PEDIATRIC DENTISTRY

Preclinical Laboratory Syllabus

and

Clinical Manual

This manual must be brought to all Pediatric Dentistry rotations in the 3rd and 4th years.

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Revision March 2007 Dr. Robert Berson Course director Dr. Sharon Freudenberger Lecturer Dr. Clarice Law Assistant Professor

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INTRODUCTION

This manual is intended to serve as a guide in your preclinical lab course as well as in your clinical experience. The information contained within will aid in your understanding of the basic concepts necessary in the treatment of the child in the primary, mixed and early permanent dentition.

MODULE 1 Restorative Projects:

1. Apply the principles of rubber dam application by properly placing a rubber dam for restorative procedures.

2. Describe the morphological and histological differences between the deciduous and permanent dentitions and how these differences require modifications in the restorative procedure.

3. Apply the general principles of cavity design for the various classes of caries in deciduous teeth by preparing and restoring typodont teeth.

4. Apply the principles of tooth and crown preparation for stainless steel crowns by preparing and fitting typodont teeth.

Appliance Projects

1. Apply the principles of appliance construction by fabricating a lower lingual holding arch (LLHA) space maintainer.

MODULE 2

1. Given a childs sample dental record, relate the data presented to correlate medical and dental histories, oral examination, radiographic findings, and model analysis: and formulate a preliminary treatment plan giving proper consideration to the childs need for preventive, restorative and orthodontic intervention.

2. Given a laboratory case, compute an arch length analysis, correlate the information with other diagnostic aids available, and describe the needs for dental intervention.

3. Identify the various occlusal patterns, arch forms, tooth arrangements, and observable soft tissue irregularities that are depicted from a given set of dental study casts.

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TABLE OF CONTENTS

RUBBER DAM APPLICATION ................................................................................................. 5

CLASS II CAVITY PREPS ........................................................................................................ 7

MANDIBULAR RIGHT 2ND PRIMARY MOLAR #T ................................................................. 8

MANDIBULAR RIGHT 1ST PRIMARY MOLAR #S ................................................................. 13

MAXILLARY LEFT 1ST PRIMRY MOLAR #I ............................................................................ 13

MANDIBULAR LEFT 1ST PERMENANT MOLAR #19 ............................................................ 15

MAXILLARY LEFT 2ND PRIMARY MOLAR #J ........................................................................ 16

MATRIX APPLICATION ............................................................................................................ 17

CLASS III CAVITY PREPS ....................................................................................................... 20

MANDIBULAR LEFT CUSPID #M ........................................................................................... 20

CLASS V CAVITY PREPS ....................................................................................................... 23

MAXILLARY LEFT LATERAL INCISOR #G ............................................................................ 23

STRIP CROWNS ...................................................................................................................... 24

MAXILLARY LEFT CENTRAL INCISOR #F ........................................................................... 25

STAINLESS STEEL CROWNS: #J AND #L .......................................................................... 27

LOWER LINGUAL HOLDING ARCH ....................................................................................... 34

PATIENT EXAMINATION & TREATMENT PLANNING ......................................................... 39

PROPHYLACTIC ANTIBIOTIC REGIMENS ........................................................................... 46

EXAMINATION CHECKLIST .................................................................................................... 49

OCCLUSION SUMMARY ......................................................................................................... 50

SUMMARY & TREATMENT PLAN .......................................................................................... 51

RADIOGRAPHIC GUIDELINES ............................................................................................... 53

MIXED DENTITION ANALYSIS ............................................................................................... 54

MOYERS MIXED DENTITION ANALYSIS WORKSHEET .................................................... 57

CLINICAL RESPONSIBILITIES ............................................................................................... 58

CARIES RISK ASSESSMENT TOOL (CAT) ........................................................................... 61

SAMPLE PATIENT QUESTIONNAIRES ................................................................................. 63

INJECTION PROCEDURE FOR THE PEDIATRIC PATIENT ............................................... 69

TECHNIQUE FOR FISSURE SEALANT ................................................................................. 73

ENDODONTIC TREATMENT OF PRIMARY TEETH ............................................................ 75

KNEE TO KNEE EXAM ............................................................................................................ 79

COMMON ANALGESICS ......................................................................................................... 81

COMMON PRESCRIPTIONS .................................................................................................. 82

BENEFITS OF FLUORIDE THERAPY .................................................................................... 84

MANAGEMENT OF DENTAL TRAUMA ................................................................................. 89

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METHOD OF RUBBER DAM APPLICATION Armamentarium

1. Rubber dam sheets, 5 X 5 or 6 X 6, pre-cut squares, medium or light weight

2. U-shaped rubber dam frame. 3. Rubber dam clamp forceps 4. Rubber dam punch 5. Scissors 6. Dental floss and wooden wedges 7. Rubber dam clamps

Punching the dam

1. Place dam on Youngs frame, lightly stretch over four corner nubs. 2. Use appropriate size hole for a particular tooth. 3. Holes are punched to coincide with treated quadrant. 4. For a posterior tooth to be clamped, punch largest hole from an inked

horizontal line across the center of the dam (slightly below for mandibular tooth and slightly above for a maxillary tooth). The punched hole should be 1 inches from side of frame.

5. Additional holes, if needed, should be spaced 2-3 mm apart and punched at a 45 degree angle toward the midline.

6. The number of teeth isolated is limited to the ones which are necessary to accomplish the procedure.

Clamp selection and placement

1. Select the appropriate clamp.

a. W 14 A Ivory Partially erupted permanent molars b. W 8 A Ivory Primary second molars or small permanent

molars c. Ivory #4 with wings Primary second molars d. 27 S. S. White Primary first molars; Small primary second

molars e. 26 S. S. White Primary second molars; first permanent molars f. 0 Ivory Permanent Incisors

2. Deliver clamp to tooth and gently push gingivally.

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Placement

1. Carry dam and frame to mouth with tip of finger of each hand on either side of hole.

2. Place hole over bow and spread downward with fingers; snap over clamp.

3. Push additional rubber behind bow to minimize tension. 4. Stretch dam and expose remaining teeth. 5. Push dam through contacts and floss. 6. Reposition if necessary and secure dam to frame. Anchor dam with

floss, piece of rubber or wooden wedges. Clinical Notes: a. ALWAYS tie dental floss around bow of clamp prior to placing

clamp in patient. b. NEVER leave child with rubber dam unattended. c. NEVER leave anything in the mouth that is not visible to you at

all times (i.e. leaving cotton rolls under the rubber dam). Dam removal

1. Cut ligated dental floss and interproximal septae 2. Be certain no part of rubber dam or floss remains.

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Class II Preps. #T MO, #S DO, #I DO, #J MO Restorations: #T Amalgam, #S Composite

Principles of Class II Cavity Preparation

Amalgam preparation:

The outline form for Class II restorations in primary molars can be seen in the figures below:

Maxillary first and second primary molars (occlusal view).

Mandibular first and second primary molars (occlusal view).

The cavosurface margin should be placed out of stress-bearing areas and should have no bevel. All internal angles should be slightly rounded. The buccolingual walls should converge slightly in an occlusal direction. (Oblique ridges should not be crossed unless they are undermined or are deeply fissured.) The proximal box should be broader at the cervical portion than at the occlusal portion. On primary molars there should be a distinct convergence of the buccal and lingual walls of the proximal box. It is this convergence that supplies the retention for the proximal box. The walls should parallel the respective buccal and lingual surfaces, especially on the buccal surface, as a result of the distinct bulge in the gingival third of the tooth. The broad, flat contacts of primary molars necessitate comparatively greater convergence for clearance into the embrasures. The buccal, lingual, and gingival walls should all break contact with the adjacent tooth, just enough to allow the tip of an explorer to pass. The wedge should be just visible when contact is broken gingivally. This is equivalent to a 0.5 mm clearance. The buccal and lingual walls should create a 90-degree angle with the enamel. The gingival wall should be flat, not beveled and all unsupported enamel should

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be removed. Ideally the axial wall of the proximal box should be 0.5 mm into dentin and should follow the same contour as the outer proximal contour of the tooth. The mesiodistal width of the gingival seat should be 1 mm, which is approximately equal to the width of the #330 bur. It is essential that the isthmus nearest the proximal box be wide enough to provide adequate bulk of amalgam. Just as in a Class I occlusal preparation, the isthmus width should be one-third the intercuspal distance, plus or minus 0.5 mm. Armamentarium

1. Typodont 2. Dental mirror 3. Explorer 4. Periodontal probe 5. Rubber dam equipment 6. Wedges 7. #330 bur, F.G., #1 and # round bur, finishing burs 8. Operative set, including instruments necessary to complete amalgam

and/or composite fillings i.e. condensers, hatchets, carvers, etc. 9. Articulating paper

Mandibular Right Second Primary Molar #T Pertinent morphological features: In general, the mandibular second primary molar is morphologically similar to the first permanent molar. The primary molar is smaller in size and has more angular (sharper) cusps. The mesial surface of the mandibular second primary molar narrows toward the occlusal surface and is crossed by the mesial groove that extends about one-third of the way from the occlusal surface toward the gingiva. Contact with the first primary molar occurs just below the mesial groove. On the distal surface contact with the first permanent molar is not as broad as the contact of the mesial surface with the first primary molar. The distal surface is smaller than the mesial surface and flattens toward the cervix. Description of the lesion (Figure 1 and Figure 2) In this example, it is assumed the incipient caries is present on the mesial surface, just gingival to the contact area and in the occluso-lingual groove area.

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Figure 1: A lesion shown from the distal surface. The lesion (black area) is gingival to the broad contact

area of the primary tooth (dotted line).

Figure 2: Mandibular right second primary molar with carious occlusal surface.

Description of the cavity preparation (Figure 3 and Figure 4) . Place rubber dam. A wedge can be placed between #T and #S in order to prevent nicking the adjacent tooth when preparing the proximal box. The outline form should include retentive fissures but should be as conservative as possible. Ideal pulpal floor depth is 0.5 mm into dentin (approximately 1.5 mm from the enamel surface). The #330 bur is 1.5 mm and therefore an ideal tool for gauging cavity depth. The central groove of this tooth is prepared from the distal pit through the mesial marginal ridge. The lingual and buccal grooves are also prepared to remove all caries. The pulpal and axial wall depth is 1.25 to 1.5 mm. The isthmus ranges from 1.0 to 1.25 mm. The converging buccal and lingual walls of the proximal box curve smoothly into the occlusal portion of the preparation.

Figure 3: A Class II cavity preparation viewed from the proximal surface. Note the occlusal convergence of proximal walls and that the gingival wall is slightly rounded and perpendicular to the long axis of the crown. .

Figure 4: Mandibular right second primary molar showing cavity preparation outline.

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Description of amalgam restoration: Place a matrix band. (See page 17) While holding the matrix band in place, insert a wedge between the matrix band and the adjacent tooth, beneath the gingival seat of the preparation. Triturate the amalgam. Add the amalgam to the preparation in single increments, beginning with the proximal box. Condense the amalgam into the corners of the proximal box and against the matrix band to reestablish a tight proximal contact. Carve the occlusal portion. The marginal ridge can be carved with the tip of an explorer or with a Hollenback carver. Remove the wedge and the matrix band. Remove excess amalgam. Gently floss the interproximal contact. Burnish the restoration, and use a wet cotton pellet for final smoothing. Remove rubber dam. Check occlusion.

Figure 5: Back-to-back amalgam fillings. A. After placing matrix band (not seen in illustration) and wedging, begin condensing the adjacent proximal boxes alternately. B. Continue condensing the amalgams

alternately until both preparations are slightly overfilled. Composite preparation: (Figure 6) The Class II composite preparation is generally the same as a Class II amalgam preparation. The difference is, the composite preparation removes only enough tooth structure to gain access to the proximal decay. Start the preparation with a #330 bur located over the marginal ridge and direct the bur gingivally. The occlusal outline form is dictated entirely by the extent of the decay present. The cavosurface angles should be near 90 degrees. Do not instrument the preparation with sharp internal line angles.

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Figure 6: Modified Class II cavity preparations for composite restorations. Note the short bevel around the

preparations and small retentive grooves. A. Maxillary right second and first primary molars. B. Proximal view C. Mandibular right first and second primary molars.

Description of composite restoration: Place a matrix band. (See page 16) While holding the matrix band in place, insert a wedge between the matrix band and the adjacent tooth, beneath the gingival seat of the preparation. Etch the preparation for 15 to 20 seconds After etching, rinse and dry the preparation well. Place a dentin-bonding agent in the preparation with a small brush. Gently blow compressed air into the preparation to disperse a thin layer of bonding agent evenly. Polymerize the bonding agent. With a plastic instrument or a pressure syringe, add the first layer of composite to gingival portion of proximal. Do not exceed 4 mm thickness. Cure for 20 seconds. Repeat procedure until proximal is filled. (Figure 7) Complete occlusal composite build-up. Do not exceed 4 mm thickness. Cure for 20 seconds. Remove matrix cure composite on buccal side for 20 seconds and lingual side for 20 seconds. Use composite finishing burs to adjust occlusal surface anatomy. Use a flame-shaped finishing bur to polish interproximal surfaces. Remove rubber dam and floss interproximal areas. Check occlusion.

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Figure 7: Add first layer of composite to gingival portion of proximal. Do not exceed 4 mm thickness. Cure 20 seconds. Then add second layer of composite. Repeat procedure until proximal is filled

Figure 8: Complete composite build up. Remove matrix, cure composite on buccal side for 20 seconds and

lingual side for 20 seconds.

Figure 9: Use 12 sided finishing burs to adjust occlusal anatomy. Then use a flame-shaped finishing bur to polish interproximal surfaces. Check occlusion and adjust premature contact spots with 12 sided finishing

burs.

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Mandibular Right First Primary Molar #S Pertinent morphological features: The mesial surface of the mandibular first primary molar is quite flat from the contact area to the cervical region. The well-developed cervical ridge is especially prominent on the mesio-buccal surface and angles abruptly toward the occlusal surface. Description of the lesion: For this example, it is assumed that there is incipient caries on the distal surface, just gingival to the contact. Description of the cavity preparation (Figure 10 and Figure 11): Pulpal and axial depth on this first primary molar is 1.0 to 1.25 mm. The carious central and distal pits are prepared as well as the central groove. The transverse ridge is left intact. The isthmus is 1.25 to 1.5 mm wide.

Figure 10: Outline of a Class II cavity preparation in a mandibular right first primary molar.

Figure 11: Back to back Class II preparations in mandibular first and second primary molars.

Maxillary Left First Primary Molar #I Pertinent morphologic features: The maxillary first primary molar is characterized by a prominent and well developed buccal-cervical ridge. The widest mesiodistal part of the crown is at the contact area. Contact with the primary second molar occurs in the occluso-lingual half of the distal surface. The mesial surface is in contact with the primary canine on the occluso-buccal third.

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The large mesio-buccal pulp horn of the maxillary first primary molar is of special concern in Class II mesial preparations. Description of the lesion #I DO: For this preparation, assume that incipient caries is present on the distal surface of the tooth gingival to the contact. Description of the cavity preparation (Figure 12 and Figure 13) Pulpal wall depth on this first primary molar is 1.0 to 1.25 mm. No enamel should remain on the pulpal wall. The entire central groove is prepared to a width of 1.0 to 1.25 mm. There is a slight extension (sometimes familiarly referred to as a dovetail) into the fissured mesio-buccal groove. At least 1.25 mm of tooth structure remains between the cavosurface margin of that extension and the buccal surface. The axial wall of the proximal box is the same depth as the pulpal wall (1.0 to 1.25 mm) at the gingival extension. As in all Class II cavity preparations for incipient lesion, the buccal, lingual, and gingival walls are extended only so far as to remove all caries and break contact with the adjacent second primary molar. (The tip of an explorer should be able to just pass through sideways.) As in all Class II preparations, the buccal and lingual walls converge occlusally, paralleling the respective external surfaces of the tooth and flow smoothly into the occlusal portion of the preparation. The gingival wall that is perpendicular to the long axis of the crown is slightly concave.

Figure 12: Outline of a distal Class II cavity preparation on a maxillary first primary molar in contact with the

second primary molar.

Figure 13: Lingual view of a Class II cavity preparation in a primary first molar showing a pulpal and axial

wall depth of 1.0 1.25 mm.

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Mandibular Left First Permanent Molar #19 (Figure 14) Description of the lesion: For this example it is assumed that there is a carious central pit. The caries extends slightly into dentin. Description of the cavity preparation: Using # , # or #1 round bur on the slow speed, remove caries. Description of the PRR restoration: Isolate tooth. Etch tooth for 15-20 seconds. Apply dentin bonding agent and air dry tooth. Place a flowable composite resin in the central pit. Apply a thin layer of flowable composite on the entire occlusal table. Polymerize and adjust for occlusion.

Figure 14: A. The occlusal surface of a molar with a small area of decay in the central pit. B. A small bur (no. or round using slow speed) is used to remove the decay, which is confined to the enamel. C. A

filled sealant (S) is applied into the preparation and over all pits and fissures. This is a sealant procedure. D. In this example, the caries extends into the dentin. A small bur (no. or round) is used to remove decay.

E. A bonding agent (BA) and resin-based composite (CR) material are placed in the preparation. Then a sealant (S) or flowable composite is applied over all remaining pits and fissures. This is a PRR procedure.

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Maxillary Left Second Primary Molar #J Pertinent morphologic features: The crown of the maxillary second primary molar is approximately 0.5 mm larger mesio-distally that the crown of the maxillary first primary molar. but the bucco-lingual measurement of the second molar is often as much as 2 mm greater than of the first molar. The mesial and distal surfaces of the second molar are also relatively flat bucco-lingually, and they form especially broad contacts with the first primary molar and first permanent molar. The mesial surface is also characterized by the mesial groove that extends from the occlusal surface. Description of the lesion For this example it is assumed that the incipient caries is present on the mesial surface, just gingival to the contact area, and on the occlusal surface in the central pit near the buccal groove. Description of the cavity preparation (Figure15) The carious mesial pit and central pit of this tooth are prepared with an extension into the non-coalesced buccal groove. Isthmus width on this second primary molar is slightly greater than on the first primary molar (1.25 mm to just over 1.5 mm). Depth of both the pulpal and axial walls on the second primary molar is 1.25 mm to 1.5 mm. It is important to keep in mind the difference for axial depth on the first and second primary molars, especially when preparing the two teeth back to back as is common in treatment of children.

Figure 15: Maxillary first and second primary molars showing outline of Class II cavity preparation.

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Matrix Application

Matrices must be placed for interproximal restorations to aid in restoring normal contour and normal contact areas and to prevent extrusion of restorative materials into gingival tissues. Both the contour and the large open area of the proximal box of Class II preparations on primary teeth are of special concern in adapting a matrix that is firm enough to sustain the pressure of condensation. T-bands, sectional matrix, and AutoMatrix are commonly used in pediatric dentistry. These types are more convenient when several cavity preparations are being restored during the same appointment. T-bands allows for multiple matrix placements. Sectional-matrix allows for multiple matrix placements; is not circumferential. AutoMatrix allows for multiple matrix placements; requires special tightening and removing tools. T-Band Matrix Procedures T-bands are available in several sizes, contours and materials. A straight, narrow, brass T-band will be sufficient in almost all pediatric restorative procedures. (Figure 16)

Figure 16: T-band matrix strip.

Forming and Placing a T-band matrix:

1. SHAPE THE T-BAND INTO A CIRCLE AND ADJUST IT TO A SIZE SLIGHTLY SMALLER THAN THE TOOTH.

With flat-nosed pliers bend up wings of the T-band (Figure 17) Fold the band back on itself in the form of a circle and fold over the extension wings of the T to make an adjustable loop.

Figure 17: Shaping a T-band.

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2. ADJUST THE MATRIX TO THE TOOTH With the sliding joint of the matrix over the tooth and the long end toward the mesial, place the matrix over the tooth and seat it so that it extends 0.5 mm to 1.0 mm past the gingival cavosurface margin. Pull the tab end and tighten the band around the tooth. Fold the tab distally back over the joint (Fig. 18) to crease for size. Remove the band from the tooth. If the original fit was not snug, decrease the circumference, and replace the band on the tooth, and crease again.

Figure 18: T-band tab folded to form a crease.

3. TRIM THE MATRIX BAND TO SIZE. Remove the band and flatten the fold with pliers back against the wings. Cut the tab with the ends of the wings and round the corners. 4. RESEAT THE MATRIX BAND AND WEDGE IT Replace the band on the tooth with the trimmed end directly distally. With a good tight fit some resistance should be felt as the band is seated. Select a wedge, trim if necessary, and insert.

Wedges All matrices need to be wedged securely under the gingival margin to allow the band to withstand the pressure of condensation and prevent flash at the gingival margin. The slight separation provided by the wedge allows room for proper placement of the matrix band and forceful condensations and ensures tight contact when the wedge is removed. Anatomically shaped wedges are available. (Figure 19) When triangular wedges are used, it may be necessary to trim the apex to permit a snug fit against the band and under the broad, flat, contact area typical of primary molar. The wedge should be inserted from the larger embrasure usually the lingual on primary molars or from the buccal if the proximal box has been opened up wider on that side. During the insertion of the wedge, the matrix band should be secured.

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Figure 19: Triangular wedges either trimmed or anatomically preformed.

Removing the T-Band matrix

1. OPEN THE JOINT OF THE MATRIX BAND. After removing gross amalgam/composite excess from the proximal area and the marginal ridge, but before carving either, open the joint of the matrix band by raising the tab end with a spoon excavator or plastic instrument and loosen the T wings (Figure 20).

Figure 20: Opening the T-band.

2. REMOVE THE MATRIX Remove the wedge. The band may be removed by one of two methods. Secure the restored marginal ridge area, if necessary. Then either cut the band close to the restoration with a crown and bridge scissors and pull buccally, or gently rock the band occlusally and/or lingually through the contact. Replace the wedge to inhibit further hemorrhaging if necessary 3. COMPLETE THE RESTORATIVE PROCEDURE

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Class III: Cavity Preparation and Restorations

Principles of Cavity Preparation

The extremely small size of the primary anterior teeth, the very thin enamel and weak incisal edge, and the proximity of the pulp to the surface must all be taken into consideration when preparing Class III cavities. Obtaining access to the lesion and providing adequate retention are the two principal factors affecting the design of a Class III cavity preparation. In any Class III cavity preparation for an incipient lesion the axial wall should be just into dentin. Depth as measured from the cavosurface varies depending on the tooth. Mandibular canines 1.0 mm to a maximum of 1.25 mm Maxillary incisors and canines 0.75 mm to 1.0 mm Mandibular incisors 0.5 mm to 0.75 mm A #1 round bur is appropriate for canines and maxillary incisors; a # round bur is appropriate for the smaller mandibular incisors. When access to the Class III lesion is from the proximal, low speed, using air only is recommended for preparing the cavity. Mandibular Left Canine #M Pertinent Morphologic Features: The mandibular primary canine is convex in the cervical third. On the mesial and distal surfaces the height of contour is much nearer the cervix than the permanent canine. Mandibular primary canines contact adjacent teeth near the incisal third of the tooth. The incisal is highest at the apex of the cusp, and the distal incisal edge is lower than the mesial aspect. Generally, the pulp chamber follows the surface contour of the tooth. The enamel layer is approximately 0.8 mm thick and, on the mesial and distal surfaces, tapes as it nears the cervix. The distance from the pulp to the incisal surface is approximately 3.3 mm at the apex and 2.3 mm on the mesial and distal aspects of the incisal surface. To the mesial and distal surfaces this distance is approximately 1.5 mm, and to the buccal and lingual surfaces, 2.3 mm. Description of the lesion (Figure 21) On the model for this preparation it is assumed there are extensive caries on the distal surface just above the gingiva and below the contact approaching the lingual surface. Loss of translucency in the proximal area is apparent.

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Figure 21: Mandibular canine showing mesial and distal convex curvatures. A Class III caries lesion is

shown beneath the contact area. Description of the cavity preparation (Figures 22) The extensive caries on the distal surface of this tooth requires a disto-lingual dovetail preparation. A #1 round bur or #330 bur is used, with access to the lesion from the lingual. The axial wall of the proximal is 1.0 mm to 1.25 mm from the cavosurface on the canine (just into dentin on a natural tooth). When the caries is removed, all cavity walls are established in sound tooth structure and just break contact with the adjacent tooth. The dovetail portion of the preparation is larger than the proximal portion (Figure 22). It is joined to the proximal portion by an isthmus that is similar to the isthmus linking the occlusal and proximal portions of a Class II preparation. The dovetail should always be prepared at the expense of the thicker gingival enamel whether on the labial or lingual. The gingival wall of the dovetail should follow the contour of the gingiva at a distance of no closer than 1.0 mm. The inciso-gingival dimension of the canine dovetail (one-third to one-half the incisal height of the crown) is between 1.5 and 2.0 mm, or slightly greater than twice the diameter of the bur at the points of greatest dimension. The mesial wall is parallel with the long axis of the anatomic crown. The mesio-distal width of the dovetail is no greater than the mesio-distal width of the tooth, as measured from the mesial cavosurface margin. Depth of the axial wall in the dovetail on this tooth is 0.75 to 1.0 mm. Place a short bevel (0.5 mm) at the cavo-surface margin.

Figure 22: Mandibular left primary canine showing a Class III preparation with a dovetail.

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Figure 23: Transverse section of a mandibular primary canine showing Class III axial wall depth at both the

interproximal and dovetail area. Description of restoration of Tooth #M Clean and dry the preparation with water and compressed air. Place a plastic or sectional metal matrix. The matrix is placed interproximally and a wedge is inserted. Etch the preparation for 15 to 20 seconds. After etching, rinse and dry the preparation well. Place a dentin-bonding agent in the preparation with a small brush. Gently blow compressed air into the preparation to disperse a thin layer of bonding agent evenly. With a plastic instrument or a pressure syringe, place the composite in the preparation. Pull the matrix tightly around the cavity preparation with finger pressure and hold until cured. The preparation should be cured from both the buccal and lingual side. Finish and polish after polymerization. Gross finishing can be accomplished with fine-grit diamonds or with carbide finishing burs. A flame carbide bur is excellent for finishing the facial and interproximal surfaces. The lingual surface is best finished with a football shaped carbide finishing bur. Final interproximal polishing of the restoration is completed with sandpaper strips. When finishing is completed, remove rubber dam and floss the interproximal areas.

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Class V: Cavity Preparations and Restorations

Principles of Cavity Preparation

A #330 bur is recommended for preparing Class V lesions. On a primary tooth, the axial wall of an incipient lesion should be just into dentin using the following as a measurement guide.

1.0 mm to 1.25 mm from the cavosurface of canines 0.75 mm to 1.0 mm on maxillary incisors 0.5 to 0.75 mm on mandibular incisors

The pulpal wall should be convex, parallel to the outer enamel surface. The lateral walls are slightly flared near the proximal surfaces to prevent undermining of enamel. The final external outline is determined by the extent of decay. Mechanical retention at the gingivoaxial and incisoaxial line angles can be achieved with a #35 inverted cone bur or a round bur. For resin based composites, a short bevel is placed around the entire cavosurface margin. Maxillary Left Lateral Incisor #G Pertinent morphologic features: All maxillary primary incisors have similar morphology, including an incisal edge formed from one developmental lobe and a pronounced ridge. The pulp generally conforms to the surface contour of the tooth. The enamel layer of the maxillary lateral incisor is approximately 0.5 mm. The distance from the pulp to the incisal surface is approximately 2.0 mm, 1.4 mm to the mesial and distal surfaces, and 1.4 to 1.9 mm to the buccal and lingual surfaces. Description of the lesion (Figure 24): It is assumed that on the tooth for this preparation, there is a small incipient lesion just above the gingiva on the labial surface. The area appears slightly decalcified and could be penetrated with an explorer.

Figure 24: Maxillary left lateral primary incisor with incipient carious lesion (left) and a transverse section

(right) showing the preparation (dotted line).

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Description of the cavity preparation (Figure 25): The preparation follows the shape of the carious lesion. Axial depth is 0.75 mm to 1.0 mm. The mesial and distal walls diverge when the mesial and distal walls of the preparation are closer to the labial line angles. Maximum dimensions of the cavity preparation should in no case be more than 0.5 mm greater than the carious lesion that was removed. No retention grooves are required for this prep.

Figure 25: Maxillary left primary lateral incisor showing minimum preparation (left) contrasting with a

maximum preparation (right). Description of restoration of Tooth #G Etching, bonding, material placement, and finishing are similar to that described for Class III restorations, except that no matrix is used.

The Composite Strip Crown

The composite strip crown is utilized to restore primary incisors for the following indications:

1. Incisors with large interproximal lesions 2. Incisors that have received pulp therapy 3. Incisors that have been fractured 4. Incisors with multiple hypoplastic defects or developmental

disturbances 5. Discolored incisors 6. Incisors with small interproximal lesions that also demonstrate large

areas of decalcification Armamentarium (in addition to above)

1. Strip crowns 2. #169L bur, #35 inverted cone 3. Scissors

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Maxillary Left Central Incisor #F Pertinent morphologic features: See information given for tooth #G (page **) Description of the lesion (Figure 26): It is assumed that on the tooth for this preparation, there is extensive, deep proximal decay.

Figure 26: Primary central incisor with extensive, deep proximal decay.

Description of preparation of Tooth #F: Select the shade of resin to be used. Place and ligate rubber dam. Select a primary incisor celluloid crown with a mesiodistal width approximately equal to the tooth being restored. Reduce the incisal edge by 1.5 mm using a fine tapered diamond or #169L bur. Reduce the interproximal surfaces by 0.5 to 1.0 mm (Figure 27). The reduction should allow a crown form to slip over the tooth. The interproximal walls should be parallel, and the gingival margin should have a feather edge. Reduce the facial surface by at least 1.0 mm and the lingual surface by at least 0.5 mm. Create a feather-edge gingival margin. Round all line angles. Place a small undercut on the facial surface in the gingival one third of the tooth with a #330 bur or a #35 inverted cone.

Figure 27: The proximal surfaces are sliced with a 169L bur to make the proximal surface free of the

adjoining tooth. The incisal surface is reduced 1 - 1 mm.

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Figure 28: Composite Strip Crown preparation. A. Labial view. B. Proximal view. C. Incisal view. The

proximal slice should be parallel to the natural external contours of the tooth. Description of restoration of Tooth #F: Trim the selected crown form by cutting away excess material gingivally with crown-and-bridge. Trial fit the crown. Crown form should fit 1 mm below the gingival crest. After the crown is fitted, punch a small hole in the lingual surface with an explorer to allow for the escape of trapped air and filling material. Etch the tooth for 15-20 seconds. Rinse and dry the tooth, then apply a dentin bonding agent. Blow compressed air on the tooth for a couple of seconds. Fill the crown form approximately 2/3 full with a resin-based composite material and seat onto the tooth. While holding the crown in place, remove excess material with an explorer. Polymerize the material from both buccal and lingual directions. Peel the form from the tooth using an explorer. Remove rubber dam and evaluate occlusion. Finish with a flame carbide bur smoothing out any irregularities. A football shaped bur may be used for final contouring of the lingual surface.

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Stainless Steel Crown (SSC) #J, #L

The stainless steel crown remains one of the most useful restorations in Pediatric Dentistry. Its ability to restore severely broken down teeth allows for teeth to be retained, in instances when amalgam and composites would be sure to fail. Full coverage should be used in all cases where a partial or complete pulp removal has occurred. Learning to place stainless steel crowns requires some skill and much practice. It reverses your normal train of thought in that the tooth must be prepared to fit the crown. Although rules are given for preparation and crown adaptation, they are no substitute for analytical thought during tooth preparation and placement of the crown. Clinical note:

A local anesthetic should be used even when the involved tooth is non-vital, due to the potential for soft tissue trauma during tooth preparation.

A rubber dam should be used for better visibility and patient control. Wedges may be placed in the interproximal for better tissue retraction and

to help avoid contact of the bur with adjacent teeth. Armamentarium (in addition to above)

1. Stainless Steel Crowns 2. Football diamond 3. Crown scissors 4. Contouring pliers - # 114 ball-and-socket pliers 5. Crimping pliers - # 800-417 (Unitek) 6. Heatless stone 7. Rubber wheel 8. Glass ionomer cement (K-tac cem)

Steps for Preparation: Check occlusion. Note the dental midline and the cusp-fossa relationship bilaterally. Place rubber dam to isolate the tooth and separate tooth from adjacent teeth using wedges. (Figure 29)

Figure 29: Tooth at start of preparation

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Reduce occlusal surface with the high speed handpiece using a #169L taper fissure bur or a football diamond. Make depth cuts by cutting the occlusal grooves to a depth of 1.0 1.5 mm, and extend through the buccal, lingual, and proximal surfaces. (Figure 30)

Figure 30: Occlusal view of occlusal grooves cut for depth.

Next place the bur on its side and uniformly reduce the remaining occlusal surface by 1.5 mm, maintaining the cuspal inclines of the crowns. (Figure 31)

Figure 31: Reduction of occlusal using cut grooves as depth guide.

Use a taper fissure bur or a thin, tapered diamond to cut through the contacts. (Figure 32)

Figure 32: Completed mesial and distal slices should be straight and smooth.

Contact with adjacent tooth must be broken gingivally and buccolingually, maintaining vertical walls with only a slight convergence in an occlusal direction. The gingival proximal margin should have a feather-edge finish line. (Figure 33)

Figure 33: Occlusal and proximal reduction completed.

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Buccolingual reduction is often limited to the occlusal one third of the tooth. Further reduction may be necessary if there is a large mesiobuccal bulge. (Figure 34)

Figure 34: Excessive undercuts are reduced.

All angles of the preparation should be rounded to remove corners. (Figure 35, Figure 36 and Figure 37)

Figure 35: The occlusal line angles are rounded.

Figure 36: The completed crown preparations (tooth # T on the left and teeth #I and #J on the right)

showing rounded line angles.

Figure 37: The mesial and distal contact points are cleared and a smooth taper from occlusal to gingival should be obtained that is free from ledges or shoulders.

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Selecting and seating the crown: There are two commonly used types of SSCs:

1. Ni-Chro Ion i. These are pretrimmed, precontoured and precrimped. They

are composed of a softer metal so that they can snap over the prep without any alterations. If trimming of these crowns become necessary, the precontour will be lost and the crown will fit more loosely.

2. Unitek [3M]

i. These are pretrimmed, but they must be contoured and crimped. They are primarily composed of chromium and steel and are stronger than ion crowns.

Figure 38: Buccal view of two types of stainless steel crowns. On the left is a Ni-Chro Ion crown. The lettering on the crown identifies it as a left mandibular first molar size 6. On the right is a Unitek [3M] crown.

Note how much longer the Unitek crown is, as well as its straight, noncontoured proximal surfaces.

Select the smallest crown that can be seated on the tooth. Start with #4 crown, that is the most commonly used, and progress to a larger or smaller crown as necessary. Seat the lingual first and apply pressure in a buccal direction so that the crown slides over the buccal surface into the gingival sulcus Slight resistance should be felt as the crown slips over the buccal bulge. After seating the crown, check preliminary occlusal relationship by comparing adjacent marginal ridge heights. If the crown does not seat, occlusal reduction may be inadequate; the crown may be too long, a gingival proximal ledge may exist; or contact may not have been broken with the adjacent tooth.

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An extensive area of gingival blanching around the crown indicates that the crown is too long or is grossly over contoured. Ideally the crown should extend 1 mm into the gingival sulcus. If the crown is too long, place the crown onto the preparation and lightly mark the level of the gingival crest on the crown with a sharp instrument. (Figure 39)

Figure 39: Scoring a line at the gingival margin prior to final trimming and seating of the stainless steel crown.

The crown is then removed and trimmed 1 mm below the mark with crown-and bridge scissors or a heatless wheel on the low speed straight hand piece. Contour and crimp the crown to form a tightly fitting crown. Contouring involves bending the gingival one third of the crowns margins inward to restore anatomic features of the natural crown and to reduce the marginal circumference of the crown. This aids in ensuring a good fit. Contouring is accomplished with a #114 ball-and-socket pliers. Final adaptation of the crown is achieved by crimping the cervical margin 1 mm circumferentially with a #800-417 pliers. (Figure 40)

Figure 40: A. #114 pliers are used for contouring. B. # 800-417 pliers are used for final crimping.

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After contouring and crimping, resistance should be encountered when the crown is seated. (Figure 41)

Figure 41: Mesio-distal cross section of crown (left) and bucco-lingual cross section of crown (right).

When removing the crown, a spoon excavator or amalgam carver can be used to engage the gingival margin and dislodge the crown. Remove rubber dam. Replace crown and check occlusion. Final smoothing and polishing of the crown margin should be performed prior to cementation. Use a heatless stone to thin the margin. Rinse and dry the crown. Use glass ionomer cement, zinc phosphate or self-curing resin to cement the crown. The crown is filled 2/3 with cement. Dry the tooth with compressed air and seat the crown completely. Cement should be expressed from all sides. Check centric occlusion prior to the cement setting. Remove excess cement from gingival sulcus with a sharp explorer. The interproximal areas can be cleaned by tying a knot in a piece of dental floss and drawing the floss through the interproximal region. PROBLEMS SEATING THE CROWN?

Figure 42: Gingival ledge; contact is not broken.

Inadequate occlusal reduction Inadequate reduction of buccal cervical bulge SSC too long

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Clinical Note:

CHOOSING A CROWN IN AREAS OF SPACE LOSS Rectangles vs. squares (mandibular 1st molars vs. maxillary 1st molars)

Extensive distal caries on a mandibular or maxillary primary 1st molar will change its shape to look more like a square or rectangle, respectively. (See figures below)

When this happens, choose a primary 1st molar crown from the opposite quadrant (opposite side, opposite quadrant).

Note the space loss is due to mesial drift of the 2nd primary molar.

Figure 43: Mandibular left 1st primary molar. Tooth structure distal to dotted line lost to extensive distal caries would change the shape from a rectangle to a square.

Figure 44: Maxillary left 1st primary molar. If tooth structure distal to the dotted line is lost due to extensive distal decay, a right mandibular 1st primary SSC crown is rotated to fit the preparation.

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LOWER LINGUAL HOLDING ARCH The lingual arch is basically a fixed orthodontic appliance, it is commonly adapted for use as a holding arch and as a bilateral space maintainer. It is especially useful for those young or physically and mentally compromised patients who might not adapt well to a removable appliance (Figure 48). The lingual holding arch is commonly used to prevent collapse of the lower anterior teeth as is seen in patients with hyperactive lip and mentalis habits. As well, a pontic may be added to the arch for replacement of a lost anterior tooth. In orthodontic use, for example, the arch can be constructed to be activated for tooth movement such as the expansion of the arch. Auxiliary wires may be added to arch wire for individual tooth movements. When used as a space maintainer, the lingual holding arch permits unhindered growth of the jaws and alveolar bone, permits eruption of succedaneous and adjacent teeth and is physiologic and inconspicuous. CONSTRUCTION: Band Placement and Adaptation: 1. Preformed bands are adapted and contoured to fit molar teeth, either the second primary or the first permanent molars. Since the bands will support a fair sized appliance they must be adapted very well with special attention paid to the band engagement of the buccal and lingual undercuts to aid the mechanical retention of the band. 2. Commercially pre-formed bands are available for each tooth group and in several basic sizes within each group. For this exercise, the faculty has pre-selected the proper size band that can be found in your laboratory kit. In general, band selection consists of trial and error until a band is found that seems just right to fit very snugly when properly contoured. A band that easily slides over the tooth in the beginning selection process will usually be too large after proper contouring and, if used, will require excessive cementation and incur the possibility of decreased adhesion and early appliance breakdown. 3. The most important factor in band adaptation is the preliminary positioning of the band. Examine the tooth and illustration in Figure 45. The buccal and lingual surfaces are compound curves. It we mentally survey these surfaces on mandibular molar teeth it can be seen that undercut areas are usually lower on the buccal surface than on the lingual. The band is to be positioned so that is extends into, and engages, these undercut areas. Thus, the band must be positioned diagonally across the tooth to be lower on the buccal than on the lingual. If the band placed on a lower molar engages the buccal and lingual undercuts it will fit snugly and not be easily displaced (Figure 46). If the band does not engage the buccal and lingual undercuts it will be loose and easily displaced.

35

4. In clinical use, the band would be adapted directly to the patients tooth rather than to a model. The pre-formed bands have also been partially contoured in the manufacture process to be already lower on the buccal side than on the lingual. In addition, a small V notch, or indentation, is usually found around the occlusal rim of the band. This indentation is on the lingual occlusal ridge and is meant to fit into the crevice formed by the junction of the two lingual cusps. 5. Using your laboratory typodont, push one of the pre-selected bands onto either tooth 19 or tooth 30 keeping the occlusal height of the band just below the interproximal marginal ridges of the tooth. 6. While holding the lingual surface in this position, push the band down buccally using a serrated plugger, gold foil condenser or band seating instrument. The buccal portion of the band should extend low enough to reach the buccal undercuts. 7. The band is crimped in or rimmed in around the gingival circumference using a pair of smooth jawed pliers. A contouring, or swaging, pliers is quite useful for this purpose as well. The crimping in process provides for a tight adaptation of the band into the buccal and lingual undercut areas. The band is now ready for placement onto the tooth. 8. Place the band in position on the tooth using a band seating, or serrated plugger and complete the band contour by burnishing the occlusal rim to adapt snugly to the tooth. The finished band will have no open margins either around the occlusal or lingual margins. 9. Complete the band construction for the lingual arch by repeating Steps 5 through 8 above and adapt a band to the antimere molar tooth (#19 or #30). Making a Working Model: 10. A working model is used for the contouring of the lingual arch wire and its attachment to the molar bands. Take an alginate impression of the typodont (or patients arch) with the adapted molar bands in placed on the teeth. The completed impression is removed and the bands are then removed from the teeth. 11. Trim impression material that squeezed between the band and the tooth with a carver until the impression of the edge of the band is clear all the way around. Carefully reposition each molar band in its proper place in the impression. Accurate positioning of the bands in the impression, and their fixation in place, is absolutely necessary for a finished appliance that fits the typodont (or patient) accurately. CARE is mandatory.

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12. Place a bead of sticky wax on the inner lingual surface of each band is the area where the lingual attachments, or the lingual arch wire, will be soldered. The bead of wax should be sufficiently thick enough to provide an air space between the working model and the band to facilitate heat transfer between the band and wire, or attachment, during soldering. The wax should firmly hold the band in place in the impression. 13. A working model is poured in yellow stone. Vibrate the stone while mixing but not while pouring. The use of a vibrator is not recommended during pouring for the vibration often shakes a band loose from its position in the impression and results in a misplaced band on the working model. Instead, carefully add the stone, in small portions, to each of the tooth areas avoiding air pockets as much as possible. Gently vibrate the impression with a wiggling motion of the hand alone. Complete the model build-up with stone and set it aside to harden. Do not invert the impression but rather build up a sufficient amount of stone to serve as a base. The impression, removed from the case, should reveal a working model with a minimum of air holes and with the bands seated in their respective proper positions. The lingual band wax may be carefully removed with an explorer. Trim the stone to form a flat base. Contouring the Arch Wire: 14. Figure 48 shows two sample lingual arch wires. Figure 48A is a simple arch wire adapted from molar to molar beneath occlusal interference, touching the lingual contours of most of the buccal teeth and resting on the cingulae above the gingivae of most of the anterior teeth. It is the anterior teeth that resist the anterior movement of the molar teeth. The arch is bent back and down from the midpoint of the canine and then along the lingual-gingival margins of the buccal teeth and then back up to the solder joint. This keeps the wire out of the occlusion and free of the erupting premolars. The arch wire is soldered to the molar bands and is cemented in place as a single unit. Figure 48B is an arch wire similar to that in Figure 48A but has, in addition, an Omega shaped loop (inverted) and contoured just anterior to each band extending marginally into the lingual sulcus. The purpose of this loop is to allow for some adjustment of the arch if necessary before cementation, or importantly, for possible activation before cementation to apply tooth moving forces to the molar teeth for uprighting the teeth in cases of space loss and molar tipping. This arch is similarly cemented as a single unit after activation. 15. In this laboratory exercise, you will contour and solder the arch wire as in Figure 48A using 0.036" diameter steel wire. It is a simple holding arch as is frequently used to maintain the existing dental arch integrity at the time of appliance placement.

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16. The 0.036" steel arch wire can be contoured by starting at one molar band and shaping the wire as it extends forward and returns to the molar band on the other side, or it may be contoured by starting in the middle, in the lingual incisor area, and extending the arch wire on each side back to the molar area. In either technique, the arch wire should rest on the incisor cingulae above the gingivae. It is not necessary for the arch wire extended distally to be contoured perfectly to the shape of each tooth. Instead, it should contact the lingual surfaces of those teeth that lie in the general shape of the arch as it would be represented in a smooth contour. The distal end of the arch wire extends on each side over the molar band to 1/2 to 3/4 the width of the band. The arch should be placed so as not to interfere with occlusion or impinge on the gingivae. 17. After removal of any sharp edges from the distal ends of the arch wire, it is positioned on the model and held in place by sticky wax covering a portion of the anterior lingual wire and then plaster is placed over the wires, sticky wax and teeth to secure the arch wire in place. The plaster should be kept away from the area to be soldered. The arch wire adjacent to each band should be well adapted to the band for proper soldering. 18. Gently heat the band-archwire joint to burn off any residual wax and to free air space inside each band. Steel can only be soldered using fluoride flux. Flux the joint well on both sides of the wire and direct the flame toward the inner surface of the band while feeding solder externally to the band-archwire joint. 19. The appliance is removed from the working model and polished making sure that there are no rough spots at either solder joint that may later irritate the patients tongue. Polishing must not remove all of the solder that covers the archwire because the solder bonds by physical forces, not chemical bonding. The finished appliance is seated on the typodont by working each band simultaneously, in steps, until both bands are seated properly and the archwire rests in the predetermined position on the cingulae of the anterior teeth.

Figure 45: The buccal and lingual highlight contours Figure 46: Orthodontic band placed as to engage of a mandibular posterior tooth when surveyed. undercut areas for retention. Band is placed higher on lingual surface and lower on buccal surface.

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Incorrectnot contoured

Correct"Barrel" shaped

Figure 47: Band contour showing the difference between a non-contoured cylinder (or band) and a precontoured band placed on a posterior tooth. The non-contoured band will have gingival overhanging areas that impinge on the tissues.

A B

Figure 48A and 48B: Lingual holding arches, with the arch wire soldered to

bands affixed to posterior molar teeth. The arch wire is contoured from side to side and rests anteriorly on the cingulae of the anterior teeth. Extending backward to the bands the arch wire dips down in the premolar area to avoid occlusal interference and premolar development and eruption. Figure 167B differs from Figure 167A in that an inverted omega loop is contoured anterior to the molar band. This loop allows for adjustment of the arch wire where tooth movement is desired.

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PATIENT EXAMINATION & TREATMENT PLANNING It can be said that a problem needs to be recognized to be diagnosed and that its treatment depends upon the diagnosis. An accurate diagnosis depends upon (a) a full written health history, (b) interviews to verify and support the history, (c) an extra- and intraoral examination of the patient, and (d) obtaining additional diagnostic aids such as x-rays, dental casts, laboratory tests, or consultations with other health professionals. Pages 39 to 45 are pages from the Dental Chart in Pediatric Dentistry at UCLA. Included is the Pediatric Health Questionnaire filled out by the parent at the initial visit to the clinic. From this, and from subsequent interviews with the parent to discuss elements of the history, it can be determined that the patient is of good general health or that there may be a need for consultation with the family physician, hospital or health care facility. It is important to determine the need for antibiotic support in any patient before dental manipulation is initiated. Therefore, note the charts on the following pages: 46 to 48.

40

41

42

43

44

45

46

PROPHYLACTIC ANTIBIOTIC REGIMENS

Dental procedures for which endocarditis prophylaxis is recommended1

Dental extractions Periodontal procedures including surgery, scaling, and root planing,

probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated

1Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions

Dental procedures for which endocarditis prophylaxis in not recommended

Restorative dentistry (operative and prosthodontic) with or without retraction cord

Local anesthetic injections (nonintraligamentary) Intracanal endodontic treatment; post placement and buildup Placement of rubber dam Postoperative suture removal Placement of removable prosthodontic or orthodontic appliances Taking of oral impressions or oral radiographs Fluoride treatments Orthodontic appliance adjustment Shedding of primary teeth

Clinical judgment may indicate antibiotic use in selected circumstances where significant bleeding may occur

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Prophylactic Regimens for Dental, Oral, Respiratory Tract or Esophageal Procedures

SITUATION AGENT REGIMENTA

Standard general prophylaxis

Amoxicillin Adults: 2.0g; Children: 50mg/kg orally one hour before procedure

Unable to take oral medications

Ampicillin

Adults: 2.0g intramuscularly (IM) or intravenously (IV); Children: 50mg/kg IM or IV within 30 minutes (min) before procedure

Clindamycin or

Adults: 600mg; Children: 20mg/kg orally one hour before procedure

CephalexinB or

CefadroxilB or

Adults: 2.0g; Children: 50mg/kg orally one hour before procedure

Allergic to penicillin

Azithromycin or

Clarithromycin

Adults: 500mg; Children: 15mg/kg orally one hour before procedure

Clindamycin or

Adults: 600mg; Children: 20mg/kg IV within 30 min before procedure

Allergic to penicillin and unable to take oral medications Cefazolin

B Adults: 1.0g; Children: 25mg/kg IM or IV within 30 min before procedure

A Total childrens dose should not exceed adult dose B Cephalosporins should not be used in individuals with immediate type hypersensitivity reaction (urticaria, angiodema, or anaphylaxis) to penicillins

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Cardiac Conditions Associated with Endocarditis

ENDOCARDITIS PROPHYLAXIS RECOMMENDED Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot)

High-risk category

Surgically constructed systemic pulmonary shunts or conduits Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunction (e.g., rheumatic heart disease) Hypertrophic cardiomyopathy

Moderate-risk

category Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED Isolated secundum atrial septal defect Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residual beyond 6 months) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation Physiologic, functional, or innocent heart murmurs Previous Kawasaki disease without valvar dysfunction Previous rheumatic fever without valvar dysfunction

Negligible-risk

category (no greater risk than

the general population)

Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

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EXAMINATION CHECKLIST

EXTRAORAL EXAMINATION

Cranium: Inspect for sore, flaking, inflammation, swelling and symmetry. Neck: Thyroid gland palpate and inspect for swelling. Musculature inspect and palpate for suppleness. Lymph nodes palpate for lymphadenopathy. Hair: Inspect for thickness, color, dryness and consistency. Ears: Inspect for normal appearance, cartilaginous defects, pits and and cutaneous lesions. Eyes: Inspect for inflammation, deviation, ptosis, and exophthalmos. Nose: Evaluate patency, note any discharge. Perioral: Inspect for inflammation, scarring, eruption ulcerations.

SOFT TISSUE EVALUATION

Gingiva: Inspect for inflammation, bleeding and abscesses. Mucosa: Inspect for inflammation, palate for swelling; inspect parotid duct opening for function. Pharynx: Inspect for inflammation, note gag reflex. Tonsils: Inspect for size, inflammation. Palate: Inspect and palpate for deviation and integrity. Tongue: Inspect for inflammation, coating, observe range of motion, inspect for atrophy, and deviation. Lips: Inspect for chapping, ulcers, and cheilitis.

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OCCLUSION SUMMARY

Examinations of the following conditions should be noted under each of the following headings. Deviations from the ideal or norm should be noted. Those that must be noted are starred (*), others are noted only as they occur or differ from normal limits. Alignment: *Tooth size-arch length discrepancy. Space loss, alignment, rotations, missing or supernumerary teeth, eruption abnormalities, ankylosis Transverse Relations: *Midline discrepancies (max and mand.), posterior crossbite. Facial asymmetry, mandibular displacement, maxillary midline diastema frenum Vertical Relations: *Overbite (%); openbite (mm); lip posture (open, closed) tongue size, shape and position, lower face height Anterior Posterior *Overjet (mm), Cuspid relation Class I, II, III Relations: *Molar relation Class I, II, III, or MS, DS, FTP Profile (skeletal) convex, straight, concave Lip posture (tight, loose, mentalis strain) Tongue thrusting (swallowing) Dental/ Family History *Home care; caries rate low, medium, high Accidents trauma, speech defects, oral habits, speech defects, family other requiring orthodontics Patient Compliance *Behavior precooperative, cooperative, anxious but cooperative, etc. Willingness to accept appliances, braces, frequent appointments SUMMARY OF FINDINGS: Summarize problems noted in each area. The instructor assigns the cases to the pre-doctoral or post-doctoral clinic for continuing care and signs his/her name with the note. This may require an orthodontic consultation.

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SUMMARY & TREATMENT PLAN

Pages 40-45 are the pages in the dental chart where intraoral charting is recorded, an outline of dental need is recorded and a treatment plan is developed from the data obtained in the earlier examinations. The needs are to be assembled in a visit by visit plan, or sequence of visits, to provide total care to the patient in the least possible number of visits.

ADDITIONAL DIAGNOSTIC AIDS

X RAYS FOR PEDIATRIC PATIENTS

Initial films for all pediatric dentistry patients

1. New Patients: Two (2) bitewing x-rays (largest size that fits) if the contacts are closed. If contacts are open, do not take x-rays unless other reasons exist. 2. Recall Patients:

a. If patient has had previous caries, two (2) bite-wing x-rays (as above) once each year.

b. If patient was caries free last exam, bitewing x-rays should be taken at 2

year intervals.

3. Special Circumstances:

a. Maxillary anterior occlusal x-ray (#2 of #3 (occlusal) film) at 6-8 years of age (eruption patterns, missing and supernumerary teeth, eruption problem, etc.).

b. Panoramic film: age 16-18 (3rd molar eruption).

c. Any film or combination of films deemed necessary by the dentist. For

example:

1. B/W or P/A in area of deep caries or abscess formation. 2. Cephalometric, F.M.S. (full mouth series), etc. for orthodontic

treatment.

3. In any area where pathology is suspected upon careful clinical examination.

4. Films to locate position of tooth for surgery or orthodontics, etc.

5. Follow-up films in areas of pulpotomy or pulpectomy.

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Clinical situations for which radiographs may be indicated include:

A. Positive historical findings: 1. Previous periodontal or endodontic therapy 2. History of pain or trauma 3. Familial history of dental anomalies 4. Postoperative evaluation of healing 5. Presence of implants

B. Positive clinical signs/symptoms: 1. Clinical evidence of periodontal disease 2. Large or deep restorations 3. Deep carious lesions 4. Malposed or clinically impacted teeth 5. Swelling 6. Evidence of facial trauma 7. Mobility of teeth 8. Presence of fistula or sinus tract 9. Clinically suspected sinus pathology 10. Growth abnormalities 11. Oral involvement in known or suspected systemic disease 12. Positive neurologic findings in the head and neck 13. Evidence of foreign objects 14. Pain and/or dysfunction of the temporomandibular joint 15. Facial symmetry 16. Abutment teeth for fixed or removable partial prosthesis 17. Unexplained bleeding 18. Unexplained sensitivity of teeth 19. Unusual eruption, spacing, or migration of teeth 20. Unusual tooth morphology, calcification or color 21. Missing teeth with unknown reason

C. Patients at high risk for caries may demonstrate any of the following: 1. High level of caries experience 2. History of recurrent caries 3. Existing restoration of poor quality 4. Poor oral hygiene 5. Inadequate fluoride exposure 6. Prolonged nursing (bottle or breast) 7. Diet with high sucrose frequency 8. Poor family dental health 9. Developmental enamel defects 10. Developmental disability 11. Xerostomia 12. Genetic abnormality of teeth 13. Many multisurface restorations 14. Chemo/radiation therapy

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RADIOGRAPHIC GUIDELINES

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MIXED DENTITION ANALYSIS: DETERMINATION OF CROWDING OR SPACING

Orthodontic study models may be used to quantify the amount of crowding or spacing present in any given arch. This is done by comparing the space available with the space required for all of the teeth to fit. Space analysis carried out in this way involves two major assumptions: 1) The anteriorposterior position of the incisors is correct, and 2) The space available will not change because of growth. Quantifying Crowding/Spacing in the Adult Dentition (space available) (space required) = crowding/spacing A negative number indicates crowding: (e.g. 6.6mm is 6.6mm of crowding) A positive number indicates spacing: (e.g. +5.0mm is 5.0mm spacing) Space available in the permanent dentition can be measured by dividing the dental arch into four straight line segments. The measurements are taken from the mesial of the first molar to the mesial of the canine and from the mesial of the canine to the mesial of the central incisor (or midline in the case of a midline diastema).

Space required in the permanent dentition is the sum of the mesiodistal widths of all individual teeth measured from contact point to contact point.

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Quantifying Crowding/Spacing in the Mixed Dentition

Patients often present for consultation and/or treatment during the mixed dentition stage of occlusion. It is desirable to predict if any given patient may later develop a problem with crowding or spacing. Since we are unable to directly measure the size of the unerupted permanent teeth, we must estimate their size. Proffit (Chapter 6) explains several methods of estimating the size of permanent teeth including:

1. Measuring the permanent teeth on periapical films. This is then multiplied by a correction factor that compensates for enlargement of the radiographic image.

2. Estimates from proportionality tables. Proportionality estimations are

possible because there is good correlation between the size of the mandibular incisors and the unerupted canines and premolars. Proffit highlights two different proportionality methods including:

A. Tanaka and Johnson:

TANAKA AND JOHNSTON PREDICTION VALUES

+ 10.5mm = Estimated width of mandibular canine and premolars in one quadrant

One half of the mesiodistal width of the four lower incisors + 11.0mm = Estimated width of maxillary canine and premolars in one quadrant

From Tanaka MM, Johnston LE: Am Dent Assoc 88:798, 1974.

B. Moyers Mixed Dentition Analysis: The Moyers Mixed Dentition Space Analysis is the preferred method of prediction at the UCLA School of Dentistry. It is a method of estimating arch length discrepancies in the mixed dentition period and uses the same basic strategy of comparing space available with space required.

Moyers Mixed Dentition Space Analysis Step by Step Step 1: Calculate maxillary space available. We must know how much space is available for the already erupted permanent incisors as well as the unerupted permanent canines and premolars. This assumes that the treated arch will be the same dimension as the current arch and that the incisor position will remain unchanged.

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Step 2: Calculate mandibular space available. As in step 1, we must know how much space is available for the permanent teeth once they all erupt. Step 3: Measure mandibular incisor width. Since these teeth are erupted, it is most ideal to use the direct measurement of these teeth in mesiodistal width to determine how much space they will require when in ideal alignment. Step 4: Measure maxillary incisor width. Again, since these teeth are erupted, we will use the actual measurement to determine how much space will be needed to align them. Step 5: Predict the widths of the unerupted canine and premolars. The summed width of the mandibular incisors is used to estimate the space required for the permanent canines and premolars in both the maxillary and mandibular arch. This estimation is extrapolated from the probability chart created by R.E. Moyers. This chart is designed to predict the sizes of unerupted canine and premolars in one quadrant at a certainty level of 75%. Step 6: Calculate space required. For both maxillary and mandibular arches, add the actual measurements of incisors to the predicted widths of unerupted canines and premolars to predict the space required for permanent teeth. Step 7: Calculate arch length discrepancy. Subtract the predicted space required from the space available in each arch to predict the arch length discrepancy once the permanent teeth erupt. Note:

The method used to measure space available is identical to that used for adult dentition.

Space required in the posterior segments is provided by Step 5 and the anterior space required is simply measured from the mesiodistal widths of the four incisors.

As always, (space available) (space required) = crowding/spacing.

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CLINICAL RESPONSIBILITIES

NEW PATIENTS

1) Introduce yourself and encourage the child and/or the parent to volunteer information regarding the childs teeth.

2) If it is a new patient, review medical history and complete the yellow form behind the medical questionnaire. Complete extraoral, intraoral examinations and occlusion summary. See samples.

3) Determine the appropriate radiographs to be taken. 4) Get a start check and review the type and number of radiographs that will

be taken with the instructor.

INTRODUCTION TO DENTAL PROCEDURES

1) Orient the child to the chair and explain the purpose of todays visit. Use Tell, show, and do.

2) Perform head and neck exam. 3) Initiate the oral examination with fingers, then a mouth mirror. 4) Chart teeth, do ortho evaluation. See sample.

CARIES EXAMINATION

1) Dry tooth with air syringe. 2) Examine each tooth surfaces for caries. 3) Note findings. 4) Prepare treatment plan in the order of greatest priority.

CARIES RISK ASSESSMENT

1) The American Academy of Pediatric Dentistry (AAPD) has determined that caries-risk assessment is an essential part of clinical care for infants, children and adolescents.

2) Use the AAPD Caries-risk assessment tool (CAT) to determine caries risk. See page 61.

3) Note caries-risk assessment in the SOAP notes. PROPHY AND FLUORIDE

1) Tell, show, and do regarding handpiece and prophy cup. 2) Remove deposits of plaque with a universal scaler, floss, and then polish

all tooth surfaces with rubber cup and prophy paste. 3) Explain to patient that you will be applying some fluoride tooth vitamins

to his/her teeth. 4) Encourage one last drink and/or rinse. Explain that the child will not be

able to eat or drink for hour.

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5) Explain that fluoride is good for the teeth and not for the stomach. Fluoride should not be swallowed. Demonstrate the use of the salvia ejector.

6) The use of fluoride trays is the preferred method of topical applications. Both trays are placed in the mouth and the patient occludes on them. The salvia ejector is placed in the mouth. The trays should remain in position from 1-4 minutes. This depends how long the patient can tolerate the procedure.

7) Try in the trays prior to filling them with fluoride. If it appears that the patient cannot tolerate the trays, the following methods are possible:

a) One tray at a time. b) Paint on with a cotton tip applicator c) Brush on with a toothbrush

ORAL HYGIENE INSTRUCTION

1) Give a toothbrush and some floss to the child and ask the child to demonstrate the way you usually brush and/or floss.

2) Assist the child in correct brushing and flossing techniques. 3) Parents with children 8 years of age and younger should be advised to

assist their child with brushing and flossing. COMPLETION OF APPOINTMENT

1) Present case to instructor. 2) The final diagnosis and treatment plan is to be entered in ink only after approval by instructor. 3) Give the child the toothbrush and floss and also a toy and/or sticker. 5) Discuss all your findings and treatment plans with the parent or guardian. 6) Make sure to ask the parent if they have any concerns or questions regarding the diagnosis or treatment plan. Discuss your plan for the next visit.

RECORD PROCEDURES

1) Use SOAP note format for chart entries. 2) Detail any instructions to a patient. 3) Note behavior of the child and what is to be done next visit.

NOTE: Accurate diagnosis and treatment planning depends upon:

A full written health history Interviews to verify and support history An extra and intra oral examination of the patient Obtaining additional diagnostic aids such as x-rays, dental casts, laboratory tests or consultations with other health professionals.

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Review the Pediatric Health Questionnaire filled out by the parent at the initial visit to the clinic. From this and from subsequent interviews with the parent to discuss elements of the history, it can be determined that the patient is of good health or that there may be a need for consultation with the family physician, hospital or health facility. It is important to determine the need for antibiotic support in any patient before dental manipulation is initiated. See guidelines with regards to cardiac conditions associated with endocarditis and the dental procedures that are listed needing endocarditis prophylaxis. RECALL PATIENTS

1) Seat the patient, review medical history, have parent sign a medical history update, and determine if radiographs need to be taken.

2) Get a start check for prophy and fluoride treatment and confirm with the instructor the number and type of radiographs to be taken if necessary.

3) Prepare the treatment plan in the order of greatest priority and present the case to the instructor.

OPERATIVE PATIENTS 1) Seat the patient, review medical history, place most recent x-rays on the

viewbox and determine the operative procedure that has the highest priority. 2) Get a start check and confirm with the instructor the procedure you wish to

perform. Be prepared to explain your reasoning. 3) Give a short explanation as to how you are going to approach the procedure

and, if necessary, the amount of anesthesia that will be used. 4) High and low speed handpieces must be in the operatory prior to beginning

treatment. 5) The instructor needs to approve each of the following steps before the

student is permitted to proceed: a. Rubber dam isolation b. Ideal access preparation c. Extension of cavity prep if necessary d. Placement of matrix band and wedge if necessary e. Final restoration prior to removing rubber dam

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CARIES RISK ASSESSMENT TOOL (CAT)

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INJECTION PROCEDURE FOR THE PEDIATRIC PATIENT The control of pain during dental procedures is one of the most important factors in child management. Topical anesthetics, such as benzocaine, if used properly, produce surface anesthesia of the mucous membrane and reduce or eliminate the discomfort of the needle penetration. The best results behaviorally and physiologically is to use the gel sparingly and apply to a dry mucosal surface for at least 2 minutes. Most dissatisfaction with topical anesthetics results from prematurely injecting the tissues. There are occasions when it is more appropriate to proceed with the local anesthetic injection without the benefit of topical anesthesia. This is recommended for those patients in whom undesirable behavior is noted due to the taste and/or numbing effect of the topical anesthetic. This occurs most often in younger patients usually between the ages of 2-4. A short (20 mm) or long (32 mm), 27 or 30 gauge needle may be used for most Intraoral injections for children, including mandibular blocks. An extra short (10 mm), 30-gauge needle is appropriate for maxillary anterior injections.

LOCAL ANESTHETICS Most dentists routinely use one or two local anesthetics agents. Be familiar with the maximum allowable dosages for the size of the patient and the potential undesirable effects of the agent. See charts below.

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MOUTH PROPS Mouth props can be used to help the child keep his mouth open sufficiently so that dental treatment can be performed. There are several mouth props available and of those evaluated, the scissors or Molt mouth prop serves the widest variety of situations.

Molt mouth prop

PREPARATION FOR INJECTION It is important to prepare the child to receive a local anesthetic. The choice of words is extremely important. It should be explained to the child in terms that he can understand and with phrases that will not upset him. For example, the following comments can be used. Im going to put some sleepy juice on your tooth, so that the tooth will go to sleep. Its going to feel kind of weird and funny.

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If the child asks, will it hurt? a good answer would be: well, its going to feel kind of weird; and you may feel a little pressure or pushing. Never tell the child it is not going to hurt. The injection will feel uncomfortable (and may hurt a bit) and hell never believe you again. You will have lost his trust. Try to keep away from words like pinching, biting and stinging to describe the injection. These terms should be avoided for fear of producing undesirable responses. Dont use the word shot or injection. If the child comes in and says, Are you going to give me a shot? A good answer would be, well we dont give shots like you get at the doctors office. Its really different here, we put a special kind of juice (or magic juice) near your tooth and it makes the tooth go to sleep. The child should be allowed to look in the mirror following the injection, to see that his face is not swollen or distorted. The necessary local anesthetic armamentarium should be kept out of sight. It should be place behind the patient where it is easily accessible to the dentist and the assistant. The injection procedure should proceed as a smooth act. If the child does become upset, it is important to continue with the injection procedure. Dont stop. It will be very difficult to reinject. Slowly inject the anesthetic. Rapid injections tend to be more painful because of rapid tissue expansion. They also increase the possibility of a toxic reaction if the solution is inadvertently deposited in a blood vessel. It is very important to explain to the parent before beginning dental treatment all that is planned for that particular visit. Make sure to address any questions the parent may have prior to beginning treatment. During the injection, the assistant must be alert in order to anticipate abrupt movements of the child. Often at the instant the needle penetrates the soft tissues, the child will lift his arms up and it is at this time that the assistant must block the childs arms.

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As soon as the tip of the needle penetrates the tissue, a small amount of anesthetic solution should be slowly and continuously expressed. The operator should aspirate in order to determine the position of the needle point. The operator can direct the operating light as to encourage the child to close his eyes during the injection. If the childs behavior begins to deteriorate during the injection, instruct the child to open his eyes and begin talking to him. Tell him the funny feeling will go away soon, I am just going to count to 10 and then thats it. Start counting and usually the child will start to calm down. Most children like counting because it gives them the assurance that the procedure will end soon. As soon as the syringe is removed, the child should have his mouth rinsed with water. This will divert the childs attention away from what has just happened. Discuss the funny feeling and caution the child about biting his tongue and lips. When administering the local anesthetic and also when proceeding with the treatment; try not to spend too much time explaining what it is and why it has to be done. Your goal is to get the child in and out of the chair as quickly as possible. Briefly explain what is to be done and do it. Distraction can be accomplished by continuing a constant monologue with the child. POSTOPERATIVE INSTRUCTIONS Instruct the parent to remind the child not to bite or chew the lips, tongue and cheek.

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TECHNIQUE FOR FISSURE SEALANT

ISOLATE TOOTH Rubber dam isolation is the ideal way to keep the tooth from salivary contamination. Cotton roll isolation with adequate suction to remove salvia from the operating field is also acceptable. CLEANSE TOOTH SURFACE Use pumice slurry to cleanse the tooth surface. Rinse the tooth thoroughly with copious amounts of water. Some practitioners recommend cleaning the surface with 3% hydrogen peroxide to remove additional debris from the fissures. ACID-ETCH TOOTH SURFACE Apply etching with a fine brush, or a minisponge to the tooth surface. Exposure time varies from 15 to 30 seconds. RINSE AND DRY-ETCHED TOOTH SURFACE Rinse the etched tooth surface for 30 seconds. Dry the tooth for at least 15 seconds. If cotton roll isolation has been used, replace the cotton rolls at this time, making certain that salivary contamination is not occurring. If it is possible to avoid salivary/water contamination, application of a bonding agent prior to sealant application may improve retention of sealant to the tooth. If a dentin-bonding agent was placed, gently blow compressed air onto the tooth to disperse a thin layer of bonding agent evenly. APPLY SEALANT TO TOOTH SURFACE Apply the sealant material to the tooth surface and allow the material to flow into the pits and fissures.

Light cure sealant for 20-30 seconds.

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EXPLORE THE