PEDODONTICS 19 LOUIS W. RIPA, D.D.S., M.S MILTON |. HOUPT, D.D.S., M.D.S., M.Ed., Ph.D. MORPHOLOGY ‘QUESTIONS ANSWERS Which primary molar crown most resembles the (a) The primary second molars re- crown of a permanent premolar? semble first molars; the mandibular (a) maxillary first first primary molar does not re- {b) maxillary second semble any permanent tooth. (c) mandibular first (d) mandibular second (e) none of the above are correct How do pulp chambers in primary teeth compare (©) Although primary teeth are general- proportionally with those in permanent teeth? ly smaller than their successors, (a) smaller in primary teeth their pulp chambers are proportion- (b) larger in primary teeth ally larger. (c) similar in both dentitions (d) variable in permanent teeth During which stage of tooth development could (d) Disturbances in any stage after initi- aberrations cause congenital absence of lateral in- ation result in a malformed tooth. cisors? (a) apposition (b) histodifferentiation (c) morphodifferentiation (a) initiation {e) eruption What is the proper sequence of the histological (by stages of tooth development? (a) initiation, histodifferentiation, proliferation morphoditferentiation, mineralization (b) initiation. proliferation, _histodifferentiation morphodifferentiation, mineralization (©) proliferation, initiation, morphodifferentiation mineralization (d) proliferation, morphodifferentiation, histod! ferentiation, mineralization 480PEDODONTICS 481 QUESTIONS ANSWERS Which of the following anomalies occurs during (d) If initiation or proliferation is inter the initiation and proliferation stages of tooth develop- rupted, then a tooth will not form ment? and oligodontia results. If no teeth (a) amelogenesis imperfecta form, anodontia results. (b) dentinogenesis imperfecta (c) enamel hypoplasia (d) oligodontia (e) ankylosia Which statement is appropriate for natal teeth? (0) Occasionally, normal primary in- {a) eruption is soon after birth cisors are erupted at birth; these are (b) usually normal primary incisors referred to as natal teeth, They (c) usually supernumerary teeth should not be extracted unless they (2) extraction is indicated are very loose. Development of the other teeth usually proceeds nor- mally In a four year old child with less than a normal num- (c) Concrescence refers to teeth joined ber of erupted teeth, the mandibular lateral incisor only by cementum. When teeth are crown is bifid in shape and appears radiographically also joined by dentin and enamel with two roots and two root canals, What is the probable they are labeled geminated if there diagnosis? is a single root canal and a normal (a) dilaceration number of erupted teeth. If there (b) concrescence is one less than the normal number. (c) fusion the tooth is likely a fusion of the (4) gemination central and lateral incisors. Indicate which of the following characteristics are (a) A (b) A (c) B (d) A (e) A() B (g) B found in primary (A) and which in permanent (B) teeth (AW BUB (a) more prominent pulp horns (0) relatively larger pulp chambers (©) less vascular pulp ‘) lighter in color e) more pronounced cervical bulge ) gingival enamel rods may slope api- cally (9) more pronounced contact point (h) has higher incidence of prismiess outer layer of enamel (i) ——. larger occlusal table i wider mesiodistally How do the widths of the second primary molarand —(c) The average mesiodistal width of its successor compare? the maxillary second primary molar (a) about the same is 8.2 mm and that of the mandibular (b) successor is wider second primary molar is 9.9 mm (c) primary molar is wider The average width of the permanent (d) depends on tooth size in relation to jaw size premolars is 7.0 mm How does the thickness of dentin in primary teeth (c) compare with that of permanent teeth? (a) 1/4 (b) 1/3 (c) 1/2 (a) 2/5 (44482 PEDODONTICS DEVELOPMENT OF OCCLUSION QUESTIONS ANSWERS Which is the most frequently observed sequence of eruption of the mandibular permanent teeth? (a) central incisor, first. molar, lateral incisor. canine. first premolar, second premolar. sec- ond molar central incisor, first molar, lateral incisor, first premolar, second premolar, canine, second moiar (c) first molar. central incisor, lateral incisor. canine, first premolar. second premolar, sec- ond molar (4) first molar, central incisor. lateral incisor, first premolar, second premolar, canine, second molar (e) first molar, central incisor, lateral incisor, ca- nine. first premolar, second molar, second premolar co (c) This eruption pattern is seen in ap- proximately 45 per cent of children. The next most frequently observed sequence is (e), in which the second molar erupts before the secand pre- moiar. ee Which is the most frequently observed sequence of eruption of the maxillary permanent teeth? (a) central incisor. first molar, lateral incisor, ca- nine, first premolar, second premolar, second molar (b) central incisor, first molar. lateral incisor, first premolar. second premolar, canine, second molar (c) first molar, central incisor, lateral incisor, first premolar, canine, second premolar, second molar (d) first molar, central incisor, lateral incisor, canine, first premolar, second premolar, sec cond molar (e) first molar, central incisor. lateral incisor, first premolar. second premolar, canine, second molar (e) This eruption pattern is seen in ap- proximately 50 per cent of children. The next most frequently observed sequence is (c). in which the canine erupts before the second premolar. + Between which primary teeth do “primate” spaces oceur? {a) maxillary canine and first molar; mandibular canine and first molar (b) maxillary lateral incisor and canine; man- dibular lateral incisor and canine (c) maxillary lateral incisor and canine: mandib- ular canine and first molar (d) maxillary canine and first molar: mandibular lateral incisor and canine (c) These interdental spaces are c: primate spaces because of their existence in other primates besides man. They are usually present when the primary dentition is spaced and are usually absent when it is crowded, In the same child, primate Spaces may be present in the maxil- lary arch but not in the mandibular. or Vice versa.PEDODONTICS 483 ‘QUESTIONS ANSWERS Figure 19-1 What is the terminal plane relationship of the (a) The terminal plane describes the re- primary dentition depicted in Figure 19-1? lationship between the distal prox (a) mesial step mal surfaces of the maxillary and distal step ‘mandibular second primary molars straight during the period of the primary Class | dentition. The other terminal plane Class 1 relationships are shown in Figure 19-2 (distal step) and Figure 19-3 (straight terminal plane). The straight terminal plane is the most common, Figure 19-2. Distal step terminal plane relation: ship in the primary dentition, Figure 19-3, Straight terminal plane rela- tionship in the primary dentition,484 PEDODONTICS ‘QUESTIONS ANSWERS How is a Class | permanent molar relationship achieved in a primary dentition with a mesial terminal plane? (a) an early mesial shift of the mandibular first permanent molars (b) a late mesial shitt of the mandibular first per- manent molars (c) utilization of the maxillary leeway space (d) utilization of the mandibular feeway space (e} none of the above are correct (e) In either a spaced or crowded pri- mary dentition that terminates in a distinct mesial step. the first per- manent molars erupt into a Class | interdigitation. A shift of the pri- mary molars is not necessary, How is a Class i permanent molar relationship achieved in a nonspaced primary dentition with a straight terminal plane? (a) immediate eruption into Class | cuspal inter- digitation (b) an early mesial shift of the mandibular first permanent molars (c) a late mesial shift of the mandibular first per- manent molars (a) none of the above are correct (c) In this type of dentition. the first permanent molars erupt into an end-to-end position (Figures 19- 4A and B) and achieve a Class | molar relationship by the mandibu- lar molars migrating mesiaity when the mandibular second. primary molars exfoliate (Figure 19-4C). This is called a late mesial shift. fa straight terminal plane is present in a spaced primary dentition, a Class { permanent molar relationship can be achieved by an early mesial shift A Figure 19-4. A. Nonspaced primary dentition with straight terminal plane, B. First permanent molars erupt into end-to-end rolationsip €. Late mesial shift of mandibular first perman- ent molars occurs after primary molars extoliate‘QUESTIONS PEDODONTICS 485 ANSWERS The leeway space is. (a) the sum of the mesiodistal widths of the pri- mary canine, first primary molar, and second primary molar minus the sum of the mesiodistal widths of the underlying permanent canine, first premolar, and second premolar {e) The average leeway space is given as 0.9 mm in the maxitla and 1.7 mm in the mandible (unilateral measure- ments). There is much individual variation; some children may have no leeway space. (b) approximately twice as large in the mandibular arch as itis in the maxillary arch (c) largely determined by the difference in widths between the relatively wide second primary molar and the smaller second premolar (d) utilized to achieve a normal permanent molar occiusion in certain dentitions (e) all of the above are correct Figure 19-5. Diagram illustrating arch length (a) and arch circumference (b) in the early mixed dentition, Between the ages of 3. and 18 years, the arch length of the average child will (a) decrease approximately 2 mm in each arch (b) decrease approximately 6 mm in each arch (c) increase approximately 2 mm in each arch (d) increase approximately 6 mm in each arch mm in each arch. There is a de- (a) While there 1s usually an increase in arch length at the time of the erup- tion of the permanent incisors. the net change between ages 3 and 18 years is a loss of approximately 2 le) not change crease at age 6 when the first per- manent molars erupt and between ages 10 to 12 when primary molars have exfoliated and a relatively stable permanent molar interdigita tion is achieved. + With the eruption of which teeth do maxillary ante. (d) The maxillary central incisors erupt rior diastemas normally clase? with a slightly distal inclination of (a) first molars the crown and some midline space (b) third molars (diasterma) between them. in most (c) premolars children with a normal labial {d) canines frenum, the diastema decreases with the eruption of the lateral in cisors and closes when the cuspids erupt.PEDODONTICS QUESTIONS ANSWERS How will measurements of overbite usually change in a group of children followed from ages 3 to 187 (a) increase in absolute value (mm) but show a rel- ative (percentage) decrease (b) increase in absolute value but show no relative change (6) decrease in absolute value and show a rela- tive change (d) decrease in absolute value but show no rela- tive change (e) increase in absolute value and increase rela- tively (b) Overbite is the distance that the maxillary incisal edge closes verti: cally past the mandibular incisal edge when the posterior teeth are in occlusion. The overlap may be measured absolutely (for example, in millimeters) or relatively (for ex- ample, expressed as a fraction or Per cent of overlap). When mea- sured in millimeters, overbite in creases with age and the change from the primary to permanent den- tition. This is due, in part, to the difference in size between the pri- mary and permanent teeth. When expressed as a percentage of the mandibular crown height over lapped by the maxillary incisor, the Proportionate amount of overbite between ages 3 to 18 is relatively unchanged. It is not possible, how- ever, to predict overbite changes in an individual child. Moorrees has shown that the degree of overbite may increase, decrease, or remain the same as a child gets older. DENTAL CARIES QUESTIONS Which is the same as dental plaque? (a) materia alba (b) debris (c) pellicle (d) all of the above are correct (2) none of the above are correct Where does @ proximal lesion ia a primary molar usually initiate? (a) at the area of contact with the adjacent tooth (b) slightly occlusal to the contact area (c) slightly gingival to the contact area (d) none of the above are correct; there is no specific site for the development of proximal lesions ANSWERS (e) Dental plaque consists of an or- ganized microbial mass that is closely adherent to the tooth or restoration surface. Materia alba is an unorganized mass of bacteria and cellular material; debris con- sists mainly of food particles. Both materia alba and debris are easily dislodged by vigorous rinsing, while dental plaque cannot be removed in this manner. Pellicies are bac- teria-free organic membranes. (c) Caries on a proximal surface gen- erally initiates slightly gingival to the contact area, where cariogenic plaque accumulates and is difficult to mechanically remove.‘QUESTIONS PEDODONTICS 487 ANSWERS What is the earliest appearance of carious demin- eralization of the enamel that can be detected clini- cally? (a) an opaque white area that is hard to the ex- plorer tip (b) a chalky white area that can be penetrated by pressure from an explorer tip (c) a dark brown area that resists penetration by an explorer (6) cavitation of the enamel surface that appears radiolucent on radiographs (e} cavitation of the enamel surface that is not detectable radiographically (a) The early carious lesion appears clinically as a “white spot” because loss of mineral salts alters the re- tractive qualities of the affected enamel. The initial loss of mineral is a subsurface loss and therefore the enamel surface remains intact. What is the order in which caries usually develops on the occlusal and proximal surfaces of second pri- mary molars? (a) first-mesial; second—occlusal; third distal (b) first—occlusal; second—distal; 'third—mesial (c} firstocclusal; second—mesial; third—distal (d) first— mesial; second—distal; third— occlusal (c) Occlusal caries develops first be- cause of the greater susceptibility of pits and fissures. The mesial sur- face is in contact with the distal sur- face of the first primary molar from age two; thus. caries may eventu- ally initiate in the plaque-retentive area beneath the contact. Caries usually does not develop on the distal surface of the second primary molar until after the first permanent molar has erupted and established approximal contact. There are hard dark brown lesions on the labial surfaces of all four primary cuspids in a seven year old child. The teeth are not painful and scraping with a spoon excavator yields only a few flecks of dry dis- colored dentin. What are these lesions? (a) active carious lesions (b) arrested carious lesions (c) local enamel hypoplasia (b) Arrested, or eburnated. caries has a hard texture, is darkly pigmented and is painless. Hypoplasia may be white or pigmented and. if of focal origin, would not affect the cuspids in ali four quadrants. (d) abrasion In which group of Atlantic Coast states is the caries prevalence highest for comparably aged children? (a) New England states (b) Central Atlantic states {c) Southern states (d) none of the above are correct (a) The prevalence of dental decay in the United States varies on a geo- graphic basis. Caries prevalence is, higher in Atlantic and Pacific Coast states than in the Central Plains states. Also caries prevalence in- creases progressively from south to north along both coasts. During dental examinations on ten year old chil- dren, which permanent tooth surface would show the highest carious or filled prevalence? (a) the mesial surface of the central incisors (b) the occlusal surface of the first premolar (c) the labial surface of the canine (d) the occlusal surface of the first molars (d) The occlusal surfaces of molars are the most caries-susceptible sites in the permanent teeth of children.488 PEDODONTICS QUESTIONS ANSWERS Which primary teeth are most severely involved in (d} The contents of the nursing bottle the nursing bottls caries syndrome? pool around the maxillary incisors, (a) maxillary molars especially while the child sleep: (b) maxillary and mandibular canines resulting in severe destruction of (c) mandibular incisors, these teeth (d) maxillary incisors Which primary teeth are least affected in the (c} The tongue overlies the mandibular nursing bottle caries syndrome? ncisor teeth during sucking, min- (a) maxillary molars mizing the contact between the (b) maxillary and mandibular canines contents of the nursing bottle and (c) mandibular incisors. these teeth. A diagnostic feature of (d) maxillary incisors nursing bottle caries is the severe destruction of the maxiliary incisors, white the mandibular incisors are usually caries free (Figure 19-6) Figure 19-6. Nursing bottle caries, The extreme involvement of the maxillary primary incisors, while the man- dibular incisors are caries-free, is typical Which of the following teeth and surfaces are (d) A diagnosis of rampant caries characteristically involved when a child or adolescent made when there is carious in- S diagnosed as having rampant caries? volvement of those teeth and sur- (a) occlusal surfaces of permanent molars faces that are regarded as least (b) proximal surfaces of maxillary incisors susceptible to decay, (c} lingual pits of maxillary molars and incisors, and buccal pits of mandibular molars (4) proximal surfaces of mandibular inci cervical areas of any teeth sors andPEDODONTICS 489 PERIODONTAL DISEASE ‘QUESTIONS ANSWERS Which factor is not used in the diagnosis of normal gingiva in a young child? (a) color of Nasmyth's membrane (a) Nasmyth’s membrane 1s on the sur- face of an erupting tooth and not on the gingiva (b) contour of papitiae (c) stippling {(d) sulcular depth (e} tight-fitting gingival cotlar What is the most common cause of generalized (a) Acute herpetic gingivostomatitis acute gingival inflammation in a preschoot child? usually occurs. in preschool chil- (a) acute herpetic gingivostomatitis dren. The condition develops sud- (b) vitamin C deficiency denly with general malaise, light (c) acute necrotizing gingivitis fever, acute gingivitis. and small (d) vitamin B deficiency vesicles in the oral mucosa. Acute le) drug therapy necrotizing gingivitis, characterized by necrosis of the interdental papillae, occurs more frequently in young adults What causes the green stains frequently seen on ——(d) Chromogenic bacteria cause stains children’s teeth? to form in the materia alba on (a) materia alba teeth (b) enamel defects (c) dentin defects (d) chromogenic bacteria Breath odors are sometimes important in diagnosis. fe) Patients with diabetes produce of the following cause bad breath? ketones that produce sweet breath cleft lip odors. Patients with draining fis- draining fistula tulas or rhinitis may have disagree. rhinitis able breath odors from putrescence cretinism recurrent herpes labialis diabetes mellitus 1 2. 3 4. 6 (a) 1.3. and 4 b) 1. 4, and 6 (c) 1,$,and6 (a) 2.3. and 5 (e) 2.3. and6 (f) 2,4 and 6 What shouid be done for a patient with generalized (a) Herpetic stomatitis is of viral origin acute herpetic stomatitis? and would not be affected by pen (a) prescribe oral penicillin cillin. The patient should be treated (b) culture to distinguish from necrotizing uicera- symptomatically until the disease tive gingivitis subsides in 7 to 10 days. Anti (c) desensitize patient with vaccines biotics should be used only if there (a) gently clean the mouth and treat any elevated is a superimposed secondary in- temperatures fection490 PEDODONTICS ‘Questions ANSWERS What is usually done with an “eruptive cyst area of the second molar in a two year old child? (a) observe (b) incise and drain o) excise (g) prescribe antibiotics (e) fenestrate (a) “Eruptive cysts” usually resolve by themselves. No treatment should be rendered unless the cyst severely retards the eruption of a tooth What is the prognosis for a patient who develops gingivitis while weacing orthodontic bands? (a) good: this usually disappears when the bands are removed (b) fair: the gingivitis will probably persist (6) poor: periodontitis will probably result in the future (a) unpredictabie (a) The gingivitis usually subsides when the irritant is removed and good oral hygiene methods are re- sumed. No lasting effects occur. What is a common cause of draining fistulas in gingival tissue in children? la) periapical cysts (b) chronic periapical abscess (c} acute periodontal abscess {d) acute periapical abscess (b) Draining fistulas are chronic condi- tions caused by long-standing pres- sure on the bone and soft tissue that produces a tract from the site of infection to the oral cavity, What dental condition may frequently occur in pa~ tients at the time of puberty? (a) periapical abscess (b) pronounced gingivitis, (c) periodontal pockets (b) At the time of puberty, adolescents frequently experience a generalized marginal gingivitis that might be caused by a change in the level of sex hormones, (d) periodontal abscess [e) none of the above are correct, Which of the folowing is not usually related to _—_(d) Spirochetes_are associated with gingival inflammation in children? acute necrotizing gingivitis, which {a) endocrine disturbances rarely occurs in children, (b) viral intection (c) mouth breathing (4) spirochetes (e) streptococci A 14 year old female has deep vertical pockets with (c} Periadontosis affects females more bone loss on the mesial aspect of all first molars and than it does males and usually be- some drifting of maxillary incisors; however, only gins during puberty with destruc- minimal inflammation and minimal plaque are present. tion of bone and the formation of What is the probable diagnosis? periodontal pockets around incisors {a) gingivosis and the mesial surfaces of per- (b) periodontitis manent molars, Offen the gingiva (c} periodontosis appears normal and gross subgin- (d) osteomyelitis, gival calculus is absent.Questions PEDODONTICS 491 ANSWERS Which of the following is a correct statement con- cerning Dilantin hyperplasia? (a) oral manifestations similar to those of heredi- tary gingival fibromatosis (b) foliows a familial pattern {c) responds readily to antiinflammatory drugs {d) usually not manifested ia patients with good oral hygiene (e) more severe in adults than in children {a} Dilantin, which is used in the con- trol of epilepsy, causes extreme gin- gival hyperplasia in approximately 50 per cent of patients treated. There are no race or sex differ erences in occurrence: children and adolescents tend to experi- ence more hyperplasia than adults PREVENTION ‘QUESTIONS ANSWERS What effect will office dental prophylaxes at regu- jar six-month intervals have on children’s oral health? (a) reduce caries incidence by approximately 30 per cent (®) provide a long-term improvement in oral hygiene (c) provide a short-term improvement in oral hygiene (0) prevent gingivitis (e) both (b) and (d) are correct (©) Biannual office prophylaxes can supplement home care, but by themselves are insufficient to pre: vent gingivitis or dental caries. This is because an office prophylaxis provides only a temporary improve ment in oral hygiene, Within days. plaque and oral debris can return to pretreatment levels. Daily practice ‘at accepted dental _ preventive measures is necessary to improve gingival health and reduce caries incidence. It is recommended that the brushing of a preschool child's teeth (a) be performed by the child himself (b) be performed by the child's parent {c) be performed only after all primary teeth have erupted (d) not be done (b) Children can develop carious le- sions even before their ful! comple- ment of primary teath have erupted. therefore, brushing should be in- stituted a5 soon as the child will tolerate the procedure. Since the preschool child cannot be expected to master an effective toothbrush- ing technique, it is recommended that the parent do the brushing. The lactobacillus count of a caries active 16 year old adolescent is 128,000 lactobacilli per cc of saliva Based upon the interpretation of this count, what dietary tecommendation is indicated? (a) temporary elimination ot ali carbohydrates (b) elimination of between meal consumption of carbohydrates {c) increase in digtary consumption of carbo- hydrates (a) no dietary modifications are ni cessary (2} Because of the number of variables that influence the results of the lactobacillus test, it is not con- sidered a reliable caries susceptibil- ity test for an individual patient However, there is believed to be a correlation between a high dietary level of carbohydrates and a high salivary lactobacillus count. The combination in an individual pa- tient of a high caries attack rate and a lactobacillis count of 10.000 or more calls for a severe carbohydrate restriction in order to control the caries problem,492 EDODONTICS, QUESTIONS ANSWERS To achieve a caries reduction, diet modification must be directed toward (a) high calcium and vitamin intake (b) foods that will buffer the saliva (©) “detergent” foods (d) reduction of carbahydrate intake (d) Certain carbohydrates act as sub- strates for cariogenic microflora. Eliminating or reducing the amount of these ‘carbohydrates and de- creasing the frequency of their con- sumption are the most important modifications of the diet to reduce the caries attack rate Which of the following sugars present in the human diet is considered the most caries promoting? (a) sucrose (b) fructose (c) lactose {d) glucose (e) xylitol (a) Sucrose is metabolized by the oral bacteria to organic acids, which dis- solve tooth enamel. It is consid- ered by many to be the most cario- genic sugar in the human diet. Its cariogenic potential in humans is further exaggerated because more sucrose is consumed than any other sugar. The per capita annual consumption of sucrose in the United States and most other coun- tries Is approximately 110 pounds (60 kg) What factors are important in determining the cariogenicity of a patient's diet? {a} type of carbohydrate consumed (b) physical form of the food c} frequency of consumption (a) all of the above are correct (d) In addition to the type of carbo- hydrate, for example, sucrose. the other listed factors are also impor- tant in determining the cariogenicity of a diet. The physical form of the carbohydrate is important, since sticky, retentive foods have a slow oral clearance and, therefore, are potentially more damaging to the teeth than foods that are quickly cleared. Snacking frequency has also been associated with caries, The more frequent the snacks, the greater the caries activity. Absorbed fluoride ion is mainty eliminated by the: (a) lungs (p} intestines (c) kidneys (d) saliva {c) The kidneys are the principal route of fluoride elimination. The intes- tines mainly excrete nonabsorbed, insoluble fluoride _ compounds Saliva is not a primary route of fluoride elimination and. generally. the salivary fluoride concentration is the same as that of the blood: 0.1 ppm (parts per million). The lungs Under certain industrial conditions. are a source for fluoride absorption rather than eliminationQUESTIONS PEDODONTICS 493 ANSWERS As part of a controlled experiment. an individual is ingesting fluoride only through the daily consumption of fluoride-containing tablets. Which of the following equations best indicates the amount of fluoride ab- sorbed through the gastrointestinal tract? (a) fluoride ingested minus fluoride excreted in urine and feces (b) fluoride ingested minus fluoride excreted in feces (©) fluoride ingested minus fluoride in circulating body fluids (d) fluoride ingested minus fluoride in calcified tissues (b) Only soluble fluoride will be ab- sorbed through the stomach and intestine; the rest will pass through the gastrointestinal tract and be eliminated in the feces. The other choices to this question are identi fied as follows, (a) = Amount of fluoride retained n the body (c) — Amount of insoluble fluoride ingested. {d) ~ Amount of fluoride excreted through urine and. feces. In which of the following body tissues would the highest fluoride concentration be expected? (a) brain (b) liver (c) blood (d) saliva {e) bone {e) The tluoride content of bone in a community with a tluoride-defici- ent water supply (F 0.3 ppm) was found to be approximately 500 ppm, Fluoride does not concentrate in the soft tissues of the body About 1 ppm is found in most tis- sues on a {resh weight basis. The level of fluoride in the blood and saliva is approximately 0.1 ppm What level of caries reduction is associated with optimal fluoridation of community water supplies? (a) 15% (b) 30% (c) 55% (d) 80% (o) What is the range of concentration of fluoride in drinking water for optimal dental therapeutic effects with no significant dental fluorosis? a) 0.1-0.6 ppm (b) 0.7-1.2 ppm (c) 1.2-2.0 ppm (d) 20-35 ppm (b) There is no single optimal level of fluoride in the drinking water. The concentration depends upon the annual average dally temperature in the community, which influences the amount of water that local residents will consume. When the annual average maximum daily temperature is between 79.3 to 90.5°F (26.3 to 32.5°C). as it 1s for some of our more southern states, the recommended level of fluoride is 0.7 ppm. When this temperature is 50.0 to 53.7 F (10.0 to 12.1 C), the recommendation is 1.2 ppm fluor- ide Which of the following levels of fluoride in drinking water is associated with enamel fluorosis? (a) 0.1 ppm fluoride (b) 0.7 ppm fluoride (c) 1.2 ppm fluoride (d) 2.4 ppm fluoride (d) Ameloblasts are sensitive to fluor Ide, and at concentrations above approximately 2.0 ppm. hypomin eralization and hypoplasia of tooth enamel can occur. The higher the level of fluoride the mare severe 1s the fluorosis for comparaple amounts of water consumption494 PEDODONTICS Questions ANSWERS What is the recommended daily dose of fluoride for the 3 to 12 year old child? (a) (b) (co) id) 1/4 mg 1/2 mg img 2g (c) This dosage can be obtained by pre- scribing one 2.2 mg NaF tabiet per day or one teaspoonful of a 0.5 per cent NaF solution, A child who con- sumes one liter of water per day ina community with 1.0 ppm fluoride in the drinking water will ingest 1mg fluoride. What is the recommended daily dose of fluoride fora two to three year old child? (b) io ‘6) 1/4 mg v2mg 1'mg 2mg (b) What is the recommended daily dose of fluoride for a child from birth to 24 months? (a) (b) (c} (a) 1/4 mg 1/2 mg hina amg (a) in what communities can the regular professional topical application of sodium fluoride, stannous fluor- ride. or acidulated phosphate fluoride reduce dental caries by approximately 80 to 40 per cent in children? (a) tb) (©) @) optimally fluoridated fluoride deficient both optimally fluoridated and fluoride defici- ent neither deficient optimally fluoridated nor fluoride (b) The results of clinical studies with these agents indicate that a 80 to 40 per cent reduction can be ex- pected when performed on a bi- annual basis on children residing in a fluoride-deficient community. Significant caries reductions have not been consistently obtained when these agents are used in fluoridated communities fow frequently should a professional topical fluoride application with stannous fluoride or acidu- lated phosphate fluoride be administered for optimal s (a) every three months tb) (o) (a) every six months every tweive months every eighteen months (b) More frequent fluoride applications are generally associated with higher caries reductions. A six-month re- application regimen is recommend- ed for most children residing in a fluoride-deficient community. What directions should be given to a child follow- ing a prophylaxis and topical fluoride application? (a) {b) do not eat, drink, of rinse for 30 minutes rinse immediately but do not eat or drink for 30 minutes eating or drinking is permissible, but do not rinse for 30 minutes No specific directions regarding ingestion of food or liquid {a} The patient should take nothing by mouth for 30 minutes after the topi- cal fluoride application. This pro- hibition allows optimal reaction be- tween fluoride and the hydroxy- apatite of the toothQuestions PEDODONTICS 495 ANSWERS. Compared with professionally administered topical fluoride, which of the following statements are true concerning self-application topical fluoride techniques? 1, more frequent applications are possible 2. more sustained and higher levels of fluoride in enamel have been reported 3, more economical 4, higher caries reductions have been reported (a) 1 and 2 only (b) 1 and 3 only (c) 2and 4 only (d) 2 and 3 only {e) 1, 2,3, and 4 are correct (e) Selt-application techniques are economical, whether they are part of an individual home program or a public health school program. The more frequent applications, as many as once a day. result in higher levels of fluoride in the enamel than results from professional topical applications that are administered once or twice a year. The relatively high enamel fluoride levels from certain. self-application programs have been maintained. even after discontinuation of the program. In a school-based daily self-applica- tion study using sodium fluoride gels in custom mouth guards. caries, reductions of over 70 per cent (OMFS) were obtained after two school years. Which of the following procedures is replaced by the use of occlusal sealants? (a) occlusal amalgam restoration (p) topical fluoride application (c) prophylactic odontotomy {d) all of the above are correct (c) Currently, sealants are used 10 pre- vent caries specifically on the oc: clusal surfaces; thus, this tech- nique is used in the place of a pro- phylactic odontotomy. which is al 80 a preventive technique limited to ‘occlusal surfaces. When occlusal caries has been diagnosed, a res- toration should be placed instead of sealants. PATIENT MANAGEMENT QUESTIONS ANSWERS The child who misbehaves in the dental office during the first appointment 1. is often the innocent victim of circumstances 2, will bear a grudge if the dentist forces him or her to behave 3, looks upon the dentist as a symbol, and dis pleasure toward the dentist is not personal (a) 1 and 2 (b) Zand 3 () tand 3 (d) all of the above are correct (c) Children misbehave for many rea sons that are not directly related to their own previous dental experi- ences. If the dentist is firm and as- serts his authority at the first visit, the child usually comes to respect and like the dentist.496 | PEDODONTICS QUESTIONS ANSWERS What is the best approach to managing a healthy six year old who has to be forcibly separated from his mother and carried to the operatory? (a) dismiss the child and appoint when coopera tion can be expected {b} use nitrous oxide analgesia {c) use voice control {d} premedicate {c) Voice control is the best method for managing a temper tantrum. It genuine fears are present, these may be managed with the “tell show, and do” technique. Nitrous oxide analgesia may be used after the tantrum has been controlled. During a dental visit, the child may attempt to test the dentist with uncooperative behavior, What should the dentist do? (a) dismiss the child and reappoint when better cooperation can be expected (b) bribe the child with a gift {c} engage the child in conversation {d) bring the parent in to observe le) assert authority and require cooperation (e) Children react much better if there are prescribed rules for their be- havior and they know the boun- daries within which they can act. Authority, however, should not be so inflexible that the patient's gen- uine concerns about the dental experience go unheeded What is the strongest fear that children have when visiting the dentist for the first time? (a) fear of the unknown {b) fear of the equipment {c} fear of tooth extraction (a) fear of the dentist (e) fear of pain (a) Most children have a general fear of the unknown even though they might not have gone through speci- fic painful experienc Which of the following are considered effective methods for the management of fears? (a) reassurance, shaming, scolding (b) reconditioning, reassurance. explanation {c) ridiculing, overprotection. bribery {@) reconditioning, indifference. overprotection (e) bribery. forcefuiness, reassurance (b) The dentist should provide empathy and emotional support to assist the child. Children should not be shamed, ridiculed, or bribed into behaving, since these techniques are ultimately unsuccesstul During a child's first dental visit, what does a good management procedure include? (a) entertaining the child with air-water syringe (b} talking about the child's brothers and sisters, (c) greeting the mother before the child (d) restoring small carious lesion (e) talking about the child's pet or other interests (e} During the first appointment the operator should show a genuine concern for the child's interests. Brothers and sisters should not be discussed at length in case there is sibling rivalry. low is a two year old positioned for an emergency examination of a fractured incisor? (a) on the dental assistant's lap (b) on the parent's lap (c} on the dental chair (d) in the Papoose board ) The infant is best examined in the security of a parent. The parent's presence will frequently calm the infant although crying may occur. The parent is asked to assist in con- trolling the child's movements.QuEsTions For what children are mothers usually encouraged to remain in the operatory? (a) fearful six year old (b) overprotected four year old (c) apprehensive two year old (d) all of the above are correct {e) none of the above are correct Should the “hand-over-mouth" technique ever be used in patient management? (a) no, it will psychologically traumatize the child (b) yes, with retarded patients who would not otherwise understand (c) no, it is not legal to use {d) yes. with temper tantrums in four year olds (e) no. the parents might object How should toys be used in child management? (a) reward (b) bribe (c) gift (d) all of the above are correct Should a new patient be shown a cooperative brother or sister experiencing a dental procedure? (a) not usually (b) only if the new patient is younger (c) yes, it's a good idea (d) makes no difference What should the dentist do to help establish rap- port with a fearful child? (a) communicate with words familiar to the child (b) remain silent to permit the child to evaluate the situation (c) stand at full height to show that he is in com- mand {¢) assure the child that he will not be hurt PEOODONTIC 497 ANSWERS (c) When a child is to young to com- Prehend (usually three years or younger. older for retarded indi- viduals) behavior is improved with the mother's presence in the opera- tory, (d} The “hand-over-mouth” technique may be used judiciously with a child exhibiting an extreme temper tan- trum. The child is quieted in order to hear the dentist talking. With this technique, the mouth is covered firmly with the dentist's hand, but the nose is not covered and the air- way is not blocked (c} A toy may be used as a pleasant re- minder of the visit. Using it as a bribe will be ultimately unsuccess- ful, as the child may decide that the toy is not worth the effort of co- operation. (c) Showing a new patient another co operative cinld receiving treatment may be a good modeling technique to shape the behavior of the new patient. (a) To establish rapport with a child the dentist should begin communica- tion with language appropriate to the child's age. If some unpleasant- ness is to occur. the dentist should not assure the child that he will not be hurt.498 PEDODONTI EXAMINATION, DIAGNOSIS, AND TREATMENT PLAN QUESTIONS ANSWERS When a treatment plan is formulated, what should be performed first? (a) toothbrush instruction. initiate fluoride therapy (b) restoration of tooth with deep carious lesions (c) extraction of exfoliating tooth giving some discomfort to patient {d) treatment of tooth with buccal parulis (a) Once emergency conditions have been managed. preventive care Should be instituted before other dental care continues. A tooth with a parulis usually is a chronic infec- tion with no immediacy for care. Exfoliating teeth frequently cause some discomfort: however, they should routinely be allowed to ex- foliate, Occasionally, they are re- moved if infection or abnormal root resorption occurs. How do hypoplastic defects of enamet appear radiographically? {a} radiolucent {b) radiopaque (c} sclerotic (d) indistinguishable from sound enamel (e) sometimes radiopaque and sometimes radio- uucent (a) Hypoplastic areas are morphologi- cally defective and lack the full thickness of enamel. Consequently, they appear less radiodense, or more radiolucent, when compared with normal enamel How should the interpretation of a full mouth radiographic survey begin? (a) search for caries (b) assess the trabecular pattern of bone {c} examination of the periodontal ligament space (d) count the teeth (e) note the alveolar bone height (b) The examination of radiographs should progress from the general to the specific. First the bone is as- sessed and the development of the permanent teeth is examined. Then the roots and pulp chambers of the primary teeth are studied and finally crown defects, including decay, are noted When. if ever. is it acceptable for the dentist to hold a radiographic film packet in the patient's mouth? (a) the patient is very young and cannot under- stand directions (v) the patient is physically handicapped and is unable to hold the film (c) the film should never be held by the dentist (d) there is a lack of time ard a radiograph is essential (c) The dentist should never hold the film packet! Continuous exposure to low levels of radiation may cause cancer, Ina three and a half year old male the mandibular second premolars were not evident radiographically. What may be assumed about these teeth? (a) congenitally missing (b) may develop late {c) will develop with hypoplastic enamel (d) probably extracted (b) It is quite common for mandibular second premolars not to be evident radiographically in children age three and a half years. Occasionally, these teeth do not become evident until age seven or eight.PEDODONTICS 499 QUESTIONS ANSWERS What is @ major reason for taking a medical history (c) There are many reasons for taking a before treating a patient? medical history. but perhaps the {a) for medical-legal protection most important is to rule out any {b) to determine growth rates of the patient abnormal systemic condition that {c) to determine if the patient has a bleeding would affect or be affected by treat- tendenc ment {d) to-determine if the patient has a communicable disease Approximately what percentage of incipient inter- (d) Interproximal lesions usually do not proximal caries will be undetected in preschool chil- become clinically evident until they dren if good bitewing radiographs are not used? have progressed into the dentin (a) 10% causing moderate destruction (b) 25% When lesions are incipient and con- (c) 50% fined to the enamel, they are usu- (d) 75% ally undetected in preschool chil- (2) 100% dren unless radiographs are used. What information is not routinely collected at the (a) A mixed dentition analysis is per- time of the first examination of a nine year old? formed only if there is a developing (a) mixed dentition analysis malocclusion in which there might (b) medicat history be insufficient space for the un- (0) classification of occlusion erupted permanent canines and (d) family history premolars PREMEDICATION QUESTIONS ANSWERS Why is the oral route recommended for premedica- (€) The oral route for premedication is, tion of children? not very predictable and the effect (a) it is easiest to administer of drugs is much slower than by in- (b} its effect is most predictable jection: however, oral premedica- (c) itis usually a pleasant route tion is usually not unpleasant for (d) it is the quickest way to administer drug and the patient. antagonist Why is chloral hydrate one of the safest drugs for (a) Chloral hydrate is not avery predict oral premedication of a two year old? able drug but it is used because itis (a) there are rarely any adverse side effects in a very safe premedicant recommended doses (b) it exhibits gastric irritability, preventing ex- cessive doses (c) it produces a sleepy child, allowing treatment to progress (d) onset of sedation is usually after 45 minutes, allowing time for overdoses to be managed500 PEDODONTICS QUESTIONS ANSWERS What drug should be available it meperidine (©) An effect of excess meperidine ad- (Demerol) 1s used for premedication? ministration 1S respiratory depres- {a} atropine sion. Naloxone is an antagonist of 'b) Xylocaine meperidine and should be available (c) promethazine (Phenergan) in case of emergency. (d) nitrous oxide naloxone (Narcan) For which group of drugs is respiratory depression (c) Synthetic narcotics (for example. a common side effect? Demerol or Nisentil) may produce {a) tranquilizers respiratory depression, and a nar- (b) antihistamines cotic antagonist (for example. (c) synthetic narcotics Narcan) should be readily available (d) nonbarbiturate sedative hypnotics for emergency use. What s the fate of nitrous oxide when adminis: (c) Nitrous oxide is physically dissolved tered for relative analgesia? in the blood, butit does not undergo fa) excreted by kidney any ctiemical change. Almost all of (b) detoxified in liver it is exhaled unchanged through the (c} exhaled by lungs lungs. [d) metabolized into NO and O. (e) metabolized into NO and CO. For which systemic condition is nitrous oxide- (2) Nitrous oxide is rarely contraindi- oxygen sedation contraindicated? cated. It is particularly helpful for (a) sickle cell anemia patients with respiratory difficulties, (b) asthr because it allays anxiety and at the (c) congestive heart failure three months previously same time is given with a high con- (a) mental retardation centration of oxygen (e} none of the above are correct Which formula may be used as an aid in calculating (c) A formula based on weight provides the drug dose for children? an approximate estimate of drug (a) Jones’ rule considering development of the dosage for a particular patient, The child exact dosage must be verified by (b) Smith’s rule considering the adult dose Clinical experience with the patient (c} Clark's rule considering weight of the child and the drug (d} Young's rule considering the size of the child A child who has been given a sedative dose of a (a) One of the disadvantages of bar. short-acting barbiturate is very active and somewhat biturates is that with insufficient excited. What does this indicate? doses they excite rather than sedate (a) insufficient dose of drug the child. (b) normal response to the drug (c) excessive dose of drug d) unexpected reaction‘QUESTIONS PEDODONTICS 501 ANSWERS Why is Nisentil (alphaprodine) used to premedicate children? (a) it is sufficiently potent that local anesthetic is unnecessary (b) it has a pleasant flavor {c) it is very safe and produces little depression (4) it is a potent drug taking effect in 10 to 20 minutes, and if an overdose is noted an anta gonistic drug can be administered {d) Nisentil is a synthetic narcotic that can cause respiratory depression with large doses. It is used by some practitioners to control undesirable behavior in children age three to six years. It is usually injected into the buccal vestibule and has rapid on- set of effect. Narcan (naloxone) may be used as its antagonist Which drug is not indicated for premedicating a seven year old with severe apprehension? a) hydroxyzine (Vistaril) (b) alphaprodine (Nisentil) (c) meperidine (Demerol) (d) chloral hydrate (Noctec) (e) naloxone (Narcan) (e) Naloxone is a narcotic antagonist LOCAL ANESTHESIA QUESTIONS ANSWERS Which of the following local anesthesia techniques is recommended for extraction of a primary mandibular molar? (a) labial and lingual infiltration (b) inferior alveolar nerve block (c) intraosseous injection near apices (d) inferior alveolar nerve block and long buccal nerve block (e) inferior alveolar nerve block and mental nerve block {d) In addition to an inferior alveolar nerve block. a long buccal injection 's required in order to anesthetize the buccal soft tissue innervated by the buccal nerve On the day following a formocresol pulpotomy of a mandibular primary molar, a three year old patient re- turned with a large ulcer near the midline of the lower lip. What is the probable cause of the ulcer? (a) lip biting by the patient (b) allergy to the anesthetic solution (c) pressure by the rubber dam frame {d) leakage of formocresol onto the lip (a) Parents must be cautioned to ob- serve young children following mandibular block anesthesia, other- wise the child may chew on the anesthetized lip. producing a large ulcer. What is the probable cause of the sensation of tissue tearing” during local anesthetic administration? (a) passage through a cyst (D) passage through muscle (c) passage through an area of infection {d) barb on the needle (e) too large a needle gauge (d) If a needle is sharp it will not cause a “tissue tearing” sensation unless it strikes bone. producing a barb on end.502 PEDODONTICS ‘QUESTIONS ANSWERS What type of drug is used to eliminate all sensa (d) An analgesic eliminates pain, but a tion? properly administered anesthetic, (a) analgesic eliminates all sensation (bj narcotic (d) sedative 4) anesthetic e| soporitic How should syncope be managed in an apprehen- (b) Syncope, or fainting, is one of the sive teenage patient? most frequent complications as- (a) administer premedicant drugs sociated with local anesthesia. It is (b) tilt the patient back with feet elevated caused by decreased blood flow to (c) tilt the patient forward with the head between, the brain because of a drop in blood the legs pressure associated with vasodila~ (d) suspend further treatment and dismiss the pa- tion and an increase in the periph- tient until more cooperative eral vascufar bed. Tilting the patient (e) consult with patient's physician back allows additional biood to flow to the brain RESTORATIVE DENTISTRY ‘QUESTIONS ANSWERS Which pulp horn is most likely to be exposed (a) The mesiobuccal pulp horn of the during cavity preparation on primary molars? first primary molar is quite high and (@) mesiobuccal of first molar close to the surface of the tooth. (b) distobuccal of first molar (c) mesiobuccal of second molar {¢) distobuceal of second molar Why is it sometimes difficult to adapt matrices for _—_(b) Because primary teeth are short primary teeth? with buccal and lingual surfaces that (a) matrices hurt child patients taper toward the occlusal, matrices (b) primary teeth converge toward the occlusal may slip when they are tightenea in {0} children have small mouths that dislodge the place. matrix retainers (¢) children have high gingival attachments What does etching of intact enamel with phospho- (a) Phosphoric acid etching produces ric acid produce? microscopic tags of enamel that in- (a) an increase in surface area crease the enamel surface area. (b) a decrease in surface area Slight undercut areas increase the (c) no change in surface area physical, but not the chemical, (d) an increase in chemical bonding capabilities bonding capabilities. le) a decrease in chemical bonding capabilities‘QUESTIONS PEDODONTICS 503 ANSWERS Why is it difficult to produce an adequate gingival seat of a Class Il preparation in a primary molar if the seat is placed too far gingivally? (a) the contact area is broad and flat (b) the enamet rods incline occlusally (c) the tooth has a marked cervical constriction (d) the buccal and lingual tooth surfaces are tapered (c) Because of the cervical constriction in primary molars, there is insuffici- ent enamel thickness to provide adequate width (pulpally) of the gin- gival seat when it is placed at or near the cementoenamel junction, A pulpal exposure could result if the axial wall was placed deeper into dentin to produce a wider gingival seat What should be done with a moderate sized Class i amalgam preparation with undermined enamel at a marginal ridge? ia) construct a stainless stee! crown (b) place amalgam under the undermined enamel (c) place zinc phosphate cement under the under- mined enamel (d) remove the undermined enamel (d) Undermined enamel should be re- moved or it will subsequently frac- ture. A stainless steel crown is not indicated unless the caries is ex- tensive and has undermined a cusp. Are gingival margin trimmers usually used for Class tl cavity preparations in primary molars? {a) yes, to remove unsupported enamel rods (b) no, enamel rods slope occlusally (c) yes, the marginal level is similar to that in per- manent teeth (d) no, access is too difficult (b) In primary molars cervical enamel rods do not slope apically and do not have to be trimmed When primary molars are prepared for stainless steel crowns, should the depth of reduction of the proximal surfaces be similar to the depth of the buccal and lingual surfaces? {a) reduction of all surfaces is similar for best re- tention (b) proximal reduction is greater to allow the crown to pass the contact area (c) the buccal surface has the greatest reduction to remove the cervical bulge (d) all undercuts are uniformly removed so that the steel crown can be seated. (b) Proximal surfaces must be reduced sufficiently to allow room for the steel! crown. Buccal and lingual sur- faces are reduced only slightly if at all. Undercuts remain to give reten- tion for the crown: What is the recommended relationship of the buc- cai and lingual walls of an occlusal amalgam prepara. tion in a primary molar? (a) converge at the occlusal (b) parallel each other c) diverge at the ocel (d) follow the enamel rods (e) depends on the extent of decay (a) The lateral walls converge slightly toward the occlusal, providing re- tention for the restorative material The walls do not siope to such an extent as to undermine the enamel804 PEDODONTICS QUESTIONS ANSWERS: Should amalgam be burnished after it has been carved? {a} no. it brings mercury to the surface of the margin [b) no, it might destroy the crystal structure (c} yes. it continues condensation at the margins (d) yes. it makes the surface look shiny (c) The American Dental Association Guide to Dental Materials and Devices” (1976) recommends that amalgam be burnished after carv- ing. The burnishing under pres- sure is a continuation of the con- densation and with newer con- trolled mercury techniques it does not bring excessive amounts of mercury to the surtace. How many teeth are isolated when a rubber dam is, placed for an occlusal preparation ina second primary molar of an eight year old? (a) the whole quadrant (b) only the second primary molar (c) the first permanent molar and both primary molars (d) the primary molars and canine (b) A minimum number of teeth should be isolated for efficiency. When it is easy to do so the tooth distal to the one receiving an occlusal restora~ tion may be isolated to move the clamp away from the operating area. If @ Class tl preparation is to be made, the teeth on either side of the prepared tooth should be iso- lated PULP THERAPY QUESTIONS ANSWERS A four year old child presents with a carious man- dibular second primary molar. Caries has reached the pulp. which is vital but hyperemic. What treatment should be performed? (a) extr (b) indirect pulp treatment (c) pulpotomy using formocresol (d) pulpotomy using calcium hydroxide (e) pulpectomy (c) A pulpotomy using formocresol is indicated for a primary tooth with a carious exposure. The tooth should have at least one-third of its roots: that is, exfoliation should not be imminent, and the tooth should be restorable. The presence of an un- derlying systemic condition, such as rheumatic fever or congenital heart disease, should be considered a contraindication to the use of this technique, since an unsuccessful pulpotomy might systemically affect the patient. What is the histologic effect of formocresol on the vital pulp of a primary tooth in which a pulpotomy has been performed? (a) a zone of fixation occurs in the cervical portion of the root (b) a zone of fixation occurs in the apical portion of the root {c} pulpal necrosis occurs throughout the root (a) a dentin bridge forms at the site of amputation (e) an acute inflammatory reaction occurs through- out the root (a) Formocresoi has a protein binding effect and will “fix” tissue that it contacts. Histological studies have demonstrated zones of fixation in pulps treated with formocresol solutions; vital tissue, however, has also been found in the apical por- tion of treated teeth. Formocresol has also been found to be antiins flammatory. which might explain the usual lack of postoperative symptoms associated with the for- mocresol pulpotomy technique.QUESTIONS PEDODONTICS 505 ANSWERS Asix year old child presents with a carious maxillary second primary molar with a necrotic pulp. What treat- ment should be performed? (a) extraction (b) indirect pulp treatment (c) pulpotomy using formocresol (d) pulpectomy (e) antibiotic coverage (c) or (d) At this age. the tooth should be preserved, if possible, in order to maintain arch circumference. Since the pulp is necrotic, it must be treated. If a pulpectomy is done, the necrotic contents of the pulp cham- ber and canals are removed, endo- dontic instrumentation and tavage are performed, and the tooth is filled with a resorptive paste. If a pulpotomy is performed. only the contents of the pulp chamber are removed, the tooth is treated with formocresol, and a medicating paste is placed in the pulp chamber. ‘A pulpotomy is performed on a cariously exposed, vital mandibular first permanent molar in a seven year old child, and calcium hydroxide is placed over the amputation site. What demonstrates a histologically successful result? (a) eventual pulpal necrosis (b) chronic pulpal inflammation (c} the formation of a dentin bridge slightly below the level of amputation (a) the formation of a dentin bridge at a con- siderable distance trom the level of amputation (e) fixation of pulpal tissue (c) Calcium hydroxide will often stimu- late an odontoblastic response with the production of new butsomewhat irregular dentin. The dentin bridge. when present, will form at a slight distance from where the calcium hydroxide was placed, What is the usual cause of failure of a pulpotomy that employs calcium hydroxide in primary molars? (a) pulp fibrosis (b) pulp calcification (c) ankylosis (d) external resorption (e) internal resorption (@) Internal root resorption is a com- mon sequela in cases of pulpotomy employing calcium hydroxide in primary teeth. This may be due toa stimulation of odontoclastic activ- ity in undifferentiated cells of the pulp. Pulpotomy using calcium hy- droxide has been successful when used to treat young permanent teeth, especially traumatically ex- posed incisors: however. the use of this technique in primary teeth is no longer recommended because of the high clinical failure rate. An inadvertent mechanical pulp exposure occurs when a cavity on a mandibular first primary molar is prepared. The exposure is small (less than 1 mm diameter) and treatment was being performed with rubber dam isolation, What treatment should be performed? (a) direct pulp capping (b) indirect pulp treatment (c) pulpotomy with formocresol (d) pulpotomy with calcium hydroxide (a) In the primary dentition, direct pulp capping is limited to instances in which the pulp has been accidently breached during instrumentation. in contrast to a pulpal exposure that ‘occurred when carious dentin was excavated. The use of a rubber dam prevents contamination of the ex- posed pulp by saliva and oral micro- organisms that would otherwise limit the success of the capping procedure.806 | PEDODONTICS QuEsTiONs ANSWERS For at least how long should calcium hydroxide remain when it is applied to residual carious dentin in the indirect pulp treatment technique? (a) 6 months (b) 6 to 8 weeks (c) 2 weeks (d) 5 to 7 days (@) 5 to 7 minutes (b) Calcium hydroxide, when used in the indirect pulp treatment tech- nique, is associated with a decrease in the number of invading micro- organisms, an arrestment of the carious lesion, and a remineraliza- tion of the residual affected dentin. While changes in the dentin have been clinically observed as early as two weeks after treatment, if re~ entry of the tooth is contemplated. it is empirically recommended that at least 6 to 8 weeks elapse follow- ing placement of the calcium hy- droxide Which of the following medicaments have an anti- bacterial effect when applied to contaminated tooth tissue as part of a therapeutic pulp procedure? (a) calcium hydroxide (b) zinc oxide-eugenol (c) formocresol (d) all of the above are correct (e) none of the above are correct (d) While the antibacterial effects of formocresol are the most profound. both calcium hydroxide and zinc oxide-eugenol_ also. exhibit anti- bacterial properties. ANTERIOR TOOTH INJURY Questions ANSWERS In what group of children is fracture of a maxillary permanent incisor most likely to occur? (a) males with Class | malocclusion (b) females with Class | malocclusion (c) males with Class II malocclusion (d) females with Class I malocclusion (c) Epidemiologic studies have shown that boys sustain twice as many anterior permanent tooth injuries as Girls, The greater the magnitude of Maxillary protrusion (or overbite). such as in Class Il, division | mal- occlusions, the more susceptible is the child to fracture of an incisor tooth A child sustains a fracture of a maxillary permanent central incisor. Although the fracture involves only the mel, there is sufficient loss of tooth tissue for the altered esthetics to be of concern to the parent and child. What treatment at the emergency visit should be performed? (a) calcium hydroxide applied to the fracture site and a stainless steel band calcium hydroxide applied to the fracture site and a stainless steel crown (c) acid etch-composite restoration (d) reduction of tooth for a fabricated acrylic crown (e) no treatment indicated, since the long-term vitality of the pulp cannot be predicted (0) (¢) Care of a child with a traumatic den- tal injury includes the allaying of anxiety associated with the altered appearance caused by the fractured tooth. Although the pulpal prog- nosis cannot be determined at the time of injury, there is no contrain- dication to placing an esthetic restoration at the emergency visit This can be best accomplished with an acid etch-composite restoration, since no burring of tooth structure. which can further damage a re- cently concussed pulp. is involved.QUESTIONS PEDODONTICS $07 ANSWERS ‘A maxillary central incisor in a 10 year old child gave no response to electrical and thermal pulp tests two days after sustaining a fracture through enamel and dentin. What is the diagnosis of the pulp’s con- dition? (a) acute hyperemia (b) chronic hyperemia (c) chronic degeneration (d) acute necrosis (nonvital) (e) no definitive diagnosis of pulp status is pos- sible (e) A pulp “shocked” by a traumatic episode is likely to give aberrant responses to vitality tests. Thus. tests administered immediately or within several days of injury are not reliable indicators of pulpal via- bility. It is common for there to be a change in the response of a trau- matized tooth to vitality tests be- tween the emergency visit and visits three months or more later. For predictive purposes. however, it should be remembered that it 2 fractured tooth tests vital at the time of injury. it 1s likely to remain vital: if it initially tests nonvital, it may nevertheless test vital at future visits, An eight year old child who has sustained a frac- ture of a maxillary permanent central incisor in which a large portion of the pulp is exposed presents for treat- ment three hours after the injury. What emergency treatment of the pulp should be performed? (a) pulpotomy using calcium hydroxide {b) pulp capping using calcium hydroxide (c) pulpotomy using formocresol (d) pulpectomy and immediate root filling (e) pulpectomy and apexification (a) Pulpotomy with calcium hydroxide is indicated when there is a rela- tively large pulp exposure and the patient is seen within 72 hours. While the pulp is infected, it is con- sidered recoverable. A tooth with a wide, immature apex is considered a good candidate for this technique because of the recuperative powers and degree of vascularization of the young pulp. An eight year old child sustains a fracture of a maxillary permanent central incisor in which a large portion of the pulp is involved, The child was not in acute pain and did not present to the dental office for several days, What treatment of the pulp should be performed at this time? (a) pulpotomy using calcium hydroxide (b) pulp capping using calcium hydroxide (c) pulpotomy using formocresol (d) pulpectomy and immediate root filling (e) pulpectomy and apexification (e} Pulpectomy is indicated if the ex- posure is of longer than 72 hours duration, since the pulp is generally infected beyond recovery. The apexification technique will allow apical constriction to occur in a nonvital immature permanent tooth, The root-end narrows sufficiently to subsequently enable complete closure of the root apex by conven- tional endodontic procedures. Which medicament is generally used when per- forming apexification techniques on recently erupted permanent teeth that have been devitalized by trauma? (a) zinc oxide-eugenol (b) calcium hydroxide, alone or with other medica- ments (c) formocresol-zinc oxide-eugenol mixture (d) corticosteroids (e) amaigam (b} Although root closure has been re- ported without the use of any med- cating agent. calcium hydroxide. alone or in combination with differ- ent medicaments. has been most frequently employed in the apexi- fication procedure.508 PEDODONTICS QUESTIONS ANSWERS A permanent incisor with an incomplete root apex (0) Avulsed teeth should be repianted was traumatically avulsed 25 minutes before the pa- and immobilized as scon as possi- tient presented at the dental office. When should pul- ible, since a favorable prognosis is pectomy be performed? more likely when the extraoral per- (a) Prior to replantation iod is short. When the extraoral per- (b) immediately after replantation iod is less than two hours, endo- (c) two weeks after replantation dontic therapy should not be done (d) at a future visit it there is evidence of pulpal at the emergency visit, since the necrosis or root resorption procedure would unnecessarily pro- long the time the tooth is out of the mouth. If the avulsed tooth has a fully formed apex, a pulpectomy should be scheduled about two weeks after replantation; however, if apical development is incom- plete, there is a chance that pulp re- vascularization will occur, and endodontics should be postponed indefinitely What is the most frequent cause of failure in cases (©) Although any of the listed condi- of replantation? tions may be a sequela of avulsion, (a) pulp infection the most frequent cause of replanta- {b) pulp necrosis tion failure is external resorption (c) external resorption The root undergoes an inflammatory (d) internal resorption resorption in which no bony re- (e) ankylosis placement occurs. The tooth even- tually loosens and must be ex- tracted What should the immediate treatment of a tooth (c) The emergency treatment af a root that has sustained a fracture to the middle third of the fracture involves the apposition of root include? the fractured parts, immobilization, (a) puipectomy to the coronal portion and apico- and controt of infection, ectomy of the root portion (b) pulpectomy to both portions of the tooth (c) splinting (d) no treatment required Which of the following areas of root fracture is (c) Prognosis is least favorable feast conducive to a favorable prognosis? when the fracture occurs in the (a) apical third cervical third of the root, This is be- (b} middle third cause of the difficulty of stabilizing (c) cervical third the crown segment and because of (d) prognosis is equal in all cases provided the the easy access of oral microor- tooth remains vital ganisms to the fracture areaPEDODONTICS 09 ORAL SURGERY QuEsTiONs ANSWERS. Prophylactic antibiotic coverage, prior to oral surgery, for a child with a history of rheumatic fever, 's a precaution against: (a) anaphylactic reactions (b) bacterial endocarditis (c) moniliasis (d) glomerular nephritis (b) Patients with a history of rheumatic fever or congenital hear! disease are susceptible to bacterial endo- carditis. Manipulations during oral surgical procedures can cause a transient bacteremia, enabling bac- teria to be lodged on the heart valves or other portions of the endo- cardium. Such patients should be protected with an appropriate anti- biotic prior to any oral surgical pro- cedures. Some authorities recom- mend that antibiotic coverage should be started several days be- fore the operation, while others arguing that such a regimen could promote the emergence of anti- biotic-resistant microorganisms. in- stitute antibiotic coverage immedi- ately before the procedure What is a suitable alternative antibiotic when a child is sensitive to penicillin? (a) tetracycline (b) erythromycin (c) sulfanilamide (d) ampicillin (b) Erythromycin has an antimicrobial spectrum similar to that of peni- cillin and thus is an exceltent sub- stitute in the (reatment of dental infections in those patients who are allergic to penicillin. What unfavorable oral sequela is associated with prolonged use of antibiotics in children? (a) aphthous ulcers (b) acute necrotizing gingivitis, (c) noma (d) moniliasis Moniliasis (thrush), a disease caused by the fungus Candida al- bicans, can be caused by over enthusiastic use of oral antibiotics. The antibiotics suppress the growth of indigenous oral flora that nor- mally check the growth of the fun- gus in the mouth. Nystatin (200.000 units per ml) is used topically to contro\ the monilial infection: how- ever, lesions may recur. 0) A primary tooth extraction is included in the treat- ‘ment plan for an eight year old child. When should the child first be informed of the impending extraction? (a) at the treatment planning visit even though the tooth will not be extracted for another six weeks (b) immediately before extracting the tooth (c) during the visit before the extraction is planned (d} never: the child should be informed of the procedure after the tooth has been extracted (c) Studies have shown that children want to be informed of an imgend- ing extraction so that they can psychologically prepare for it. in- forming the child about the extrac tion and then performing the actual procedure at the next appointment allows a child to cope with the situ- ation and master his or her anxiety810 PEDODONTICS ‘Questions ANSWERS How should a primary molar with relatively unre sorbed roots encompassing the permanent tooth bud be extracted to avoid the inadvertent removal of a de- veloping bicuspid? (a) roll a mandibular tooth to the buccal and a maxillary tooth to the palatal (b) raise a buccal flap (c) remove the crown portion only, allowing the roots to resorb (d) section the tooth vertically and remove each root separately (d) The furcation of a primary tooth is located much closer to the crown than in a permanent tooth; there- fore, sectioning is easily accom- plished with a high-speed tapered fissure bur. The tooth is then re- moved in sections without disturb- ing the underlying developing per- manent tooth What routine postoperative instructions should be given to a child or his parents following a primary tooth extraction? (a) the child's activity should be restricted for the remainder of the day (b) the parent should contact the dentist if there is, any blood on the child's pillow the next morn- ing (0) the child should not bite his anesthetized lip or cheek (d) the child should not eat or drink for the rest of the day (c) Unless cautioned, young children will frequently bite their anesthe- tized lip, producing a traumatic ulcer. To prevent this postanesthe- tic complication, both parents and children must be routinely admon- ished after a dental appointment in which an injection was given. Figure 19-7. A traumatic ulcer caused by biting an anesthetized lip.PEDODONTICS 511 ‘QUESTIONS ANSWERS $$ What should be done if a permanent tooth bud is (b) A permanent tooth bud that has removed during the extraction of a primary tooth? been accidently moved during the (a) leave the permanent tooth out of the mouth extraction of a primary tooth should (b) reposition the bud in its original site and suture be repositioned and immobilized. the socket closed Generally, the tooth will continue to (©) reposition the bud and provide antibiotic develop and erupt normally. coverage (d) replace the pulp of the bud with calcium hy- droxide before repositioning the bud in its original site Where is the point of insertion of the needle when (a). The child's ramus is shorter than an an inferior alveolar block injection is given to a child, adult's. This is compensated for by ‘as compared with an adult? inserting the needle a few milli- (a) lower than for an adult meters closer to the mandibular oc- (b) higher than for an adult ciusat plane than in adults. (c) at the same level as an adult (d) more anterior than for an adult (e) more posterior than for an adult INTERCEPTION OF DEVELOPING MALOCCLUSION QuesTiONS ANSWERS: Which of the following conditions could act as (e) All of the conditions listed can po- etiological factors in the development of a malocclu- tentially promote a malacclusion, sion? Of the conditions listed, the 1. an ankylosed primary molar most frequent factor producing a 2. an erupted or unerupted mesiodens malocclusion is the premature loss 3, prolonged retention of a primary tooth of a primary tooth. 4. premature loss of a primary tooth (a) 1 and 2 only {b) 2 and 3 only (c) and 4 only (d) 1 and 4 only {e) 1, 2,3, and 4 are correct Following the premature loss of which primary (a) Loss of arch dimension is generally tooth can loss of space be most rapid? greater following the premature {a) maxillary second molar loss of second primary molars, as (b) maxillary first molar opposed to first mciars. However, {c) mandibular second molar the most rapid loss and the greatest (@) mandibular first molar magnitude of closure occur follow- ing the loss of maxillary secona primary molars.512 PEDODONTICS ‘QUESTIONS ANSWERS In which of the fotiowing situations can loss of arch (e) All of the listed conditions can lead circumference occur? to loss of arch circumference and premature loss of a primary molar thus promote the development of a unrestored proximo-occlusal carious lesion malocclusion. ankylosis of a mandibular primary molar ectopic eruption of a maxillary first permanent molar (a) 1 and 2 only (b) 2 and 3 only (c) 3 and 4 only (a) 2and 4 only (0) 1,2, 3, and 4 are correct Which primary teeth are most frequently affected (a) Ectopic eruption occurs most fre- by ectopic eruption of first permanent molars? quently with maxiliary first per- (a) mandibular first primary molars (b) mandibular second primary molars, (©) maxillary first primary molars (d) maxillary second primary molars manent molars. The mesial eruption of this tooth will cause resorption of the distal root of the maxillary sec- ond primary molar (Fig. 19-8) Figure 19-8. Radiograph showing ectopic eruption of a maxillary first permanent molar. Note the resorption of the distal root ot the second primary molar What is the effect on arch dimension of a properly (d) Unrestored proximal carious lesions contoured occiusoproximal restoration in a primary in primary molars allow excessive molar? mesial drift of first’ permanent (a) prevents loss of arch length molars and lead to loss of arch (b) prevents loss of arch circumference length and circumference. A prop- (6) prevents loss of intermolar width erly contoured Class If restoration (a) both (a) and (b) in a primary maiar will prevent the (©) (a), (b), and (c) development of a crowded per- manent arch and restore mastic tory function to the tooth‘QUESTIONS PEDODONTICS 513 ANSWERS For what malocclusion is a brass ligature wire used as one type of treatment? (a) an anterior crossbite (b) a unilateral posterior crossbite (c) an ectopically erupting permanent molar (d) a maxillary midline diastema (c) A brass ligature wire (.02 to 026 inch gauge) looped and tightened around the area of contact between a second primary molar and first permanent molar is one method of intervention when a permanent molar is erupting ectopically A mandibular lingual holding arch with loops mesial to each molar band is used for: (a) space maintenance only (b) space regaining (c) correction of unilateral posterior crossbite (d) correction of bilateral posterior crossbite (b) A mandibular loop lingual arch is used to regain arch length by dis- talization of the first permanent molars to which it is banded. The loops are opened in increments, usually 1 mm per adjustment, for activation, Unless an abnormally large labial frenum is pres- ent, when should a maxillary midline diastema usu- ally be treated? (a) after the maxillary central incisors erupt (b) after the maxillary lateral incisors erupt (c) after the maxillary canines erupt (4) after the first permanent molars have under- gone a late mesial shift (c) A maxillary midline diastema rep- resents a normal phase of develop- ment during the mixed dentition. Provided there is no physical ob- struction, for example. a large labial frenum or masiodens, the diastema will usually close as the incisors align to accommodate the erupting maxillary permanent canines. What may cause crossbite of a maxillary per- manent incisor? (a) persistent thumb-sucking (b) large labial frenum (c) premature loss of a maxillary primary incisor (d) overretention of a maxillary primary incisor (d) Retention of a maxillary primary in- cisor beyond its normal exfoliation time may deflect the eruptive path of its permanent successor, The permanent tooth may erupt in linguoversion and be locked lingu- ally by the mandibular incisors. A nine year old child has a Class | malocclusion characterized by a lingually locked maxillary lateral incisor. What treatment Is indicated for this child? (a) extract the maxillary primary canines (6) place an acrylic inclined plane on the man- dibular incisors provided there is adequate maxillary arch circumference (c) place an acrylic inclined plane on the man- dibular incisors, irrespective of tooth size and arch circumference considerations (d) place crossbite elastics between the mandibu- lar incisors and the lingually locked maxillary incisor (b) Interceptive therapy of this type should be instituted only after it has. been judged that there is adequate space in the arch to accommodate the tooth in linguoversion What is the soft tissue profile (line from forehead- lips-chin) of a child with a malocclusion caused by persistent thumb sucking? (a) concave (c) convex (c) straight (a) round (b) A chronic thumb habit will cause the maxillary incisors to protrude. resulting ina convex soft tissue profile814 PEDODONTIC: QUESTIONS ANSWERS ‘A nine year old child traumatically avulsed the maxillary right central incisor. The tooth was lost and could not be replanted. What treatment is indicated for the edentulous space? (a) fabricate a fixed bridge using the maxillary left central and right lateral incisors as abutments (b) fabricate a removable appliance incorporating an acrylic replacement incisor in the design (c) construct a maxillary removable partial denture with a small cast saddle area in the edentulous 8p (d) no treatment is indicated, since the mandibular arch will prevent lingual collapse of the maxil- lary incisors (b) Replacement is necessary to pre- vent mesial drifting of adjacent maxillary incisor teeth and for esihe- tic and functionat reasons. A re~ movable space maintainer with an acrylic incisor should be inserted as. soon as possible and worn until a more permanent replacement can be constructed when the patient is older. Which of the following statements about “tongue thrust” activity is false? {a) in the presence of an anterior open bite, tongue thrust activity may develop as an adaptive mechanism (b} not all patients who demonstrate tongue thrust activity have a malocclusion (©) the incidence of tongue thrust activity de- creases with age (d) ail anterior open bites are a result of tongue thrust activity (d) An anterior open bite may be the result of tongue thrusting, thumb sucking, or bath, or it may be due to a skeletal malrelationship between the maxilla and mandible. How long should a palatal crib be worn by a pa- tient being treated for thumb sucking? (a) one week (b) one month (c) three months (d) six months or longer (d) Investigations have shown that most children will stop sucking their thumbs within seven days after in- sertion of a corrective appliance. However, if the appliance is re- moved within three months of in- sertion, the habit is likely to recur. It is therefore recommended that the appliance be worn not less than six months, and it is not uncommon. for the appliance to be worn for as. long as one year, THE SPECIAL PATIENT ‘QUESTIONS ANSWERS What caries incidence is found in patients with Down's syndrome? a) higher than in normal children (b) lower than in normal children (c) same as in normal children (4) none of the above are correct; no correlation has been found between caries incidence and Down's syndrome (b) Several studies have indicated that children with Down's syndrome have less dental decay than do similar aged non-Down's children. Since Down's children have a pat tern of late eruption. the lower caries incidence may, in part, be related to the lower at-risk factor for similar aged children.Quesrions PEDODONTICS 515 ANSWERS Which of the following devices may be more fre- quently employed during the dental management of the handicapped child? (a) restraining devices (b) bite blocks oF props (c) metal mouth mirrars (d) all of the above are correct (e) none of the above are correct (d) It may be impossible for a handi- capped child to adequately contro! his or her movements so that den- tistry can be satisfactorily accom- plished. Special restraining devices may be necessary to contro! body movements, and props may be necessary to keep the mouth open. Metal, rather than glass, mirrors are also recommended so that they de. not splinter should the patient in~ advertently bite them. What are the two most common types of cerebral palsy? {a} rigidity and tremor (b) ataxia and athetosis (c) spasticity and rigiaity (d) spasticity and athetosis (d} The types of cerebral paisy. with the approximate percentage afflicted. are as follows: spasticity —40% athetosis— 40-50% ataxia~ 10% rigidity — 10% tremor —5% What oral conditions children with cerebral palsy? (a) malocclusion (b) bruxism {c) enamel hypoplasia (d) dental caries and periodontal disease (e) all of the above are correct ur more frequently in The higher incidence of malocclu- sion and bruxism may be due to faulty muscle patterns. The incid- ence of enamel hypoplasia is ap proximately five to six times higher in children with cerebral palsy than in nonaffticted children (approxi- mately 36% vs 6%). Frequently, a correlation can be established be- tween the time of the injury that caused the cerebral palsy and the Gistribution of hypoplasia on ine teeth, The higher incidence of den- tal disease is believed to be associ- ated with a poor pattern of home and professional care rather than with an innate increased suscepti- bility te What is the most common type of hemophilia? (a) hemophilia A (b) hemophilia B (c) hemophilia © (d) von Willebrand's disease (a) Approximately 80 per cent of hemo- philiacs have hemophilia A. or classic hemophilia; 10 to 20 per cent have hemophilia B, also called Christmas disease; and 5 per cent have hemophilia C. Von Wille- brand's disease is a less common vascular hemophilia. Which of the following should not be given to hemophihe patients? (a) penicillin (b) aspirin {c) epsilon aminocaproic acid (d) diphenylhydantoin sodium (b) Hemophiliac patients should never be given aspirin (or aspirin-contain- ng products), since it has an itri~ tant effect on the gastrointestinat mucosa and can cause severe gas trointestinal_ hemorrhage, and it also has an adverse effect on hemo- stasis,