-Developing self-awareness is source of fears (real and unreal)

-Abstract thought not part of reasoning

-Time frames unimportant until age five

-Similar management for above procedures around age 2

-Change in management towards age 6 as child becomes more independent and self-aware

-Use of N₂O with older children

Transition Years

6 à 12 yrs

-Moderate but constant physical growth

-More independent

-Stress may induce more childish behavior

-Stronger peer group influence

-Able to reflect, reason, and understand logical relationships

-Dental Examination

-Routine

-Share findings with patient

-Dental Radiography

-Routing

-Be sure to account for developing / exfoliating teeth

-Prophy/Fluoride

-Routine

-Emphasize good habits

-Minor Dental Caries

-Routine management

- N₂O still useful

Adolescent

12 à 18 yrs

-Major Dental Caries

-Can usually manage in office by quadrants with N₂O

Know Yourself and Your Team

·        Strengths vs. weaknesses

·        Define comfortable behavior limits

A Kid-Friendly Office

·        Area of office scaled for children

·        Toys in waiting room

·        Videos or other entertainment

·        Small patient mirrors in operatories

·        Euphemism vocabulary for office

Pre-Appointment Communication with Parents

·        Relay office policies on behavior management

·        Get accurate patient information

·        Get parent input on child’s responses/actions

·        Parents should not voice dental fears in front of children

·        Parents should not use dentistry as a threat or punishment

·        Parents should not promise what the dentist will or will not do

·        Parents should not shame, scold or ridicule to allay fears of treatment

Be Prepared

·        Understand age-related typical behaviors

·        New Patients
-Inquire/note any past behavior problems
-Clearly communicate policies
-Confirm parent/legal guardian status
-Be prepared to answer questions on current media attention

·        Patients of Record
-Review past behavioral notes
-Discuss game plan with dental team prior to appointment

Appointment Considerations

·        Morning appointments are better for younger patients

·        Plan minimal waiting time

·        Schedule with team members who can translate if necessary

·        Short appointments

·        Offer parent information to prepare child for first visit

·        Be well prepared

·        Have flexible goals and back-up plans

Dental Term

Euphemism

Air-water syringe

Wind, air, squirt gun

Alginate material

Pudding, dough, cake mix

Alloy

Silver star

Silver filling

Anesthetic

Sleepy juice

Blood

Red, heme, pink

Caries/decay

Tooth bugs, Sugar bugs

Germs, Sick tooth, Spot

Dental explorer

Tooth counter, Tooth feeler

Etchant

Blue paint, Blue shampoo

Evacuator

Vacuum cleaner, Mr. Thirsty

Extraction

Wiggle the tooth, Sunshine

Fluoride

Tooth vitamins

High-speed handpiece

Tooth cleaner, water whistle

Mr. Whistl

Hurt/pain

Bother, Discomfort, Uncomfortable, “Owie”

Matrix

Fence for Star

Molt mouth prop

Tooth Pillow

Needle

Straw

Nitrous oxide

Space Gas, Silly Gas

Papoose board / Pedi-wrap

Blanket, Sleeping Bag

Prophy paste

Special toothpaste

Rubber dam

Raincoat

Rubber dam clamp

Tooth ring

Rubber dam forceps

Tooth ring holder

Rubber dam frame

Coat rack

Sealant

Plastic covering, White paint

Nail polish for your tooth

Slow-speed handpiece

Tooth Cleaner, Mr. Bumpy

Stainless steel crown

Silver Hat

Study models

Tooth Statues

Topical anesthetic

Cherry or Strawberry jelly

X-ray equipment

Tooth camera

X-ray film

Tooth picture

Technique

Use In Behavior Management

Appointment considerations

(See Question 6)

Approaching the patient in the waiting room

·        Evaluate patients potential behavior

·        Approach at child’s level to greet à use nickname

·        Talk with parent to establish trust

·        For solo visits, position yourself between parent and child in waiting room
-Parent are only allowed at Pacific Pediatric Clinic for:
    prevention instruction and treatment plan
    emergencies
    disabled child as needed
    interpretation
    very young children (pre-cooperative à >2-3 yrs)

·        Make positive statements about plan

·        Reassure child that parent will be waiting

·        Distract child as you walk back

Communication styles

·        Only one person should speak to child at a time

·        Voice modulation
-quiet, empathetic for scared patient
-firm, directive for confrontational patient
-always return to calm

·        Gender of speaker may influence child’s reaction

·        Non-verbal communication
-smile
-gentle reassuring touch
-tone between team members

Honesty

·        Never lie to a pediatric patient

·        Be understanding and try to explain

·        Empathize with child’s fears

Tell-Show-Do

·        Standard Policy for Pacific Pediatric Clinic

·        Tell the patient what you are going to do

·        Show the patient any instruments

·        Do the procedure

Knee-to-Knee exam

·        Standard Policy for Pacific Pediatric Clinic

·        Used in very young children

·        Patient is seated in assistant/parent lap facing assistant/parent

·        Operator sits knee-to-knee with assistant/parent

·        Assistant/parent holds one leg under each arm while holding patients hands

·        Patient is reclined on the operators lap

·        Operator stabilizes head and performs exam

Staff/Parent restraint

·         Standard Policy for Pacific Pediatric Clinic

·        Passive restraint à assistant/parent holds hands over patients hands at key points

·        Active restraint à assistant/parent actively holds patients hands (legs, shoulders if needed)

Mouthprops

·        Molt Mouth Prop
-Standard Policy for Pacific Pediatric Clinic
-Ratchet-type, adjustable, extraoral control

·        McKesson Prop
-Less effective
-Not adjustable, difficult to control in mouth

Injections

·        Use euphemisms, reassure patient, don’t lie

·        Use topical, inject slowly, distract patient

·        Hidden Syringe Technique
-Standard Policy for Pacific Pediatric Clinic
-Operator stabilizes head, finds landmarks
-Assistant transfers syringe under patient’s chin
-Assistant uncaps syringe
-Operator performs injection while stabilizing head
-Assistant manages patients arms/hands
-Operator removes syringe from mouth, passing it over arm while maintaining head stabilization
-Operator recaps syringe

·        Always confirm profound anesthesia before proceeding

Papoose board / Pedi-wrap

·        Papoose board is Standard Policy

·        Immobilizes child’s limbs for difficult procedures

·        Most often used in pre-cooperative child, disabled or uncooperative in emergencies

·        Specific parental consent required

·        Presented as positive as possible (euphemisms)

·        Usually used with sedated patients

Nitrous Oxide and Oxygen

·        Works well with cooperative patient

·        Will not work w/ patient who is defiant or who cannot breath through nose

·        Can be presented to patient as and adjunct that patient can control

·        Vomiting is the most common complication

·        Confirm that patient has not eaten prior to appointment

·        Avoid adjusting level of nitrous à leads to vomiting

·        Usual working range à 30-50% nitrous

·        Standard Policy à requires instructor administration

Conscious sedation & general anesthesia

·        Most often used in pre-cooperative, defiant or disabled patients

·        Conscious sedation à protective reflexes intact

·        General anesthesia à no protective reflexes

·        Extra training and certification required

·        GA administered in hospital, outpatient surgery, office

·        Additional treatment costs à often not covered by insurance

Discuss behavior with patient

·        Praise positive behavior and make suggestions for future improvement

·        Never berate the patient for negative behavior

Discuss next procedures with patient

·        Repeat this information to parents

Report on child’s behavior to parent

·        Give parents honest assessment of patient’s behavior

·        Praise any positive behavior and make suggestions for future improvement

·        Discuss and future behavior management techniques with parent

Explain to parents how they can help

·        Reinforce what has been told to patient while at home

Surgeon General’s Report, 2000

·        Specifically addressed oral health

·        Underserved pediatric patients

·        Will drive federal/state funding for many years

American Academy of Pediatric Dentistry

·        Longstanding public awareness campaign

·        Combined educational efforts with American Academy of Pediatrics

Public Information

·        Increase internet access

·        State and Federal initiatives via Medicaid, etc.

Assess expectant mother’s OH status and improve where possible

·        Take care of all restorative needs

·        Advise on oral hygiene practices

·        Consider chlorhexidine, xylitol gum, etc.

Educate mother on infant oral hygiene care

·        Initiate intraoral cleaning before teeth erupt

·        Teething management

·        Feeding guidelines

Topical

Systemic

Concentrates in plaque

Disrupts bacterial enzyme structure

Buffers bacterial acids

Inhibits demineralization

Promotes remineralization

Qualitatively improves enamel crystal structure

Reduces acid solubility of enamel

OTC

Professional Prescibed/Applied

Toothpaste (ADA seal)

          Supervised until age 6

          Avoid excess ingestion

          Kid flavors

          Pea-sized amount only

Prophy Paste

          Minimal due to rinsing

Gel or Foam

          Applied in trays

          Brushed on for less coop. pts

Topical Rinses

          Use on brush, after toothpaste

          Supervised until age 6

          Avoid excess ingestion

          Kid flavors – bubble gum

          Use at bedtime after brushing

          No eating/drinking after

Fluoride varnishes

          May have some systemic effects

          Resin-based varnish embedded with fluoride

          Typically applied to facial surfaces of all teeth

          Causes transient discoloration – yellow/brown

          Unpleasant taste

          Highly concentrated fluoride à use care

Prescribed rinses for home use

          Usually applied weekly

          Risk of alcohol and excess fluoride ingestion

          Avoid patients with poor compliance

Prescribed gels for home use

          May require custom trays

          Usually applied daily or weekly

          Risk of excess fluoride ingestion/toxicity

OTC

Professionally Prescribed

Very little, except vitamins

Considerations

          Always based on patients current fluoride exposure

          Always inquire if patient is taking multi-vitamins

          Water should be in plastic for assay

          Dose based on patient’s age and ambient exposure

          Can be dispensed as chewable tablets, lozenges or liquid

Age

< 0.3ppm

0.3 – 0.6ppm

> 0.6ppm

 Birth to 6 mo.

0.0 mg F/day

0.0 mg F/day

0.0 mg F/day

6 mo. – 3 yrs

0.25

0.0

0.0

3 yrs – 6 yrs

0.50

0.25

0.0

6 yrs – 16+ yrs

1.00

0.50

0.0

Description

Occurrence

·        Permanent intrinsic white-to-brown discoloration of enamel

·        Microabrasion may or may not improve appearance (more effective with white lesions)

·        Teeth highly resistant to caries

·        Increasing frequency due to increased ambient fluoride exposure

·        Inclusion in vitamins

·        Inappropriate prescribing

·        Chronic toothpaste or fluoride rinse ingestion

·        Increased diet exposure

Child’s First Visit?

·        Young child (< 3yrs) indicates concern for dental health or emergency situation

·        First visit for a school age child à lack of interest and low dental IQ

Family Seeking New Dentist?

·        Just moved

·        Unhappy with previous dentist à Why?
    cost, management
    parents are tough to please
    remember there are always two sides
    avoid criticizing previous practitioner or care

·        Referral due to complex treatment needs
    additional information may be available

Parent’s Expectations of Child’s Behavior

·        Honest predictions are usually accurate, and helpful

·        Parents sometimes expect dentist to deal with negative behavior

·        Child will use strategies that are effective at home

Community Fluoride

·        Many don’t know the status of fluoride in community water

·        Maps are available indicating fluoridation areas

·        Water assay à plastic bottle

Past Dental Experiences

·        May have had unpleasant past experiences

·        “Will treatment be the same or different?”

·        A common complaint is lack of communication

Facial Anaylsis

Profile

Flat, concave, convex

Lip Posture

Protrusive, retrusive, open, closed

Lip Closure

Strained, unstrained

Facial Symmetry

Yes, no

Oral Exam

Nodes

Unilateral, bilateral, submandibular, sublingual, cervical, palpable, non-palpable, fixed, fluctuant, tender

Gingiva

Edematous, erythematous, BOP, rounded vs. sharp margins, stippled vs. smooth, pigmentation

Frenum

High, low, involved

Attached Gingiva

Sufficient, insufficient

Plaque

Generalized, localized, mild, moderate, severe

Calculus

Yes/no, supragingival, subgingival

Mucosa

Pink, pigmented, lesions and location, dry, moist

Lips

Labial salivary glands, mucoceles, commisures

Palate

u-shaped, v-shaped, high/moderate/shallow, narrow/moderate/wide, lesions

Tonsils

Brodsky’s Tonsil Classification System

          0 à not obstructing airway

          1 à just outside tonsillar fossa; obstruction < 25% of airway

          2 à readily seen in airway; obstruction of 25-50% of airway

          3 à obstruction of 50-75% of airway

          4 à obstruction of > 75% of airway

Tongue

Range of motion, borders, dorsum, ventral surface, coating, lesions

Floor of mouth

Symmetrical, asymmetrical, lesions

Saliva

Serous, mucous, copious, xerostomia

Caries

Mild, moderate, severe

Dental Maturity

On time, delayed, precocious

Teeth

Number, size, shape, color

Occlusion

Primary à flush, mesial step, distal step

Permanent Molar Classification à Class I, II, III

Canine Classification à Class I, II, III

Open bite à anterior/posterior

          Vertical distance from max. to mand. incisal/occlusal in mm

Overbite à vertical expressed as a percentage of overlap

Overjet à horizontal in mm (lingual of max. to facial of mand.)

Midline deviation

Crossbite, crowding, space loss

Spacing, Orthodontic needs

Oral Habits

Tongue thrust

Digit habit

Lip licking, chewing

Tobacco use

Other Aids

Photography, transillumination, study casts, vitality testing, percussion, laboratory testing