105 Children’s Dentistry

Treating children can be very rewarding and a great deal of fun. This course will give you some methods of handling children. It will also include the painless injection, a must when you are treating children.

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Pediatric Dentistry

About the Course

Treating children can be very rewarding and a great deal of fun. This course will give you some methods of handling children. It will also include the painless injection, a must when you are treating children.

Children respond to us. If you enter the operatory with a dreading demeanor, you can count on the child not cooperating. If you are having a bad day, it is best to reschedule the child. When you treat children, you are forming their future behavior as patients. There is never a call to be rough with children.

Children like to be entertained. They respond well if they think you are playing with them. Of course, this is very hard to do with the child’s parents in the operatory. In fact, it is very hard to do dentistry when someone else is in the operatory watching your every move.

You have several problems with the parent in the operatory. The child has responded to the parent all of his life. Now for you to communicate with the child you must go through a third party, the parent. This is very difficult.

You will hear statements: “Listen to the doctor. The shot will hurt only a little bit. Do what the doctor says. Hold still for the doctor. If you are a good boy, we will go to the ice cream store afterwards.”

Then when you give the injection, the parent hides their face translating to the child it will hurt. How many of us can watch our child bleed and not show some emotion? It is best the parent is not in the operatory. Of course, if the child should let out a piercing scream, the parent will come running. Children have been mistreated in the dental office to the point of children dying as in a case in California. We have not earned the parent’s trust.

It is understandable why the parent wants to be with the child. In cases where I cannot persuade the parent to leave, I have them stand behind the child and outside the operatory. It is not good and makes your job more difficult, but at least the child does not see them and will respond to you.

Antidote:

Years ago, before the disposable needle, I went to the dentist suffering from a decayed lower right first deciduous molar. I was five years of age at the time. The doctor did not usually take children, but my mother was very persuasive. She promised me a quarter if I behaved. A quarter was very large then. You could buy a loaf of bread for seventeen cents.

I sat in his huge chair and watched the large number twelve-gauge needle coming towards my mouth. It had nothing, but pain written all over it. My two small hands grasped his wrist and held on for dear life. When he saw that was not going to work. He scraped up some topical on a cotton swab and came at me again. It wasn’t sharp, and I allowed it to enter my mouth.

Again, with the number twelve needle, my two hands had it before it reached my mouth. It was not going inside. He had my mouth held open with one of his rubber block. My only defense was my two hands. He laid the needle down, picked up his forceps, placed his large knee on my small chest, took hold of the tooth, twisted and jerked it out. I let out a loud scream letting my mother know in the waiting room, the doctor hurt me. He was angry and told my mother I was never to enter his office again. She did not give me my quarter taking the doctor’s side.

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Waiting Room:

If you specialize in children’s dentistry, then the office should reflect this, and have items in the waiting room the child can relate to starting with the video screen on the wall. Instead of placing a movie on the screen, it should be a place you can educate the patients and their parents. It can have office procedures, and treatments of various problems done it a very simplified way. You may even what to use cartoons for this.

The office should have something the child can play with. Video games, hands on items that are very safe for small children. Of course, this would not apply to offices that rarely treat children. Children should be encouraged to draw pictures for the office. These can be displayed in the operatories or front the office.

If your office uses pictures as part of their diagnosing procedure, the front facing picture could be placed in a special place in the office representing the patient of the month or week. When they are removed, they could be placed in a large photo book for the patient to view in later years. They are now part of your office.

You are trying to make your office personable, and the patient comfortable. This is better than reading some old magazine, listening to soft music waiting for your turn in the pain department inside. Again, this will depend on your office and the type of patients you are seeing. You need to cater to these people be it children or adult. In any case make it a friendly office with the front office personnel removing the glass in front of them, communicating with the patients, and listening to their problem.

Anecdote:

I worked in an office as an associate for a short time. It had old equipment, and the waiting room had an old TV on a table stand for entertainment. One of the assistant’s working with me commented the office was not sterile and compared it with another office she had worked at that had a children friendly waiting room with nice equipment in the operatories. I was given the opportunity to work in the said office one weekend.

Yes, the waiting room had a nice children friendly look to it and the back office was filled with new equipment, but the sterilization and cleanness was not up to par with my office with the old equipment.

Lesson I learned: Patients looked closer at old equipment then they do at nicely painted and new furniture.

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The Microscope:

When I first started my practice and had some time, I set up my microscope from my school days. It was an oil immerse 1000 magnification. I would take a swipe of biofilm from the child’s mouth, wipe it on the glass slab, thin it out and place a glass cover. This went under the microscope after adding a drop of oil.

When I found an interesting spot, I brought the child to microscope and allowed him to watch the movement of the bacteria. It was usually enough to encourage the child to brush. It was not difficult to do and only took a few minutes to put in place. It would be good to know the names of some of the moving bacteria and spirochetes.

The Operatory:

When should you start treating children? It is very difficult to treat children while the mother is holding the child. Even though I have treated emergency situation this way. You have no control. You have two patients in the chair rather than one, and you have to work through the parent to treat the child.

I would say when the child can remain in the chair on their own and can understand what you are saying would be the ideal age to start. This can be two years of age for some children and not for others. You should consider a specialist if you think you will have difficulty treating the child.

Anecdote:

When I first started my practice some years ago. I was willing to see anyone coming through the door. A woman in her early thirties was pushing her five-year-old young lady through my door. She did not have an appointment, but her daughter was in pain. The mother said the tooth on the lower right side had a hole in it. The little girl had been up all-night crying from the pain. The look in the little girl’s eyes said she was scared and didn’t want her tooth fixed. Her mother was not taking no for an answer and dragged the screaming child toward the door to the operatory. The child put out her three remaining appendages and braced herself against the door frame. She was not moving.

Her mother tried pushing her through the door, but the freed fourth appendage went to the door frame. Here was this irritated mother trying to force her spread-eagle child through the office door to my operatory.

This was the child’s first experience in the dental office. It was not going well. The child had been to many physician’s offices. She knew what doctors did to her. Finally, after everyone calmed down, the child walked back, and climbed up on the chair. I think her tooth started hurting from all the clenching, or maybe it was her mother’s no-nonsense attitude.

Upon inspection of her mouth, the lower right second deciduous molar had a large decay. Since she was in pain, I assumed the tooth was exposed. The child would have to be numbed before we could work on the tooth.

It took me a half hour to get the child to allow me to give her an injection. It took another half hour to get her numb enough to work on. Then each procedure had to be carefully explained before we could proceed. Meanwhile my waiting room was filling up with other patients who had appointments.

They all waited patiently while I worked on this child. I managed to accomplish a pulpotomy and a temporary amalgam filling. She would need a stainless-steel crown later.

The child came out of the ordeal in good spirits. She did not feel any pain from the experience. The mother came to the front office desk for her child in a bad demeanor. She was angry because she had to wait two hours while her child was being treated.

I was exhausted from the ordeal. The mother was ungrateful. The other patients with appointments had to wait, but the child was smiling. Her pain was gone, and I didn’t hurt her.

I wanted to have the mother take the child somewhere else for her next appointment, but the child would not allow this. I continued to see the child for the next ten years.

This was my first experience in children’s dentistry. I learned children take time. They don’t always fit into a busy schedule. I would have been better to have taken the emergency child prior to lunch. Then the two hours in the operatory could have extended into my two-hour lunch period and not disturbed my other patients.

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Medical History

Most office have a health form the parent fills out for the child. This should not be place in the chart and forgotten. This is only an outline for you to ask question from. You may find you need to contact the patient’s physician before you treat the child. You will also want to know the child’s previous history with a doctor. Has he had a bad experience? Is this his first time?

Child’s First Time Visit to the Dental Office:

Three to Four Years:

The way you will treat the child will depend on how far along the child has developed. Some you will be able to move right along and start some dentistry. It also depends on whether the child is under stress from a painful tooth. This would exclude the preliminary office get acquainted procedure. You will find most of your patients will be in this category because parents usually do not think the get acquainted technique is necessary and would like you to proceed with the job at hand. Depending on where you are practicing, the parents will differ in their thinking.

Ideally:

The First Appointment (get acquainted - no emergency)

This is usually the X-ray and diagnosis appointment. If the child is very young (this is mature young), the first appointment may be no more than a ride in the chair, and a walk around the operatories. The X-rays can be taken another day if the child is not up to sitting for the X-ray. The doctor always sees the child. If the X-rays are not taken, the doctor should still do a preliminary exam of the child’s mouth. You can count the child’s teeth with your mirror. This gives you an opportunity to look at the child’s teeth. I never count right. I usually miss a few numbers or get them mixed up. The child will usually correct me. Then I will go on not believing I made the mistake and do it again.

The child knows his numbers. Basically, you are having fun with the child, but you are also examining his teeth. You can show him the X-rays and count the teeth while you examine them. You are going to verify you are correct in your counting. The child is made part of the exam process.

You can blow air from the air syringe and accidentally blow air up the child’s sleeve. You act surprised and blow the air on the child’s hand. No, it goes on the child’s teeth. The idea is to play with the child while you are examining him. You get the information you need, and the child is having a good time.

Every child is different. What works well for one child may not work well for another. You need to read the child. A quiet child may be frightened of you and the dental office. By doing something silly, the child will relax. You are playing with him. You may need to go slower with this child. Another child may be out-going and will love playing with you.

Every doctor is different in personality. What is easy for one doctor may not come easy for another. A doctor with children at home will know how to play with children. One who does not have children will need to learn.

Before the child leaves each time, he is given a prize from the treasure chest or a sticker from the doctor. Patients come back years later and tell me how much they looked forward to the treasure chest when they were children.

The Second Appointment:

This is the prophylaxis appointment. The dental assistant works the prophylaxis cup around the child’s mouth. Depending on the sensitivity of the child, the prophylaxis may only include the anterior teeth. The idea is to have the child become used to things moving around inside of his mouth. There is no pressure to complete the prophylaxis.

It is important the doctor make an appearance and play with the child a moment. This gives the doctor a chance to make a pleasant connection. This can be a look in the child’s mouth, or a light touch on the child’s nose. You need to improvise on the spot according to the child’s demeanor.

When I was younger, I used to swing the child up in from the chair. This usually put a big smile on his face before he went racing back to his mother. Of course, the child will not let you forget the treasure chest.

The Third Appointment:

This is the appointment you want to start some of the operative work. It should be something very easy and quick. The child at this point will trust you not to hurt him. He thinks coming to the dentist is fun. Of course time is important and expensive, but this early beginning is important if you plan on seeing this child for the next twenty years.

The Very Young child:

The age of the child makes a difference on how you will handle him. If he is a two to three-year-old child, you may not want to numb him on this visit. In fact, you may not want to numb him at all. The after effect of the anesthetic may far outweigh the benefit of the anesthetic.

Anecdote:

A young child of three came into the office with decay on his posterior molars and his four maxillary anterior teeth. He was put through the three-appointment process. On the third appointment the work was started on the lower left side. He was anesthetized using the painless technique with lidocaine, and the lower left second deciduous molar was treated with an amalgam filling. The patient did not feel any pain and left with a smile on his face.

The parent was warned the child needed to be watched. This was his first experience being numb. There was the possibility he would chew his cheek. The patient came back for his next appointment with his lower left lip swelled. A huge hole went from the lower left lip to the inside of his cheek. The chewed cheek was already in the healing phase. The wound was open. There was nothing to suture.

It took two weeks for the cheek to heal. I did not give him more anesthetic. The child simply did not understand he was not to chew his cheek. We continued the remaining fillings without the benefit of anesthetic using the technique described below.

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Procedure without anesthetic:

If the child has anterior decay in the maxillary anterior incisors, this may be the area to start. The location is accessible, and the cooperation of the child is not critical.

Usually you can remove the decay with a small or large spoon. The hand piece can be used to give access if it is necessary, but you cannot use the hand piece to remove any deep decay or set any undercuts. All of the hand piece work is finished before the decay is removed with the spoons. The restorations are filled with composite because the undercuts are not critical to the restoration. All of this can be done without numbing the child

To make this work better, the child can be instructed to close his eyes and visualize a television set. He thinks you are playing with him.

You go through the following sequence with him:

You tell him to close his eyes and visualize a television and turn it on. You wait a few seconds, and then ask him if the television is turned on.

He will say yes.

You tell him to pick his favorite cartoon and turn the channel until the cartoon comes on. You wait a few seconds, and then ask him what he is watching.

He will give you a description of the cartoon.

Now you tell him to step inside the cartoon and play with the people in the cartoon.

You wait a few seconds and ask him how he is doing?

He will start into an extensive dialog of what is going on.

Now you may proceed with the composite. He will feel pain if you hurt him, but he will ignore any the low ebb pain. You can proceed with the decay removal. This is still a spoon procedure. You cannot do this with an exposed tooth. The X-rays need to be checked closely. If there is a chance of any exposure, you will need to numb the tooth.

Once the decay is removed, the composite can be place and smooth with the hand piece.

I would not overdo this visit. The child is going to become bored with his cartoon in ten to fifteen minutes. One or two filling should be the limit.

This procedure can be done on posterior teeth if the decay is limited to dentin. When exposing the decay, the bur needs to remain above the decay. The spoon can remove the decay.

The above procedure is a hypnosis technique. Children are hypnotized everyday with the television and video games. They possess great imaginations. You are only taking advantage of this to help the child overcome the discomforts of dentistry.

The Young Child Five to Seven:

If this is a first-time patient, you should go through the three-appointment procedure.

The X-ray and diagnosis is on the first appointment, and the prophylaxis is on the second. The treatment starts on the third. This can be a fun age to work with.

Developing a relationship with the child makes the dental procedures easier. Look for something on the child that is obviously pretty or cute. If a young lady’s eyelashes are long and flowing, you can make a comment about them. Example: “Those sure are pretty eyelashes. Where did you buy them?” She will make some comment that she didn’t buy them. You keep going on about them, saying you would like to buy some for yourself. Ask her how they would look on you?

If it is a young man you are dealing with, you would inquire about his shoes. You would tell him how great they look. Then you would flop your size twelves up on the chair beside his shoes and ask him if he would like to trade. This works with young ladies as well.

The point here is the conversation is absurd. This makes it funny and the child relaxes. It can be anything, a purse or book. Tell the child you want to buy one like it. Ask the child how you would look with one. The child knows you are playing with them. You can go on about the trade as you work on them.

Sometimes the child is not up to the work you are into. There is no law that says you must finish the procedure at that moment. To place a temporary and have the child back for another session is always better. To finish the procedure and lose the patient is not good dentistry.

A child between the ages of two and eight years should never be left alone.

This is an important concept. A child left alone becomes frighten making him very difficult to handle. The child should remain with his parent until you are ready for him. If the office is busy, the child can be sent back to the parent after the anesthetic injections are given. This is better than leaving the child by himself in the operatory.

The anesthetic injection is an important part in dealing with children. Giving a painless injection to a child is very easy compared to an adult. The child will follow directions without apprehension. The adult patient will react out of previous painful injections. This makes it difficult for them to relax. The child does not have this memory. He can relax immediately and allow you to give the injection into loose tissue.

You do not show the child the needle or even indicate you have a needle. Again, this is a first-time patient. The child believes the dental appointments are fun. The patent is smiling and looking up at you. If you change your mood the slightest, the child will catch on immediately.

Smiling, you tell the child you are going to shake his cheek. You take his cheek and shake it. The child thinks you are playing with him again. You place the light just below the child’s eyes. If he tries to see the needle, the light will hit his eyes. You bring the needle around the child’s head and give the painless injection. Again, you do not allow the child to see the needle. He knows needles bring pain.

Immediate upon securing the needle, you rub your finger along the child’s check and tongue. You tell the child your finger is magic. Your finger will make his cheek and tongue fuzzy. The child thinks you are still playing with him. When the anesthetic begins to take hold, he will think it is a magic trick. The child comes in smiling and leaves smiling.

When the child is asked later about the injection, the child will say you did not give him one. You will need to eventually tell the child you are giving him an injection, but this can be years down the road.

I have had children arguing with their siblings that I had not given them an injection. This would go on for many years until I finally confessed I was giving them an injection.

Things to Think About:

 Never leave a young child alone in the operatory.

 Give the child a prize after the treatment is completed.

 Do not force a child to finish the procedure.

Older Children Seven to Twelve:

The X-ray and prophylaxis can be the first appointment for the older children. Unless it is an emergency, you might want to start treatment on the second appointment. It allows time for the child to become acquainted with your staff and office procedures. If the child has never been exposed to a dental office before, this can be a good experience for them.

The child should never be pushed beyond what he can handle. There is always another day. Example: If the child has a difficult time with the pulpotomy, the stainless-steel crown can be done another day.

Children pick up on you very quickly. If you are relaxed, they will be relaxed. If you are pushing to move your production along, they will respond in kind and be hard to manage. They usually are good at following directions. When they find you give a painless injection, they will return to their parents with glowing reports. Many parents will send their children to you before they allow you to work on them. If the kids come back with all smiles, then you will probably be seeing the parent.

Older children should know you are going to numb them. What age you should tell them will depend of their emotional development. You do not use terms like: “I am going to give you a shot.” Rather, “I am going to numb you along here.” Using your finger, you run it along the side of the child’s face and tongue you are going to numb. It is important the child knows what is expected of him. You do not show the needle, meaning you do not place the syringe and needle on the tray.

The Apprehensive Child:

This child is easy to recognize. The child is obviously frightened. Probably his older sibling has been telling him the horrors of dentistry. If you try to give the injection, the child turns away or clutches your hand. This situation calls for the ‘Money Bribe.’

‘Money Bribe.’

Children are accustomed to being bribed. You take a dollar from your pocket and place it on the tray in front of the child. It may require a five-dollar bill for older children, or a twenty-dollar bill for adults.

You tell the apprehensive child you will give them the money if you hurt them in any way. The child will be the sole judge whether it hurts or not. Now you would think the child would say it hurts just to take your money, but the apprehensive child will not. The child does not want it to hurt. The money is to make you give the injection painlessly. He would gladly give you the money not to hurt him. You tell him, “I have never lost any money!” When the patient’s belief is locked into this, he will allow you to give him the painless injection.

Extreme apprehensive adults will respond the same way. You cannot fool these people. They fear the injection. Dentists have lied to them in the past. They will believe you when you place the money on the tray. Fortunately, extreme apprehensive patients follow directions very well. They do not want it to hurt. This allows you to give a painless injection.

Things to Think About:

 Never show the patient the needle.

 Remain relax and the patient will remain relax.

 Find something of interest with the older child, school, sports, etc.

 Only use the money bride on extreme apprehensive patients. You could lose your twenty dollars.

The Painless Injection:

When is a Patient Numb?

An apprehensive patient will tell you he is numb after the first injection. The patient fears the needle more than the pain from the hand piece. So, when is a patient numb? The patient is numb when you can perform the dental procedure without inducing pain.

The patient may exhibit all the signs of being numb, cheek, tongue, lips, etc., but still feel pain when you begin your procedure. There is nothing wrong with your technique. The patient is numb. The problem is the tooth you are working on. It is hypersensitive too cold because the patient is clenching his teeth.

When you leave the room, the patient will often clench his teeth to see if he is numb. The patient is not aware of the damage he is doing. The normal pain sequence from clenching is gone with the numbing. This allows the patient to bite very hard and make the tooth very sensitive. You cannot numb through pain caused from clenching. You may as well send the patient home.

If a patient is a known clencher, it would be wise to place a cotton roll between the patient’s teeth (the opposite side of the mouth) after the injection. After the procedure is completed, the patient should be encouraged to continue with the cotton roll. Often after surgery, the patient will complain of pain from the extraction site. Instead of giving him drugs, you might consider asking them to place something between his teeth on the opposite side. The pain will usually go away.

The patient is not aware he is clenching. He will even deny doing it. You will need to convince him to try leaving the cotton roll in for a half hour. The pain will reduce over that period of time.

The Technique:

The technique is a series of injections. The first injection goal is to numb the injection site. Only half a cartridge of anesthetic is required for this. The anesthetic is given slowly while the surrounding tissue is distracted with a massaging motion.

The needle of choice is the 27 gauge. It allows aspiration and enters the tissues as easy as the 30 gauge that do not allow aspiration. You are not reducing the pain level by reducing the size of the needle.

The Inferior Alveolar Nerve Block Injection:

The 27-gauge long needle is used.

Monheim

The needle is penetrated into the tissues until gently contacting bone on the internal surface of the ramus of the mandible. This should be in the area of the mandibular sulcus which funnels into the mandibular foramen

The First Injection:

This is probably the easiest to accomplish because your left thumb is resting on the coronoid notch (right if you are left-handed). The thumb points to the injection site and your left-hand fingers are touching the soft tissue around the angle of the mandible. The fingers shake the tissue gently as the tissue and mandible are lifted into the approaching needle. The tissue moves over the needle as the needle moves into the tissue. You take the needle all the way to bone. If you miss, remove the needle and try again using the same technique. There is a tendency to push the needle hard into the tissue. This is not necessary. A gentle touch here is all you need. The patient is not feeling anything. There is no rush to inject the needle. There is no need to damage bone here.

If you find it is difficult to move both hands at the same time, take the needle point up to the tissue. Then lift the mandible and tissue and shake them into the needle. It is more dropping of the tissue then shaking it. You are only penetrating three to five millimeters into the tissue before you reach the bone.

Once the needle is in place, the shaking stops, and the tissues over the mandible where your left fingers are located begin to gently massage the tissues over the ramus. This distracts the smaller sensory nerve fibers allowing the larger massaging nerve fibers to block them out. The brain only receives the gentle massaging. The fingers continue to work, remember gentle. You aspirate and inject a small amount of anesthetic very slowly. After a small amount of anesthetic (forth to half of a cartridge depending on the size of the child) is injected, you remove the needle and stop massaging the tissue. You are only numbing the injection site.

There is a chance to strike the lingual nerve and defeat the whole purpose of the pain-free injection if the injection site is not forward of the pterygotemporal depression. It is best to stay on the bone between the depression and coronoid notch.

It is good to warn the child you are going to shake his cheek before you begin. An older child may become upset when you shake him around without being forewarned. Younger kids will think it’s fun and think nothing of it. Of course, you cannot shake tissue that is taunt. The patient needs to relax his tissues by closing his mouth slightly.

You do not give a topical anesthetic before you begin. Topical anesthetics only numbs the surface of the tissue. The movement of the tissue nullifies the need for a topical anesthetic. We are concerned more with the deeper layers of tissue where the topical anesthetic does not affect.

You should wait a few minutes before you give the second injection. The tissue needs a chance to numb.

The Second Injection:

The second injection is easier. The site is already numbed. You look for the correct anatomical site for your injection. You will be trying to numb the inferior alveolar and lingual nerves in the pterygotemporal depression. Again, there is no hurry here.

You will use the same technique as in the first injection. You will bring the needle to the tissues while your fingers gently shake the tissues over the mandible into it. The patient is not numb at this point. Once you reach your location, you massage the tissue, aspirate, and inject half or all of the remaining anesthetic in the cartridge (depending on the size of the child) very slowly.

The needle is removed and the massaging stops. You should wait a few minutes before you inject a third time. If you find an injection site in close proximity to the inferior alveolar nerve, you might achieve anesthesia immediately.

The Third Injection:

The area where you injected the needle is numb. You do not need to shake the tissue. You may use your regular technique for finding the correct spot for your injection. This time you will inject the remaining third of the anesthetic or another third of another cartridge. Often this is all you need to numb the child.

If the child is not numb after one cartridges of anesthetic, you should check to see if your location is correct. If the patient is not numb after one-and-a-half cartridges, you might want to consider another day. The child may not be emotionally ready to have a dental experience. Unless it is a dental emergency, there is no need to force a painful experience on the patient.

McDonald, Avery, Dean, “Dentistry for the Child and Adolescent”

“The toxic dose of lidocaine would be obtained if more than one-and-a-half of two percent lidocaine with 1:100,000 epinephrine was injected in a patient weighing 14 kg (30lb). Yet five-and-one-half cartridges of the same anesthetic agent would be required to reach the toxic level in an adolescent patient weighing 46 kg (100 lbs.).”

The amount of anesthetic depends on body weight. The rule of thumb: I would limit the dosage to one cartridge for children weighting thirty pounds and limit the dosage to two cartridges for children weighing eighty to a hundred pounds.

Things to Think About:

 The needle is never pushed into the tissues, rather the tissues are pushed into the needle.

 The tissue distraction does not allow the brain to focus on the injection site.

 The injections should not be rushed.

 This is a series of injection.

 The first injection is limited to a small amount of anesthetic.

 The patient should never see the needle.

 You cannot shake taunt tissues.

The Infiltration Method of Injection:

The 27-gauge short needle is used.

The relaxed tissue is allowed to drop over the needle point as the needle moves into the tissue. This can be an easy flip of tissue or simply a release of the cheek or lip tissue. Aspirate and inject a small amount of anesthetic into the tissue while the fingers that released the tissue gently massage it. You are only numbing the injection site.

You do not need a topical anesthetic. The injection site is deeper than the benefit a topical anesthetic can give.

Technique:

To make this more effective the needle needs to be bent to a forty-five-degree angle. It should not be bent more because you will not be able to replace the needle in the plastic cover. The bent is done with the plastic cover to keep the gloved hands off the needle.

The needle is inserted in the cartridge inside the syringe as normal, but now when you break the cover seal, you move the edge of the cover to the needle and bent it a forty-five angle. This forces the bent to leave a millimeter of the needle that is still straight. The weakest part of the needle is where it attaches to the hub. You do not want to make the bend there or you will be fishing for a broken needle in the child’s tissue.

When you are replacing the needle, the cover is on the counter and the needle is inserted. When it is in most of the way the other hand can pick up the cover below the point of the needle. The needles do pierce the plastic covering. (Or discard the needle into the needle container and not make an attempt to place the cover.)

The First Injection:

You should first select an injection site free of visible veins. It does not help the child to run the needle through a vein. It is preferable to be against bone, but this is not always possible.

The child relaxes the tissue you want to numb by closing his mouth slightly. Lift the tissue (lip or cheek) and move it around to insure total relaxation. You can make a game out of it with the child.

Lift the loose tissue taunting it. Place your needle point against the taunt tissue. Then simply flip or drop the tissue over the needle. The needle point does not move. The tissue comes to the needle point. Once you are confident in the technique, the needle can move into the tissue when it drops over the point. It is not necessary for the needle to move more than a few millimeters into the tissue at this point.

You might miss the tissue with the needle. This should not discourage you. Simply allow the patient to rinse the bitter liquid from his mouth and try the technique again.

Aspirate and slowly inject a small amount of anesthetic while the fingers massage the tissue above the needle point. There is no hurry here. The child is not feeling anything. Remove the needle while you are massaging the tissue. This is not a heavy massaging technique. You are only interested in distracting the patient.

When the needle is removed, you may stop the massaging. The child will only perceive the massaging. He will not feel the needle point.

When you are numbing for more than one tooth, the procedure is the same. A small amount of anesthetic is administered in each site using the above method. You may only use a third of the cartridge numbing the entire upper left side during the first injections.

The Second Injection:

Using the same technique as the first injection, leave the needle in longer and inject a larger amount of anesthetic. The anesthetic in the cartridge should be down a fourth at this point, again depending on the size of the child. You cannot see under the tissue. If you keep the amount of anesthetic injected to small amounts, it will prevent loading up a vessel with the anesthetic liquid.

The needle can be taken deeper into the desired location with this injection. The injection site is numb.

The Third Injection:

The patient is fairly numb. You may not need this third injection. You can place the needle point straight to the bone without the massaging. It is still a good idea to give the anesthetic slowly. The total amount of anesthetic used for a single tooth should be no more than a third to a half of a cartridge.

If you see blanching of the tissue, you are in a vessel. If the blanching is extensive, you should stop injecting additional anesthetic. You do not know where the vessel is located. If you inject more anesthetic, you run the risk of causing more blanching and discomfort to the patient. Usually the patient is not numb enough to continue the appointment.

Injections into Hard Tissue (gingiva) After the Inferior Alveolar Nerve Block is given:

The 27-gauge short needle is used.

The hard tissue, gingiva, around the tooth can be numb very easily from the lingual side since this hard tissue is already numb from the inferior alveolar block. This is a good test to determine if the block took.

The pressurized anesthetic liquid will extrude from the site. To prevent the liquid from reaching the taste buds, a two-by-two gauze is placed beside the site. This will capture the excess liquid and keep the child from the tasting the bitter anesthetic. If a dental assistant is available, she can aspirate the excess liquid, and the two-by-two gauze will not be necessary.

Starting from the numbed lingual side of the tooth, the first injection is placed near the inter-proximal mesial area. This can be distal, but mesial is easier. Taking the needle to the bone, a small amount of anesthesia is injected into the hard tissue (gingival) while a two-by-two gauze collects the excess liquid. This takes some pressure but be careful of overdoing the pressure. It is better to find another injection site then to blow a large amount of anesthetic behind the fascia. Stay away from the mucosa and soft tissues.

The tissue will blanch around the injection site. Staying in this blanched area, you give another injection. Following your blanching, you can take the anesthetic any direction you choose.

The buccal side is reached by taking the blanching into the inter-proximal. You need to give enough to cause some blanching on the buccal side of the tooth. Once you are on the buccal side, you may continue the injections. You may take the blanching any direction. As long as you remain in the blanching area, the patient will not feel the injections.

You should always aspirate before giving these injections. Vessels are not supposed to be in the hard gingiva, but they are. A pressured injection into a vessel will cause deep blanching and later discomfort to the patient.

Special care needs to be taken to avoid taking the blanching into the soft tissue unless this is desired. The pressurized injection into soft tissue will immediately cause the soft tissue to swell and distort.

You could give another injection using the “Infiltration Method” into the long Buccal Nerve area to numb the buccal side.

The maxillary and the mandibular anterior teeth:

These teeth will be numb on the buccal or labial side. You start your blanching in the gingiva on the numb side just above the injection site. Each injection follows the blanching around the tooth. The excess anesthetic liquid will extrude from the site. A two-by-two gauze is needed to collect this unless the assistant is available to aspirate the liquid.

Injections into Hard Tissues After the Maxillary Teeth Are Numbed by the Infiltration Method:

The 27-gauge short needle is used.

The infiltration method usually is used for the maxillary.

Starting on the labial gingiva, the injections are given above the injection site and taken to the inter-proximal on each side of the tooth. You should place enough anesthetic to blanch the lingual inter-proximal. Once you are on the lingual side, you may take the blanching anywhere on the hard palate and not hurt the patient. A palatal injection should originate on the labial or Buccal and then be taken to the lingual with the blanching technique to achieve anesthesia without pain.

Mandibular Anterior teeth

The lower anterior injections are done in a similar manner. Once you are on the lingual, you may take the blanching either direction on the gingiva. It is important to start the blanching above the injection site.

Things to Think About:

 The pressure technique is not recommended for the soft tissue.

 Only a small amount of anesthetic is necessary to numb the gingiva.

 Heavy pressure is not necessary to achieve gingiva anesthesia.

 If the injection cannot be made with moderate pressure, then another injection site should be found.

 The patient will not feel any pain if the injection remains in the blanched area.

 You should always aspirate before injecting the anesthetic.

 A two-by-two gauze placed at the injection site will prevent seepage of the extruding anesthetic to the back of the child’s throat and taste buds.

Mental Block Injection:

The 27-gauge short needle is used.

The infiltration method is used to give the block. The patient is instructed to relax the lower lip by closing his mouth slightly.

Taking the relaxed lip and cheek in your left hand, you stretch the tissue outward. You locate an injection site free of vessels above the foramen, but not in it, place the short #27-gauge needle at the site and drop the stretched tissue over it. Then you massage the tissue over the needle point, aspirate, and slowly inject a small amount of anesthetic. You stop the massaging after you remove the needle point.

After waiting a few minutes, the second injection is given. This is done the same way except you inject more anesthetic.

The third injection does not require massaging and may not be needed. The injection site is numb. You may inject the site without causing pain to the patient. The needle should be taken to the bone to reduce the possibility of filling a vessel with the anesthetic liquid. Since you are near the foramen, it would be prudent to keep the amount of anesthetic injected into the site at any one time to a minimum. This prevents overloading a vein or artery. Aspirating before you inject the anesthetic does not always preclude placing the anesthetic in a vessel.

Things to Think About:

 The infiltration method works well in the mental block injection.

 The injection site should be clear of vessels.

 A small amount of anesthetic should be given at any one time to avoid overloading a vessel.

Injecting Exfoliating Deciduous Teeth:

The 27-gauge short needle is used.

The infiltration method is the preferred method followed by the blanching technique. This is not always possible because the permanent tooth may be in the injection site blocking out accessibility to the deciduous root.

This leaves only a direct approach to the deciduous tooth. A painless injection can be achieved by lightly placing the needle into the gingiva enamel sulcus. You use a slight pressure to place the anesthetic in the sulcus, and then gradually increase the pressure.

There is no hurry here. You are waiting for the blanching to occur. Once the blanching starts, you may follow the blanching around the tooth and in-between the roots.

When the blanching is complete, you can insure anesthesia by finding the space between or below the roots of the deciduous tooth. You should administer a fair amount of anesthetic under medium pressure to numb the tooth. Since the gingiva is light in this area, the injection pressure should not be extremely heavy.

Things to Think About:

 The gingiva sulcus is the injection site for a deciduous tooth blocked by the permanent teeth.

 The blanching technique is the method of preference for numbing blocked deciduous teeth.

 The best location for numbing the deciduous tooth is the space between the roots.

The Bent Needle vs. The Straight Needle:

The Bent Needle:

The weakest point of the #27-gauge needle is where the needle joins to the hub. If the bend in the needle is done slightly forward of this point, the needle will retain its strength. The bent is made with the plastic covering to avoid the glove touching it. This is a thirty to forty-five-degree bend. A needle bent larger than forty-five degrees will not return to the plastic covering. If it becomes necessary to bend the needle more, then the needle should be discarded without replacing the covering.

The main downside of bending the needle is the replacement of the cover. If you slightly unbend the needle with the plastic covering, there will be less chance of a needle punching through when the cover is replaced. If this still is a concern, simply do not cover the needle once it is bent.

The needle should be removed by twisting the hub with a pair of pliers to avoid the hands touching the needle. The needle is placed in the sharp’s container and disposed of in the proper manner.

The advantage of the bend needle is the ease of location. The maxillary posterior is easily handled with a bent needle. It is almost impossible to reach this area and use the pain-free method of injecting the anesthetic. The ease of handling the injection makes the added inconvenience of dealing with a bent needle acceptable.

Straight Needle:

The straight needle works very well in giving the inferior alveolar nerve block. It has serious short comings when you try to infiltrate posterior areas. The replacement of the plastic covering is still a concern, but the chance of the needle punching through the plastic covering is less.

The One-Handed OSHA accepted method of replacing the needle cover is as follows:

Holding the syringe with the bare needle in one hand, the needle is pushed into the free-standing plastic cover on the counter top. After the needle passes through the open end of the cover and the hub is resting against the plastic cover, it can be secured (tighten) with the other hand.

Replacing the plastic covering is the most likely area for a needle stick. It is best the employee never replace the plastic coverings. To insure your own safety, it would be wise to never replace a plastic covering. The additional expense of using more needles is less costly than a needle stick.

Things to Think About:

 The bent needle allows easier accessibility in the infiltration method.

 The straight needle is best for the inferior alveolar nerve block injection.

 You should never replace the plastic covering over a used needle.

Handling the Child in Pain:

Usually you are dealing with deciduous teeth. The parents do not see the value of taking care of the child’s teeth. Now the child is in pain, the tooth is infected, and the parents want you to extract the offending tooth. Unless the tooth is exfoliating, you will not be extracting it.

You are probably the child’s first dentist. Your goal is to remove the pain and to have the child back for more extensive work. Usually the child in excessive pain will cooperate, but occasionally you will find one who will not. It is better to refer the child to a specialist oppose to forcing the child to cooperate.

The child in pain usually will open his mouth and allow you to give the anesthetic injection. If the anesthetic can be given using the painless technique, the patient will not be aware of the injection. You can run your finger along the area you are numbing and tell the child your finger is magic. Once you are playing with the child, you may continue with your examination. Sometimes it is easier to take the X-ray after the child is numb. When the child is no longer hurting, he can be more cooperative in holding the x-ray.

Sometimes it is difficult to know when a child is numb. The child will nod saying his tongue, cheek, lips, etc., are numb, but you must still exercise care. The child may not know what you mean by numb. A slow approach with the drill is advisable.

Sedation:

It is not recommended to use sedation in children’s general dentistry. Using a little patience, the child will respond. He is in pain, he wants you to relieve him of the pain. He will allow you to do this once his fear of the procedure is reduced. Children under two years of age should be seen by the specialist, but if the child can be handled in his mother’s arms, emergency procedures can be done. This still does not require the use of sedation medicine.

The idea of treating young children is to build their confidence and produce good patients as they grow older. Sedation does nothing, but delay this learning process, and places the child in harm’s way. Yes, it allows the doctor to accomplish his goals in a busy office, but it does little in helping the child overcome his fears. The slow approach described above works well and does not require sedation.

If the doctor cannot handle the child in his office, he should refer the child to a specialist. This is better than medicating the child and accentuating the problem.

Treatment Immobilization Papoose Board:

Almost all children can be treated without medication or the papoose board. In my forty plus years of practice I only found three children I could not handle. These were emergency patients under the age of two that required a restraint.

The papoose board has its place, but it should be the specialist who uses it. The general public does not accept its use well. It is not a practice builder.

Mc Conald, Avery, Dean: Dentistry for the Child and Adolescent

The use of immobilization is indicated in the following situations:

 A patient requires diagnosis or treatment and cannot cooperate because of lack of maturity.

 A patient requires diagnosis or treatment and cannot cooperate because of mental or physical disabilities.

 A patient requires diagnosis or treatment and does not cooperate after other behavior management techniques have failed.

 The safety or the patient or practitioner would be at risk without the use of protective immobilization.

X-Rays

Every office should make it a priority to invest in a digital X-Ray equipment. It is the life blood of your practice. If you cannot see it, you cannot treat it. The main advantage of the digital is the fact you can change the contrast. This allows you to see things you would not otherwise be able to see.

The other main advantage is the amount of exposure time is greatly reduce compared to X-ray film that sometimes required a full second. Then there is no developing time needed.

When the sensor is placed, the point of the X-ray head needs to be at a ninety-degree angle to produce accurate X-rays.

When the sensor is not at a ninety-degree angle to the X-ray machine, the roots of the teeth will come out elongated or too short giving a false image of the teeth. This is especially important when the X-ray is being taken to establish the length of the root canal in an endodontic periapical surgical procedure.

The sensor is placed in a specialized plastic bag and secured with a rubber thimble. Younger children may not be able to tolerate the large sensor in their mouth and will only allow a periapical using the ‘Snap-a-Ray’ holder. You may have to shorten the holder’s grip to place it the child’s mouth.

The sensor needs to be held with a holder if it is possible. Often with small children this is impossible requiring someone to hold the sensor for the child. It would be good to use a parent for this if possible.

Mandibular Posterior Teeth:

The top edge of the sensor should be level with the flat surface of the sensor holder unless the muscles in the floor of the mouth prevents it. The idea is to place as much sensor behind the teeth as possible to insure the roots of the teeth are exposed. The sensor side pushes the tongue out of the way and slips in behind the molars.

If you are having difficulty moving the sensor back far enough, have the child close his mouth slightly. This will allow room to push the sensor further posteriorly in the mouth.

Maxillary Posterior Teeth:

The patient bites the occlusal portion of the Snap-a-Ray. The X-ray sensor remains parallel behind the teeth, and the point of the X-ray head is ninety degrees to the sensor. This may require moving the sensor toward the center of the palate. The X-ray sensor’s parallel alignment with the teeth may not always be possible, but the ninety-degree placement of the X-ray head is possible.

Bisecting Angle Technique:

This technique works well for taking endodontic X-rays with the file or files in place. The sensor is placed tight against the lingual side of the tooth and the child holds the sensor in place with his finger or thumb. It does not matter where the sensor is place, the point of the X-ray head is ninety degrees to the sensor.

This runs into some problems when the sensor is against the maxillary molars. The zygomatic process (boney arch) may interfere with the ninety-degree rule. It may be necessary to lower the point of the X-ray head below this process.

Anterior Periapical Incisal X-ray:

Children with large mouths (older children) three anterior X-rays are taken across the maxillary teeth and three X-ray are taken across mandibular anterior teeth. These include the two cuspids X-rays and one central incisor X-ray. Children with smaller mouths (younger children)) only one X-ray is used.

The small end of the X-ray sensor fits into the two brackets at one end of the Snap-a-Ray. The sensor is placed against the lingual side of the anterior teeth. The holder is placed against the teeth with sensor side against the tongue. The patient holds the Snap-a-Ray in place with the handle. The point of the X-ray head is set ninety degrees to the sensor, and the button is pushed.

The X-ray sensor is placed behind the anterior teeth keeping the sensor as parallel as possible with the long axis of the teeth. There is a tendency to place the maxillary anterior X-ray sensor toward the occlusal plane. If the patient is biting on the Snap-a-Ray and the point of the head is shooting through the end of the patient’s nose, you can assume the angle is wrong.

The point of the X-ray head needs to be ninety degrees to the sensor. The sensor needs to be as parallel as possible to the long axis of the teeth.

It may be necessary to move the X-ray sensor further posteriorly on the palate to keep the sensor parallel with the long axis of the teeth.

The mandibular anterior teeth are sometimes difficult to take in small mouths. It helps when the child closes his mouth slightly after the X-ray sensor is placed. This relaxes the muscles in the floor of the mouth allowing the sensor to drop lower. It is important to place the point of the X-ray head ninety degrees to the sensor in this area. This may require the head pointing from a lower angle on the chin.

It is also helpful to move the sensor further back in the mouth either by the raising the tongue or by placing the sensor on the tongue. The child is holding the Snap-a-Ray and applying the pressure. He can relax the tongue enough to accomplish this.

Bite Wing:

The bitewing X-ray is used to detect decay between the contacts of the teeth. Sticky paper tab is attached to the sensor leaving out a bite portion to be placed between the teeth with the senor on the lingual side of the teeth (bite side of the tab). The patient bites the tab and holds the sensor up tight to the lingual side of the teeth.

The main difficulty with a bitewing X-ray is the overlapping of the teeth. The overlapping can be avoided if the angle of the X-ray head is exactly ninety degrees. Sometimes this is difficult to see.

The jaw (mandible) usually has an anterior and posterior angle. The bisecting point is usually at the second molar. If the point on the X-ray head uses the anterior angle, the teeth will be at ninety degrees. The cause of most overlapping in the bitewing X-rays is the point of the X-ray head uses the posterior angle.

The Finger Roll Method of Placing the Bitewing X-ray sensor:

The right and left forefinger hold the bitewing X-ray sensor and tab. The tongue is pushed lingually with the fingers and the sensor is placed against the lingual side of the mandibular teeth. The mesial edge of the sensor should be to the middle of the cuspid. One exposure will cover the contacts in most mouths, but large people may require another X-ray exposure.

The tab is pulled tight toward the buccal crossing the occlusal and the patient is instructed to bite on the tab slowly. Sometimes the upper part of the bitewing sensor needs to be guided to the lingual of the maxillary teeth.

Possible Problems:

1. The child may play with the bitewing in his or her mouth and displace the sensor. This can be corrected by the Monster Face.

Monster Face Technique:

The child is told to make a monster face by gritting his or her teeth together and growling. When the child has the idea, the bitewing is placed in the child’s mouth using the two-finger roll. The tab is pulled across the occlusal and held. The child is instructed to bite down and make the monster face. The child clinches and growls. The button is pushed, and the sensor is removed.

2. The patient gags when the X-ray sensor is placed in the posterior region of the mouth.

a) The patient should be instructed to hold his breath while the X-ray sensor is in his mouth. It is important to have the point of the X-ray head in the correct location. The sensor is placed, and the button is pushed. The patient will remove the x-ray sensor.

b) Usually the patient gags because the X-ray sensor is not tight to palate or the mandibular lingual tissue. This can be alleviated, if the patient holds the x-ray sensor with his forefinger or thumb using the bisecting angle technique.

1. If the point of the X-ray head is not ninety degrees to the X-ray sensor, the roots of the teeth are elongated on the X-ray sensor.

2. When the X-ray is brought up on the screen, it shows ribbing and appears to be overexposed. You can correct this by reversing the X-ray sensor. It was in backwards. This is one of the most common mistakes in taking X-rays.

Decay – How does it occur?

How does hard enamel making up the protective outer layer of our teeth succumb to decay? Teeth have been found whole in fossils over a million years old, yet in our mouths they disintegrate in just a few years. What is so deadly in our mouth?

The culprit is the biofilm (plaque) loaded with bacteria that begins to form on our teeth a few minutes after the teeth have been polished with a fluoride paste. The biofilm loaded with bacteria begins to collect in the crevices and irregular area of the tooth surfaces. It loves the dry saliva left on the teeth from a night of mouth breathing.

Normally bacteria flowing free in the mouth are washed away with eating, drinking, etc., but the bacteria in the biofilm have learned to be more resistant.

Biofilm Sequence

Pellicle Formation: Shortly after the teeth are cleaned, the first phase of the biofilm begins. The pellicle formation starts with a thin coat of proteins over the teeth and mucosa. This forms an adhesive for the gram positive aerobic cocci bacteria (Streptococcus and actinomyces) and others. They take advantage of the oxygen content in the mouth. This initial thin layer of biofilm (1-20 layer) is almost always present on the teeth.

Young Supragingival Plaque - Reversible Adhesion: The bacteria continue to add to the biofilm either by acquiring additional bacteria or by their own cell division. A weak attraction continues between the pellicle coat of proteins and the bacteria building up the cell layers. These layers of bacteria come off the tooth surface slightly to allow a much stronger attachment.

Irreversible Attachment: This allows the molecules on the bacteria cell wall to interact with the receptor proteins on the pellicle surface becoming a strong irreversible attachment. This stability attracts other microbes that show their adhesion abilities and become part of the colony.

Co-Adhesion: The growing colony continues their interactions between the receptors and the pellicle. Different bacteria join the colony and create biochemical synergistic activities such as providing nutrients for the colony.

The gram negative anaerobic bacteria can now hide in the colony using the thick colony of other bacteria and enlarged pellicle to protect them from the oxygen rich oral cavity.

Inter communication between the cells in the biofilm occurs allowing the dental plaque to become a single unit. This is what makes the whole process work.

Aged Supragingival - The biofilm has thickened between 100-300 cell layers. The anaerobic bacteria can live deeper in the biofilm.

The colony has created pathways for the transport of nutrients and oxygen.

Cooperation between the diverse bacteria has increased.

The diverse bacteria in the colony make it difficult for antibiotics to penetrate.

The polymer production has created a matrix of insoluble glucans, fructans and herteropolymers allowing the plaque to increase in size.

Subgingival Plaque Formation: The subgingival plaque becomes established 3 to12 weeks after the beginning of the Supragingival plaque formation.

The gingival inflammatory occurs when the bacteria population in the biofilm (plaque) changes from gram positive aerobic bacteria to one of gram negative anaerobic bacteria. The most prevalent are the actinomyces naeslundii. Some spirochetes are also present.

The biofilm moves down into the periodontal pocket by flowing out of the established plaque leaving it hollow following the loose periodontal ligament.

The bacteria primarily increase in numbers from cell division early in its development going through periods of blooms. Later the biofilm increases in size from waves of bacteria colonizers pushing away from the tooth.

The biofilm forms a sessile mushroom-shaped micro-colonies attachment to the tooth that increase in thickness and size as the growth moves out from the tooth. The extra cellular slime layer protects the bacteria from the onslaught of antibiotics. The few bacteria that are killed are easily replaced. To kill the bacteria hidden in biofilm would require a dose of antibiotics that would kill the patient.

Formation of Caries:

Caries are the direct result of acid attacking the enamel or cementum of the tooth. The amount of demineralization will depend on the number of acid loving bacteria present and the amount of sugar that has been ingested. High sugar concentrations will increase fermentation and acid content allowing an increase in the growth of acid loving bacteria.

The Streptococcus mutans, S. Sorbrinus, and lactobacillus casei are bacteria that can tolerate a high acid environment. A high acid biofilm colony of bacteria will demineralize enamel, but a low acid colony will allow remineralization of the enamel.

The demineralization of tooth enamel can also occur from the ingestion of drinks with high acidity content making the whole mouth acidic. There are also emotional and physical factors that can lead to a high acid content in the patient’s mouth. When people go through extreme stress or sudden growth spurts, the salvia will take on an acidic characteristic allowing the bacteria to bloom and produce more acid at the site. Salvia with no acidic characteristics will make it difficult for acid to exist in the plaques.

The Streptococcus Mutans are not always present when tooth demineralization is taking place and it is found in healthy plaques. This indicates the acid attack on tooth enamel is biofilm (plaque) community attack.

The amount of acid produced will depend on the amount of nutrients the gram negative anaerobic bacteria receive. Tooth surfaces exposed to the oral salvia and out of range for the tongue or tooth brush to reach provide the best sites for high acid producing anaerobic bacteria attack on the enamel and cementum. The biofilm colony of bacteria need nutrients to produce acid to dissolve tooth enamel. Deep in the periodontal pocket where there is only a small amount of nutrients, the acid producing bacteria have nothing to work with. Therefore, you will find very few dental caries deep in the periodontal pocket away from the nutrients, and why teeth survive millions of years in the Earth’s soil.

At various stages in our lives we tend to have acidic salvia. This tends to occur during times of stress or rapid growth periods. I ran a survey for two years in my practice to confirm this. I recorded a litmus paper reading on every patient. The results were illuminating. The patients with high decay had acid salvia. This occurred usually in children at ages of six to eight and again during puberty. Decay usually slows after eighteen to twenty years of age in adult unless they are under stress.

Anecdote:

After the Viet Nam war, the United States took in over 200,000 Vietnamese. A large number of them were children. I was shocked to see children four and five with no teeth, and the older children with extensive decay. It seemed the decay rate in Viet Nam suddenly increased after our GI arrived and handed out candy bars to the children. Instead of treating the rapid decay in the children’s teeth, they were extracted. I was building dentures and partials for children. It was also interesting to note the lack of any immunity to the invasion of the bacteria in the children’s mouths.

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The teeth do have a defensive mechanism if the decay rate is slow enough. The tooth will rebuild dentin away from the acid invading it. That is way you will see very small pulp chambers in teeth at times and large decay areas. I am always amazed to see how large the decay can become before it finally exposes the pulp chamber.

The Sequence of Infection:

By: Tyldesley:

Clinical characteristics are, therefore initial pain during the intrabony phase, followed by a sudden relief of pain on perforation of the bone and the release of pressure. Oedema of the soft tissues follows, and then increasing pain with the spread of the infective process.

Sequence:

1. The exposed pulp chamber allows bacteria to enter the tooth. The tooth will respond by being sensitive to cold and then heat. Usually when the tooth responds to heat, it is infected with bacteria.

2. The vessels and nerve tissue in the tooth become necrotic and the bacteria increase in number and push out the apical end of the tooth placing pressure on the nerve in the alveolar bone. The white blood cells increase in number and attack the bacteria. The debris from the battle leaves behind a large serous fluid (pus) buildup that seeks relief. The patient experiences a great deal of pain from the building pressure.

Treatment:

If the tooth is opened at this point, a large amount of serous material (pus) will extrude from the opening and the pain will be relieved. Antibiotics are given to aid the white blood cells.

3. The building pressure will push pus through the porous bone leaving a lined channel behind. The bacteria, white blood cells and the residue (pus) will enter the soft tissue. The soft tissue swells (edema) as the serous fluid spreads out into the tissue. The pain from the building pressure is relieved. The tissue will feel hot to the touch.

Treatment:

If the tooth is opened at this point a small amount of pus will extrude from the opening. The white blood cells will continue fighting the bacteria. Antibiotic therapy will delay or stop the growth of bacteria. A cold compress is placed over the warm tissue to delay the swelling. You cannot extract the tooth at this point with local anesthetic.

4. The swelling (edema) will subside. The body will build up a defensive wall of fibers to wall off the infection and residue creating a pocket of serous material (dead bacteria and white blood cells.) in the soft tissue.

Treatment:

The pocket of serous material (pus) is found and drained with a number twelve blade. Antibiotic therapy is continued.

5. The body will create a lined channel and drain the serous fluid (pus) to the outside. The channel will seek warmth, point (a white pimple), and drain the fluid.

Treatment:

The serous fluid is drained at the point with a number twelve blade. Antibiotic therapy is continued.

6. Once the body has drained the serous fluid, the channel closes off, and a defensive wall of fibers builds up around the apical end of the root creating a cyst. The tooth remains in this chronic mode until the bacteria build up enough pressure to rupture the cyst sac. This usually happens when the tooth root canal or canals become plugged to the outside. The pressure against the nerve in the bone creates pain and starts the process all over again.

Treatment:

Using a number fifteen or twenty-five file, the canal is reopened to relieve the pressure of the serous fluid. The file must go through the apical to reach the cystic sac. Antibiotic therapy is started.

7. The body may keep the channel and point open to allow the serous fluid to continue draining into the mouth. The tooth will remain asymptomatic as long as the canals remain open.

Treatment:

Antibiotic therapy continues until the infection is reduced.

Discussion:

The antibiotics will control the infection at any of these points in the progression of the infection. Once the infection is controlled, the hole in the tooth can be closed and root canal therapy can be started, or the tooth can be extracted.

It is not recommended to place a heat pad against the cheek to relieve pain from the edema. The tissue channel will seek the heat and point leaving a scar on the cheek. It is better to have the point be inside the mouth where it can be controlled and not leave any visible scar. A cold compress will take the heat away from the cheek and turn the point to the inside.

Some would argue the tooth should not be opened to relieve the pressure buildup. They believe antibiotic therapy should be given to bring the infection under control. When you can relieve the patient of pain immediately by opening the tooth, then this should be the treatment of choice

Periodontal Disease:

It can be argued children do not have periodontal disease. In fact, most insurances will not pay for periodontal treatment on children up through age eighteen. If you are an orthodontist, you have seen gingivitis on many occasions when you have tried to move the teeth too fast placing stress on tissues.

Anecdote:

Some years ago, I was treating a large number of patients from Mexico. I remember two sisters with periodontal disease affecting the lower anterior teeth. The older sister of twelve had six to eight-millimeter pockets and extreme periodontitis on teeth 22 through 27. Her sister of eight years had the same condition, but her pockets were only four to six millimeters.

The teeth were sensitive to percussion and had a number two mobility. The alveolar bone and gingiva were down four millimeters on the labial side of the teeth indicating the teeth were under stress from either pressure from the tongue or the girls were clenching their teeth extremely hard. The tissue was full of debris and painful to the touch.

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1. Children do clench their teeth extremely hard at times bringing on these conditions. If they continue to smash into their anterior teeth, they will create a periodontal problem. This is excluding the children who constantly grind their teeth until they are almost to the gingival tissues. You cannot place stainless steel crowns on these teeth unless you can keep the occlusal surfaces the same vertical as the other teeth without creating a very sensitive tooth and a periodontal condition. The child will work on that high tooth until it is out of his mouth or worn down to match the other teeth.

Treatment:

The cause needs to be address before the treatment can be started. A bite appliance should be considered in the treatment plan. Why is the child experiencing a periodontal condition?

Hold the child’s condyles as he opens and closes slowly. If you feel the grating in the condyles, you know the child has been clenching his teeth.

Where is the periodontal condition? If it is the lower anterior teeth, you can assume the child is bringing his jaw forward and working his front teeth over. If he has been doing this awhile, you might see some wear on the teeth.

Sometimes it is only one tooth that has the problem:

2. The child has been clenching hard on one tooth causing the gingival tissues to swell and become inflamed.

This can occur during the eruption of a lower molar tooth. The tissue is still over the tooth, but the maxillary (opposing tooth) lingual cusp is punching into the tissue over the mandibular tooth causing pain from sore tissue. This is normal for erupting teeth, but to take the patient out of pain, the lingual cusp can be reduced a couple of millimeters to give the tissue some rest and the patient relief of pain.

3. The tooth erupting has pushed the teeth anterior to it up into the occlusion allowing the opposing tooth to strike it first. Again, a slight occlusal adjustment will relieve the pain.

4. The child clenches his teeth on one side or he singles out a tooth creating inflammation around it. A bite appliance is recommended and an occlusal adjustment to relieve the pain and tissue inflammation.

5. A tooth is trying to erupt breaks a blood vessel creating a purple swelling over the tooth, or the opposing tooth is biting into it. You can either allow the condition to continue or solve the problem by opening the tissue and taking the pressure off the erupting tooth.

6. The third molar eruption had difficulty coming through the tissue creating an inflammation condition. Partially open tissue allows bacteria to develop below the tissue.

Treatment:

Reduce the infection with antibiotics and remove the tissue over the tooth with an electrosurge tip or use a #15 blade. You do not need to remove everything. You want to leave it open to allow the buildup of infection to drain away.

7. Teenagers may develop Necrotizing Ulcerated Gingivitis. This is where ulcers develop in the gingival tissue. It usually includes the entire mouth. It is thought to be a condition brought on by stress causing the patient to clench his teeth creating the ulcerated condition. It could also be the body’s immune condition is poor and the gingiva responds accordingly.

Treatment:

 A bite appliance will take the pressure off the teeth.

 Treating the gingival condition with SnFl2 gel using thin bleaching trays that extend over the gingival tissues twenty minutes two times a day will relieve the inflammation.

 An older method is to place a periodontal pack over the ulcerated gingival. It takes the pain away and allows the tissue to heal.

8. Excessive wear on the teeth caused by a grinder can become very severe. The parent will tell you: “I hear him grinding his teeth at night.” The teeth can wear down to the gingival tissue and actually affect the tissues. A bite appliance is the only cure. It is either solved early or after the permanent teeth come in. All the teeth wear at once leaving no clicks. If you attempt to place stainless crown on a severely worn tooth, keep in mind the crown needs to be low enough to avoid clicking creating a periodontal condition. The child is not going to stop grinding.

Your office should have the ability to make bite and bleaching appliances. This means you need a Proform machine. The procedure is not difficult. It is a matter of heating the material and dropping it over a stone impression of the patient’s mouth using the Proform machine.

Sensitive Tooth:

1. The child comes in with pain on his upper right first molar: There is no decay, but there is slight swelling around the tooth. Slight percussion sends pain radiating up towards the right eye. You numb the buccal and lingual side, but the child still feels the tooth when you bring the air to it.

2. The tooth has decay and appears in the X-ray it may be exposed. You numb the tooth on the buccal and lingual, but the child still feels the air from the hand piece.

In both instances the tooth has been sensitized from child clenching on the tooth. The first situation the child has been clenching for some time to create the pain and gingival condition. Check the X-rays: If the Periodontal Ligament has enlarged slightly or a great deal, the child has been clenching his tooth.

In the second instance the child was clenching his teeth after you numbed him. Unaware of the pain because he is numbed. The tooth has become sensitized. It is either place a cotton roll on the other side and wait for a half hour for the tooth to calm down or send the child home. Of course, you could push the process and hurt the child.

Pulp Capping:

Case One No Exposure:

The X-ray reveals a large mesial decay in the lower right primary second molar with a possibility of an exposure, and decay on the first primary molar. There are no symptoms coming from either tooth.

 The teeth are numbed with the painless injection technique.

 The Mesial-Occlusal preparation is cut on the second primary molar exposing the mesial decay.

 The decay is removed with a spoon to avoid exposing the pulp chamber.

Discussion:

There is a tendency to want to use a large round bur to remove the decay thinking you will take the preparation back to good sound dentin. This is a sure way to create an exposure of the pulp chamber.

Using the spoon (small or large depending on the size) to remove the decay allows you to approach the pulp chamber with some control. It is good to remove the shallower decay first to give you a better view of the decay near the pulp chamber. Now a decision has to be made. Will the removal of the remaining decay create an exposure?

I would suggest removing the very soft decay by easing it out of the tooth. The harder decay which is really dentin soften from the acid deposits of the bacteria, could be left rather than be removed forcibly and create an exposure. This is referring to the decay you could remove if you applied enough pressure using the spoon. The tooth is asymptomatic indicating the pulp chamber has not been exposed.

If you decide to go with this, you place a layer of calcium hydroxide, base it with Fuji cement and place your restorative material.

Or you can place a layer of MTA (Mineral Trioxide Aggregate). A recent material that forms a gel in ten minutes and becomes very hard in four hours. It comes in a powder form and can be mixed with your liquid anesthetic before placement. This can be covered with a glass ionomer base and followed with the restorative material.

What happens now under the filling material depends on whether you have created a good seal. The MTA is very compatible with dentin and its watery properties. If the seal remains secure, the dentin will continue to repair itself by adding more dentin to wall off the acid filled bacteria. If you were to remove the filling a year later, you would find the soft dentin had become hard. Remember the bacteria producing acid no longer has a nutrient supply. It can no longer produce acid.

Case Two Pulp Capping:

You used a bur, or you removed the remaining soft dentin from the cavity exposing the pupal horn of the pulp chamber.

 Again, the tooth is asymptomatic.

 There is no gushing out of blood, but you do have blood seepage indicating the tooth is alive.

 The exposure is slight.

Discussion:

If the pulp chamber has not become infected, you can continue with the pulp capping. This is indicated by the amount of blood coming from the wound.

 Thin gushing blood means inflammation in the pulp chamber and infection in the pulp chamber.

 Yellow serious material is definitely infection

 Nothing coming out means you did not strike a vessel or the pulp chamber is empty of vessels and the tooth has been long dead.

If your bur took out a good portion of the pulp chamber, you will have some bleeding from the torn blood vessels.

You need to stop the seepage of blood.

 Formocresol could be placed in the cavity, it foams, and cauterizes the exposed tissue. Definitely not my favorite method.

 You could use your electrosurge rounded tip and cauterize the exposed tissue. It’s less messy and treats the tissues better.

 You could heat the end of a ball burnisher and cauterize the tissue. It is easy and fast. This seals the exposure.

Seal It:

Mix the MTA powder with the anesthetic liquid and place it over the exposure. The watery properties of the material work well with liquid dentin and blood. Or, you could use the older Dycal (Calcium Hydroxide) for the seal. This is followed by the glass ionomer and restoration.

Case Three:

You have a large carious exposure created by the careless use of the hand piece and bur, or you have a large exposure created from the removal of decayed dentin with an aggressive spoon.

 There is no excessive bleeding, but you have cut some vessels.

 The tooth is asymptomatic.

The decision: Do you attempt a pulp capping procedure, or do you proceed to the pulpotomy.

Discussion:

 The dentin can repair itself to some degree, but the process is slow. There have been some studies showing success in the pulp capping procedure using MTA (Mineral Trioxide Aggregate) for large exposures because of its ability to bond with the tooth structure, and cure in a watery substance (blood).

 This is a judgment call and depends on the size of the exposure. Remember the pulpotomy will seal the root or roots of the tooth. Is the exposure larger than the canals in the roots?

 Behind this exposure is a large cavernous space. Any break in the seal will immediately allow the bacteria to have a field day in the pulp chamber.

 The safe road: Go direct to the pulpotomy and seal the root canals.

Procedure for the large Pulp Capping:

1. The bleeding needs to be stopped. If you have a large exposure, the bleeding will probably be extensive. This needs to be cauterized with electrosurge ball attachment or a hot ball burnisher. I would not use formocresol because it would leave a large amount of the liquid in the pulp chamber working on the delicate tissue after the closure.

2. The best materials to use would be the MTA because you can build the material up to enclose the chamber, compatible with the cauterize blood it is not affected by moisture and will create a good seal.

3. This is followed by a glass ionomer and the restoration. Some practitioners would place a cotton pellet and temporary to wait for the MTA to harden. The glass ionomer would be place on a second appointment.

The three situations above require the following to be successful:

 The tooth is asymptomatic. Meaning: There is no swelling over the tooth.

 The patient was not complaining of pain in the tooth.

 The tooth has not been under extreme pressure from clenching that would lead to the pulp chamber tissue becoming inflamed and bleeding excessively.

 The exposure has not been long standing, meaning the soft decay has not reached the pulp chamber exposing it to bacteria (infection). When you scooped out the decay with the spoon it did not leave behind a large exposure?

A pulp capping not under these conditions may leave infection inside the pulp chamber resulting in pain for the patient.

Pulpotomy

Pulpotomy in the past have been regulated to deciduous teeth. It has always been thought of as a temporary solution to keep the tooth functional, but now it is gradually including permanent teeth as well, especially those teeth that have undeveloped root apices. No one likes to perform root canal on teeth with wide open apices. If a good pulpotomy can be performed, it will allow the apexogenesis to continue.

Case One:

The lower right second deciduous molar has a large mesial decay. Upon removing the decay, the pulp chamber is exposed.

 The tooth is asymptomatic.

 There is no swelling present.

 The X-ray reveals the tooth is exposed.

 There is no excessive bleeding coming from the wound.

 The pink tissue in the pulp chamber is exposed.

Discussion:

You need to determine if the pulp chamber is infected. You cannot perform a successful pulpotomy on a tooth that is infected. A tooth with serous material flowing out would not be a successful candidate for a pulpotomy.

Check the bleeding: If it is pouring out of the exposure, it would indicate the pulp chamber is full of inflamed tissue. This is a judgment call. If you are in doubt continue the pulpotomy until the bleeding is overwhelming. Pulp chambers do bleed when the small vessels are nicked.

If the bleeding continues to push out of the chamber do not try to close it again. You will create pressure and pain for the patient. It is better to leave it open and allow it to bleed. When it calms some, you continue your preparation. The decay is removed, and the occlusal surface of the pulp chamber is opened to reveal the pulp tissue.

Using a large number 8 round bur with water, the pulpal tissue is removed, and the chamber is enlarged in the root canal areas to allow a ball burnisher to fit snuggly. Care must be taken not to place a hole in the pulpal floor. You need to see the orifices of the root canals.

At this point the bleeding should only be easing out of the root canals. If the bleed is still coming out rapidly, the root canals are probably infected, and you will need to proceed to root canal therapy. Again, this is a judgement call.

“If you decide root canal will be your choice, you need to start the procedure by removing the tissue in the canals to stop the bleeding. If it does not stop, you will have to leave tooth open to allow drainage and place the patient on antibiotic therapy. Some doctors would close the chamber at this point, but then you are running the risk of the pressure building and causing pain for your patient. It is already infected. Closing the tooth does not prevent this. After the patient has been on antibiotics for a few days, the pulp chamber can be closed. If the patient can tolerate the closure, the root canal therapy can be started.”

Pulpotomy Procedure:

1. A rubber dam is placed to wall off the rest of the mouth.

2. The pulp chamber is opened to expose the pulpal tissue. A large #8 round bur is used to remove the pulpal tissue and prepare the chamber for treatment. This means exposing the root canals to allow a ball burnisher to fit snugly into the root canals.

3. The walls of the pulp chamber are beveled with a forty-five-degree angle at the cavo margin using a flame shaped diamond bur to allow better viewing of the chamber.

4. The chamber is rinsed and air dried.

5. The tissues in the root canals are cauterized and the pulp chamber is sterilized.

6. A seal is placed over the cauterized root canals.

7. The pulp chamber is filled with a restoration that is dentin friendly.

8. On a deciduous tooth a stainless-steel crown preparation is prepared and inserted.

9. On a permanent tooth a restoration is placed unless the tooth will not support a filling then a crown is another option.

Methods of Cauterizing the tissue:

1. Using an electrosurge, the ball burnisher is attached, it fits into the root canals and the tissues are cauterized.

2. Using a ball burnisher, the end is held over a flame making it very hot. This is taken directly to the tissues cauterizing them. The patient is numb. He does not feel it.

3. A cotton pellet is filled with formocresol and inserted into the pulp chamber. It will immediately foam and chemically burn the tissues in the root canals killing live tissue the length it travels down the root canal. If too much formocresol was placed on the cotton pellet, the material will overflow the pulp chamber and onto the rubber dam and possibly into the tissues beneath it. It is wiped clean from the pulp chamber sterilizing it in the process. You will not need to use an irrigate.

4. Sterilizing the chamber using one of the irrigates below. The saturated cotton pellet wipes the cavity floor, and the cavity is air dried.

a) Calcium Hydroxide liquid does the least damage and will kill bacteria.

b) Chlorhexidine digluconate0.2 - 2% kills bacteria

c) MTAD (by Dentsply) Tetracycline isomer, citric acid, and a detergent

d) Sodium Hypochlorite: 0.5 - 5.25% will also burn tissue if it should come in contact.

e) Ethyenediamine Traacetic Acid (EDTA) 17% Liquid

Root canal sealer:

1. Calcium Hydroxide (Dycal) comes in a tube. Using the end of a ball burnisher or a small brush, it is applied over the root canal openings. Allowed to dry forming a seal.

2. ZOE (Zinc Oxide Eugenol) powder is added to the liquid until it seems no more can be added, then add some more. You want to make a thick ball of the material that will not stick to your fingertips. The ball of ZOE is placed in the cavity and packed to place with a plugger. If you packed enough powder, the material will dry quickly. If you did not shape it well with the plugger, you can reshape it with a hand piece and bur after it hardens to receive the final restoration.

3. MTA Mineral Trioride Aggregate is mixed with sterile water or anesthetic and placed over the root canal openings. It needs ten minutes to gel set or longer depending on the amount of powder you incorporated into the liquid. The material is not affected by moisture in the canals and seals to the dry pulp chamber. It actually needs moisture to set. The final cement like hardening takes four hours. Some of the literature recommends placing a moist cotton pellet in the chamber and temporarily closing the pulp chamber with a temporary. This allows the MTA to set firmly. Upon reentering at the next appointment, the cotton pellet is removed, and the Glass Ionomer is placed to seal and restore the tooth. Some practitioners will make the pulp canal MTA seal small and finish the treatment with the Glass Ionomer in the one appointment.

Restoration that completes the seal:

1. Amalgam is placed over the ZOE Sealer using the matrix band and tofflemire. A stainless-steel crown can be placed if the tooth is too weak to support an amalgam filling.

2. Glass ionomer is flowed over the pulpal floor and cured with a light or self-cure forming a barrier over the MTA sealer. It can be used as the restoration material if the tooth will support the restoration. Otherwise a stainless-steel crown will be needed.

Types of Medicaments:

1. The formocresol was very popular in the sixties, but the dental profession shifted away from it because of its effect on the body. We resorted to other methods using the electrosurge or the heated ball burnisher. They cauterized the root canal tissues without the foaming formocresol effect. There was no after effects to worry about.

2. The Dycal sealer has been around for years and still works very well, but the newer developed MTA seems to seal better and is not affected by the wet tissue. It becomes very hard and seals very well.

3. The older method of using ZOE after the cauterizing can work very well. You can use it as part of the restoration. The canal tissues are cauterized, sterilize, and a ball of ZOE cement goes over the exposed canals. The final restoration, amalgam filling or stainless-steel crown is placed. The ZOE becomes hard to allow this.

4. Today we have better materials. The pulp chamber is sterilized after the cauterizing, MTA is placed to seal the canals. This is followed by glass ionomer restoration that can completely fill the pulp chamber into its final restoration or and stainless crown can be placed over this. The glass ionomer seals very well to dentin and enamel.

Discussion:

The goal for a successful pulpotomy is no existing infection and a good seal. When the seal fails the pulpotomy fails. To place a pulpotomy into an infection site will lead to failure in at least forty percent of your patients. Now you will have to open the tooth and allowed it to drain. This is followed with antibiotics before the root canal therapy can be started

Pulpotomy on Permanent Teeth Rational

Case One:

A child comes into the office with a severe toothache on tooth number three. There is no decay. The patient is crying wanting relief. The X-rays only show an enlarged periodontal ligament around the roots of the tooth. You diagnose the problem to be irreversible pulpitis. The patient is difficult to numb because the tooth is very sensitive to air, touch, and water. You suspect the patient has been biting very hard on the tooth until he killed it.

You start the opening of the tooth. The patient is still feeling your bur until you expose the pulp chamber and you are able to place anesthetic directly into the pulp chamber. Now you can take the coronal portion of the pulp chamber off. There is no excessive bleeding. All you see is nice pink tissue staring up at you. You have just opened a perfectly healthy tooth.

At this point you can proceed with a pulpotomy or you can set up for an expensive root canal and crown. There is no infection to deal with. If the seal can be made, the tooth can still function with a pulpotomy and glass ionomer restoration.

All the child really needed was an occlusal adjustment to relieve the symptoms from the clenching.

Case Two:

The eight-year-old child has an exposure on tooth number 3 that does not appear to be infected. The apical foramens are still wide open, and the canals will take a 90 file with no problem. Now, do you try root canal, or do you place a pulpotomy in the tooth and allow the canals to close up more.

If there is no infection, then the pulpotomy is the treatment of choice.

Case Three:

A five-year-old child has an exposure on the lower right deciduous second molar. It has become infected. You can tell because when the decay material was removed a large hole existed and it bled profusely. Upon removal of the coronal portion of the pulp chamber, you do not see nice pink tissue. Instead it is hemorrhaging. The patient will tell you he has been in pain. That is way he is in your dental office.

Discussion:

You can extract the tooth and place a spacer to keep the erupting first molar from closing the space, or you can do a root canal on the tooth. The patient will be keeping the tooth for another six to seven years before the second bicuspid erupts.

The parent decides the root canal is the preferred treatment. There is not going to be much savings by extracting the tooth and placing the spacer. Then how does one eat with a spacer in his mouth?

Root canal the Deciduous Molar:

A painless injection is given numbing both sides of the tooth. A rubber dam is placed, but this is not easy with deciduous teeth requiring the tissues to be very numb.

The preparation is prepared in the tooth to receive the restorative material, and the coronal portion of the pulp chamber is opened. It is made wider by placing a forty-five-degree angle on the cavo margin. You will be surprised how much better you can see the canals.

If the infection is severe (bleeding profusely), you will need to wait for another day to allow the infection to settle out. The canal is left open and taken out of occlusion. The patient is given antibiotics for a week. If you try to close the pulp chamber at this point, you will place the patient back into pain from the pressure buildup inside the tooth.

At the second appointment the pulp chamber can usually be closed. It should be tested to see if tooth can take a closure for a few days. I have had to open the tooth back up on many occasions. Once the seal can be made, the root canal can proceed.

Discussion:

Whatever you place in the root canals, it will be hanging free as the roots absorb during the eruption of the second bicuspid. I have no problem seeing hanging gutta percha when the tooth finally exfoliates. I think it is better than seeing pieces of MTA or Calcium Hydroxide floating around in the tissue, or worst the body absorbing some of it.

Case Four:

A seven-year-old child fell, fractured tooth number 8 exposing the pulp chamber. Too much of the crown portion of the tooth is missing to allow a pulp capping procedure. The tooth is not infected at this point.

Pulpotomy:

First Appointment:

The tooth is numbed using the painless injection technique numbing the labial and lingual side of the tooth. You will have to give a direct injection into the pulpal tissue once he is numbed to insure the tissue is numb. You might want to change to a number thirty needle for this.

1. A rubber dam is placed. The remaining portion of the pulp chamber is exposed, and the pulpal tissue is removed with a large number 8 round bur.

2. The root canal is cauterized and sterilized.

3. MTA is applied over the root canal and allowed to gel.

4. A damp cotton pellet is placed followed by a temporary filling. You need to allow time for the MTA to harden (four hours).

Second Appointment:

1. The pulp chamber is reopened, the pellet is removed, and glass ionomer is placed.

2. The tooth can be restored with a composite filling material, or the tooth can be crowned.

Case Five.

The seven-year-old child fell and fractured the tooth number 8, but he did not think it was serious until it began to hurt him a week later. He is in your office wanting help. The tooth has become infected. It will have to be root canaled.

Discussion:

The apical portion of the tooth is still wide open. There is no constriction. How do you place a seal at the bottom of the canal and still achieve apexogenesis? More importunately how do you file a canal that will take a 120 file to start with?

Anecdote:

This goes back to the seventies before we had the beautiful techniques of today. We had gutta percha. Our files went up to 140, but our gutta percha stopped at 100. I was treating a fractured tooth on a seven-year-old child with wide open apical on tooth number 8. The tooth was infected requiring a root canal procedure.

The root canal was filed up pass 140. I had to work it around the canal to remove the debris. It was irrigated and dried, now for the gutta percha. There were no gutta percha of this size, and I could not round out the canal because of its size.

I place four large gutta percha points (100) on my metal mixing spatula. Using my torch, I heated the bottom of the spatula bringing the gutta percha to a pliable stage. You can easily over heat the material. You are only interested in making it pliable. The pliable gutta percha is rubbed onto one of the glass slabs. Using the other glass slab, the four gutta percha points are rubbed together making one large gutta percha point. While it was still warm, I placed it into the large canal taking it to the bottom. The warm gutta percha took the form of the canal. The X-ray revealed it was in the correct position. The gutta percha was cut off at the incisal edge of the tooth. This is the measurement of the canal depth. A go-to point insuring the gutta percha is all the way to the apical.

Coating the large gutta percha point with a sealant, it was inserted into the canal and sealed with a hot ball burnisher removing the excess. A thin layer of Calcium Hydroxide (Dycal) followed with a composite restoration. The large pulp chamber worked as an excellent anchor for the restoration. The apical tissues were not disturbed to allow the apexogenesis to occur.

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MTA Mineral Trioxide Aggregate Approach:

 MTA is a powder made up of fine trioxides (tricalcium oxide, silicate oxide, bismute oxide) it has hydrophilic particles (tricalcium silicate and tricalcium aluminate).

 MTA is an endodontic cement that is biocompatible.

 It is capable of stimulating healing.

 It is osteogenesis and hydrophilic

 It sets up in the presence of water

 Once the powder is mixed with water it forms a gel and becomes hard in four hours.

 The colloidal gel has a pH of 12.5.

Discussion:

Calcium Hydroxide paste can be used for this technique, but MTA is a newer product and has some qualities that make it the preferred product.

Procedure:

1. A rubber dam is placed.

2. The canal is cleaned using files and irrigates, but care to avoid sending copious amounts of irrigate out the large apical foramen. I would use large paper points saturated with an irrigate to clean and sterilize the canal.

3. Find the location where you want to place the apical seal. I would use a large gutta percha point and cut it off at the incisal edge when you have reached the desired position as determined by an X-ray. Now you will know where you want the seal.

4. You will need some device to place the MTA material. The Dovgan carrier works very well using the long narrow spout to place the MTA mixture. The idea is to place the MTA gel at the apical end of the canal to create a seal. There is no hurry. The MTA mixture takes ten minutes plus to gel.

5. You should also have a long plugger to push the MTA material further down into the canal. Using your ultra sound scaler tip to vibrate the plugger will also help move the material along. A premeasured large gutta percha (cut it at the incisal edge after you have found the apical position with the X-ray) can be used to push the material towards the apical and it will give you some control on location. A twisting motion with the gutta percha will distribute the material along the walls.

6. The idea is to create a seal at the apical opening before it flares out into the tissue. The canal needs to be dry to allow the MTA to stick to the walls, though the material does not need to be dry to set. Instead, it needs moisture to set.

7. After the seal is established with the MTA, a wet paper point is placed in the canal to give moisture to the MTA material, and the canal is closed with temporary cement. It takes four hours for the MTA material to become hard to allow you to place pressure and finish the root canal with gutta percha or other material. This will allow apexogenesis to take place.

8. If the canal is extremely large leaving thin walls, you could fill the canal with a composite instead of gutta percha to give the tooth more strength.

Calcium Hydroxide:

This is an older method and it is done very similar to the MTA procedure. Some research has shown the benefit of removing the Calcium Hydroxide and redoing the root canal every three months up to eighteen months to allow the apexogenesis to take place. Of course, there is always the risk of pushing the calcium hydroxide out of the foramen and into the tissues in the process, and there is the risk of infecting the canal upon opening.

Anecdote:

Irrigate we used in the seventies was hydrogen peroxide followed by liquid calcium hydroxide. I was pleased with technique until I opened the tissue over tooth number 8. I was doing an apicoectomy. I had the canal cleaned and waiting for the irrigate. I had a clear view of the apical foramen. Usually I would have completed the root canal first, but I wanted to see how the tissue reacted to the irrigates.

When I sent the hydrogen peroxide into the canal, it came squirting out the apical. The tissue it touched immediately turned dark brown. I quickly followed with the calcium hydroxide irrigate, but the tissues were already dead. I finished the root canal, curetted the tissue at the apical to induce a good blood flow and l closed the tissue. I learned something as innocent as hydrogen peroxide can have a devastating effect on tissues.

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You need to keep your apical penetration one plus millimeters from the apical. If this cannot be accomplished, then you need extreme care in placing your irrigate. Perhaps using a paper point filled with the irrigate instead. You also should use syringes with side venting to keep the pressure off the apical area.

Other Techniques:

1. It has been suggested using a resorbable matrix (Collacote) to form a stop at the end of the canal. This will give you something to push against while placing the MTA. The matrix is absorbed leaving a solid MTA seal.

2. The MTA powder can be carried to the site. A wet paper point is inserted. It touches the powder. Then by capillary action it hydrates the powder.

3. If you have an operating microscope, this is an excellent place to use it to check the positioning of the MTA seal.

4. The human body has learned how to remove infection over million plus years, but the irrigate is a new intrusion. Which one do you think it will tolerate best?

Stainless Steel Crown

This is a temporary crown at best that will last about two years before it will need to be replaced. Of course, I have seen them last many years on permanent teeth. The aesthetics is not good compared to porcelain crown, but the cost is considerably less, and the tooth is retained in the mouth.

They make stainless steel crowns for all the deciduous teeth and most of the permanent teeth. Usually the stainless-steel crowns are marked right or left and type of crown (1st and 2nd molar etc.). Today you can purchase crowns that are already crimped to some degree oppose to having to shape a crown with no contour.

The rational for stainless crowns:

 Used for weak teeth with extensive decay or large fillings (pulpotomies).

 To hold a spacer that replaces a missing tooth.

 To cover a dental implant.

A stainless-Steel crown should have:

 It should cover the entire tooth taking the margins below the gingiva on the lingual and buccal sides.

 The contacts need to be tight with no spaces.

 The crown portion must be in occlusion. That means the other teeth need to occlude properly.

 The buccal and lingual margins need to be crimp into the undercuts of the tooth.

 The crown needs to be difficult to remove even with no cement.

 The crown needs to be able to slip over the entire tooth and seat.

Case: One

The lower right deciduous second molar had a pulpotomy placed and now has a large glass ionomer filling that needs a stainless-steel crown.

Procedure

The tooth is isolated with a rubber dam.

Crown Preparation:

1. Using a long thin diamond bur (or a 169 L carbide bur), the contacts are removed on the mesial and distal side of the deciduous tooth. Once you have broken the contact, it can be enlarged carrying the margin to a millimeter of the tissue. This should open the contact a good two millimeters. The corners need to be rounded to make it easier for the stainless crowns to slip over the deciduous tooth. You may even have to remove some of the buccal wall if the stainless crown is having trouble seating later.

2. The crown portion is removed with a flame shaped diamond bur. Remove half of the occlusal surface first to gauge the depth, but you want to remove a good two millimeters of tooth structure or temporary filling. Especially be concern with the distal half of the tooth where the opposing comes in close. This should be checked by having the patient close his mouth. Using a mirror, you need to have 2mm clearance all the way around.

Crown selection

The stainless-steel crown is selected. These are usually marked, otherwise look at the crown shape. A lower right first deciduous crown is quite different from a lower left deciduous crown. The stainless crown needs to fit over the tooth. This may mean removing more of the tooth structure to accomplish this. It needs to go into the gingival tissue for retention.

Fitting the stainless-steel crown

1. Sometimes there is no right crown that will fit. This means you will have to make one fit. Select one slightly longer mesial-distally. You do not want an open contact. Therefore, the smaller crown will not work. Using a flat plier, the contact areas are crimped removing the round corner. This should give you two millimeters less in length and should fit.

2. If it still is not going down because of the buccal thickness, a portion of buccal tooth structure can be removed with a diamond bur.

3. Check the corners again. You may have to make them more rounded.

4. The crown seats all the way but the occlusal is not allowing the other teeth to occlude. You can remove more of the occlusion of the crown or you can use the crimping plier. Reverse them and push in the occlusal portions causing the interference. Do not overdo this. You may need a larger crown.

The crown needs to be trimmed:

A curved scissors is used to remove buccal and lingual gingival edges. The crown needs to go under the gingival tissues

The contact areas are hard to trim with a scissors. Therefore, I would recommend using the flame shaped diamond bur to shape the contact margins. The margins should fit all the way to the tissue.

Crimping the Stainless-Steel Crown (crimping plier #114 and #109)

1. Using the crimping plier, the gingival edges are crimped more on the buccal then the lingual. This is what holds the crown on the tooth. It must have sticking ability.

2. The gingival margin of the stainless crown now is ready for the crimping all the way around the crown to give it a slight bend and smooth out the cut marks. This is done by pulling the crown gingival margin through the crimping plier while you are placing some pressure on it. This is not heavy pressure. You want to be able to pull it through the plier.

3. The stainless-steel crown is checked:

4. It fits all the way: the margins go below the tissue.

5. The occlusion is not interfering with the other teeth.

6. Run a periodontal probe around the margin. If you find an opening, you will have to crimp it more to close it. This is important for the longevity or the tooth.

Cementing to place:

1. The best material is probably Glass ionomer cement. It is strong material and will give the crown support underneath. Remember you need self-cure cement.

2. ZOE cement is good for sensitive teeth, but it needs the margins to be well adapted.

Discussion:

Placing stainless steel crowns takes patience. You may have to do a few before it starts to come easier for you. Usually the major problem is the failure to remove enough tooth structure. Remember the round corners will allow a difficult seating crowns to seat. The second most common mistake is not taking enough off the distal lingual occlusal portion of the crown. It is difficult to see and can be easily missed.

Open-faced Stainless-Steel crown

Procedure:

1. Once the cement has hardened, you remove the buccal face of the stainless crown with a diamond bur or carbide 557, but it may jump around until you have placed a hole in the crown. You do not have this problem with a diamond bur.

2. You make a face in the crown staying a millimeter from the gingival tissues and extending short of the occlusion. The width should remain out of the contact areas.

3. Remove some of the cement to give you a depth of at least two millimeters. Working against a glass ionomer works better here than other cements. You need something for the composite to attach to. You could place some retentive areas with a 1/2 round bur.

4. The edges of the opening are smoothed with a green stone followed with a white stone using plenty of water.

5. The area is dried, and a glass ionomer liner is placed to mask the color of the tooth and cement.

6. A bonding agent and the resin-based composite is placed and cured unless you are using a self-cure composite.

7. The restoration is finished with a green stone followed with a white stone. A prophy cup and paste finishes the procedure.

Discussion:

You could also use disks to finish the case, but you run the risk of taking the metal of the stainless-steel crown into the composite leaving black streaks. Remember is it always composite to metal. The technique is quick and leaves the child with a more acceptable restoration. The tooth retains its strength from the glass ionomer below the crown. Actually, the stainless-steel crown is only the matrix for the glass ionomer and composite.

If the liner was not thick enough, the gray color of the tooth may show through. This technique is more acceptable for the posterior teeth

Pre-veneered Stainless-Steel Crowns

The buccal or facial surface of the stainless-steel crown is colored coated with a polyester/epoxy hybrid composition. The only surface that can be crimped is the lingual where lower half of the crown is metal. Once it is fitted, it is cemented to place with a self-cured glass ionomer cement. The excess should be wiped clean before it hardens. The cement fills the voids between the crown and the tooth at the margins.

Advantages and disadvantages:

 It will require more tooth surface removal especially on the buccal gingival bulge.

 You can adjust the contacts some, but otherwise the crown needs to fit the tooth meaning you will need to make your adjustments on the tooth (rounded corners).

 It leaves a nice hard surface.

 The esthetics are very good.

 The margins need to be slightly below the gingival tissues to protect them better.

Dental Transparent Crown Anterior and Posterior matrices

Anterior teeth should not have stainless steel crowns. Instead, I would use transparent crown matrices. The decay is removed in the tooth, and a matrix is selected to match the tooth size. The excess is trimmed with a scissor. The anterior tooth is etched. The transparent crown matrices are filled with a composite matching the tooth shade and inserted over the tooth. The excess is wiped clean with a cotton two-by-two and allowed to set. The matrix is removed. The composite will cure with a nice shine. Just bring in the margins and check the occlusion. It needs to be slightly out of occlusion when the patient goes into protrusion.

Advantage:

 The thin material can slip between the contacts.

 It does not require removing large amounts of tooth structure.

 It leaves a pleasing result.

 It uses the total tooth for support.

 It is easy to fabricate.

 It is not expensive.

Polycarbonate Temporary Crown:

They work very well for prepared teeth. A crown preparation is required. They come in deciduous and permanent teeth sizes. Sometimes to make the polycarbonate crown fit, you need to remove some of the inside of the crown and more of the tooth. It needs to extend to the gingival tissues. The composite is placed inside the temporary crown and placed over the tooth. The excess is wiped off. The margins and occlusion are brought in after the composite hardens.

Advantages and disadvantages:

 More tooth structure need to be removed to fit the crown.

 It has a hard finish and good esthetics.

 It is not a difficult procedure.

Zirconia Crowns

These are crowns made in the office using a CAD-CAM machine. The preparation is digitally photographed from different directions. These go into a computer where the crown is drawn on a screen. A machine produces the crown by reducing a block of porcelain to fit the measurements. This technique is fairly expensive for deciduous teeth, but they work very well for permanent teeth.

The crown will fit the preparation. The major concern will be the length of the preparation walls and how parallel they are to establish retention. The preparation is a regular crown preparation creating the four wall and occlusal reduction. If the machine is in the office, the crown can be produced in twenty plus minutes requiring no temporary for the patient. It can be done in one appointment.

Spacers:

A spacer is placed in a child’s mouth to hold a position until the permanent tooth erupts. This can be a removable spacer or a fixed spacer.

Removable Spacer:

It is usually made of acrylic with wire clasps. It is very similar to an orthodontic retainer. It replaces one or more teeth and is usually laboratory produced. An impression is taken, and the stone model is sent to the laboratory. You may have to adjust the wire clasps with a plier to make it fit.

Advantages and Disadvantages

 The removable space relies on the child to keep the appliance in his mouth. It is easy to misplace the appliance when it is removed while the child eats.

 It works well for missing teeth, especially anterior teeth.

 It requires the patient to maintain it.

 It acquires slime and other debris from the particles in the child’s mouth.

 Dogs love to chew them.

Fixed Spacers:

These use an adjacent tooth to hold the spacer. This can be a stainless-steel crown or a stainless-steel band. These can be made in a laboratory or they can be office produced. If you are using a laboratory an impression and stone model needs to be produced.

Case: One

A five-year-old child had a badly decayed lower second deciduous molar extracted. You need to make a distal shoe appliance to hold the six-year-old molar from closing the space and crowding the later erupting #29 bicuspid.

Procedure:

Impressions are taken, and stone models poured. Before sending the models to the lab, you need to mark on the stone model where you want the end of the shoe. This can be obtained by looking at the X-rays. You also want the shoe portion long enough to reach the buried six-year-old molar. This information goes to the laboratory.

The shoe spacer comes back from the laboratory with a flat shoe at the end of steel band that fits the first deciduous molar.

The patient is numbed where the shoe will insert. Using a #15 blade, an incision is made where the shoe potion will penetrate the tissue. The shoe is tried in to be sure it fits the primary tooth and your incision. Then take an X-ray to be sure the shoe is in the right position, and cement to place.

Advantages and Disadvantages:

 These usually work very well in holding the six-year-old molar in place.

 Some Practitioners do not make the cut into the tissue first, but simply shove the shoe into the tissue.

 These usually hold in place very well.

 It may need to be replace as the permanent tooth erupts with a regular spacer.

Case two:

A eight-year-old child is missing the lower second deciduous molars on both sides.

This will be a laboratory case to make a lingual wire that remains on the lingual tissues going from one side of the mouth to the other inserting into the stainless-steel bands on the six-year-old molars on each side. It is a horseshoe wire with steel bands on the ends.

The bands will be cemented to place on the permanent molars to hold them in place and not allow them to drift forward. The wire against the tissues prevent their movement forward.

Advantages & Disadvantages:

 They work very well if they remain in place.

 The six-year molars need to be completely erupted or the shoe technique would be preferred.

 Sometimes the patient will work his tongue into the wire dislodging the spacer.

Case Three

A seven-year-old child had his mandibular first deciduous molar extracted. Whether to place a spacer here is a debatable question. Many practitioners would leave the space thinking there is no pressure being applied here with erupting teeth.

Case Four: Band Movement Spacer

An eight-year-old boy has lost his mandibular second deciduous molar. Tooth number 30 is fully erupted.

This is a good case to place a Band Movement type spacer. You do not need a laboratory and the whole procedure can be done in twenty or less minutes. This is an Adjustable-in-Office spacer. A stainless-steel band with two sleeves attached receives the horseshoe wire spacer. It slides back and forth inside the two sleeves.

Procedure:

The correct band is selected for #30 molar. This is tried in the mouth with the two sleeves pointing towards the first deciduous molar.

The wire horseshoe loop is cut to fit and placed in the two sleeves on the band. The band with the wire horseshoe loop is inserted in the two sleeves and tried in again. The loop is position against the distal contact of the deciduous first molar.

Removing it from the mouth, the loop is brought forward slightly, and the two sleeves are crimped to the wire loop. These are bent slightly with a three-prong plier to give it a curve.

The spacer is tried in the mouth again. The band should fit over the molar and the end of the loop should press slightly on the distal contact of the first primary tooth.

If the loop is too long, the three-prong plier can place the bend deeper in the sleeves to shorten it. If it is too short, the three-prong plier can reverse the bend and length it.

Check the bite to be sure the loop is not interfering with the occlusion. You may have to bend it some more.

At this point you are ready for cementation. I usually will solder the loop to the sleeves with a torch and a light touch of solder. It will work either way.

Using a glass ionomer cement, the molar band is cemented to place. Use a bite stick to seat the band on the molar. You want to keep the loop end on the distal contact of the first deciduous molar, and not in the tissue.

Wipe the excess cement and check the bite again.

This technique works very well placing a shoe to hold the six-year-old erupting molar in place. Instead of the horseshoe loop, a shoe is used.

Advantages and Disadvantages:

 It works very nice in the office and can be done in one appointment.

 It does not require a laboratory or the taking of impressions.

 You need to crimp the sleeves leaving some excess in the loop to allow for the bend the three-prong plier will make. You need some room to adjust the spacer.

 Often the loop ends up in the tissue and not on the contact of the primary tooth. This is due to the band suddenly seating lower than anticipated. The band does little good in the tissue.

Emergencies

Emergencies will take time. You need to schedule for them. I usually book them just before lunch or the last patient of the day. If the emergency took an excessive amount time usually only my lunch suffered. Of course, this will depend on the emergency. A child with a tooth hanging out of his mouth will be taken right in.

Case One:

A four-year-old child comes in the office with deciduous tooth #E hanging from his mouth. He fell on the coffee table and struck his tooth. The tissue is torn, but the tooth is still attached.

Procedure:

The patient is numbed with the painless injection and the surrounding tissues are numbed. The tooth is slipped back into the socket. This may take some pressure. The fractured alveolar bone is pushed back into place and held.

A wire splint is cut and shaped to fit the anterior teeth from #C to #H. I used rectangle orthodontic wire (.018 by .025). The teeth are etched, and glass ionomer cement is placed on the teeth. The wire is placed in the cement and light cured on all the teeth except the loose #E.

The #E tooth is pushed into place in the correct position and the cement is cured.

The tissue is sutured.

Anecdote:

My four-year grandchild was with her mother at the store shopping. When they returned to the car, she was riding on the end of the shopping cart with her hands holding onto the bar with her feet stuck in the basket below. When her bother was lifted out of the shopping cart, it suddenly flew up sending the end my granddaughter was holding on to down.

The bar struck her anterior teeth dislodging all six anterior deciduous teeth. Her mother was able to find five of the six missing teeth on the pavement. She placed them in milk and came to my office. She heard somewhere that was the correct procedure.

Calming the parents was my biggest problem. The child behaved very well. The tissues were numbed with the painless technique. The teeth were removed from the milk and rinsed with water. These were placed directly into the sockets and the labial alveolar bone was pushed back into place.

Now, my problem was how to stabilize the teeth? The deciduous tooth #H was missing. The only stabilized teeth were the primary molars. I covered all of the teeth with a composite making a splint. I adjusted her occlusion and tried to make the splint look like teeth.

She worn the splint for six weeks. The only difficult part of the procedure was the removal of the composite from the teeth. It was difficult to recognize the teeth under the tooth colored composite. Therefore, I would recommend using a darker composite.

The tissue around the teeth healed and when she was six years of age the teeth exfoliated right on time with the roots of the teeth resorbing as normal.

_______________________________________

Discussion:

When should you not place the exfoliated teeth back into the child is a judgment call determined by the amount of root structure and the length of time before the child’s permanent teeth erupt. You do not wash the roots off with soap and water or try to disinfect them with medicaments. The body can handle the bacteria, but it does not do well with the chemicals. The jagged torn tissue on the roots need to remain to allow the body’s tissues to reattach to the tooth.

This may seem against proper protocol, but I have seen many failures because the root of the exfoliated tooth was scrub and sterilized. The sooner the tooth can be reinserted the greater is the chance of the tissue taking hold.

Failure results in space developing around the root. The body is rejecting the tooth. It is very important the tooth is taken out of occlusion. If this requires a bite appliance to keep the anterior teeth from touching, then one should be made with the anterior teeth cut of the appliance. This is an office made appliance using a Proform machine.

If it is a permanent tooth you are reinserting, I would not do the root canal until after the tooth has been stabilized in the mouth, or not at all. I used to do the root canal on the exfoliated tooth while it was out of the mouth. Then I washed and sterilize the root before reinserting the tooth only to have it fail.

Usually the apical end of the tooth will heal closed. I observed a tooth I had inserted without root canal for years and it remained stabilized with no rejection or infection.

Case Two:

A two-year-old boy had fallen walking around a coffee table striking his primary ‘E’ tooth forcing the tooth to be pushed up into the socket four millimeters. The parent is concern.

Procedure:

You do nothing. The tooth will push its way back out of the socket and return to normal.

Case Three:

A two-year young lady has place a marble up her nose. Actually, she has two marbles up her nose. She is not in pain, but the parent is excited.

Procedure:

The marbles move further up her nose every time you attempt to clasp one of them with your cotton pliers. You simply have the child blow through his nose. While the marbles are down and in sight, you place your fingers on his nose above them and squeeze enough to keep the marbles stationary. Then it is an easy extraction with the cotton pliers.

Four: Case

A young man of eight years has a fractured incisal edge taking out the distal half of the tooth #9. It is not exposed, but a large portion of the tooth is missing. The pulp chamber is large, and the crown dentin layer is still relatively thin making it difficult to cut a preparation to receive a crown.

Procedure:

If it is possible to place an undercut with a ½ round carbide bur in the dentin, one should be place for added retention.

A transparent thin matrix is held in place with a wedge on the distal.

The tooth is etched, and a sealant is applied and cured.

The composite build up starts in layers as you light cure. Using your fingers, you can guide the composite into the distal contact giving it a nice contour.

The matrix is removed.

The whole tooth is given a layer of composite to blend the tooth color with the repair. It is very difficult to match the many shades of the tooth.

The tooth is shaped taking special care in matching the incisal edge with Number 8.

The protrusion occlusion is checked to be sure the tooth is not touching the lower anterior teeth. You want the other incisors to touch first to keep the pressure off the repair.

The tooth is polished with a white stone and water followed by a pumice prophylaxis.

Finally, to give it a shine, a thin layer of flowable composite is floated over the labial surface and light cured.

If you have difficulty shaping the contour of the tooth, you could use a transparent crown filled with composite. It will also leave a nice glaze look to the tooth.

Case Five:

A young man of twelve comes into the office with a large swelling below his right eye to the point of forcing his eye to close. He was in extreme pain, but now the pain has subsided, but the swelling is very tender.

X-ray reveals a tooth number 3 has a large mesial decay exposing the pulp chamber.

Looking inside the child’s mouth, you see a large swelling above the tooth.

Procedure:

You do not give the patient anesthetic unless it is a block, but it is not necessary in this case. The nerves in the pulp chamber have long since died. The tooth will be sensitive to the vibrations created by the hand piece, or any pressure applied.

I would use a diamond bur to remove the occlusal coronal portion of the tooth to expose the decay and pulp chamber. The 557-carbide bur has a tendency to vibrate the tooth. The decay is removed with a spoon. You could take the decay out with a large #8 round bur, but you have no control.

If the patient has been experiencing pain, you will find serous material flowing out along with the red and white blood cells. Allow the fluids to flow to relieve the pressure.

The occlusion is reduced. Usually the tooth has extruded because of the swelling allowing the Mandibular teeth to strike the tooth first, sensitizing it.

The buccal tissue is next. You want to relieve the pressure by creating a drain. Using the syringe with a number 27-gauge needle, you insert it in the swelled tissue that will most likely drain it. This is usually just above the hard-gingival tissues. You insert a small amount of anesthetic and aspirate the liquid inside the swelling.

If the serious material has been walled off by the body, and the infection is ready to be drained, the cartilage will show serous material from the aspiration.

If the syringe shows blood, then the body has not walled it off or you did not puncture the walled off sac of infection (serous material). This is probably the case if the swelling of the tissue is relatively recent.

The serous material fills the cartilage in the syringe upon aspiration. You will be draining the infection. Using the Number 12 blade, it is inserted into the swelling following the point the needle made. You should be prepared for a huge flow of serous material meaning place the evacuator next to incision. It can fly several feet once it is punctured.

When it has stopped flowing, a piece of rubber dam can be sutured in the incision for a few days to allow more of the serous material to flow out. It prevents having to reopen the tissue later. Though, I have had to do this only a few times. Usually the first incision is enough.

A blood filled the cartilage means the battle is still ragging and the sac has not yet formed. If you puncture into the tissue at this point expect a great deal of bleeding. It will relieve the pressure, but the cost is excessive bleeding.

The patient is given antibiotics and the tooth is left open to allow the fluids to drain.

A week later after the infection has subsided, the tooth can be sealed with temporary cement. I would not start root canal therapy yet. You may have to reopen the tooth. That is very hard to do with gutta percha in the canals.

When the patient can tolerate the closure, then the root canal therapy can be started.

Case Six

A ten-year-old young man come in with a slight swelling below the right second primary molar. The tooth has decayed out revealing the pulp chamber and the root canals. The pulp tissue has been gone for some time. The X-ray reveal a small cyst around apical of the distal root. The tooth never bothered the young man before, but now he is in pain.

Procedure:

The pain is coming from the buildup of serous material below the distal root. He did not experience this before because the distal root canal had been draining the buildup of infection. Now the distal canal is closed.

Using a #15 to 25 file, the distal root is open to allow the drainage. If you do not see any drainage coming out, you are probably not through the foramen. You need to be to reach the infection site.

Once the canal is opened and the flow of serous material (infection) is established, the pain will subside.

The patient should be given antibiotic for a week before progressing to an extraction to prevent infection spreading to other areas of the mouth bringing with it more swelling.

Never do surgery when infection is present!

Extractions

The patient is numbed with the painless injection. You will need to numb the lingual and buccal tissues. The tissue need to be pushed back from the tooth you are extracting with a periosteal instrument. It saves having the tissue hanging onto the tooth as you extract it. That is the wrong time to remove the tissue from the tooth.

Second Deciduous Molar:

This tooth should always be split if the roots are still fully developed. Attempting to take the tooth out towards the buccal (twisting) with the roots intact will usually tear up the tissue.

There is also the possibility of taking the bicuspid tooth bud along with the tooth in younger children. If this should occur, the tooth bud is placed back in the socket and sutured. Avoid the situation by splitting the tooth buccal-lingually and use the elevators to remove the roots.

Sometime the roots are very thin and long. Even using extreme care, these roots sometimes fracture off leaving them imbedded in the tissue. If they can be eased out without disturbing the tooth bud, okay, but if the tooth bud is in danger, the root tip should remain until the child is older. The root tips will come to the surface with the second bicuspid eruption.

Sometimes on the rare occasions the bicuspid is caught under the alveolar bone because the deciduous second molar was extracted early and the alveolar bone has healed over it. You may have to make an incision and remove the alveolar bone trapping the tooth.

Conclusion:

Children’s dentistry is fun and very rewarding. The process of treating children should be thought of as long-term treatment. This will carry over into their adult years as your practice matures. It is a building process to create better patients and friends. Time spent with children early will give you excellent patients later who will refer others to you.

Information:

The Author has taken care to ensure the quality and accuracy of information contained in this course and that information meets standards that are generally accepted. The Author disclaims all damages that may occur, all losses, and all liabilities, either directly or indirectly in the performance and utilization of the education material herein. It is the responsibility of the licensed dental professional to take due caution when incorporating new skills or processes into their practice. The information contained in these courses are for review of already acquired knowledge and meant for refreshing and recertifying purposes.

Resources:

1. The Dental Advisor 10 West Liberty, Ann Arbor, Michigan 48103

2. Dentistry Today is The Nation's Leading Clinical News Magazine for Dentists. Here you can get the latest dental news from the whole world quickly.

3. Dr. Ellis Neiburger is a general practitioner in Waukegan, Illinois.

4. Is It Time to Do Routine Adult Pulpotomies? Chairside Magazine: Volume 7, Issue 1

5. British Dental Journal 197, 735 - 743 (2004) Published online: 25 December 2004 | doi:10.1038/sj.bdj.4811897

6. JCDA • www.cda-adc.ca/jcda • November 2005, Vol. 71, No. 10 •749 Debate

& opinion most pediatric dentists in the United Kingdom and North America

7. J Can Dent Assoc 2005; 71(10):749–51 This article has been peer reviewed. 750 JCDA www.cda-adc.ca/jcda • November 2005, Vol. 71, No. 10 •

8. The Dental Advisor 3110 West Liberty, Ann Arbor, Michigan 48103

9. Viewpoint The Use of Mineral Trioxide Aggregate in Clinical and Surgical Endodontics

Category: Endodontics Created: Saturday, 01 March 2003 00:00

10. Dentistry Today is The Nation's Leading Clinical News Magazine for Dentists. Here you can get the latest dental news from the whole world quickly.

11. Oral Implantol (Rome). 2009 Jul-Sep; 2(3): 37–44. Published online 2010 Apr 20.

PMCID: PMC3415346 MTA applications in pediatric dentistry P. Maturo, M. Costacurta, M. Bartolino, and R. Docimo

12. British Dental Journal 197, 735 - 743 (2004) Published online: 25 December 2004 | doi:10.1038/sj.bdj.4811897

13. Subject Category: Endodontics: Part 9 Calcium hydroxide, root resorption, endo-perio lesions P Carrotte

14. Textbook of Endodontics, written by Nisha Garg, Amit Garg in 2010 and Pathways of the Pulp, article written by Nguyen Thanh Nguyen

15. Pediatric Dentistry – 24:5, 2002 Seale 501 Stainless steel crowns N. Sue Seale, DDS, MSD Department of Pediatric Dentistry, Baylor College of Dentistry, Dallas, Tex.

16. Dental Care.com, Full Coverage Aesthetic Restoration of Posterior Primary Teeth Stainless Steel Crowns by Steven Schwartz D.D.S.

17. Fractured, Loosened, or Knocked-Out Teeth By David F. Murchison, DDS, MMS, Texas A & M Health Science Center, Baylor College of Dentistry; University of Texas at Dallas

18. Dental Plaque Biofilms: Jill S. Nield-Gehrig, RDH, MA

19. Dental Plaque Biofilms: Microe Wiki


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