Modern University for Technology &

Information
Faculty of Dentistry
Pediatric Dentistry and Dental Public Health
Department

For Fifth Year Students

By
Professor Dr. /Rania Abdallah Nasr
Professor of Pediatric Dentistry and Dental Public
Health Department
Faculty of Oral and Dental Medicine
Cairo University
Dr. /Esraa Hamid
Lecturer of Pediatric Dentistry and Dental Public Health
Department, MTI University

2023
 :‫الرؤیة‬

‫تتطلع الكلية الي أن تكون من أكثر الكليات تميزا علي المستوي المحلي و اإلقليمي في مجال طب الفم و األسنان من خالل‬

‫وضع برامج و أساليب أ كاديمية متطورة في تعليم طب األسنان ودعم البحث العلمي في هذا الميدان و أن تقدم مستوي متميز‬

. ‫من خدمات المهنة للمجتمع المحيط من خالل كوادر الكلية من الخريجين و القائمين علي النشاط العلمي‬

:‫الرسالة‬

‫تلتزم الكلية بإعداد أطباء أسنان يتميزون بالجدارة المهنية من خالل برامج تعليمية متطورة قادرين علي التوافق مع سوق‬

. ‫العمل و مواكبة التطور العلمي و اإلسهام فيه بالألنشطة البحثية مع تلبية احتياجات المجتمع من خدمات طب األسنان‬

Vision:
The college aspires to be one of the most distinguished colleges at the local and
regional levels in the field of Oral and Dental Medicine through the development of
advanced academic programs and methods in dental education and support for
scientific research in this field, and to provide an outstanding level of professional
services to the surrounding community through the college cadres Alumni and
associates of the activity.

Mission:
The college is committed to preparing dentists of professional merit through advanced
educational programs who are able to comply with the requirements of the labor market,
keep pace with scientific development and contribute to it through research activities
while meeting the community's needs of dental services.
 INDEX

Subject: Page:
 Management of Traumatic Dental Injuries in Children. 1

 Extraction of Teeth in Children. 19

 Management of Space Maintenance Problems in 23

Children.

 Gingival and Periodontal Problems in Children. 40

 Dental Management of Special Health Care Needs.

60

 Child Abuse and Neglect. 80

 Management of Traumatic Dental Injuries in
Children
Facial trauma that results in fractured, displaced or lost teeth can have significant
negative functional, esthetic & psychological effects on children. The greatest
incidence of trauma to the primary dentition occurs at 2-3 years of age when the
motor coordination is still developing, while the greatest incidence of trauma to the
permanent dentition occurs at 10-12 years of age. The prevalence of traumatic
dental injuries among boys and girls does not differ to a great extent until the age
of 9 years. After this age, boys show higher prevalence than girls with a ratio 1.5:1.
This is probably because of active participation of boys in contact sports.

Predisposing Factors to Dental Trauma:

1. Mentally handicapped patients and those with neurological disorders.
2. Class II division 1 malocclusion with protruded upper incisors and increased
overjet. Dental trauma is as twice as frequent in those children; early
orthodontic treatment may prevent traumatic injuries.
3. Enamel hypoplasia, extensive caries or other structural defects of teeth that
results in weakening of the tooth structure, can cause fracture of the crown
under even slight trauma.
4. Sports activities as: contact sports, bicycle or horse riding.
5. Other factors as: falls, road accidents or acts of violence.

1
Classification of Trauma to Anterior Teeth:
Several classifications have been advocated by several authors:
I. Descriptive Classification:
1. Fractures of Teeth:
 Uncomplicated crown fracture (without pulp involvement).
 Complicated crown fracture (with pulp involvement).
 Crown-root fracture.
 Root fracture.

2. Involving the Whole Tooth:

 Concussion: Sensitivity of the tooth due to mild blow without abnormal
loosening or mobility. The tooth may be sensitive to percussion.
 Subluxation: Loosening of the tooth without displacement, due to a more
severe blow resulting in injury to periodontal ligament.
 Displacement:
- Intrusion: Displacement of a tooth in an apical direction. Tooth is pushed
into the socket, causing fracture of the bone at the floor of the socket in most
of the cases.
- Extrusion: Displacement of a tooth in a coronal direction. Tooth is seen
extruded partially out of the socket.
- Labial/lingual/palatal: Displacement of a tooth in a labial or lingual
direction.
- Lateral: Displacement of a tooth in a mesial or distal direction.
- Avulsion: loss of tooth, where the entire tooth is out of the socket.

3. Trauma to the Supporting Bone:

 Involves alveolar bone fractures.
2
II. Ellis and Davey classification:
Class 1: Simple crown fracture with little or no dentin.
Class 2: Extensive crown fracture involving considerable amount of dentine
without pulp exposure.
Class 3: Extensive crown fracture involving considerable amount of dentine with
pulp exposure.
Class 4: Non-vital traumatized tooth with or without loss of crown structure.
Class 5: Loss of the tooth.
Class 6: Root fracture with or without crown fracture.
Class 7: Tooth displacement without crown or root fracture.
Class 8: Fracture of crown en-mass.
Class 9: Traumatic injuries of deciduous teeth.

III. Modified Ellis and Davey classification:

Class I: Traumatized teeth with fracture involving enamel only or enamel and little
dentine.
Class II: Traumatized teeth with fracture of enamel and considerable amount of
dentine.
Class III: Traumatized teeth with fracture of enamel and dentine with pulp
exposure.
Class IV: Traumatized teeth where amputation of the crown en-mass occurs.
Class V: Traumatized teeth where there is root fracture accompanied with or
without crown fracture.

3
Class I Class II Class III Class IV Class V
Modified Ellis and Davey classification

Management of Traumatic Dental

Injuries

Diagnosis Treatment Prognosis

History Clinical Examination

Diagnosis:
To efficiently determine the extent of injury and correctly diagnose injury to the
teeth, periodontium and associated structures, a systematic approach to the
traumatized child is essential. Assessment includes; a thorough history, visual &
radiographic examination as well as adjunctive tests, such as: palpation, percussion
& mobility evaluation. All relevant diagnostic information, treatments &
recommended follow-up care should be documented in the patient's record.

4
I. History:
1.Personal Information:
The patient's name, age, sex, address, source of referral…. etc.

2. Medical History:
Routine data on the patient’s general health should be obtained, particular those
relevant to dental injuries.
- Systemic diseases: which may require medical consultation.
- Diseases requiring pre-medications: cardiac disease which would necessitate
prophylaxis against Sub-Acute Bacterial Endocarditis, bleeding disorders.
- Allergies to medications.
- Current medications for possible drug interactions.
- Immunization status: especially if the child suffers from a dirty wound.
Children require active immunity through a series of injections of heat-
denatured tetanus toxoid in their first 18 months of life. They should then
receive a booster dose at 4-6 years of age.

3. Dental History:
a. Previous dental history:
Information can be obtained on the frequency of dental visits, type of treatment
performed, type of anesthesia used and to determine the patient's co-operation
level, attitude & to explore the incidence of any previous traumatic injuries.
b. History of the injury:
History should be short and to the point, only three questions need to be asked:
WHEN, WHERE and HOW.

5
 - WHEN? (Time Elapsed Since Injury)
Time is a very critical factor that will determine the technique and prognosis of
treatment given. Therefore, the shorter the time between trauma and treatment, the
better the prognosis of the case.
- WHERE? (The Place Of Injury)
If the accident occurred in a dirty environment, prophylactic tetanus treatment is
indicated.
- HOW? (How Did The Injury Occur?)
It may be:
Direct Trauma: causing tooth fracture, displacement or root fracture.
Indirect Trauma: which may cause sub-condylar fracture or TMJ dislocation.
For young children, where there is a marked discrepancy in clinical findings and
the history given, child abuse should be suspected.

II. Clinical Examination:

1. Extra-Oral Examination:
The extra-oral examination begins immediately when the patient enters the office.
- Lacerations, abrasions, contusions and swellings on the face, head, neck
and exposed limbs can be noted visually.
- Any asymmetries including any deviations in the mandibular path during
mouth opening.
- Extra-oral wounds should be inspected for foreign bodies.
2. Intra-Oral Examination:
a. Soft tissue Examination:
- Note any laceration of the tongue, gingiva, lip, labial and buccal mucosa.
- Presence of embedded tooth fragments should be suspected in case of
penetrating wounds.
6
 - Hematoma of the floor of the mouth may indicate mandibular fractures.
b. Hard tissue Examination:
- Displacement: Teeth may suffer labial, lingual, palatal or lateral displacement as
well as intrusion, extrusion or avulsion.
- Mobility: If two or more teeth are mobile, an alveolar fracture should be
suspected.
- Tooth fracture: A modification of Ellis and Davey classification of crown
fracture is useful in recording the extent of damage involving young permanent
teeth.
- Percussion: Sensitivity to slight tapping may reveal injury to the periodontium &
possible periapical pathology.
- Color change: Non-vital teeth often appear discolored. This is due to an
interruption in the blood supply of the tooth. The blood already present in the pulp
chamber undergoes a normal breakdown process, but the products are unable to
dissipate. This results in tooth discoloration varying from gray-brown to black.
- Trans-illumination Test: Reflecting intense light through the crown can detect
enamel cracks & infractions.
3. Sensitivity or Vitality Test:
Vitality testing just following traumatic injury is of a little value because false
responds often occur. Further testing should be performed at subsequent visits.
4. Radiographic Examination:
All traumatized teeth should be examined radiographically to investigate:
- The size of the pulp chamber.
- The stage of root development.
- The presence of any root fractures.
- The presence of any periapical pathology.

7
 - Injuries to the supporting periodontal membrane, such as the degree of
intrusion or extrusion of the tooth.
- Integrity of tooth buds.
- Presence of tooth fragments or foreign bodies in the soft tissues.
- If teeth are missing and no accurate history of their whereabouts, it is
advisable to refer the patient to a hospital for a chest radiograph.
- Alveolar fractures.
- If a jaw fracture is suspected, extra-oral radiographs are indicated.
Treatment of Traumatic Dental Injuries (Permanent Dentition):
I. Soft tissue injuries:
a. Determination of child immunization status:
- If the child had received a primary immunization the antibody forming
mechanism may be activated with booster injection of toxoid.
- Unimmunized child can be protected through passive immunization.
b. Debridement, suturing and/or hemorrhage control of open soft tissue wounds,
and when needed refer the child to family physician.
II. Concussion:
- A mild blow to the tooth resulting in mild sensitivity requires little or no
treatment. Examination and regular vitality testing at follow up visits is
required.
III. Subluxation:
- Mobility of the tooth but no displacement, there is often hemorrhage around
the gingival margin of the tooth, and the tooth may be sensitive to
percussion.
- Treatment is similar to that of concussed tooth.
- If mobility is extensive, splinting the tooth is required.
- Follow up is essential to monitor for loss of vitality and abscess formation.
8
IV. Tooth Fracture:
Class I:
A crack or craze of the enamel without loss of tooth structure:
- Horizontal or vertical crack or craze lines in enamel do not require
immediate treatment.
- Injury to the blood supply and supporting structures may have occurred,
therefore vitality testing at follow up visits is essential.
Fracture of enamel only:
- No treatment is needed except smoothing of the sharp fracture to prevent
irritation of the lips or tongue and the application of topical fluoride.
- Follow up and periodic vitality testing.
Class II:
Immediate Treatment Of The Crown Is Required To:
- Protect the pulp from chemical or thermal insult and bacterial contamination.
- Restore normal esthetics & function.
- Maintain the arch integrity by restoring normal contact with adjacent teeth.
Treatment:
- Covering the exposed dentine with calcium hydroxide to prevent further
irritation to the pulp. The tooth is then restored using composite resin.
- Fragment restoration: When the fractured tooth fragment remains intact
and is recovered after injury, the dentist should consider re-attachment of
this fragment. In this technique, the tooth requires no mechanical preparation
because retention is provided by enamel etching and bonding techniques.
For cases in which considerable dentin has been exposed, some controversy
exists.

9
Prognosis:
Depends upon;
- Concomitant injury to periodontal ligament.
- Extent of dentin exposure.

Class III:
Clinical & radiographic findings reveal loss of tooth structure with pulp exposure.
Treatment Objectives:
- Maintain pulp vitality.
- Restore normal esthetics and function.
- Induce apical closure of young permanent teeth.

The Treatment Depends On Many Factors Such As:

- Size of exposure (small or large).
- Time elapsed since the fracture (early within 6 hours or late).
- Vitality of the tooth (vital or non-vital).
- Degree of root maturation and apical closure.
- Crown restorability.
- Physical condition of the patient (medically compromised).
Treatment:
1. Direct pulp capping:
Indications:
- Pin-Point or Minute Exposure.
- The patient reported immediately (within 2 hours).
- Vital tooth.
- Open or Closed Apices.

10
2. Calcium Hydroxide Pulpotomy (Apexogenisis):
Indications:
- Minute Exposure and the patient reported late.
- Or large exposure and patient reported early.
- Vital Tooth.
- Incompletely Formed roots (Open Apices).

3. Apexification:
Indications:
- This is a technique used to induce apical closure of incompletely
formed roots of permanent teeth with non-vital pulps.
4. Pulpectomy:
- Indicated in teeth with completely formed roots and closed apex.
- Vital or non-vital.

Class IV:
Crown fracture where the fracture line passes beneath the gingival margin. This
may be vertical or oblique fracture.
Treatment:
- Usually involves removing the loose fragment which is often held in a
close position to the rest of the tooth by the periodontal ligament fibers.
- Then the remaining part of the tooth can be extruded orthodontically or
a surgical approach may be required to gain access to the apical part of
the fracture line prior to pulp therapy and placement of a restoration.
Class V:
In the permanent dentition root fractures mainly affect the maxillary central
incisors and are most common in teeth whose roots are fully formed and embedded

11
in well matured alveolar bone. Below 11 years of age, the root is in its formative
stage and more resilient to the effects of trauma. Root fracture may occur in the
cervical third, middle third or apical third of root. The closer the fracture to the
apex of the root, the more favorable is the prognosis.

Treatment Objectives:
- To reposition as soon as possible & then to stabilize the coronal
fragment in its anatomically correct position to optimize healing of the
periodontal ligament & neurovascular supply while maintaining esthetic
& functional integrity.
Apical Third Root Fracture:
- No treatment is needed follow up with x-ray should be continued up to
six weeks.
- If the fracture line increases in width, this indicates failure of union &
the need for root canal treatment followed by surgical removal of the
apical fragment.
Middle Third Root Fracture:
- With this type if fracture there will be displacement of the fractured
crown-root segment, usually palatally or lingualy.
- Reduction into position by digital pressure and stabilize the tooth by
splinting (4-6 weeks).
- Types of splints:
- Composite splint. - Wire splint.
- Arch bar splint. - Split acrylic splint.
Cervical Third Root Fracture:
- Remove the coronal segment.
- If the fracture is 1-2 mm infra-bony a possible osteoplasty to expose the
12
 root or vertical orthodontic root extrusion may be required.
- Root canal treatment with post crown restoration can be accomplished
otherwise extraction is treatment of choice.

Requisites of successful treatment of root fractures:

- The fragments must be in close contact.
- The fragments must be immobilized.
- Absence of infection.
- The patient's general health must not contraindicate such procedure.

V. Displacement of Permanent Anterior Teeth:

Intrusion:
An intruded permanent tooth can be treated by one of the following ways:
- Intruded tooth with immature root, the tooth will erupt spontaneously.
- Immediate surgical repositioning, splinting and endodontic therapy.
- Orthodontic extrusion and repositioning.
Complications such as external root resorption and loss of marginal bony support
do occur in surgically repositioned teeth. Orthodontic repositioning has a better
success rate. Endodontic therapy can be performed when there is adequate crown
available.
Extrusion:
- Reposition the tooth to its original position as soon as possible, any
delay in treatment may result in it being fixed in its extruded position.
- Stabilize the tooth in its position by splinting.
- If vitality of the tooth is lost, begin root treatment immediately by
placing calcium hydroxide in the canal for 6 months to 1 year.

13
Avulsion:
Replantation is the term given to the technique in which a permanent tooth, usually
one in the anterior region, is reinserted into the alveolus within a reasonably short
time following its loss or displacement by accidental means (avulsion).

The Prognosis of Replanted Permanent Teeth Depends On:

-The stage of root development: The chance for revascularization is better in case
of open apices than in case of closed apices.
- Time interval between injury and treatment: The tooth has the best prognosis if
replanted immediately within 30-60 minutes of injury.
- Conditions under which the tooth has been stored: The tooth must be kept moist
to prevent irreversible damage to the periodontal membrane.

Storage Media (In Order of Preference):

- Viaspam.
- Hank’s Balanced Salt Solution HBSS (Tissue Culture Media).
- Cold milk.
- Saliva (buccal vestibule or floor of the mouth).
- Physiologic saline or water.

At The Dental Office:

- Splint the tooth in the socket by composite resin splint for one week.
- Calcium hydroxide should be placed in the tooth after 1 week to
prevent the initiation of inflammatory root resorption.
- Root canal therapy.

14
 - In immature teeth with open apices, the tooth should be splinted for 2
weeks to give the neurovascular tissues an opportunity to
re-anastomose.
Treatment of Traumatic Dental Injuries In The Primary Dentition:
Primary teeth are more likely to be displaced than fractured because of :
- Thinner and more elastic alveolar bone.
- Physiological resorption, which reduces the root length.
The effect of injury in the deciduous dentition is either:
Immediate effect on the primary teeth:
- Displacement: Intrusion, extrusion or avulsion.
- Fracture: Crown-root fracture.
Indirect effect on the unerupted permanent teeth:
- Hypoplasia: Turner’s hypoplasia.
- Hypomineralization.
- Dilaceration.
Treatment of Fractured Primary Teeth:
- Enamel fracture: smooth sharp edges.
- Enamel and dentin fractures: composite resin restorations.
- Fractures involving pulp exposure: pulp therapy or extraction.
- Traumatized anterior teeth that have become non-vital: no treatment is
required unless there are signs of a pathologic condition (pain, abscess
or fistula), treatment can be either pulpectomy or extraction.
Treatment of Displaced Primary Teeth:
Check the contact between a displaced primary tooth and its permanent successor
by a radiograph, then follow up.

15
Intrusion:
- Most intruded teeth will re-erupt spontaneously (either partially or
completely) over a period of few months.
- Only if there is evidence that the intruded tooth is in contact with the
underlying successional tooth consideration should be taken to remove
the intruded tooth.
Extrusion:
- The extruded primary tooth is usually extracted.
- Repositioning may result in damage to the underlying permanent tooth.
Avulsion:
- Avulsed primary teeth are not replanted. The tooth should be discarded.

Reaction of tooth to trauma:

Pulpal hyperemia:
- Occurs following minor trauma where there is congestion of blood
vessels in pulp chamber which may eventually result in pulp necrosis.
- The hyperemic tooth appears reddish in colour as compared to adjacent
teeth.
- The hyperemic tooth may undergo resolution or necrosis and treated by
root canal therapy.
Internal hemorrhage:
- Occurs following trauma which result in hyperemia and increased blood
pressure in the pulp leading to rupture of capillaries and escape of RBCs
with subsequent breakdown and pigment formation.
- Discoloration may be temporary in mild cases where re-absorption of
RBCs occurs before reaching the dentinal tubules.

16
 - Discoloration may be permanent in severe cases due to pigment formation
in the dentinal tubules.
Pulp Calcification:
- It is a rapid physiologic repair response of the pulp to trauma which may
continue until the pulp is completely replaced by calcified tissue.
- The clinical crowns of such teeth appear opaque yellow in colour and show
no response to various pulp tests.
- Primary teeth will undergo to physiologic resorption, while permanent teeth
will be indefinitely retained.
Internal Resorption:
- Destructive process caused by osteoclastic activity.
- May lead to perforation of the root or the crown which appears as a "pink
spot" where the vascular pulp tissue shines through the remaining thin shell
of the crown.
- If detected early, the pulp tissue is extirpated and Ca (OH) 2 is placed in the
canal to create an environment unfavorable for root resorption.
External Root Resorption:
- When trauma causes tooth displacement and damage to the periodontal
structures.
- The process usually continues until gross areas of the root are destroyed.
Pulp Necrosis:
- As a result of severe blow to the tooth which causes severance of apical
vessels and decreased blood supply to the pulp.
- A necrosed tooth can be treated with root canal therapy.
Ankylosis:

17
- Injury and inflammation of the periodontal membrane associated with
osteoclastic activity may result in external root resorption. This process may
be followed by repair. If repair occurs at a higher rate than resorption, this
may lead to fusion of alveolar bone and root surface.
- Radiographically, there is an interruption in periodontal membrane space of
ankylosed tooth and continuity of dentin and alveolar bone.
- Clinically, there is difference in the incisal plane of ankylosed tooth and
adjacent teeth (submerged).
- In ankylosed primary anterior tooth, extraction is done followed by a space
maintainer.
- In ankylosed permanent tooth, the tooth can be covered by an esthetic
crown.

18
 Extraction of Teeth in Children

The general principles of Oral Surgery remain the same whether applied to
the adults or to children. However, there are some factors to be considered
in oral surgery for children as compared to adults:
1. The oral cavity is small and there is greater difficulty in gaining
access to the field of operation.
2. The jaws are in normal process of growth and development and the
dentition is in continuous state of change with eruption and
resorption of primary teeth then eruption of permanent teeth. Any
premature extraction of primary teeth may lead to irregularities in
the permanent teeth.
3. The bone structure of a child contains higher percentage of organic
material, which makes it more pliable than adult bone and not as
likely to fracture.

Indications for extraction of primary teeth:

1. Teeth decayed beyond possible repair.
2. Infection of the periapical or inter-radicular area which can be
eradicated by other means.
3. Acute dento-alveolar abscess with cellulitis.
4. Teeth interfering with normal eruption of succeeding permanent
teeth.
5. Submerged teeth.

Contra-Indications for extraction of primary teeth:

Many of these Conta-indications are relative and may be overcomed with
special precautions and medications.
1. Acute infectious stomatitis stomatitis, acute ulcerative gingivitis or
acute herpetic gingivostomatitis. The acute phase should be
controlled before extraction.
2. Blood disorders: make the patient susceptible to postoperative
infection and hemorrhage. Extractions should be performed only
after consultation with hematologist and proper preparation of the
patient.
19
 3. Rheumatic heart disease, congenital heart disease and congenital
kidney disease require proper Antibiotic coverage.
4. Acute systemic infections of childhood, because of lowered body
resistance.
5. Malignancy, if suspected, on the other hand, extractions is strongly
indicated if the orofacial areas are to receive irradiation.
6. Teeth which have remained in irradiated bone.
7. Diabetes Mellitus: Extraction can be done after the condition is
controlled.

Indications for extraction of First Permanent Molars:

- If a first permanent molar is removed before the permanent second
molar has erupted through the gingiva, the chances that the second
molar will move mesially as a whole ( Bodily Movement) and
occupy the space of the extracted first molars are very good.
- When two first molars are diseased beyond repair, they should be
removed.
- But if three first molars are diseases beyond repair, all four molars
should be removed with the expectation that a more symmetrical
dentition will result.

Pre-Operative Preparation:
As the extraction of a tooth can be emotionally upsetting to the child and
the parents, some preparations are necessary.

a. Parent's Preparation:
- A parental consent is important before extraction.
- Any possible medical condition which may require special
precautions should be discussed.

b. Child Preparation:
- Avoid the use of technical words and words suggesting fear or pain.
- Explain to the child what sensation may be experienced.
- The child should realize the difference between pain and pressure.

20
Techniques for the removal of primary teeth:
Although extraction of a deciduous tooth with completely resorbed roots
is a simple task, removal of some of the deciduous teeth with all or part of
the roots present can be challenging.
- Armamentarium for extraction procedures is much the same as for
adults, But as all anatomic structures are smaller, special forceps are
available for primary teeth.
- Fracture of a slender root is common, especially there is uneven
resorption. These roots should be removed using a small elevator or
even a large spoon excavator or universal scaler.
- When removing young permanent teeth, the young elastic bone
structures and incomplete root development usually facilitate the
extraction.
EXTRACTION OF ANTERIOR TEETH:
Anterior teeth should be luxated to the labial during the extraction
procedure due to the lingual position of the permanent teeth buds then
rotated slightly and delivered labially.

EXTRACTION OF MAXILLARY PRIMARY MOLARS:

- Because the palatal root is curved, so the initial direction force is
slightly to the palatal.
- Slight force is emphasized in order not to fracture the curved palatal
root, then in a single sustained force to the buccal until the tooth is
loosened.
- A counterclockwise motion delivers the tooth out of the socket.

EXTRACTION OF MANDIBULAR PRIMARY MOLARS:

- The cross section of the mandibular first primary molar roots is flat
mesiodistally and elliptical, therefore, any rotational movement is
contra-indicated.
- The initial force is slightly to the lingual, then in a single sustained
force to the buccal until the tooth is loosened.
- A counterclockwise motion delivers the tooth out of the socket.
- During extraction, the mandible is supported with the non-extraction
hand to protect TMJ against any possible injury.

21
Post-Operative Instructions:
 FOR THE CHILD:
a. The child shouldn’t be dismissed until a blood clot has been formed,
the chils is instructed to hold between his lips a small cotton roll until
his lips " wake up".
b. Can return to the school or to his training once the numbness has
gone.
c. The child should be reassured that he will get a new tooth in the
place of the one removed.
 For the parents:
a. Tell the parents why the cotton roll is used and that they shouldn’t
be concerned if there is slight oozing or blood from the socket.
b. Light soft cold meals with no hard foods are recommended.
c. The parents are instructed not to continuously ask the child how
painful the area is.
d. Simple written instructions can be helpful.

22
 Management of Space Maintenance
Problems in Children
The damaging effect of premature loss of one or more of the primary teeth
differs greatly in patients, and presents a problem which may affect the
dentition and soft tissue throughout the patient’s life.
A tooth is maintained in its correct relationship in the dental arch as a result
of series of forces, if one of these forces is changed or removed changes in
the relationship of the adjacent teeth will occur resulting in drifting of teeth
and development of space problem.

Forces that act on a tooth to maintain its relationship in the arch.

Factors influencing development of malocclusion when a tooth is

extracted prematurely:

1. Abnormal Oral Musculature:

High tongue position coupled with a strong mentalis muscle may cause
collapse of the dental arch and distal drifting of the anterior teeth following
premature loss of one of the mandibular primary molars.

23
 2. Oral Habits:
Thumb or finger sucking habits cause abnormal forces on the dental arch.
3. Existing Malocclusion:
Arch length inadequacy and other forms of malocclusion particularly class
II, division I become more severe after early loss of mandibular primary
teeth.
4. Stage Of Occlusal Development:
In general, more space loss is likely to occur if teeth are actively erupting
adjacent to the space left by the premature loss of a primary tooth.
Space Maintenance:
It is the process of maintaining the space previously occupied by a tooth,
several teeth or tooth structure before the eruption of the permanent tooth.
Space Maintainer:
Appliance used to maintain the space created by premature loss of primary
tooth or multiple loss of primary teeth till the eruption of the permanent
successor OR Appliance used to maintain the space of the lost permanent
tooth/teeth till age of construction of fixed appliance.
Ideal Requirements of a Space Maintainer:
1. Maintain the space (Horizontally & Vertically).
2. Provide room for the eruption of the Permanent Successor.
3. Restore function and esthetics.
4. Hygienic.
5. Ease of construction.
6. Reasonable cost.

24
Indications for Space Maintainers:
If lack of a space maintainer would lead to malocclusion or to the
encouragement of deleterious habits or a psychic trauma, then a space
maintainer is indicated.
Planning for a Space Maintenance:
I. Factors to be considered when constructing a space maintainer:

1.Time Elapsed Since Tooth Loss:

 Space closure usually takes place during the 6 months following
extraction.
 It is desirable to construct a space maintainer immediately after
extraction.
 If space is lost an active space maintainer (space regainer) can be
constructed to regain the space lost.
2. Dental Developmental Age of The Child:
 The chronological age is not as important as the developmental
one.The dentist must depend upon x-ray to provide useful
information to when the tooth is going to erupt instead of the
eruption tables.
 The average eruption dates must not influence decisions regarding
the construction of a space maintainer as there is variation in the
eruption times of teeth.
 Teeth usually erupt when three-fourths of the root is developed.
3. Amount Of Bone Covering The Un-Erupted Tooth:
 If there is an amount of bone covering the crown of the permanent
successor, it can be predicted that eruption will not occur for many
months.
25
  Usually a tooth requires 4-5 months to move through 1mm of bone
as measured on a bite-wing radiograph.
 If bone is destroyed by infection related to the primary
predecessor, the eruption of the permanent successor may be
accelerated.
4.Degree of Root Development Of The Permanent Successor:
 The developing tooth does not move in its crypt till the complete
calcification of the crown and the beginning of root formation.
 At the time of extraction of the primary tooth, if the crown of the
permanent successor is not fully formed, the socket will heal with
bone formation, thus delay the eruption of the permanent
successor up to one year.
 On the other hand, if the primary tooth is extracted after the root
formation of the permanent successor, the tooth might erupt earlier
up to 6 months.
5. Sequence Of The Eruption Of Teeth:
 The relationship between the developing and erupting teeth
adjacent to the space created by the premature loss of primary
tooth should be observed.
 For example, if the first primary molar is lost prematurely during
the active stage of eruption of the lateral incisors distal drifting of
the primary canine is likely to occur, closing the space needed by
the first premolar, leading to a shift in the midline.
 If the second primary molar has been lost prematurely and the
second permanent molar is ahead of the second premolar in
eruption, there is a possibility that the second permanent molar
will exert a strong force on the first permanent molar causing it to
26
 drift mesially and occupy some of the space required by the
second premolar.

6. Delayed Eruption Of The Permanent Tooth:

 If an individual permanent tooth is delayed in development and
consequently in eruption, it is usually necessary to extract the
primary tooth, construct a space maintainer, and allow the
permanent tooth to erupt and assume its normal position.
7.Congenital Absence Of A Permanent Tooth:
 If a permanent tooth is congenitally absent, it should be decided
whether to hold the space until a fixed replacement can be provided
or to allow the space to close.
II. Factors Related To Arch Length Adequacy:
 Development of the dental arches and establishment of a functional
occlusion.
 Assess the amount of mesial movement of first permanent molars
after loss of primary and permanent canines to erupt and provide
space to alleviate anterior crowding.
 The depth of the curve of Spee may influence the available arch
length. The ideal occlusion will have a nearly flat or very slight
curve of Spee. When leveled the teeth will require more linear space

27
 than they occupied before.

Determination of Arch Length Adequacy (Arch Length Analysis):

1. Nance Arch Length Analysis:
The aim of Nance analysis was to predict the adequacy or inadequacy of
the arch length of the dental arch. Nance concluded that the length of the
dental arch from the mesial surface of one mandibular first permanent
molar to the mesial surface of the corresponding mandibular molar on the
opposite side is always shortened during the transition from the mixed to
the permanent dentition due to the normal mesial drifting of the first
permanent molars. Nance observed that in the average patient’s mandibular
arch a leeway space of 1.7mm per side exists between the combined mesio-
distal widths of the primary mandibular canine, first and second primary
molars and the mesio-distal widths of the permanent canine and premolars,
the primary teeth being the larger. The difference in the maxilla is only
0.9mm per side.

Procedure Of Nance Analysis:

1. Measure the width of the erupted four permanent incisors from the study
model using a sharp divider.
2. Measure the width of the un-erupted permanent canine, first and second
premolars from a periapical radiograph.
3. Sum both measurements to get the required space which is the space
needed for accommodation of all the permanent teeth anterior to the first
permanent molar.
4. Determine the available space for eruption of the permanent teeth using
a soft brass wire by contouring it to the individual arch shape and placed on
28
the occlusal surfaces over the contact points of the posterior teeth and the
incisal edges of the anterior. The wire should extend from the mesial
surface of the first permanent molar on one side to the mesial surface of the
corresponding molar on the other side.
5. Subtract the Leeway space from the available space.
6. Compare between the required space and the available space:
- If required space = available space i.e. arch length adequacy.
- If required space > available space i.e. crowding.
- If required space < available space i.e. spacing.

2. Moyer (Ballard Wylie) Analysis:

It was first established by Ballard Wylie and followed up by Moyer. This
analysis was developed on the assumption that in a given individual, there
is harmony between the size of permanent incisors and the size of canines
and premolars. Moyer developed a Predictograph used to predict the
mesio-distal widths of the unerupted permanent canines and premolars.

Procedure of Moyer’s analysis:

1. Measure the mesio-distal width of the erupted four permanent incisors.
2. Determine the predicted sum of widths of the unerupted permanent
canine, first and second premolars (required space) using the tables
available based on the sum of widths of the permanent incisors.
3. Measure the available space in the arch for eruption of the permanent
canine and premolars using a divider from the distal surface of the lateral
incisor to the mesial surface of the first permanent molar in each quadrant.
4. Estimate the adequacy of space for unerupted permanent canine and
premolars by comparing the required and available space.

29
Classification of space maintainers:
They may be classified in various ways:
I. According to means of retention:
A. Removable space maintainer:
1. Partial denture.
2. Complete denture.
3. Spoon denture.
B. Fixed space maintainer:
1. Band and loop.
2. Stainless steel and loop.
3. Distal shoe appliance.
4. Passive lingual arch.
5. Modified fixed partial denture.
6. Transpalatal bar.
7. Nance holding appliance.
C. Semi-fixed space maintainer:
1. Active lingual arch.
2. Active transpalatal bar.
II. According to activity:
A. Active.
B. Passive.
III. According to function of restoration:
A. Functional.
B. Non-functional.

30
Selection of a Space Maintainer:
The type of a space maintainer used varies according to the number of
teeth lost (single, multiple, unilateral or bilateral) and the area of tooth lost
(anterior, posterior, upper or lower).
I. Space maintainer for primary molar area:
A. Missing first primary molar:
1. Band and loop.
2. Stainless steel and loop.
3. Passive lingual arch (if permanent incisors are erupted).
4. Transpalatal bar.
5. Nance holding appliance.
1. Band and loop maintainer:
Advantages:
1. Ease of construction.
2. Low cost of the materials.
3. Takes little chair time.
4. The appliance can give room for the erupting permanent teeth.
Disadvantages:
1. Will not restore masticatory function.
2. Will not prevent continuous eruption of the opposing tooth.
3. The loop has limited strength so the appliance must be restricted
to holding the space of one tooth only.
Steps of construction:
1. Selection of an orthodontic band that fits the tooth (usually the tooth
distal to the space). Adapt the band well on the tooth by means of a band
pusher.
2. An alginate impression is made of the abutment tooth including the area

31
of premature loss and the primary canine.
3. The band should be removed from the tooth and replaced securely in the
alginate impression.
4. Stone is poured into the impression to produce a working model.
5. A loop of 0.7 mm stainless steel wire in contoured to rest on the tissue
and contact the distal surface of the primary canine at the gingival area.
The loop should be sufficiently wide to allow for the eruption of the
premolar.
6. The loop is soldered to the band on the stone model.
7. Smooth and polish the appliance.
8. Cement the appliance.

Modifications of the band and loop space maintainer:

A. Crown and loop:
Indicated if the posterior abutment tooth has extensive caries and requires a
crown restoration, or if the abutment tooth has had vital pulp therapy and
requires full coverage.
It requires preparation of the abutment tooth for the stainless steel crown
and then the loop is soldered to the crown. The loop may be cut off and the
crown is left to continue serve as a restoration for the abutment tooth when
there is no longer need for the space maintainer.

Band and loop space maintainer and crown and loop space
maintainer.

32
Disadvantages: it is hard to make adjustments to the loop in case of crown
coverage so it is recommended to adapt a band and loop over a cemented
crown.

B. Bonded band and loop:

The loop is bonded to the abutment tooth with composite resin.
Disadvantages: it is hard to adjust and the bond breaks easily.

2. Passive lingual arch:

It is a bilateral fixed space maintainer indicated in case of multiple loss of
teeth in the mandibular arch, if the lower permanent incisors are erupted. In
case of presence of primary incisors, a bilateral band and loop is indicated.
The wire should closely adapt to the cingulum areas of the incisors and the
lingual surfaces of the posterior teeth and attached to bands on the first
permanent molars.

Passive Lingual Arch.

There are two types of lingual arch:

A. Fixed: the appliance is entirely passive to prevent undesirable
movement of the teeth.
B. Fixed-removable (semi-fixed, active): in which the ends of the arch
wire are fitted into tubes on the bands.

33
 Transpalatal Bar

3. Transpalatal bar: .
Indicated in case of multiple or bilateral loss of primary molars in the
upper arch. Bands are adapted to the maxillary first permanent molar and
a bar adapted to the palate will be soldered to the bands, thus preventing
the maxillary molars from mesial movement as it rotates around its
palatal root.

4. Nance holding appliance:

It is a fixed bilateral space maintainer used in the upper arch in case of
bilateral loss of first primary molar or multiple loss of primary molars. It is
similar to the lingual arch except that the anterior portion of the arch does not
touch the lingual surfaces of the upper anterior teeth. Instead the arch wire is
contoured against the slope of the anterior portion of the palate approximately
1 cm distal to the lingual surfaces of the central incisors to help retain the
cured acrylic button.
Disadvantages: unhygienic and causes tissue irritation and inflammation in
the area of the acrylic button.

34
B. Missing second primary molar:
After the eruption of the first permanent molar:
The same as that recommended when the first primary molar is lost, i.e. band
and loop or stainless steel crown and loop.
Before eruption of the first permanent molar:
Mesial movement and migration of the first permanent molar will often occur
prior to eruption in case of premature loss of the second primary molar. So a
space maintainer that will guide the first permanent molar into its normal
position is indicated such as crown or band maintainer with distal shoe
extension, the first primary molar is used as the abutment tooth.
Steps:
1.The first primary molar is prepared for a stainless steel crown. A band is
prepared as mentioned before and placed over the stainless steel crown on the
abutment tooth.
2. An alginate impression is taken. The band is removed and placed in the
impression.
3. Stone model is prepared.
4. If the second primary molar is planned for extraction but has not yet been
removed, it should be cut of the prepared model.
5. A hole that simulates the position of the disto-buccal root of the extracted
tooth is drilled in the model. Measure the exact distance from the x-ray and
mark it on the model.
6. The tissue bearing wire loop is contoured with a wire extending distally
then downwards into the prepared opening on the model (forming a v-shaped
extension). The free ends of the loop are soldered to the band.
7. If the second primary molar has previously been extracted and the
extraction site has healed, a knife edge is formed at the apex of the v-shaped
35
extension so that it can be forced through the anesthetized area of the ridge.
8. If it is delivered at the time of extraction the intra-gingival extension is just
polished and not sharpened.
9. Before final placement of the maintainer in the mouth, an x-ray istaken to
determine whether the tissue extension is in proper relationship with the
unerupted first permanent molar. Any final adjustment in length and contour
of the shoe may be made at that time.

Distal shoe extension space maintainer

II. Space maintenance for the primary canine area:

If loss of primary canine occurs before the eruption of the permanent lateral
incisor there is always shift of the midline and space closure.
Space maintainers indicated for the primary canine area:Band and loop or
stainless steel crown and loop using the first primary molar as an abutment.
III. Space maintenance for the primary incisor area:
If spacing between the anterior teeth is present, there is little possibility that
drifting of the adjacent teeth will occur with resultant loss of space needed for
eruption of the permanent teeth. But if the anterior primary teeth were in
contact before the loss or if there is evidence of an arch length inadequacy in
the anterior region, a collapse of the arch following loss of the primary
incisors is almost certain.

36
Space maintainers to be used:
1. Removable partial denture:
It produces the desirable esthetic appearance reestablish function and prevents
the possibility of abnormal speech and tongue habits. Recommended only in
case of cooperative children.
2. Modified fixed partial denture:
Bands are adapted on the last molars in the arch, a wire arch will be adapted
on the bands touching the lingual surfaces of posterior teeth passively and
passing over the crest of the ridge of the edentulous area and acrylic base with
acrylic teeth will be applied engulfing the wire.
3. Spoon denture:
It is a removable appliance usually used to replace a single tooth lost in the
anterior region. It has no clasps so it depends on the vault of the palate for its
retention.
IV.Space maintenance for multiple loss of primary teeth:
1. Acrylic partial denture:
Indicated when there has been bilateral loss of more than a single
tooth.Stainless steel wire clasps are contoured for the canines if they are
present and stainless steel wire rests forthe molars for retention.
Advantages:
- It can be easily adjusted to allow for the eruption of teeth.
- It restores normal masticatory function and esthetics.
Disadvantages:
-It is easily broken from the child.
- If the appliance is removed from the mouth even for few days, changes in
the denture base will occur and drifting of teeth may make it impossible for
the child to replace the appliance without extensive adjustment by the dentist.
37
2. Complete dentures for children:
Indicated in children with loss of all primary teeth due to:
- Wide spread of oral infection.
- Teeth are extensively decayed.
- Complete anodontia.
Advantages:
- Restore function and esthetics.
- Guide the first permanent molars into their correct position.
V. Space maintenance for the first permanent molar area:
The first permanent molar is the most important unit of mastication
and is essential in the development of a functionally desirable
occlusion. The loss of a first permanent molar in a child can lead to
changes in the dental arches as: diminished local function, drifting of
teeth and continued eruption of opposing teeth.
Loss of first permanent molar after eruption of the second permanent
molars:
Consultation with the orthodontist is desirable, and the following points
should be considered:
-Is the child in need of corrective treatment other than in the first
permanent molar area?
- Should the space be maintained for fixed bridge work?
- Should the second molar be moved forward bodily into the area
formerly occupied by the first molar? The latter choice is almost
satisfactory even though there will be a difference in the number of
molars in the opposing arch. A third molar can often be removed to
compensate for the difference.
If it is decided that the space should be maintained a band or stainless
steel crown and loop space maintainer can be used.

38
Before the eruptionof the second permanent molar:
-The second permanent molar will drift mesially prior to its eruption. A
greater degree of movement will occur in children in the 8-10 years’ age
group. Premolars will show the greatest amount of distal drifting and all
teeth anterior to the space will show evidence of movement.
- Repositioning of this tooth orthodontically is possible after its eruption.
However, the child must then be considered for prolonged space
maintenance until the time when a fixed bridge can be constructed.
- If the first permanent molars are removed several years prior to the
eruption of the second permanent molar, there is an excellent chance that
second molars will erupt in an acceptable position by drifting mesially.
However, the axial inclination of the second molars, particularly in the
lower arch, may be slightly greater than normal.
- The decision to allow the second molar to drift mesially or to be guided
forward in an upright position may be influenced by the presence of a
third molar of normal size.
- If there is a question regarding the favorable development of a third
molar on the affected side, then the decision to reposition the drifted
second molar and hold it for fixed bridge work is the treatment of choice.
- If it is decided that the space should be maintained, band and loop or
stainless steel crown and loop with distal extension is the space
maintainer of choice.

39
 Gingival and Periodontal Problems in Children
The gingiva is the mucous membrane that extends from the cervical portion
of the tooth to the mucobuccal fold. The gingiva is divided into:
1- Papillary portion: occupying the interdental space
(Interdental papilla).
2- Marginal portion: forming a collar of free gingiva around
the neck of each tooth.
3- Attached portion: attached to the underlying alveolar bone
by dense fibrous tissue.
During Adulthood:
1. The gingiva is pale pink in colour.
2. Firmly bound to the alveolar bone.
3. Stippling varies from fine to coarsely grained appearance.
4. Gingival margin has a sharp knife like edge.
During Childhood:
A. GINGIVA:
1. More reddish: because of thinner and less hornified epithelium
and great vascularity.
2. Lack of stippling: because of the shorter and flatter connective
tissue papillae of the lamina propria.
3. Flabbier, associated with decreased density of the connective
tissue of lamina propria.
4. Rounded and rolled margins, related to hyperemia and edema
that accompany eruption.
5. Greater sulcular depth, relative to ease of gingival retraction.
B. CEMENTUM:
Thinner and less dense.
C. PERIODONTAL MEMBRANE:
1. Wider.
2. Fiber bundles are less dense with less fibers.
3. Increased hydration, greater blood supply.

40
D. ALVEOLAR BONE:
1. Thinner lamina dura ( Radiographically).
2. Fewer trabeculations.
3. Wider marrow spaces.
4. Decreased degree of mineralization.
5. Greater blood supply.
6. Flatter alveolar crest associated with primary teeth.

Gingivitis in Children
Classification:
Gingival and periodontal diseases in children can be classified as follows:
I- Acute Lesions:
1) Eruption cyst or eruption Hematoma.
2) Acute gingival problems associated with eruption of teeth.
a) Eruption gingivitis.
b) Periocoronitis.
3) Acute gingival problems associated with exfoliation of primary teeth.
4) Acute Herpetic Infection.
5) Recurrent Aphthous Stomatitis.
6) Acute Necrotizing Ulcerative Gingivostomatitis (ANUG).
7) Acute Oral Moniliasis (Candidiasis or Thrush).
8) Acute Bacterial Gingivitis.
II- Chronic Gingivitis in Children.
III- Conditioned Gingival Enlargement.

41
I- Acute Lesions:
1) Eruption cyst or eruption Hematoma:
Definition: A type of dentigerous cyst associated with erupting primary
primary teeth. Occurs in all ages including new born.
Etiology: Unknown or due to mechanical trauma resulting in
hemorrhage and accumulation of blood in the detailed space above the
crown of an erupting tooth.
Clinical Features: Bluish fluctuant swelling over an erupting tooth.
Treatment: Usually unnecessary but if it causes delayed eruption or if
parents are excessively worried, surgical excision can be done to expose
the crown.
2) Gingivitis during tooth eruption:
a) Eruption gingivitis:
Definition: Localized inflammation at the site of an erupting tooth
which subsides after the tooth emerges in the oral cavity.
Treatment: Topical anaesthesia e.g. Xylocaine ointement before meals
to relief pain.
b) Periocoronitis:
Definition: Acute inflammation of gingiva surrounding an erupting
tooth, most commonly the mandibular third molar. In children, it is
related to an erupting lower second primary molar or a lower first
permanent molar.
Etiology: Accumulation of food debris and bacteria under the gingival
operculum of the erupting tooth.
Clinical Features:
1. The gingival operculum becomes red, swollen and painful.
2. With gentle pressure, a purulent exudate is discharged.
3. Swollen operculum may be further traumatized the opposing
tooth.
4. In severe cases, there may be regional lymphadenopathy, fever
and general malaise.

42
Treatment:
1. Gentle debridement under the inflamed operculum with a curette to:
- Remove the debris.
- Permit discharge of the purulent exudate which usually relieves
some of the acute symptoms.
2. Warm saline mouth rinses.
3. Antibiotics may be necessary in the presence of fever and
lymphadenopathy.
4. Once the acute symptoms subside, surgically remove the operculum
if it was creating a retention area.
5. The condition improves when the tooth reaches functional occlusion.

3) Gingivitis associated with tooth exfoliation:

Etiology: The sharp, uneven, partially resorbed root ends of primary
teeth may cause mechanical irritation to the underlying tissues. This
results in loss of function on this side, accumulation of deposits,
gingival enlargement, bleeding and discomfort.
Treatment:
Extraction of primary tooth eliminates the pathologic condition and
encourages eruption of permanent successor.

4) Acute Herpetic Infection:

a) Primary Herpetic Gingivostomatitis:
Etiology: Caused by Herpes Simplex Virus.
Types:
1- Primary:
 99% of primary infections of the subclinical type.
 1% of all primary infections is of the clinical type.
2- Secondary (Recurrent Herpes Labilais):

43
Duration:
1- Disease is self-limiting.
2- Its course is about 10-14 days.
Age:
- Priamary infection rarely affects children under the age of one year
due to the presence of maternal antibodies.
- It occurs before the age of 5 years, before the formation of
neutralizing antibodies.
- It reaches its peak at the age of 3 years.
Transmission:
Contagious disease and spreads by direct contact.
Clinical Picture:
1- Systemic Findings:
- Appear before the oral signs.
- Usually sever and include high fever, irritability, headache,
anorexia, malaise and submaxillary gland involvement.
2- Oral Findings: Firey red diffuse inflammation of the gingiva and
alveolar mucosa associated with multiple small vesicles filled with
yellowish fluid, which rupture leaving shallow painful ulcers with
inflamed borders 1-3 mm in diameter anywhere in the mouth EXCEPT the
tips of interdental papillae. Oral lesions usually heal in 5 to 7 days without
scar formation.
Treatment:
- Supportive and Palliative treatment to relieve acute symptoms.
- Soft diet with high fluid intake because of high body temperature
and discomfort in taking fluids result in dehydration.
- Avoid sour, spicy or rough food.
- Vitamin Supplements.
- Topical anesthetic before meal time e.g. Xylocaine ointement to
enable the child to eat.
- Bed rest and isolation from other children in the family because the
disease is contagious.

44
 antiviral at the first 72 hours

- Analgesics to relieve pain.

- Secondary infection of ulcers may be reduced by chlorohexidine
mouth wash or spray.
- Oral oxytetracycline used as mouth wash controls secondary
infection and shortens the duration of disease (avoid other
tetracyclines to avoid staining of developing teeth).
b) Recuurent Herpes Labialis:
Following the primary herpetic infection, the disease may recur in the form
of small lesions outside the mouth usually on the lips.
Etiology:
May be related to emotional stresses, lowered tissue resistance or excessive
exposure to sunlight.
Treatment:
Zovirax cream (antiviral) may be used 5 times for 5 days.

5) Recurrent Aphthous Ulcer (Recurrent Aphthus Stomatitis):

Recurrent ulceration of oral mucous membrane.
Age: In school aged children and in adults.
Etiology: Unknown or mat be due to autoimmune reaction of oral
epithelium, trauma, stress, nutritional deficiencies or gastrointestinal
disorders.
Clinical Picture:
Predromal Symptoms of burning and tingling sensation are experienced
by patient 24 to 48 hours preceding the ulcerations.
1- Ulcers may be single or multiple and start as small localized erosions of
the oral epithelium which are not preceded by vesicles.
2- Within 2 to 3 days, ulcers increase in size to reach 1 to 10 mm, with a
grayish center and raised reddened margins.
3- Pain and discomfort are striking clinical features.
4- Healing occurs without scarring in 10 to 14 days.

45
Treatment:
 Mild cases: require no treatment.
 Sever cases:
- Surface anaethetic ointement, 4-5-times daily.
- Oral Acromycin 250 mg suspension used as mouth wash 4 times daily
after meals for 5- 7 days to shorten the course of the disease.
- Topical paste e.g. Aphthasol applied four times daily.
- Anti microbial mouth wash e.g. Listeriene twicw daily.
- More recently, Carbon Dioxide laser application.

6) Acute Necrotizing Ulcerative Gingivostomatitis (ANUG or

Vincent Infection):
Etiology: Bacterial infection caused by Borrelia Vencenti and Fusiform
Bacilli.
Predisposing Factors: Mal nourished children with history of
debilitating disease e.g. viral infections (Measles and Chicken Pox).
Age:
- In developed countries acute necrotizing ulcerative gingivitis is
primarily limited to adolescents.
- In the less developed countries, it affects young children.
- The disease was seen in 18 months old children.
- Duration: Disease is not self-limiting. In neglected malnourished
children, the intra-oral necrotic process may spread extraorally
resulting in Noma or Cancrumoris.
Transmission: Not contagious disease.
Clinical Picture:
- Rapid destruction of interdental papillae with pain and bleeding.
- Gingival margin is covered by pseudomembrane necrotic covering.
- Punched out interdental papillae with an erythromatous line below
the necrosed tissue.
- Characterisitic foul odour and excessive salivation.
46
 - In severe cases, fever, malaise, anorexia and lymphadenopathy may
occur.
Treatment:
1. Removal of laocal irritating factors.
2. Subgingival curettage and debridement of necrotic tissue.
3. Hydrogen Peroxide mouth rinse after meals to remove debris and
necrotic material.
4. In severe cases with massive necrosis, fever or lymphadenopathy,
antibiotics are indicated e.g. Penicillin
5. Gingivoplasty can be done to correct gingival deformity after the
relief of acute symptoms.
Recurrence:
Frequently recurrent, may be the result of:
i. An immunological phenomena.
ii. Persistent gingival deformity.
iii. Failure to eliminate local factors.
iv. After cessation of the acute symptoms, the patient may not return for
definitive treatment.
7) Acute Oral Candidiasis (Moniliasis or Thrush):
Etiology: Fungal infection caused by yeast like fungus called Monilia
Albicans which is a common inhabitant of oral cavity.
1. Monilia Albicans may multiply and cause a pathologic condition
when: Tissue resistance is lowered and the equilibrium between oral
microorganisms is altered following prolonged use of broad
spectrum antibiotics.
2. Usually in premature, debilitated or malnourished children.
3. Common in institutions where there is crowding.
4. Mothers with Monilial Vaginitis may transmit the infection to their
newborns during labour (Neonatal Candidiasis).
Clinical Picture:
- Elevated bluish white adherent patches anywhere on the oral mucosa
(sometimes extending to circumoral mucosa) which when removwd,
leaves a raw painful bleeding surface.

47
 - Any mucosal surface in the mouth may be involved.
Treatment:
- Stop antibiotics.
- Give 1 ml of antifungal mycostatin (Nystatin) suspension 100,000
units/ ml to be dropped and held in mouth before swallowing for
local action 4 times a day.

8) Acute Streptococcal Gingivitis:

Very rare type of gingivitis, difficult to diagnose without laboratory tests.
Clinical Picture:
Gingiva is red, painful and bleeds easily.
Treatment:
1. Broad spectrum antibiotics.
2. Improve oral hygiene.

II- Chronic Non-Specific Gingivitis:

Etiology: May be due to:
Local Factors e.g. Plaque, Calculus, Maloccusion, Sharp irritating tooth
margins, Over hanging restorations and mouth breathing.
Systemic Predisposing Factors e.g. Nutritional deficiency, Hormonal
disturbances and Diabetes Mellitus.
Clinical Picture:
- Gingivitis may be localized to anterior region or generalized.
- Gingival margin is red, swollen with loss of stippling and bleeds on
slight touch or on eating on moderately rough food.
- Pseudopockets are formed due to gingival enlargement.
Treatment:
- Correct predisposing factors (Local and Systemic).
- Improve oral hygiene.

48
III- Conditioned Gingival Enlargement

1) Puberty Gingival Enlagement:

Age: During the pre-pubertal and pubertal periods.
Etiology:
- Hormonal changes occurring during the pre-pubertal and pubertal
periods.
- Sub-clinical nutritional deficiencies as the result of faulty dietary
habits during these periods e.g. quick meals.
Clinical Characteristics:
- Gingival enlargement confined to the anterior region.
- Interdental papillae are bulbous and prominent.
- The gingival margin is red and bleeds on slight touch.
- Tooth brushing is usually avoided by those patients due to excessive
bleeding.

Treatment:
- Encourage proper oral hygiene.
- Removal of local irritating factors such as plaque and calculus.
- Dietary recommendations to ensure adequate nutrition.
- Oral administration of ascorbic acid.
- Usually the gingival enlargement will regress after puberty (Above
18 years).
- In sever persistent cases gingivoplasty may be required.

2) Gingival Fibromatosis:
Etiology: A rare type of gingival enlargement which has been referred to
as elephantiasis gingivae. It may be due to:
a) Idiopathic (of unknown cause).
b) May follow a familial pattern.

49
Clinical Characteristics:
- Gingival enlargement involves the free and attached gingiva.
- The enlarged gingiva is painless, firm and dense (feels like bone).
- Colour is slightly paler than normal gingiva with coarse stippling.
- Enlargement may be localized or generalized.
- At birth the gingival tissues appear normal, but begin to enlarge with
the eruption of primary teeth. This enlargement continues with the
eruption of permanent teeth until the enlarged tissues cover the
clinical crowns of the teeth.
- The enlarged fibrous tissues may delay the eruption of teeth or cause
displacement of the teeth or malocclusion.
- During mastication, the enlarged tissues may become traumatized
resulting in secondary inflammation.
Treatment:
- Gingivectomy in severe cases, although it may be followed by
recurrence.
- Recurrence has not been reported following removal of the teeth and
construction of dentures.

3) Dilantin Gingival Hyperplasia:

Etiology:
Dilantin is a widely used anti-convulsant drug in the treatment of
epilepsy. This drug causes gingival enlargement in 50% of patients
which develops a few weeks following therapy. Children and young
adults show more hyperplasia than adults.
Clinical Characteristics:
- Hyperplasia is generalized.
- It appears first in the interdental papillae which appear lobulated,
granular and stippled.
- The lobules coalesce together such that the entire occlusal surfaces
of the teeth are covered.
- The enlarged tissues may delay the eruption of the teeth.

50
 - The enlarged tissues become traumatized during mastication which
results in secondary infection.

Treatment:
- Encourage proper oral hygiene measures.
- Removal of local irritating factors and prophylaxis.
- Gingivectomy in severe cases.
- Antihistaminic drugs, corticosteroids, folic acid and ascorbic acid
have been used with limited success.
- Cooperation with physician to change the drug.
- More recently, folic acid therapy has been used (oral rinsing twice
daily with topical folic acid solution gives better results than
systemic folic acid).

4) Scorbutic Gingivitis:
Etiology: Due to Vitamin C deficiency. The chief function of ascorbic
acid is the formation of cementing substance in capillary epithelium.
Deficiency of Vitamin C results in defect in the integrity of capillary
walls resulting in capillary fragility and bleeding.

Clinical Characteristics:
- Mild cases of Vitamin C deficiency are common than severe cases.
- Mild cases may be manifested by impaired wound healing,
petechiae, tendency for hematoma and chronic gingivitis.
- In mild cases, the interdental papillae and marginal gingivae are
swollen and bleed easily on slight touch.
- Severe cases of Vitamin C deficiency are rare in children nowadays.

Treatment:
- No therapeutic administration of Vitamin C is indicated unless
laboratory findings suggest survey.
- Improvement of oral hygiene.

51
 - Correction of diet.
- Therapeutic dose of Vit. C is 100-300 mg/day in divided doses.
- Poly vitamin preparations can be used to correct other vitamin
deficiencies.

PERIODONTAL DISEASES IN CHILDREN

Periodontitis, is an inflammatory disease of the gingiva and deeper tissues
of the periodontium, it is characterized by pocket formation and destruction
of the supporting alveolar bone.
I. AGGRESSIVE PERIODONTITIS
II. PERIODONTITISAS A MANIFESTATION OF
SYSTEMIC DISEASE
III. SELF-MUTILATION
IV. GINGIVAL RECESSION

I. Aggressive Periodontitis
The primary features include rapid attachment loss and alveolar bone loss
with familial aggregation. It can be localized or generalized.
Aggressive periodontitis of the primary dentition can occur in a localized
form but is usually seen in the generalized form.

 Localized aggressive periodontitis (LAP):

- Localized attachment loss and alveolar bone loss only in the primary
dentition in an otherwise healthy child.
- Appears around or before 4 years of age,bone loss is usually seen on
radiographs around the primary molars and/or incisors.

52
 - Abnormal probing depths with minor gingival inflammation, rapid
bone loss, and minimal to various amounts of plaque at the affected
sites. Extensive proximal caries facilitating plaque retention.

 Generalized aggressive periodontitis (GAP):

- The onset of GAP is soon after the eruption of the primary teeth. It
results in severe gingival inflammation and generalized attachment
loss, tooth mobility, and rapid alveolar bone loss with premature
exfoliation of the teeth.
- The gingival tissue may initially demonstrate only minor
inflammation with plaque accumulation at a minimum.
- It often affects the entire dentition. Alveolar bone destruction
proceeds rapidly, and the primary teeth may be lost by 3 years of
age.

Localized aggressive periodontitis:

(Localized juvenile periodontitis):
The term for the previously described condition of localizedjuvenile
periodontitis has also been replacedby the term localized aggressive
periodontitis.
- This condition presents a classic pattern and occurs in otherwise
healthy children and adolescents without clinical evidence of
systemic disease.
- It is characterized by the rapid and severe loss of alveolar bone
around more than one permanent tooth, usually the first molars and
incisors.
- It appears self-limiting. Clinically, LAP patients have less tissue
inflammation and very little supragingival dental plaque or calculus.

53
 However, they do present with evidence of subgingival plaque
accumulation, both tissue-associated and tooth-associated.
- A variety of neutrophil defects has been reported in patients with
LAP.
Treatment of aggressive periodontitis:
Successful treatment of aggressive periodontitis depends on early
diagnosis, the use of antibiotics against the infecting microorganisms, and
the provision of an infection free environment for healing. Treatment of
aggressive periodontitis, both LAP and GAP, includes oral hygiene
instructions, consultation with the patient’s physician if necessary, and
mechanical removal of supragingival and subgingival microbial agents via
nonsurgical and/or surgical treatment modalities with adjunctive
antimicrobial therapy.

II. Periodontitis as a Manifestation Of Systemic Disease

A. Associated with hematological disorders
1. Acquired neutropenia
2. Leukemias
3. Other
B. Associated with genetic disorders
1. Familial and cyclic neutropenia
2. Down syndrome
3. Leukocyte adhesion deficiency syndromes
4. Papillon-Lefèvre syndrome
5. Chédiak-Higashi syndrome
6. Histiocytosis syndromes
7. Glycogen storage disease
8. Infantile genetic agranulocytosis
9. Cohen syndrome
54
10. Ehlers-Danlos syndrome (types IV and VIII)
11. Hypophosphatasia
12. Other

C. Not otherwise specified (NOS)

Advanced alveolar bone loss associated with systemic disease occurs in
children and adolescents, as well as in adults. In the primary dentition, this
is rare.
Papillon-Le fevre syndrome:
Etiology:
- It is a rare genetic condition inherited as an autosomal recessive trait.
- It is associated with severe gingival inflammation and exfoliation of
both the primary and permanent dentition.
- Hyperkeratosis of the palms and soles are present.
- The periodontal involvement and alveolar bone loss start between
second and third year and progress till the fifth year of age (complete
primary teeth loss).
- The same cycle is repeated with the permanent teeth.
- Prognosis is bad and a complete denture is inserted at an early age.

Down syndrome:
- Periodontal disease in Down syndrome is characterized by
generalized early periodontitis, which affect both deciduous and
permanent dentition.
- The most frequent sites of periodontal destruction are around the
incisors and molar teeth.
- The progression of the periodontal disease is very rapid, with
premature loss of lower incisors.

55
Juvenile diabetes (insulin dependent diabetes mellitus (IDDM)
associated periodontitis):

- Due to decrease or absence of insulin secretion from pancreatic beta

cells.
- Characterized be severe gingival inflammation and periodontitis.
- Periodontal therapy in well controlled insulin dependent diabetic
patients can be achieved without any unusual complications.

III. Gingival Recession

Gingival recession is often observed in children. Several factors predispose
patients to gingival recession. These factors include:
- Toothbrush trauma.
- Tooth prominence.
- Orthodontic tooth movement.
- Oral habits.
- Periodontitis.
Treatment:
- Elimination of the predisposing factor.
- Maintain an excellent oral hygiene.

IV. Self-Mutilation
- Children purposely traumatize their oral structures.
- The majority are emotionally unstable.
- Tension and conflicts at home can cause it in young patients.
- Child may traumatize the gingiva with fingernail or pins.

56
EXTRINSIC STAINS AND DEPOSITS ON TEETH
It has been generally accepted that the staining of children’s teeth is of
microbial origin, oral iron preparations or other medications.
The accumulation of dental deposits and stains is affected by:
- Salivary composition and flow rates.
- Poor oral hygiene.
- Enamel defects.
- Aging with exposed extrinsic factors (medications, coffee, tea and
tobacco).
Extrinsic stains are identified by color, distribution, and tenaciousness
along with age, gender, and home care. Staining is generally believed to be
caused by extrinsic agents, which can be readily removed from tooth
surfaces with an abrasive material. The agents responsible for staining are
deposited in enamel defects or become attached to the enamel without
bringing about a change in its surface. Pigmentation, in contrast to extrinsic
staining, is associated with an active chemical change in the tooth structure,
and the resulting pigment cannot be removed without alteration of the tooth
structure.
Green stain:
- The cause of green stain is unknown, although it is believed to be
the result of the action of chromogenic bacteria on the enamel
cuticle.
- Boys are more frequently affected than girls.
- The color of the stain varies from dark green to light yellowish-
green.
- Seen in the gingival third of the labial surfaces of the maxillary
anterior teeth.
- The stain collects more readily on the labial surfaces of the maxillary
anterior teeth in mouth breathers.
57
 - It tends to recur even after careful and complete removal. The
enamel beneath the stain may be roughened or may have undergone
initial demineralization.
- Fungi (Penicilliumand Aspergillus) and fluorescent bacteria have
been associated with the discoloration.

Orange stain:
- The cause of orange stain is unknown.
- Orange stain occurs less frequently and is more easily removed than
green or brown stain.
- Most often seen in the gingival third of the tooth and is associated
with poor oral hygiene.
Black stain:
- A black stain occasionally develops on the primary or permanent
teeth of children.
- Much less common than the orange or green type.
- A thin black line of dots or band of stain may be seen following the
gingival contour or it may be apparent in a more generalized pattern
on the clinical crown, particularly if there are roughened or pitted
areas.
- The black stain is difficult to remove, especially if it collects in pitted
areas.
- More frequent in females.
- Many children who have black stain are relatively free of dental
caries and have excellent oral hygiene.
- The chromogenic bacterium primarily associated with this stain is
Actinomyces.

58
Removal of extrinsic stains:
- Extrinsic stains can be removed by polishing with a rubber cup and
flour pumice.
- Improving the oral hygiene minimizes the recurrence of the stain.
Pigmentation caused by stannous fluoride application:
During the first clinical trials involving the topical application of an 8%
stannous fluoride solution, certain areas of the tooth became discolored. A
characteristic pigmentation of both caries and pre-caries lesions has been
found to be associated with exposure to stannous fluoride.

Calculus
- Calculus is not often seen in preschool children, and even in children
of grade-school age, it occurs with much lower frequency than in
adult patients.
- A low caries incidence is related to high calculus incidence.
- Childrenwith mental retardation often have accumulations of
calculus on their teeth. This accumulation may be related to
abnormal muscular function, a soft diet, poor oral hygiene, and
stagnation of saliva.
- Early calculus formation in children and adults begins as a soft,
adherent, bacteria-laden plaque that undergoes progressive
calcification.
- Supra-gingival deposits of calculus occur most frequently and in
greater quantity on the buccal surfaces of the maxillary molars and
the lingual surfaces of the mandibular anterior teeth. These areas are
near the openings of the major salivary glands. Local factors are
unquestionably important in the initiation of calculus formation.

59
 DENTAL MANAGEMENT OF HANDICAPPED
CHILDREN
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
(CSHCN)

Definition:
Handicapped children are those having certain physical, mental, social
and dental conditions that prevent them from achieving full potential
when compared with other children.

The term Children with Special Health Care Needs (CSHCN) could
replace some terminologies which were given to those children as:
handicapped or disabled.

Approximately 54 million children and adults in the United States have a

disabling condition. The American Academy of Pediatric Dentistry
defines individuals with special health care needs (SHCN) as those with
“any physical, developmental, mental, sensory, behavioral, cognitive, or
emotional impairment or limiting condition that requires medical
management, health care intervention, and/or use of specialized services
or programs.”

Many children with SHCN are best managed initially by a

multidisciplinary team in which a dentist is available to evaluate the
child’s extraoral and intraoral findings.

Classification:
(CSHCN) could be classified into three main categories according to the
typed of handicapping condition into:

60
I- Dental handicapping conditions as :
- Cleft lip and palate.
- Amelogenesis Imperfecta.
- Dentinogenesis Imperfecta .
- Early Childhood Caries.
- Sever Skeletal Malocclusion.

II- Medical (Physical) handicapping conditions as :

1- Cardiovascular disorders either congenital or acquired.
2- Bleeding disorders e.g. Hemophilia.
3- Neuromuscular disorders e.g. Epilepsy, Cerebral Palsy.
4- Sensory Disorders e.g. Hearing and visual impairments (Deafness
and Blindness).
5- Metabolic disorders e.g.  Diabetes Mellitus.
6- Respiratory disorders e.g.  Asthma.
7- Neoplasms.

III- Mental handicapping conditions :

- Down's syndrome (Trisomy 21).
- Cerebral palsy. (Neuromuscular disorder accompanied by
mental retardation).
- Any physical or medical disease accompanied by mental
retardation.

61
 Management of (CSHCN)

1-General considerations
2-Specific Management
should be followed with
for each condition.
all disabled children.

1- General considerations

First dental visit: it usually runs and follows the same guidelines of the

Objectives of the first dental visit:

a) To establish good communication with the child and his parents.

b) To obtain background information about the child regarding :
Social , dental and medical history.
c) Examination of the child :
- Extra oral examination to evaluate general appearance.
- Intra-oral examination to detect any abnormalities in the teeth.
d) Taking radiographs:
- To detect any abnormalities in the developing dentition.
- To detect specific problems.
- To detect dental caries.

N.B.:

 Stabilization of the film should be done.

 Reverse bitewing technique : some disabled children cannot
control gagging reflex. Therefore bitewing film could be put in the

62
 vestibule rather than the floor of the mouth, and the x-ray tube put
below the lower border of the mandible on the opposite side.
e) Introduce the child to a simple treatment procedure e.g. Fluoride
application.
f) Explain the treatment objectives to the child ( if possible ) and his
parents.
e.g. - Length and number of treatment visits.
- Importance of oral hygiene measures and disease prevention.

g) Preventive Measures:

All (CSHCN) are at high risk to develop oral and dental diseases, so the
dentist should design a preventive dental program for them and follow its
implementation with the parents.

Among these preventive measures:

1) Home Dental Care :

It is the prime responsibility of the parent to establish good oral

hygiene to their disabled child.

Home dental care should be performed for:

- Infants : The dentist should instruct the parents to clean the

child's teeth with a piece of soft cloth.
- For an older child : The parents should brush the child's teeth
using the scrubbing technique.
- Certain modifications are found in the toothbrushes used to help
children with poor motor and neuromuscular skills.
2) Diet counseling :
- Diet history analysis should be evaluated by the dentist, and diet
modifications should be listed and given to the parents.

63
 - Certain drugs as sedatives, hypnotics and anticonvulsants not
only contain sugars, but also reduce salivary flow rate and
therapy reduce the protective effect of saliva against dental
caries.
- With certain neuromuscular disorders, the masticatory function
of the child is so compromised and they are fed soft diet, which
is highly cariogenic.
3) Fluoride Application :

The level of Fluoride in the drinking water should be evaluated at first.

- If between 0.7-1 ppm : No need for fluoride supplements.

- If less that: Fluoride supplements are needed either systemically
or topically applied.
4) Preventive Restorations :

Such as:

- Fissure sealants are highly indicated for those children who at

high risk.
- Stainless steel crowns are highly indicated for patients with
severe bruxism.
- ART (Atruamatic Restorative Treatment) is also indicated.
5) Regular professional Supervision:

Recall dental visits every 3 months are very important for those
children to re-examine and re-evaluate the oral and dental conditions
and to apply fluoride if needed.

h) Physical (Body) Restraints :

Body restraints or immobilization is indicated (To prevent the

involuntary or risky movements of the child).

64
  Indications:
- Lack of the child's co-operation due to physical or mental
disability.
- Lack of the child's co-operation (Resistant child) and failure of
all behavior shaping techniques performed by the dentist.
- If the safety of the child or the dentist is at high risk without the
use of body restraints.

 Contrindications:
- With cooperative child.
- If there is an underlying medical or systemic problems e.g.
Cardiac children.
- Shouldn’t be used as a punishment.
- Shouldn’t be used in the first visit.

Restraining Devices

Intra-oral to keep Extra-oral for body Devices to stabilize

the mouth open control the head

Intra-Oral Restraining Devices:

- Mouth Prop.
- Rubber Bite Blocks.

Extra-Oral (Body Control) Restraining Devices:

-Safety belt.
Pedi-Wrap restraints.

65
 Head stabilizing Devices:

- Head positioner.
- Extra assistants.

N.B. The choice of G.A. for disabled child should be kept in mind if the
dentist fails to treat him under local anaesthesia.

2- Specific Management of each Condition

 Cardiac Diseases

66
 Rheumatic Heart Disease:

Definition:

It is a serious inflammatory disease of the heart characterized by

deformity or damage of the heart valves. Children with rheumatic
heart are susceptible to Sub-acute Bacterial Endocarditis (infection of
endocardium with streptococcus viridians). This may occur due to
bacteraemia following the dental procedures.

Streptococcus viridians introduced to the blood stream following any

dental procedure which may initiate bacteraemia will colonize on
Endocardium at or near damaged heart valves resulting in Sub-acute
Bacterial Endocarditis.

Dental Management:

1. Consult the patient's cardiologist.

2. In apprehensive patients prescribe sedative after medical
consultation.
3. If general anaesthesia is indicated hospitalize the patient.
4. Pulp therapy in primary teeth is not recommended due to the
possibility of producing infection.
5. Endodontic treatment in permanent teeth can be done after
careful selection.
6. If extraction is indicated, give a prophylactic antibiotic to
reduce the incidence of Sub-acute Bacterial Endocarditis.

According to the American Heart Association the following can be given:

1) Amoxicillin (Unasyn or Augmantin): For children 50mg/ kg,

Orally, one hour before the dental treatment.

67
 2) In patients who are unable to take oral medications: Ampicillin
50mg/kg IM injectin 30 min. before treatment.
3) In patients allergic to penicillin: Clindamycin e.g.Dalacin-C or
Erythromycin orally one hour before treatment.
 Dental Procedures requiring prophylactic antibiotic:

Procedures known to induce bleeding &precipitate transient bacteremia

as:

- Extraction of a tooth.
- Scaling and Root planning.
- Endodontic treatment and instrumentation beyond the apex.
- Placement of orthodontic bands.
- Intraligamentary local anesthesia.
- Dental implants.
 Dental Procedures not requiring prophylactic antibiotic:
- Filling and restoration.
- Local anesthesia injection.
- Placement of rubber dam.
- Impressions.
- Removal of sutures.
- Shedding of primary teeth.
- Placement of orthodontic brackets.
- Taking radiographs.

we give it only in high risk as heart transplantation prosthetic valves previous infective endocarditis and
certain congenital heart disease

68
  Bleeding Disorders

Hemophilia:

Definition:

It is a blood coagulation disorder due to deficiency of one or more of the

clotting factors which results in severe bleeding. Hemophilia A is the
most common bleeding disorders which results from deficiency of factor
VIII ( antihemophilic factor). This disease occurs in males while females
act as carriers ( sex linked recessive trait) transmitting the disease to
males from one generation to another. Bleeding time is normal (1-3 min.),
while coagulation time is prolonged (30min. or more).

Oral Manifestations:

1. Intra-oral hemorrhage due to trauma.

2. Prolonged oozing from the gingiva during shedding.
3. Poor oral hygiene due to irregular tooth brushing (fear from bleeding
from his gingiva).
4. High caries incidence as the patient usually eats soft carbohydrates.

Dental Management:
1) Consult patient's hematologist to know the severity of bleeding
(Mild, Moderate, Severe).
2) Local Anesthesia :
 Nerve block anesthesia is contra-indicated as it may lead to
hematoma due to puncturing large vessels and bleeding into
pharyngeal spaces leading to respiratory obstruction.
 Infilteration anesthesia containing vasoconstrictor is
recommended using finest gauge needle.

69
  General anesthesia may result in traumatic hemorrhage during
induction and endo-tracheal intubations.

3) Restorative treatment:
- Rubber dam should be used to isolate the operating field & to
protect the cheeks, lips and tongue. Care should be taken during
placement of rubber dam clamps, wedges and matrices.
- Precautions should be taken during preparation of the teeth for
crowns, while cavity preparation can be done safely.
- For taking an impression, the periphery of the tray should be
lined with wax to prevent injury of the soft tissues.

4) Pulp Therapy:
- Pulpotomy and pulpectomy are preferred over extraction and
indirect pulp capping is preferred over pulpotomy.
- If vital pulp is exposed, an intrapulpal anesthesia should be
given to control pain. Bleeding from the pulp champer doesn’t
present a significant problem and could be controlled by
pressure with a cotton pellet.

5) Periodontal Therapy:
- Gingivitis can predispose to spontaneous gingival bleeding.
- Supra-gingival calculus can be removed atraumatically with an
ultrasonic scaler or hand instrument.
- Sub-gingival scaling and root planning could be performed only
after factor replacement therapy.
6) Oral Surgery:
- Consultation with the hematologist for pre-operative evaluation
and post operative emergencies.

70
 - Patient should receive whole blood transfusion or should be
infused with the missing factor.
- Simple extraction can be done with 40% factor replacement one
hour before dental procedure.
- Extraction should be atraumatic as much as possible.
- Bleeding can be controlled by local measures e.g. pressure
packs and hematostatic agents such as thrombin or surgicel.
- Avoid using sutures as much as possible unless it enhances
healing.
- Avoid distributing clot by finger, tongue or by rinsing.
- Patient should receive liquid diet for 72 hours postoperative and
then a soft pureed diet for another 10 days because hard food
may disturb the formed blood clot.
- Analgesics for pain may be prescribed e.g. Tylenol. avoid
Salicylates e.g. Aspirin and anti-inflammatory drugs as they
may alter platelet function and increase the risk of bleeding.
- Normal exfoliation of primary teeth doesn’t require factor
replacement and bleeding could be controlled by direct finger
pressure and gauze with topical application of local hemostatic
agent.

 Neuromuscular Disorders
A. Epilepsy:

Definition:

It is a disease characterized by repeated attacks of unconsciousness

which may last for a moment or for a period of minutes. This loss of

71
consciousness may or may not be accompanied by muscular contractions
or convulsions.

Etiology:

- Idiopathic: Genetic or acquired.

- Post traumatic – Post infectious.
- Post toxic (Lead or Arsenic poisoning).
- Secondary to brain injury.

Types:

Petit mal: characterized by loss of consciousness only for a few

seconds, there is no evidence of muscle spasm and the condition presents
no difficulty during dental treatment.

Grand mal: characterized by prolonged loss of consciousness,

generalized convulsions and severe muscular spasm. This may lead to:

 Slipping of patient from the dental chair.

 Hitting himself against any object.
 Severe tongue biting.
 Sudden closure of the mouth due to contraction of jaw muscles.

Oral Manifestations:

1. Tooth fractures, dental arch fractures and avulsion of teeth due to

frequent falls.
2. Gingival hyperplasia which occurs in 32-84% of epileptic patients
due to Dilantin used to suppress seizures in those patients.

72
Management of the gingival hyperplasia:

1. Proper oral hygiene measures should be stressed and gingival

curettage can be done.
2. Gingivectomy to return the gingiva to its normal anatomy.
3. After surgery: Follow up by the dentist is important to prevent the
recurrence of gingival hyperplasia. Chlorhexidine mouth wash
may be beneficial in prevention of recurrence of the condition.

Dental Management:

1. Give antianxiety drug if needed before dental treatment e.g.

Valium.
2. Keep the dental atmosphere relaxed. Dentist should avoid the
precipitating factors that may lead to convulsions as :
a) Operating light (should be focused on the patient's eyes).
b) Loud noise and high music.
c) Insufficient sleeping hours before dental appointments.
3. If an attack occurs, lower the dental chair and put the patient in a
supine position with the head tilted to one side to facilitate the exit
of saliva or vomitus.
4. Use suction for any secretions to prevent aspiration.
5. Use wrapped tongue blades to prevent tongue biting.
6. Floss is attached to small objects introduced in the mouth to
facilitate quick withdrawal in case an attack occurs.

73
 B. Cerebral Palsy :

Definition:

It is a collection of neuromuscular disorders as a result of permanent

brain damage in the prenatal and perinatal periods during which time
the CNS is still maturing. The condition is usually associated with
mental retardation.

Etiology:

Brain damage which may result from :

 Congenital brain defect.

 Trauma to the head.
 Infections of the brain.
 Anoxia (decreased oxygenation).
 Premature birth.

General Manifestations:

 Mental retardation in 60% of the cases.

 Seizures disorders and hyperirritability.
 Sometimes presented as hearing or visual impairments.
 Speech disorders as the patient cannot articulate because
of lack of control of speech muscles.
 Abnormal limb position and limited control of neck
muscles.

Oral Manifestations:
 Periodontal Diseases due to :

74
 a) Eating soft diet as the patient can't chew food because of
poor muscular coordination.
b) Neglection of the oral hygiene and tooth brushing due to
lack of manual dexterity.
c) Patients taking anticonvulsants (Dilantin) resulting in a
degree of gingival hyperplasia.
 Dental caries due to:
a) Poor oral hygiene.
b) Impaired chewing and swallowing will lead to poor eating
habits as soft diet.
c) Patients show higher incidence of enamel hypoplasia.
 Malocclusion:
a) Protrusion of maxillary anterior teeth.
b) Excessive overbite and overjet.
c) Open bite.
d) Unilateral cross bite.

N.B. The most important causative factor of malocclusion may be:

1. Disharmony between introral and perioral muscles.

2. Uncoordinated and uncontrolled movement of the jaws, lips and
tongue.
 Bruxism which result in :
a) Severe attrition of primary & permanent teeth.
b) Loss of the vertical dimension.
c) TMJ disorders.
 Trauma to maxillary anterior teeth due to :
a) Repeated fall accidents.
b) Protrusion of maxillary teeth.
 Tongue trust and mouth breathing.

75
Dental Management:

1. Cough reflex is delayed with increased risk of aspiration of foreign

objects, so:
- Use of rubber dam.
- A piece of floss is attached to small objects e.g. files and clamps
to facilitate withdrawal.
2. Use of restraining devices due to involuntary movements such as :
- Pedi wrap which controls all the limbs.
- Safety belts to maintain the patient on the dental chair.
3. To stabilize the jaws opened by using :
- Molt mouth prop.
- Mckesson rubber bite blocks.
- Several wrapped tongue blade.
4. Stabilizing the head by plastic head positioned to avoid sudden
movements.
5. Treat patient while sitting in his wheel chair.
6. During dental treatment, maintain patient's body in middle of
dental chair with his limbs as close as possible to his body.
7. Elevate the back of the dental chair due to difficulty in
swallowing.
8. Avoid sudden jerky movement to reduce startle reflex.
9. Introduce oral stimuli slowly to avoid gag reflex.
10. Prevention:
a. Stress on home dental care.
b. Diet and nutrition:
- Survey the diet with the parents.
- Replace solid forms of sugar with soluble forms.
- Avoid sugary snacks.

76
 c. Fluoride exposure.
d. Preventive restorations:
- Use pit and fissure sealants.
- Use long withstanding restorations e.g. Amalgam
restorations.
- Use chrome steel crown for badly broken down teeth.
e. Regular dental visits: every 2-4 months.

 Sensory Handicapping Conditions

A. Deafness and hearing impairments.
B. Blindness and visual impairments.
A. Dental management of patients with hearing impairment:
 Oral Manifestations:
1. Deafness is usually accompanied by bruxism.
2. Poor oral hygiene due to inability to perform oral
hygiene instructions in a correct manner.
 Dental Management :
1. The child can be communicated either by: Lip reading, Sign
language, Writing notes or combinations.
2. Face the patient and maintain a visual contact with him.
3. Employ Show Do approach and allow the patient to use
other sensations as taste or touch to communicate.
4. In case of hearing aid, it should be turned off before dental
procedure, as those children are very sensitive to vibrations
coming from the handpiece.
5. Keep smiling, be calm and communicate kindly.

77
 B. Dental management of patients with hearing impairment:
 Oral Manifestations:
1. Poor oral hygiene due to visual impairment.
2. Hypoplastic teeth.
3. Higher incidence of traumatic injuries.
4. Early childhood caries due to prolonged bottle feeding.
 Dental Management:
1. Describe the dental office in details to the child.
2. Sit close to the patient and keep the physical contact with the
child. E.g. holding his hand.
3. Allow the patient to ask questions about the treatment.
4. Utilize Tell Do approach and allow the patient to touch, taste
and smell for explaining the treatment.
5. Maintain a relaxed atmosphere and limit the patient's dental
care to one dentist.

 Mental Handicapping Conditions
Down Syndrome (Trisomy 21)
Definition:

Down syndrome is the leading cause of mental retardation. It occurs in

about 1 of every 660 births. It is associated with an extr chromosome 21,
so each cell contains "three" number 21 chromosome rather than "two",
i.e. trisomy of 21 chromosome. This syndrome is most common among
first born infants of women over 35 years of age.

Oral Manifestations:

1. Prognathic class III relationship, which lead to open bite.

2. Mouth breathing and xerostomia.

78
 3. Protruded scrotal tongue.
4. Delayed eruption and exfoliation of the teeth.
5. Microdontia and partial anodontia.
6. Small conical roots.
7. Rapid destructive periodontal disease.
8. Lower caries index.
9. Hypodonia: decreased muscle tone of the lips and cheeks which
may lead to inefficient chewing.

Dental Management:

- Many children with Down syndrome are affectionate and

cooperative, and dental procedures can be provided if the dentist
works at a slightly lower rate.
- Light sedation and immobilization may be indicated in those
children who are moderately apprehensive.
- Severely resistant patients may require general anesthesia.

79
 Child Abuse and Neglect
 What is child Abuse & Neglect?

- The Federal Child Abuse Prevention and Treatment Act (CAPTA),

defines child abuse and neglect as, at minimum:

“Any recent act or failure to act on the part of a parent or caretaker

which results in death, serious physical or emotional harm, sexual abuse
or exploitation; or an act or failure to act which presents an imminent risk
of serious harm.”

- To help an abused or neglected child, you must first learn to recognize

the signs of child abuse and neglect.

- The presence of a single sign does not mean that child maltreatment is
happening- -

A closer look at the situation may justify your concerns if these signs are
repeated or occur in a combination form.

- This presentation is intended to help you understand the definition of

child abuse &neglect, types, reasons & how to help those little kids.

 Types of Child Abuse and Neglect :

 Physical Abuse
 Sexual Abuse
 Failure to Thrive
 Intentional Drugging or Poisoning
 Munchausen Syndrome by Proxy
 Health (Medical) Care Neglect

80
  Dental Neglect
 Safety Neglect
 Emotional Abuse and Neglect
 Physical Neglect

1-Physical Abuse

Physical abuse is the most visible form of child maltreatment.

It is defined as the physical injury caused by punching, beating, kicking,

biting, burning or harming a child in any other way.

Many times, physical abuse results from inappropriate or excessive

physical discipline.

Sometimes when the caretaker is in anger, he may be unaware of the

magnitude of force with which he/she smacks the child.

Its severity can be rated as mild, moderate or severe.

81
2-Sexual Abuse

A child is sexually abused when they are forced or persuaded to take part
in sexual activities.

This doesn't have to be physical contact, it can happen online.

Sometimes a child won't understand that they are being abused

They may not even understand that it's wrong!

 Signs & symptoms:

a) Stay away from certain people
 They might avoid being alone or seem frightened
of a specific person.
b) Show sexual behavior that's inappropriate for their age.
 Child might become sexually active at a young age
 Child could use sexual language or know
information that they shouldn’t know compared to
their age.

c) Have physical symptoms:

Anal, oral or vaginal soreness-

An unusual discharge

Sexually transmitted infection (STI)

Pregnancy.

82
3-Nutritional Neglect:

Failure to thrive=Underweight malnourished condition

Child’s weight is below the 3rd percentile while his height and head
circumference are above the 3rd percentile on the growth curves.

Physical examination reveals gaunt faces, prominent ribs, wasted

buttocks, and spindly extremities

It is seen in the first 2 years of life when the child is dependent on adults
for feeding

 Reasons:

The mother may neglect to feed her baby because

a) She’s overwhelmed with responsibilities

b) She’s chronically depressed and hostile towards the baby.

83
4-Intentional drugging or poisoning:

It is not a common form of abuse

Administration of drugs that are harmful & not intended for children

Enhances drug addiction in young children

It can be lethal

E.g. Sedatives

84
5- Munchausen Syndrome by Proxy:

Children who are victims of parentallyfabricated or induced illness.

This leads to unnecessary medicalinvestigations, hospital admissions, and

treatment.

 Signs:
a) Recurrent sepsis from injecting contaminated fluids
b) Chronic diarrhea from laxatives
c) Fever from rubbing thermometers
d) Rashes from rubbing the skin or applying caustic substances

85
6- Health care Neglect:

Serious deterioration in health condition of the child because parents

repeatedlyignore healthcare recommendations.

The child usually has a serious condition that’s not acknowledged by

parents.

Some parents refuse healthcare due to religious beliefs.

86
7- Dental Neglect:

Willful failure of parent or guardian to seek & followthrough with

treatment which is important to ensure a level oforal health that allows
adequate function & freedomfrom pain & infection.

Dental neglect is closely related to healthcare neglect.

 Note that:

Willful neglect should be differentiated from ignorance and lack of

knowledge.

When barriers to the needed care exist, the physician or dentist should
attempt to assist the families in finding financial aid, transportation or
public facilities for the needed services.

87
8- Safety Neglect:

When injury occurs due to gross lack of supervision.

Occurs in children < 4 years.

Injuries include burns, poisonings,falls & any other preventable

accidents.

9- Emotional Abuse & Neglect:

It is defined as a pattern of behavior by parents orcaregivers that can

seriously interfere with a child’s cognitive ,emotional, psychological or
social development.

It’s also known as mental abuse or psychological maltreatment.

 Includes:
a) Ignoring : parent is not present to respond to the child
b) Rejecting : ex, refusing to touch the child or denying his needs

88
c) Isolating :preventing the child from socializing normally with his
peers or family members
d) Corrupting: the child is taught & encouraged to develop illegal
behaviors.
e) Verbally assaulting: excessive use of language to undermine the
child’s dignity and security through insults or humiliation, in a
sudden or repeated manner.
f) Terrorizing: creating a climate of fear for the child
g) Neglecting: denying the child need for education or even medical
treatment.

This psychological trauma will cause the child to grow into an

anxious and insecure one who develops slowly & has low self-
esteem.

89
10- Physical Neglect:

a) Dirty hair
b) Dirty or inadequate clothing
c) Inadequate lunches
d) Incomplete immunizations
e) Unsanitary home environments
f) Inadequate after-school supervision
g) Excessive work
NB: It is easy to confuse neglect with poverty and ignorance

 Risk factors:
I- Parents related:
- Young or single parents
- Parents with learning difficulties
- Stress or family violence
- Social isolation
- Poor parenting skills
- Lack of available resources & poor housing

90
 - Parents were emotionally abused themselves as children.
- Drug and alcohol abusers
II- Child related:
- Babies and toddlers most vulnerable
- Children with disabilities
- Older girls (vulnerable to sexual abuse(
- Children with abnormal behavior
- Children in foster or residential care

 The role of the dentist in identifying child abuse:

The dentist can suspect child abuse in the following conditions:
 During history taking (vague , contradicting , lack of adult
supervision)
 Delay in seeking dental treatment
 Repeated missed appointments
 Failure to complete planned treatment.
 Returning in pain repeatedly

These risk factors can be noted during the appointment via history,
previous knowledge of the family or from previous dental /medical
records.

 Avoid discussions with parents if:

 Discussion will put child into danger
 Organized sexual abuse by a family member is in doubt
 Munchausen syndrome by proxy is suspected
 Parents are being violent which can put you or your staff
at risk
 Parents are not present and any delay in action would put
child in danger.

91
  Statistics:
 40million children subjected to abuse each year
worldwide.
 A quarter of all adults report having been physically
abused as children.
 One in 5 women and 1 in 13 men report having been
sexually abused as a child.
 Consequences of child maltreatment include impaired
lifelong physical and mental health, and the social and
occupational outcomes can ultimately slow a country's
economic and social development.
 In 2009 found that 84 per cent of Egyptian children aged
2 to 14 years were disciplined at home by physical and
emotional violence.

Child Protection Services in Egypt:

‫المجلس القومي لالمومة و الطفولة‬

‫مركز حقوق الطفل المصري‬
‫جمعيات حماية الطفل المصري‬
00111‫الخط الساخن لنجدة الطفل المصري‬

92
 PEDIATRIC DENTISTRY
DEPARTMENT:
Clinical Requirements (PEDO 2):

1. 10 Examination and Treatment

Planning Sheets (Diagnostic Charts).

2. One Cavity Preparation & Restoration

of Primary Molars.
3. One Primary Molars Pulpotomy with
Chrome Steel Crowns.
4. These clinical requirements will be
commenced only after submitting 5
pulpotomies on extracted primary
molars.

COMMENTS:

BEST OF LUCK
DR. Rania Nasr
 Epidemiology

Subject: Page:

1- Epidemiology of Periodontal Diseases. 1

2- Indices Used for Assessment of Periodontal Diseases. 5

3- Dental Needs and Dental Demands. 11

4- Organization of Dental Care. 16

5- Group Practice and Team Work. 21

6- Ethics in Dentistry. 25
 EPIDEMIOLOGY OF PERIODONTAL
DISEASES
Factors affecting the prevalence and incidence of periodontal diseases:

I. Host Factors:

1- Age:

 Periodontal diseases progress steadily with age, indicating that it is

a cumulative disease.
 Starting from the age of 13 there is an increase in the number of
individuals having pockets and bone loss.
 Gingivitis is also common in the mixed dentition stage associated
with shedding and eruption of teeth.

2. Sex:

 Periodontal condition is better in females in USA and

Europe due to a better status of oral hygiene.
 On the contrary in developing countries the periodontal
condition is worse in females after the age of 20 as they give
birth to many children so they suffer from recurrent
pregnancy gingivitis.

3. Correlation with Oral Hygiene:

The main cause of periodontal disease is the accumulation of debris,

plaque and calculus on teeth. Those deposits can be prevented from
accumulation by oral hygiene care.

1
4. Socioeconomic Status:

Gingival and periodontal health improves with increase in the

educational level and income.

5. Effect of Tobacco:

 There is a high correlation between the periodontal

condition and smoking.
 Gingivitis increase with high consumption of tobacco.
 Also, young cigarette smokers suffer from ulcerative
gingivitis.
 This may be due to the effect of tobacco and heat derived
during smoking.

6. Systemic Disease:

In general, there is not a definite correlation between

systemic diseases and the periodontal condition but some
systemic diseases modify tissue response to dental plaque.
• Diabetes: There is a significant correlation between
diabetes and periodontal disease especially if the patient has
poor oral hygiene.
Effect of diabetes:
a. The increase in blood sugar level causes atherosclerosis
and deposition of mucopolysaccharides in blood vessels.
This leads to narrowing of the blood vessels of the gingiva
decreasing the blood supply and nutrition of the gingival
tissues.
b. Decrease in the chemotaxis and phagocytosis of PNL.

2
 • Leukaemic patients manifest gingival bleeding,
enlargement and ulcerations.

7. Nutrition:

Reliable data on the effect of nutrition on periodontal

diseases are rare. Some gingival diseases are correlated to
vitamin deficiency e.g. scorbutic gingivitis occur as a result
of vitamin C deficiency.

8. Traumatic occlusion:

Some correlation exists between gingivitis and areas of

traumatic occlusion in the oral cavity.
A. Crowding:
Areas of crowding cause food accumulation and present a
difficulty in maintaining good oral hygiene at those sites.

B. Protruded maxillary incisors:

Causes incompetent lips, mouth breathing which cause

dryness of gingival tissues and cracking.
9. Race:

 Epidemiological studies found an increase in

gingival condition among Asian and African races
compared to Scandinavian and White Americans.
 Although those studies show a racial predisposition,
yet, no clear difference can be seen if education,
professional dental care and oral hygiene measures
were kept equal.

3
II. Agent Factors:

1. Plaque and calculus:

They are the main etiological factors in periodontal diseases. A
positive correlation exists between plaque index and degree of
gingival inflammation.

2. Food:
a. Nature of food: Soft or fibrous diet.
b.Contents: Vitamin C and Niacin.
III. Environmental Factors:

1. Geographic distribution of periodontal diseases:

Some epidemiological studies revealed that periodontal diseases are more

prevalent in some Asian and African countries than in the United States
of America.

2. Fluoride concentration in drinking water:

Gingival and periodontal status improves as the fluoride intake

increases. This may be due to the decrease in the number of carious
cavities especially cervical and proximal.

3. Oral Environment:

a. Dental Appliances:

Prosthetic or orthodontic appliances favors the

accumulation of plaque on the abutment teeth
particularly if they are improperly designed or the
patient has poor oral hygiene.

b. Dental caries:

There is apositive correlation between dental caries

and periodontal diseases.

4
INDICES USED FOR ASSESSMENT OF PERIODONTAL
DISEASES:
Periodontal diseases are inflammatory conditions affecting the periodontium. The
periodontium comprises the gingiva, the periodontal ligament, the alveolar bone
and the cement covering the roots of the teeth.
Simple and reliable periodontal disease indicators (indices) are available to
help clinicians and researchers to assess current periodontal status as well as to
evaluate the risk of developing periodontal disease. Furthermore, they facilitate
comparison with other populations.
* Used to determine and record the gingival and periodontal health condition of
individuals and groups.
Periodontal indices can be divided into:
I. Indices measuring extent of dental plaque and oral hygiene performance.( OHI&
OHI-s)
II. Indices measuring amount of gingival inflammation, oedema, bleeding and
crevicular fluid flow. (Sulcus bleeding index, Gingival index, Loe and Silness)
III. Indices measuring the extent of destructive periodontal disease.
(Periodontal index, Russel index, CPITN)
I. Indices measuring extent of dental plaque:
Oral hygiene index and oral hygiene index simplified (OHI, OHI-s):
The original OHI was developed by Green and Vermillion. The OHI-s is a
shortened version which can provide the same information on the oral hygiene
status of large population groups.
Both have two components:
a- Oral debris score.(DI)
b- Calculus score.(CI)
In the OHI-s soft and hard deposits are evaluated. The surfaces to be examined
are the buccal surfaces of upper first molars, the labial surface of upper right

5
central, the labial surface of lower left central and the lingual surfaces of lower
first permanent molars. If any of these teeth is missing the adjacent tooth is
taken.
In the OHI: Each jaw is divided into 3 segments, anterior, premolar and posterior.
Examine the buccal and lingual surface and score the worst tooth in each segment.
The OHI comprises 12 surfaces of 6 teeth.

The criteria for the Oral Hygiene Index scores (OHI):

Score Criteria
0 No debris or stain present
1 Soft debris covering not more than one third of the tooth surface.
2 Soft debris covering more than one third but not more than two thirds
of the tooth surface.
Soft debris covering more than two thirds of the tooth surface.
3

6
Criteria for calculus score:
Score Criteria
0 No calculus
1 Supragingival calculus covering < 1/3
2Supragingival calculus covering1/3 – 2/3 tooth surface,and/or individual
flecks of subgingival calculus
3 Supragingival >2/3,and/ or continuous heavy band of subgingival calculus
Scoring:
For determining OHI:
- DI equals the summation of the DI scores of the 12 surfaces examined
divided by 12.
- CI equals the summation of the CI scores of the 12 surfaces examined
divided by 12.
- So, OHI= DI + CI.

For determining OHI-S:

- DI equals the summation of DI scores of 6 examined surfaces divided by 6.
- CI equals the summation of CI scores of 6 examined surfaces divided by 6.
- So, OHI-S = DI + CI

7
II. Indices measuring amount of gingival inflammation:
The gingival Index (GI):
The index was developed by Loe and Sillness. The severity of the gingival
condition is indicated on a scale running from 0-3.

Criteria:
0 No inflammation.
1 Mild inflammation, slight redness, slight odema, probing with a blunt probe
do not result in bleeding.
2 Moderate inflammation: odema, redness, glazing the marginal gingiva is
swollen, probing with a blunt probe elicits bleeding.
3 Severe inflammation: marked redness and odema, spontaneous bleeding
and/or ulceration.
It is a partial recording system; six teeth are selected for the examination.
62 4
4 26
Scoring:
- For each of the six teeth, mesial, distal, buccal and lingual gingival units are
scored independently.
- The tooth scores are summed and divided by 4 which gives the gingival
index of the tooth.
- The scores of the 6 teeth are summed and divided by their number which
gives the GI of the individual.

8
Ill. Indices of destructive periodontal disease:
The periodontal index (PI) Russel's Index:
Criteria: The criteria of the PI index are:
0: Negative: There is neither obvious inflammation in the investing tissue
nor loss of function.
1: Mild gingivitis: There is an obvious area of inflammation in the free
gingiva, but this area does not circumscribe the tooth.
2: Gingivitis: inflammation completely circumscribes the tooth but there is
no apparent break in the epithelial attachment.
6: Gingivitis with pocket formation: The epithelial attachment has been
broken, and there is pocket formation there is no interference with normal
masticatory function, the tooth is firm in its socket.
8: Advanced destruction with loss of masticatory function, the tooth
may be loose, may have drifted, may have dull sound on percussion, may be
depressive in its socket.
Scoring:
- All the present teeth are examined.
-The teeth scores are summed and divided by their number; this will give the
PI of the individual.
-PI of a group equals to the summation of the PI scores of the individuals in
the group divided by their number.

Why did the author write score 6 after score 2?

- If the PI score of an individual is small (i.e. 1 or 2) this indicates that this
individual has gingival affection.
- If it is high (6 to 8), this indicates that this individual has periodontal
affection.
- If the score is inbetween 2 and 6, this indicates that this individual is
affected by both gingival and periodontal disease.
- This index is most suitable for assessment of the gingival and periodontal
condition in adult populations.

9
Modification:
Lilienthal et al. (1964) modified Russel's index by using a partial recording system
to be easier with large surveys. The teeth used are:

7 14

41 7

Here the authors take 7 instead of 6 due to the frequent loss of the latter due to
caries.

10
DENTAL NEEDS AND DENTAL DEMANDS
Dental Health Needs
Taxonomy of need:
1. Normative needs:
A condition whicha professional person (dentist) defines this need as
requiring some action
e.g: carious tooth ---------- need cavity preparation & filling.
2. Felt need:
Asking people whether they feel that they need it can make an assessment of the
need for a service. This is inadequate since some asymptomatic conditions; people
feel that they don’t need to be treated.
3. Comparative need:
Identified in an area by comparing it with other areas regarding disease or service.
E.g. if other areas have a decrease in level of disease or increase of service,
therefore there is a need in the examined area.
4. Expressed need or Demand:
It is a felt need turned to action. Mean that when a patient feels pain, stain
or Cavity, he may demand the dental service.
*Dental needs are the resultant of two forces, the disease susceptibility and
previous care.
*Surveys are needed to assess dental needs, and to implement dental health
services.
Factors which influence Dental Needs:
Dental needs vary from one country to another according to:
1- Degree of Development:
a- Underdeveloped countries: (primitive areas)
Their demands are to be kept alive and free of pain.
11
Their needs are simple & include:
1- Exodontia (extraction).
2- Little amount of dental health education. e.g. instructions in good oral
hygiene and nutrition.
3- Water fluoridation may be valuable.
b- Developing countries: (slightly developed)
Their demands are mainly for:
1- Exodontia.
2- Prosthodontia.
Which can be accomplished in hospitals or in private practices.
c- Developed countries:
Their needs include:
1- Restoration of serviceable teeth.
2- Replacement of missing teeth.
3- Routine dental examination for early control of dental diseases.
4- Preventive and educational measures.e.g. water fluoridation, instructions in
proper oral hygiene & nutrition.
This is called Comprehensive dental care.
2- Age:
- Need for treatment of traumatic injuries to anterior teeth is maximum at age
of 12-14 years.
- Need for fillings reaches a peak between 15-24 years.
- Need for extraction, increases with age.
- Need for periodontal treatment is high at middle age but reaches a peak at 40
years.

12
- Need for crown and bridge is high in middle age (only a small group of teeth
have been extracted).
- Need for partial dentures follows.
- Need for complete dentures, is in later years of life.
- Oral cancer is in later years of life.
3- Sex:
- Need for fillings and periodontal treatment is the same in both sexes.
- Need for extraction and dentures is lower in women than in men (women
show more interest in their oral health to avoid cosmetic disfigurement).
4- Income:
a- In developed countries:
Dental needs are lower among patients with increased income due to:

b- In less developed countries:

People with increased income need more dental care especially young age groups.
5- Race:
- In USA it was shown that blacks need fillings, periodontal treatment, extractions
and prosthodontia more than whites.
- Indian and Chinese groups have high needs for periodontal treatment than USA
citizens but lower needs for caries treatment.

13
Demand for Dental Care
Factors affecting demand:
1. Automatic factors:
They are termed automatic because any increase in one or more of them is
automatically associated with an increase in the demand. These factors will
increase the quantity of demand for dental care regardless the effort of dentist.
A- Gross increase in population:
The larger the community the greater the demand for dental care.
B- Urbanization:
More persons in urban than in rural areas visit the dentist more regularly. This may
be due to difficulty of transportation in rural areas.
C- Education:
Demand for dental services increases with the increase in the level of education.
D- Occupational changes:
Persons in professional occupation visit the dentist more frequently than manual
workers.
E- Income per capita:
Income per capita is correlated positively with demand of dental service. On the
other hand, cost was found to be a major barrier for utilization of dental service.
2-Dentist’s efforts to stimulate demand:
This includes dentist’s efforts in dental health education to make the patient
recognize the sequelae of neglected oral and dental condition and to maintain the
dental apparatus healthy and functioning.

14
Dental Manpower
The demand and the supply of dental care are linked with the number of people in
the dental profession (Dentists & Auxiliaries) and the way they make use of their
time.
Many factors affect the measurement of the dental manpower:
1. Supply of dentist:
The Dentist: Population ratio varies from country to another.
2.Geographic distribution within the country:
*Most dentists are practicing in private offices, and smallernumber join
together to form group practices.
3. Growth trends in supply of manpower:
Growth in the number of manpower should copy with:
a. Gross increase of the population
b. Increase of demand associated with the increase of education and
socioeconomic level.
4.Productivity of dentist:
It is hard to be measured but it is known that increase in dentist age is correlated
with decrease of the manual dexterity and reduction in the working time.
5.Utilization of the dental health manpower:
Utilization may be affected by:
a. Number of manpower. As any decrease in the manpower supply
will lead to a decrease in the dental health utilization.
b. Dentist productivity: A rational measure for dental productivity
includes information on the reduction in incidence and prevalence
of dental disease.

15
ORGANIZATION OF DENTAL CARE
THE DENTIST AND HIS PROFESSION
Dentistry is a specialty of medicine. The dentist practices his specialty in his
private dental clinic or belongs to some sort of health care organization as a
specialist beside his medical colleagues. The organization can be governmental or
non- governmental.
In the past century, dentistry has become more specialized. Expensive equipment
and elaborate techniques were developed for every specialty. The coordination of
the services of the general dentist with the orthodontist, the oral surgeon, the
pedodontist, and other specialties makes the delivery of high standard dental
services easier.
Members involved in providing dental services are:
1- The dentist:
- Someone who is properly licensed and registered to practice dentistry, graduated
from a recognized college or a university.
- The dentist is the only member of the dental team qualified to make a diagnosis
and provide treatment strategies.
- Two-thirds of all dental school graduates become general practitioners. The
remaining one-third becomes dental specialists.
2- Recognized dental specialists:
Once a dentist becomes a specialist, he or she must limit their practice to that
specialty. The eight recognized dental specialists are:
1) Public health dentist: is a dental specialist who provides dental services mainly
prevention, field studies and epidemiological studies to the community.
2) Pediatric dentist: is a dental specialist who treats children from their first
dental visit through approximately age 14.
3) Orthodontist: is a dental specialist who applies dental braces, retainers and
other appliances to correct dental deformities straighten the teeth and align jaw
movements.
16
4) Periodontist: is a dental specialist who performs gingival and periodontal
treatment whether surgical or non-surgical and deals with dental implants.
5) Prosthodontist: is a dental specialist who replaces lost natural teeth with fixed
prosthesis (crowns, bridges or implants) or removable prosthesis (full or partial
dentures).
6) Endodontist: is a dental specialist who performs root canal treatment and
related procedures, such as apicectomies and retrograde fillings.
7) Oral Surgeon: is a specialist who extracts teeth, removes diseased tissues,
surgically exposes impacted teeth; wires fractured jaws and places dental implants.
A maxillofacial surgeon may also treat accident victims or diseases e.g. cancer
which require reconstruction of facial features.
8) Oral Pathologist: is a dental specialist who diagnoses and studies oral diseases
and conducts research related to the oral cavity and its diseases.
3- Dental intern:
A graduate of dental school serving a first year internship of clinical training under
supervision in a teaching hospital.
4- Dental auxiliaries:
A person who is trained to give help and support to the dentist.
Types of Dental Ancillaries
I- Non-operating ancillaries:
A- Clinical:
1. Dental assistant (dental surgery assistant)
They are usually females and there is a great variability in their utilization from
office to office.
Duties:
1- Reception of patient.
2- Preparation of mouthwashes and napkins.

17
 3- Sterilization and preparation of instruments, cleaning instruments and
preparing new instruments for next appointment.
4- Mixing of restorative materials and impression materials.
5- Filing of patients.
6- Assistance in x-ray work, developing and processing.
7- Instructions to patient in good oral hygiene e.g. tooth brushing.
8- After care of patients with general anesthesia.

2- Chair – Side Dental Assistant:

- One chair-side dental assistant, increases number of treated patients by
33%.
- Two chair-side dental assistants, increase number of treated patients by
62%.
- This is because dentist will work under less physical and mental strain &
provides better service.
- Four-handed dentistry: is the art of seating the dentist and his assistant in
such a way so that both can reach easily patient's mouth, with patient in fully
supine position.
Duties:
1- Handling instruments and materials.
2- Retraction.
3- Aspiration.

B- Laboratory:

Dental laboratory technician:

- They are usually men.
- Originally training was done in dental office which resulted in variation
in quality of training.
- Nowadays there are commercial dental laboratories working for a lot
of dentists. This is better because:

18
1- Dentists do not have enough work to employ a full-time technician.
2- Technician can profit by division of labor in these laboratories e.g.
expert in gold, expert in porcelain……..
N.B. Dental technicians are generally not considered auxiliaries
because their work in most cases is performed in a private
commercial laboratory rather than in the dental office.

Qualifications:
Receive their training at dental schools or technical colleges for two
years.

II- Operating ancillaries

1. Dental auxiliaries (ancillaries)
They are trained dental assistants who perform dental procedures that
don’t harm the patient’s health and are repairable.
1. Placing and removing rubber dam.
2. Placing and removing temporary restorations.
3. Placing and removing matrix bands.
4. Condensation, carving and polishing of amalgam restorations.

2. School dental nurse:

Established in New Zealand in 1923 to provide dental services in schools
in areas where there are insufficient dentists.
Duties:
1- Preparation of cavities and restoration of teeth with amalgam.
2- Extraction of deciduous teeth.
3- Scaling and polishing of teeth.
4- Give infiltration anesthesia.
5- Provide dental health education.
6- Application of topical fluoride solutions.
7- Referring more complex cases to the dentist.
Qualifications:
Training courses for two years’ duration.

3- Dental Hygienist: Two ranks:

19
A-Public Health Dental Hygienist:
Trained for one or more years in dental health education and public
health beyond dental hygiene certificate.
Duties:
1- Screening or examination of school children or workers in industries
and refer them to the dentist for treatment.
2- Classroom teaching in dental health.
3- They are very efficient in public health programs.

B-Clinical dental hygienist

They receive less training than public health dental hygienist.
Duties:
1- Dental prophylaxis (removal of calculus & stains).
2- Polishing restorations.
3- Topical fluoride application.

III- New auxiliaries for underdeveloped areas

The WHO suggests two types of dental ancillaries in areas with shortage
of dentists or in countries with no facilities to train dentists.

1. The dental licentiate:

They are semi-independent operators trained for not less than 2 years to
perform:
1 - Cavity preparation & restoration of primary and permanent teeth.
2 - Extractions under local anesthesia.
3- Drainage of dental abscess.
4 – Dental prophylaxis

2. Dental aids:
They receive less training (4-6 months) and perform first aid procedures
such as:
1 - Relief of pain including extraction of teeth under local anesthesia.
2 - The control of hemorrhage.
3 -Recognition of dental disease which need referral to a specialist.
20
GROUP PRACTICE
Definition:

Group practice is a term given when more than one specialist are gathered
and work under one roof. The ideal size of group practice may range from
6- 12 individuals.

The group may be independent (private) or operated by governmental or

non-governmental agency.

The non-governmental group practice may be owned by the partners

(with equal votes), owned by a small organization (social, charity or
cooperative) or by one senior practitioner responsible for recruiting a
number of associates.

In a successful group practice, there must be at least one skilled general

dentist working along with other specialists as well. A dental specialist
limits his practice to a certain specialty, while the skilled general dentist
can provide periodic recall, preventive services and referral to other
specialists. In such group practices, patients accept a multiple dentist-
patient relationship when they realize that the group operates as a team.

Advantages of group practice: -

I-Advantages for the patient: -

a) Better care through quick and easy consultation.

b) Easy referral between operators.

c) Records are available for all operators

d) Economical as reduction of cost is reflected on fees.

e) Security: the patient feels more secure as many services of good

quality are within his reach.

f) Convenient to the patient and his family members as different services

can be offered in one place.

21
II-Advantages for the dentist: -

a) Daily contact between operators and regular staff meetings improve

professional knowledge.

b) Emergencies and vacations can be better organized.

c) Convenience: due to the presence of many services in one building.

This can increase the number of patients served per year.

d) Economic due to sharing common facilities e.g. one reception room,

one x-ray unit and one sterilization system.

e) Group practice gives a quicker start to a young dentist.

Disadvantages of group practice: -

1- Personal conflicts due to loss of individuality.

2- Some patients may find it a disadvantage being shuttled back and
forth from one operator to another.
3- Location and business procedures may not please all members.

Team Work
A team is a group of individuals with different roles and functions whose
combined efforts towards a mutually shared goal are required for the
successful completion of a specific task. A team usually consists of
professional and paraprofessional personnel.

Applications of team work:

I- At the community level:

- Conducting epidemiological studies for the population e.g. survey team.

- This team consists of a group of workers who come together to provide

dental health services for the community.

22
The team includes:

1. Expert epidemiologists

2. Public health worker

3. Dental hygienist

4. Statistician.

Objectives:

1-Provision of services and programs to prevent and control

common dental diseases.

2-Provision of emergency services to relieve pain and control any

condition that may be life threatening.

II- At the patient level

Definition of clinical team: A close, cooperative, democratic,

multi-professional union devoted to a common purpose “the best
treatment of the fundamental needs of the patient”.

Team members must communicate effectively among themselves

with the patient or child patient and parents.

The patient should be a member of the team during discussion of

and making decision about his or her treatment (respect patient’s
rights) in order to achieve more cooperation during the course of
treatment.

Examples of a clinical team:

1- Cleft lip and palate team.

2- Maxillofacial team.

The team working in such cases are different specialists who work
together to treat complicated cases.

23
Since optimal care is best achieved by multiple types of clinical
expertise, the cleft lip palate team may be composed of individuals
in:

1- Dental specialties: orthodontist, oral surgeon, pediatric dentist

and prosthodontist.
2- Medical specialties: genetics, pediatrics, plastic surgery and
psychiatry.
3- Allied health care: nurses, social worker, ENT specialist, speech
therapist.
These care providers’ assess patient’s medical status and general
development, dental development, facial esthetics, psychological
well-being, hearing and speech development.

24
 Dr. Esraa Hamed Aly
Lecturer of Pediatric Dentistry & Dental Public Health
BDS, MDS, PHD
 Ethics in Dentistry
Definition:

The word ‘ethics’ is derived from the Greek word “ethos’ meaning
custom or character. Ethics is the philosophy of human conduct, a way
of evaluating principles by which problems of behavior can be solved.

Ethics is concerned with standards of judging whether actions are right

or wrong.

Dental ethics would mean moral duties and obligations of the dentist
towards his patients, professional colleagues and to the society. They
focus primarily on individuals’ rights and duties.

Ethical principles:

1- To do no harm ( Non-maleficence)
2- To do good ( beneficence)
3- Respect for persons
4- Justice
5- Veracity or truthfulness
6- Confidentiality
1- To do no harm ( Non – maleficence):

It is the corner stone of Hippocratic Oath that states: “ Above

all, do no harm”. It is considered to be the foundation of social
morality.
- What is harm in general?
• Discomfort
• Inconvenience
• Emotional distress
• Deprived of freedom of action
• Deprived of opportunities/choices
• Pain
• Disability: Esthetic disability or Functional disability or both
• Death
- What is harm in medicine?
1. Suffering (physical, psychological)
2. Pain
3. Injury
4. Disease – Iatrogenic disease (Doctor – induced illness)
5. Disability: esthetic and/or functional
6. Death
 e.g. Overhanging restorations……..leading to periodontal
disease
Non sterilized instruments…….leading to infection.

2- To do good (Beneficence):
To do good or beneficence is required of all health care
providers. It should be the role of dentists to benefit patients, as
well as not to inflict harm. There is an agreement between the
doctor and the patient that some good will result.

• It is producing benefits or enhance welfare . Making your

actions good as possible
How to do it:
1- Not to do harm: e.g: No need to do a restoration in a sound
teeth
2- Prevent harm: e.g: prevent new caries lesion / oral hygiene
education to patients
3- Removing harm: e.g: Therapeutic intervention (all dental
treatments)
4- Promoting/Doing good: e.g: Special cosmetic interventions
when the standards are accepted.
 - Other examples of beneficence due to our profession
improvement:
• Smoking cessation
• Behavioral clinician advisors
• Violence reporters
• Special needs patients
• Cancer screening
- Examples of serious issues trying to balance between non
malfiesance and beneficence:
• Extraction Vs Endodontic treatment
• Implant placement Vs Orthodontic closure
• Coronectomy Vs total extraction of a tooth
• Amalgam Vs Composite in posterior teeth

3- Respect for persons:

It incorporates two fundamental ethical considerations:
A) Autonomy
B) Informed consent

A) Autonomy:
It dictates that health care professionals respect the
patient’s capacity for self determination in making
decisions concerning their treatment.
 The freedom to think , judge and act independently
without undue influence. An action reflecting a thoughtful
and individualized choice based on adequate information
without undue internal or external influences that could
affect the outcomes of the decision. The choice foresees
the expected side effects.
Your duty as a dentist is to permit individuals to make
informed decisions about factors affecting their health.
Autonomy may conflict with other principles, e.g.: with
the principal do no harm:
• Some choose Autonomy to be the most important
• Some choose Do No Harm to be the most important
Remember It is really hard to balance between Autonomy
and Do No Harm when they conflict How to insure
autonomy?
By a well designed informed consent including possible
lines of treatements and expected side effects and
management of side effects.

B) Informed consent:
It is an essential component of a patient’s right to
automony.
 The Nuremberg Code identifies 4 attributes of consent
without which consent cannot be considered valid.
4- Justice:
The difference between justice and equality:
Justice for the aim to approach others but equality for the way
you approach others.
Justice is often described as fairness or equal treatment , giving
to each her or his right or due.
In providing dental care it is difficult to distribute services to all
who are in need, but it should be the concern of health care
professionals to see that as even a distribution as possible
occurs. Justice demands that each person be treated equally.
Dentists can provide some free or discounted care in their
offices to those who are truly needy, or they can provide
financial support or donate some time to clinics for low-income
patients.

5- Truthfulness:
The patient – doctor relationship is based on trust. Lying shows
disrespect to the patient and threatens relationship.
Truthfulness is an ethical principle that one would expect to go
unquestioned, yet many health care professionals practice in a
less than truthful way. The dentist may feel that it would be
 better if the patient took a certain course of action and therefore
manipulates the information that is given to the patient.
Whatever the reason, the relationship will ultimately suffer and
the dentist will be guilty of transgressing a major ethical
principle.

6- Confidentiality:
Patients have the right to expect that all communications and
records pertaining to their care will be treated as confidential.
Earlier it was widely accepted that confidentiality could be
breached if it was thought it would benefit the patient. However
, knowledge of a patient gained in the course of examination
and treatment is privileged and should not be disclosed without
the consent of the patient or an order from the presiding judge in
a court of law.

Ethical rules for dentists ( Prescriped by the DCI ):

I- The duties and obligations of dentist towards the
patients:
1- Every dentist should be friendly and helpful.
2- He should observe punctuality in fulfilling his
appointments.
 3- He should establish a well merited reputation for
professional ability and fidelity.
4- The welfare of the patient should be conserved to the
utmost of the practitioner’s ability.
5- A dentist should not permit considerations of religion,
nationality, race, party politics or social standing to
intervene between his duties and his patients.
6- Information of a personal nature which may be learned
about or directly from a patient in the course of dental
practice should be kept in the utmost confidence. It is
also the obligation of the dentist to see that his auxiliary
staff observe this rule.

II- Duties of dentists towards one another:

1- Every dentist should cherish a proper pride in his/her
colleagues and should not disparage them either by act
or word.
2- When the dentist is entrusted with the care of the
patient of another, during sickness or absence, mutual
arrangements should be made regarding remuneration.
3- A dentist called upon in any emergency to treat the
patient of another dentist, should, when the emergency
 is provided for, retire in favor of the regular dentist but
shall be entitled to charge the patient for his services.
4- If a dentist is consulted by the patient of another dentist
and the former finds that the patient is suffering from
previous faulty treatment it is his duty to institute
correct treatment at once with as little comments as
possible and in such manner as to avoid reflection on
his predecessor.

III- Duties of dentists to the public:

Dentist has to assume a leadership role in the community
on matters related to dental health.
Some unethical practices:
1- Practice by unregistered persons employed by the
dentist.
2- Dentist signed under his name and authority issuing any
certificate which is untrue, misleading or improper.
3- Dentist advertising whether directly or indirectly for the
purpose of obtaining patients or promoting his own
professional advantage.
4- Allowing commission
5- Paying or accepting commissions
 6- If the planned treatment is beyond the dentist’s skill, the
patient is not referred to a consultant
7- In case of an emergency consultation during the
temporary absence of the patient’s dentist, temporary
service is provided and the patient is not sent back
8- If confused, the dentist accepts charge of the case
without request of the referring dentist.

Duties of physicians in general:

A physician shall

 Always exercise his/her independent professional

judgment and maintain the highest standards of
professional conduct.
 Respect a competent patient’s right to accept or
refuse treatment.
 Not allow his/her judgment to be influenced by
personal profit or unfair discrimination.
 Be dedicated to providing competent medical
service in full professional and moral
independence, with compassion and respect for
human dignity.
 Deal honestly with patients and colleagues and
report to the appropriate authorities those
 physicians who practice unethically or
incompetently or who engage in fraud or
deception.
 Not receive any financial benefits only for
referring patients or prescribing specific products.
 Respect the rights and preferences of patients,
colleagues, and other health professionals.
 Recognize his/her important role in educating the
public but should use due caution in divulging
discoveries or new techniques or treatment
through non professional channels.
 Certify only that which he/she has personally
verified.
 Strive to use health care resources in the best way
to benefit patients and their community.
 Seek appropriate care and attention if he/she
suffers from mental or physical illness.
 Respect the local and national codes of ethics.

Duties of physicians to patients:

A physician shall:
 Always bear in mind the obligation to respect
human life.
  Act in the patient’s best interest when providing
medical care.
 Owe his/her patients complete loyalty and all the
scientific resources available to him/her.
Whenever an examination or treatment is beyond
the physician’s capacity, he/she should consult
with or refer to another physician who has the
necessary ability.
 Respect a patient’s right to confidentiality. It is
ethical to disclose confidential information when
the patient consents to it or when there is a real
and imminent threat of harm to the patient or to
others and this threat can be only removed by a
breach of confidentiality.
 In situations when he/she is acting for a third
party, ensure that the patient has full knowledge
of that situation.

Duties of physicians to colleagues:

A physician shall:
 Behave towards colleagues as he/she would have
them behave towards him/her.
  Not undermine the patient-physician relationship
of colleagues in order to attract patients.
 When medically necessary, communicate with
colleagues who are involved in the care of the
same patient. This communication should respect
patient confidentiality and be confined to
necessary information.

Informed Consent
The informed consent is a “ two-step” process. First information is
presented to the patient by the doctor. Secondly the patient satisfies
himself or herself that he or she understands and based upon this
understanding either agrees or refuses to undergo the treatment.

Requirements of a Consent:
- Voluntary
- Legally competent
- Informed
- Comprehending

Informed consent consists of:

1- A description of the procedures to be carried out.
 2- A description of any reasonably foreseeable risks or discomforts
to the subject.
3- A description of any benefits to the subject or to others which
may reasonably be expected from the treatment.
4- A disclosure of appropriate alternative procedures or courses of
treatment, if any, that might be advantageous to the subject.
5- A statement describing the extent, if any, to which
confidentiality of records identifying the subject will be
maintained.
6- A statement that the patient has understood the procedure and is
willing to undergo the treatment.
7- The signature of the patient and of a witness.

The NUREMBERG CODE (1947):

It is a code designed to protect the integrity of the research subject set

out conditions for the ethical conduct of research involving human
subjects emphasizing their voluntary consent to research.

1- The voluntary informed consent of the human subject is absolutely

essential. The duty and responsibility for ascertaining the quality of
the consent rests upon each individual who initiates, directs, or
engages in the experiment.
2- The experiment should be such as to yield fruitful results for the
good of society.
3- The experiment should be so designed and based on the results of
animal experimentation and a knowledge of the natural history of
the disease that the anticipated results justify the performance of
the experiment.
4- The experiment should be so conducted as to avoid all unnecessary
physical and mental suffering and injury.
5- No experiment should be conducted where there is a prior reason
to believe that death or disabling injury will occur.
6- The degree of risk to be taken should never exceed that determined
by the humanitarian importance of the problem to be solved by the
experiment.
7- Proper preparations should be made to protect the experimental
subject against even remote possibilities of injury, disability or
death.
8- The experiment should be conducted only by scientifically
qualified persons.
9- During the course of the experiment the human subject should be
at liberty to bring the experiment to an end if he has reached the
physical or mental state where continuation of the experiment
seems to him to be impossible.
10- During the course of the experiment the scientist in charge
must be prepared to terminate the experiment at any stage if he
believes that the continuation of the experiment is likely to result
in injury, disability, or death to the experimental subject.

- At the time of being admitted as a member of the medical

profession , the new dentists must make the professional swear.
- Principles for all medical research:
1- It is the duty of physicians who participate in medical research
to protect the life, health ,dignity, integrity and privacy of
personal information of research subjects.
2- Medical research involving human subjects must conform to
generally accepted scientific principles be based on a complete
knowledge of the scientific literature.
3- Appropriate caution must be exercised in the conduct of medical
research that may harm the environment.
4- The design and performance of each research study involving
human subjects must be clearly described in a research protocol.
The protocol should contain a statement of the ethical
considerations involved and should indicate how the principles
in this declaration have been addressed.
5- The research protocol must be submitted for consideration,
guidance and approval to a research ethics committee before the
 study begins. This committee must be independent of the
researcher, the sponsor and any other undue influence. No
change to the protocol may be made without consideration and
approval by the committee.
6- Medical research involving human subjects must be conducted
only by individuals with the appropriate scientific training and
qualifications.
7- Medical research involving a disadvantaged population or
community is only justified if the research is responsive to the
health needs and priorities of this population or community.
8- Every medical research study involving human subjects must be
preceded by careful assessment of predictable risks and burdens
to the individuals and communities involved in the research.
( pilot study)
9- Physicians may not participate in a research study involving
human subjects unless they are confident that the risks involved
have been adequately assessed and can be satisfactorily
managed. (Benefits greater than the risks)
10- Participation by competent individuals as subjects in medical
research must be voluntary.
11- Every precaution must be taken to protect the privacy of
research subjects and the confidentiality of their personal
information.
12- In medical research involving competent human subjects,
each subject must be informed of the aims, methods, benefits
and risks of the study. The potential subject must be informed of
the right to refuse to participate in the study or to withdraw
consent to participate at any time.
13- When seeking informed consent for participation in a
research study the physician should be particularly cautious if
the potential subject is in a dependent relationship with the
physician.
14- For a potential research subject who is incompetent or
physically or mentally incapable of giving consent, the
physician must seek informed consent from the legally
authorized representative.
15- Authors, editors and publishers all have ethical obligations
with regard to the publication of the results of the research.
Negative as well as positive results should be published or made
publicly available.
16- At the conclusion of the study, patients entered into the study
are entitled to be informed about the outcome of the study and
to share any benefits that result from it.
 Modern University of Technology & Information
Faculty of Oral and Dental Medicine
Pediatric Dentistry and Dental Public Health Department

Logbook For Pedodontics II

PEDO 521

Student’s Name:

Student’s I.D. :

Section Number:
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

1
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

2
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

3
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

4
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

5
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

6
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

7
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

8
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

9
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

Evaluation A B C

10
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….………………………………………………………………………….

11
 Patient Assessment Chart
Student’s Name: …………………….………………………..Section: ………… Number: ………….
Date: / /
Personal History:
Pt Name: …………………………………….…………………………... Age: ……….. Sex: …………
Address: ………………………………………………………… Telephone number: …..…………….
Chief Complaint: …………………………………………………………………………………………
Past and Present Medical History:
………………………………………………………………………………………………………………
Past Dental History:
………………………………………………………………………………………………………………
Clinical Examination:
- Extra Oral Examination:
……………………………………………………………………………...………………………
…………………………………………………………....................................................................
- Intra Oral Examination:
• Soft Tissue Examination:
…………………………………………………………………………..…………………
……………………………………………………………………………………………..
• Hard Tissue Examination (teeth):
E D C B A A B C D E

E D C B A A B C D E
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Dental Caries Indices Used:
D =…….. + M = …….. + F =…….. DMF =……..
d =…….. + e = …….. + f =…….. def =……..
d =…….. + m = …….. + f =…….. dmf =……..
Occlusion:
……………………………………………………………………………………………………………….
Diagnosis:
- Chief Complaint:…………………………………………………………………………………...
……………………………………………………………………………...……………………….
- Other Dental Defects:……………………………………………………………………………..
……………………………………………………………………………..……………………….
………………………………………………………..…………………………………………….
Treatment Plan:
…………………………………………………………………………………….…………………………
…………………………………………………………….…………………………………………………
…………………………………….…………………………………………………………………………

12
List of required Instruments and Materials Needed
- 2 Diagnostic sets
- 2 Metal syringes
- Topical anesthesia
- Anesthetic carpules
- Rubber dam kit (sheet, holder, punch, clamps molars and premolars)
- Excavators
- Short and long needles
- Burs (330,245, round burs size 3 &4, inverted burs size 2 & 3, fissure burs size 1 &2)
- Fissure sealant
- Composite / etch / bond
- Finishing kit for composite
- Bond brushes
- Topical fluoride
- Scissors
- Adam Plier
- T- bands
- Wooden wedges
- Glass slab
- Spatulas
- Condensors
- Burnishers
- Amalgam carriers
- Stones (flame, fine needle
tapered)
- Formocresol
- Endodontic H files (15-40)
- Paper points (15-40)
- Plastic syringes
- Saline
- Gauze
- X ray films
- Metapex
- Zinc oxide powder and eugenol
- Zincnol
- Stainless Steel Crowns (size will be determined by supervisor according to the case)

13
Clinical Requirements for PEDO 521

Clinical requirements Method of grading Total

marks
2 Local anesthesia and extraction 1 mark for each L.A and 1 mark for 4
each extraction
2 Cavity preparation and restoration 0.5 mark for cavity and 0.5 mark 2
for restoration
2 Pulpotomy with stainless-steel 1.5 mark for pulp and 1 mark for 5
crown crown
1 Pulpectomy with stainless-steel 1.5 mark for pulp and 1 mark for 2.5
crown crown
1 space maintainer 0.5 mark for impression and 1 mark 1.5
for cementation
Total 15
marks

N.B.
The case will not be counted until:
1. A completed chart is recorded in the logbook and signed by the supervisor.
2. The case is signed in the logbook by the supervisor at the same section.

14
 Rubric for Assessment of Class I Cavity Preparation in Primary Molars

Step A B C D
Including all pits Including ¾ of Including ½ of Not following
1- Outline form
and fissures. pits and fissures. pits and fissures. the outline form.
- Not exceeding - Over extended - Undermining
- Not exceeding
1/3 occlusal buccolingual both marginal
1/3 occlusal
2- Extension of surface. width. ridges and over
surface.
the cavity - Under - Undermining extended
- Following
extended one marginal buccolingual
proper outline.
margin. ridge. width.
0.5 mm below Shallow cavity
Deep cavity Very deep cavity
3- Depth of the DEJ = 1.5 – 2 Depth < 1.5 mm
2mm from > 2.5 mm from
cavity mm from from occlusal
occlusal surface. occlusal surface.
occlusal surface. surface.
4- Shape of Flat or slightly Irregular pulpal 2 levels or more Convex pulpal
pulpal floor concave. floor. pulpal floor. floor.
Rounded Straight line
Straight line
internal line angles.
angles if Line angles
5- Resistance angles and side Internal outline
corrected diverge
and retention walls. Internal = external
undermine the occlusally.
outline > outline but can
cusps.
external outline. be corrected.
Irregular line
Rounded
Irregular line angles and side
internal line Irregular line
angles. walls if
angles with angles and side
6- Finishing Need corrected
sweeping curves walls beyond
smoothening and overextended
and no sharp correction.
roundation. cavity will
lines.
result.
7- Overall A B C D

15
 Rubric for Assessment of Class II Cavity Preparation in Primary Molars

Step A B C D
Including all pits Including ¾ of pits Including ½ of pits Not following the
1- Outline form
and fissures. and fissures. and fissures. outline form.
- Not exceeding 1/3 - Not exceeding 1/3 - Over extended - Undermining both
2- Extension of the occlusal surface. occlusal surface. buccolingual width. marginal ridges and
cavity - Following proper - Under extended - Undermining one over extended
outline. margin. marginal ridge. buccolingual width.
Shallow cavity
0.5 mm below DEJ Deep cavity 2mm Very deep cavity >
3- Depth of the Depth < 1.5 mm
= 1.5 – 2 mm from from occlusal 2.5 mm from
cavity from occlusal
occlusal surface. surface. occlusal surface.
surface.
4- Shape of pulpal Flat or slightly Irregular pulpal 2 levels or more Convex pulpal
floor concave. floor. pulpal floor. floor.
Rounded internal
Straight line angles. Straight line angles
line angles and side
5- Resistance and Internal outline = if corrected Line angles diverge
walls. Internal
retention external outline but undermine the occlusally.
outline > external
can be corrected. cusps.
outline.
- Width ½
- Width > ½ - Over extended
intercuspal - Width 1/3
intercuspal width of isthmus
dimension of the intercuspal
dimension of the that undermine the
tooth without dimension of the
6- Isthmus tooth. cusps.
weaking the cuspal tooth.
- Irregular - Undermined
area. - Axiopulpal line
axiopulpal line axiopulpal line
- Axiopulpal line angle is straight.
angle. angle.
angle is beveled.
Inverted truncated
cone: Proximal box:
Inverted truncated
a- Converging Straight walls
cone: a- Converging
occlusally. and/or over Proximal box
7- Proximal box occlusally.
b- In self cleansable extended diverge occlusally.
b- Small not in self
area. buccolingually
cleansable area.
c- Not undermining undermining cusps.
the cusps.
Gingival seat:
Height→ beneath
free gingival margin
Gingival seat: Gingival seat:
just above Gingival seat:
Height→ above Height→ below
maximum Height→ too low at
maximum convexity cervical line.
convexity. the cervical line.
8- Gingival seat too much needs to Depth→ too
Depth→ 1mm from Depth→ 0.5mm.
and axial wall be lowered. shallow.
outer tooth surface
Depth→ 0.5 mm.
to allow amalgam Axial wall:
Axial wall: Axial wall:
condensation. Irregular.
Straight Indefinite.
Axial wall:
Following outline of
the outer surface.
Irregular line angles
Rounded internal Irregular line
and side walls if Irregular line angles
line angles with angles.
9- Finishing corrected and side walls
sweeping curves Need smoothening
overextended cavity beyond correction.
and no sharp lines. and roundation.
will result.
10- Overall A B C D

16
 Rubric for Assessment of Pulpotomy Procedure in Primary Molars

Step A B C D
-Adequate - Inadequate - Wide outline. - Wider outline
access to pulp (small) access to with
1- Access cavity chamber. pulp chamber. undermining of
- Visible walls.
orifices.
- Complete - Incomplete pulp - Incomplete - Damage to
pulp amputation. pulp pulpal floor
2- Complete amputation. amputation. and/ or
pulp - Anatomy of - Slight damage perforation.
amputation floor of pulp to pulpal floor.
chamber is
maintained.
- Smoothly - Roughness in - Thinning of - Undermined
finished cavity cavity walls. cavity walls. cavity walls
3- Finishing walls. - Overhanging and/ or
- No overhanging dentin ledges. perforation.
dentin ledges.
4- Overall A B C D

17
 Evaluation of requirements
Date Clinical Evaluation Mark Signature
requirement A B C D
Cavity preparation
(0.5 mark)
Restoration
(0.5 mark)
Cavity preparation
(0.5 mark)
Restoration
(0.5 mark)

Date Clinical Evaluation Mark Signature

requirement A B C D
L.A (1 mark)
Ext (1 mark)
L.A(1 mark)
Ext (1 mark)

Clinical Evaluation Mark Signature

requirement
A B C D
Space maintainer
Impression
(0.5 mark)
Space maintainer
Cementation
(1 mark)

18
 Date Clinical Evaluation Mark Signature
requirement
A B C D
Pulpotomy
(1.5 mark)
Stainless-steel
crown (1 mark)
Pulpotomy
(1.5 mark)
Stainless-steel
crown (1 mark)
Pulpectomy
(1.5 mark)
Stainless-steel
crown (1 mark)

Total logbook grade =

Good Luck
2023

19