Summer Midterm Exam Review

Pediatric Dentistry – Summer Midterm Exam Review

Topics for Summer Final

Topics for Fall Midterm

Topics for Fall Final

Growth and Development

Development of the Primary Dentition

Dental Anomalies

Diagnosis of Soft Tissue & Periodontal Problems

Radiographic Technique and Interpretation

Sample Questions

Growth and Development

1) Describe the growth assessment parameters

Chronologic age	Amount of time since birth (years and/or months)
Biologic age	Progress toward various developmental stages
Developmental age	Physical changes related to specific chronologic ages, as compared to established developmental milestones
* Skeletal age	An assessment of skeletal age must be based on the maturational status or markers within the skeletal system à Hand and wrist radiographs show degree of calcification à very accurate in terms of development
* Dental age	Determined according to which teeth have erupted, the amount of resorption of the roots of primary teeth and the amount of development of the permanent teeth à some differences between boys and girls
Behavioral age	Assessing typical personally characteristics related to specific chronological age
Mental age	Intellectual development, assessing mental abilities in relationship to chronological age

Height – most common measured parameter

From 6 months to puberty à extremities grow more rapidly than the trunk à then the rates become similar

Body Weight – alone is not always a good indicator

Related to nutrition

Average birth weight is 7.5 lbs with an initial drop immediately after birth

Child gains weight @ 1 lb/month

Head Circumference – normally reflects an increase in size of brain

Bones remain separated for first 2-3 years

By age 2, ~90% of adult head size is attained

Factors Affecting Growth

Genetic – race, body size, skeletal maturation, sexual maturation

Environmental – pre-natal insults, post-natal insults, disease, socio-economic status

Hormones – hormonal secretion (insulin, TSH, thyroid, pituitary)

Nutrition – malnutrition delays growth and affects the quality of tissues

2) Describe the patterns of systemic growth

Neural	Brain, spinal cord, upper face, skull, optic/auditory systems 95% brain growth by 7-8 years
Lymphoid	Thymus, lymph nodes, intestine Peak at 10-12 years Large tonsils normal between 6-12 years
General	Skeleton, musculature, respiratory and digestive tracts, kidneys, etc Head and neck are not included Accelerated growth during adolescence
Genital	Testis, ovaries, urethra and prostate Primary and secondary sex characteristics Puberty onset is usually 2 years later in boys compared to girls

3) Describe the types of growth in the craniofacial complex and the primary growth sites

Cranial Vault – made of flat bones; initial growth by periosteal activity; later growth by apposition

Cranial synostosis – premature fusion of fontanelles; cranial vault shape deformities

Cranial Base – initially formed by cartilage; later transformed by endochondral ossification

Maxilla – develops postnatally entirely by intramembranous ossification

Growth occurs by apposition at the sutures and surface remodelling

Movement is downward and forward

Some bone is added in the tuberosity region

Mandible – growth by endochondral and periosteal activity

Principle sites of growth à posterior surface of ramus; condylar and coronoid process

Length à Appositional growth on the posterior surface of the ramus and resorption on the anterior surface of the ramus

Height à Endochondral replacement at condyle and surface remodeling

Movement is upward and backward

Craniofacial Primary Growth Sites

Cranium	Sutures and synchondroses
Midface	Sutures and cartilaginous nasal septum
Mandible	Posterior surface of ramus, condylar and coronoid processes

Pre-natal Developmental Milestones

3^rd – 6^th week	Major development of the face
6^th week	Deciduous tooth buds appear
7^th – 8^th week	Fusion of palatal shelves (potential for cleft palate)
14^th week	Deciduous teeth begin to calcify
Birth	Permanent teeth begin to calcify

4) Understand the three phases of Margaret Mahler’s Separation-individuation theory
Autism – at infancy; child only aware of stimuli and responses

Symbiotic – through first year; child understands role of caretaker

Separation-Individuation – through the third year; child must cope with separation anxiety

Separation Conflict – arises again during adolescence;

5) Understand the psychosocial theory of Erik Erikson

Birth to three years – Begins with achieving a sense of trust; oral period; increased autonomy

Three to six years – increased sense of independence and ambition; ready to leave home

Adolescence – identity conflict eventually resolving into a true sense of identity

6) Understand the sensorimotor theory of Jean Piaget

Newborn – two sets of reflexes à 1) stimulus-response pattern not altered by experience

2) stimulus-response pattern influenced by repeated and changing experiences

By Age 1 – child achieves intentional motor exploration and temporal-spatial concept of place and objects

By Age 3 – increased intelligence and stable motor ability

By Age 6 – sensorimotor tasks are very important; artistic and competitive sports interests are evident

7) Describe typical behavior patterns of children 2 to 16 years of age and how the dentist should respond

Preschooler – tries to please; able to reason; respond to fantasies and imagination; talk at their level, not below;

75% of communication is non-verbal; seek cooperation rather than understanding

Middle Years – increase in fear (from separation); interested and usually cooperative

Give them some control (raise hand); give options

Adolescent – generally cooperative mixed with turmoil; some are truly apprehensive

Open door or stay all day techniques are efffective

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Development of the Primary Dentition

1) Know when calcification starts and status at birth of primary dentition

Tooth	Initial Calcification (in utero)	Status at Birth
Max. Primary Central	14 weeks	5/6 complete
Max. Primary Lateral	16 weeks	2/3 complete
Max. Primary Canine	17 weeks	1/3 complete
Mand. Primary Central	14 weeks	3/5 complete
Mand. Primary Lateral	16 weeks	3/5 complete
Mand. Primary Canine	17 weeks	1/3 complete
Mand. First Primary Molar	15 weeks	Occlusal surface calcified
Mand. Second Primary Molar	18 weeks	Distal pit area of occlusal surface not calcified
Max. First Primary Molar	15 weeks	Occlusal surface calcified
Max. Second Primary Molar	19 weeks	Coalescence of cusps
First Permanent Molars	28-36 weeks	Some calcification of cusps but no coalescence

2) Describe the anomalies in the newborn’s mouth

Inclusion Cysts – 75% of newborns; small, firm, white mucosal lesions; all typically resolve on their own

Epstein’s Pearls à mid-palatine raphe; remnants of trapped epithelium

Bohn’s Nodules à buccal and lingual aspects of the dental ridges; remnants of mucous gland tissue

Dental-Lamina Cyst à crest of ridges; remnants of the dental lamina

Natal and Neonatal Teeth – natal (present at birth) or neonatal (erupting in first few weeks); treatment depends on type

Predeciduous (1 in 4000)à supernumerary; structurally defective w/ mobility; calcified crowns w/ malformed roots

Removal is generally recommended

Primary Teeth Erupted Prematurely (1 in 2000)à normal teeth; extraction should be avoided

Differentiated by radiographs

Eruption Hematoma – bluish-purple elevated tissue a few weeks prior to eruption of a tooth

Most frequently associated with primary second molar or first permanent molar; treatment is unnecessary

3) Describe the formation and eruption pattern of primary and permanent teeth

All calcification has begun by 3-4 months in utero

While deviations may exist, eruption generally begins around 6 months of age

Typical Sequence à Mandibular central incisors 6 months

Maxillary central incisors 7 months

Mandibular lateral incisors 7 months

Maxillary lateral incisors 9 months

Mandibular first molars 12 months

Maxillary first molars 14 months

Mandibular canines 16 months

Maxillary canines 18 months

Mandibular second molars 20 months

Maxillary second molars 24 months

Formation of roots is nearly complete by three years of age

4) Describe the anatomic characteristics of primary teeth

Crowns are shorter with cervical bulge and constricted occlusal table

Contact areas are broader and more flat

Enamel and dentin are thinner (lighter color, less translucent)

Larger pulp area with horns more pointed and closer to surface of each cusp

More irregularity in canals

Roots are longer and more slender and flare as they approach the apex (may wrap around developing permanent tooth)

5) Describe the morphologic differences between primary and permanent teeth

(see above)

6) Describe the development of the primary occlusion

In general the primary occlusion is more in line and with less deviation from normal than the permanent dentition

Spacing – generalized spacing; lack of space may indicate narrow arches

Primate Space à distal to mandibular canines (0-6mm, avg. of 3mm) and mesial to maxillary canines (0-10mm, avg. of 4mm)

Arch Dimensions – the following denote growth changes in the maxilla and mandible

Arch Width à distance between corresponding teeth on the left and right side (usually cusp tips of canines, or ML cusps of

molars); width across the alveolar arch does not increase with age; growth is posteriorly

Arch Length à distance between a line tangent to labial surfaces of central incisors and a line connecting the distal surfaces

of 2^nd primary molars; measured with respect to space associated with deciduous teeth even though not present

an important factor determining the position of the first permanent molars

Arch Circumference à length of the curved line passing over the buccal cusps or incisal edges of all teeth

Arch Height à increase in height of the alveolar bone as it grows over time; difficult to measure; little or no change during

primary dentition

Overbite – distance which the maxillary incisal margin closes vertically past the mandibular incisal margin in CO

Average overbite in primary dentition is 1-2mm

Overjet – horizontal measurement of the distance between the lingual aspect of the maxillary incisal margin and the labial surface

of the mandibular incisors in CO

Average overjet in primary dentition is 1-2mm; decreases significantly with bruxers by age 6

Molar Relationship – three possibilities at primary eruption with a variety of permanent eruption possibilities

Distal Step à always results in a Class II permanent molar relation

Flush Terminal Plane à most common primary relation; typically results in a Class I permanent relation; sometimes results in

a Class II or even an End-to-End permanent relation

Mesial Step à without treatment may result in a Class III permanent relation; careful planning can result in a Class I relation

Canine Relationship – best indication of actual relationship of maxilla and mandible; very stable

Class I à mandibular canine fills embrasure between maxillary lateral and canine

Class II à any relation distal to Class I

Class III à any relation mesial to Class I

Exfoliation – many theories attempt to accurately describe how teeth exfoliate

Resorption of Primary Teeth à pressure exerted by permanent teeth; increased pressure on primary tooth; inflammation (?)

Gubernaculum Dentis à a small pore containing connective tissue, blood vessels, nerves, and remains of the successional lamina

Has some connection between the primary tooth and the developing successor, and may play a role in the resorption and

subsequent replacement (guides eruption of permanent tooth)

A multifactorial process

7) Describe the development of the mixed dentition stage

With the eruption of the first permanent molars, the mixed dentition stage begins

Mandibular First Molar	6-7 years	Early Mixed Dentition
Maxillary First Molar	6-7 years
Mandibular Central Incisor	6-7 years
Maxillary Central Incisor	7-8 years
Mandibular Lateral Incisor	7-8 years
Maxillary Lateral Incisor	8-9 years
Mandibular Canine	9-10 years	Late Mixed Dentition
Maxillary First Premolar	10-11 years
Mandibular First Premolar	10-12 years
Maxillary Second Premolar	10-12 years
Mandibular Second Premolar	11-12 years
Maxillary Canine	11-12 years
Mandibular Second Molar	11-13 years
Maxillary Second Molar	12-13 years

Notes: girls commonly erupt permanent teeth earlier than boys

eruption usually follows exfoliation by about six months

enamel is complete about 3 years prior to eruption

root formation is complete about 3 years after eruption

The eruption of the 1^st permanent molar causes a closing of the space that exists between the primary posterior teeth

This acts to reduce arch length

Incisor Transition (age 6-8) is critical for developing dentition

Maxillary and mandibular permanent incisors are bigger than primary incisors à incisor liability

Ugly Duckling Stage à extra space between centrals as canines develop and begin to erupt

Further eruption of the canines will close the space

Leeway Space à due to size difference between primary and permanent teeth

Used up by mesial movement of the permanent molars

Permanent teeth erupt when 2/3 to 3/4 of the root formation is complete

8) Describe the development of the mixed dentition occlusion

(See #7 above, or info on occlusion)

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Dental Anomalies

1) List the growth stages of a tooth

Initiation (bud)

Proliferation (cap)

Histodifferentiation (bell)

Apposition

Calcification

Eruption

Attrition

2) Describe the embryological development of teeth and state the tissue layer origin of each portion of the mature tooth

Mature tooth is a result of interaction and differentiation of ectodermal and mesodermal cell populations

3) List and discuss the normal age ranges of tooth formation, eruption and exfoliation of both dentitions

(See development)

4) Categorize abnormal appearing teeth and structures

Congenital à existing at birth

Developmental à occurring during growth or expansion

Inherited à acquisition of the trait or quality by genetic transmission

Categorized by à Number Shape Color Structure/Texture Eruption/Exfoliation Position

5) Identify the growth stage during which each type of anomaly occurs

(see above)

6) Define the various dental anomalies of number and relate their frequency in both dentitions

Anodontia	Total absence of teeth Very rare *May be associated with severe forms of anhidrotic ectodermal dysplasia
Hypodontia	*Absence of one or a few teeth
Oligodontia	Absence of many teeth Patients with absent teeth usually have other abnormally shaped teeth 1-2% in primary dentition 3-9% in permanent dentition Most commonly absent à third molars, mandibular second premolars, maxillary lateral incisors, maxillary second premolars Absence of mandibular second premolar is frequently accompanied by ankylosis and subsequent submergence of primary teeth in that area
Hyperdontia	Supernumerary Teeth Rare in primary dentition (0.5%-1%) Seen more in permanent dentition (1-4%) Seen in maxilla 9X more than mandible Seen in males 2X more than females Frequently associated with cleinocranial dysplasia, Gardner’s syndrome, cleft lip and palate *Tx à extraction

7) State at what age a definitive diagnosis of congenitally absent maxillary laterals and mandibular second bicuspids can be made

Final diagnosis cannot be made until five to six years of age

8) Discuss time and type of interceptive treatment indicated for congenitally missing teeth when unilaterally and bilaterally absent

Decisions can be made around age 4, but no treatment until age 7

Options à diastema closure; prosthetic appliance; implants

9) List the disorder syndromes commonly associated with multiple missing and extra teeth

Anhidrotic ectodermal dysplasia

Down’s Syndrome

Cleft lip and palate

Orofacial-digital syndrome

Mental retardation

Cleinocranial dysplasia

Gardner’s syndrome

10) State the most common locations for congenitally missing and supernumerary teeth

Missing à third molars, mandibular second premolars, maxillary lateral incisors, maxillary second premolars

Supernumerary à maxilla 9X more than mandible

11) State time and type of treatment indicated for supernumerary teeth in the maxillary anterior region

Extraction – performed early, even prior to eruption; often delayed until age 10

12) Discuss how you would determine the etiology of stained teeth and how you would counsel parents and child on your finding

Determined through a complete medical and family history

13) Explain the differences between hereditary, congenital, and developmental anomalies

Congenital à existing at birth

Developmental à occurring during growth or expansion

Inherited à acquisition of the trait or quality by genetic transmission

14) Define and suggest treatment (if indicated) for each of the following anomalies of shape:

Anomaly	Definition	Treatment
Gemination	One tooth bud invaginating during prolifertation Results in one tooth with one root canal and a divided crown Produces crowding	Correction of Occlusion Correction of Esthetics Restoration of Caries in Grooved Areas
Concrescence	Two tooth buds joined at the cementum Have individual roots and crowns	Correction of Occlusion Correction of Esthetics Restoration of Caries in Grooved Areas
Fusion	Two tooth buds joining to produce one tooth Fused dentin and crown Esthetic problems and crowding	Correction of Occlusion Correction of Esthetics Restoration of Caries in Grooved Areas
Dilaceration	Multiple bends in a root due to trauma during morphodifferentiation
Dens Invaginatus (Dens in Dente)	Tooth within a tooth May be in pulp chamber or PDL	Pulpal protection is necessary
Hutchinson’s Incisors	Resulting from congenital syphilis Crowns are tapered Incisal edges are notched	Correction of Occlusion Correction of Esthetics Restoration of Caries in Grooved Areas
Taurodontism	Enlarged body of tooth and smaller roots Elongated pulp chamber Associated with trisomy 21
Shovel-shaped Incisors	Prominent margins, shallow lingual surface Most common in maxillary incisors Possible formation of lingual pit	Pit sealant or other restoration
Supernumerary Cusps/Roots	Found throughout the mouth Added pits and fissures Abnormal pulpal morphology	Recontouring and bonding/sealants Endo therapy and extraction difficulty
Microdontia	Abnormally small teeth Associated with Down’s Syndrome and Fetal Alcohol Syndrome	Correction of Occlusion Correction of Esthetics
Macrodontia	Abnormally large teeth Seen in localized areas	Correction of Occlusion Correction of Esthetics

15) Discuss the differential diagnosis of the following unusually colored teeth:

Color Anomaly	Differential Diagnosis
Yellow	Tetracycline staining Abnormal calcium metabolism Amelogenesis imperfecta
Brown	Tetracycline staining Abnormal calcium metabolism Amelogenesis imperfecta Cystic fibrosis Porphyria Turner’s local trauma hyperplasia Deposition of salivary mucins with metal content
Blue (Blue-green)	Erythroblastosis fetalis Rh incompatibility Sickle cell anemia or Thalassemia Staining of secondary enamel cuticle Extrinsic stains
White	Amelogenesis imperfecta Fluorosis Snowcapped teeth Traumatic opacities
Red-brown	Porphyria
Gray	Dentinogenesis imperfecta Tetracycline staining Post trauma necrotic pulp
Pink	Internal resorption (large pulp)

16) Recognize anomalies of structure and texture of enamel and dentin (both biochemically and radiographically)

Anomaly of Structure/Texture	Characteristics
Dysplasias	Enamel or dentin Generally as hypocalcification or hypoplasias May be due to inherited disorders, systemic disorders, trauma
Amelogenesis Imperfecta	Hypocalcification or hypoplasias of enamel All are inherited (autosomal dominant) Decreased density and decreased quantity of enamel Tx à pulpal protection, occlusal protection, esthetic corrections
Dentinogenesis Imperfecta	Hypoplasia and decreased inorganic substance of dentin with increased organic matrix causing weakened dentin Coloration generally gray or brown Abnormal shape (bell shape crowns) Shell teeth
Dentinal Dysplasia	Dentin defect Characterized by shortened roots, apical bifurcation and rarefactions Early loss of teeth
Fluorosis	Abnormal enamel Increased hardness Coloration abnormalities Prevent by monitoring fluoride intake Tx à esthetic corrections
Porphyria	Normal hardness of enamel Abnormal dark coloration (red-brown) Tx à esthetic corrections
Horizontal Linear Hypoplasia	Related to many diseases and disorders Level depends on stage of formation when insult occurs Tx à protection of hypoplastic area, esthetic corrections
Localized Enamel Hypoplasia	Due to trauma, radiation, localized infection, drug therapy Related to cleft lip and palate
Hypercementosis	Excessive formation limited to apical half of root Affects vital teeth Most common in premolars May be a protective response to chronic inflammation of PDL Related to Paget’s disease

17) Differentiate between the hereditary, systematic and traumatically caused structural anomalies of dentin and enamel

Hereditary

Systematic

Trauma

Dysplasias

Amelogenesis Imperfecta

Dentinogenesis Imperfecta

Dysplasias

Dentinal dysplasia

Fluorosis

Porphyria

Horizontal linear hypoplasias

Hypercementosis

Dysplasias

Localized enamel hypoplasia

18) State the time of action of a developmental disturbance given a particular pattern of clinical lesions (i.e., linear and localized hypoplasias)

This is accomplished by understanding the timing of calcification and tooth development in addition to patient history

19) Discuss early and late eruption of teeth indicating the disorder states in which these anomalies may be found

Eruption Anomaly	Associated Disorder
Early Eruption (natal or neonatal teeth)	Hypophosphatasia, hyperthyroidism, hemifacial hypertrophy Reticular endotheliosis (Hand-Schuller-Christian disease) Ellis von Crevold chondroectodermal dysplasias Hallermann-Streiff syndrome, Sturge Weber syndrome Tx à extraction for high risk of aspiration
Premature Loss	Toxicities à mercury poisoning, radiation Metabolic errors à scurvy, acatalasia, hypophosphatasia, juvenile diabetes, Gaucher’s disease Malignancies à leukemia, cyclic neutropenia, hystiocytosis X, Wiskott-Aldrich syndrome Dental Related à dentinal dysplasia, aggressive periodontitis, Papillon-LeFevre syndrome
Delayed or Failed Eruption	Trisomy 21, Cleinocradial dysplasia, hypothyroidism Hypopituitarism, Vitamin D –resistant rickets Cranofacial synostosis, Supernumerary teeth, Follicular cysts Low birth weight, trauma, over-retained primary teeth Ankylosis of primary teeth, cryptodontic brachymetacarpalia Hunter’s and Hurler’s syndrome (mucopolysaccharidoses)
Ectopic Eruption	Most frequently seen in the lower incisal region Permanent teeth erupt lingual to the primary Buccally place canines
Over-retention of primary teeth	Especially in lower incisal area Causes anomalous eruption and position of permanent teeth Should be removed and may need orthodontic consult
Ankylosis	Discontinuous eruption of teeth Apparent submergence of dental arch Causes collapse of teeth and loss of space May be caused by trauma, with some familial pattern More common in the maxilla (primary 2^nd molar > primary 1^st molar) Anterior teeth may be involved secondary to trauma Often associated with enamel defects Tx à luxation, extraction, prosthetic replacements, orthodontic movement

20) State the frequency, location, side effects and treatment for natal (neonatal) teeth

(see info on natal and neonatal teeth in above table, or in section 2)

21) List the locations in which ectopic eruption most frequently occurs

(see info on ectopic eruption in above table)

22) Identify occlusal disharmonies related to abnormal position of teeth in the arches

May include all occlusal disharmonies but here are some examples:

Lingually erupting mandibular incisors

Loss of space due to ankylosis

Anterior crossbites

Open anterior bite due to thumb sucking

Malposition of maxillary incisors due to the presence of a mesiodens

Palatal location of an erupting premolar

Loss of space due to caries or improper restoration

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Diagnosis of Soft Tissue & Periodontal Problems

1) Describe and understand the classification of soft tissue problems based on the severity of the disease and the systemic health of the patient

Soft tissue problems are classified as gingivitis or periodontitis with associated severity in health and disease

2) Describe the conditions discussed as gingivitis associated with systemic health, and understand the etiologies, prevalence, diagnostic features and treatment for each

Condition	Information
Chronic gingivitis	Always associated with dental plaque Actinomyces, streptococcus, fusobacterium, and treponema species, and prevotella intermedia Other factors include à poor oral hygiene, malposed teeth, exfoliating teeth, erupting teeth, carious teeth, food impaction, mouth breathing S. mutans is antagonistic (increase caries = decrease gingivitis) Gingivitis in children does not usually progress to periodontitis
Pubertal gingivitis	Increased levels of estrogen and progesterone are associated with overgrowth of P. intermedia
Necrotizing Ulcerative Gingivitis (NUG)	Associated with poor oral hygiene, emotional stress, fatigue Gingival bleeding, pain, necrosis of interdental papillae, lymphadenopathy, and malaise Tx à excellent oral hygiene, peroxide or chlorhexidine rinse, antibiotics (if secondary)
Acute Primary Herpetic Gingivostomatitis	Lesions develop in 10-20% of people after first infection Fever, malaise, lymphadenopathy, mucosal inflammation Vesicular lesions that burst to form ulcers Lesions may appear anywhere in the mouth Tx à supportive (bland foods, liquid supplements, soothing mouthrinses), antibiotics not indicated Similar to NUG or herpangina
Gingival Enlargement (Orthodontics)	Caused by reaction to appliance or tissue compression during space closure Gingival overgrowth *without* inflammation Usually on the facial of anterior region Patient may have excellent oral hygiene Tx à none; usually resolves after removal of braces
Pericoronitis	Caused by food or plaque accumulation under operculum of erupting tooth Usually around mandibular permanent molars Inflammation and pain Fluctuant swelling and/or pus Fever and trismus in severe cases Tx à irrigate, no anesthesia for mild case, ibuprofen for 3 days, soft foods If more serious, anesthetize IA and Buccal then excise operculum with electrosurgery unit; antibiotics for 5 days, ibuprofen and soft foods for 3 days

3) Describe the conditions discussed as gingivitis associated with systemic disease, and understand the etiologies, prevalence, diagnostic features and treatment for each

Condition	Information
Drug-Induced Gingival Enlargement	Begins in papillary areas Poor oral hygiene enhances condition Mechanism unknown Not dose related May resolve when drug removed Dilantin, Cyclosporin, Calcium Channel Blockers (Nifedipine) Tx à meticulous oral hygiene, surgical intervention, drug substitution, positive pressure appliance
HIV-Associated Gingivitis	Punctute and diffuse erythema May involve entire attached gingival Pain is common Marginal intense erythema 2-3 mm apical to FGM Tx à meticulous oral hygiene, chlorhexidine bid

4) Describe the conditions discussed as periodontitis associated with systemic health, and understand the etiologies, prevalence, diagnostic features and treatment for each

Condition	Information
Aggressive Periodontitis	Generally occur in younger people May involve primary or permanent teeth May be localized or generalized
Localized Aggressive Periodontitis	Present in 0.2% of adolescents w/ onset at 11-13 years Radiographic severe angular bone loss of incisors and 1^st permanent molars Little gingival inflammation and supragingival plaque Subgingival plaque present Associated with Actinobacillus actinomycetumcomitans Tx à root planing and improved good oral hygiene are not good enough alone; antibiotic therapy (amoxicillin+metronidazole 250mg each tid X7 days
Necrotizing Ulcerative Periodontitis (NUP)	Essentially NUG with attachment and bone loss Tx à differs little from chronic periodontitis

5) Describe the conditions discussed as periodontitis associated with systemic disease, and understand the etiologies, prevalence, diagnostic features and treatment for each

Condition	Information
Diabetes Mellitus	Insulin dependant à 10% risk in 13-19 year olds Non-Insulin dependant à 1% risk Related to neutrophil defect
Trisomy 21	Severe and rapid periodontitis may affect both dentitions Premature loss of lower incisors Short roots worsen the problem Class III malocclusion worsens problem
HIV Periodontitis	Severe pain, soft tissue necrosis, rapid bone loss Tx à root planing, periodontal surgery, chlorhexidine rinse, frequent recall
Leukemias	Attachment loss, swollen gingival, bleeding gingival, bluish gingival, pain Tx à relieve pain and hemorrhage, maintain good oral hygiene

6) Know the common soft tissue problems in children as discussed in the lecture and the information associated with each

Condition	Information
Recurrent Herpes Labialis	Herpes lies dormant in the trigeminal ganglion Triggered by stress, trauma, UV light Vesicles erupt and form ulcers Tx à palliate (benzocaine), antivirals (acyclovir and valacyclovir not approved in children)
Apthous Ulcers	Autoimmune response Triggered by stress, trauma, foods, sodium lauryl sulfate Vesicles erupt and form ulcers Movable mucosa Tx à avoid triggers, chlorhexidine rinse, palliative (benzocaine), corticosteroids
Localized Recession	Attributed to lack of attached gingival Most common in mandibular anterior area Retract lips and check for blanching of FGM Tx à variety depending on other factors (graft, monitor)
Ankyloglossia	Higher than normal lingual frenum attachment Tx à early treatment not recommended due to potential of infection; frenectomy only if severe
Eruption Hematoma	Blue swelling of gingival as tooth is erupting Blood in dental follicle Tx à none; usually resolves on its own; incise to avoid pain
Mucocele	Cyst-like structure Most common on lower lip Due to severance or partial obstruction of salivary duct Ranula is a large mucocele on the floor of the mouth Tx à surgical excision
Dental Abscess	Arises from infection due to caries or trauma Localized swelling of gingiva or mucosa Fistula may be present Usually asymptomatic Tx à drainage; extraction; endodontic treatment no antibiotic needed if prompt drainage
Facial Cellulitis	Arises from dental, bone or periodontal infection Diffuse infection of facial planes Possible fever and leukocytosis Tx à antibiotics; remove source of infection, monitor hospitalization if periorbital swelling or difficulty in swallowing or breathing (Ludwig’s Angina)
Cheek Bite	Initially bleeding and ragged Yellow and sloughed tissue Looks worse than it is Tx à meticulous oral hygiene, antibiotics if pus or fever

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Radiographic Technique and Interpretation

1) Know the risk and benefits of pediatric dental radiography

Risk is associated with radiation exposure

Effects of radiation are cumulative

Benefit as a diagnostic tool

2) Know and clinically apply pediatric dental radiographic safety measures

Lead apron and thyroid shield for all patients

Use “F” speed film

Keep proper records

3) Understand and apply behavior management principles when taking pediatric dental radiographs

4) Prescribe a proper radiographic survey for a child based on that child’s individual needs

5) Understand the diagnostic value of specific radiographs

6) Know how to perform a systematic and comprehensive examination of children’s radiographs

7) Identify normal and abnormal anatomic structures as seen in children’s radiographs

8) Identify normal and abnormal oral and dental development as seen in children’s radiographs

9) Diagnose pathosis in children’s radiographs

10) Use radiographs to evaluate restorative and pulpal therapy procedures

11) Explain radiographic finding to parents

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Sample Questions

1) At what age do the deciduous (primary) tooth buds appear? (b)

a. 5 weeks in utero

b. 6 weeks in utero

c. 14 weeks in utero

d. 20 weeks in utero

e. at birth

2) The general growth (skeleton, musculature, etc.) curve reaches 100% of adult size _______ the neural growth curve. (b)

a. before

b. at the same time as

c. after

3) Which of the inclusion cysts in newborns is found along the crest of the alveolar ridge, and what is its tissue of origin? (d)

a. Epstein's Pearls / Epithelium

b. Bohn's Nodules / Epithelium

c. Dental-Lamina Cyst / mucus gland tissue

d. Dental-Lamina Cyst / dental lamina

e. Bohn's Pearls / Oysters

4) Your patient is 3 years old. Her primary mandibular central incisors have a demineralized, discolored band just below the incisal edges, and the incisal edges of her primary maxillary central incisors appear rough. You surmise that this is a due to a developmental disruption. When did this most likely occur? (a)

a. prenatally

b. 3 months after birth

c. 6 months after birth

d. 1 year after birth

e. 2 years after birth

5) Patients who have congenitally missing teeth also have a higher incidence of abnormally shaped teeth. (a)

a. true

b. false

6) Which of the following is associated with hyperdontia? (a)

a. Cleidocranial Dysplasia

b. Trisomy 21

c. Dens Invaginatus

d. Klinefelter's Syndrome

e. b and d

7) Gingivitis is common in very young children. A mucocele results from blockage or damage to a salivary gland duct. (b)

a. the first statement is true and the second statement is false

b. the first statement is false and the second statement is true

c. both statements are true

d. both statements are false

8) When taking a single occlusal radiograph on a pediatric patient, it is acceptable to use only the lead apron, omitting the thyroid shield. The thickness and rigidity of digital radiographic sensors makes them difficult to use in small children. (b)

a. the first atatement is true and the second statement is false

b. the first statemtne is false and the second statement is true

c. both statements are true

d. both statemtnes are false

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