Q1)Discuss regarding role of various mechanical and chemical methods of controlling dental plaque

 Mechanical, plaque control

 Dentifrice
o A dentifrice is a substance used with a toothbrush to remove bacterial plaque, material alba,
and debris from the gingiva and teeth for cosmetic and sanitary, prevention and therapeutic
purposes.
o Egyptian medical manual the Ebers Papyrus written about 1500 BC mentions the use of
dentifrice for cleaning the mouth and Hippocrates was the first to recommend the use of
dentifrices
 Toothbrush
o Parts of toothbrush
 Toothbrushes should be able to reach and effectively clean most areas of the teeth. The type of
brush is a matter of individual preferences. Parts of manual toothbrush includes:
 Handle—grasped in the hand during toothbrushing
 Head—the working part and consists of tufts of bristles or filaments
 Shank—the location that connects the head and the handle.

o Powered toothbrush
 The level of oral hygiene achieved by an individual is dependent on technique, motivations,
dexterity and perseverance.
 Since the behavioral practices can’t be modified, the greatest potential for improving oral
hygiene will come from advancements of brush design that enhance plaque removal.
 First electric toothbrush was conceived in Switzerland in 1954 by Dr Philippe-Guy Woog.
 Braun-Oral B kids power toothbrush D10 is most effective in removing plaque in children. It has
an oscillatory round brush head so causes no soft tissue damage. It appeals to children as it
plays music at one minute interval thereby monitoring brushing time.
 Current modifications of powered brushes have three motions:
 Back and forth
 Circular
 Elliptical
 Indications of powered toothbrush
 Individual lacking motor skill
 Handicapped patients
 Patients who have orthodontic appliances
 Whosoever wants to use
o Superbrush
 It is designed to simultaneously clean the outer, inner and chewing surfaces of teeth.
 Three brush heads are combined together in the Superbrush.
 When the brush is placed on the chewing surface, all the three surfaces of the tooth are
cleaned simultaneously.
 It shortens the brushing time
 Mostly indicated in disable children.
o Pulsar toothbrush
 New concept in toothbrush technology where a pulsating chip is embedded on the base of
bristles.
 Pulsar has soft vibrating bristles that help break up plaque between teeth and facilitate easy
removal.
 Oral-B Pulsar is first to incorporate this technology in manual toothbrushes.
o Ultrasonic toothbrush
 The newest development in this field is the ultrasonic toothbrushes, or simply sonic
toothbrushes using ultrasonic waves to clear the teeth.
 In order for a toothbrush to be considered “ultrasonic”, it has to emit a wave at a minimum
frequency of 20,000 hertz or 2,400,000 movements per minute.
 It is called sonic because its operating frequency (movements per minute) falls into the human
hearing range of between roughly 20 hertz to about 20,000 hertz.
o Chewable toothbrush
 A chewable toothbrush is a miniature plastic moulded toothbrush that can be used when no
water is available.
 They tend to be very small, but should not be swallowed.
 They are available in different flavors such as mint or bubblegum and should be disposed of
after use.
 Other types of disposable toothbrushes include those that are a small breakable plastic ball of
toothpaste on the bristles, can be used without water and prove to be quite handy to travellers.

o Techniques of toothbrushing
 There are 6 major techniques of toothbrushing viz Scrub, Bass, Charters, Fones, Roll and
Stillmans.
 The most recommended technique for brushing in small children is Scrub followed by Bass as
they grow up after they achieve full manual dexterity.
 Tongue cleansing
 Tongue is one such structure which retains plaque and requires brushing.
 The tongue is anatomically perfect for harboring bacteria.
 The fungiform papillae create elevation and depressions in the tongue, which can house debris
and microorganisms
 The brushing of the tongue helps reduce the debris, plaque and number of microorganisms.
 Place the head of the tongue cleaning brush near the middle of the tongue, with bristles pointed
toward the throat, then the tongue is extruded, and the brush is swept forward and this motion
is repeated 6 to 8 times
 The patient is advised to use firm, overlapping scrub-type strokes starting at the back of the
tongue and moving towards the tip.
 Interdental cleaning aids
o Anatomy of the interdental area is a major factor in the selection of interdental aids. The most
frequent interdental aids include dental floss, interproximal brush, wooden tips, oral irrigation
devices, dental tapes and end-tufted brushes.
 Dental floss
 Size of dental floss can vary from 300 to 1500 denier (D).
 Floss is constructed with the help of individual filaments 2 to 3D thick.
 Floss is dispensed in boxes and can be readily used and disposed off from there. For additional
ease of flossing various floss holders are available throughout which vary in designs
 Types of Floss
 Twisted and nontwisted
 Banded and nonbanded
 Thin and thick
 Microfilament and multifilament.
 According to ADA specification:
 Type I: Unbonded dental floss composed of yarn having no additives.
 Type II: Bonded dental floss composed of yarn having no additives other than binding agent or
agent for cosmetic performance.
 Type III: Bonded or unbonded having drug for therapeutic usage
 Technique of Flossing
 String floss method: Use 18 inches of floss. Wrap 2 to 3 inches of floss around middle finger of
left hand and similarly to the right hand.
 Circle of floss method: Take floss and tie a double knot to secure it. The size of the circle is like
an orange. Position the knot to the left side of working area and place middle, little and ring
fingers of both hand on the inside of circle to keep it taut. Rotate counter-clockwise for fresh
segments
 Flossing for Children
 Not all children can floss effectively.
 The ability to use floss is a function of age and manual dexterity.
 The ability to manipulate floss and remove plaque is highly dependent on hand and eye
coordination and age.
 Interproximal brushes
 These are cone shaped brushes made of bristles mounted on handle, single-tufted brushes or
small conical brushes.
 Interdental brushes are particularly suitable for cleaning large irregular or concave tooth surface
adjacent to wide interdental spaces.
 They are inserted interproximally and are activated in short back and forth strokes in between
the teeth.
 For best cleaning efficiency the diameter of the brush should be slightly larger than the gingival
embrasure so that the bristles can exert pressure on the tooth surfaces.
 Single tufted brushes are slightly effective on the lingual surface of mandibular molar and
premolar whereas a regular toothbrush is often impeded by the tongue.
 These brushes are classified as:
 Tapered ( Christmas tree appearance)
 Nontapered (Bottle neck appearance)

 End-tufted brush
 An end-tufted brush is a type of toothbrush used specifically for cleaning along the gumline
adjacent to the teeth.
 The bristles are usually shaped in a pointed arrow pattern to allow closer adaptation to the
gums .
 An end-tufted brush is ideal for cleaning specific difficult reach areas, such as between crowns,
bridgework, crowded teeth and fixed orthodontic appliances.
 Wooden tips
 Soft triangular wooden tips such as a Stim-U-Dent are placed in the interdental space in gingival
and they slide with contact the proximal tooth surface.
 Made up of bass wood or balsa wood
 Repeatedly moved in and out of the embrasures, removing soft deposit for the teeth and
mechanically stimulating the gingiva.
 Use is limited to the facial surfaces

 Chemotherapeutic plaque removal

 Chlorhexidine
o It is recognized, as the primary agent for chemical plaque control and its clinical efficacy is well
known to the profession.
o Antibacterial Activity
o Chlorhexidine has a wide spectrum of activity encompassing gram-positive and gram-negative
bacteria, yeasts, dermatophytes and some lipophylic viruses.
o Chlorhexidine shows different effects at different concentration.
o At low concentration the agent is bacteriostatic and at high concentration it is bactericidal.
o Disadvantage:
 Yellowish staining of the teeth.
 Alteration in taste.
 Essential oils
o These are the oldest form of mouthwashes. The most popular one being Listerine.
o It is a combination of the phenol related essential oils, thymol and eucalyptol mixed with
menthol and methyl salicylate.
o Mechanism of action is by cell wall disruption and inhibition of bacterial enzymes.
o Adverse effects include initial burning sensation and bitter taste in the mouth.

 Quaternary ammonium compounds

o The agent most commonly used in this category is Cetylpyridinium chloride at a concentration
of 0.05 percent.
o This group of chemical agents is cationic and binds to the oral tissues but not as strongly
bisbiguanide.
o When used orally, they bind strongly to plaque and tooth surfaces but are released from these
binding sites more rapidly than chlorhexidine. This rapid release is one of the reasons why they
are not as effective as chlorhexidine.
o Mechanism of action is related to their ability to rupture the cell wall and alter the cytoplasmic
contents.
o Adverse effects include a yellow brownish discoloration of the tongue and around gingival
margin of the tooth, burning sensation and occasional desquamation.
 Triclosan
 o Triclosan is available in dentifrices and mouthrinses.
o Triclosan is both a bisphenol and a nonionic germicide with low toxicity.
o It has broad spectrum of antibacterial activity and lack the staining effects of cationic agents.
o Triclosan also acts as an anti-inflammatory agent in mouthrinses.

 Sanguinarine
o It is currently used in both mouth rinse and toothpaste.
o It is an alkaloid extract from the bloodroot plant –Sanguinaria canadensis.
o The only adverse effect reported with this agent has been a burning sensation when used
initially.
 Propoile
o Naturally occurring bee product used by bees to seal opening on their hives.
o Consists of wax, plant extracts and contains flavones, flavanones and flavonls.
o It has been shown that is had very low level of clinical effectiveness but significant plaque
inhibitory action.
 Stannous fluoride
o In addition to decreasing the solubility of enamel to bacterial acids and enhance mineralization,
stannous fluoride has shown a secondary benefit of inhibiting microbial plaque accumulation.
o Mechanism of action is that it interference with bacterial biochemical synthesis, metabolism and
aggregation.
o 0.04 percent concentration is the most effective.
o Available as an aqueous gel and suggested usage is one or two times daily.
 Prebrushing rinse
o PLAX is the only available agent.
o The chemical composition is sodium benzoate. When combined with a soapy agent, may have a
surfactant action on plaque.

Q2)Classify and discuss mechanism of action of systemic fluorides

 Metabolism of fluoride
o Absorption
 Fluoride is primarily absorbed from stomach.
 This process occurs by passive diffusion and is also inversely related to pH so that factors which
promote the secretion of gastric acid increase the rate of fluoride absorption, which leads to
earlier and high peak plasma levels and vice versa.
o Transportation
 In plasma, fluoride exists in two forms : Ionic fluoride (inorganic or free fluoride) and nonionic or
bound fluoride.
 Almost all fluoride in plasma is in ionic form and is not bound to any macromolecules.
 The plasma concentration of fluoride is variable, being dependant on the level of intake and
several physiological factors.
o Soft tissue distribution
 Once absorbed, fluoride is distributed within minutes through the extracellular fluid to most
organs and tissues.
 The fluoride concentration in most soft tissues is lower than the plasma level except in the
healthy kidney where, because of urine production, an occasional fluoride accumulation may
result.
 Fluoride passes through the placenta
 The fluoride concentration of human breast milk is lower than that of maternal plasma. Thus the
fluoride intake of infants who are solely or mainly breastfed is unusually low.
 In subjects with a normal diet, the fluoride concentration in the saliva is about 1 μM/L.
o Excretion
 The main route of fluoride excretion is via the kidneys.
 Because ionic fluoride is not bound to plasma proteins, its concentration in the glomerular
filtrate is undoubtedly the same as in plasma
 The kidneys are very efficient in removing fluoride from the body.

 Mechanism of action of fluoride

o The mechanism of action of fluoride or the methods by which fluoride exhibits its anticariogenic
or antimicrobial effect are improved crystallinity, void theory, acid solubility, enzyme inhibition,
suppressing the flora, antibacterial action, lowering free surface energy, desorption of protein
and bacteria and alteration in tooth morphology (Table 29.1).
Q3)Behaviour management techniques in detail
 Pre appointment behavior modification
o Audiovisual modeling
 The goal is for the patient to reproduce the behavior exhibited by model.
 Child sees the video cassette before proceeding to dental clinic, on day of appointment.
 Type of model used can be siblings, other children or parents.
 It is best recommended to use the model of the same age as that of the child patient so that he
can easily relate himself with the model.
 Advantages:
 Stimulation of new behavior
 Facilitation of behavior in more appropriate manner
 Elimination of inappropriate behavior because of fear
 Extinction of fear.
 Disadvantage:
 Expensive
 Time consuming process.
o Preappointment mailing
 Contact with the child’s parents before the first dental visit can alienate some concerns.
 It increases the likelihood of a success as it prepares the patient for first dental visit.
 Parent can be contacted by telephone as a reminder the day before the dental appointment it
may serve in establishing good relationship.
o Communication
 First objective in successful management of the young child is to establish communication.
 By involving the child in conversation, the dentist not only learns about the patient but also may
relax the youngster.
 The fears and natural innate curiosity of the child demand that explanations be given for each
and every step of dental treatment.
 There are two ways of establishing communication:
 Verbal: Spoken language to gain confidence.
 Nonverbal: Expression without words like welcome hand shake, patting, eye contact.
 Effective vocabulary is important aspect as the dentist must only use the words that are
understandable by the child.
 Communication with children aged 2 to 7 years should be based on Piagetian concept
(Animism-giving life to an inanimate object) which involves giving life like names to dental
instruments like handpiece is called whistling Charlie.
 Honesty of approach is also very important, if the child knows that dentist is honest with his
words, it will bring out a cooperative behavior in him.
 The three most important facets of communication are source, medium and receiver. In
reference to dentistry, dentist is the source, dental clinic is medium and child is the receiver.
 If the dentist is good, sympathetic, confident and honest; dental clinic is neat, quiet, familiar to
children, full of toys; then automatically the child is communicating and is well managed.
o Use of second language(euphisms)
 Address the child at his or her level of comprehension. This does not suggest the use of baby
talk, but rather employing words that have meaning for that child.
 The dental staff as well as the dentist should be oriented to the use of a “second language.” The
different expressions that can be employed are limited only by the creativity of the dentist.
 It should be emphasized that word substitutes are most effectively used with preschool children
 The tone of the voice can also be very effective in altering the child’s behavior. A change of tone
or volume can be used to communicate a feeling or sense to the child.
 A kind, firm, or a soft or a loud voice says a lot to the child. It is not what you say but it is how
you say it.

o Tell show do- write from short notes

o Desensitization
 This technique was demonstrated by James and popularized by Wolpe.
 It means to take away ones sensitivity to a type of behavior This is used in children having pre-
established fears and uncooperative behavior.
 Desensitization is a therapeutic technique that pairs an anxiety-evoking stimulus with a
response inhibitory to anxiety. In such situations the perceived link between the stimulus and
the anxiety response is weakened.
 Technique usually involves teaching the patient to induce a state of deep muscle relaxation and
while the patient is in relaxation state, tell him to imagine scenes that are relevant to his fears.
 Imaginary scenes are presented to the patient in a graduated fashion so that scenes provoking
only minimal anxiety are initially described and gradually more stressful situations are
presented.
 Preventive desensitization is philosophically possible for the child dental patient approaching
the first dental appointment. A graded introduction of the child to dentistry, tell-show-do
approaches, and accomplishment of easy procedures (examination, prophylaxis, fluoride
treatment, brushing instruction) are aspects of preventive desensitization.Additionally, medical
appointments may have sensitized the child to any clinical setting.
o Modeling
 It is based on Bandura’s social learning theory, which states that one’s learning or behavior
acquisition occurs through observation of suitable model performing a specific behavior
 Modeling is based on the psychologic principle that much of one’s learning or behavior
acquisition occurs through observation of a suitable model performing a specific behavior.
 Modeling and/or learning by observation of a model have many synonymous terms: imitation,
observational learning, identification, internalization, introjections, coping, social facilitation,
contagion and role taking.
 The efficacy of modeling as a learning technique has been demonstrated by producing
behavioral changes in situations requiring cooperation, aggressive behavior, language
development and moral judgments.
 Modeling has been used as a technique to eliminate or minimize fear of dentistry in children by
allowing the child to observe an older sibling undergoing dental treatment.
 It is also a proven fact that if the model is of the same age group as the patient the effect is even
more pronounced.
 Types of modeling:
 Audiovisual
 Live modeling by sibling or parent
 Types of models:
 Mastery (cooperative patient who enjoys dental treatment)
 Coping (just manages to cope up with the treatment).

o Behaviour shaping
 It is defined as a process which slowly develops a behavior by reinforcing successive
approximations of the desired behavior until the desired behavior is expressed
 It is based on the established principles of social learning.
 Proponents of the theory hold that most behavior is learned and that learning is the
establishment of a connection between a stimulus and a response. For this reason, it is
sometimes called stimulus-response (S-R) theory.
 When shaping behavior, the dental assistant or dentist is teaching a child how to behave. Young
children are led through these procedures step by step. They have to be communicative and
cooperative to absorb information that may be complex for them.
 The following is an outline for a behavior shaping model:
 State the general goal or task to the child at the outset.
 Explain the necessity for the procedure.
 Divide the explanation for the procedure slowly.
 Make all explanations at a child’s level of understanding with use of euphemisms.
 Use successive approximations.
 Reinforce appropriate behavior.
 Disregard minor inappropriate behavior.

o Contingency management
 This behavior management technique is based on BF Skinner’s operant conditioning.
 The presentation of positive reinforcers or withdrawal of negative reinforcers is termed
contingency management.
 It includes:
 Positive reinforcement
 Negative reinforcement
 Omission or time out
 Punishment.
 Types of reinforcers
 Positive reinforcers: It is the one whose presentation increases the frequency of desired
behavior.
 Negative reinforcers: It is the one whose contingent withdrawal increases the frequency of a
behavior.
 Material: Stickers, pencils, small toys (preferably not candies and sweets). Rewards are given
after the dental procedure and bribes are given before. Bribes should not be given in pediatric
dental practice. The reward in one visit will act like a bribe for the next visit and the child will
behave properly to receive his gift.
 Social: Praise, positive facial expression, hand shake, smile, hug, pat on the shoulder. This is the
best kind of positive reinforcer—works well with children.
 Activity: Opportunity of participating in a preferred activity like a cartoon show, visit to the
park. Before patient can accomplish this activity he has to behave accordingly in the dental
office.
 Positive reinforcement: It is the presentation of the pleasant stimulus and is done to appreciate
the child for the good behavior. Either of the above reinforcers can be used.
 Negative reinforcement: Withdrawal of the unpleasant stimulus like high speed handpiece. Care
should be taken not to confuse this punishment. The unpleasant stimulus is withdrawn and not
given to the child. It is similar to deemphasis or substitution type of retraining.
 Time-out (or) omission: It is the withdrawal of the pleasant stimulus to reinforce good behavior.
Asking the mother (pleasant stimulus for the child) to stay out of the dental operatory to make
the child cooperative is an example of time-out.
 Punishment: It is the presentation of the unpleasant stimulus to the child, e.g. voice control,
hand over mouth exercise (HOME).
o Externalization
 It is a process by which child’s attention is focused away from the sensation associated with
dental treatment by involving in verbal or dental activity.
 Objectives:
 To decrease perception of unpleasantness
 To interest and involve children.
o Distraction
 This is a newer method of behavior management in which the patient is distracted from the
sounds and/or sight of dental treatment thereby reducing the anxiety.
 Objective is to relax the patient and to reduce anxiety during treatment.
 Use stories and fairy tales.
 Use slow instrumental music.
 Relaxation effect of music and the sound of music will eliminate unpleasant dental sounds like
the sound of handpiece.
 Choice of distraction is chosen by the patient; this will help child gain control over the
unpleasant stimulus and give them a feeling of being in a familiar environment.
 Child seeing the audiovisual presentation will have multisensory distraction as he will tend to
concentrate on the TV screen thereby, screening out the sight of dental treatment and the
sound of the program will help eliminate the unpleasant dental sounds like the sound of
handpiece.
 Placebo effect.
 Types:
 Audio distraction: Patient listens to audio presentation through headphones throughout the
course of the treatment.
 Audiovisual distraction: Patient is shown audiovisual presentation through television during the
entire treatment.
o Assimilation and coping
 Stress can act to increase pain perception while coping decrease it by a process called as
assimilation.
 Coping refers to cognitive and behavioral efforts made by individuals to master, tolerate or
reduce stressful situations.
 Behavioral coping: Efforts include physical or verbal activities in which the child engages to deal
with stress. These are readily visible to dentist, e.g. inquisitive question about the procedure.
 Cognitive coping: Efforts which involve manipulation of emotions. These are not visible to
dentist but these play a crucial role in child’s ability to deal with the treatment as well as
forming a positive outlook for future.
 Children taught coping skills like imagery, relaxation, selftalk demonstrated less stress during
treatment.
o Parental presence or absence
 Objective:
 To gain patient’s attention and compliance
 To avert avoidance behavior
 To establish authority
 Advantages of parental presence:
 Supporting and communicating with the child
 Very young patients
 Advantages of parental absence:
 Overcoming parental conditioning
 Avoiding communication interference
 Avoiding parental interference.
o Retraining
 A technique similar to behavior shaping, designed to fabricate positive values and to replace the
negative behavior.
 Children who require retraining approach the dental office displaying considerable
apprehension or negative behavior.
 This may be due to previous eventful dental visit or the effect of improper parental or peer
orientation or even due to the child’s experience in medical setting.
 The essence here is to locate the problem that it can either be avoided or distracted. The dentist
should try to build up a new relation with the child so that the child is able to forget his previous
thought process of dental clinic.
 If the child has had a previous eventful dental experience with some other dentist in another
operatory he will always have a fear and associate this clinic and dentist with the same so it is up
to the dental team to make his experience different so that he is retrained.
 Approaches:
 Avoidance (e.g. avoid extensive pulp therapy with pulp capping)
 De-emphasis and substitution (e.g. substitute high speed handpiece with spoon excavator)
 Distraction (e.g. distract the child with stories/activities/ audiovisual aids).

o Visual imagery
 Controlled day dreaming
 Subject is asked to imagine being in his favorite place/ performing his favorite activity and this
can act as a fantasy during his dental treatment.
o Flooding technique
 Described as behavior modification technique that eliminates a child’s attempts to avoid
experiences that he perceives to be undesirable, e.g. hand over mouth (HOM), physical
restraints.
o Voice control
 Given by Pinkham in 1985
 Sudden and firm commands that are used to get the child’s attention and stop the child from his
current activity.
 Soft, monotonous soothing conversation can also be used as it is supposed to function like music
to set the mood.
 In both cases what is heard is more important because the dentist is attempting to influence
behavior directly and not through understanding.
 The tone of voice and the facial expression of the dentist are also important as they function
like a mirror.
 Objectives:
 To gain the patient attention and compliance
 To avoid negative or avoidance behavior
 To establish authority.
 Indications: Uncooperative and inattentive patients
 Contraindications: Children who due to age, disability, mental or emotional immaturity are
unable to understand.
o Use of poetry and drawings
 Use of poetry
 This technique is employed in children above 7 years of age.
 The poem is written as a collective effort, the dentist contributing one line and the child next,
e.g. teeth are white, when they are bright; teeth do shine, when you clean; teeth are happy,
when they are healthy; teeth stay long, when they are strong.
 By selecting words like shine, happy and long it was easy to make the child discover clean,
healthy and strong. By doing this, it allows child to discover information about his teeth and
their well being.
 Use of drawings
 This technique was developed when it was discovered that with a little manipulation the forms
of the familiar teeth could be altered to look like common animals, birds and insects.
 This is useful for children of 3 to 5 years of age.
 Child is given a paper and pencil or a crayon and asked to draw some picture.
 Then slowly the child is asked to draw teeth and showed how teeth can be made to look like his
pets. He is then told that like his pets the tooth also have to be looked after and kept clean.
 Advantages
 It allows repetition without monotony.
 The rhyme and rhythm can be used to guide the child towards the information to be implied
 It gives the child a sense of achievement and increases self-esteem.
 Above all, it will destroy the preconception the child has formed about dentistry, the dentist and
the dental clinic.
o Hypnosis
 It is defined as a state of mental relaxation and restricted awareness in which subjects are
usually engrossed in their inner experiences such as imagery, are less analytical and logical in
their thinking and have enhanced capacity to respond to suggestions in an automatic and
dissociated manner.
 Uses
 To reduce nervousness and apprehension.
 To eliminate defense mechanisms that patients use to postpone dental work.
 To control functional or psychosomatic gapping.
 To prevent thumb sucking and bruxism.
 To induce anesthesia.
 Technique
 Patient preparation: It is important to gain informed consent from the parent and child in
accordance with the Children Act of 1989, which states that children’s wishes and feelings
should be incorporated into the decision concerning them. A simple verbal explanation of
hypnosis should be given and any questions that the parent or child may have are answered.
 The hypnotic induction: Hypnosis begins with an induction technique. The aim is to relax the
patient and to encourage them to focus. Induction essentially has three parts:
 Focus the subject’s attention on a stimuli of particular modality, which may be either visual like a
focusing light held in an out-stretched hand or body sensation like warmth, cold, tingling.
 Giving repeated instructions suggestive of relaxation and comfort.
 The coupling of focussing and suggestion to develop more powerful effect, e.g. with every
breath you feel more relaxed.
 Deepening: Deepening the hypnotic state involves the sequential use of three or four different
inductions.
 The use of a number of different inductions, focusing the child’s attention to different modalities
allows the clinician to assess how the child responds and select the most appropriate method.
 Posthypnotic suggestion: These suggestions given by the clinician during hypnosis are aimed at
altering the patient’s feelings, thoughts and behavior afterwards
 Altering patient after therapy: This is a process of bringing the patient out of the hypnotic state
and reorienting to their normal surroundings. Informing the patient that on counting from one
to five, their eyelid will become lighter and open on five count.

o Hand over mouth technique-write from short notes

o Protective stabilization
 Partial or complete immobilization of the patient is sometimes a necessary and effective way to
diagnose and deliver dental care to patients who need help in controlling their extremities.
 Immobilization is also useful for managing combative and resistant patients
 The parents must be informed and the consent must be documented, before immobilization is
used, they should have a clear understanding of the type of immobilization to be used, the
rationale, and duration of use.
 The idea is to immobilize the child benefiting and protecting both the child and the dentist.
 Indications
 A patient who requires diagnosis or treatment and cannot cooperate because of lack of
maturity.
 A patient who requires diagnosis or treatment and cannot cooperate because of mental or
physical disabilities.
 A patient who requires diagnosis or treatment and does not cooperate after other behavior
management techniques have failed.
 When the safety of the patient or practitioner would be at risk without the protective use of
immobilization.
 Contraindications
 A cooperative patient
 A patient who cannot be safely immobilized because of underlying medical or systemic
conditions
 As punishment
 It should not be used solely for the convenience of the staff.
Q4)Early childhood caries and its management in pediatric clinic

 Definition
o Davies1 (1998): Complex disease involving maxillary primary incisors within a month after
eruption and spreading rapidly to other primary teeth is called childhood caries.
 Classification
 Pathogenesis

 Clinical stages
 Primary etiological factors
o Dental plaque
o Mutans streptococci
o Infant feeding patterns
o Tooth brushing
o Salivary factors
o Sugars
o Oral clearance of carbohydrates
o Bovine milk
o Human milk
o Fluorides
 Secondary etiologic factors
o Immunological factors
o Tooth maturation and defects
o Race and ethnicity
o Acid fruit drink
o Socioeconomic status
o Dental knowledge
o Stress
 Prevention
o Early screening for signs of caries development, starting from the first year of life, could identify
infants and toddlers showing the risk of developing ECC and could also assist in providing
information of parents about how to promote oral health and prevent the development of tooth
decay.
o High-risk children should be targeted with a professional preventive program that includes
fluoride varnish application, fluoridated dentifrices, fluoride supplements, sealants, diet
counseling, and chlorhexidine.
o Prevention of ECC also requires addressing the social and economic factors that face many
families where ECC is endemic. The education of mothers or caregivers to promote healthy
dietary habits in infants has been the main strategy used for the prevention of ECC.
o There are three general approaches that have been used to prevent ECC; first is the community-
based strategy that relies on educating mothers in the hope of influencing their dietary habits as
well as those of their infants, second approach is based on the provision of examination and
preventive care in dental clinics, the third involves the development of appropriate dietary and
self-care habits at home.

 RAPIDD Scale
 The Readiness Assessment of Parents concerning Infant Dental Decay (RAPIDD) Scale was
developed to/assess a parent’s stage of change pre contemplative, contemplative, or action
with regard to his/her child’s dental health.
 This instrument based on the work by Prochaska and DiClemente, measures pro and con
parental beliefs about caring for their child’s teeth.
 Parents in pre contemplative stage show low openness and low health score whereas those in
action stage show high scores.
 Readiness assessment of parents concerning infant dental decay scale consisted of thirty-eight-
items with responses on five-point scale ranging from strongly agree to strongly disagree.
 The patient or primary caretaker was instructed to select a box under one of the five categories
after the interviewer read them the question in their native language.
 Each of the thirty-eight-items were placed into one of four constructs:
 Openness to health information
 Valuing dental health
 Convenience and change difficulty
 Child permissiveness.
 In order to categorize respondents as pre contemplators, contemplators, or action individuals
the responses to the questions within each construct were summed, these slimmed values were
ranked, and percentiles were calculated for each individual within each construct.
 The RAPIDD instrument is a tool that is used to determine parent’s stage of change for their
child’s oral health.
 Once a particular stage of change has been established the counselor then determines the best
approach to move into next stage.

 Community based education

 The goal of education is to increase the knowledge of mothers about ECC, and to improve the
dietary and nutritional habits of infants and mothers.
 It is assumed that an increase in the knowledge of mothers or caregivers will influence their
self-care habits and dietary practices and, in turn, improves the dietary and oral hygiene habits
of infants leading to the prevention of ECC.
 Positive changes in infant feeding practices have been found to be modest, even when a
community educational program was designed and implemented in collaboration with members
of a high ECC risk community.

 Prevention of transmission of cariogenic bacteria

 There is evidence that cariogenic bacteria are transmitted from mothers to their infant and
control
 Professional and home based preventive approaches
 Some of the professionally applied and home-based approaches that could be employed in the
prevention of ECC are listed based on risk status (Table 41.1).
  Professional treatment for early childhood caries ranges from diet counseling to the
prosthodontic rehabilitation of patient.
 Restorations are accomplished by GIC and composites, endodontic therapy is done as indicated
followed by placement of crowns and grossly decayed teeth are extracted followed by
placement of space maintainers
 The use of fluoride is done according to the level of fluoride in water.

 Barriers in early childhood caries

o Any proposal to improve social, mental and physical health of children cannot be successful
without adequate funding, political leadership and support.
o Some of the potential barriers in providing optimum care for children are:
 Lack of involvement and commitment from dental and other health organizations.
 The dental community lacks a shared vision of the definition of the problem, how to prevent it
and who is responsible for planning and implementation.
 There is no integrated plan to fight the social, economic and nutritional issues facing people in
low socioeconomic group.
 There is weak direct support for research on epidemiology, etiology and prevention of ECC.
 Dental health is not a priority of most programs and insurance packages.

Q5)Describe commonly occurring gingival diseases in children

 Plaque induced gingivitis

o Gingivitis is also regarded as the most common periodontal disease in children, with the primary
etiology as plaque.
o In poor oral hygiene, food debris, plaque and microorganisms also accumulate and the process
of inflammation starts.
o This leads to gingivitis, which, if not taken care of can progress to gradual destruction of
supporting soft and hard tissues of the teeth.

 Gingivitis due to habit

o Gingivitis is a very common finding in the maxillary anterior region in individuals with mouth
breathing habit.
o This habit is common among young children and it predisposes to dryness of the gingival when
the lubricating effect of saliva is absent.

 Eruption gingivitis
o This is gingival inflammation occurring around an erupting permanent tooth.
o During the eruptive phase, the epithelium displays degenerative changes at the site of fusion
between dental and oral epithelia.
o These areas are vulnerable to plaque accumulation and sets up a bacterial reaction and since
the child may be experiencing discomfort which will therefore make tooth brushing difficult.
o This will lead to plaque accumulation and inflammation.

 Infective gingivitis
o These are of viral or bacterial origin and caused by viruses or bacteria which are normal
commensals of the oral cavity becoming virulent when present in high proportions.

 Herpetic gingivostomatitis
o It affects both the gingiva and other parts of the oral mucus membrane.
o It is commonly seen in children less than three years of age.
o It is caused by the herpes simplex virus type 1.
o Infection usually follows bouts of childhood fevers such as malaria, measles and chickenpox.
o The onset of is preceded by a prodromal period with symptoms such as irritability, malaise,
vomiting and fever and the appearance of small vesicles which rupture to reveal small yellowish
painful ulcers with erythematous margins.
o The condition is associated with drooling of saliva, inability to chew and swallow and the child
may become increasingly uncooperative during tooth brushing.
o The condition is self-limiting and the management is to encourage bed rest, plenty of fluid and
maintenance of good oral hygiene through gentle debridement.
o Analgesics are prescribed to relieve the pain and application of a mild topical anesthetic gel has
been found useful in young children.

 HIV associated gingivitis

o Oral manifestations of human immunodeficiency virus (HIV) disease are an important part of the
natural history of HIV disease.
o Hairy leukoplakia, pseudomembranous candidiasis, Kaposi sarcoma, non- Hodgkin’s lymphoma,
linear gingival erythema, necrotizing ulcerative gingivitis and periodontitis were common lesions
seen in patients with HIV infection and AIDS.

 Acute Necrotizing Ulcerative Gingivitis

o Acute necrotizing ulcerative gingivitis (ANUG) used to be known as “trench mouth” because it
was seen frequently in soldiers occupying trenches during the World War I and was also called
“Vincent’s angina”, after the French physician Henri Vincent (1862-1950).
o This is an acute multiple bacterial infection of the gingiva.
o The lesion starts at the interdental papillae, spreading along the gingival margins and if
untreated, starts to destroy the underlying connective tissue and bone.
o There is a characteristic necrotic odor associated with this condition and the mouth becomes
progressively painful with sloughing off of the necrotic ulcers on the gingiva.
o The ulcers become erythematous and bleed following minimal trauma, especially tooth
brushing.
o Regional lymph nodes are enlarged and tender.
o If untreated, destruction of the soft tissues of the mouth and cheek and facial bones result, a
condition referred to as Cancrum Oris or Noma.
o Predisposing factors include poor oral hygiene, malnutrition, depressed immunity and long-term
hospitalization.
o The bacteria implicated earlier were Fusobacteria fusiformis and Borrelia vincentii.
o The treatment of choice is regular gentle debridement of the gingiva and irrigation with an
oxidizing antiseptic such as hydrogen peroxide, until the infection clears.
o Diet and oral hygiene counseling is also useful and this should be followed up to ensure speedy
healing.

 Malnutrition induced gingivitis

o Adolescence is a time of rapid growth, independent food choices and food fads. It is also a
period of heightened caries activity as a result of increased intake of cariogenic substances and
inattentiveness to oral hygiene procedures.
o There is evidence that different foods, such as dietary proteins and carbohydrates can affect the
buffering capacity of saliva and protein deficiency influences markedly the composition of whole
saliva in man.

 Pubertal gingivitis
o A higher amount of plaque has also been found in the primary dentition compared with the
mixed and permanent dentitions, but the prevalence and severity of inflammation of the oral
tissues (gingivitis and periodontitis) is low in healthy young children and gradually increases with
increasing age.
o Pubertal gingivitis has been seen with increasing frequency in young teenagers and has been
ascribed to the “rush” of sex hormones which also affects the reaction of tissues to
corticosteroids.
o The condition ranges from localized inflammation of one or two papillary gingiva, also called
‘gingival epulis’, to generalized marginal gingivitis.
o This condition is not severe if plaque is well controlled.Most cases resolve as soon as
debridement is commenced.

 Drug induced gingivitis

o Drug-induced gingival enlargement (DIGE) and gingivitis are side effects and unwanted
outcomes of antiepileptic therapy with phenytoin, or immunosuppressive therapy with systemic
cyclosporine.
o Where the oral hygiene is good and food debris and plaque are not allowed to accumulate, this
side effect of anticonvulsive therapy is not so significant.
 o Treatment includes alternation of drug followed by meticulous oral prophylaxis and in severe
cases where the enlarged tissue interferes with function and esthetics, surgical resection is
advised.
 Plasma cell gingivitis
o Plasma cell gingivitis is characterized by diffuse and massive infiltration of plasma cells into the
subepithelial gingival tissue.
o It is a rare benign inflammatory condition with no clear etiology, but an exaggerated response to
bacterial plaque, immunological reaction to allergens in food such as strong spices, medications,
toothpaste or herbs.
o In affected children, standard professional oral hygiene procedures and nonsurgical periodontal
therapy including antimicrobials are associated with marked improvement of clinical and patient
related outcomes.
o Several factors such as genetics, systemic conditions, medications, diet and individual host
response to infection have been considered as etiology of gingivitis in children.

Q6)Importance of pediatric restorative dentistry.Discuss modifications in preparation of cavities in

deciduous teeth

 Modifications of cavity preparation in primary teeth

o Owing to multiple anatomical, morphological and histological differences between the primary
and permanent teeth, the cavity preparation among the two also varies greatly.
o Some of the common modifications in case of primary teeth are:

 Class I cavity preparation

 Due to narrow occlusal table the buccolingual dimensions of occlusal part of cavity are reduced.
 The chance of inadvertent pulp exposure is minimized by limiting the cavity to 0.5 mm pulpal to
enamelo-dentinal junction.
 Maximum intercuspal cavity width should be limited.
 Walls of preparation should be parallel or slightly convergent occlusally.
 The central pit of lower first primary molar usually becomes carious before mesial pit, which
decays less frequently.
 The outline form should be limited to central pit; it is adjacent buccal and lingual grooves and
distal triangular fossa.
 It is advisable not to cross ridge to join mesiobuccal and mesiolingual cusp because of its
proximity to pulp horns.
  Pulpal roof in primary teeth is concave as compared to permanent teeth where it is nearly flat so
cavity floor should be kept little concave.
 Depth should be just 0.5 mm into the dentin so the total depth from the cavosurface should not
be more than 1.5 to 2.0 mm.
 Include all pits and fissures and lateral extension should be such so as to just accommodate the
amalgam condenser.
 Flat or slightly concave pulpal floor with rounded line and point angles.
 While extending laterally on the buccal side, bur should be kept parallel to the buccal surface
and while extending lingually, bur should be parallel to lingual surface. This makes the occlusal
convergence without much cutting.

 Class II cavity preparation

 Occlusal box: Same principles applied as for class I but extension of outline is different for
different teeth.
 For all first primary molars: Extend the occlusal box half the way mesiodistally in a dovetail like
fashion.
 For mandibular second primary molars: All pits and fissure should be involved.
 For maxillary second primary molars: Nearest occlusal pit should be involved. Oblique ridge
should not be involved until undermined by the caries.

 Sharp cavosurface angle.

 Rounded/beveled/grooved axiopulpal line angle in order to reduce stresses on this point and to
allow greater bulk of material.
 Isthmus width should be ½ the intercuspal width.
 Proximal box:
 Greater width of the proximal box in order to keep the cavity margins in the self-cleansing areas.
 More buccolingual extension of the gingival floor/seat
 Occlusal convergence
 Axial wall should follow the contour of the external surface.
 The direction of enamel rods at the cervical line is either horizontal or occlusal and therefore
gingival bevel is not given while preparing class II cavity.
 Retention grooves should not be given.
 The distance between mesial surface of lower 1 st mandibular molar and pulp horn is only 1.6
mm. Although 1.5 mm depth has been suggested for class I cavity, establishing this depth may
lead to pulp exposure

Q7)Morphogenic and histologic differences between deciduous and permanent teeth along with
applied aspect
Q8)Classify space maintainer and discuss indications,contraindications,advantage and disadvantage of
each

 Band and loop space maintainer

o Indications
 It is usually indicated for preserving the space created by the premature loss of single primary
molar.
 Bilateral loss of single primary molar before eruption of permanent incisors. This is because the
developing succedaneous tooth buds are placed lingually to permanent incisors so other space
maintainers like lingual arch can lead to obstruction of these teeth.
 It is also indicated when 2nd primary molar is lost after the eruption of 1st permanent molar.
o Advantages
 Construction is easy and faster
 Few appointments by patient
 Many modifications are possible
o Disadvantages
 Cannot stabilize the arch
 Nonfunctional
 Slippage of loop by masticatory forces
 Cannot be used for multiple loss of teeth
 Most of the time primary 2nd molar (E) is lost before eruption of premolar

 Lingual arch space maintainer

o Indications
 The appliance is usually indicated to preserve the space created by multiple loss of primary
molars when there is no loss of space in the arch.
 The use of the lingual arch is a good preventive measure, since it helps in maintaining the arch
perimeter by preventing both mesial drifting and lingual movement of the molar teeth and also
lingual collapse of the anterior teeth.
 Bilateral loss of primary molars after eruption of lower lateral incisors.
 Unilateral loss of primary molars after eruption of lower lateral incisors.
 Minor space regaining
o Advantages
 Many modifications are possible
 Can also be used to regain space
 Arch holding space maintainer.
o Disadvantages
 Construction is difficult
 More chances of distortion of appliance by tongue pressure
 May cause unwanted movements

 Nance palatal arch space maintainer

o Indications
 Nance palatal arch may be used in maintaining the maxillary 1st permanent molar positioning
when there is bilateral premature loss of primary teeth with no loss of space in arch and a
favorable mixed dentition analysis.
o Advantages
 Arch stabilizing.
o Disadvantages
 May cause tissue hyperplasia
 Irritation to palatal tissues
 Pressure effects
 Cannot be used in patients allergic to acrylic.

 Transpalatal arch
o Indications
 The best indication for transpalatal arch is when one side of arch is intact and several primary
teeth on the other side are missing.
 It is also indicated when primary molars are lost bilaterally.
 The appliance is designed to prevent the molars from rotation.
 In arch expansion.
o Advantages
 Used in multiple unilateral loss
 Can be used for expansion
o Disadvantages
 Rotation of molars
 Both molars may tip together.

 Distal shoe space maintainer

o Indications
 When the second primary molar is extracted or lost before the eruption of 1st permanent
molar.
o Contraindications
 Inadequate abutments due to multiple losses of teeth.
 Poor oral hygiene
 Lack of parent and patient cooperation.
 Medically compromized patients like patients with congenital heart disease, kidney problems,
juvenile diabetes, history of rheumatic fever, generalized debilitation and hemophiliacs.
 Congenitally missing 1st permanent molar
o Advantages
 Only space maintainer, which can be used if there is premature loss of primary 2nd molar before
eruption of permanent molars.
o Disadvantages
 Can cause deviation of permanent tooth bud
 May permit tipping if not placed properly
 Interfere with epithelialization of socket
 Can cause infection
 Can only be used in specific patients
 Retention is not good
 Construction is difficult.

 Removable space maintainers

o Indications
 Esthetics is of importance.
 The abutment teeth cannot support a fixed appliance.
 A cleft palate patient.
 Child has reached a mental age of 2½ years.
 Permanent teeth are not fully erupted for adaptation of bands.
 Multiple loss of deciduous tooth.
o Contraindications
 Lack of patient parent cooperation.
 If the child has not attained a mental age of 2½ years.
 If the patients are allergic to acrylic materials.
 Epileptic patients.
 Children with possible caries activity.
o Advantages
 Easy to clean and permit maintenance of proper oral hygiene.
 Restore vertical dimension.
 Help in mastication.
 Post insertion check up is easy.
 Stimulate eruption of underlying tooth.
  Band construction and elaborate skills and instrumentation are not required.
 Alterations can be made without changing the appliance.
o Disadvantages
 May be lost or broken by the patient.
 Cannot be used in uncooperative patients.
 Patient may not wear them.
 Lateral jaw growth may be hampered.
 May cause irritation and allergy to underlying tissues

Q9)Define and classify oral habits.etiology,clinical features and management of thumb sucking
 Definition
o Boucher OC defined habit as a tendency towards an act or an act that has become a repeated
performance, relatively fixed, consistent, easy to perform and almost automatic
 Classification of oral habits
o Useful and harmful habits
o Useful Habits
 Should include all those habits of normal function such as correct tongue position proper
respiration and deglutition.
o Harmful Habits
 All those that exert perverted stress against the teeth and dental arches, e.g. mouth breathing,
tongue thrusting.
o Compulsive and noncompulsive
o Compulsive Habit
 Acquired as a fixation in the child to the extent that he retreats to the practice whenever his
security is threatened.
o Noncompulsive Habit
 Children appear to undergo continuing behavior modification, which permit them to release
certain undesirable habit patterns and form new ones which are socially accepted.
o Primary and secondary habits
 Secondary habit is a habit that is due to a supplemental problem, e.g. large tongue causes
tongue thrusting habit.
o Meaningful and empty habits
o Meaningful Habit
 Habit with a deep-rooted psychological problem.
o Empty Habit
 Meaningless habit that can be treated easily by a dentist using reminder therapy.
o Normal and abnormal habits
o Normal Habits
 Those habits that are deemed normal by children of a particular age group.
o Abnormal Habits
 Those habits that are pursued after their physiological period of cessation.
o Physiologic and pathologic habits
o Physiologic Habits
 Physiologic habits are those that are required for normal physiologic fractioning, e.g. nasal
respiration, sucking during infancy.
o Pathological Habits
 Habits that are pursued due to pathological reasons such as adenoids and nasal septal defects
that may lead to mouth breathing.
o Retained and cultivated habits
o Retained Habit
 Those that are carried over from childhood into adulthood.
o Cultivated Habit
 Those cultivated during the socio-active life of an individual.

 Etiologic factors for thumb sucking

o Socioeconomic Status
 In high socioeconomic status the mother is in a better position to feed the baby and in a short
time the baby’s hunger is satisfied.
 Whereas in the low socioeconomic group mother is unable to provide sufficient breast milk to
the infants, hence in the process the infant suckles intensively for a long time thereby
exhausting the sucking urge.
 This theory explains the increased incidence of thumb sucking in industrialized areas when
compared to rural area.
o Working Mother
 The sucking habits is commonly observed to be present in children with working parents
because such children are brought up in the hands of caretaker and develop feelings of
insecurity.
o Number of Siblings
 The development of the habit can be related to the number of siblings because more the
number increases the attention meted out by the parents to the child gets divided.
 A child who feels neglected by the parents may attempt to compensate his feelings of insecurity
by means of this habit.
o Order of Birth of the Child
 Later the sibling ranks in the family, greater is the chance of having an oral habit.
o Social Adjustment and Stress
 Digit sucking has also been proposed as or emotionally based behavior.
o Age of the Child
 The time of appearance of digit sucking habit has significance.
 In the neonate: Insecurities are related to primitive demands as hunger
 During the first weeks of life: Related to feeding problems
 During the eruption of the primary teeth: It may be used to relieve teething
 Management
o Preventive Treatment
 Firstly, feed the child whenever he is hungry and let him eat as much as he wants.
 Secondly, feed the child the natural way; importance of breastfeeding is primarily psychological
and secondarily nutritive.
 Thirdly, never let the habit to be started, the practice must be discontinued at its inception.
 Use of a dummy/Pacifier: Encouraging the baby to suck a dummy instead of his thumb can
prevent him from acquiring the habit.
o Psychological Therapy
 Nagging, scolding or frightening the child should be avoided since this could cause negativism
and tend to make him resort to the habit.
 b-hypothesis or Dunlop’s hypothesis:
 He believed that if a subject can be forced to concentrate on the performance of the act at the
time he practices it, he could learn to stop performing the act.
 Forced purposeful repetition of habit eventually associates with unpleasant reactions and the
habit is abandoned.
 The child should be asked to sit in front of the mirror and asked to observe himself as he
indulges in the habit.
o Six Steps in Cessation of Habit (Larson and Johnson)
 Step 1: Screening for psychological component.
 Step 2: Habit awareness.
 Step 3: Habit reversal with a competing response.
 Step 4: Response attention.
 Step 5: Escalated DRO (differential reinforcement of other behaviors).
 Step 6: Escalated DRO with reprimands. (Consists of holding the child, establishing eye contact
and firmly admonishing the child to stop the habit.
o Three Alarm System: (Norton and Gellin—1968)
 A chart is designed with days of the week and blank spaces.
 When the child engage in his habit he is told to wrap the digit he sucks with coarse adhesive
tapes.
 The child feels the tape in his mouth it is the first alarm and this reminds him to stop the habit.
 The elbow of the arm with the offending thumb is firmly wrapped in two inch elastic bandage
safety pins are placed at proximal and distal ends of bandage and one safety pin is placed
lengthwise at the mesial end of the elbow and when the child sucks the thumb again, the closed
pin on the medial end of elbow, mildly jabbing the elbow indicates second alarm.
 If the habit persist, the bandage is tightened this is the final or third alarm, which will definitely
remind the child of the habit.
o Chemical Treatment
 It is the least effective method. Bitter and sour chemicals have been used over the thumb to
terminate the practice but with very minimal success, e.g. quinine, asafetida, pepper, caster oil,
etc.
o Mechanical Therapy or Reminder Therapy
 Extraoral approach:
 Mechanical restraints applied to the hand and digits like splints, adhesive tapes.
 Thumb guard is the most effective extraoral appliance for control of the habit.
 Intraoral approach:
 The early years of life culminating in the oedipal period at the age of 5 years are inappropriate
psychologically for this approach therefore the optimal time for appliance placement is between
the ages of 3 and 4½ years preferably during spring or summer, when the child’s health is at its
peak and the sucking desires can be sublimated in outdoor play and social activity.
 Following appliances are recommended:
 Removable or fixed palatal crib:
 It breaks the suction force of the digit on the anterior segment, reminds the patient of his habit
and makes the habit a nonpleasurable one.
 Oral screen:
 Oral screen is a functional appliance introduced by Newell in 1912.
 It produces its effects by redirecting the pressure of the muscular and soft tissue curtain of the
cheeks and lips.
 It prevents the child from placing the thumb or finger into the oral cavity during sleeping hours.
 Hay rakes:
 Mack (1951) advocated the use of dental appliance in children over 3½ years of age who are
persistent thumb suckers.
  The device was called hay rake as it was designed with a series of fence like lines that prevented
sucking.
 Blue grass appliance:
 Developed by Bruce S Haskell (1991).
 It is a fixed appliance using a Teflon roller, together with positive reinforcement.
 Used to manage thumb sucking habit in children between 7 and 13 years of age.
 The patient believes that he has acquired a new toy to play with.
 Instructions are given to them to roll the roller instead of sucking the digit.
 Quad helix:
 The quad helix is fixed appliance used to expand the constricted maxillary arch.
 The helixes of the appliance serve to remind the child not to place the finger in the mouth.
 Modified blue grass appliance:
 This is a modification of the original appliance with the difference being that this has two rollers
of different colors and material instead of one.
 If the patient tries to suck on his thumb the suction will not be created and his thumb will slip
from the rollers thus breaking the act.
o Current strategies
 Increasing the arm length of the night suit :
 This is useful in children who sincerely want to discontinue the habit and only perform during
their sleep.
 The arms of their night suit are lengthened so that they cannot reach the thumb during night.
 Thumb-home concept:
 This is the most recent concept. In this a small bag is given to the child to tie around his wrist
during sleep and it is explained to the child that just as the child sleeps in his home, the thumb
will also sleep in its house and so the child is restrained from thumb sucking during night.
 Thumb sucking book :
 ‘The Little Bear who Sucked his Thumb’ is a book directed at children, for children.
 The book has been written and illustrated by Dr Dragan Antolos, an experienced dentist with a
special interest in thumb sucking habits in children.
 He deals first-hand in management of dental, social, and functional problems which can arise
with persistent thumb sucking.
 The book and chart are a noninvasive and effective strategy for stopping thumb sucking
 My special shirtTM :
 This helps in minimizing the damage of finger sucking by providing a number of tools to address
the habit in a phased manner.
 This shirt keeps the child busy thereby avoiding the habit.
 By working as a team your child will gain confidence, balance emotions and stop their
dependence on need to suck.

Q10)Classify Elli’s fracture of anterior teeth.Write in detail the various treatment modalities for Elli’s
class III fracture
 Classification
 Clinical features of Elli’s class III fracture
o This occurs when there is a fracture of enamel, dentin along with exposure of pulp (Fig. 63.9).
o This usually presents as a fractured segment of tooth with frank bleeding from the exposed
pulp.

 Treatment
o The type of treatment will depend upon the extent and time of pulp exposure.
o When the exposure is small and pulp has not been exposed for more than 4 to 5 minutes then it
is advisable to do pulp capping.
o When the exposure is large and pulp has been exposed for more than 5 minutes then it is ideal
to do pulpotomy/RCT.
o Formocresol pulpotomy
o Two visit devitalization pulpotomy
Q11)Child management in dental office.Various parental attitudes and their effects on child behavior
 Factors influencing child’s behavior in dental office
o Wright summarized the following factors:
 Medical history
 Maternal anxiety
 Family and peer influence
 Dental office environment
 Growth and development
 Personal factors
 Environmental factors
 Other variables.
 Medical history
 When studying a child’s medical experience, it is the emotional quality of past visits rather than
the number of visits to the physician that is significant.
 If the patient views a physician favorably, then the child is likely to have less apprehension when
visiting the dentist.
 Fears can thus be transferred from one situation to another; hence preformed attitude
concerning health care can be of prime importance.
 Maternal anxiety
 In past years, it has been customary for mothers more often than fathers to accompany children
on a visit to the dentist, therefore, maternal anxiety was considered important. Highly anxious
mother had a negative influence on the child.

 Family and peer influence

 Socioeconomic status of the family directly affects child’s attitude toward the values of the
dental health process.
 Those of low socioeconomic class, below average education, have a tendency to attend dental
needs when symptom dictates.These families harbor anxiety from dental treatment and these
children take on these fear and tend to be less cooperative.
 On the other hand if financial and educational means are ample, families value good dental
health easily established in preventive program.

 Dental office environment

 Since the child may enter the dental office with some fear, the first objective of the dentist
should be to put the child at his ease and make him realize that his experience is not unusual
 The following factors related to the dental office which influence child’s behavior:
 Waiting room should be made in respect to home environment.
 Make the reception room comfortable, so that the room is not foreign to them.
 Have library with books for children of all ages.
 Simple but sturdy toys must be kept to amuse very small children.
 A handy record player with well-chosen records will provide comfort for a frightened child.
 Appointment cards and announcements should be made attractive to children.
 A sketch of some cartoon on card helps.
 Operating room may be made more appealing to the child if a few pictures on the wall are
suggestive of child at play.
 A portrait of a carefree and laughing child is good.
 Have an assistant skilled in making animals object out of cotton rolls.
 Try to avoid having child patient, see adults in pain or sight of blood on others.

 Growth and development

 A child’s chronological age plays a significant role in growth and developmental patterns.
 Younger the child, more atypical will be the response. The intellectual age of 3 years signifies
immaturational readiness to accept dental treatment. Different age groups will show different
behavior patterns

 Personal factors
 Temperament, general fearfulness are some of the personal characters which are known to
influence the behavior of the child.
 Although these are to influence the child’s behavior the most, personal characters are also
affected by the environmental factors.
 Environmental factors
 Various environmental factors like age of the child, socioeconomic status, family situation,
frequent exposure to invasive medical care, past experience of operative dental care, etc. have
been identified to influence the child’s behavior.
 However, parental dental fear has been noted to be the most influencing factor amongst all
environmental factors.
 Other variables
 Stephen Wei explained that many other variables affect the child in dental office like
socioeconomic status, culture, sex, sibling relation, number of children, presence of parent and
attitude of dentist.

 Maternal influence on children’s behavior in dental situation

o The parent-child relationship was termed as ‘one-tailed’ by Bell because parental characteristics
have a unilateral influence on the developing child.
o Most of the characters of the child like behavior, personality, anxiety and reaction to stress are
directly influenced by the parent’s characters.
o Both mother and the father play an important role in child’s psychologic development but more
emphasis is placed on mother. This is because mother generally has intimate contact with the
child since prenatal period.
o The mother child relationship falls into two broad categories:
 autonomy vs control,
 hostility vs love.
o Mothers either have control over the child’s behavior or they give the child freedom/autonomy.
The other category includes loving/caring or hostile mothers.
o Bayley and Schaefer summarized the maternal attitude as:
 Effect of parental presence in operatory
o As children get older and develop emotional independence, they themselves prefer they have
their parent remain in the waiting room.
o If a child exhibits uncooperative behavior, the presence of the parent will sometimes lend
support to this type of behavior and it can also limit the range of behavior control techniques of
the dentist.
o Parent should not, however, be routinely excluded from the operatory as there are certain
occasions when their presence is desirable and actually enhances positive behavior on the part
of child.
o Frankl found that children in age group of 42 to 49 months are benefited from mother’s
presence.
o Young children are more prone to a number of fears, like fear of unknown and hence exhibit
anxiety during short term separation and the degree of response is affected by length of
separations.
 Parental behavior in dental office
o Parental behavior in the dental office also plays an important role in child management.
o Parents must understand that once the child is in the office, the dentist knows how to prepare
the child emotionally for the necessary treatment.
o If a parent is invited into the treatment room he must assume the role of a passive guest and
either sit or stand away from the chair.
 Parent-child separation
o Wright noted that excluding the parent from the operating room could contribute in controlling
the child’s positive behavior.
o Most dentists probably are more relaxed and comfortable when parent remains in the
reception area and their action has positive effect on children’s behavior.
o Some factors which influence the dentist not to include parent in the operatory are:
 Parents often repeat orders, creating an annoyance for both dentist and child patient.
  Parents impose orders, becoming a barrier to the development of rapport between the dentist
and child.
 Dentist is unable to use voice intonation in the presence of the parent because he may be
offended.
 Child divides attention between parent and dentist.
 Dentist’s attention is divided between parent and child.

Q12)Discuss the modification required for class II cavity preparation in primary mandibular second
molar for silver amalgam restoration
 Class II cavity preparation
o Occlusal box: Same principles applied as for class I but extension of outline is different for
different teeth.
 For mandibular second primary molars: All pits and fissure should be involved.
 Sharp cavosurface angle.
 Rounded/beveled/grooved axiopulpal line angle in order to reduce stresses on this point and to
allow greater bulk of material.
 Isthmus width should be ½ the intercuspal width.
o Proximal box:
 Greater width of the proximal box in order to keep the cavity margins in the self-cleansing
areas.
 More buccolingual extension of the gingival floor/seat
 Occlusal convergence.
 Axial wall should follow the contour of the external surface.
 The direction of enamel rods at the cervical line is either horizontal or occlusal and therefore
gingival bevel is not given while preparing class II cavity.
 Retention grooves should not be given.
 The distance between mesial surface of lower 1 st mandibular molar and pulp horn is only 1.6
mm. Although 1.5 mm depth has been suggested for class I cavity, establishing this depth may
lead to pulp exposure and hence Rodda recommended 1 mm of depth.

Q13)Write briefly on gum pads in occlusion. Discuss various changes in dental arches from birth to
adolescence
 Predentate period
o This is the period soon after birth. During this, the neonate has no teeth but the relation of the
gum pads is of equal importance.
o The alveolar process at the time of birth is called the gum pads
o They are horseshoe shaped pads that are pink, firm and covered with a layer of dense
periosteum.
o They are divided into two parts (labiobuccal and lingual) by dental groove. The gum pad is
further divided into 10 segments by transverse groove; each segment has one developing tooth
sac.
o A very important landmark in gum pads is lateral sulcus, which is the transverse groove between
canine and 1st molar. This is helpful in predicting inter-arch relation at a very early stage.
o The maxillary gum pad is wider and longer than the mandibular thus when they are
approximated, there is a complete overjet all around.
o The only contact that occurs is around the molar region while space exists in anterior region.
This is called infantile open bite, which is considered normal and helpful during suckling.
 Deciduous dentition period
o The initiation of primary teeth occurs during first six weeks of intrauterine life and the first
primary tooth erupts at the age of 6 months.
o The individual variations apart, it takes around 2½ to 3½ years for all the primary teeth to
establish their occlusion.
o Primate spaces : Exist between the maxillary lateral incisors and the canines (present mesial to
maxillary deciduous canines) and mandibular canines and 1st deciduous molars (present distal
to mandibular deciduous canines). These spaces are also called as anthropoid or simian spaces
as they were initially found in our ancestral simian species
o Physiologic spaces : Present in between all the primary teeth and play an important role in
normal development of the permanent dentition. The total space is 4 mm in the maxillary arch
and 3 mm in the mandibular arch.]
o Nonspaced dentition : This dentition is highlighted by lack of space between primary teeth
either due to small jaw or larger teeth. This type of dentition usually indicates to crowding in
developing permanent dentition.
o Terminal planes
 The mesiodistal relation between the distal surfaces of maxillary and mandibular 2nd deciduous
molars is called as terminal plane. This is of three types
 Flush terminal plane:
 The distal surfaces of the deciduous 2nd maxillary and mandibular molars are in a straight plane
(flush) and therefore situated on the same vertical plane.
 It is usually most favorable relationship to guide the permanent molars into class I
 Mesial-step terminal plane:
 The distal surface of the deciduous 2nd mandibular molar is more mesial to that of the
deciduous 2nd maxillary molar.
 Invariably, this guides the permanent molars into a class I relationship.
 However, a few can proceed into half cusp class III during molar transition and further into full
class III relationship with continued mandibular growth.
 Distal-step terminal plane:
 The distal surface of the deciduous 2nd mandibular molar is more distal to that of the
deciduous 2nd maxillary molar.
 This relationship is unfavorable as it guides the permanent molars into distal occlusion

o Anterior teeth relationship

 Overbite:
 It is the distance, which the incisal edge of the maxillary incisors overlaps vertically past the
incisal edge of the mandibular incisors.
 The primary incisors erupt in a deep overbite which is corrected by eruption of posterior teeth
around five years of age. The average overbite in the primary dentition is 2 mm.
 Edge-to-edge bite:
 When the incisal edges of the two incisors are in the same plane. This is also called as a zero
overbite.
 This is most common due to attrition, lengthening of ramus and downward-forward growth of
mandible.
 Overjet:
 It is the horizontal distance between the lingual aspect of the maxillary incisors and the labial
aspect of the mandibular incisors when the teeth are in centricmocclusion. The average in
primary dentition is 1 to 2 mm.
o Canine relationship
 The relationship of the maxillary and mandibular deciduous canines is one of the most stable in
primary dentition.
 Class I: The mandibular canine inter digitates in embrasure between the maxillary lateral incisor
and canine (Fig. 16.10).
 Class II: The mandibular canine inter digitates distal to embrasure between the maxillary lateral
incisor and canine (Fig. 16.11).
 Class III: The mandibular canine inter digitates in any other relation (Fig. 16.12).

o Arch dimensions
 These were first measured by Zsigmondy in 1890.
 Frank and Baume later described the changes which can take place in arch dimensions by loss of
primary teeth and during the development of occlusion (Fig. 16.13).
 Arch size: Size of the primary dental arch is the arch width between primary canine and 2nd
molars.
 Arch length: Measured from the most labial surface of primary central incisor to canine and to
2nd primary molars.
 Arch circumference: It is determined by measuring the length of curved line passing over the
incisal edges and buccal cusps of teeth from the distal surfaces of primary 2nd molar around the
arch to the distal surface of 2nd primary molar on the other side.
 Arch width: Bicanine or bimolar width is called the arch width.

 Mixed dentition period

o The period during which both the primary and permanent teeth are present in the mouth
together is known as mixed dentition.
o The permanent teeth erupting in place of previous deciduous teeth are the successional teeth,
whereas those erupting posteriorly to the primary teeth are called the accessional teeth.
o This phase begins at around 6 years with the eruption of 1 st permanent molars and lasts till
about 12 years of age.
o First transitional period
 This is characterized by emergence of 1st permanent molars and exchange of deciduous incisors
with permanent incisors.
 Emergence of 1st permanent molars:
 The anteroposterior relation between the two opposing 1st molars after eruption depends on
their positions previously occupied within the jaws, sagittal relation between the maxilla and
mandible and occlusal relationship is established by the cone and funnel mechanism with the
upper palatal cusp (cone) sliding into the lower occlusal fossa (funnel).
 The mandibular molars are the first to erupt at around 6 years of age. Their position and
relation is dependent on the relation of 2nd deciduous molars as they are guided into dental
arch by the distal surfaces of these teeth (Fig. 16.14).
 If the 2nd deciduous molar is in flush terminal plane, then the erupting permanent molar will
also be in the same relation. For this, to change into class I relation the molar has to move 2 to 3
mm in a forward direction, this is accomplished by:
 Early mesial shift:
 The eruptive forces of 1st permanent molars are strong enough to push the deciduous molars
forward in the arch thereby utilizing the primate spaces and thus establishing class I relationship
 Late mesial shift:
 Many children lack primate spaces and have a nonspaced dentition and thus erupting
permanent molars are not able to establish Class I relation even as they erupt.
 In these cases, the molars establish Class I relation by drifting mesially and utilizing the Leeway
space after exfoliation of deciduous molars and this is called late mesial shift (Fig. 16.16).
 If the 2nd deciduous molar is in mesial-step terminal plane, then the erupting permanent molar
will directly erupt in Class I relation. But if further growth occurs or if there is more utilization of
spaces the relation can even change to Class III.
 If the 2nd deciduous molar is in distal-step terminal plane, then the erupting permanent molar
will erupt into Class II relation. If further growth occurs or there is more utilization of spaces
then it can lead into end on molar relation.
 Exchange of incisors:
 The deciduous incisors are replaced by permanent incisors during this phase.
 This period of transition is from 6½ to 8½ years.
 The permanent incisors are larger as compared to their primary counterparts and thus require
more space for their alignment. This difference between space available and space required is
called the incisor liability (Fig. 16.17).
 This is 7 mm for maxillary arch and 5 mm for mandibular arch.
 Some of the factors that help in alignment of incisors by gaining space are:
 Utilization of interdental spacing of primary incisors: Averages 4 mm in the maxillary arch and 3
mm in the mandibular arch.
 Increase in intercanine arch width: This occurs as the child grows. In males, it is 6 mm for maxilla
and 4 mm for mandible whereas in females, it is 4.5 mm in maxilla and 4 mm in mandible.
 Increase in intercanine arch length: This is due to growth of jaws.
 Change in interincisal angulations: The angle between the maxillary and mandibular incisors is
about 150° in primary dentition, whereas it is about 123° in permanent dentition thus allowing
more proclination and gaining space for incisor alignment. This is called incisor labiality
o Intertransitional period
 In this period, the maxillary and mandibular arches consist of permanent incisors and
permanent molars that sandwich the deciduous canines and molars.
 This phase lasts for 1½ years and is relatively stable.
 Only a few changes in the morphology of deciduous teeth are seen because they undergo
attrition.
o Second transitional period
 This phase is characterized by replacement of deciduous molars and canines by premolars and
permanent cuspids and the eruption of maxillary lateral incisors and canines.
 This takes place around 9 to 11 years of age and is very critical for the alignment of the erupting
permanent teeth.
 Replacement of Deciduous Molars and Canine
 The combined mesiodistal width of permanent canine and premolars is less than that of
deciduous canine and molars. This extra space is called Leeway space of Nance and is utilized by
mandibular molars to establish Class I relationship through late mesial shift.
 It is 1.8 mm (0.9 mm on each side) in maxillary arch and 3.4 mm (1.7 mm on each side) in
mandibular arch.
 The dimensions of deciduous 2nd molars is more than that of 2nd premolars, this excess space is
called as E-space
 Eruption of Maxillary Canine
  The other event of significance in second transition period is eruption of maxillary lateral
incisors and canines. This self-correcting malocclusion is seen around 8 to 11 years of age or
during eruption of canines and was first described by H Broadbent in 1937.
 As the permanent maxillary canines erupt they displace the roots of maxillary lateral incisors
mesially.
 This force is transmitted to the central incisors and their roots are also displaced mesially. Thus,
the resultant force causes the distal divergence of the crown in an opposite direction, leading to
midline spacing. This is called Ugly Duckling Stage or Broadbent phenomenon.
 The term ugly duckling stage indicates the unesthetic appearance of child during this stage.
 This condition corrects itself after the canines have erupted. The canines after eruption apply
pressure on the crowns of incisors thereby causing them to shift back to original positions.
 No orthodontic treatment should be attempted at this stage as there is a danger of deflecting
the canine from its normal path of eruption.
 Permanent dentition
o The entire permanent dentition is formed within the jaws after birth except for the cusps of 1st
molar, which are formed before birth.
o Some changes that can be seen in permanent dentition are:
 Horizontal overbite decreases
 Dental arches become shorter.
 Vertical overbite decreases up to the age of 18 years by 0.5 mm
 Overjet decreases by 0.7 mm between 12 and 20 years of age .

Q14)Define rampant caries.Write in detail etiology,clinical features,management and treatment of the

same
 Definition
o Massler (1945) defined rampant caries as suddenly appearing widespread, rapidly spreading,
burrowing type of caries, resulting in early involvement of pulp and affecting those teeth, which
are usually regarded as immune to decay.
o Winter et al. (1966) defined rampant caries as caries of acute onset involving many or all the
teeth in areas that are usually not susceptible. They further defined the condition to be
associated with rapid destruction of crowns with frequent involvement of dental pulp.
 Clinical features
o The pattern of rampant caries in the primary dentition is usually related to the order of tooth
eruption with the exception of the mandibular primary incisor.
o The mandibular incisors are probably more resistant to caries because of their close proximity
to the secretions of the submandibular salivary glands as well as the cleansing action of the
tongue during the process of suckling the bottle.
o The initial lesion usually appears on the labial surface of the maxillary incisors, close to the
gingival margins, as a whitish area of decalcification or pitting of the enamel surface shortly
after eruption.
o These lesions soon become pigmented to a light yellow and at the same time, extend laterally
to the proximal surfaces and downward to the incisal edge.
o At a more advanced stage, the carious process will often extend around the circumference of
the tooth, leading to pathologic fracture of the crown on minimal trauma.
o Other teeth, namely the first primary molars, the second primary molars, and eventually the
canines, will gradually become involved.
o Nursing bottle caries is a form of rampant dental caries in the primary dentition of infants and
children. In most cases, the problem is found in an infant who frequently falls asleep with a
baby bottle filled with milk or sugar-containing substances like vitamin C syrup, sweetened fruit
juice, or even carbonated drinks.
o The condition can also be associated with breastfed infants who have prolonged feeding habits
or with children whose pacifiers are frequently dipped in honey, sugar, or syrup.
o The decrease in salivary flow rate during sleep, as well as the pooling of sweet fluids around the
teeth, results in a highly cariogenic environment.
o Rampant caries may also occur in the permanent dentition of teenagers, because of their
frequent intake of cariogenic snacks and sweet drinks between meals.
o Typical rampant caries in adolescents is characterized by buccal and lingual caries of premolars
and molars and proximal and labial caries in the mandibular incisors.
o A specific form of rampant caries may occur in children and adolescents who have a greatly
reduced salivary flow as a result of radiotherapy for the treatment of cancer of the head and
neck region or as a result of the surgical removal of neoplasm in the oral cavity, this is called
radiation caries.
 Treatment
o The type of treatment instituted for patients with rampant caries depends on the patients and
parents motivation toward dental treatment, the extent of the decay, and the age and
cooperation of the child. These factors should be assessed during the child’s first few visits to
the dentist.
o Initial treatment, including provisional restorations, diet assessment, oral hygiene instruction,
and home and professional fluoride treatments, should be performed before any
comprehensive restorative treatment commences.
o Caries stabilization and provisional restorations should be placed in symptom-free teeth with
established dentinal caries to minimize the risk of pulpal exposure in the future and to improve
function.
o However, in patients presenting with acute and severe signs and symptoms of gross caries, pain,
abscess, sinus, or facial swelling, immediate treatment is indicated.
o Because diet is one of the major factors in the initiation and development of caries, a dietary
assessment should form a fundamental part of the examination.
o Parents should be educated to reduce the frequency of sucrose consumption by their child,
especially between meals.
o Consumption of sugar-containing foods and beverages should be restricted to meal times.
Parents can be instructed to record the amount and quantities of food and beverages consumed
during and between meals for 3 consecutive days.
o Dietary vitamin supplements as well as oral medications must also be included.
o If bottle feeding is still being practiced, particularly at night, it should be stopped by gradually
diluting the bottle contents with water as well as decreasing the amount of added sugar over a 2
or 3 weeks period and finally substituting the bottle with a feeding cup.
o Young adults usually brush their teeth for less than 40 seconds and spend only 30 percent of
the time on the caries-susceptible surfaces. Therefore, it is important to teach children the
proper techniques of toothbrushing at different age groups.
o Both systemic and topical fluoride treatments are useful for preventing dental caries; the choice
depends on the level of fluoride in the drinking water and the stage of development of the
dentition. Children with a primary dentition will benefit from both fluoride tablets and the use of
a small amount of fluoride toothpaste.
o The child should be encouraged to chew or suck the tablet, preferably at bedtime. This provides
a topical effect on dental enamel of the erupted teeth followed by a systemic effect on
developing enamel after swallowing.
o Once rampant caries is under control, comprehensive restorative treatment can be carried out.
o If the patient is seen at an early stage, when caries is still in the incipient or white spot stage,
and there is minimal or no loss of enamel surface integrity, an improvement in oral hygiene
technique, a change in dietary habits, and weekly home or professionally applied topical fluoride
therapy will help arrest the lesions, and the need for restorations may be obviated.
o Acid-etched composite resin restorations can be used to restore anterior maxillary teeth
whereas pedo-form strip crowns, which are more esthetic, functional, and durable, are
indicated in anterior teeth with gross caries and extensive crowns, which are more esthetic,
functional, and durable, are indicated in anterior teeth with gross caries and extensive coronal
destruction.
o Acid etched composite resin restorations, glass-ionomer-silver cermet cements, and stainless
steel crowns can be used to store the posterior teeth.
o Depending on the extent of the lesions, pulpotomies, pulpectomies, or extraction may be
indicated. Where extractions of teeth have been carried out, a prosthesis should be provided for
maintenance, function, and esthetics.

o Successful management of rampant caries depends on a coordinated team approach among the
pediatrician, pediatric dentist, parents, and child.
 o The pediatrician should educate the parents about good nursing and dietary habits and the
importance of good oral hygiene to their child’s teeth and should encourage parents to bring
their child to the dental office before he or she is 12 months of age for a screening examination
and counseling, because pediatricians are often the first medical personnel to see the newborn
baby.
o Consequently, educational efforts should be emphasized and reinforced, especially in areas
where the prevalence of rampant caries is high.

Q15)Define handicapped child.Write briefly on management of various handicapped condition for

dental treatment in a pediatric patient
 Definition
o Handicapped child (American public health association) A child who cannot within limits play,
learn, work or do things other children of his age can do; he is hindered in achieving his full
physical, mental and social potentialities.
o Handicapped child (WHO): One who over an appreciable period of time is prevented by physical
or mental conditions from full participation in the normal activities of their age group including
those of social, recreational, educational and vocational nature.

 Dental treatment of a person with mental retardation :

o Providing dental treatment for a person with mental retardation requires adjusting to social,
intellectual, and emotional delays.
o A short attention span, restlessness, hyperactivity, and erratic emotional behavior may
characterize patients with mental retardation undergoing dental care.
o The following procedures have proved beneficial in establishing dentist patient rapport and
reducing the patient’s anxiety about dental care:
 Give the family a brief tour of the office before attempting treatment. Introduce the patient and
family to the office staff. This will familiarize the patient with the personnel and reduce the
patient’s fear of the unknown.
 Allow the patient to bring a favorite item (stuffed animal, blanket, or toy) to hold for the visit.
 Be repetitive; speak slowly and in simple terms.
 If the individual has an alternative communication system, such as a picture board or electronic
device, be sure it is available to assist with dental explanations and instructions.
 Give only one instruction at a time.
 Reward the patient with compliments after the successful completion of each procedure.
 Actively listen to the patient.
 People with mental retardation often have trouble with communication, and the dentist should
be particularly sensitive to gestures and verbal requests.
 Invite the parent into the operatory for assistance and to aid in communication with the patient.
 Keep appointment short.

 Management of cerebral palsy patient

o To an uninformed dentist, a person with cerebral palsy might be perceived as an uncooperative
and unmanageable patient.
o A clinician who is not knowledgeable about physically and mentally disabling conditions may feel
uncomfortable about treating such patients and may refuse to do so.
o The following suggestions are offered to the clinician as being of practical significance in treating
a patient with cerebral palsy:
 Consider treating a patient who uses a wheelchair in the same itself.
 If a patient is to be transferred to the dental chair, ask about a preference for the mode of
transfer. If the patient has no preference, the two person lift is recommended.
 Make an effort to stabilize the patient’s head through all phases of dental treatment.
 Try to place and maintain the patient in the midline of the dental chair with arms and legs as
close to the body as feasible.
 Keep the patient’s back slightly elevated, to minimize swallowing (supine position).
 On placing the patient in the dental chair, determine the patient’s degree of comfort and assess
the position of the extremities. Do not force the limbs into unnatural positions.
 Use immobilization judiciously for controlling movements of the extremities.
 For control of involuntary jaw movements choose from a variety of mouth props and finger
splint. Patient preference should weight heavily, since a patient with cerebral palsy may be very
apprehensive about the ability to control swallowing. Such appliances may also trigger the
strong gag reflex.
 To minimize startle reflex reactions, avoid stimuli, such as abrupt movements, noises and lights,
without forewarning the patient.
 Introduce intraoral stimuli slowly to avoid eliciting a gag reflex or to make it less severe. Children
with cerebral palsy may have a severe gag reflex — making it difficult to take dental radiographs.
 Consider the use of the rubber dam, a highly recommended technique, for restorative
procedures.
 Work efficiently and minimize patient’s time in the chair to decrease fatigue of the involved
muscles.

 Dental treatment in an autistic child

o Offer parents and children to tour your dental office.
o Allow autistic child to bring comfort items, e.g. a toy.
o Make the first appointment short and positive.
o Approach the autistic child in a quiet, nonthreatening manner.
o A prominent symptom of infantile autism is an intense desire to maintain consistency in the
environment.
o Solicit suggestions from the parent or caregiver on how best to deal with the child as the minor
changes in the environment may elicit extreme anxiety in autistic children.
o They often exhibit an extreme resistance on being held and show an inappropriate reaction to
fearful situations.
o Autistic children are hypersensitive to loud noises, sudden movement, and things that are felt.
Eye contact is difficult to achieve, and the children are prone to tantrums and aggressive or
destructive behavior.
o Invite the child to sit alone in the dental chair to become familiar with the treatment setting.
o Talk in direct, short phrases. Talk calmly.
o Begin a cursory examination using only your fingers. Keep the light out of the eyes.
o Oral hygiene is often very poor because of finicky dietary habits.
o The key to all behavior modification programs lies in the use of positive reinforcement to
promote desirable behavior.
o In the early, stages of the program, sweet foods can serve as desirable rewards. In the latter
stages of modifying behavior, such oral rewards should be changed to social rewards, such as a
pat on the back or a hug.
o Some autistic children can be calmed by moderate pressure, such as by using a papoose board
to wrap the child.
o Some children will need sedation or general anesthesia so that dental treatment can be
accomplished.

 Dental treatment in visual impairment patient

o A distinction should be made between children who at one time had sight and those who have
not and thus do not form visual concepts.
o More explanation is needed for children in the later category to help them perceive the dental
environment.
o The modalities of listening, touching, tasting, and smelling are extremely important for these
children. Some recommended treatment modalities are:
 Determine the degree of visual impairment (e.g. can the patient tell light from dark).
 If a companion accompanies the patient, find out if the companion is an interpreter. If he or she
is not, address the patient.
 Establish rapport; offer verbal and physical reassurance.
 Avoid expressions of pity of references to visual impairment as an affliction.
 In guiding the patient to the operatory, ask if the patient desires assistance. Do not grab, move
or stop the patient without verbal warning. Encourage the parent to accompany the child.
 Paint a picture in the mind of the visually impaired child, describing the office setting and
treatment. Always give the patient adequate descriptions before performing treatment
procedures. It is important to use the same office setting for each dental visit to ally the
patient’s anxiety.
 Introduce other office personnel very informally.
 When making physical contact, do so reassuringly. Holding the patient’s hand often promotes
relaxation. Allow the patient to ask questions about the course of treatment and answer them
keeping in mind that the patient is highly individual, sensitive and responsive.
 Allow a patient who wears eyeglasses to keep them on for protection and security.
 Rather than using the tell-show-feel-do approach, invite the patient to touch, taste, or smell,
recognizing that these senses are acute. Avoid sight references.
 Describe in detail instruments and objects to be placed in the patient’s mouth. Demonstrate a
rubber cup on the patient’s fingernail.
 Because strong tastes may be rejected, use smaller quantities of dental materials with such
characteristics.
 Some patients may be photophobic. Ask parents about light sensitivity and allow them to wear
sunglasses.
 Explain the procedures of oral hygiene and then place the patient’s hand over yours as you
slowly but deliberately guide the toothbrush.
 Use audio-cassette tapes and Braille dental pamphlets explaining specific dental procedures to
supplement information and decrease chair time.
 Announce exits from the entrances to the dental operatory cheerfully. Keep distractions
minimal, and avoid unexpected loud noises.
 Limit the patient’s dental care to one dentist whenever possible.
 Maintain a relaxed atmosphere. Remember that your patient cannot see your smile.

 Dental treatment of hearing loss patient

 o Prepare the patient and parent before the first visit with a welcome letter that states what is to
be done and include a medical history form.
o Let the patient and parent determine the initial appointment how the patient desires to
communicate (i.e. interpreter, lip reading, sign language, writing notes, or a combination of
these).
o Look for ways to improve communication. It is useful to learn some basic sign language.
o Face the patient and speak slowly at a natural pace and directly to the patient without shouting.
o Assess speech, language ability, and degree of hearing impairment when taking the patient’s
complete medical history.
o Identify the age of onset, type, degree, and cause of hearing loss, whether any other family
members are affected.
o Enhance visibility for communication.
o Watch the patient’s expression.
o Have the patient use hand gestures if a problem arises.
o Write out and display information. Reassure the patient with physical contact; hold the patient’s
hand initially, or place a hand reassuringly on the patient’s shoulder while the patient maintains
visual contact.
o The child may be startled without visual contact so explain to the patient if you must leave the
room.
o Use visual aids and allow the patient to see the instruments, and demonstrate how they work.
o Display confidence; use smiles and reassuring gestures to build up confidence and reduce
anxiety.
o Adjust the hearing aid (if the patient has one) before the handpiece is in operation, since a
hearing aid will amplify all sounds.

Q16)Discuss in detail the various developmental stages given by Eric Ericson in his theory in
psychosocial analysis
 Description
o The psychosocial theory was proposed by Erikson in 1950 in his book ‘Childhood and Society’.
o This theory postulates that society responds to a child’s basic needs or developmental tasks in a
specific period of life and in doing so society ensures child’s healthy growth and survival in
culture and traditions.
o According to Erikson each individual passes through eight developmental stages. Each stage is
characterized by a different psychological crisis, which must be resolved by the individual before
he can move on to the next stage.
o If the person copes with a particular crisis in a maladaptive manner the outcome will be more
struggles with the same issue later in life.
 Stage 1: Infancy- age 0 to 1 year
 Crisis: Trust vs Mistrust.
 Description: In the first year of life infants depend on others for food, warmth and affection and
therefore must be able to blindly trust the parents (or caregivers) for providing these.
 Positive outcome: If their needs are met consistently and responsively by the parents, infants
not only will develop a secure attachment with the parents but will learn to trust their
environment in general as well.
 Negative outcome: If no infant will develop mistrust towards people, environment and even
towards themselves.
 Dental applications: This stage identifies with development of separation anxiety in the child. So,
if necessary to provide dental treatment at this early age, it is preferable to do with the parent
present and preferably with parent holding the child.

 Stage 2:Toddler- Age 1 to 2 years

 Crisis: Autonomy vs Doubt.
 Description: Toddlers learn to walk, talk, use toilets and do thinks for themselves. Their self-
control and self-confidence begins to develop at this stage.
 Positive outcome:
 If parents encourage their child’s use of initiative and reassure him when he makes mistakes,
the child will develop the confidence needed to cope with future situations that require choice,
control and independence.
 The parents should not discourage the child, but neither should they push. A balance is
required.
 People often advise new parents to be “firm but tolerant” at this stage. This way, the child will
develop both self-control and self-esteem.
 Negative outcome:
 If parents are over protective or disapproving of the child’s acts of independence he may begin
to feel ashamed of his behavior or have too much doubt of his abilities.
 Another failure factor is unrestricted freedom, or if you try to help children do what they should
learn to do for themselves, you will also give them the impression that they are not good for
much.
 If you are not patient enough to wait for your child to tie his or her shoe-laces, your child will
never learn to tie them, and will assume that this is too difficult to learn.
 Dental application:
 Child is moving away from mother, but still will retreat to her in threatening situations. So,
parent’s presence is essential in dental clinic.
 At this stage as the child takes pleasure in doing tasks by himself; dentist must obtain co-
operation from him by making him believe that the treatment is his choice not of the
dentist/parent.

 Stage 3 :Early childhood- Age 2 to 6 years

 Crisis: Initiative vs Guilt.
 Description:
 Children have new found power at this stage as they have developed motor skills and become
more engaged in social interaction with people around them.
 They now must learn to achieve a balance between eagerness for more adventure and more
responsibility and learning to control impulses and childish fantasies.
 Positive outcome: If parents are encouraging but consistent in discipline, children will learn to
accept without guilt that certain things are not allowed and at the same time will not feel shame
when using their imagination and engaging in make believe role plays.
 Negative outcome: If no children may develop a sense of guilt and may come to believe that it is
wrong to be independent.
 Dental application:
 Going to the dentist can be considered a new and challenging adventure in which the child can
experience success.
 Success is coping with the anxiety of visiting the dentist can help develop greater independence
and produce a sense of accomplishment.
 Poorly managed, of course, a dental visit can also contribute toward the guilt that accompanies
failure.
 A child at this stage will be intensely curious about the dentist’s office and eager to learn about
the things out there. An exploratory visit with little work is often a good way to start the dental
experience.

 Stage 4: elementary and middle school years – age – 6 to12 years

 Crisis: Industry vs Inferiority.
 Description:
 School is the important event at this stage.
 Children learn to make things, use tools and acquire the skills to be a worker and a potential
provider and they do all these while making the transition from the world of home into the
world of peers.
 The child who, because of his successive and successful resolutions of earlier psychosocial crisis,
is trusting, autonomous, and full of initiative will learn easily enough to be industrious
 The influence of parents as role models decreases and the influence of peer group increases.
 Positive outcome: If children can discover pleasure in intellectual stimulation, being productive,
seeking success they will develop a sense of competence.
 Negative outcome: If the child is allowed too little success, because of harsh teachers or
rejecting peers, for example, then he or she will develop a sense of inferiority or incompetence.
 Dental application:
 Children at this age are trying to learn the skills and rules that define success in any situation,
and that includes the dental office.
 A key to behavioral guidance is setting attainable intermediate goals, clearly outlining for the
child how to achieve those goals and positively reinforcing success in achieving these goals.
 Because of the child’s drive for a sense of industry and accomplishment, cooperation with
treatment can be obtained.
 Children at this stage still are not likely to be motivated by abstract concepts rather they can be
motivated by improved acceptance or status from the peer group. This means that emphasizing
how the teeth will look better as the child cooperates is more likely to be a motivating factor
than emphasizing a better dental occlusion.

 Stage 5: adolescence- age 12 to 18 years

 Crisis: Identity vs Role confusion.
 Description:
 This is the time when we ask the question ‘Who am I’? To successfully answer this question
Erikson suggests the adolescent must integrate the healthy resolution of all earlier conflicts;
 adolescents who have successfully dealt with earlier conflicts are ready for the identity crisis,
which is considered by Erikson as the single most significant conflict a person must face.
 Adolescence, a period of intense physical development, is also the stage in psychosocial
development in which a unique personal identity is acquired.
 This sense of identity includes both a feeling of belonging to a larger group and a realization
that one can exist outside the family. It is an extremely complex stage because of the many new
opportunities that arise.
 Emerging sexuality complicates relationships with others.
 At the same time physical ability changes and academic responsibilities increase, and career
possibilities begin to be defined.
 Members of the peer group become important role models, and the values and tastes of
parents and other authority figures are likely to be rejected.
 Positive outcome: If the adolescent solves this conflict successfully he will come out of this age
with a strong identity and ready to plan for the future.
 Negative outcome:
 If not the adolescent will sink into confusion unable to make decisions and choices especially
about vocation, sexual orientation and his role in life in general.
 As adolescence progresses, an inability to separate from the group indicates some failure in
identity development.
 This in turn can lead to a poor sense of direction for the future, confusion regarding one’s place
in society, and low self esteem.
 Dental application:
 Behavior management of adolescents can be challenging. Any orthodontic treatment should be
carried out if child wants it and not parents as at this stage, parental authority is being rejected.
 Approval of peer group is extremely important. For example, orthodontic treatment has become
so common that there may be a loss of status from being one of the few in the group who is not
receiving treatment, so that treatment may even be requested in order to remain “one of the
crowd”.
 It is extremely important to realize that treatment is being done for him not to him.
 Abstract concepts can be grasped readily, but appeals to do something because of its impact on
personal health are not likely not to be heeded.

 Stage 6: Young adulthood- age 19 to 40 years

 Crisis: Intimacy vs Isolation.
 Description:
 In this stage, the most important events are love relationships. No matter how successful you
are with your work
 Successful development of intimacy depends on a willingness to compromise and even to
sacrifice to maintain a relationship.
 An individual who has not developed a sense of identity usually will fear a committed
relationship and may retreat into isolation.
 Positive outcome: The adult individuals can form close relationships and share with others if
they have achieved a sense of identity. Success leads to the establishment of affiliations and
partnerships both with a mate and with others of the same sex, in working toward the
attainment of career goals.
 Negative outcome: If not they will fear commitment, feel isolated and unable to depend on
anybody in the world. Failure leads to isolation from others and is likely to be accompanied by
 strong prejudices and a set of attitudes that serve to keep others away rather than bringing
them into closer contact.
 Dental application: At this stage, external appearances are very important as it helps in
attainment of intimate relation. Hence, the focus is orthodontic and esthetic treatments.

 Stage 7: Middle adulthood- age 40 to 65 years

 Crisis: Creativity vs Stagnation.
 Description:
 The next generation is guided in short not only by nurturing and influencing one’s own children
but also by supporting the network of social services needed to ensure the next generation’s
success.
 The opposite personality trait in adults is stagnation, characterized by self-indulgence and self-
centered behavior.
 Positive outcome: People can solve this crisis by having and nurturing children or helping the
next generation in other ways.
 Negative outcome: Person will remain self-centered and experience stagnation later in life.

 Stage 8: Late adulthood –age 65 to death

 Crisis: Integrity vs Despair.
 Description: Old age is a time for reflecting upon one’s own life and seeing it filled with pleasure
and satisfaction or disappointments and failures.
 Positive outcome:
 If the other seven psychosocial crises have been successfully resolved, the mature adult
develops the peak of adjustment: integrity.
 If the adult has achieved a sense of fulfillment about life and a sense of unity within himself and
with others he will accept death with a sense of integrity just as healthy child will not fear life.
 Negative outcome: The opposite of this is despair. This is often expressed as disgust and
unhappiness on a broad scale, frequently accompanied by a fear that death will occur before a
life change that might lead to integrity can be accomplished.

Q17)Enumerate etiology,clinical features,treatment plan of Acute herpetic gingivostomatitis

 Description
o Also called as Primary Herpes Simplex Infection,‘herpes labialis’, ‘fever blister’, ‘cold sore’ and
‘infectious stomatitis’.
o It occurs in patients with no prior infection with HSV-1. HSV reaches nerve ganglion supplying
the affected area, presumably along nerve pathways and remains latent until reactivated.
o The usual ganglion involved is the trigeminal for HSV-1 and lumbosacral, for HSV-2.
 Transmission
o Close contact—it occurs during close personal contact, in which exchange of saliva or other
secretion happened.
o Newborn infection—primary infection of newborn is believed to be caused by vaginal secretions
during birth, which results in viremia and disseminated infection of brain, liver, adrenals and
lungs.
o Socioeconomic status—incidence varies according to socioeconomic group. Person who is
having lower economic status will have earlier exposure.
 Clinical Features
o Age—it develops in both, children and young adults. It can be seen in high school and college
students where it is transmitted by kissing and sexual contact.
o Incubation period—incubation period is 5 to 7 days.
o Prodormal symptoms—prodormal symptoms precede local lesion by 1 to 2 days and it includes
fever, headache, malaise, nausea, vomiting and within a few days, mouth becomes painful.
There is also irritability, pain upon swallowing and regional lymphadenopathy.
o Location—this lesion mainly occurs on the hard palate, attached gingiva and dorsum of tongue.
In some cases, lesion may be presented on the skin
o Appearance—after this, small vesicles, which are thin walled, surrounded by inflammatory base
are formed. They quickly rupture leaving small, shallow, oval shaped discrete ulcers.
o Size—As the disease progresses, several lesions may coalesce, forming larger, irregular lesions.
o Base—the base of the ulcer is covered with grayish white or yellow plaque.
o Margins—the margins of the sloughed lesions are uneven and are accentuated by bright red
rimmed, well demarcated, inflammatory halos.
o Lips—in severe cases, excortication involving the lips may become hemorrhagic and matted with
serosanguinous fibrin-like exudate and parting of the lips during mastication and speech may
become extremely painful and difficult.
o Acute marginal gingivitis—appearance of generalized marginal acute gingivitis is typical feature
of herpes simplex infection. Entire gingiva is edematous and swollen and small gingival ulcers
are seen.
o Pharynx—examination of posterior pharynx reveals inflammation causing difficulty in
swallowing.
o Lymph nodes—cervical and submandibular lymphadenopathy is present.
o Healing—the disease is self limiting and lesions begin healing in a week to 10 days and leave no
scar.
 Management
o Symptomatic
 Pain control measures—
 topical anesthetics like 2% lidocaine, 0.1% diclonine hydrochloride, 0.5% benzocaine
hydrochloride are used.
 Solution of diphenylhydramine hydrochloride (Benadryl) 5 mg mixed with equal amount of milk
of magnesia can also reduce the pain. In some cases systemic administration of analgesics is also
given.
 Topical anti-infective agents—it is given to prevent secondary infection. Agents used are 0.2%
chlorhexidine gluconate, tetracycline mouth wash and elixir or diphenylhydramine.
 Supportive care—fluid is given to maintain proper hydration and electrolyte balance.
Antipyretics can also be given to control the fever.
 Good oral hygiene—oral hygiene should be properly maintained to avoid any secondary
infection.
o Specific
 Acyclovir—it inhibits DNA replication in HSV infected cells reducing the duration of illness but
with few side effects. The optimum oral dosage of acyclovir is 1,000 to 1600 mg daily, for 7 to
10 days. It should be ideally given in a dose of 15 mg/kg five times a day.
 Valacyclovir—it is prodrug of acyclovir and it has far better biocompatibility as compared to
acyclovir. It should be used in combination with famciclovir.
Q18)Name the professionally administered and topically applied solutions of fluoride on teeth.Discuss
the technique of application and mechanism of action of each

 Sodium fluoride
o Knutson and Feldman(1948) recommended a technique of 4 applications of 2 percent NaF at
weekly intervals in a year at 3, 7, 11 and 13 years.
o Sodium fluoride has neutral pH, 9200 ppm of F–
o Caries reduction in 1st year was 45 percent and in 2 nd year was 36 percent.
o Method of preparation
 Two percent NaF solution can be prepared by dissolving 20 g of NaF powder in 1 liter of distilled
water in a plastic bottle.
 It is essential to store fluoride in plastic bottles because if stored in glass containers, the
fluoride ion of solution can react with silica of glass forming SiF2, thus reducing the availability
of free active fluoride for anticaries action.
 Stannous fluoride
o All yielded some cariostatic benefit but SnF2 was found to be three times more effective than
NaF.
o Dudding and Muhler in 1957 tried single annual application of 8 percent SnF2 and reported 32
percent caries reduction.
o Method of preparation
 Stannous fluoride solution has to be freshly prepared before use each time (stannous form of
Tin gets oxidized to stannic form, thus making the SnF2 inactive for anticaries action), as it has
no shelf life.
 For convenient preparation number ‘o’ gelatin capsules are priorly filled with 0.8 g powdered
SnF2 and are stored in airtight plastic containers. Just before application the content of one
capsule is dissolved in 10 mL of distilled water in a plastic container and the solution thus
prepared is shaken briefly. The solution is then applied immediately.

o Method of application
 The recommended procedure for application of SnF2 begins with thorough prophylaxis
followed by isolation with cotton rolls and drying preferably with compressed air.
 Either a quadrant or half of the mouth can be treated at one time.
 A freshly prepared 8 percent solution of SnF2 is applied continuously to the teeth with cotton
applicator and reapplication of the solution to a particular tooth is done every 15 to 30 seconds
so that the teeth are kept wet for 4 minutes.
 The recommended frequency of application is once per year.

 Acidulated phosphate fluoride

o They concluded that semiannual application of 1.23 percent APF for 4 minutes is helpful in
reducing caries by 28 percent.
o One of the practical difficulties of doing the topical application is that the teeth must be kept
wet with solution for 4 minutes and, moreover, APF solution is acidic and sour and bitter in
taste, so repeated applications are often difficult.
o Method of preparation
 It is prepared by dissolving 20 g of NaF in 1 liter of 0.1M phosphoric acid.
 To this 50 percent hydrofluoride acid is added to adjust the pH at 3.0 and F concentrations at
1.23 percent.
 For the preparation of APF gel, a gelling agent like Methylcellulose or Hydroxyethyl cellulose is
to be added to the solution and the pH is to be adjusted between 4 to 5.
 Newer topical fluorides
o Amine fluoride
 Amine fluoride is superior to inorganic fluorides in reducing enamel solubility because of
chemical protection by fluoride and physicochemical protection by organic portion.
 They are also surface active because they hold fluoride on enamel surface for longer time.
o Stannous hexafluorozirconate
 Researchers at Indiana University have developed SnZrF6 effective in reducing the solubility of
enamel and in preventing dental caries.
 Fluoride varnish
o The cariostatic effect of topical fluoride agents has generally been related to their ability to
deposit fluoride in the enamel and also their depth of penetration.
o The topical fluoride solutions that are currently in use have a major disadvantage that they
remain in contact with teeth for a very short time, i.e. 5 to 10 minutes before getting diluted by
saliva and consequently can exert relatively a superficial effect on the dental enamel.
o A second drawback with topical fluoride solutions is that soon after application much of the
acquired fluoride, probably representing unreacted F and CaF2, leaches away.
o To enhance the caries inhibitory property of topical fluorides, experiments were carried out
aiming at overcoming above mentioned drawbacks, by developing methods for prolonging the
contact of fluoride solutions with tooth enamel leading not only to deeper penetration but also
a more permanently bound form of fluoride.
o The two most commonly used varnishes are Duraphat (NaF varnish containing 2.26% F) in
organic lacquer and Fluor protector (Silane fluoride with 0.7% F).
o Duraphat is sodium fluoride in varnish form containing 22.6 mg F/mL (2.26%) suspended in an
alcoholic solution of natural organic varnishes. It’s available in bottles of 30 mL suspension
containing 50 mg NaF/mg. The active fluoride available is 22,600 ppm (

o Mechanism of action
  Duraphat is NaF in varnish form with neutral pH.
 When applied topically under clinically controlled conditions, a reservoir of fluoride ions gets
built up around the enamel of teeth.
 From this, fluoride keeps on slowly releasing and continuously reacting with the hydroxyapatite
crystals of enamel over a long period of time leading to deeper penetration of fluoride and more
formation of fluorapatite.
 A part of CaF2 so formed in low concentrations further reacts with crystals of hydroxyapatite
and forms fluorapetite.
 The literature shows that in spite of lower fluoride content in fluorprotector as compared to
duraphat, the fluoride deposited in enamel is twice as much, but on the contrary, its ability to
inhibit caries is far less than duraphat.
 Silane fluoride of fluorprotector reacts with water to produce considerable amount of
hydrofluoric acid (HF), which penetrates into enamel more readily than fluoride.
 Fluorosilanes also enhance retention and penetration of fluoride in enamel by utilizing enamel
network as a conduit.
 Fluoride dentrifice
o Fluoride dentifrices have been proven to be effective anticaries agents since 1955.
o The most commonly evaluated fluoride dentifrices are sodium fluoride and stannous fluoride
and more recently the sodium monofluorophosphate and amine fluoride, are also being used.

o Sodium fluoride and stannous fluoride dentrifice

 Tin fluoride compound (SnF2) in dentifrices containing 0.4 percent SnF2 in a calcium
pyrophosphate abrasive system.
 However, this also failed to get the desired results because of its compatibility with abrasives,
staining of anterior restorations of composites resins and a metallic astringent taste, which was
not acceptable.

o Amine fluoride dentrifrices

 This was first tested for its cariostatic potential in Zurich, Switzerland.
 This showed organic fluorides to have antibacterial and anticariogenic properties, which were
superior to inorganic fluorides and demonstrated significant reduction in caries rate.
 These dentifrices are marketed only in Europe
o Monofluorophosphate
 Monofluorophosphate (MFP) is the basic incompatibility of the NaF and SnF2 compounds with
calcium abrasives leading to decrease available fluoride has been overcome with the
introduction of MFP
 Dentifrices containing MFP at a concentration of 0.76 percent, 0.1 percent F with sodium
metaphosphate as abrasive, have led to variable reductions in caries rates ranging from 17
percent for unsupervised brushing and about 34 percent for supervised brushing in
nonfluoridated areas.
 At present there are two possible modes of action regarding caries inhibitory mechanism of
mono-fluoriophosphate (MFP

Q19)What do you mean by term handicapped child. Discuss management of patient suffering from
hemophilia in your dental clinic
 Definition
o Handicapped child (American public health association) A child who cannot within limits play,
learn, work or do things other children of his age can do; he is hindered in achieving his full
physical, mental and social potentialities.
o Handicapped child (WHO): One who over an appreciable period of time is prevented by
physical or mental conditions from full participation in the normal activities of their age group
including those of social, recreational, educational and vocational nature.
 Hemophilia
o Hemophilia is a group of hereditary genetic disorders that impair the body’s ability to control
blood clotting or coagulation.
o Classification
 Hemophilia A or classic hemophilia is a deficiency of factor VIII is the most common form of the
disorder, occurring at about 1 in 5,000–10,000 male births.
 Hemophilia B or Christmas disease is caused by a deficiency in factor IX occurs at about 1 in
about 20,000–34,000 male births.
 Von Willebrand’s disease is a hereditary bleeding disorder resulting from an abnormality of the
Von Willebrand’s factor (VWF).
o Manifestations
 Frequent bleeding episodes.
 Hemarthroses are common and symptoms include pain, stiffness, limited motion.
 Individuals may develop debilitating painful arthritis.
 Pseudotumors (hemorrhagic pseudocysts).
  Mouth lacerations are a common cause of bleeding in children.
o Treatment
 Hemophilia A • Factor VIII concentrate is used for treatment of hemophilia A.DDAVP (1-
deamino-8- D-arginine vasopressin)
 Hemophilia B- Purified coagulation factor IX concentrate
 Von Willebrand’s Disease -DDAVP

Q20)Discuss in detail the phases of developing occlusion during mixed dentition period.Also
enumerate various self correcting anomalies during this period
 Occlusion during mixed dentition period
o The period during which both the primary and permanent teeth are present in the mouth
together is known as mixed dentition.
o The permanent teeth erupting in place of previous deciduous teeth are the successional teeth,
whereas those erupting posteriorly to the primary teeth are called the accessional teeth.
o This phase begins at around 6 years with the eruption of 1 st permanent molars and lasts till
about 12 years of age.
o First transitional period
 This is characterized by emergence of 1st permanent molars and exchange of deciduous incisors
with permanent incisors.
 Emergence of 1st permanent molars:
 The anteroposterior relation between the two opposing 1st molars after eruption depends on
their positions previously occupied within the jaws, sagittal relation between the maxilla and
mandible and occlusal relationship is established by the cone and funnel mechanism with the
upper palatal cusp (cone) sliding into the lower occlusal fossa (funnel).
 The mandibular molars are the first to erupt at around 6 years of age. Their position and relation
is dependent on the relation of 2nd deciduous molars as they are guided into dental arch by the
distal surfaces of these teeth.
 If the 2nd deciduous molar is in flush terminal plane, then the erupting permanent molar will
also be in the same relation. For this, to change into class I relation the molar has to move 2 to 3
mm in a forward direction, this is accomplished by:
 Early mesial shift: The eruptive forces of 1st permanent molars are strong enough to push the
deciduous molars forward in the arch thereby utilizing the primate spaces and thus establishing
class I relationship (Fig. 16.15).

 Late mesial shift:

 Many children lack primate spaces and have a nonspaced dentition and thus erupting
permanent molars are not able to establish Class I relation even as they erupt. In these cases,
 the molars establish Class I relation by drifting mesially and utilizing the Leeway space after
exfoliation of deciduous molars and this is called late mesial shift (Fig. 16.16).
 If the 2nd deciduous molar is in mesial-step terminal plane, then the erupting permanent molar
will directly erupt in Class I relation. But if further growth occurs or if there is more utilization of
spaces the relation can even change to Class III.
 If the 2nd deciduous molar is in distal-step terminal plane, then the erupting permanent molar
will erupt into Class II relation. If further growth occurs or there is more utilization of spaces
then it can lead into end on molar relation.
 Exchange of incisors:
 The deciduous incisors are replaced by permanent incisors during this phase.
 This period of transition is from 6½ to 8½ years.
 The permanent incisors are larger as compared to their primary counterparts and thus require
more space for their alignment.
 This difference between space available and space required is called the incisor liability (Fig.
16.17).
 This is 7 mm for maxillary arch and 5 mm for mandibular arch.

 Some of the factors that help in alignment of incisors by gaining space are:
 Utilization of interdental spacing of primary incisors:
 Averages 4 mm in the maxillary arch and 3 mm in the mandibular arch.
 Increase in intercanine arch width: This occurs as the child grows. In males, it is 6 mm for maxilla
and 4 mm for mandible whereas in females, it is 4.5 mm in maxilla and 4 mm in mandible.
 Increase in intercanine arch length: This is due to growth of jaws.
 Change in interincisal angulations: The angle between the maxillary and mandibular incisors is
about 150° in primary dentition, whereas it is about 123° in permanent dentition thus allowing
more proclination and gaining space for incisor alignment. This is called incisor labiality (Fig.
16.18).
o Intertransitional period
 In this period, the maxillary and mandibular arches consist of permanent incisors and
permanent molars that sandwich the deciduous canines and molars.
 This phase lasts for 1½ years and is relatively stable.
 Only a few changes in the morphology of deciduous teeth are seen because they undergo
attrition.
o Second transitional period
 This phase is characterized by replacement of deciduous molars and canines by premolars and
permanent cuspids and the eruption of maxillary lateral incisors and canines.
 This takes place around 9 to 11 years of age and is very critical for the alignment of the erupting
permanent teeth.
 Replacement of Deciduous Molars and Canine
 The combined mesiodistal width of permanent canine and premolars is less than that of
deciduous canine and molars. This extra space is called Leeway space of Nance and is utilized by
mandibular molars to establish Class I relationship through late mesial shift.
 It is 1.8 mm (0.9 mm on each side) in maxillary arch and 3.4 mm (1.7 mm on each side) in
mandibular arch.
 The dimensions of deciduous 2nd molars is more than that of 2nd premolars, this excess space
is called as E-space.
 Eruption of Maxillary Canine
 The other event of significance in second transition period is eruption of maxillary lateral
incisors and canines. This self-correcting malocclusion is seen around 8 to 11 years of age or
during eruption of canines and was first described by H Broadbent in 1937.
 As the permanent maxillary canines erupt they displace the roots of maxillary lateral incisors
mesially. This force is transmitted to the central incisors and their roots are also displaced
mesially. Thus, the resultant force causes the distal divergence of the crown in an opposite
direction, leading to midline spacing.
 This is called Ugly Duckling Stage or Broadbent phenomenon. The term ugly duckling stage
indicates the unesthetic appearance of child during this stage.
 This condition corrects itself after the canines have erupted. The canines after eruption apply
pressure on the crowns of incisors thereby causing them to shift back to original positions.
 No orthodontic treatment should be attempted at this stage as there is a danger of deflecting
the canine from its normal path of eruption.
Q21)Discuss the indications,contraindications and procedure for pulpectomy in deciduous teeth.What
are the obturating materials used in primary teeth
 Definition
o Mathewson (1995) defined it as the complete removal of the necrotic pulp from the root canals
of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in
the dental arch.
 Objectives
o Maintain the tooth free of infection
o Biomechanically cleanse and obturate the root canals
o Promote physiologic root resorption
o Hold the space for the erupting permanent tooth.
 Indications
o General Indications
 Patient should be in good general health with no serious disease.
 Maximum cooperation of patient and parents.
o Clinical Indications
 A tooth previously planned for a pulpotomy that shows uncontrolled pulpal hemorrhage.
 Indicated for any primary tooth in absence of its permanent successor.
 Any deciduous tooth with severe pulpal necrosis provided there is no radiographic
contraindication.
 Primary teeth with necrotic pulps and minimum of root resorption.
 Pulpless primary teeth with stomas.
 Pulpless primary teeth in hemophiliacs.
 Pulpless primary anterior teeth when speech, esthetics are a factor.
 Pulpless primary molars holding orthodontic appliance.
o Radiographic Indications
 Adequate periodontal and bony support.
 Contraindications
o General Contraindications
 Young patient with systemic illness such as congenital ischemic heart disease, leukemia.
 Children on long-term corticosteroids therapy.
o Clinical Contraindications
 Excessive tooth mobility.
 Communication between the roof of the pulp chamber, and the region of furcation
 Insufficient tooth structure to allow isolation by rubber dam and extra coronal restoration.
o Radiographic Contraindications
 External root resorption.
 Internal root resorption in the apical 3rd of the root.
 Radicular cyst, dentigerous/follicular cyst in association with the primary tooth.
 Inter-radicular radiolucency that communicates with the gingival sulcus.

 Single visit pulpectomy

o This is carried out as an extension of pulpotomy procedure, probably on the spot decision when
hemorrhage from amputated pulp stumps is uncontrollable but the tooth does not show any
periapical changes.
o Indication
 Large carious exposure with frank involvement of radicular pulp but without any periapical
changes.
 Primary teeth with inflammation extending beyond coronal pulp, indicated by hemorrhage from
the amputated radicular stumps that is dark red, a slowly,oozing and uncontrollable.

 Multiple visit pulpectomy

o Indications
 Indicated where infection, an abscess or chronic sinus exists
 Nonvital primary teeth
 Teeth with necrotic pulp and periapical involvement
 Materials used for obturation
Q22)Discuss in detail demineralization and remineralisation cycle.What is critical ph and how these
factors lead to development of white spot lesions
 Demineralization-remineralization concept
o Dental caries is not a result of a single acid attack caused by the acid formed as a result of
fermentation of dietary substrates by the oral microflora.
o Rather it is an outcome of the imbalance occurring in the demineralization remineralization
cycle that is continuously operating in the oral cavity.
o This balance is governed by a number of factors which is either caries promoting (promotes
demineralization) or caries inhibiting (promotes remineralization).
o An important point to be mentioned is all these factors are present in every individual’s oral
cavity but in different proportions determining the direction of the demineralization-
remineralization cycle.
o Stephan Curve
 Stephan curve is a graph published by Stephan and Miller in 1944 which reflected the fall in
salivary pH following a glucose rinse.
 Stephan selected patients who were either caries-free or caries-inactive or who exhibited
various degrees of caries activity.
 Subjects were asked not to brush their teeth for three to four days prior to the measurement of
the plaque biofilm pH on the labial surfaces of the anterior teeth.
 Prior to rinsing with 10 mL of a 10 percent glucose solution for 10 seconds, pH readings were
obtained. After rinsing with the glucose solution, pH readings were obtained at various time
intervals until the pH returned to its original value.
 The graph has four landmarks viz: resting pH, the rapid fall in pH, the critical pH and the
recovery phase.
 Resting plaque pH: This describes plaque that has not been exposed to fermentable
carbohydrates for approximately 2 hours and generally has a pH of between 6 and 7. The resting
plaque pH value for an individual tends to be stable and may remain so for long periods
  Decrease in plaque pH: After exposure of dental plaque to fermentable carbohydrates, the pH
decreases rapidly. The rate at which the pH decreases is due in part to the microbial
composition of dental plaque. The rate of pH decrease is also dependent on the speed with
which plaque bacteria are able to metabolize the dietary carbohydrate.
 Critical pH: The critical pH is the pH at which saliva no longer remains saturated with calcium
and phosphate, thereby permitting the hydroxyapatite in dental enamel to dissolve. It is the
highest pH at which there is a net loss of enamel from the teeth, which is generally accepted to
be about 5.5 for enamel.
 Increase in plaque pH: The low pH remained for some time, taking 30 to 60 minutes to return to
its normal pH (in the region of 6.3–7.0). The gradual recovery of the plaque pH is influenced by
various factors. These include the buffering capacity of saliva, whether fermentable
carbohydrate remains in the mouth and the diffusion of acids from plaque into saliva or teeth.
 Application of Stephan’s curve in day-to-day life:
 The initial flat part of the graph represents the resting pH of saliva which is mostly constant for
an individual.
 The first dip in the graph represents the fall in salivary pH soon after the breakfast. The degree
of fall depends upon the constituents of the breakfast. A breakfast more rich in fermentable
carbohydrates will lead to a steeper fall of pH and to a lower level of pH.
 Once the pH goes below the critical pH the saliva no longer remains saturated with calcium and
phosphate ions. This results in the shifting of the demineralization remineralization equilibrium
towards demineralization.
 By the action of buffering agents of saliva and other protective actions like the washing and
flushing action of saliva the pH starts rising. During this event if the pH rises above the critical
pH remineralization of the tooth will start.
 In a situation where an individual consumes snacks before the pH rises above the critical pH (as
showed between the lunch and dinner), the salivary pH again falls and does not allow the repair
process of remineralization. This outlines the deleterious effect of frequent snacking on the
caries process in oral cavity.
 In contrast to this if an individual rinses his oral cavity or brushes his teeth after meals (as
showed after dinner) this leads to the flushing out of the acid produced by the microorganisms.
In addition this also lowers the microbial load of the oral cavity and removes the trapped food
particles which acts as a reservoir for the substrate required for acid production. All these
events results into a steeper rise in the pH thus exposing the tooth to the acid attack for a lesser
time period.
 Remineralize early lesions:
o Remineralization should be recognized and utilized as far as possible for any tooth that has been
subject to attack by caries, because there is no real substitute for natural tooth structure.
o It has been known for many years that “white-spot” lesions on the visible surfaces of teeth can
be remineralized and repaired.
o Successful remineralization requires intensive patient education and cooperation; the patient
must have a full understanding of the implication of food types, the need for plaque removal,
and the possible need for additional oral lavages for control of bacterial populations

Q23)What are stainless steel crowns.Write in detail about composition,indications and steps involved
in adaptation of stainless steel crowns
 Definition
o Defined as prefabricated crown forms that are adapted to individual teeth and cemented with a
biocompatible luting agent.
o Indications
 Extensive caries: If the caries is involving three or more surfaces this leads to insufficient tooth
structure to hold a restoration and in such cases crown proves to be more cost effective and
prevents further damage.
 Extensive decalcification: On any one surface like proximal is also an indication as it might lead
to space loss at a later stage.
 Rampant caries: In such cases there is need for multiple restorations on a single tooth so it is
much cost effective and much less traumatic to place a stainless steel crown on the tooth.
 Recurrent caries: Placement of crown will also help in removing the possibility of recurrent
caries around existing restoration.
 After pulp therapy: Following pulp therapy the tooth structure is weakened due to removal of
dentin. Such teeth are prone to fractures and hence crown coverage is mandatory to avoid it.
 Inherited or acquired enamel defects, e.g. hypoplasia, amelogenesis imperfecta (permanent and
primary teeth): Such patients have a tendency to fracture teeth while normal eating practices
along with the common associated pain. It is imperative to provide crown for these patients to
avoid pain and fracture and also restore the vertical dimension.
 Intermediate restoration: In children with class 2 division 1 malocclusion with hypoplastic or
carious molar, this can be planned till eruption of premolar and 2nd molars.
 Fractures of permanent and primary incisors : If an incisor is fractured, crowns in anterior teeth
can be given as a temporary dressing to cover the exposed dentin.
 Severe bruxism: When teeth show extreme wear and tear owing to bruxism crown is a good
restorative choice. This is because stainless steel crown can neither wear down nor fracture and
at the same time restore lost vertical dimension.
 Abutment teeth to prosthesis: These are useful extra coronal restorations in abutment teeth to
removable prosthesis.
 As part of a space maintainer: Crowns can be a part of crown and loop or crown band and loop
space maintainer.

 Composition
o Stainless steel crowns(18-8 crown)
 Stainless steel are low-carbon alloy steels that contain at least 11.5 percent chromium.

o Nickel base crowns

 These are Ion crowns constructed of Iconel 600, a relatively new addition to the category of
preformed crowns, and is primarily nickel-chromium.
 Crown adaptation
o If rubber dam is being used then it is necessary to remove it at this stage.
o Festooning of the proximal surface should be performed before trying the crown as it will
facilitate in ease of placement and will limit false blanching signs.
o The buccal and lingual gingiva around second primary molars and the lingual marginal gingiva of
first primary molars resemble smile (∪) while the buccal marginal gingival mimic S shape that
looks stretched (∼).
o The proximal contours of all the primary molars look like frown (∩). The gingival margins of the
trimmed crowns must correspond to their respective gingival margins of the tooth.
o Place the crown on the lingual side and rotate it towards the buccal side. The crown should fit
loosely, with 2 to 3 mm excess gingivally.
o With a scaler, scratch around the gingival margin on the crown or mark with a glass marking
pencil. This scratch line indicates the gingival line and the gingival contour, as well as the portion
of the crown to be removed.
o Remove the crown from the prepared tooth, exposing the scratch line. With the help of crown
and bridge scissors, cut the crown 1 mm below the scratch line.
o Now smoothen the edges with finishing burs. Retry the crown on the tooth. If there is blanching
of the gingiva, it may be necessary to rescribe the crown and retrim it. Trim only in the areas
where blanching is visible.
o Check the gingival extent of crown with the help of probe; it should not be more than 1mm on
buccal aspect and 0.5 mm on the lingual side
o The goal is to extend the crown 1 mm beneath the free margin of the gingival sulcus and to
approximate the gingival margins of the crown to the gingival crest around the tooth.
o The subgingival placement of crown margin is justified since for primary teeth the buccal,
lingual and proximal contours are just above the gingival crest and the objective is to engage the
crown in natural undercuts.
 Contouring
o The next step in adaptation is to contour the crown with pliers so as to reciprocate the original
contour of the tooth.
o Most of the crowns provided today are precontoured but minimal contouring aids in better
anatomy hence better retention and its obvious advantages.
o The advantage of contouring is that the crown gets work hardened by manipulation and
becomes more retentive.
 Crimping of crown
o This is very important to the gingival health of the supporting tissue as a poorly adapted crown
will serve as a collection point for bacteria, contributing to recurrent caries or incipient
periodontal disease.
o The procedure of crimping is that the pliers must be ‘walked’ through the entire crown
continuously without lifting.
 o After completion of crimping there will be a gradual bend in the gingival third of crown. The uses
of crimping are protection of soft tissues, prevention of leakage of cements, prevention of
contamination and adequate retention.

Q24)Define pulpotomy and discuss the technique,material used,indications and contraindications in

detail
 Definition
o Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp,
followed by placement of a suitable dressing or medicament that will promote healing and
preserve vitality of the tooth.
 Indications
o Mechanical pulp exposure in primary teeth.
o Teeth showing a large carious lesion but free of radicular pulpitis
o History of only spontaneous pain
o Hemorrhage from exposure sites bright red and can be controlled
o Absence of abscess or fistula
o No interradicular bone loss
o No interradicular radiolucency
o At least 2/3rd of root length still present to ensure reasonable functional life
o In young permanent tooth with vital exposed pulp and incompletely formed apices.

 Contraindications
o Persistent toothache.
o Tenderness on percussion
o Root resorption more than 1/3rd of root length
o Large carious lesion with nonrestorable crown
o Highly viscous, sluggish hemorrhage from canal orifice, which is uncontrollable
o Medical contradictions like heart disease, immunocompromised patient
o Swelling or fistula
o External or internal resorption
o Pathological mobility
o Calcification of pulp.
  Formocresol pulpotomy/Single stage pulpotomy
o Formocresol was introduced by Buckley in 1904
.
o Composition of formocresol:
o Buckley’s Formula
 Cresol – 35 percent
 Glycerol – 15 percent
 Formaldehyde – 19 percent
 Water – 31 percent.
o Mechanism of Action
 It prevents tissue autolysis by bonding to the proteins.
 This bonding is of peptide groups of side chain amino acids and is a reversible process
accomplished without changing the basic structure of protein molecules
 Two-visit devitalization pulpotomy
o This is two-stage procedure involving the use of paraformaldehyde to fix the entire coronal and
radicular pulp tissue in two visits.
o Indications
 There is evidence of sluggish bleeding at the amputation site that is difficult to control
 Pus in the chamber, but none at the amputation site
 There is thickening of the PDL
 History of pain.
o Contraindications
 Nonrestorable tooth
 Tooth with necrotic pulp
 Glutaraldehyde pulpotomy
o It was first suggested by S Gravenmade and was introduced by Kopel in 1979.
o He suggested that inflamed tissue that produces toxic by products should be fixed, rather than
being treated with strong disinfectants.
o Mechanism of Action
 Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue.
 A narrow zone of eosinophilic, stained and compressed fixed tissue is found directly beneath the
area of application, which blends into vital normal appearing tissue apically.
 With time, the glutaraldehyde fixed zone is replaced by macrophagic action with dense
collagenous tissue, thus the entire root canal tissue is vital.

 Electrosurgical pulpotomy

 Cvek’s pulpotomy
o This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy.
o This was proposed by Mejare and Cvek in 1978.
o Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial
means and the remaining radicular tissue is judged vital by clinical and radiographic criteria
whereas the root closure is not complete.
o Rationale
 To preserve vitality of radicular pulp and allow for normal root closure.
 Mortal pulpotomy
o It is also called nonvital pulpotomy
o Ideally, nonvital tooth should be treated by pulpectomy, but sometimes it is impracticable due
to non-negotiable root canals and limited patient cooperation, mortal pulpotomy is indicated for
such patients
Q25)Define dental caries and preventive approach to caries control in India
 Definition
o Dental caries is an irreversible microbial disease of the calcified tissues of the teeth,
characterized by demineralization of the inorganic portion and destruction of the organic
substance of the tooth, which often leads to cavitation.”
 Preventive approach
o Primary Prevention of Dental Caries Keeping children’s teeth healthy before disease occurs.
[A] Behaviour Modification
o Dental Health Education
 The goal of dental health education is to establish good oral hygiene and dietary habits.
 The dental and allied professions have an ethical responsibility to inform patients about disease
and how to prevent it.
 A systematic review has demonstrated that dental health education carried out by a
professional at the chair-side is more often effective than other types of oral health promotion
interventions.The dental and allied professionals should carry out dental health education.
Consistent preventive messages should be reinforced.
 Dental health education advice should be provided to individual patients at the chair-side as this
intervention has been shown to be beneficial.
o Oral Hygiene
 The value of tooth-brushing in caries prevention lies with the regular topical application of
fluoride.
 Toothpastes containing fluoride at 1000-2800 parts per million (ppm) have been shown to be
effective in preventing dental caries in children aged between six and 16 years
 o Diet and Sugar Consumption
 Lowering sugar intake reduces the incidence of caries in children
 Limiting the ingestion of refined carbohydrate to meal times is also widely recommended
[B]Tooth Protection
o Sealants
 The use of resin pit and fissure sealants has been shown to be an effective barrier method of
preventing caries in pits and fissures
 Improvements in dental materials have increased retention and improved technique sensitivity.
 Sealants should be applied and maintained in the tooth pits / fissures.
 For optimal efficiency, the sealant should be present in all affected pits and fissures. The
condition of the sealant should be reviewed regularly with further coatings added as required.
The condition of sealants should be reviewed at each check-up.
 Glass ionomer sealants have poorer retention than composite resin materials and their effect on
caries reduction is equivocal. Therefore, glass ionomer sealants are mainly used when it is not
possible to use a resin material
o Fluoride Tablets
 Fluoride supplements may be considered for children with intractable caries risk.
 Fluoride tables (1 mg Fluoride daily) for daily sucking should be considered for children. Ideally,
tooth brushing and tablet taking should occur at different times to permit the longest possible
period for topical fluoride uptake from each fluoride source.
o Topical Varnishes/ Fluoride Solutions
 For children reliance on the home based use of fluoride toothpaste and tablets is deemed to be
insufficient, professional application of a fluoride varnish help to prevent dental caries.
 Correct application according to the manufacture’s instruction is important. Fluoride
concentrations may vary between products and only the recommended amount should be used.
o Chlorhexidine
 Chlorhexidine prophylaxis in the form of a rinse, gel or paste can achieve a substantial (average
46%) reduction in caries irrespective of application method, frequency, caries risk, caries
diagnosis, tooth surface, or fluoride regimen.
 Professional flossing four times a year with chlorhexidine gel has been shown to lead to
significant reductions in approximal caires.
 Chlorhexidine varnish should be considered as an option for preventing caries.
o Secondary and Tertiary Prevention
 Limiting the impact of caries at an early stage. Rehabilitation of the decayed teeth with further
preventive care.
 Treating any carious lesions operatively will not prevent further disease and primary preventive
measures must be continued
o Diagnosis of Dental Caries
 In order to deliver effective prevention, accurate diagnosis and monitoring of lesions over time
are required.
 Early diagnosis of approximal enamel lesions is important as the majority of lesions in the outer
half of enamel will take at least two years to progress into dentine, and progression is not
inevitable.With intervention, lesion progression can be slowed, arrested or even reversed.
 A thorough clinical examination of clean, dried teeth should be carried out to assist caries
diagnosis and to identify the patient’s caries risk category prior to deciding whether to take a
radiograph.
 Early caries detection methods should be an adjunct to clinical decision making, supporting
preventive treatment planning in conjunction with caries risk assessment but not justifying
premature restorative intervention.
o Management of Carious Lesions
 The management of carious lesions can be divided into three caries sites: Occlusal caries
Approximal caries and Smooth surface caries. The patterns of caries initiation and progressions
are different in each site, as are the management options.
 Management Of Occlusal Caries
 Once a decision has been taken to initiate operative intervention, it has been shown that sealant
restoration are as effective as amalgam restorations in managing small to moderate sized fissure
caries and involve less tooth destruction.
 Using composite instead of glass ionomers improves sealant retention. If amalgam is used as a
filling material, any remaining fissures which are caries free should be fissure sealed in
preference to extension for prevention. If only part of the fissure system is involved in small to
moderate dentine lesions with limited extension, the treatment of choice is a composite sealant
restoration.
 If fissure caries extends clinically into dentine, the current treatment of choice is to remove the
caries and place a restoration, rather than sealing over the caries
 However, if caries is inadvertently covered by a fissure sealant which is then well maintained,
the caries is very unlikely to progress.If caries extends clinically into dentine, then carious
dentine should be removed and the tooth restored. For more extensive lesion still there is a
wealth of evidence to support the use of well placed conventional amalgam fillings
 Management of Approximal caries
 Application of fluoride can slow or arrest progression of approximal enamel lesions and
therefore operative intervention is not indicated when lesions are at this stage of development.
 Preventive care (e.g. topical fluoride varnish) rather than operative care is recommended when
approximal caries is confined (radiographically or visually) to enamel.
 Management strategies for lesions confined to the enamel should also include: Twice daily use
of toothpaste containing at least 1000 ppm fluoride. Flossing Dietary advice.
 For approximal lesions requiring restoration, a Class II approach should be used in preference to
a tunnel preparation, which is technically very demanding and has been shown to have limited
durability.
 Composite resin is suitable for the restoration of small to moderate sized (not subjected to
direct occlusal loading) Class II cavities in premolar teeth.
 Management of Smooth surface caries
 In free smooth surfaces, caries is easier to detect and manage.
 The management strategy is the same as that for approximal lesions confined to enamel.
 Management strategies for smooth surface (non-cavitated) lesions should include: Twice-daily
use of a toothpaste containing at least 1000 ppm fluoride Plaque removal Dietary advice
(including the use of sugar free chewing gum, when acceptable)
o RE-RESTORATION
 It is common to find a range of previous restoration in high risk patients. Restorations may fail
for a number of reasons, including factors associated with the material or technique used or the
operator’s skill. However, for children further decay is a particular problem.
 The margin between restoration and tooth tissue is a potential site for new decay, known as
secondary or recurrent caries.
 More extensive lesions which continue to progress in spite of preventive care should be
restored with an appropriate material depending on their degree of visibility. However, the
 diagnosis of secondary caries is extremely difficult and there is a risk that large numbers of false
diagnoses of secondary caries will lead to unwarranted replacement and re-replacement of
fillings.
 If only part of a restoration is judged to have failed, then consideration should be given to
repairing rather than replacing it.
 The present review documents effects for several interventions to prevent caries since
extensive damage from caries can lead to major problems for the individual, affecting quality of
life both functionally and esthetically.
 Good general health also includes good oral health. Hence, preventing caries is an important
element in public health efforts

Q26)Define dental caries and classify it.Discuss in detail the treatment modalities for early childhood
caries
 Definition
o Shafer (1993) “Dental caries is an irreversible microbial disease of the calcified tissues of the
teeth, characterized by demineralization of the inorganic portion and destruction of the organic
substance of the tooth, which often leads to cavitation.”
 Classification
o According to occurrence:
 Incipient—initial primary caries often reversible
 Recurrent—secondary caries
 Residual—carries left due to mistake of dentist

o According to speed:
 Acute—fast spreading
 Chronic—slow spreading
o According to location:
 Pit and fissure
 Smooth surface
 Root surface
o According to direction:
 Forward caries—when caries in enamel is in a V-shape, i.e. base pointed towards DEJ.
 Backward caries—when the more extensive destruction is towards DEJ with small apex.
o According to age:
 Early childhood caries
 Adolescent caries
 Senile caries
o According to surface:
 Simple—one surface
 Compound—two surfaces
 Complex—more than two surfaces
o According to type of surface:
 Occlusal
 Proximal.
 Prevention of early childhood caries
o Early screening for signs of caries development, starting from the first year of life, could identify
infants and toddlers showing the risk of developing ECC and could also assist in providing
 information of parents about how to promote oral health and prevent the development of tooth
decay.
o High-risk children should be targeted with a professional preventive program that includes
fluoride varnish application, fluoridated dentifrices, fluoride supplements, sealants, diet
counseling, and chlorhexidine.
o Prevention of ECC also requires addressing the social and economic factors that face many
families where ECC is endemic.
o The education of mothers or caregivers to promote healthy dietary habits in infants has been
the main strategy used for the prevention of ECC. There are three general approaches that have
been used to prevent ECC; first is the community-based strategy that relies on educating
mothers in the hope of influencing their dietary habits as well as those of their infants, second
approach is based on the provision of examination and preventive care in dental clinics, the
third involves the development of appropriate dietary and self-care habits at home promotion

 RAPIDD Scale

Keeping children’s teeth healthy before disease occurs.


TThe goal of dental health educaon is to establish good
oral hygiene and dietary habits. The dental and allied
professions have an ethical responsibility to inform pa ents
about disease and how to prevent it.
A systemac review has demonstrated that dental health
educaon carried out by a professional at the chair-side
is more oen eecve than other types of oral health
6
The dental and allied professionals should carry out dental
health educaon. Consistent prevenve messages should
o The Readiness Assessment of Parents concerning Infant Dental Decay (RAPIDD) Scale was
developed to/assess a parent’s stage of change pre -contemplative, contemplative, or action
with regard to his/her child’s dental health.
o This instrument based on the work by Prochaska and DiClemente, measures pro and con
parental beliefs about caring for their child’s teeth.
o Parents in pre-contemplative stage show low openness and low health score whereas those in
action stage show high scores.
o Readiness assessment of parents concerning infant dental decay scale consisted of thirty-eight-
items with responses on five-point scale ranging from strongly agree to strongly disagree.
o The patient or primary caretaker was instructed to select a box under one of the five categories
after the interviewer read them the question in their native language.
o Each of the thirty-eight-items were placed into one of four constructs:
 Openness to health information
 Valuing dental health
 Convenience and change difficulty
 Child permissiveness.
o In order to categorize respondents as pre-contemplators, contemplators, or action individuals
the responses to the questions within each construct were summed, these slimmed values were
ranked, and percentiles were calculated for each individual within each construct.
o The RAPIDD instrument is a tool that is used to determine parent’s stage of change for their
child’s oral health.
o Once a particular stage of change has been established the counselor then determines the best
approach to move into next stage.

 Community based education

o The goal of education is to increase the knowledge of mothers about ECC, and to improve the
dietary and nutritional habits of infants and mothers.
o It is assumed that an increase in the knowledge of mothers or caregivers will influence their
self-care habits and dietary practices and, in turn, improves the dietary and oral hygiene habits
of infants leading to the prevention of ECC.
o Positive changes in infant feeding practices have been found to be modest, even when a
community educational program was designed and implemented in collaboration with members
of a high ECC risk community.

 Prevention of transmission of cariogenic bacteria

o There is evidence that cariogenic bacteria are transmitted from mothers to their infants.
 Professional and home based preventive approaches
o Professional treatment for early childhood caries ranges from diet counseling to the
prosthodontic rehabilitation of patient.
o Restorations are accomplished by GIC and composites, endodontic therapy is done as indicated
followed by placement of crowns and grossly decayed teeth are extracted followed by
placement of space maintainers.
o The use of fluoride is done according to the level of fluoride in water.

 Barriers in early childhood caries

 o Any proposal to improve social, mental and physical health of children cannot be successful
without adequate funding, political leadership and support. Some of the potential barriers in
providing optimum care for children are:
 Lack of involvement and commitment from dental and other health organizations.
 The dental community lacks a shared vision of the definition of the problem, how to prevent it
and who is responsible for planning and implementation.
 There is no integrated plan to fight the social, economic and nutritional issues facing people in
low socioeconomic group.
 There is weak direct support for research on epidemiology, etiology and prevention of ECC.
 Dental health is not a priority of most programs and insurance packages.

Q27)Causes of midline diastema between upper central incisors.Describe treatment plan for central
incisor diastema in child of 13 years
 Causes
o Transient malocclusion occurring during mixed dentition period which self corrects by itself
o Tooth material arch length discrepancy
o Unerupted mesiodens
o Abnormal frenal attachment
o Proclination
o Midline pathology
o Iatrogenic causes
o Racial predisposition
o Ectopic maxillary canines
 Treatment of midline diastema is done in three ways
o Removal of cause
o Active treatment
o Retention
o Removal of cause
 First phase involves removal of etiology
 Habits should be eliminated using removal or fixed habit breakers


o Second phase –active treatment
 It can be done using removable appliance or fixed appliance
 The principle applied here is of reciprocal anchorage(in fixed)
 The types of movement is either bodily or more commonly by tipping

 Removable appliance
 An active plate with palatal finger spring
 A spilt labial bow
 Hawleys plate with active labial bow

 Fixed appliance
 Fixed appliances incorporating springs or elastics bring about the most rapid correction of
midline diastema
 Elastics can be stretched between the two central incisors in order to close the space
 M shaped springs incorporating helices can be inserted into central incisors brackets.The spring
is activated by closing the helices
 A stainless steel band with a bracket or more commonly a bracket may be banded to tooth and
elastics utilized to bring the central incisors towards each other
 Third phase of treatment involves retraining the treated malocclusion
 Midline diastema is easy to treat but difficult to retain
 In order to prevent a relapse,a long term retention is required in these cases.Lingual bonded
retainers are required
  Other treatment measures
 Role of cosmetic restoration
 Esthetic composite resin
 Composite restoration
 Prosthesis/crown
 Missing teeth should be replaced with fixed or removable prosthesis

Q28)Define and classify space maintainence.How would you clinically manage a case of premature
loss of multiple teeth in children
 Definition
o This term was coined by JC Brauer in 1941. It is defined as the process of maintaining a space in
a given arch previously occupied by a tooth or a group of teeth.

 Incisors
o Premature loss of primary incisors is much more common in the maxilla than in the mandible.
o This loss is usually because of severe early childhood caries where multiple teeth are affected.
o One or more incisors may also be lost as a result of trauma. Space loss is usually minimal unless
the tooth or teeth are lost at a very young age or if there is crowding, excess overjet or deep
overbite.
o Functionally, early loss of maxillary incisors has minimal impact on mastication, although incisive
function is compromised.
o If the child has not yet developed lingual-dental sounds, speech may be affected and an
appliance may be indicated.
o In most instances, space maintenance is not required. If multiple teeth are lost early, an
appliance replacing these teeth may be offered for esthetic concerns.
o Appropriate appliances for this type of tooth loss include bilateral fixed or removable
appliances.
 Canines
o When a canine is lost prematurely, it is usually because of severe crowding in the incisor region
with ectopic eruption of the permanent lateral incisors accelerating the resorption of one or
both primary canine roots.
o This can occur in both the mandibular and maxillary arches.
o Unilateral loss of a primary canine is usually accompanied by a shift of the incisors toward the
affected side and a resultant midline discrepancy
o Bilateral loss reduces the lateral shifting, but can result in lingual tipping of mandibular incisors
and a decrease in the space available in the arch
o An appropriate appliance for primary mandibular canine loss is a lower lingual holding arch.The
appliance can be designed to include soldered spurs to resist distal migration of the incisors.
 First Molars
o Primary first molars are commonly lost because of caries or infection — both unilaterally and
bilaterally.
o There is space loss within the first four to six months after extraction,with migration of the
primary canines and permanent incisors toward the edentulous space in both arches
o Space loss can result in blocked out permanent canines, more commonly occurring in the
maxilla
o Space maintenance is generally considered to be important for children during the mixed
dentition stage.
o An appropriate appliance for isolated loss of the primary first molar is the band and loop. In the
event of loss of multiple teeth, fixed bilateral space maintainers or removable appliances may be
considered.
 Second Molars
o Early loss of primary second molars is less controversial. There is a high probability of space loss,
with a greater loss of arch length in the maxilla than in the mandible.
o The effects are far worse when tooth loss occurs prior to the eruption of the permanent first
molar, whose eruption into the oral cavity is guided by the distal surface of the primary second
molars.
o Premature loss of primary second molars clearly requires space maintenance. If tooth loss
occurs after the permanent molar erupts, a bilateral fixed appliance is the most appropriate,
although a reverse band and loop may be appropriate.
o Prior to eruption of the permanent molar, a distal shoe or a removable appliance can be
considered. In the event of multiple teeth lost, bilateral fixed appliances or removable
appliances are appropriate options.
 Space Maintenance Options
o Space maintainers can be classified into three categories, described below.
o An orthodontic assessment should be completed prior to determination of the most applicable
appliance, as malocclusion and degree of crowding influence the success and appropriateness of
space maintenance efforts.
o Some cases of early tooth loss may be better served with an immediate orthodontic referral for
space regaining efforts or to address problems with occlusion.
o Fixed Unilateral Space Maintainers
 The band and loop is one of the most commonly used space maintainers. In its traditional
design, it consists of a band around one of the teeth adjacent to the edentulous area and or
stainless steel wire loop that forms a cantilevered loop from soldered attachments on the buccal
and lingual surfaces of the band to the tooth on the other side of the edentulous space
 It is primarily used in cases with single tooth loss and is generally not recommended when
multiple teeth have been lost.
 The band is usually placed on the tooth distal to the extraction space (e.g., on the primary
second molar to contact the primary canine or on the first permanent molar to contact the
primary first molar).
 Placement of the band and loop traditionally involves two appointments — one to fit the band
and take an impression for a dental cast on which to fabricate the appliance and one to deliver
the appliance.
 As with any of the space maintainers using bands or stainless steel crowns as abutment teeth,
separators may be placed one to two weeks prior to the first appointment to facilitate the fitting
of bands if there are adjacent teeth.
  There are a few variations on the traditional band and loop. If used to maintain space after loss
of a primary second molar and the permanent first molar hasn’t erupted enough for band
placement, the band may be placed on the primary first molar with the loop extending distally
to contact the mesial surface of the permanent first molar.This is often called a reverse band
and loop
 The distal shoe is another fixed unilateral space maintainer that is specifically indicated when
the primary second molar is lost prior to the eruption of the permanent first molar.This
appliance consists of a band or a stainless steel crown that is adapted to the primary first molar
with a wire loop extending over the extraction space.
 Without space maintenance, the permanent molar will drift mesially into the extraction space.
o Fixed Bilateral Space Maintainers
 For the mandibular arch, there is only one passive bilateral space maintenance appliance — the
lower lingual holding arch. This appliance consists of two bands, typically placed on the
permanent first molars with lingual attachments to a round, stainless steel orthodontic wire
extending along the lingual surfaces of the mandibular arch.
 For the maxillary arch, there are two options if a fixed bilateral space maintainer is indicated —
the Nance appliance or the transpalatal arch. The Nance appliance is reported to be the more
commonly used appliance.This appliance consists of a stainless steel wire soldered to the lingual
surface of the two molar bands and extends to the anterior palate where it is embedded in an
acrylic button to provide greater resistance to the mesial movement of the abutment teeth .
 The transpalatal arch (TPA), also known as the Goshgarian arch, is similar to the other fixed
bilateral appliances. Bands are placed on the permanent first or primary second molars with a
stainless steel wire extending between the two abutment teeth.The wire may extend straight
across (transpalatal bar) or it may incorporate an omega loop in the center (Goshgarian or
transpalatal arch
 A variation on the fixed bilateral space maintainer is the pedi partial or Groper appliance
 This also has a very specific indication as a replacement for missing maxillary incisors.
o Removable Appliances
 Removable appliances are less standardized than any of the other space maintainers. There is
room for creativity in the design of each appliance.
 The only requirements are to have a mass of acrylic to fill the edentulous spaces and some type
of retention system, with any combination of anterior labial bows, ball clasps, Adams clasps or
C-clasps.
 These appliances are generally indicated for cases in which multiple teeth are missing. They are
a good option when the permanent molars have not yet erupted.
o Recent Innovations
 In order to decrease the number of visits required to deliver space maintainers, some
alternatives have been proposed.
 One recent innovation is the direct-bonded retainer.This consists of a stainless steel wire formed
on a stone cast, then bonded with flowable composite to the buccal surfaces of the teeth
adjacent to the extraction space.
 Another innovation, which is mostly being evaluated overseas, is the fiber reinforced space
maintainer.
Q29)Discuss the causes,sequel and management of early loss of primary teeth
 Causes
o Dental decay
o Poor oral hygiene
o Dental injuries
 Sequel
o Premature loss of primary teeth leads to poor arch length.Poor arch length leads to crowding,
ectopic eruption or impaction of permanent teeth
o Delayed eruption or premature eruption of permanent teeth
o The teeth both on right and left to the extracted tooth move to close the space, hence the space
designated for permanent tooth that will erupt after few years is lost and the tooth is blocked
inside the bone
o Relationship between the molars and canines is usually disrupted which more often calls for
treatment with braces
o Midline of teeth shift towards the extraction site
o Tooth opposing the extraction side usually elongates and over erupts
o Alteration in overbite and overjet of teeth
o Development of abnormal muscle activity and habits such as thumb sucking or tongue thrust in
newly created space, which creates further disruption in the bite
o Speech defect
o Poor nutrition and feeding
o Aesthetic and emotional problem
Q30)Classify injuries to anterior teeth.Discuss the management of Elli’s Class III fracture of permanent
central incisor at age of 9 years

 Management
o In young patient with open apices,it is important to preserve the pulp vitality by pulp capping
and partial pulpotomy in order to secure further root development
 Pulp capping-referQ10
 Partial pulpotomy-Refer Q24
o In young patients with open apices and non vital pulp,treatment of choice is apexification
 Apexification-refer cons question paper
o In older patient with closed apex treatment of choice is root canal treatment or pulpectomy
 Pulpectomy-Refer Q21

Q31)Enumerate Elli’s and Davey’s classification of traumatic injuries to anterior teeth.Discuss

management of a case of avulsion of maxillary central incisor at 9 years of age
 Treatment
o Reimplantation depends on extraoral time.
o If apical foramen is not closed—endodontic therapy is delayed till first signs of apical closure are
seen.
o If apical foramen is closed—endodontic therapy is done after 1 to 2 weeks depending on type of
reimplantation.
 Prognosis
o Tooth survival: 51 to 89 percent
o PDL healing: 9 to 50 percent
o Pulp healing: 4 to 15 percent.
 Reimplantation
o Case history should include exact information on the time interval between injury and
reimplantation as well as conditions under which the tooth has been stored (e.g. saline, saliva,
milk, tap water or dry environment).
o The following conditions should be considered before replanting a permanent tooth:
 The alveolar socket should be reasonably intact in order to provide a seat for the avulsed tooth
 The extra-alveolar period
 Short extra-alveolar storage: This is done if the tooth since the time of injury has been placed in
a suitable medium and the extra-alveolar time elapsed is short
 Long extra-alveolar storage: This is done in cases where the extraoral dry period of tooth is long
Q32)Define growth and development.Explain in brief prenatal and postnatal development of
mandible
 Definition of growth
o It is a dynamic process with stable pattern of changes resulting in the increase in physical change
of mass during the course of development.
o It has been defined by a number of authors as:
 Stewart (1982): Defined as developmental increase in mass
 Proffit (1986): Growth refers to increase in size or number
 Moyer (1988): Changes in amount of living substance
 Moss: Change in any morphological parameter which is measurable
 Todd (1931): Growth refers to increase in size
 JS Huxley: Self multiplication of living substance.
 Definition of development
o It is defined as:
 Todd (1931): Increase in complexity.
 Moyers (1988): Naturally occurring unidirectional changes in the life of an individual from its
existence as a single cell to its elaboration as a multifunctional unit terminating in death.
 Pinkham (1994): Development addressess the progressive development of a tissue.
 Enlow: A maturational process involving progressive differentiation at the cellular and tissue
levels.
 Prenatal Development of Mandible
o Mandible develops from the cartilage of 1st arch, i.e. Meckel’s cartilage (Fig. 12.22).

o At 6th week of IUL a hyaline cartiligenous rod surrounded by fibrocellular capsule extends from
otic capsule to midline of fused mandibular process from both sides.
o
o Condensation of mesenchyme occurs.
o During 7th week intramembranous ossification begins from center of mandible and spreads
anteriorly and posteriorly along lateral aspect of Meckel’s cartilage.
o Bone troughs from both side of mandibular process come in close approximation and remain
separated in symphysis region till birth.
o Posteriorly ossification proceeds till the point of division of mandibular nerve.
o Medial and lateral alveolar plates develop upwards in relation to tooth germs.
o Ramus develops by rapid spread of ossification posteriorly into the mesenchyme of 1st arch
turning away from Meckel’s cartilage.
o An area of mesenchymal condensation is seen on ventral part of developing mandible in 5th
week of IUL. This cone shape cartilage starts ossification about 14 weeks and then fuses with
ramus to form condylar process.
o Accessory cartilages appear in coronoid region also but they disappear before birth, however
when these appear in mental region they form mental ossicles.

 Postnantal growth of mandible

o Mandible is the most diverse bone in human craniofacial structure as it is made-up of many
small individual bones which on their own are mini-skeletal units.
o Ramus
  Deposition on posterior aspect and resorption on anterior aspect to move the ramus posteriorly
to accommodate for molars and to accommodate increasing muscle mass of masticatory
muscles.
o Body
 Due to resorption of ramus the old ramal bone changes to posterior body limit.
 Bone deposition also occurs along inferior margins of body of mandible, thus lengthening
mandibular body.
o Lingual tuberosity
 This moves posteriorly by deposition along posterior surface and resorption below in lingual
fossa
o Angle
 Lingually, there is resorption on posterioinferior aspect and deposition on anteriosuperior
aspect.
 Buccally, there is deposition on posteriosuperior aspect and resorption on anteriosuperior
aspect. This results in flaring of angle of mandible
o Coronoid process
 Deposition occurs on lingual surface and further growth is based on enlarging ‘V’ principle takes
place posteriorly
o Condyle
 Growth may either occur by bone deposition along condylar cartilage which then interacts with
cranial base thus displacing mandible downward and forward or it may occur as growth of soft
tissues surrounded in the region later followed by bone formation
o Alveolar process
 Develops as a response to presence of teeth by increasing in thickness and height by depositions
at margins.
o Chin
 Bone resorption occurs in superior aspect over the concavity in mental region

Q33)Define dental caries.Explain in brief various methods of caries detection for management of
clinical caries in children along with principles,advantage and disadvantage
 Conventional diagnostic methods
o Visual inspection
 Principle
 Visual inspection, the most ubiquitous caries detection system, is subjective.
 Advantages
 Assessment of features such as color and texture are qualitative in nature.
 Disadvantages
 These assessments provide some information on the severity of the disease but fall short of true
quantification.
 They are also limited in their detection threshold and their ability to detect early, noncavitated
lesions restricted to enamel is poor.
 The clinical accuracy of visual examination with regards to caries detection is only 25 to 50
percent.
o Tactile examination with a probe
 Disadvantages
 Tactile examination of dental caries has been criticized because of the possibility of transferring
cariogenic microorganisms from one site to another, leading to the fear of further spread of the
disease in the same oral cavity.
 Moreover, use of an explorer can cause irreversible damages to the iatrogenic and
demineralized tooth structure
o Dental floss
 When a string of unwaxed floss is moved on the carious proximal tooth surfaces there is
resistance on withdrawal and the fibers appear torn.
o Tooth separation
 Principle
 Separating the tooth for visualizing the posterior approximal surfaces is now regained
popularity.
 This method uses orthodontic modules or bands and achieves slow separation.
 Taking impressions of the approximal surfaces thus separated have been used to assist in the
detection of cavitations.


 Disadvantage
 Tooth separation have detected more noncavitated enamel lesions than visual-tactile
examination without separation or bitewing examination
o Ultraviolet Illumination
 Principle
 Ultraviolet (UV) light has been used to increase the optical contrast between carious lesion and
the surrounding soft tissue.
  In area of less mineral content like the carious lesion, the natural fluorescence of tooth enamel
as seen under UV illumination is decreased.
 Under UV illumination carious lesion appears as a dark spot against fluorescent background.
o Caries detector dyes
 Principle
 The property of dyes to enhance contrast by their color can be used in clinical dentistry.
 They are applied for about 10 seconds and rinsed off.
 Any deeply stained tooth structure should be removed, usually with slow speed burs or spoon
excavators.
 They should be reapplied after you remove all the stained dentin to confirm no residual caries
remains in the tooth.
 Following dyes are used to detect carious enamel specifically:
– 0.5 percent basic fuchsin
– Procion dyes
– 1 percent acid red in propylene
– Methylene blue
– Procion dyes react with OH– and NH 2+.
 Conventional radiographs
o Dental radiographs are indispensable part of the contemporary dentist armamentarium for
diagnosis of caries.
o Disadvantage
 Though conventional radiographs like bitewing and intraoral periapical radiograph are most
frequently used for the detection of caries, they may cause overlapping of teeth due to faulty
angulations and may also miss the initial lesion.
 The limitations of radiographs are that it is not able to differentiate between an active and an
arrested caries lesion, and also to distinguish a cavitated and a non-cavitated lesion.
o Advantage
 In such situation bitewing radiographs are absolutely required to detect proximal lesions in
primary molars.
 Advanced diagnostic methods
o Digital radiography
 Advantages
 The image is displayed immediately and no need of processing
 Reduction in radiation dose
 Digital manipulation of the image is possible to enhance the viewing
 It can be used as a visual aid to be shown to the patient on the computer screen
 It increases the confidence and credibility in the treatment-decision making process.
 Disadvantages
 The rigidity and thickness of sensor can cause discomfort to the patient
 The lifespan of sensor is unknown
 High initial system cost
o Digital subtraction radiography
 Advantage
 Distinguish small differences between subsequent radiographs that otherwise would have
remained unobserved because of over-projection of anatomical structures or differences in
density that are too small to be recognized by the human eye.
 Principle
 The procedure is based on the principle that two digital radiographic images obtained under
different time intervals, with the same projection geometry, are spatially and densitometrically
aligned using specific software.
 If the two digital images are identical, this method will produce an image without details (the
result is zero).
 However, if caries has regressed or progressed in the mean time, the result will be different
from zero. When there is caries progression, the outcome will be a value above zero (increase in
pixel values). In case of caries regression, the result is opposite and the outcome will be a value
below zero (decrease in pixel values)
 Disadvantage
 very sensitive to any physical noise occurring between the radiographs and even minor changes
leads to large errors in the results.
o Fiberoptic transillumination
 Principle
 Fiberoptic transillumination, it is a practical method of imaging teeth in the presence of multiple
scattering
 The light propagates from the fiber illumination across tooth tissue to nonilluminated surfaces.
The resulting images of light distribution are then used for diagnosis.
 Carious area appears as darkened shadow that follows the decay
 Advantage
 accurate as bitewing radiography and superior to visual examination in diagnosis of inter-
proximal caries.
 simple noninvasive examination technique, no radiation hazards, can be used on all surfaces.
 Disadvantage
 system is subjective rather than objective, as there is no continuous data outputted and it is not
possible to record what is seen in the form of an image.
o Quantitative light induced fluorescence
 Principle
 Fluorescence is a phenomenon by which an object is excited by a particular wavelength of light
and the reflected light is of a larger wavelength. When the excitation light is in the visible
spectrum, the fluorescence will be of a different color.
 Demineralization of enamel results in a reduction of this auto-fluorescence. This loss can be
quantified using proprietary software and has been shown to correlate well with actual mineral
loss; r = 0.73–0.86.
 Advantages are high reproducibility, detection of small incipient lesions in enamel and dentin,
image storage and transmission and can act as motivational tool for patient.
 Disadvantage is that it is a isolation sensitive procedure.

o Fluorescence camera
 Principle
 On these images, it is possible to see different areas of the dental surface that fluoresce in green
(sound dental tissue) and in red (carious dental tissue)
 Advantages include motivation for patient and storage of data.

o Digital imaging fiberoptic transillumination

 Advantage is that it can indicate the presence of incipient and recurrent caries even when
radiological images fail to show their presence.
o Laser fluorescence
 Principle
 Principle of DIAGNOdent is based on the fact that the caries induced changes in teeth lead to
increased fluorescence at specific excitation wavelength.
 Advantages are early detection of lesion, quantification of caries and improved diagnostic
accuracy.
 Disadvantages are that it cannot detect secondary caries and proximal caries accurately.

o Electrical conductance measurements

 Principle
 It is based on the principle that sound tooth surfaces possess limited conductivity whereas
demineralized or carious enamel act as conductive pathway.
 Advantage is that it is small, handy and provides accurate diagnosis.
 Disadvantages are that area of diagnosis is confined to dimension of probe, it is technique
sensitive and the status of lesion is not known like arrested or active.

o Ultrasound caries detector

 Principle
 This is a new ultrasonic proximal caries detector that works by transmitting surface ultrasonic
waves.
 This detector records specific profiles of ultrasonic echoes obtained from the enamel surface,
dentino-enamel junction and pulpo-dentinal junction.
 Advantage
 superior in sensitivity and specificity as compared to bitewing radiography in detection of
approximal caries.
o Midwest caries ID(LED technology)
 Principle
 This technology utilizes a handheld device which emits a soft light emitting diode (LED) between
635 nm and 880 nm and analyzes the reflectance and refraction of the emitted light from the
tooth surface, which is captured by fiberoptics and is converted to electrical signals for analysis.
 Advantage is that sensitivity and specificity is higher than that of DIAGNOdent.
 Disadvantage is that Midwest Caries ID is not able to differentiate enamel lesions from sound
surfaces
o Cariescan pro
 Principle
 It involves the passing of an insensitive level of electrical current through the tooth to identify
the presence and location of the decay.
 During measurement, a green color display indicates sound tooth tissue, while a red color
indicates deep caries requiring operative, and a yellow color associated with a range of
numerical figures from 1 to 99 depicts varying severity caries, which require only preventive
care.
 Disadvantage is that it cannot be used to assess secondary caries, the integrity of a restoration,
dental root caries, and the depth of an excavation within a cavity preparation.
o Intraoral television camera
 Advantages are increased vision and magnification.
 Disadvantage is loss of specificity.
  D-Carie Mini
 Principle
 uses laser fluorescence to detect occlusal lesions.
• Advanced radiographic techniques
o Magnetic resonance microimaging (MRMI)
 Principle
 The basis of MRMI is that different species of atomic nucleus have different intrinsic nuclear
spins.
 When a magnetic field is applied, the nuclear spins align in a finite number of allowed
orientations. If these orientations are perturbed by a pulse of radio frequency energy, the
energy gets absorbed and then retransmitted. The chemical environment of tooth determines
the frequency of the retransmitted energy peak.
 Advantage
 Carious regions give an intense image that is readily distinguishable from other soft tissue
 This technique is noninvasive and allows a specimen to be re-imaged after further exposure to
clinically relevant environment.
 Disadvantage
 cost and clinical testing.

o Photo stimulable phosphor radiography

 Principle
 A latent image is produced by exposing the storage phosphor screen with X-rays.
 Advantages
 can be used with existing X-ray sources, wider exposure range and transfer of images is possible.
 Disadvantages
 high cost and chances of cross infection.

o Tuned aperture computed tomography (TACT)

 Advantages
 TACT is a new imaging device which enhances the image by decreasing the superimposition of
anatomical structures.
 It uses digital radiographic images and its software correlates these images into layers so that
sliced sections can be viewed.
 A series of 8 radiographs can be assimilated one TACT image.
 It is effective in evaluating primary stimulated recurrent caries and simulated osseous defects
and can localize a lesion accurately with minimal radiation.
 Advanced dye detection techniques
o Confocal laser scanning microscopy (CLSM)
 Principle
 This is operated simultaneously with Ar and Kr ion lasers and an appropriate set of filters, the
reflection image of the dentin structure and the fluorescent images of the labeled Carisolv can
be recorded simultaneously.
o Dye-enhanced laser fluorescence (DELF)
 Principle
 This technique is based on a hypothesis that if a fluorescent dye penetrates a carious lesion the
accuracy of current laser fluorescence for caries detection is enhanced.
 Advantages
  Useful in diagnosis of subsurface lesion.
o Species specific monoclonal antibodies
 Principle
 Identifies specific monoclonal antibodies that recognize the surface of cariogenic bacteria.
 Advantages
 The probes are tagged with fluorescent molecules that measure quantitatively with
spectrometer.
 They can be used at chair side by dentist and provide instant results.
o Infrared thermography
 Principle
 Thermal radiation energy travels in the form of waves. It is possible to measure changes in
thermal energy when fluid is lost from a lesion by evaporation.
 The thermal energy emitted by sound tooth structure is compared with that emitted by carious
tooth structure.
 Disadvantage
 It’s a method of determining lesion activity rather than a method of determining the presence
or absence of a lesion.

Q34)Classify various diseases of pulp as applicable to primary teeth.Write in brief step by step
management of primary mandibular second molar with history of spontaneous severe pain with
involvement of periradicular structure on radiograph
 Multiple visit Pulpectomy
 Obturation
o Properties of ideal root canal filling material for primary teeth
 Resorable,antiseptic,non inflammatory,non irritant,radiopaque,easy to use and does not
discolor the tooth
o No such material exists;CaOH+iodoform comes closest
o Gutta percha and siver points are contraindicated as they interfere with physiologic primary root
resorption
o ZnOEugenol and CaOH with iodoform are used
o Obturation techniques
 With a reamer
 A thin mix is made and carried into root canal with no 15 or no.20 reamer
 The reamer is then
 Rotated clockwise and simultaneously tilted 10-15 times(facilitates entry)
 Moved vertically and simultaneously tilted 10-15 times(facilitates lateral condensation and
coating of canals)
 Withdrawn anticlockwise 5 times(material stays inside the canal)
 With wet cotton: similar to above but squeezed wet cotton pellet is used to condense material
 With a lentulospiral: material is taken inside the canal with a lentulo or lentulospiral
 Endodontic pressure syringes,jiffy tubes and tuberculine syringes may also be used
 Obturation techniques for CaOH with iodoform
 Canal is dried and an injectable syringe is loaded
 The syringe is taken inside the canal,the material is extruded slowly while syringe is withdrawn
 This technique may also be used with calcium preparation lacking iodoform
 Final restoration: Stainless steel crown
o Prefabricted semi permanent restorations for both primary and permanent teeth
o Available in range sizes from 2 to 7
o Technique
 Anaesthetize the patient and isolate tooth
 Reduce the occlusal surface by 1.5-2mm with a no 69 or 169 bur
 Round all sharp line angles by moving the bur at 45 degree
 Reduce the proximal surface
 Select a crown,seat it and mark its extention
 Trim the crown to below the mark
 Contour and crimp it
 Cementation is frequently done with GIC
 Check the margins
o Hall technique
 A unique and minimally invasive approach to managing deep carious lesion in deciduous
dentition by cementing metal crowns over them
 Does not require local anesthesia,tooth preparation or even caries removal
 Requires careful case selection,a high level of clinical skill and excellent patient management
 Procedure
 Protect child’s airway
 Size the crown
 Fill it with cement
 Locate and seat fully
 Wipe away excess
 Seat further by asking the child to bite on it
 Check and clean
 Extraction
o Indications
 Infectious process can’t be arrested
 Lack of bony support
 Lack of root support
 Inadequate tooth structure remaining for restoration
 Patient has medical factors that contraindicate saving primary tooth(congenital cardiac
defects,immune-suppression)