Pedodontics IV BDS Brief Notes - 1-1

Department of Pedodontics & Preventive dentistry
DEPARTMENT OF PEDODONTICS & PREVENTIVE
DENTISTRY
VISHNU DENTAL COLLEGE, BHIMAVARAM.
PEDODONTICS BRIEF NOTES
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INTRODUCTION TO PEDODONTICS
1. Define pediatric dentistry.

American Academy of Pediatric Dentistry (1999) defined “Pediatric dentistry as an age defined
specialty that provides both primary and comprehensive preventive and therapeutic oral health
care for infants and children through adolescence, including those with special health care
needs.”
2. Give a brief history of pediatric dentistry.

A: 1935 – BDS: Licentiate in Dental Science becomes Bachelor in Dental Surgery—4 year course
1950 – Pedodontics is introduced: Government Dental College, Amritsar starts pedodontics as a
speciality not as an independent speciality (one or two questions in operative dentistry) Later–
Section ‘B’ in orthodontics
1978 – Pedodontics for undergraduates: Pedodontics was introduced as a speciality in the
undergraduate curriculum
1979 – Indian Society of Pedodontics and Preventive Dentistry: The Association of Indian
Pedodontists holds the 1st conference. Dr BR Vacher is made the “Father of Pedodontics in
India”
1982 – Affiliated to IADC: Indian Society of Pedodontics and Preventive Dentistry becomes an
affiliate member of IADC (International Academy for Dentistry for Dr R Ahmed Children)
3. What are the aims and objectives of pedodontics?

a) Health of a child as a whole: The pedodontist is a part of the health team concerned with
the individuals’, i.e. total physical, mental and emotional well-being of patient. We must be
certain that our effort to improve dental health is always in accordance with the general
health of patient.
b) More specifically we are concerned with oral health: The other aim should be preventing
disease. The earliest attempt at prevention is at expectant mother. She should be advised
on dental health of her future child. After child is born we advise the mother to continue
appointments. First dental appointment for a child is usually at 6 months.
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c) Early diagnosis and prompt treatment: Introduce and implement the principles of
preventive dentistry from birth so that early diagnosis is initiated. Occlusal guidance and
early treatment of developing malocclusion should be done to avoid complications.
d) Restoring the mouth to good health: If dental treatment is unpleasant then the child will
develop resistance and reluctance for further treatment. In order to overcome those
problems, early diagnosis leading to proper treatment is required. Regular attendance,
sound diagnosis, adequate local analgesia, modern cutting equipments are important but,
these only arrest the essential empathy that the dentist must have towards child.
e) To observe and control the necessary developing dentition of child patient: A general
dentist who sees the child every time is in an excellent position to study his oral
development and to intervene himself or refer to a specialist for the necessary treatment.
f) Relief of pain: As and when necessary bearing in mind patient’s total well-being.
g) Educate the patient regarding dental health. Following this we will produce a service for
the child as an individual population which is dentally educated which also leads to elevation
of the profession.
h) Instil a positive attitude and behavior: This not only will help in accomplishing the
treatment in a desired manner but also make the child a good dental patient even in
adulthood.
i) Restore the lost tooth structure: To maintain tissue harmony between the hard and soft
tissue.
j) Management of special patients: Managing physically mentally disabled and medically
compromised children in an efficient and orderly manner so as to avoid discomfort to the
patient and at the same time avoiding any bias towards the special condition of the children.
4. What are the attitudes/responsibilities of a pedodontist ?

A: Attitudes/ responsibilities of Pedodontist
a) Develop an attitude to adopt ethical principles in all aspects of pedodontic practice.
b) Professional honesty and integrity are to be fostered.
c) Treatment care is to be delivered irrespective of the social status, cast, creed and religion of
the patients.
d) Willingness to share the knowledge and clinical experience with professional colleagues.
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e) Willingness to adopt, after a critical assessment, new methods and techniques of

pedodontics management developed from time to time, based on scientific researches,
which are in the best interest of the child patient.
f) Respect child patient’s rights and privileges, including child patient’s right to information
and right to seek a second opinion.
g) Develop an attitude to seek opinion from allied medical and dental specialities, as and when
required.
5. Importance of primary teeth in oral cavity.

Primary teeth serve a number of critical functions:
a) Maintain good nutrition by permitting your child to chew properly.
b) Involved in speech development.
c) Helps in the eruption of permanent teeth by saving space for them.
d) A healthy smile can help children feel good about the way they look to others ie to maintain
psychological well being.
6. Explain the concept of pedodontic triangle

The concept of Pedodontic triangle was given by GZ Wright in 1975 (fig :1). Patient-doctor
relation in adults is linear but in Pedodontics the relation is triangular. This is because in
Pedodontics, the parent and the child both are involved and child is at the apex of triangle as he
is the focus of attention. Moreover the arrows indicated that the communication is not only
limited to the benefit of the child but is reciprocal in nature
Later modified (fig :2)with the addition of the society in the center of the triangle. As
community has become a major part of all components of environment therefore, recently a
new parameter has also been added, that is society.
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7. Who is the father of pedodontics

A: Robert Bunon is Father of Pedodontics.
8. Who is the Father of Pedodontics in India

A: BR Vacher is Father of Pedodontics in India.
9. Who is the father of Children’s Dentistry organizations ?

A: Samuel D Harris is Father of Children’s Dentistry organizations.
10. Who published first book on children’s dentistry ?

A: Joseph Hurlock published first book on children’s dentistry.
11. When was Indian Society of Pedodontics and Preventive Dentistry is formed ?
A: Indian Society of Pedodontics and Preventive Dentistry is formed in 1979
12.What is pediatric dentistry treatment model ?

A: Vivek P et al. (2012) have proposed a new model based on the pedodontic triangle and have
termed it pediatric dentistry treatment model.3 It presents the former triangle as a square
which has the pediatric dentist, pediatrician, family and society playing important roles and
definitely the child patient is the center of attention (Fig. 1.3).
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13. What is the scope of pedodontics?

A: The scope of pediatric dentistry virtually includes the essence of all branches of dentistry like
diagnosis, oral surgery, rehabilitation, endodontics, orthodontics, preventive dentistry and also
includes the newer avenues like lasers and nanodentistry. For diagram refer Shobha Tandon
textbook.
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DIFFERENCES BETWEEN PRIMARY AND PERMANENT TEETH

Dr P.Ahalya
1. Enumerate differences between primary and permanent teeth
General differences
a) Primary teeth are present within the age of 6 months-10 to 12 years ( @ the age of 13 years only about 5%
of primary teeth remains). Primate space is absent in primary teeth. 
b) 1st tooth to erupt into the oral cavity is mandibular incisor whereas in permanent teeth it is the mandibular
first molar. 
c) Primary teeth are smaller in size when compare to permanent teeth. 
d) Bicuspids and third molars are absent in the primary set of tooth. 
e) Teeth formula:- ICPM/ICPM primary- 2102/2102 permanent- 2123/2123 
f) No. of teeth present:- primary-20 permanent – 28-32
Primary teeth Permanent teeth
Incisors are Larger in mesiodistal dimension than Larger in cervico-occlusal dimension than the
cervico-incisal dimension. So looks wider mesiodistal dimension. this gives a longer
appearance to permanent anterior teeth
smaller in all dimensions . Exposed area is Larger in dimensions.  Grayish white to
about one-half that of the permanent teeth.  yellowish white in color.  Wider mesio-distally
Bluish white in color. Refractive index similar to in relation to cervico-occlusal dimension. this
that of milk( RI=1). gives a cup shaped appearance to the anterior
teeth and squat shaped appearance to the
molars. 
Buccal and lingual surface of molars , There is less convergence of buccal and lingual
especially 1st molar, converge towards occlusal surface of molars towards occlusal surface
surface so they have a narrow occlusal table in
the bucco- lingual plane. 
 Cervical ridges are more pronounced The cervical ridges are flatter
especially on buccal aspect of first primary
molar.
Cuspids are slender and to be more conical.   Cuspids are less conical
The contact areas between molars are broader The contact point between permanent molars is
, flatter and situated gingivally.  situated occlusally.
Molars are bulbous and are sharply constricted  They have less constriction at the neck. 
cervically.  Occlusal plane is relatively flat. Occlusal plane has relatively curved contour
1st molar is smaller in dimension than the 2nd 1st molar is larger in dimension than the 2nd
molar  molar
Mammelons are absent.  Mammelons are present on incisal edges of 
newly erupted incisors
Supplemental grooves are more. Supplemental grooves are less
 High potential for repair.  High degree of Comparatively less potential for repair.
cellularity and vascularity in tissue. Comparatively less degree of cellularity and
vascularity in tissue. . 
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 Pulp horns are closer to the outer surface. The pulp horns are comparatively away from
Mesial pulp horn extends to a closer the outer surface.  Pulpal outline follows DEJ
approximation of surface than the distal pulp less closely
horn.  Pulpal outline follows DEJ more closely.
 Pulp chamber is larger in relation to crown Pulp chamber is smaller in relation to crown
size. size.
Floor of pulp chamber is porous. Accessory Floor of pulp chamber does not have any
canals in primary pulp chamber floor leads accessory canal
directly into interradicular furcation.  
Root canals are more ribbon like. the radicular Root canals are well defined with less
pulp follows a thin , tortuous and branching branching. 
path.
 Greater thickness of dentin over occlusal Comparatively lesser thickness of dentin over
fossa of molars.  the pulpal wall at the occlusal fossa of molars. 
Comparatively less tooth structure. More tooth structure protecting the pulp. 
Undergo physiologic resorption during Physiologic resorption is absent.
shedding of primary teeth.  ..
. At the cervical region, the roots of the primary Marked flaring of roots is absent. 
molars flare outward and continue to flare as
they approach the apices to accommodate
permanent tooth buds
Roots are narrower mesio-distally Roots are broader mesio- distally. 
Furcation is more towards cervical area so that  Placement of furcation is apical , thus the root
root trunk is smaller .  trunk is larger.
 Roots are larger and more slender in Roots are shorter and bulbous in comparison to
comparison to crown size crown.
Anatomical differences
Enamel :
a) Enamel is thinner and has a more consistent depth of a) The enamel is thicker and has a
about 1mm thickness throughout the entire crown thickness of about 2-3mm.
b) Neonatal lines are present in all teeth b) Bands of retzius are less common.
c) The enamel of primary teeth is thin but of uniform This maybe partly responsible for the
thickness . bluish white color.
d) The enamel surface tends to be parallel to the c) Enamel rods are oriented
DEJ. gingivally. 
e) Enamel rods at the cervical slopes occlusally from the d) Neonatal lines are only present in
DEJ. 1st molars 
e) Bands of retzius are more common.
Dentin : a) Dentinal tubules are less regular.

a) Dentinal tubules are more regular. b) Interglobular dentin is present
b) Interglobular dentin is absent.  c) .Dentin is denser and difficult to cut.
c) Less dense and easy to cut.  d) The density of dentin in regard to
d) Dentin thickness is half that of permanent teeth. Thickness dentinal tubules is more and so the
is limited in some places.  pulp is proportionately smaller than
e) The dentin also has less bulk or thickness, and so the pulp that of the primary teeth . 
is proportionately larger than that of the permanent teeth . 
Pulp: a) The pulpal horns are smaller and
a) The pulpal horns are longer and more pointed than the less approaching to the cusps.
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cusps would indicate. 

b) The pulpal outline follows the DEJ more closely than that
of the permanent teeth . 
Periodontium : a) Gingivitis is common in adults.
a) Gingivitis is generally absent in a healthy child. Similarly b) Alveolar atrophy occurs. 
recession is in frequent.  Alveolar atrophy is rare.  c) Secondary cementum is present.
b) Cementum is very thin and o the primary type. Secondary
cementum is characteristically absent.
Morphological differences
a) The buccal and lingual surfaces of the molars a) Broader occlusal table
converging sharply occlusally results in a narrow
occlusal surface or food table. 
b) The sharp constriction at the neck of the primary b) No prominent cervical
molar necessitates special care in the formation of constriction for the teeth
the gingival floor during class2 tooth preparation .  c) Crowns are larger and less
c) The characteristic sharp lingual inclination bulbous
occlusally of the facial surfaces results in the d)
formation of distinct faciogingival that ends
abruptly at the CEJ. 
d) Crowns are smaller and more bulbous than their
permanent counterparts, and the molars are bell
shaped ,
e) Crowns have a definite constriction in the cervical
region
2. Enumerate histological differences between primary and permanent teeth

Pulp nerve fibers pass to the odontoblastic area, Pulp nerve fibres terminate mainly among
where they terminate as free nerve endings. the odontoblasts and even beyond the
predentin.  19.
Reparative dentin formation is less.  Reparative dentin formation is more

Incidence of reparative dentin formation beneath
carious lesion is more extensive and irregular
Roots have enlarged apical foramens. Thus , the  Foramens are restricted. Thus reduced
abundant blood supply demonstrates a more typical blood supply favors a calcific response and
inflammatory response. healing by calcific scarring
Density of innervations is less because of which Density of innervations is more. 

primary teeth are less susceptible to operative
procedures.
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Localization of infection and inflammation is poorer in Infection and inflammation in pulp is

pulp \ localized
Neural tissue is the first to degenerate when root

resorption takes place.
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Eruption and shedding

Dr Devi V
1) Nolla stages of tooth development?
2) Natal teeth and neonatal teeth?

 Eruption of teeth at or immediately after birth is a relatively rare phenomenon. These have been
defined byMassler and Savara6 (1950). These teeth are known as “natal” teeth if present at the
time of birth and “neonatal” teeth if they erupt during the first thirty days of life.
Etiology:
 The current concept suggests that natal and neonatal teethare attributed to a superficial position of
the developing tooth germ, which predisposes the tooth to erupt early.
 The tooth was notlocated in an alveolus but slightly below the surface of the alveolar bone, very
much above the germ of the permanent successor.
Clinical Appearance
• Natal and neonatal teeth may resemble normal primary teeth; but, in many instances, they are poorly
developed, small, conical, yellowish, with white hypoplastic enamel and dentin, and with poor or total
failure of development of roots.
Treatment:
 A radiograph should be made to determine the amount of root development and the relationship
of a prematurely erupted tooth to its adjacent teeth.
 King and Lee11 recommended that inflamed gingival tissue around teeth should be controlled by
applying chlorhexidine gluconate gel 3 times a day.
 •In some cases, the sharp incisal edge of the tooth may cause laceration of the lingual surface of
the tongue and selective grinding of tooth is advisable in such conditions.
 Most prematurely erupted teeth are hyper mobile because of the limited root development. Some
teeth may be mobile to the extent that there is danger of aspiration, in which case the removal of
the tooth is indicated.
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 If extraction of tooth is indicated, after the tooth is removed, careful curettage of the socket is
indicated in an attempt to remove any odontogenic cellular remnants that may otherwise be left in
the extraction site.
 Such retainedremnant may subsequently develop a typical tooth like structure that requires
additional treatment (Medley, Stanley and Cohen).
 Earlier it was recommended to delay surgical procedures on newborns until after 10th postpartum
day due to inability of clotting but nowadays it is no longer considered because of prophylactic
administration of vitamin K as a standard procedure in most hospitals.
3) Ectopic eruption?
Classification:
1) Young classified ectopic eruption of the permanent first molar into two forms:
(1) reversible; and (2) irreversible (called “jump” and “hold”).
 In the reversible form, the ectopically erupting permanent first molar frees itself spontaneously
from a locked position and erupts into occlusion. This reversible pattern occurs in approximately
66% of ectopically erupting permanent maxillary first molars.
 In the irreversible form, the permanent first molar remains in a locked position until active
treatment is provided or premature exfoliation of a primary second molar occurs
Etiology:
 There is disagreement among various investigators regarding the etiology of ectopic eruption.
Sweet, in 1939, expressed the view that it was related to evolutionary changes, as a result of
which a gradual reduction is occurring in the number of permanent teeth in the human dentition.
 O’Meara stated that multiple factors were probably involved, but that a major factor was
insufficient intercanine and anterioposterior growth of the jaws.
 Nikiforuk and others also share this view of lack of regional bone growth.
Managment
 When an impacted first permanent molar has not erupted through the alveolar bone, it should be
watched carefully. Although most ectopic teeth will eventually erupt into normal position,
intervention is advisable immediately after the tooth penetrates the alveolar crest.
 It has also been shown that at age seven most children's permanent molars with reversible ectopic
eruption laid freed themselves.
 Therefore, postponing treatment to a later age is not recommended. Sim stated that early
treatment may prevent a space loss of 6 to 8 mm.Several methods of treating ectopically erupting
maxillary permanent first molars have been suggested such as interproximal wedging and distal
tipping.
4)Eruption cyst?
Clinical features
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Clinically, eruption cyst appears as a dome shaped raised swelling in the

mucosa of the alveolar ridge, which is soft to touch and the color ranges from
transparent, bluish, purple to blue-black. The color of the cyst ranged from
reddish black to bluish black in all the four cases presented here. Sometimes,
the cyst occupies the whole or part of an unerupted crown area including the
lingual area. It has been reported that approximately it measures about 0.6 cm
in diameter. However, the size depends on whether it is associated with a
primary or permanent tooth and the number of teeth involved. In one of the four
patients, the cyst was larger in size, measuring about 1 × 1cm in diameter.
They can occur unilateraly or bilateraly, and are either single or even multiple.
Boj and Garcia-Godoy reported a case of simultaneous occurrence of six
eruption cysts in a 15-month old child.
2)
3)
Etiology
The exact etiology of occurrence of eruption cyst is not clear. Aguilo et al., in
their retrospective clinical study of 36 cases, found early caries, trauma,
infection and the deficient space for eruption as possible causative factors.
4)
Treatment
Mostly, the eruption cysts do not require treatment and majority of them
disappear on their own. [6],[8],[9] Surgical intervention is required when they
hurt, bleed, are infected, or esthetic problems arise. [1],[5] Treatment has to be
performed in order for the child to lead a healthy and comfortable life. T
5)What are the important considerations to be kept in mind while removing natal and neonatal
teeth
Most prematurely erupted teeth are hyper mobile because of the limited root development. Some teeth may be
mobile to the extent that there is danger of aspiration, in which case the removal of the tooth is indicated.
• If extraction of tooth is indicated, after the tooth is removed, careful curettage of the socket is indicated in an
attempt to remove any odontogenic cellular remnants that may otherwise be left in the extraction site.
• Such retainedremnant may subsequently develop a typical tooth like structure that requires additional treatment
(Medley, Stanley and Cohen). Earlier it was recommended to delay surgical procedures on newborns until after
10th postpartum day due to inability of clotting but nowadays it is no longer considered because of prophylactic
administration of vitamin K as a standard procedure in most hospitals.
6) Sequence of primary and permanent tooth eruption?
For primary:
Central incisors> latral incisors> 1st decidious molars> canines> 2nd decidious molars.
For permanent tooth:
Central incisors> 1st permanent molar> latral incisors > canine > 1st premolar > 2nd premolar> 2nd molar > 3rd
molar.
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7) Timing of eruption of: permanent max lateral incisor and primary mandibular canine.
Permanent maxillary latral incisor: 8-9 years.

Permanent mandibular canine : 9-10 years.
8) Shedding pattern of anterior and posterior teeth?

The shedding of deciduous teeth is the result of progressive resorption of the roots of teeth and their supporting
tissues. In general the pressure generated by the growing and erupting permanent tooth dictates the pattern of
deciduous tooth resorption.
Resorption of Anterior Teeth
• The position of the permanent anterior tooth germ is lingual to the apical third of the roots of primary tooth hence
the resorption is in the occluso-labial direction, which corresponds to the movements of thepermanent tooth germ.
• Later the crown of the permanent tooth lies directly apical to the root of primary tooth, which causes resorption to
proceed horizontally.
• This horizontal resorption allows the permanent tooth to erupt into the position of the primary tooth.
Resorption of Posterior Teeth
• The growing crowns of the premolars initially are situated between the roots of the primary molars.
• The initiation is by the resorption of the inter-radicular bone followed by resorption of the adjacent surfaces of the
root of primary tooth.
• Meanwhile, the alveolar process is growing to compensate for lengthening roots of the permanent tooth. As this
resorption position of anterior teethoccurs, the primary molars move occlusally, this allows
the premolar crowns to be more apical.
• The premolars continue to erupt until the primary molarsroots are entirely resorbed and the teeth exfoliate. The
premolars then appear in place of the primary molars.
9) write the anatomic stages of eruption?

Stage I : preparatory stage ( opening of the bony crypts)
Stage II : Migration of the tooth towards the oral epithelium.
StageIII : Emergence of crown tip into the oral cavity ( Beginning of clinical eruption)
Stage IV: First occlusal contact.
Stage V: full occlusal contact
Stage VI: continuous eruption.
10) Theories of tooth eruption?

 Root elongation theory
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 Growth of periodontal tissues theory

 Pulpal constriction theory
 Pressure from muscular action upon the alveolar process theory
 Resorption of alveolar crest theory
 Hormonal theory
 Foreign body theory
 Cellular proliferation
 Vascular theory.
 Blood vessel thrust theory
 Periodontal ligament contraction theory
 Bone remodeling theory
 Dental follicle theory.
11) Factors affecting development of dentition?
A) systemic factors:
An accelerating effects:
Hyperthyroidism, Hyperpituitarism, Turners syndrome
An retarding effects:
Hypothyroidism, Hypopituitarism
Cleidocranial dysostosisDowns syndrome
Osteopetrosis, Amelogenesis Imperfecta
B) local factors:
Tumor, Cyst, Ankylosis of predecessors, Lack of space in the arch, Aberrant tooth position, Ectopic eruption,
Supernumerary tooth, Congenital abscence of the teeth
12) what is dental age? How to estimate dental age?
The simplest but least accurate dental age indicator involves recognizing teeth clinically present and comparing
them to the dental eruption charts.
Estimation of dental age:

1) number of teeth erupted in the oral cavity or the last tooth erupted: this medthod is rather rough, however, as
individual variations in eruption age are extensive.; endogenic and local factors may affect tooth eruption.
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2) Tooth formation stage of every tooth or of only 4-5 selected teeth may be recorded from a radiograph,
preferably orthopantamograph and corresponding age for each child. The tooth formation age of the child is
then obtained by calculating the mean of the age estimates fir the defined tooth formation stage.
The four teeth recommended for this purpose:

a) From birth to 9 years: teeth 46,44,43,11
b) From 10 years onwards: teeth 47,44,43,13.
13) Importance of 1st permanent molar.
Largest and strongest teeth in the dental arch

Mainly plays a major role in mastication (grinding and chewing of food)
Important in maintaining the vertical dimension
Vital role in aesthetics by making the cheeks appera full and vibrant
Important in maintaining continuity within dental arches(. Keeping other teeth in alignment)
14) What are the causes of delayed eruption?
Syndromes
Many syndromes are associated with eruption delays in permanent dentition.
– Down syndrome or trisomy 21;
– Turner syndrome (XO);
– gardner syndrome or familial adenomatous polyposis
– Cleidocranial dysostosis or Pierre–Marie Foy and Sainton’s disease;
– Anhidrotic ectodermal dysplasia orChrist–Siemens–Touraine disease;
– Hutchinson–gilford syndrome or pr- ogeria (dwarfism and pseudosenility, often associated with dentaldelays,
dentinal dysplasias and abnormal position, dysplasias.
– Bloch–Sulzberger syndrome or Incontinentia pigmenti;: a condition that is transmitted according to the dominant
X-linked mode and associates dental delays with oligodontia;
Apert syndrome or acrocephalosyn- dactylyia: associated craniosynos- tosis, syndactlylia of the feet and hands,
various synostoses, as well as frequent dental congestion;
– Axenfeld–Rieger Syndrome: associated oligodontia, multiple dental delays and primary mesodermal dys- genesis
of the iris.
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15) Riga-fede disease?
Traumatic ulceration on the ventral surface of the tongue, frenulum or lip is the most commonly associated
complication of natal teeth.
• Ulceration of the sublingual area in infants was first described in 1857 by Cardarelli.
• In 1881 and 1890, Riga and Fede described this lesion histologically and it has subsequently been known as “Riga-
Fede disease12” (Fig. 15.8). Although a more appropriate, descriptive term is “neonatal sublingual traumatic
ulceration.”
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Developmental anamolies of teeth

Dr Malathi
1)Supernumerary teeth
Ans: Results from continued proliferation of permanent or primary dental lamina to form third tooth
germ.
• More often in permanent dentition than primary dentition

• More in maxilla than in mandible
• May be impacted or erupted
• Because of additional bulk it causes mal position of adjacent teeth, prevent the adjacent tooth eruption
• Supernumerary teeth found in cledocranial dysplasia syndrome
• Other ex:Mesiodens, paramolar,
2.Mesiodens
Ans:Most common supernumerary teeth
• Situated between maxillary central incisors

• Which are single, paired, erupted or impacted, inverted,
3.Oligodontia
Ans:Lack of development of 6 or more teeth
Pseudo anodontoa:When teeth are absent clinically because of impaction or delayed eruption
False anodontia:When teeth have been exfoliated or extracted
• Syndromes associated with oligodontia is ectodermal dysplasia, van Der wonder syndrome, Down’s
syndrome.
4.Ankylosis
Ans:Fusion of a tooth to surrounding bone
• With focal loss of periodontal ligament, bone +cementum become inextricably mixed.
• Cause fusion of teeth to alveolar bone
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5.Fusion
Ans:Joining of 2 developing tooth germs
• Resulting in a single large tooth structure

• May involve entire length of teeth
• Or may involve roots only, in which case cementum + dentin are shared
6.Gemination
Ans:Fusion of 2 teeth from a single enamel organ
• Partial cleavage
• Appearance of 2crowns that share same root canal
• Trauma has been suggested as possible cause, the cause is still unknown
7.Taurodontism
Ans:Variation in root form
• Elongated crowns
• Apically displaced furcations
• Resulting in pulp chambers that have more apical occlusal height
• May be associated with syndromes like Down syndrome, klinifelter syndrome
• Little clinical significance
• No treatment is required
8.Talons cusp
• Well delineated additional cusp

• Located on the surface of an anterior teeth
• Extends at least half the distance from CEJ to Invisalign edge
9.Concrescence
Ans:2 fully formed teeth
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• Joined along the root surfaces by cementum

• Noted more frequently in posterior and maxillary regions
• Often involves a 2nd molar tooth in which it’s roots closely approximate the adjacent impacted 3rd
molar
• May occur before or after the teeth have erupted

• Usually involves only 2 teeth
• Diagnosis can frequently be established by radiographic examination
• Often requires no therapy unless union interferes with eruption, then surgical removal may be
warranted
• Since with fused teeth extraction of one may result in extraction of the other.
10.Dilaceration
Ans:Angulation or a sharp bend or curve in root or crown of a formed teeth
• Trauma to a developing tooth can cause root to form at an angle to normal axis of tooth rare deformity
11.Amelogenisis imperfects
Ans:Also known as Hereditary Enamel dysplasia
• Group of conditions caused by defects in the genes encoding enamel matrix proteins like enamel in,
amelogenin etc
• Affects both primary and permanent dentition

• Classified based on pattern of inheritance
• Hypoplasia, hypomaturation, hypocalcified
• No treatment except for improvement of cosmetic appearance
12.Dentinogenisis imperfects
And:Also known as hereditary opalescent Dentin
• Mutation in dentin sialophosphoprotein

• Affects both primary and permanent teeth
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• Have blue to brown discolouration

• With distinctive translucence
• Enamel frequently separates easily from underlying defective dentin
• Radiographically we can see bulbous crowns, cervical constriction, thin roots, early obliteration of root
canals+pulp chambers
• 3 types type I-occurs in families with osteogenesis imperfects

• Type II-only have dentin abnormalities and no bone disease
• Type III- Bradwine type
• Treatment- Prevent loss of enamel and subsequent loss of dentin through attrition
• Cast metal crowns on posterior
• Jacket crowns on anterior teeth
13)Dens Evaginatus
Ans:developmental aberration of a tooth resulting in formation of an accessory cusp
• Enamel covering a dentin also core that usually contains pulp tissue that occasionally may have a
slender pulp horn which extends various distances up to the full length of the tubercles dentin core.
• Most commonly seen on lingual surface of anterior teeth (mainly maxillary lateral incisors) & occlusal
surface of Mandibular premolars
• Etiology: remains undetermined

• Autosomal dominant or x linked dominant inheritance patterns are seen.
• Localised trauma
• Treatment:with out enamel+ normal pulp : apply acid etched flowable composite followed by
evaluation
• Inflamed pulp: pulpotomy / root canal therapy based on extension
14)Dens invaginatus
Ans: it is a developmental variation where Infolding the outer surface of the tooth into its interior surface
before calcification of crown
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Etiology:Focal growth retardation

Active proliferation
Continuous differentiation
Increased pressure
Local causes
Management: To prevent caries, pulp infection and premature loss of tooth, dens in dente must be treated
prophylactically.
15)Twinning
Ans:it is referred as to the development of two separate tooth that arose from the complete separation of
one tooth bud.
16)Hypercementosis
Ans:it is an idiopathic non neoplasticism condition characterised by the excessive build up of normal
cementum on the roots of one or more teeth. A thick layer of cementum can give the tooth an enlarged
appearance, which mainly occurs at the apex or apices of the tooth.
17)Natal and neonatal teeth

Ans:Eruption of teeth immediately after birth is rare phenomenon. So if teeth present at birth called as
natal teeth and neonatal teeth if they erupt during the first 30 days of life.
Etiology: hormonal stimulation
Hypovitaminosis
Trauma
Syphilis
Febrile status
Common site:Lower anterior tooth region
Management:If child has sharp Incisal edge may cause laceration to the lingual surface of the tongue. So
grinding necessary.
• Some teeth are may mobile so there are chances of aspiration extraction is indicated
• If patient doesn’t have any problem better to leave the teeth in place and to explain the parents
importance of growth.
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Development of occlusion
Dr KS Roja Ramya
1. Define occlusion.
A. Occlusion is defined as the relationship between all the components of the masticatory
system in normal function, dysfunction, and parafunction.
2. What are the various stages of occlusal development
A. The various stages of occlusal development are:
• Pre-dentate jaw relationship
• The deciduous dentition period
• The mixed (transitional) dentition period
• The permanent dentition period.
3. What is lateral sulcus. Write its importance
A.It is a very important landmark in gum pads, which is the transverse groove between canine
and 1st molar.
This is helpful in predicting inter-arch relation at a very early stage.
4. What are Physiologic spaces.
A.These are Present in between all the primary teeth and play an important role in normal
development of the permanent dentition.
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The total space present may vary from 0 to 8 mm with the average 4 mm in the maxillary arch
and 1 to 7 mm with the average of 3 mm in mandibular arch
5. What are Primate spaces
A. The spaces that exist between the maxillary lateral incisors and the canines (present mesial
to maxillary deciduous canines) and mandibular canines and 1st deciduous molars (present
distal to mandibular deciduous canines). These spaces are also called as anthropoid or simian
spaces.
6. What are the Characteristic features of deciduous dentition
A. Both the dental arches are half round in shape or ovoid
• Shallow cuspal interdigitation
• Slight overjet
• Deep bite
• Vertical inclination of the incisors
• Spaced dentition
7. Write the Baume’s classification of deciduous molar relation.
A. The mesiodistal relation between the distal surfaces of maxillary and mandibular 2nd
deciduous molars is called as terminal plane. This is of three types:
1. Flush terminal plane:
• The distal surfaces of the deciduous 2nd maxillary and mandibular molars are in a straight
plane (flush)
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• It is seen in 74 percent.
2. Mesial-step terminal plane:
• The distal surface of the deciduous 2nd mandibular molar is more mesial to that of the
deciduous 2nd maxillary molar.
• Seen in 14 percent.
3. Distal-step terminal plane:
• The distal surface of the deciduous 2nd mandibular molar is more distal to that of the deciduous
2nd maxillary molar.
• Seen in 10 percent.
8. Write deciduous canine relationships
A. Class I: The mandibular canine interdigitates in embrasure between the maxillary lateral
incisor and canine
Class II: The mandibular canine interdigitates distal to embrasure between the maxillary lateral
incisor and canine
Class III: The mandibular canine interdigitates in any other relation
9. Write about mixed dentition period
A. This phase begins at around 6 years with the eruption of 1st permanent molars and lasts till
about 12 years of age.
First transitional period:
– Emergence of the first permanent molars
– Incisors transition
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• Inter transitional period
• Second transitional period:
– Emergence of cuspids, bicuspids and the 2nd permanent molars.
– Establishment of occlusion.
10. What is early mesial shift
A. The eruptive forces of 1st permanent molars push the deciduous molars forward in the arch
thereby utilizing the primate spaces and thus establishing class I relationship.
11. What is late mesial shift
A. Molars drift mesially utilizing the Leeway space of nance after exfoliation of deciduous
molars and this is called late mesial shift
12. What is Incisal liability.
A. The permanent incisors are larger as compared totheir primary counterparts and thus require
more space for their alignment. This difference between space available and space required is
called the incisor liability
– This is 7 mm for maxillary arch and 5 mm for mandibular arch.
13. What are the factors that help in overcoming incisal liabilty
• Utilization of interdental spacing of primary incisors: Averages 4 mm in the maxillary arch

and 3mm in mandibular arch.
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• Increase in intercanine arch width: This occurs asthe child grows. In males, it is 6 mm for
maxilla and 4 mm for mandible whereas in females, it is 4.5 mm in maxilla and 4 mm in
mandible.
• Increase in intercanine arch length: This is due to growth of jaws.
• Change in interincisal angulations: The angle bet ween the maxillary and mandibular incisors
is about 150° in primary dentition, whereas it is about 123° in permanent dentition thus
allowing more proclination and gaining space for incisor alignment.
14. Leeway space of nance
A. The combined mesiodistal width of permanent canine and premolars is less than that of
deciduous canine and molars. This extra space is called Leeway space of Nance and is utilized
by mandibular molars to establish Class I relationship through late mesial shift.
• It is 1.8 mm (0.9 mm on each side) in maxillary arch and 3.4 mm (1.7 mm on each side) in
mandibular arch.
15. Ugly Duckling Stage or Broadbent phenomenon.
A. As the permanent maxillary canines erupt they displace the roots of maxillary lateral incisors
mesially. This force is transmitted to the central incisors and their roots are also displaced
mesially. Thus, the resultant force causes the distal divergence of the crown in an opposite
direction, leading to midline spacing. This is called Ugly Duckling Stage or Broadbent
phenomenon.
Child looks unesthetic during this stage
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• This condition is a self correcting anomaly, corrects itself after the canines have erupted.
16. What are Andrew’s six keys of occlusion
A. -Molar inter-arch relationship
– Mesiodistal crown angulation
– Labiolingual crown inclination
– Absence of rotation
– Tights contacts
– Curve of spee
17. What is the Sequence of eruption of permanent teeth
A. Maxillary arch 6-1-2-4-5-3-7-8
(1st molar-central incisor-lateral incisor-1st premolar-2nd premolar- canine-2nd molar-3rd
molar)
Mandibular arch
6-1-2-3-4-5-7-8
(1st molar-central incisor-lateral incisor- canine-1st premolar-2nd premolar-2nd molar-3rd
molar)
18. What is the Sequence of eruption of primary teeth?
A. Maxillary arch A-B-D-C-E
(central incisor-lateral incisor-1st molar-canine-2nd molar)
Mandibular arch A-B-D-C-E
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(central incisor-lateral incisor-1st molar-canine-2nd molar)
19. What are the self correcting anomalies in predentate period & how they get corrected ?
• Retrognathic mandible - corrects with differential and forward growth of mandible
• Anterior open bite. - corrects with eruption of primary incisors
• Infantile swallow - corrects during first year of life with the eruption of buccaneers Teeth
20. What are the self correcting anomalies in deciduous dentition period& how they get
corrected ?
• Anterior deep bite - corrects with eruption of deciduous molars, attrition of incisal edges,
forward and downward growth of mandible
• Flush terminal plane - corrects with eruption of first permanent molar, late mesial shift
utilising leeway space
• Primate and physiologic spaces - corrects with eruption of first permanent molar
21. What are the self correcting anomalies in mixed dentition period& how they get
corrected ?
• Anterior deep bite - corrects with eruption of first permanent molar
• End- on molar relation - corrects with eruption of first permanent molar, late mesial shift
• Mandibular anterior crowding - corrects with tongue pressure, increase in inter canine width
• Ugly duckling stage - corrects with maxillary canine eruption.
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30
EXAMINATION, DIAGNOSIS & TREATMENT PLANNING,

PEDIATRIC DENTAL RADIOLOGY
Dr P.Chaitanya
1) Explain chief complaint and the history related to it.
• This is concerned about what made the patient visit the dentist or what they are seeking
from treatment.
• It is better to ask the child about this chief complaint before involving the parent which
helps to establish a good rapport with the child. But it is mandatory to get an answer from
the parent also regarding the child’s complaint.
• It is recommended to record the chief complaint in patient’s own words.

History of present illness:
• It is the elaboration/detailed description of the chief complaint.– Several factors need to

be evaluated regarding the chief complaint like duration, mode of onset, severity, nature,
aggravating or relieving factors, associated symptoms, diurnal variation, postural variation,
any medications or treatment received for the same.
• Gives an insight towards possible cause and nature of disease/ condition.
• Hint towards the possible disease/condition
2) What is the importance of past dental history?
• Helps in formulation of treatment plan
• Knowledge about patient’s habits
• Helps evaluate attitude of parents towards dentistry
• Medicolegal purpose.
3) Write in detail deciduous molar relationship.
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The mesio distal relation between the distal surfaces of maxillary and mandibular second
molars is called as terminal plane which determines primary molar relationship. This is of
three types:
A. Flush terminal plane: The distal surfaces of the deciduous second maxillary and
mandibular molars are in a straight line.
B. Mesial-step terminal plane: The distal surface of the deciduous second mandibular
molar is more mesial to that of deciduous second maxillary molar.
C. Distal-step terminal plane: The distal surface of the deciduous second mandibular molar
is more distal to that of deciduous second maxillary molar.
4) Explain the deciduous canine relationship.
• Class I: The mandibular canine interdigitates in embrasure between the maxillary lateral
incisor and canine.
• Class II: The mandibular canine interdigitates distal to embrasure between the maxillary
lateral incisor and canine
• Class III: The mandibular canine interdigitates in any other relation.
5) What is the difference between provisional and final diagnosis.

Provisional diagnosis is a general diagnosis based on clinical impression without any
laboratory investigation. Whereas final diagnosis is a more confirmed diagnosis analysing all
the available data including the results of investigation.
6) Enumerate the different investigation procedures.
• Radiographic investigation
• Pulp testing
• Study models & model analysis
• Photographs
• Cephalometric study
• Percussion
• Blood investigations
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• Histopathological examination
• EMG etc.
7) Explain dental age.
• Dental age is estimated according to the last tooth erupted in oral cavity in normal
sequence.
• This involves recognising the teeth clinically present in the oral cavity in comparison to
dental eruption charts.
• This is the simplest but least accurate method.
• The disadvantage of this technique is wide variations in time of eruption, influence of local
and environmental factors and the factors the fact that no or several teeth may erupt during
the same time interval.
8) What are the different phases in treatment planning?
• Emergency phase: Any treatment that is advised to allay pain or stop the spreading
dentoalveolar infections is called emergency treatment. Eg: Incision & Drainage,
emergency extraction, emergency access opening in cases of acute pulp involvement,
antibiotic coverage.
• Preventive phase/prophylactic phase: Objective is to upkeep the general condition of oral

cavity. It includes oral prophylaxis & patient education towards good oral hygiene,
delivery of oral hygiene instructions, topical fluoride application, pit & fissure sealant
application, diet counselling.
• Restorative phase: It includes restoration of teeth with no pulpal involvement.
• Endodontic/surgical phase: It includes non emergency extractions, non emergency pulp

therapies.
• Interceptive/Corrective phase: Rhabilitation of the lost integrity of the arch is the focus of
this phase. This phase includes stainless steel crowns, full coverage tprestorations on
endodontically trated teeth, early orthodontic treatment, abnormal oral habit intervention
and all types of space maintainers.
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• Recall/ Maintenance phase: Objective to recall patient after completion of treatment is to

assess the caries activity and as a preventive measure for early detection of disease. Recall
every 6 months is recommended. If caries activity is high review at every 3 months is
required.
9) What are vital statistics?
• It is a systematic approach to collect and compile all the information related to the vital
events like birth, death, recognition, social structure and legislation. Recording personal
details of the child is required for both record purposes and for communication.
• These include: Name & Nick Name, age, gender, address, source of information,
occupation of parent, accompanying person, contact number.
10) What are the different shapes of head?
• Mesocephalic— average shape of head h
• Dolicocephalic—long and narrow head; narrow dental arches
• Brachycephalic—broad and short head; broad dental arches
11) What are the different shapes of face?
• Mesoprosopic—average facial form
• Euryprosopic—broad and short facial form
• Leptoprosopic—long and narrow face
12) What are competent, incompetent and potentially competent lips?
• Competent—lips are in contact when musculature is relaxed
• Incompetent—lip seal is not formed in normal circumstances, only hyperactivity of oral

musculature can help in forming closure.
• Potentially competent lips - lip seal is prevented due to protrusion of maxillary incisors
despite normally developed lips
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13) What are the methods of reducing radiation exposure to a child?
• Wearing lead apron, thyroid collar, lead goggles, lead cap.
• Use of faster speed films (F speed)
• Panoramic radiography uses film screen combinations that have reduced exposure time
• Long rectangular collimator reduces the area unnecessarily exposed to radiation by almost
4 square inch compared to a round collimator
• Use of high kilovolt peak (KVp) Setting
• Good dark room procedures thus reducing retakes
• Minimising cone cuts and unnecessary exposure to patient
14) What are the indications of radiographs in children?
• Caries
• Pulp pathology
• Traumatic injuries
• Problems of eruption
• Anomalies of developments
• Orthodontic evaluation
• History of pain
• Evidence of swelling
• Unexplained tooth mobility
• Unexplained bleeding
• Deep periodontal pocket
• Fistula formation
• Unexplained sensitivity of teeth
• Evaluation of sinus condition
• Unusual spacing or migration of teeth
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• Lack of response to conventional dental treatment
• Unusual tooth morphology calcification/color
• Evaluation of growth abnormality
• Altered occlusal relationship
• Aid in diagnosis of systemic disease
• Family history of dental anomalies
• Postoperative evaluation
15) What are different radiographic surveys?
Survey Radiographs
4 film survey Maxillary and mandibular anterior occlusal and two posterior bitewing
radiographs
8 film survey Maxillary and mandibular anterior occlusal (or periapicals), right and left
maxillary posterior occlusal (or periapical), right and left mandibular posterior
periapicals and two posterior bitewing radiographs
12 film Two primary molar-premolar periapical radiographs, four canine periapical
survey radiographs, two incisor periapical radiographs, two posterior bitewing
radiographs
16 film 12 film survey, four permanent molar radiographs
survey
16) What are the indications, advantages, disadvantages of panoramic radiographs?

Indications:
• Condylar fracture.
• Traumatic cysts
• Evaluation of tooth development (mixeddentition).
• Developmental-anomalies.
• Disabled-child.
Advantages
36
•broad anatomic region imaged.

•Relatively low radiation dose
•Convenience, speed and ease .
•Useful in patients who are unable to open the mouth.
Disadvantages
• Lack of image details for diagnosis of early carious lesion
• Cost of X Ray machine
• Overlapping images of teeth
• Making a young child sit without movement for long time is difficult
17) Name different extra oral radiographic techniques.

This is accomplished with the film placed outside the oral cavity and it includes:
• Panoramic radiography
• Skull projections which include Reverse-Towne, Submentovertex, PA view, PNS view and
lateral cephalogram
• Hand and wrists radiograph
• Cephalometric radiography.
18) What are operator radiation protection guidelines?
• Dental radiographer must avoid primary beam
• Follow position distance rule by staying 6 feet away and at an angulation of 90 to 135
degrees to the primary beam
• Use protective barriers
• The operator must never hold a film in place for a patient during X-ray exposure
• Never hold a tube head during X-ray exposure
• Operator should stand behind protective barrier like lead screens
• X Ray machine should be monitored for leakage radiation
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• Use of film badge to monitor amount of radiation exposure by the operator. This should
be worn at waist level. After the dental radiographer has worn the film badge for a specific
time interval it has to be returned to service company for dosage calculation.
19) What are the radiographic recommendations for children with disabilities?
• Only radiographic investigations appropriate to the limitations imposed by the patient’s

age, cooperation or disability, should be attempted.
• Select intraoral films of appropriate size, modifying standard techniques as necessary.
• Utilise assistants to help hold the film.
• Avoid dental panoramic radiography because the patient will have to sit still for 18
seconds.
• Oblique lateral radiograph should be regarded as the extraoral view of choice.
• Use of paralleling technique, if possible for periapical radiography because with this
technique the relative positions of film packet, teeth and X-ray beam are maintained
irrespective of position of patient’s head.
20) What are the tube head vertical angulations for Children?
Maxillary teeth Mandibular teeth

Primary incisors + 45° -10º
Primary canines +40° -10º
Primary molars +20° - 5º
21) Write about PSP (Photo- Stimulable Phosphor) storage plates.
• Photo-Stimulable Phosphor Storage plates (PSPPs) appear very similar to analog film and
also come in different sizes. This technique is also referred to as indirect digital imaging
because the image is captured in an analog format and converted to a digital image when
scanned and is not displayed immediately when the radiographic image is captured.
38
• The phosphor layer is comprised of europium-activated barium fluorohalide which, when

exposed to x-rays, will capture a latent image. The phosphor plate emits a blue
fluorescent light when exposed to a red helium laser light inside the PSPP scanner. The
blue emissions captured by a photomultiplier are subsequently converted into a visible
image. Once the image is generated, the scanner will expose PSPPs to white light to erase
the latent image. Because PSPPs are sensitive to white light, the scanner cannot be placed
in a brightly lit area, since this will degrade the image once the phosphor plates are freed
from the light-tight barrier.
• PSPPs come in different sizes and can be used for either intraoral or extraoral
applications. When used for intraoral radiography, they should be wrapped in a single-use
plastic light-tight barrier to avoid both cross-contamination and the toxicity of the
phosphor layer. When PSPP is used in a cassette for extraoral radiography, there is no need
for it to be wrapped in a plastic barrier. The cassette, however, should be light-tight and
should not contain intensifying screens, as is the case with analog indirect film.
• Because of the various sizes and flexibility of PSPPs, it is acceptable for intraoral
radiography in pediatric patients and patients with special needs.
• The biggest disadvantage of PSPPs is their susceptibility to scratches, bite marks, and
creasing, which could damage the phosphor layer.
• This damage is irreversible and will always be visible as a radiopacity in the image. Just as
with analog film, double exposures are possible with this technology.
22) Write about solid state sensors. (Or)

Write about Charged Couple devices (CCD) (Or)
Write about Complementary Metal Oxide Semiconductors (CMOS).
• Solid-state sensors are also known as direct digital receptors because they display the
radiographic image instantaneously following exposure. There are two different types of
solid-state sensors: charged coupled devices (CCD) and complementary metal oxide
semiconductors (CMOS). These sensors differ in how the image is captured but appear
similar in both external appearance and image output.
39
• Both CCD and CMOS sensors use a scintillation screen (usually gadolinium oxysulfide or
cesium iodide) to transform the x-ray energy into visible green light, which is then
converted into a visible image.
• Direct digital sensors are available in sizes 0, 1, and 2.
• The primary disadvantage of these sensors is that they are relatively bulky and not
always easy to position in the patient’s mouth. The majority of direct digital sensors are
attached to a computer by a shielded wire cable, which can be damaged by repeated biting.
• The solid-state sensors are also incorporated into extraoral radiography devices, such as
panoramic machines and cephalometric units. The sensors are arranged in a vertical array
and capture the x-rays while the panoramic or cephalometric machine scans. The image is
formed by vertical lines or columns of pixels. Some manufacturers use a lens in front of the
solid-state sensor so that the image from a cephalometric unit can be obtained in one
exposure, instead of via a scanning motion from anterior to posterior. This saves time and
radiation dose and helps reduce motion artifacts.
23) What are different radiographic object localisation techniques?

Clark’s Technique:
• This is also cladded as same side lingual - opposite side buccal (SLOB) rule, tube shift
localization technique or buccal object rule.
• It was discovered by Clark in 1910.
• To locate or determine the bucco-lingual relation of an impacted tooth/ foreign body

within the maxilla.
• Buccal object rule states that the image of buccally oriented object appears to move in the
opposite direction from a moving X-ray source. And the image of any lingually oriented
object appears to move in the same direction as a moving X-ray source.
Miller’s Technique
• This is also called as right angle technique.
• It is used to achieve the same goals as Clark’s technique but in case of mandible
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Cross-sectional Occlusal Radiograph
• Radiographs are taken at right angles to each other.
• Cross-sectional occlusal radiograph of maxilla with patient’s sagittal plane is perpendicular

and ala-tragus line is parallel to the floor.
24) What are the measures to reduce gag in children during film placement in oral cavity?
• Distract the child by asking to count numbers, alternatively moving the right and left leg
etc.
• Patient can suck a topical local anaesthetic lozenge
• Wetting the Polythene (film packet)
• Never mention to relax tongue
• Never slide the film along the palate or tongue
• Advice patient to breathe rapidly through nose
• Bend the film slightly while placing in the lingual sulcus
25) FDI Systems of Tooth notation
• FDI( Federation Dentaire Internatinale) is a two-digit numbering system which is widely

used in many countries.
• In this system, among the two digits the first number represents the quadrant (1-4)
starting from upper right, upper left, lower left, and lower right for permanent teeth and
similarly 5 to 8 for the primary , the second number represents the tooth (1-8).
Permanent teeth:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Primary dentition:
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
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26) Bite wing radiographs:
• Developed by Howard Raper in 1925.
• Peri apical films are used to record the coronal portions of both maxillary and mandibular
teeth in one image.
• Size 1 film is used in children and size 2 films are used in adults.
• Used mostly to detect inter proximal caries and to check the level of bone.
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Plaque and Plaque control
Dr Devi V
1) what is plaque control? List various methods of plaque control?

It is the removal of plaque and the prevention of accumulation on the teeth and adjacent gingival surfaces.
Methods:
Dentifrices
Tooth brush
Dental floss
Oral irrigation
Interdental cleaning aids
Mouth washes
2) list out various disclosing agents? Write Indication of disclosing solution?
A) Iodine preparations
B) Skinners solutions
C) Mercurochrome preparation
D) Bismark brown
E) Erythrosine
F) 2-tone solutions
G) Plak light system
Indications:
 Patient education
 Instructions to patient about plaque control
 Self assessment by the patient
 Assessment of the clinician
 Effectiveness of effective plaque control measures.
 Preparation of plaque indices.
3) tooth brush modification and current concepts?
43
A) powered tooth brush

B) Super brush
C) Pulsar tooth brush
D) Ultrasonic tooth rush
E) Chewable tooth brush.
4) powered tooth brushes?

Powered toothbrush
 The first electric toothbrush was conceived in Switzerland in 1954 by Dr. PhilippeGuy Woog and
was manufactured in Switzerland and later in France for Broxo SA.
 The device plugged into a standard wall outlet and run on AC line voltage.
 Electric toothbrushes were initially created for patients with limited motor skills, as well as
orthodontic patients.
Indications of powered toothbrush

– Individual lacking motor skill
– Handicapped patients
– Patients who have orthodontic appliances
– Whosoever wants to use
Current modifications of powered brushes have three motions:
– Back and forth
– Circular
– Elliptical
5) Difference between powered and manual tooth brushes?
Characteristic Manual Powered
Brushing duriation 20-40 sec 1-3 min
Teeth brushed at a time Multiple One/multiple
Brush head motion Cross and multiple Minimal
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Brush head speed Zero 1000s/ min
Brush head stroke 40-100/min 10-40/min
Brush head load 150-1000 gm 50-250 gm
6) Dental floss types?
Twisted and nontwisted

• Banded and nonbanded
• Thin and thick
• Microfilament and multifilament.
• According to ADA specification:
– Type I: Unbonded dental floss composed of yarn having no additives.
– Type II: Bonded dental floss composed of yarn having no additives other than binding agent or agent
for cosmetic performance.
– Type III: Bonded or unbonded having drug for therapeutic usage.
7) list out the various methods of tooth brushing?

a) scrub
b) Bass
c) Charters
d) Fones
e) Roll
f) Stillman’s
g) Modified stillman’s
8) classify chemotherapeutic plaque removal agents?
Bisguanides and related compundes:

Chlohexidine,alhexidine
Quaternary ammonium compounds:
Cetylpyridinium
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Enzymes:
Dextranase
Glucose-amyloglucosides
Fluoride and inorganic ions:
Stannous fluoride
Hydrogen peroxide
Antibiotics:
Penicillin
Metronidazole
Organic compounds:
Sanguinarine
Menthol/thymol.
9) Chlorhexidine as a plaque controlling agent?
 The dental profession has used chlorhexidine for over two decades. It is recognized, as the
primary agent for chemical plaque control and its clinical efficacy is well known to the
profession.
 Anti-plaque mode of action: Chlorhexidine (0.12 to 0.2%) binds to the differentsurfaces within
the mouth(teeth and mucosa) andalso to the pellicle andsaliva.
 After a singlerinse with chlorhexidine,the saliva itself exhibitsantibacterial activity forup to 5
hours, whereas persistence at the oral surfaces has been shown for over 12 hours
Disadvantage:
– Yellowish staining of the teeth.
– Alteration in taste.
10) Guidlines for home oral hygeine measures for infants?
 In Infants: It is generally recommended that parents begin clearing the infant’s mouth by the time
first tooth erupts. It is suggested that secure and consistent physical support with slow,careful
movement is to be employed at all time.
46
 Most have suggested that the parent wraps a damp washcloth or a piece of gauze around the index
finger and clean the teeth and gum pads once a day.
 As more teeth erupt the parent can begin using a small soft toothbrush. At this age toothpaste is
not necessary and may interfere with visibility for the parent.
 Additionally, the infant will be unable to effectively expectorate, causing unwanted toothpaste
ingestion. Several methods of positioning the infants for daily oral hygiene procedures have been
suggested.
 One effective method is to have the parent cuddle the infant in his or her arm with one of the
child arms gently slipped around the parents back. In this way the parent can stabilize the child
with one hand and work with the other.
11) list out various modified tooth brushes in handicapped children?
Collis curve, Improve, Action 2, Twinbrush, Omnia-Dent, Vac-U-Brush,Colgate Plus, Flex ( Aquafresh),
Radius.
12) what are the tooth brush modification in handicapped children?
The aim of the toothbrush adaptation is to provide a handle with a stable grip, whilst its shape enables the
person to feel how to manipulate the brush in the mouth adequately during cleaning.
• Grasp: For people who cannot grasp and hold, the objective is to fasten the brush handle to the hand.
This can be achieved by using a velcro strap with a pocket on the palm side into which the toothbrush can
be inserted.
• Fixed fingers: For a patient with fingers permanently flexed or fixed in a fist, toothbrushes with
variation in the grip and handle width in all shapes and sizes are available commercially and a suitable
brush that inserts directly into the patient’s grasp can be selected.
• Limited hand closure or reduced manual dexterity: Objective is to enlarge the diameter of the brush
handle to fit the hand. The simplest method of improving the grip involves inserting the brush handle
into another material to improve its size, shape or surface characteristics. Simple and successful
47
methods of adapting the toothbrush grip include the use of sponges, tubing, bicycle handlebar grips or
pushing it into a soft rubber ball
13) What is the difference between plaque,acquired pellicle and materia alba?
 Dental plaque: Is a specific but highly variable structural entity, resulting from sequential
colonization of microorganisms on tooth surface, restorations and other parts of oral
cavity,composed of salivary components like mucin, desquamated epithelial cells,debris and
microorganisms, all embedded in extracellular gelatinous matrix.
 Acquired pellicle: may be defined as a homogenous, membranous,acellular film that covers the
tooth surface and frequently form the interface between the tooth, the dental plaque and calculus.
 Biofilm:It describes the relatively indefinable microbial community associated with a tooth
surface or any other hard, non shedding material.
 It consists of one or more communities of microorganisms embedded in glycocalyx, that are
attached to solid surfaces.
48
Gingival and periodontal diseases in children

Dr Devi V
1) papillon-Lefevre syndrome
-It is characterized by hyperkeratosis of the palms and soles combined with a precocious
periodontal destruction and shedding of the deciduous and permanent dentitions.
Etiology:
 Vit A deficiency
 Deep subgingival flora includes bacteroides gingivalis, capnocytophaga,spirochetes.
 Deficient chemotaxis and phagocytic function of neutrophilic granulocytes.
Clinical features:
 Hyperkeratosis palmar-plantar, precocious periodontal destruction with loss of both
dentitions,ectopic intracranial calcifications.
Differential diagnosis:
Acatalasia,chediak-higashi syndrome,neutropenia.
Treatment:
 Vitamin A metabolites(Retinoides) are involved in the regulation of growth and differentiation of
the epithelial cells.they are known to have a profound effect on the keratinization by decreasing
the total keratin content of the keratinocytes.
2) Hypophosphatasia
 It is rare genetic disease manifested by bone pain with spontaneous fractures,rickets like bone
lesions during childhood which are resistant to treatment with vit D, premature loss of deciduos
teeth.
Etiology:
 It is familial disorde4 of the inborn error of metabolism.
 There is a strong evidence that most cases of the disease results from an autosomal recessive
trait,although in other instances dominant inheritance is indicated.
Clinical feartures:
 The disease is characterized by abnormal mineralization of bone and dental tissuesand is usually
manifested by premature exfoliation of the primary teeth.only the deciduous incisors and
sometimes the canines are affected and the permanent teeth are usually normal.
49
Treatment:
 Oral phosphates supplements have been attempted with a limited success and intravenous
infusion of plasma from patients with paget’s disease and hyperphosphatemia was also of no
clinical benefit.
3) cyclic neutropenia
 This refers to the disappearance of neutrophils occurs perodically,approximately every 3 weeks .
After 5-8 days,the neutrophils begin to reappear.
Clinical features:
 Skin lesions,ear infections,mucous membrane ulcerations,severe stomatitis
 The attached papillary and marginal gingiva are enlarged,edematous and erythematous and bleed
easily on gentle provocation.
 There is an extreame inflammation with proliferation of the marginal gingiva accompanied by a
cleft formation and recession.
 During the neutropenic stage, periodontal diseases and destruction occurs and during the non
neutropenic stage oral health returns.
Prognosis:
 Prognosis,both medically and dentally, is not encouraging. The patients are at risk of an
overwhelming and fatal bacterial infections during the severe neutropenia cycles.
3)Juvenile periodontitis
 It is localized disease of the supporting tissues of the teeth in teenagers.
Etiology:
 Presence of polymorphonuclear leukocytes with diminished chemotactic and phagocytic
responses
Clinical features:
 Initially bone and attachment loss are seen around the molars and insisors.least effected teeth are
cuspids and premolars
 Premature and excessive mobility of the maxillary and mandibular primary incisors and molars.
 Regional lymphadenopathy
 Distolabial migration of the incisors with diastema formation
 Denuded root surface becomes sensitive to heat and cold.
Radiographic findings:
50
 An arc shape bone loss extending from distal surface of second premolar to mesial surface of 2nd
molar is seen.
Treatment:
 Augmentation of scaling and root planing with surgical therapy either with or without adjunctive
tetracyclines therapy.
 Subgingival irrigation with iodine and hydrogen peroxide has also been proposed.
4) Drug induced gingival enlargement.
Etiology:
 Disturbances in adrenocortical function resulting in an exaggerated response to tissue injury.
 Direct action of phenytoin on fibroblast
 Local response to metabolic products of phenytoin in saliva
Clinical features:
 Initially painless swelling of interproximal gingiva
 The buccal and anterior regions are commonly affected than posterior and lingual surfaces.
 Unless secondarily infection or inflammation present, the gingiva appears pink and firm and does
not bleed easily upon probing.
 Lesions remain purely fibrotic in nature or combined with a noticeable inflammatory component.
Treatment:
 Antihistamines,topical corticosteroids,ascorbic acid,folic acid used with limited success
 Vigorous gingival massage coupled with effective tooth brushing and gum stimulators.
 Gingivectomy with periodontal knifes,lasers,lasers,electro surgery, and internal bevel flap.
5) list out the key difference b/w the gingiva of the adult and the child?
Characteristics Children Adult
Color Pale pink Colar pink
Surface Smooth Stipples
Gingiva Thick and round Knife edged
51
Free gingiva Keratinized saddle area Non-keratinized interdental

col
Interdental gingiva Interdental clefts Not present
Attached gingiva Retrocuspid papilla Retrocuspid pappila not

present
Sulcus depth 2.1-2.3 mm 2-3 mm
Alveolar mucosa Red,thin,vascular Pink
Periodontal ligament Wide Narrow
Collagen bundles More hydrated,less More differentiated

differentiated
Polypeptide chains Normal cross-linking Tight cross linked
Ground substances Low ration of collagen to Ground substances to

ground substances collagen ratio normal
Fibers Gingival fibers are immature Matured and organized
Trabeculae Thick trabeculae with large More trabeculae with less

marrow spaces marrow spaces
6) Drugs causing gingival enlargement?

Anticonvulsants:
phenytoin
Sodium valproate
Phenobarbitone
Vigabatrin
Immunosuppressants:
Cyclosporin
Calcium channel blockers:
Dihydropyridines
Nifedipine
Felopdipine
Amlodipine
52
Phenylalkylamine
Verapamil
Diltiazem
7) ANUG
Acute necrotizing ulcerative gingivitis (ANUG) used to be known as “trench mouth” because it was seen
frequently in soldiers occupying trenches during the World War I and was also called “Vincent’s angina”,
after the French physician Henri Vincent (1862-1950).
C/F
• This is an acute multiple bacterial infection of the gingivae.
• The lesion starts at the interdental papillae, spreading along the gingival margins and if untreated, starts
to destroy the underlying connective tissue and bone. There is a characteristic necrotic odor associated
with this condition and the mouth becomes progressively painful with sloughing off of the necrotic ulcers
on the gingivae. The ulcers become erythematous and bleed following
minimal trauma, especially tooth brushing.
• Regional lymph nodes are enlarged and tender.
• If untreated, destruction of the soft tissues of the mouth
and cheek and facial bones result, a condition referred to
as Cancrum Oris or Noma.
Predisposing factors include:
• poor oral hygiene, malnutri- tion, depressed immunity and long-term hospitalization.
Microorganisms
• The bacteria implicated earlier were Fusobacteria fusiformis and Borrelia vincentii. However, modern
electron microscope studies have shown the lesion to be colonized by various species of gram-negative
anaerobes and spirochaetes such as Treponema species, Bacteroides,
Veillonella, Fusobacteria and Actinomyces.
Treatment:
• The treatment of choice is regular gentle debridement of the gingiva and irrigation with an oxidizing
antiseptic such as hydrogen peroxide, until the infection clears. Diet and oral hygiene counseling is also
useful and this shouldbe followed up to ensure speedy healing.
53
8) features of normal gingiva in children.
Characteristics Children
Color Pale pink
Surface Smooth
Gingiva Thick and round
Free gingiva Keratinized saddle area
Interdental gingiva Interdental clefts
Attached gingiva Retrocuspid papilla
Sulcus depth 2.1-2.3 mm
Alveolar mucosa Red,thin,vascular
Periodontal ligament Wide
Collagen bundles More hydrated,less differentiated
Polypeptide chains Normal cross-linking
Ground substances Low ration of collagen to ground substances
Fibers Gingival fibers are immature
Trabeculae Thick trabeculae with large marrow spaces
9) Acute herpetic gingivostomatitis
 It affects both the gingiva and other parts of the oral mucus membrane.
 It is commonly seen in children less than 3 years of age.
 It is caused by the herpes simplex virus type 1.
Clinical features:
54
• Infection usually follows bouts of childhood fevers such as malaria, measles and chickenpox. The onset
of is preceded by a prodromal period with symptoms such as irritability, malaise, vomiting and fever
and the appearance of small vesicles which rupture to reveal small yellowish painfululcers with
erythematous margins.
• The condition is associated with drooling of saliva, inability to chew and swallow and the child may
becomeincreasingly uncooperative during tooth brushing.
Treatment
• The condition is self-limiting and the management is to encourage bed rest, plenty of fluid and
maintenance of good oral hygiene through gentle debridement.
• Analgesics are prescribed to relieve the pain and application of a mild topical anesthetic gel has been
found useful in young
children.
10)prepubertal periodontitis
Etiology:
Extremely rare category of periodontitis, usually having an onset during or soon after the eruption of the
deciduous teeth.
Both familial clustering of prepubertal periodontitis and a higher incidence in females have been
documented.
Clinical features:
• There-is a very rapid destruction of the alveolar bone and gingiva
• Extremely acute inflammation is present, with proliferation of the gingiva
• Profound functional defects of peripheral blood neutrophils and monocytes are seen
• Pheripheral blood white cells count is markedly elevated.
• Otitis media and skin and upper respiratory infections are frequent findings.
• Periodontitis may be refractory to antibiotic therapy.

Treatment:
• Curettage, antibiotics therapy, and improved oral hygiene arrest the progression of localized
prepubertal periodontitis.
• The periodontal status has been reported to improve remarkably after transfusion with granulocytes
from normal donars.
55
• Success in resolving the inflammation by combining extraction of the hopeless molars with an
aggressive plaque control can be obtained.
11) when does a stippling start to appear?what is the histological picture causing it?
• Stippling first becomes evident at about sex years of age and increases gradually upto
adulthood.stippling frequently begins to disappear in old age and in these cases appears similar to
that found in childhood.
• The presence or absence of gingival stippling can lead to early diagnosis of clinical gingivitis
which can be stopped from further destruction and progression towards periodontal
diseases.presence of gingival stippling is a sign of a healthy gingiva which corresponds to
absence of gingivitis.
12) ANUP
• Necrotizing ulcerative periodontitis is preceded by necrotizing ulcerative gingivitis, which is an acute

inflammatory condition associated with a fusospirochetal microbiota
Microbiota:
• Fusiform bacteria, other anaerobic gram-negative bacteria and Spirochetes have been associated with
the gingival lesions.
Predispose factors:
• Related factors may include emotional stress, poor diet, cigarette smoking, seasonal changes and HIV
infection.
Clinical features:
• Necrotizing ulcerative periodontitis is characterized by necrosis of gingival tissues, periodontal

ligament and alveolar bone.
• Nectrotizing ulcerative gingivitis is characterized by gingival necrosis presenting as ‘punched-out’
papillae, with gingival bleeding and pain.
• Halitosis and pseudomembrane formation may be secondary diagnostic features.

Treatment:
•It involves mechanical debridement,oral hygeine instructions, and careful follow-up
56
• Debridement with ultrasonics has been shown to be particularly effective and results in a rapid decrease
in symptoms.
• If the patient is febrile,antibiotics may be an important adjunct to therapy
• Metronidazole and penicillins have been suggested as drug of choice.
13) Localized aggresive periodontitis?
Etiology and risk factors.
• Actinobacillus actinomycetemcomitants usually, although not invariably,is present in subgingival

plaque.
• Serum antibody response to A.actinomycetemcomitants is present
• Neutrophil defects may have a role
• Multifactorial nature,possibly genetic element may be present.
• Severity of periodontal destruction may not be commensurate with level of plaque.

Clinical features:
• Rapidly destructive form of periodontitis,with a distinctive tendency to aggregate in families in

individuals who are systemically healthy
• Interproximal attachment loss on at least two permanent first molars and incisors,
withattachement loss on no more than two teeth first molars and incisors
• Attachement loss of atleast 3 mm, usually with associated deep pockets.
• Radiographs may reveal angular defects on incisors and arc-shaped bone defects on affected first
permanent molars.
Treatment:
• They should be monitored a little earlier, 6-8 weeks after initial therapy.
• Non responding sites should be re- root planed and adjunctive systemic antimicrobials considered
at this stage, when the cause-related therapy will have non specifically reduced the mass of
microbial plaque.
• Systemic antimicrobial therapy should not be administered without prior mechanical therapy to
disrupt the subgingival biofilm prevents the antibiotic from touching the target organisms.
57
Fluorides
Dr Chandana
1. SHOE LEATHER SURVEY
It is study of relationship between fluoride concentration in drinking water, mottled enamel and
dental caries by a young Dental Officer Dr H Trendley Dean to pursue full time research on
mottled enamel. His aim was to find out the minimal threshold of fluoride— The level at which
fluorine began to blemish the teeth. He showed conclusively that the severity of mottling
increased with increasing fluoride concentrations in the drinking water.
He gave the following observations:–
• Water concentration was 4ppm or more— Signs of discrete pitting.
• Water concentration was 3ppm or more— Mottling was wide spread.
• Water concentration was 2 to 3ppm— Teeth had dull chalky appearance.
• Water concentration was 1ppm or less— No mottling of any esthetic significance.

He also reported that the incidence of caries in these teeth was less as compared to
nonfluoridated teeth.
2. CLASSIFY FLUORIDES
Systemic fluorides Topical fluorides
School water fluoridation Sodium fluoride
Salt fluoridation Stannous fluoride
58
Systemic fluorides Topical fluorides
Milk fluoridation Acidulated phosphate fluoride
Dietary fluoride supplements Amine fluoride
Fluoride tablets Fluoride varnish
Fluoride gels
Self applied fluorides like fluoride tooth

paste, fluoride mouth wash, fluoride
prophylaxis paste
3. MECHANISM OF ACTION OF FLUORIDE

The mechanism by which fluoride exhibits its anticariogenic or antimicrobial effect are
• improved crystallinity,
• void theory,
• acid solubility,
• enzyme inhibition,
• suppressing the flora,
• antibacterial action,
• lowering free surface energy,
• desorption of protein and bacteria and
• alteration in tooth morphology.
4. VOID THEORY
Hydroxyapatite crystals are known to have inherent voids due to missing hydroxyl groups which
makes it unstable. In hydroxyapatite crystal OH– group is present slightly above or below the
plane formed by Ca++ ion. To maintain symmetry equal number of OH– ions should be present
on both the sides of the Ca++ plane. At times when hydrogen of adjacent OH– groups point
59
towards each other, this results in to stearic interference resulting into the elimination of one OH–
group, there by forming a void in the place. Voids in the crystal decreases the stability and
increases chemical reactivity. When these voids are filled by Fl–, the stability of the crystal
increases and the reactivity decreases greater stability of the crystal impart lower solubility and
greater resistance to dissolution in acids. Incorporation of a small amount of Fl– in the apatite
crystal improves its properties considerably. Fl– ions also form hydrogen bonds with
neighbouring OH– ions this further helps in the stabilization of the crystal
5. SCHOOL WATER FLUORIDATION

This program helps in limiting caries in school children who are our prime concern. School water
fluoridation is a suitable alternative where community water fluoridation is not feasible.
The amount of fluoride added in school drinking water should be greater than normal because
children have to stay in school for a short time of the day and to compensate for holidays and
vacations. The current recommended regimen for school water fluoridation is adding 4.5 times
more fluoride. There has been around 25 to 40 percent decrease in dental caries with this
program. Simple fluoridators particularly that employ the Venturi system are most suitable,
because they require almost no maintenance and can be utilized effectively in small installations
of small or medium sized schools.
Advantages
• Good results in reducing caries
• Minimal equipment
• Not expensive.
Disadvantages
• Children donot receive the benefit until they go to school
• Not all children go to school in poor countries like India
• Amount of water drunk cannot be regulated.
6. KNUTSON TECHNIQUE:
60
Knutson and Feldman in 1948 recommended a technique of 4 applications of neutral 2% NaF

at weekly intervals in a year at 3, 7, 11 and 13 years. This technique is called Knutson’s
technique.
Advantages
• Chemically stable
• Acceptable taste
• Nonirritating to gingival tissues
• Doesnotdiscolor the teeth
• Cheap and inexpensive.
Disadvantages
• Continuous application for 4 minutes
• Patient has to make four visits in a short time
• Follow-up is difficult.
7. FLUORIDE VARNISH
The topical fluoride solutions that are currently in use have a major disadvantage that they
remain contact with teeth for a short time, i.e. 5 to 10 minutes before getting diluted by saliva
and consequently can exert relatively a superficial effect on the dental enamel. A second
drawback with topical fluoride solutions is that soon after application much of the acquired
fluoride, probably representing unreacted F and CaF2, leaches away. To enhance the caries
inhibitory property, a new coating method was developed in which the teeth are coated with a
lacquer containing fluoride called F-lacquer, which released fluoride ions in high concentrations
for several hours in the moist atmosphere of the mouth. The two most commonly used varnishes
are Duraphat in organic lacquer and Fluor protector.
8. FLUORIDE TOOTH PASTE
61
Fluoride dentifrices have been proven to be effective anticaries agents. The most commonly used
fluoride dentifrices are sodium fluoride and stannous fluoride and more recently the sodium
monofluorophosphate and amine fluoride, are also being used.
Sodium Fluoride and StannousFluorideDentifrices:

NaF was the first fluoride compound to be added as an active ingredient but its efficacy was very
limited. Stannous fluoride failed to get the desired results because of its compatibility with
abrasives, staining of anterior restorations of composites resins and a metallic astringent taste,
which was not acceptable.
Amine FluorideDentifrices: This showed organic fluorides to have antibacterial and

anticariogenic properties, which were superior to inorganic fluorides and demonstrated
significant reduction in caries rate.
Monofluorophosphate: the basic incompatibility of the NaF and SnF2 compounds with calcium
abrasives leading to decrease available fluoride has been overcome with the introduction of
MFP.
At present there are two possible modes of action regarding caries inhibitory mechanism of
mono-fluorophosphate
a. MFP is deposited in the crystalline lattice and in subsequent intracrystalline transposition and
fluoride is released and replaces the hydroxyl group to form fluorapatite.
b. The second mode of action attributes to the anticariogenic activity.
c. MFP differs from other agents, in the aspect that its F-atom is covalently bonded to
phosphorous atom.
Advantages include
• Neutral pH,
• greater stability to oxidation and hydrolysis,
• longer shelf life,
• increased availability of fluoride and
62
• no staining of teeth.
Recommendations for use of fluoride dentifrice

Below 4 years - Not recommended
4 to 6 years - Once daily with fluoride paste and twice without paste
6 to 10 years - Twice daily with fluoride paste once without paste
Above 10 years - Thrice daily with fluoride paste.
9. CHOKING OFF EFFECT:

When NaF is applied topically, it reacts with hydroxyapatite crystals to form CaF2 which is the
dominant product of the reaction. Once a thick layer of CaF2 gets formed it interferes with the
further diffusion of fluoride from the topical fluoride solution to react with hydroxyapatite. This
is called choking off effect. It is because of this reason NaF is once applied and left to dry for 4
min. CaF2 reacts with hydroxyapatite to form fluoridated hydroxyapatite which increases the
concentration of surface fluoride.
• Making the tooth structure more stable
• Less susceptible to dissolution by acids
• Interferes with plaque metabolism
• Helps in remineralisation of the initial decalcified areas.
10. MUHLERS TECHNIQUE

It is single annual application of 8 percent SnF2. The recommended procedure for application of
SnF2 begins with thorough prophylaxis followed by isolation with cotton rolls and drying
preferably with compressed air. Either a quadrant or half of the mouth can be treated at one time.
A freshly prepared 8 percent solution of SnF2 is applied continuously to the teeth with cotton
applicator and reapplication of the solution to a particular tooth is done every 15 to 30 seconds so
that the teeth are kept wet for 4 minutes. The recommended frequency of application is once per
year.
11. BRUDEVOLD TECHNIQUE:
63
It is semiannualapplication of 1.23 percent APF for 4 minutes which is helpful in reducing

caries. This is called brudevold technique. After through prophylaxis, teeth are isolated with
cotton rolls. For application of gel patient is positioned in an upright position with saliva ejector
in mouth. Trays are filled upto 1/3rd . These loaded trays are placed over the arch and buccal and
lingual surfaces are squeezed forcing the gel between the teeth. Allow the trays to remain for 4
min. Instruct the patient to expectorate immediately and avoid drinking and eating for the next 30
min.
12. ACIDULATED PHOSPHATE FLUORIDE

It is prepared by dissolving 20g of NaF in 1 litre of 0.1M phosphoric acid. To this is 50 percent
hydrofluorideacid is added to adjust the pH at 3.0 and F concentrations at 1.23 percent. For the
preparation of APF gel, a gelling agent like Methylcellulose or Hydroxyethyl cellulose is to be
added to the solution and the pH is to be adjusted between 4 to 5. It is recommended
semiannualapplication of 1.23 percent APF for 4 minutes by Brudevold technique which is
helpful in reducing caries.
13. STANNOUS FLUORIDE

Stannous fluoride solution has to be freshly prepared before use each time. If stored Stannous
form of Tin gets oxidized to stannic form, thus making the SnF2 inactive for anticaries action, as
it has no shelf life. For convenient preparation number ‘o’ gelatin capsules are priorly filled with
0.8g powdered SnF2 and are stored in air tight plastic containers. Just before application the
content of one capsule is dissolved in 10 mL of distilled water in a plastic container and the
solution thus prepared is shaken briefly. The solution is then applied immediately. It is
recommended single annual application of 8 percent SnF2 which is called Muhlers technique.
14. FLUORIDE MOUTH RINSE

In those areas where water fluoridation is not possible or has not been implemented, the fluoride
mouth rinses have been found to be effective tool in prevention of dental caries. The
recommended dosage of mouth rinse are 0.2% NaF solution (900ppm F) for fortnightly or
0.05%(225ppm F) for daily use. 0.2% NaF is prepared by dissolving 200mg NaF tablet in 25ml
of fresh clean water which is sufficient for daily mouth rinse of about 4 members.
64
15. FLUORIDE TOXICITY

It can be defined as excessive ingestion of fluoride. Fluoride can be harmful if large amounts are
ingested in a single dose or over a period of time.
There can be two types of toxicity- acute and chronic.
Acute Toxicity: Ingestion of large doses of fluoride at one time.

Signs and Symptoms:
• Nausea, vomiting, abdominal pain, diarrhoea, excess salivation and mucosaldischarge,

generalized weakness and carpopedal spasms, weak thready pulse, fall in blood pressure,
depression of respiratory center, decreased plasma calciumlevel, increased potassium level,
cardiac arrhythmia, coma and death.
Chronic Toxicity: It is defined as ingestion of variant doses of fluoride over a prolonged period
of time.
It is of two types:
1. dental fluorosis and 2. skeletal fluorosis.
Dental fluorosis is a developmental disturbance of dental enamel, caused by successive
exposures to high concentrations of fluoride during tooth development, leading to enamel with
lower mineral content and increased porosity.
Skeletal Fluorosis also called osteofluorosis. Water fluoride levels over 4 ppm causes a mild
variant but levels over 8 ppm cause severe skeletal fluorosis.
16. NALGONDA TECHNIQUE:

Nalgonda technique is so simple and adaptable that even illiterate persons can make use of it.
This involved the addition of three readily available chemicals, i.e. sodium aluminate or lime,
bleaching powder and filter alum to the fluoride water in the same sequence which leads to
flocculation, sedimentation and filtration. Sodium aluminate or lime hastens settlement of
precipitate and bleaching powder ensures disinfection. This technique can be used both for
domestic as well as for community water supplies.
65
17. DENTAL FLUOROSIS

Dental fluorosis can be defined as hypoplasia or hypomaturation of tooth enamel or dentin
produced by chronic ingestion of excessive amounts of fluoride during the period when teeth are
developing. There is direct inhibitory effect on enzymatic action of ameloblasts leading to
defective matrix formation and subsequent hypo mineralization. Major cause is water
consumption containing higher levels of fluoride during the 1st 6 years of life. Both primary and
permanent teeth will be affected but greater fluorosis in permanent teeth is seen because, much
of the mineralization of primary teeth occurs before birth and also because the placenta serves as
the barrier to the transfer of high concentrations of plasma fluoride from a pregnant mother to her
developing fetus.
18. DEAN’S FLUOROSIS INDEX

It was given by Trendly H Dean in 1934. According to this
• Rating • Public health significance
0 • normal- enamel shows the usual translucency.
0.5 • questionable- enamel shows slight aberrations ranging from a few white
flecks to occlusal white spots
1 • Very mild- small opaque paper white areas scattered irregularly over tooth
but not involving more than 25%
2 • mild- opaque, paper white areas involving more than 50%
3 • moderate- all the enamel surface is affected and also show attrition
4 • severe- discrete con fluent pitting with brown stains is seen.
19. THIXOTROPIC GEL
66
Gels which flow under pressure are called thixotropic gels. This thixotropic nature is seen in
APF gel which facilitates deeper penetration between teeth. Thixotropic property seen in APF
gel is because of water soluble polymer.
20. DURAPHAT:
Duraphat is sodium fluoride in varnish form containing 22.6 mg F/mL(2.26%) suspended in an
alcoholic solution of natural organic varnishes. It’s available in bottles of 30 mL suspension
containing 50mg NaF/mg. The active fluoride available is 22,600 ppm. It has neutral pH. When
applied topically under clinically controlled conditions, a reservoir of fluoride ions gets built up
around the enamel of teeth. From this, fluoride keeps on slowly releasing and continuously
reacting with the hydroxyapatite crystals of enamel over a long period of time leading to deeper
penetration of fluoride and more formation of fluorapatite.
10Ca5(PO4)3OH + 10F = 6Ca5(PO4)3F + 2CaF2 + 6Ca3(PO4)2 + 10OH
A part of CaF2 so formed in low concentrations further reacts with crystals of hydroxyapatite and
forms fluorapetite.
10Ca5(PO4)3OH + CaF2 = 2Ca5(PO4)3F + Ca (OH)2
21. SODIUM FLUORIDE:

Knutson and Feldman recommended a technique of 4 applications of 2 percent NaF at weekly
intervals in a year at 3, 7, 11 and 13 years called Knutson technique. Two percent NaF solution
can be prepared by dissolving 20g of NaF powder in 1liter of distilledwater in a plastic bottle. It
is essential to store fluoride in plastic bottles because if stored in glass containers, the fluoride
ion of solution can react with silica of glass forming SiF2, thus reducing the availability of free
active fluoride for anticaries action.
22. TOXIC DOSE OF FLUORIDE:

Probably toxic dose (PTD): Defined as the threshold dose that could cause serious or life
threatening systemic signs and symptoms.
67
Safely tolerated dose: 8 mg – 16 mg/kg body weight

Toxic dose: 16 mg – 32 mg/kg body weight
Lethal dose: 32 mg – 64 mg/kg body weight
23. MECHANISM OF ACTION OF FLUORIDE VARNISH

Duraphat is NaF in varnish form with neutral pH. Varnish when applied topically under
clinically controlled conditions, a reservoir of fluoride ions gets built up around the enamel of
teeth. From this, fluoride keeps on slowly releasing and continuously reacting with the
hydroxyapatite crystals of enamel over a long period of time leading to deeper penetration of
fluoride and more formation of fluorapatite.
10Ca5(PO4)3OH + 10F = 6Ca5(PO4)3F + 2CaF2 + 6Ca3(PO4)2 + 10OH
A part of CaF2 so formed in low concentrations further reacts with crystals of hydroxyapatite and
forms fluorapetite.
10Ca5(PO4)3OH + CaF2 = 2Ca5(PO4)3F + Ca (OH)2
24. RECENT ADVANCES IN FLUORIDE

Copolymer Membrane Device:
This system was designed as a membrane-controlled reservoir-type and has an inner core of
hydroxyethyl methacrylate (HEMA)/methyl methacrylate (MMA) copolymer (50:50 mixture),
containing a precise amount of sodiumfluoride(NaF). This core is surrounded by a 30:70
HEMA/MMA copolymer membrane which controls the rate of fluoride release from the device.
usually attached to the buccal surface of the first permanent molar by means of stainless steel
retainers that are spot welded to plain, standard orthodontic bands or are bonded to the tooth
surfaces using adhesive resins.
Fluoride Glass Device: The F glass device dissolves slowly when moist in saliva, releasing F
without significantly affecting the device’s integrity. The original device was dome shape, with a
diameter of 4 mm and about 2 mm thick, being usually attached to the buccal surface of the first
permanent molar using adhesive resins
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Hydroxyapatite-Eudragit RS100 Diffusion Controlled F System This is the newest type of

slow-release F device, which consists of a mixture of hydroxyapatite, NaF and Eudragit RS100.
Placed on labial aspect of maxillary incisors,buccal aspect of molars and lingual aspect of
mandibular incisors.
Cariology
Dr Malathi
1.Miller’s Chemoparasitic theory?
Ans.-The microorganisms of the mouth, by secretion of enzymes or by their own metabolism,

degrade the fermentable carbohydrate food material as to form acids.
Carbohydrate food material lodged between and on surfaces of teeth is the source of acid,
which demineralises the tooth.
So it leads to enamel and dentin breakdown and forms a cavity on the tooth surface
2.What is Keys triad?
Ans: keys stated that In the epidemiological model a disease state is due to Interplay of three
primary factors.
Host (tooth), the agent (microflora)or recruiting factor and environmental influences (resistance
of the tooth) -primary factors.
Newbrun postulated that many secondary factors also influence the rate of progression of caries
So interaction of these factors is essential for the initiation and progression of caries.
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3. Stephen curve
Ans: Stephen curve is a

graph which is introduced by
Stephen and miller in 1944, Here
there was a continuous
change in salivary ph following consumption of foods and beverages, especially with
fermentable carbohydrates. (Or) it is a fall in salivary ph following a glucose rinse
4.Critical pH
Ans:The critical pH is the pH at which saliva no longer remains saturated with calcium and
phosphate, there by permitting the hydroxyapatite in dental enamel to dissolve . It is the highest
pH at which there is a net loss of enamel from the teeth,which is generally accepted to be about
5.5 for enamel.
5.Enumerate functions of saliva
Ans:a)when saliva is swallowed , any bacteria contained therein are removed from the oral
cavity and pass into the stomach
b)fluoride present in saliva which helps for remineralisation
c)saliva contains antibacterial substances like lysozyme, lactoperoxidase, lactoferrin and IgA.
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d)saliva contains bicarbonates which helps in buffering capacity
e)It moistens food and helping create a bolts, so it can be swallowed easily
F)it helps in appreciation of taste
6)Hope wood house study
Ans:It is 10 yr longitudinal study conducted on 3 -14 yr children residing in hope wood house in
Bowral, New South Wales
Absence of meat and rigid restriction of refined carbohydrate were the principle
At the end of a 10yr period, the 13yr old children of Hope wood house had a mean DMF per
child child of 1.6 the corresponding figure for the general population of the state of NSW was
10.7. Only 0.4% of the 13 yr old state school children were free from dental caries, whereas
53%of the Hopewood children experienced no caries.
7)Mention any five sugar substitutes
Ans:The ideal agent would provide sweetness, but with no unpleasant after taste, have little or
no calories, not be carcinogenic or mutagenic, be economical to produce, and would not be
degraded by heat when cooked.
Ex:Aspartame, Acesulfame potassium, Saccharin, Sucralose, Sorbitol, Xylitol, Neotame.
8) Snyder test
Saliva is collected before breakfast by chewing paraffin
A tube of Synder glucose agar is melted and then cooled to 50c
Saliva specimen is shaken vigorously for 3 minutes
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0.2ml of saliva is pipetted into the tube of agar and immediately mixed by rotating the tube
Agar is allowed to solidify in the tube and is incubated at 37c
Color change of the indicator is observed after 24, 48 and 72 hrs of incubation by comparison
with an uninoculated tube against a white background.
9)Alban Test
60gms of Synder test agar is placed in 1 lit of water
Suspension is brought to a boil over a low flame
After suspension has melted the agar is distributed using about 5ml per tube
These tubes should be autoclave for 15min; allowed to cool stored in a refrigerator
2 tubes of Alban medium are taken from the refrigerator and the patient is asked to
expectorate a small amount of saliva directly into the tubes.
The tubes are labelled and incubated at 98.6F for 4 days
The tubes are observed daily for color change from blue to green to definite yellow with
decrease in pH
10)Evaluation of cariogram
Ans:Dark blue- Diet-Combination of diet contents and diet frequency
Red-Bacteria-Combination of amount of plaque and mutants streptococci
Light blue- Susceptibility - Combination of flouride programme, saliva secretion, saliva buffer
capacity
Yellow- Circumstances- Combination of caries experience and related diseases
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Green- Chance of avoiding caries
11)Name some recent advanced diagnostic aids for dental caries
Ans:Digital radiography
Digital subtraction radiography
Fibre optic trans illumination
Digital Fiber optic transillumination
Quantitative light induced fluorescence
Diagnodent
Electrical conductivity measurements
Tuned aperture computed tomography
Cone Beam computed tomography
12)DIAGNOdent
It is another device employing fluorescence to detect the presence of caries. It has two intra oral
tips; one designed for pits and fissures, and the other for smooth surfaces. These tips emits the
excitation light and collects the resultant fluorescence. This is then displayed as a numerical
value on two LED displays. The signal comes out as a number on instrument on a scale 0 to 99.
Higher the number more is caries.
13)Differences between Early childhood caries and Rampant caries
Ans:Earlychildhood caries: Specific form of rampant caries, acute generalised spread of caries
and pulp all involvement in selected teeth of dentition.
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-Seen in infants and toddlers
-etiology- mainly for improper feeding habits
Rampant caries: acute generalised spread of caries and pulp all involvement in all teeth
Both the dentitions are involved
-etiology- mainly for frequent intake of sugary substances
14)Define Early childhood caries
Ans:According to AAPD ECC is defined as presence of one or more decayed, missing or filled
tooth surfaces in any primary tooth in a child 71 months of age or younger. In children younger 3
years of age, any sign of smooth surface caries is indicative of severe earlychildhood caries.
15)Etiological factors for Earlychildhood caries
• Dental plaque
• Mutant streptococci
• Infant feeding pattern
• Improper tooth brushing
• Salivary factors
• Sugars
• Oral clearance of carbohydrates
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• Bovine milk
• Human milk
• Insufficient fluoride supplements
16)Classification of Early childhood caries
Ans:stage I- Initial reversible - 10 to 18 months- cervically and occasionally interproximal areas

of chalky white demineralisation, not observe any pain in this stage.
Stage II:Damaged carious stage: 18 to 24 months- Lesion in max anterior teeth,may spread to
dentin, may observe pain while taking cold substances
Stage III:24-36 months-Pulpal involvement in maxillary incisors, molars also affected, seen
frequent complaint of pain
Stage IV: 36-48 months- teeth become so weekend, patient c/o history of trauma, almost all the
teeth affected, Molars are now associated with pulp albums problems.
17)Prevention of Earlychildhood caries
Ans:Early screening for signs of caries development, starting from the first year of life, could
identify infants and babies showing the risk of developing ECC and could also assist in
providing information of parents about how to promote oral health and prevent the development
of tooth decay. High risk children should be targeted with a professional preventive program that
includes varnish application, fluoridated dentifrice, fluoride supplements, sealants, diet
counselling .
Prevention of ECC also requires addressing the social and economic factors that face many
families where ECC is endemic. The education of mothers or caregivers to promote healthy
dietary habits in infants has been the main strategy used for the prevention of ECC.
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There are 3 approaches that have been used to prevent ECC
1.Community based education : The goal of education is to increase the knowledge of mothers
about ECC and to improve the dietary and nutritional habits of infants and mothers. It helps to
increases mother and caregivers knowledge which influences their self care practices and dietary
habits and in turn, improves the dietary and oral hygiene of infants leading to the prevention of
ECC.
2.prevention of transmission of cariogenic bacteria from mother to infant
3.professional and Home based approaches
18)Management of Earlychildhood caries
Ans:1st visit:All lesions should be excavated and restored
• Indirect pulp capping or pulp therapy procedures can be evaluated by further investigation
• If the abscess present we have to drainage the abscess
• Xrays should be taken
• Parent counselling-parent should be questioned about the child feeding habits, nocturnal
bottles, demand for breast feeding, pacifiers.
2nd visit: should be scheduled 1 week after 1st week
• Analysis of diet chart & explanation of disease process of child’s teeth
• Isolate the sugar factors from diet chart and control sugar exposure
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• Reassess the restoration redo if needed
• Caries activity tests can be started & repeated at monthly interval to monitor the success of
treatment
3rd visit: Restoring all grossly decayed tooth
• Endodontic treatment
• In case of unrestorable teeth, extraction followed by space maintainer
• Crowns given for grossly decayed tooth and endodontically treated tooth
• Review and recall after every 3 months.
19)What is chemo mechanical caries removal
Ans: The chemomechanical caries removal method was developed to overcome disadvantages
with conventional methods
Advantages:Elimination of Local anesthesia and bur
Conservation of the sound tissue
Effective
Gives more comfort to the patient esp. in child patients
Reduces the risk of spillage
Ex:Caridex, Carisolv,Papain gel
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20) Balanced Diet
Ans:One providing each nutrient in the needed to maintain optimum health.
A balanced diet is important because your organs and tissues need proper nutrition to work
effectively. Without good nutrition, your body is more prone to disease, infection, fatigue and
poor performance.
21)Diet counselling
Ans:Optimal growth and development are the primary objectives of pediatric nutrition.
• One of the focuses with Dietary counsellingis making step by step approach, so that changes
are achievable in the long term
• Step 1: pt selection: diet counselling will not succeed with every dental old patient.positive
attitude patients and patients who are giving high priority to preventive dentistry.
• Step2: FoodDiary:it is a record of all food and beverages consumed during specific period.
• The patient is instructed to be as accurate as possible in determining quantities and to record

in detail everything eaten or drunk during or between meals, the size serving in household
measures, the addition of sugar, milk, syrups to anything consumed.
• A food or diet diary can be either of 24hrs or 1 week.
• Step 3: Communication : communication is the giving and receiving of information; it

involves the knowledge, thoughts, and opinions of the counselor and patient
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• Because diet and inadequate nutrition are major etiological factors in dental oral health
problems, it is necessary that the dentist or dental hygienist give diet counselling when
indicated.
• Step 4: Interviewing: The basic goal of interviewing is to understand the problem, the
factors that contribute to it, and the personality of the patient
• Step 5:Counselling: Approches of the counselling may be direct or indirect
• In directive counselling, the role of the patient is passive and the decisions are made by
counselor
In non directive counselling the counselor role is merely to aid the patient in clarifying and
understanding his or her own situation and to provide guidance so that the patient can make his
or her own final decision as to the type of action that should be taken.
22)Diet score
Ans:Diet score=Food score+Nutrient score-sweet score
Food score (highest possible score 96)
Food RDA Number of servings
Milk 3 *8
Meat 2 *12
Fruits and vegetables 1 *6
Vitamin C 1 *6
Others 2 *6
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Breads and cereals 4 *6
Nutrient score
Mark one score for each nutrient
Protein and vitA Iron Frolic acid Riboflavin Vitamin C
Cheese, dried peas, Beef,eggs,liver,veget Cereals,spinach,yeast Broccoli,chicken Grapefruit, green peppers, oranges, strawberries, tomato
dried ables breast,eggs, milk,
beans,eggs,fish,meat mushroom
,milk,apricot,butter,c
arrot,liver,milk and
spinach
Sweet score table
Liquid*5 Solid and sticky *0 Slowly dissolving *15
Soft and fruit drinks,cocoa,sugar and honey in beverages, ice Cake,doughnuts,sweet rolls,pastry,bananas,cookies,chocolate Hard candies, breathe mints, a
cream candy,caramel
Assessment of diet score
Score Result Interpretation
72-96 Excellent Counselling not required
64-72 Adequate Educate the patient
56-64 Barely adequate Counselling required
56 or less Not adequate Counselling with diet modific
23)Sugar substitutes
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Ans:Aspartame :it is dipeptide methyl Ester, it is most widely used non cariogenic artificial
sweetener.it is 200 times sweeter than the sucrose.it has been shown protective effect against
some mycotoxins na dis claimed to be safe for use by type II diabetics. But disadvantages are
reduced number of sickle cells in the blood, relative toxic effects on growth.
• Acesulfame potassium : it is approved for a use in foods, beverages,cosmetics.but

disadvantage is there have been some health issues raised relative to dose dependent
cytogenetic toxicity.
• Saccharin :200 -50p times sweeter than the sucrose and is the oldest non cariogenic
sweetener. It is non cariogenic and non caloric available in liquid and tablet forms. It was
identified as a potential bladder carcinogen, and its use has hence been limited.
• Sucralose: it is a non nutritive, non caloric, trichlorinated derivative of sucrose. It is widely

used in many food products such as coffee, tea,carbonated and non carbonated beverages. No
health concerns have been reported with it.
• Sorbitol :It is a sugar alcohol that occurs naturally in many fruits and berries. Sorbital used
as a bulk sweetener in a variety of foods in chewing gums, chocolates etc..it is half as swee t
as sucrose and is considered non cariogenic, but it may be absorbed from the gastrointestinal
tract and can cause diarrhoea if ingested in large quantities.
• Xylitol :it is non fermentable, pleasant tasing, non cariogenic polyol derived from pentose
sugar xylose.it is as sweet as sucrose. It is used in chewing gum and possesses approximate
sweetness of sucrose. Recently xylitol has been credited in reducing the transmission of
cariogenic bacteria from mother to infant and has been shown to have bactericidal qualities.
• Stevia
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• Neotame
24)Classification of sugar substitutes
Ans: Caloric :polyalcohols/sugar alcohols:xylitol
Sorbitol
Lactitol
Hydrogenated starch hydrolysate: Lycacin
Palatinit
Coupling sugars: Sorbose
Palatinose
B)Non caloric: Saccharin
Aspartame
Sucralose
Neotame
Cyclamate
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RESTORATIVE DENTISTRY
Dr P.Chaitanya
1) What are the modifications of class I cavity preparation for a primary tooth?
• Due to narrow occlusal table the bucco lingual dimensions of occlusal part of cavity are
reduced.
• The chance of inadvertent pulp exposure is minimised by limiting the cavity to 0.5 mm pulpal
to enamelo-dentinal junction.
• Maximum intercuspal cavity width should be limited.
• Walls of preparation should be parallel or slightly convergent occlusally.
• The central pit of lower first primary molar usually becomes carious before mesial pit, which
decays less frequently. The outline form should be limited to central pit; it is adjacent
buccal and lingual grooves and distal triangular fossa. It is advisable not to cross ridge to join
mesiobuccal and mesiolingual cusp because of its proximity to pulp horns. Pulpal roof in
primary teeth is concave as compared to permanent teeth where it is nearly flat so cavity
floor should be kept little concave.
• Depth should be just 0.5 mm into the dentin so the total depth from the cavosurface should
not be more than 1.5 to 2.0 mm.
• Include all pits and fissures and lateral extensions should be such so as to just accommodate
the amalgam condenser.
• Flat or slightly concave pulpal floor with rounded line and point angles.
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• While extending laterally on the buccal side, bur should be kept parallel to the buccal surface
and while extending lingually, bur should be parallel to lingual surface. This makes the
occlusal convergence without much cutting.
2) What are the modifications of class II cavity preparation for primary tooth?
• Occlusal box: Same principles applied as for class I but extension of outline is different for
different teeth.
- For all first primary molars: Extend the occlusal box half the way mesiodistally in a dovetail
like fashion.
- For mandibular second primary molars: All pits and fissure should be involved.
- For maxillary second primary molars: Nearest occlusal pit should be involved. Oblique ridge
should not be involved until undermined by the caries.
• Sharp cavosurface angle.
• Round/ beveled/ grooved axiopulpal line angle inorder to reduce stresses on this point and
to allow greater bulk of material.
• Isthmus width should be 1/2 the intercuspal width.
• Proximal box: Greater width of the proximal box inorder to keep the cavity margins in the self-
cleansing areas.
• More buccal lingual extension of the gingival floor/seat.
• Occlusal convergence
• Axial wall should follow the contour of the external surface.
• The direction of the enamel rods at the cervical line is either horizontal or occlusal and
therefore gingival bevel is not given while preparing class II cavity.
• Retention grooves should not be given.
• Kennedy (1997) contraindicated the idea of dovetail lock. He said that when occlusal fissure
are prepared this does not result in straight-line cavity that would require dovetail lock, instead
it produces a curved shape that itself provides retention. Hence if the dovetail was given it
would lead to unnecessary cutting of sound tooth structure.
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3) What is matricing? What is the rationale and functions and ideal requirements of using
matrix?
Matricing is a procedure where by a temporary wall is created opposite the axial wall
surrounding the areas of tooth structure lost during preparation. The appliance used for building
these walls is called matrix.
Rationale for Using Matrix:
• Accurate production of contours of teeth.
• To prevent inter-proximal excess
• To establish tight contacts
• To maintain arch dimensions in primary dentition.
• To maintain integrity of normal gingival papillae.

Functions of Matrix
• To replace the missing wall.
• Lose adaptation of restorative material.
• Retain restorative material during placement.
• Allow restoration of contact point and external crown contour.
• Isolation of cavity.
Ideal Requirements of Matrix
• Rigid to allow condensation.
• Promote desired contour.
• Should form positive contact with the tooth.
• Should be of minimal thickness.
• Compatible with restorative material.
• Easy of application
• Economical.
4) List out or classify various matrices used in pediatric dentistry.

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Classification of matrices:
According to place of application Posterior: T- band, Toffelmire

Anterior : Celluloid Crown’s
According to constituents Metallic: Ivory no.1, Ivory no.8, Toffelmire
Nonmetallic: Mylar strips
According to presence or absence of With retainer: Ivory no.1, Ivory no.8
retainer Without retainer: S - band
According to form Anatomical: Celluloid crown form
Non - anatomical: Ivory no.1
According to patent Patent: Ivory no.1
Non patented: Celluloid crown form
According to use Universal: Ivory no.8, Toffelmire
Unilateral: Ivory no.1
5) What are the recent modifications in matrix?

Sectional matrix: This system is easy to place, gives a large preparation area thus reducing the
working time. An added advantage of this system is that both mesial and distal proximal
restorations can be accomplished by one matrix placement
Smartview matrix system: The SmartView Matrix System also comes with SmartBands
Sectional Matrices and titanium instruments. The SmartBands have a nonstick surface, are
anatomically contoured, and integrate a reinforced placement tab while the instruments and
are made of high -grade, blue titanium. The specially designed titanium instruments are strong,
durable, and lightweight. These are mostly used for composite restorations.
6) What are wedges? What are the types, ideal requirements and functions of wedges?
Wedge is defined as a piece of wood, metal, etc. one end of which is an acute angled edge
formed by two converging planes used to tighten or exert force in various ways.
Types:
According to anatomy
• Anatomical—in shape of embrasure
• Non anatomical—round
According to material used
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• Wooden—can be made of either hard or soft wood
• Plastic—available in various shapes

According to colour
• Coloured—all types
• Light reflecting—to be used with composites.

Ideal requirements of wedges
• Easy to apply and withdraw
• Should be of the shape of the embrasure.
• Should not cause deformation of the matrix.
• Be disposable
• Be radiopaque
• Be rigid
• Non toxic and non irritant
• Stable in oral fluids.

Functions:
• Assures close adaptation of matrix band with the tooth
• Prevents gingival overhang
• Assure proper health of interdental col
• Tooth separation
• Stabilisation of band
• Absorbs fluid.
7) What is isolation and are the various methods of isolation?

Isolation: A technique to protect a tooth against contamination from oral fluids during a surgical
or restorative procedure, usually through the application of a rubber dam or various other
measures.
Methods of isolation:
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Direct methods
• Rubber dam
• Cotton rolls and cotton roll holder
• Gauze pieces
• Absorbent wafers
• Suction devices
• Gingival retraction cord
• Mouth props
Indirect methods:
• Comfortable position of patient and relaxed surroundings
• Local anesthesia
• Drugs :- Anti – sialogogues, Anti anxiety , Muscle relaxants.
8) What is rubber dam? Mention advantages & disadvantages of using rubberdam.

RUBBER DAM
• The Rubber Dam is a flat , thin sheet of latex or non latex that is held by a clamp (retainer) and
a frame that is perforated to allow the teeth that will be worked on to protrude through the
perforations in the sheet while all the other teeth are covered and protected by the rubber dam.
• It is used to define the operating field by isolating one or more teeth from oral environment.
ADVANTAGES
• Improvement of access.
• Retraction and protection of soft tissues.
• Provision of a dry operating field.
• Improve visibility.
• Provision of an aseptic environment.
• Prevention of ingestion and inhalation of foreign bodies.
• Aid to patient management.
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• Aid to cross-infection control by reducing aerosol spread of micro-organisms.
• Minimization of mouth breathing during inhalation sedation procedure.

DISADVANTAGES
• Time consuming.
• Patient’s objection.
• Trauma to marginal gingiva.
• Trauma to cementum
• Poorly retentive clamps.
• Metal crown margins show microscopic defect following clamp removal.
• Ceramic crowns may fracture at the margins if clamp is allowed to grip the porcelain.
9) What are the indications & contraindications of rubber dam isolation?
INDICATIONS
• The use of the dam is indicated in virtually all (99.9%) cases.
• In all operative procedures and endodontics.
• When using high copper amalgam, as it is influenced by moisture contamination.
• It has been used in diagnosis to isolate teeth for thermal test and interdentally during electric
pulp testing.
• In periodontal therapy as an aid in root planing and in combination with a periodontal pack as
a dressing following flap surgery.
CONTRAINDICATIONS
• In the presence of some fixed orthodontic appliances.
• Partially erupted tooth can’t receive a retainer.
• Some third molars.
• Children suffering from asthma , some upper respiratory infections or mouth breathing
problems.
• Cannot be used in case of extremely mal-positioned teeth.
• Latex allergy.
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• Psychological intolerance.
• Patient at risk with transient bacteremia.
• Severe gingival disease.
10) List out the armamentarium for rubber dam isolation.
• Rubber dam sheets
• Rubber dam clamps or retainers
• Rubber dam holder (frame)
• Rubber dam retaining forceps
• Rubber dam punch
• Rubber dam templates or stamps
• Dental floss
• Napkin
• Wooden wedges , orthodontic elastics & commercially available latex cord.
• Lubricant
• Modelling compound
• Scissors
11) Write about rubber dam sheets.
• Rubber dam sheets are available in 2 sizes

Size:5×5inch(12.5x12.5cm) for children
Size:6×6 inch(15x15cm) for adults
• Various thickness of rubber dam sheets include:
Thin 0.15 mm (0.006 inch)
Medium 0.20 mm (0.008 inch)
Heavy 0.25 mm (0.010 inch)
Extra heavy 0.30 mm(0.012 inch)
Special heavy - 0.35 mm (0.014 inch)
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• Colors - green , blue , black , pink and burgundy Darker color offers better visual contrast.
• Flavors – mint , banana and strawberry
• It has shiny and dull surface. Dull surface is kept facing occlusally since it is less reflective.
12) Write briefly about rubber dam clamps/retainers
• Rubber dam clamps/ retainers are used to secure the dam to the teeth that are to be isolated &
to minimally retract the gingival tissue.
• Parts : Clamps have 4 prongs that rest on the mesial and distal line angle of the tooth and 2 jaws
connected by a bow.
• Prongs should not extend beyond the mesial and distal line angles of tooth. If extended beyond,
- Interfere with matrix and wedge placement
- gingival trauma is more likely to occur
- a complete seal around the anchor tooth is more difficult to achieve.
Types :
• Winged
• Wingless
• Serrated
• Clamp with jaws inclined cervically to engage erupting tooth or severely broken down teeth.
• Clamps with endo – illuminator system to illuminate pulp chamber and canal orifices.
13) What are the steps in rubber dam placement?

The steps in rubber dam placement include:
Step 1 : SELECTION OF THE DAM
• Heavy and extra heavy dams are used for restorative procedures while medium is considered
ideal for endodontic purposes since it:
- retracts the tissues better than thin type
- is easier to place than heavier type.
• The natural or translucent rubber dam has advantages for endodontic radiography with the dam
in place.
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Step-2 : MARKING THE HOLES
• Punch an identification hole in the upper left corner of the rubber dam for ease of location of
that corner when applying the dam to the holder.
• Isolation of a minimum of three teeth is recommended except when endodontic therapy is

indicated , and in that case only the teeth to be treated is isolated.
• The distance between the holes is equal to the distance from the centre of one tooth to the
centre of the adjacent tooth , measured at the level of the gingival tissue. This is approximately
1⁄4 inch (6.3mm).
POSITION OF THE HOLES:
Single tooth isolation
• It should be near the centre of the rubber sheet within the area of the sheet corresponding to the
quadrant under treatment.
• It is recommended that the top edge of the rubber sheet is positioned to lie above the lip of the
patient during endodontic procedures.
Multiple tooth isolation
• If the dental arch is regular , a rubber stamp or template can be used to indicate the positions of
the holes.
• Templates are designed to be placed behind the rubber dam and the tooth positions marked
with a pen
Step-3: PLACEMENT OF RUBBER DAM
Three methods of rubber dam placement include:
1. Dam first technique
2. Clamp first technique
3. Clamp and dam together technique
Clamp should be sure with floss before placing on to the tooth.
Step-4: Removal of rubber dam by,
• Cutting the septa
• Removing the retainer
• Removing the dam
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• Wiping the lips
• Rinsing the mouth
14) What is slit dam method of rubber dam placement?
• Rubber dam use in primary dentition is simplified by the slit-dam method.
• Rather than punching multiple tooth holes in the dam and isolating each tooth in the quadrant ,
three large holes are punched out 1-2 cm apart and are joined by a scissors cut.
• Such rubber dam application is rapid (5-10 sec) and the desired teeth are completely available
for restorative treatment
15) What are the advances in rubber dam?
• Hat Dam
• Cushioning Metal Clamp Jaw
• Liquid Dam / Opal Dam
• Cushees
• Fiber Optic Clamps
16) Properties & Classification of Glass ionomer cement

Glass ionomer cements (GICs) were developed in an attempt to capitalize on the favorable
properties of both silicate and polycarboxylate cements.
Properties of Glass Ionomer Cement:
• Low solubility
• Coefficient of thermal expansion similar to dentin (10.2 to 11.4)
• Fluoride release and fluoride recharge
• High compressive strengths (Upto 200 Mpa)
• Bonds to tooth structure by primarily chemical (calcium-carboxyl groups), micromechanical
• Low flexural strength
• Low shear strength

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• Dimensional change (slight expansion) (shrinks on setting, expands with water sorption)
• Brittle
• Lacks translucency
• Rough surface texture
• Biocompatible to tissues.
Classification of Glass Ionomer Cement:
According to intended applications,
• Type I – Luting
• Type II – Restorative
• Type III – Liners & Bases
• Type IV – Fissure sealants
• Type V – Orthodontic cements
• Type VI – Core build up material
• Type VII – Fluoride releasing
• Type VIII – GIC for ART
• Type IX – Geriatric and paediatric
17) What is the composition of GIC? Write its Setting reaction.

Composition:
Liquid:
• Polyacid (Acrylic, maleic, itaconic)
• Water
• Comonomer: D-Tartaric: accelerates set, increases working time, translucency, strength
• Recently added: Poly vinyl phosphoric acid.

Powder:
• Alumina(Al2 O3): 16.6 %, Forms the skeletal structure, increase opacity.
• Silica(SiO2): 29%, Increase translucency
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• Calciumfluoride(CaF2): 34.2 %, Increases opacity, acts as flux
• Aluminium phosphates(AlPO4): 9.9%, Decrease melting temperature, increase translucency
• Cryolite(Na3AlF6): 5%, Increases opacity, acts as flux
• Other ions: NA+, K+, Ca+, Sr+3
• Fluoride: Decrease fusion, anti cariogenic property, increase translucency.

Setting Reaction of Glass Ionomer Cement:
• Glass-ionomers set within 2–3 min from mixing by an acid-base reaction.
• The first step is a reaction with hydrated protons from the polyacid at basic sites on the surface
of the glass particles. This results in the movement of ions such as Na+ and Ca2+ (or Sr2+)
from the glass into the polyacid solution, followed quickly by Al3+ ions. These ions then
interact with the polyacid molecules to form ionic crosslinks, and the insolubilised polysalt that
forms becomes the rigid framework for the set cement. When this setting reaction occurs, all of
the water becomes incorporated into the cement, and no phase separation occurs.
• Subsequently, there is a cross linking process involving Al3+ ions. This second step is slow,
and continues for approximately a day.
• After this initial hardening, there are further reactions, which take place slowly and are
together known as maturation. They are associated with various changes in the physical
properties of the resulting glass-ionomer cement. Strength typically increases, as does
translucency. In addition, the proportion of tightly-bound water within the structure increases.
18) What are the indications & contraindications of GIC?

Indications:
• Non-stress bearing areas
• Class III and V restorations in adults
• Class I and II restorations in primary dentition
• Temporary or “caries control” restorations
• Crown margin repairs
• Cement base under amalgam, resin, ceramics, direct and indirect gold
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• Core build-ups when at least 3 walls of tooth are remaining (after crown preparation).
Contraindications:
• High stress applications
• Class IV and class II restorations
• Cusp replacement
• Core build-ups with less than 3 sound walls remaining
19) What are the advantages & disadvantages of GIC?

Advantages:
• Bonds to enamel and dentin
• Significant fluoride release, can be recharged
• Coefficient of thermal expansion similar to tooth structure
• Tooth colored
• Low thermal conductivity.

Disadvantages:
• Opacity higher than resin
• Less polishability than resin
• Poor wear resistance
• Brittle, poor tensile strength
• Poor longevity in xerostomic patients.
20) What are the modifications of Glass ionomer cement?

Modifications of Glass Ionomer Cement:
• Metal modified glass ionomer
• Cermet (glass sintered with silver)
• Resin modified glass ionomer
• “High strength,” “packable,” or “high viscosity” glass ionomers
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21) What are the properties of Calcium hydroxide cement?

Calcium hydroxide is a white odorless powder with the formula Ca (OH)2, and a molecular
weight of 74.08. It has low solubility in water which decreases as the temperature rises; it has a
high pH (about 12.5±12.8) and is insoluble in alcohol. This low solubility is, in turn, a good
clinical characteristic because a long period is necessary before it becomes soluble in tissue f
luids when in direct contact with vital tissues.
Properties:
• Arrangement is amorphous matrix, crystalline fillers
• Bonding = covalent; ionic
• Setting reaction = acid base reaction
• Insulator for thermal and electrical conductivity
• Solubility: 0.3-0.5
• Elastic modulus is 588
• Compressive strength >24 hr is 138.
22) Explain mechanism of action of calcium hydroxide cement
• Mechanism of action (MOA) of hydroxyl ions bacteria: Calcium hydroxide is an antibacterial

agent due to its elevated pH which influences the specific activity of the proteins of the
membrane with a combination with specific chemical groups and can lead to alterations in the
ionization state of organic components, depending on pH, there will be an intense transfer of
available nutrients through membrane, inducing inhibition and toxic effect on cell. Thus, the
influence of elevated pH (12.6) of OHions, transfer capacity and permeability of cytoplasmic
membrane explains the action of calcium hydroxide on bacteria, this is known as lipidic
peroxidation.
• MOA on tissues: Elevated pH of calcium hydroxide activates alkaline phosphatase from the
tissue. This is hydrolytic enzyme that liberates phosphate from esters of phosphates. This
phosphate ion, once free, reacts with calcium ion from the blood stream to form a precipitate,
calcium phosphate, in the organic matrix. This precipitate is the molecular unit of
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hydroxyapatite. Calcium hydroxide when in direct contact with adjacent tissue gives origin to a
zone of necrosis through rupture of glycoproteins resulting in protein degeneration within 7 to
10 days.
23) What are the uses of Calcium Hydroxide cement?
• As an intracanal medicament
• As an endodontic sealer
• As a pulp capping agent
• For apexification procedure
• As an pulpotomy agent
• As a intra canal dressing for weeping canals
24) What are the advantages & disadvantages of calcium hydroxide cement?
Advantages:
• Initially bactericidal then bacteriostatic
• Promotes healing and repair
• High pH stimulates fibroblasts
• Neutralises low pH of acids
• Stops internal resorption
• Inexpensive and easy to use
Disadvantages of calcium hydroxide
• Associated with primary tooth resorption
• Dissolve after one year with cavosurface dissolution
• May degrade during acid etching
• Degrades upon tooth flexure
• Marginal failure with amalgam condensation
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• Does not adhere to dentin or resin restoration
25) What are Compomers?
• The word “Compomer” comes from composite and glassionomer.
• The material itself is a polyacrylic / polycarboxylic acid modified composite.
• Composer are composed of composite and glass ionomer components in an attempt to take
advantage of the desirable qualities of both materials: the fluoride release and ease of use of
the glass ionomers and the superior material qualities and esthetics of the composites.
• Compomer restorations have been shown to have insufficient retention without pretreatment of
the dental hard tissue with an adhesive system.
• Compomer are most suitable for restorations in the deciduous dentition due to their low
abrasion resistance.
• In cervical restorations, composer restorations performed better than resin-modified glass

ionomers but not as well as hybrid composites.
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CHILD PSYCHOLOGY
Dr Malathi
1.Enumerate the theories of child psychology
Ans:child psychology theories can be broadly classified in two groups
A.Psychodynamic theories
a.psychosexual theory by Sigmund Freud
b.Cognitive theory by Jean piaget
c.Psychosocial theory by Erickson
B.Theories of learning and development of behaviour
a.Classical conditioning by Ivan Pavlov
b.Operant conditioning by BF skinner
c.Hierarchy of needs by Abraham Maslow
d.Social learning theory by Albert Bandura
2.Psychic traid
Ans:Freud made the tripartite structural model of ego,ID, and superego to understand the
intrapsychic process
ID:It is basic structure of personality, which serves as a reservoir of instincts. It is present at birth
as impulse and strives for immediate pleasure and gratification.
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Super ego: part of personality that is internalized representation of the values and morals of
society as taught to the child by parents and others. It is essentially an individual conscience, and
it judges whether the action is right or wrong.
Ego:It is part of self, that is concerned with overall functioning and organisation of personality
through its capacity to test reality and utilisation ego defence mechanism and other functions like
memory,language and creativity.
3)Iceberg phenomenon
Ans:Freud compared the human mind to an iceberg the small part that shown above the surface
of the water represents the conscious experience, and the much larger base belo water represents
the unconscious experience.
Conscious level: which relates to the awareness of an individual to his environment. It function
when the individual is awake.
Precocious level:it is described as that part of mind in which ideas and reactions are stored and
partially forgotten.
Unconscious level:it is largest part in the mind, Elements of unconscious mind are in accessible
to conciousness. They become conciousness only through precocious mind. It is a
Storehouse for all the memories, feelings and responses experienced by the individual during his
entire life.
4)Stages in Freud theory
Ans:According to Freud, all human being pass through a series of five psychosexual stages:
Oralstage 0 to 2 years – During the first year of life the mouth is the principal organ.
Gratification is by sucking the breast of mother and bottle.
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Analstage 2 to 3 years – Membranes of the anal region provide pleasure. Not passing fecal
matter also gives pleasure to the child.
Phallicstage 3 to 6 years – self-manipulation of the genital organs; the child also identifies group
to which he belongs’; what is the difference between him and his younger sister.
Latencystage of 6 to 12 years – this is a stage of psychosexual development when overt sexual
interest is repressed and sublimated. The child’s attention is focused on learning skills and other
peer activities.
Genitalstage – This is the final stage of psychosexual development reached in puberty when the
deepest feelings of pleasure are said to come from heterosexual relations.
5)Ego defence mechanism
Ans:
COMPENSATION:
Compensation a pattern of adaptive behaviors by which anxiety from feeling of inadequacy or
weakness is relieved as individual emphasizes of intensive training of some personal or social
attribute that over shadows his inadequacy and gain social approval .It can be seen in infant who
substitute his thumb for nipple to relieve tension and compensate for some pleasurable sensation
of sucking.
DISPLACEMENT:
When an individual unconsciously believes he would be in great danger of that person knew his
feelings about same person. He discharge of feelings on to a person or object entirely different
from the one to which they actually belong. He displaces his emotion to other person or object
which is less anxiety producing.
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SUBLIMATION:
In mechanism of sublimation the energy involved in anxiety produced primitive impulses is
unconsciously redirected into constructive and socially acceptable channels. It is one of positive
adaptation to anxiety and responsible for much of artistic and cultural achievements of civilized
people. It is when woman redirects her sexual desires into successful career of poetess.
SUBSTITUTION:
Mechanism used to reduce tension resulting from frustration. Substituting action must have
certain similarities to the frustrated one.
FIXATIONS:
It is arrest of emotional development at a stage. Fixation refers to the point in the individual’s
development at certain aspects of emotional development cease to advance. Further development
is blocked. They cannot bypass that phase, he is always handicapped in proceeding to the stages
that follow.
DENIAL:.
It is a process where the individual truly does not recognize the existence of an event or feeling.
Denial is used in Schizophrenia. It is often seen as a reaction of the healthy person when he is
confronted by a disastrous situation.
IDENTIFICATION:
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It useful mechanism because it plays a large part in development of a child personality. Through
this process individual defends against anxiety resulting from feeling of inadequacy by
unconsciously taking on desirable attributes found in people for whom he has admiration and
affection. He integrates these attributes into his own personality..
INTROJECTIONS:
Mechanism of introjections is closely related to identification. Introjection tends to replace all or
part of personality. Introjection is that entire personality of a second person has been
incorporated and has replaced the original personality. Introjections may operate in a less
constructive way than identification.
ISOLATION:
Where feelings are detached from the event in the individual’s memory, enabling the person to
recall the event without anxiety. It is found in (OCN) compulsive personality. They value
efficiency, cleanliness and punctuality
RATIONALIZATION:
Rationalization is a mental mechanism that is almost universally employed. It is an attempt to
make his behavior as result of logical thinking rather than result of unconscious desires that are
anxiety producing. It is a face saving device that may or may not deal with the actual truth.
Rationalization is almost unconscious avoidance. It relieves anxiety temporarily but not an
effective mechanism of adjustment because it helps the person to avoid facing the reality. Person
gives logical excuse. Student says that due to sickness she could not pass. It is” grapes are sour
mechanism.”
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REGRESSION:
Regression occurs when an individual is faced with anxiety from a conflict, that cannot to solved
by using the adaptive mechanism with which he used to solve problems. In such a situation, he
may unconsciously return to the patterns of behavior appropriate to an earlier developmental
stage. Any retreat into a state of dependency on others to avoid facing acute problems “Crying
on someone shoulder” is symbolic of infants seeking comfort on maternal bosom.
REPRESSION:
Painful experiences unacceptable thoughts and impulses are dismissed from conscious mind to
unconscious mind. During child hood they are repressed and becomes unconscious source of
emotional conflict in later life. Selfish, hostile, sexual feeding are repressed. Such repression
cause internal conflict.
PROJECTION :
Projection is transferring the responsibility for unacceptable ideas, wishes or thoughts to another
person when individual’s own aggressive thoughts are unacceptable to him and cause anxiety, he
blames some one else for it. It is used in paranoid, he is suspicious about infidelity of his wife
when actually he lack of fidelity in his mind..
CONVERSION:
Conversion refers to the expression of emotional conflict through physical symptoms for which
there is no organic basis. It is preceded after repression. All painful experience repressed into
unconscious mind when the conflict reappears as physical symptoms, pt. is not aware of
connection between two pheromones. Although physical symptoms is symbolically related to the
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nature of conflict. This symptom always serves to distract attention from his real problem. He
gains two ways.
His anxiety is relieved (primary gain).
He gains attention and sympathy of others (secondary gain).
SYMBOLIZATION AND CONDENSATION.
Symbol is an idea or object used by conscious mind in lieu of actual idea or object. Instinctual
desires may appear through symbols, the meanings of which are not clear to conscious mind.
REACTION FORMATION:
When individual experiences anxieties resulting from unconscious feeling that are unacceptable
to him and relieve the anxiety by doing in a may that is directly opposite to which he really feels.
6)Stages in psychosocial theory:
Ans:stage 1 - Integrity vs despair
Stage 2 - Generativity vs stagnation
Stage 3-Intimacy vs isolation
Stage 4 - identity vs role confusion
Stage 5 - industry vs inferiority
Stage 6 - initiative vs guilt
Stage 7 - Autonomy vs shame and doubt
Stage 8 - Trust vs mistrust
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7)Stages in Cognitive theory
Ans:Sensorimotor stage :The first stage of Piaget's theory lasts from birth to approximately age
two and is centered on the infant trying to make sense of the world. During the sensorimotor
stage, an infant's knowledge of the world is limited to his or her sensory perceptions and
motoractivities.
Pre operational stage:-The preoperational stage occurs roughly between the agestwoand seven.
Language development is one of the hallmarks of this period. During the preoperational stage,
children also become increasingly adept at using symbols, as evidenced by the increase in
playing and pretending.Concrete operational stage- The concrete operational stage begins
around ageseven and continues until approximately age eleven. During this time, children gain a
better understanding of mental operations. Children begin thinking logically about concrete
events, but have difficulty understanding abstract or hypothetical concepts
Formal operational stage-The formal operational stage begins at approximatelyage twelveto
and lasts into adulthood. During this time, people develop the ability to think about abstract
concepts. Skills such as logical thought, deductive reasoning, and systematic planning also
emerge during thisstage.
8)Constructivism
Ans:The child likes to explore things and make own observations. For ex: Child surveys the
dental chair and airway syringe.
9)Animism
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Ans:Child correlates things with other objects which they are more used to or accustomed, foe
ex: the hand piece can be called “whistling Willie” who is happy when he works at polishing the
child’s teeth.
10).Schema
Ans:It represents a dynamic process of differentiation and reorganisation of knowledge with the
resultant evolution of behaviour and cognitive functions apparatus for the age of child.schemas
are categorised of knowledge that help us to interpret and understand the world.
11)Equilibration
Ans:Piaget believed that children try to balance between assimilation and accommodation,
which is achieved through a mechanism called equilibration. As children progress through the
stages of cognitive development, it is important to maintain a balance between applying previous
knowledge (assimilation) and changing behaviour to account for new knowledge
(accommodation).
I 2)Operant conditioning theory
Ans:positive reinforcement: if a pleasant consequence follows a response, the response has
been positively reinforced and behaviour that led to this pleasant consequence become more
likely in the future.ex:child is giving a reward for behaving well during treatment.
Negative reinforcement: it involves withdrawal of an unpleasant stimulus which increases the
likelihood response in the future.
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Omission:involves removal of a pleasant stimulus after a particular response. Ex:if a child who
throws a temper tantrum has his favourite toy taken away for short time as a consequence of this
behaviour, the probability of similar misbehaviour is decreased.
Punishment:where as unpleasant stimulus is presented after a response. This also decreases the
probability that the behaviour prompted punishment will occur in the future.ex:voice control,
using of palatal crib appliance.
13)Classical conditioning theory
Ans:Acquisition:Learning a new response from the environment by conditioning.
Generalisation:wherein the process of conditioning is evoked by a band of stimuli centered
around a specific conditioned stimulus.ex:A child who had a painful experience with doctor in
white coat will always associate any doctor in white coat with pain.
Extinction: Removal of conditioned behaviour results if the association between the conditioned
and the unconditioned response is not reinforced. Ex: in a fearful child, subsequent visits to the
doctor without any unpleasant experience result in extinction of fear.
Discrimination:It is the opposite of generalisation. Ex: the conditioned association of white
coats with pain can easily be generalised to any office setting. If child is exposed to clinical
setting which are different to those associated with painful experiences, a dental office, for
instance, where painful injections are not necessary, the child learns to discriminate between two
clinics and a generalised response to any office as a place where painful things occur will be
extinguished.
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14)Bandura’s Modelling theory
Ans:Attention:Observational learning can be an important tool in management of dental
treatment. If a young child observes an older sibling undergoing dental treatment without
complaint an uncooperative behaviour, he or she is likely to intimate this behaviour. If the older
sibling is observed being rewarded, the younger child will also expect a reward for being well.
Retention: If the observer is to reproduce the model’s behaviour when the model is no longer
present to serve as a guide, the response must be memorised and coded in symbolic form.
Motoric reproduction:Our ability to actually perform the actions we observe.
Motivation/Reinforcement:When positive incentives are provided, observational learning will
be promptly translated over performance. therefore, the influence of modelling upon behaviour
will be weakened as a result of failure to observe the relevant activities.
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Emotional development
Dr KS Roja Ramya
1. Define fear and anxiety
A. Fear is defined as a reaction to a known danger.
Anxiety is a reaction to a unknown danger.
2.What are the various types of fears
• Types of fears
1. Innate fear – Inborn fear
2. Objective fear - produced by direct physical stimulation of the sense organs
3. Subjective fear - those based on feelings and attitudes that have been suggested
to the child by others
A. Imaginative fears .
B. Suggestive fears.
C. Imitative fears
3.what are types of cries
A. Obstinate cry:
• Show temper tantrum and deny dental treatment
• Loud, high pitched, Siren like wail
Frightened cry:
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• Accompanied by torrent of tears
• Convulsive breath-catching sobs
Hurt cry:
• More frequently accompanied by whimper
• Initially child shows a single tear from the corner of eye & running down the child’s
cheek without making any sound or resistance to treatment procedure
Compensatory cry:
• It is a sound that child makes to drown out, for example an airotor drill.
• Cry is slow, monotone.
4. Name few anxiety rating scales
•. Venham picture test
• Children’ fear survey schedule –dental subscale (CFSS-DS)
• Corah’s dental anxiety scale (DAS)
• Visual analogue scale
5.Define Phobia and write types of Phobia
A. It is an irrational fear resulting in the conscious avoidance of a specific feared object activity
or situation.
Types of Phobia
• Exogenous phobia
• Endogenous phobia
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CLASSIFICATION:
1. Simple phobia
2. Situational phobia
3. Social phobia
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BEHAVIOUR MANAGEMENT
Dr KS Roja Ramya
1. Define behaviour
A. Behavior is an observable act or any change in the functioning of an organism.
2. Define Behavior management
A. It is the means by which the dental health team effectively and efficiently performs
treatment for a child and at the same time, instils a positive dental attitude (Wright, 1975).
3. Define Behavior modification
It is defined as the attempt to alter human behavior and emotion in a beneficial manner according
to the laws of modern learning theory
4. Define Behavior shaping
A. it is the procedure which slowly develops behavior by reinforcing a successive
approximation of desired behavior until desired the desired behavior comes into being
5. WHAT ARE THE FACTORS INFLUENCING CHILD’S BEHAVIOR IN
DENTAL OFFICE
•Maternalanxiety
• Family and peer influence
• Dental office environment
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• Growth and development
• Personal factors
• Environmental factors
6. What are the Objectives of behavior management
A. • To establish effective communication with child and parent
B. . • Gain child and parent confidence for dental treatment.
C. • Teach child positive aspect of preventive dental care.
D. • Provide a comfortable, relaxing environment to the child
7. What are the Fundamentals of behavior management
A. • Team attitude • Organization • Positive approach • Truthfulness
• Tolerance • Flexibility
8. Write the Wright’s classification of behaviours
A. Cooperative behavior
B. • Lacking cooperative behavior
C. • Potentially cooperative behavior (5 subtypes)
Uncontrolled
Defiant
Tense cooperative
Timid
Whining
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Stoic
9. Write Frankel’s behaviour rating scale
Rating 1: definitively negative(--)
• Refusal of treatment
• Crying forcefully, fearful / any other overt evidence of extreme negativism
Rating 2 : negative(-)
• Reluctant to treatment
• Un cooperative, evidence of negative attitude, not pronounced
Rating 3 : positive(+)
• Accept treatment, at time cautious
• Willingness to comply with the dentist , at times with reservation but follows the
dentist direction cooperatively
Rating 4: definitively positive(++)
• Good rapport with dentist ,
• Interested in the dental procedures laughing & enjoying
11. Write about Communication
A. Establishing communication is the First objective in successful management of the young
child
• There are two ways of establishing communication:
– Verbal: Spoken language to gain confidence.
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– Nonverbal: Expression without words like welcome hand shake, patting, eye contact.
The three most important facets of communication are source, medium and receiver. dentist is
the source, dental clinic is medium and child is the receiver.
Communication with children aged 2 to 7 years should be based on using euphemisms (word
substitutes)
• The tone of the voice can also be very effective in altering the child’s behavior.
12. TELL-SHOW-DO technique.
• Tell-show-do (TSD), the cornerstone of behavior management
Objective:
– To familiarize the child with the dental setting.
– To shape patients response to various procedures.
• Specifically, the dentist tells the child what is going to be done in words the child can
understand. Second, the dentist demonstrates to the child exactly how the procedure will be
conducted. Finally, the practitioner performs the procedure exactly as it was described and
demonstrated.
12. MODELING
Modeling has been used as a technique to eliminate or minimize fear of dentistry in children by
allowing the child to observe an older sibling undergoing dental treatment.
• It is based on Bandura’s social learning theory.
Objectives of modeling
• Stimulates acquisition of new behavior.
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• Elimination of avoidance behavior.
• Extinction of fear.
Types of modeling:
– Audiovisual
– Live modeling by sibling or parent
13. CONTINGENCY MANAGEMENT
• This behavior management technique is based on BF Skinner’s operant conditioning.
• It includes:
– Positive reinforcement
– Negative reinforcement
– Omission or time out
– Punishment.
Positive reinforcement: It is the presentation of the pleasant stimulus
Negative reinforcement: Withdrawal of the unpleasant stimulus like high speed hand piece.
Time-out (or) omission: It is the withdrawal of the pleasant stimulus to reinforce good behavior.
Eg: sending mother out
Punishment: It is the presentation of the unpleasant stimulus to the child, e.g. voice control, hand
over mouth exercise (HOME).
Types of Reinforcers
• Material: Stickers, pencils, small toys
• Social: Praise, positive facial expression, hand shake, smile, hug.
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• Activity: Opportunity of participating in a preferred activity like a cartoon show, visit to the
park.
14. VOICE CONTROL
• Sudden and firm commands are used to get the child’s Attention.
• Soft, monotonous soothing conversation can also be used as it is supposed to function like
music to set the mood.
• The tone of voice and the facial expression of the dentist are also important
• Objectives:
– To gain the patient attention and compliance
– To avoid negative or avoidance behavior
– To establish authority.
• Indications: Uncooperative and inattentive patients
• Contraindications: very young Children, disability children, mental or emotional immature
children.
15. Distraction technique
This is a newer method of behavior management in which the patient is distracted from the
sounds and/or sight of dental treatment thereby reducing the anxiety.
• Objective is to relax the patient and to reduce anxiety during treatment.
• Use stories and fairy tales.
• Use slow instrumental music.
Types:
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– Audio distraction: Patient listens to audio presentation through headphones throughout the
course of the treatment. Relaxation effect of music will
eliminate unpleasant dental sounds.
– Audiovisual distraction: Patient is shown audiovisual presentation through television during
the entire treatment.
16. FLOODING TECHNIQUE or IMPLOSION THERAPY
This is a behavior modification technique in which child is flooded with many stimuli.
Child has no other choice but to face it until negative behaviour disappears. e.g. Using hand over
mouth (HOM), voice control and physical restraints together.
17. HAND OVER MOUTH TECHNIQUE
This is a behaviour management technique used in uncooperative child.
Objective
• To gain child’s attention
• To eliminate inappropriate avoidance behavior to dental treatment
• To assure child safety in delivery of quality dental care.
Indication:
A healthy child who is able to understand and cooperate but who exhibits defiant, or hysterical
behavior to dental treatment.
Contraindications:
• Immature child
• When it prevents child from breathing
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Technique
A hand is placed over child’s mouth and behavioral expectations are calmly explained. Child is
told that the hand will be removed as soon as the appropriate behavior begins. When child
responds, the hand is removed and child’s appropriate behavior is reinforced. If the child shows
negative behavior again the procedure is repeated.
18. Physical restraints
A. Indications for Using Immobilization :
A patient cannot cooperate because of lack of maturity,mental or physical disabilities.
When all other behavior management techniques have failed.
When the safety of the patient or practitioner would be at risk Contraindications :
A cooperative patient
Any underlying medical or systemic conditions
As punishment
• FOR BODY:
• Papoose Board
• Triangular Sheet
• Pedi wrap
• Bean Bag Dental Chair Insert
• EXTREMITIES:
• Posey Straps
• Velcro Straps
• Towel and tape
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• Extra Assistant
HEAD:
• Forearm Body support
• Head Positioner
• Plastic Bowl
• Extra Assistant
FOR MOUTH:
• McKesson Mouth Props
• Molt Mouth Props
• Rubber bite blocks
19. Define Conscious sedation
A. A minimally depressed level of consciousness that retains the patient’s ability to
independently and continuously maintain an airway and respond appropriately to physical
stimulation or verbal command and that is produced by a pharmacological or
nonpharmacological method or a combination thereof.
20. What are the indications of conscious sedation
• Lack of psychological or emotional maturity
• Medical, physical, cognitive disability
• Fearful, highly anxious patient
• A patient whose gag reflex interferes with dental care
• A cooperative child undergoing a lengthy dental procedure

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21. What are the objectives of conscious sedation
• Reduce or eliminate anxiety
• Reduce untoward movement and reaction to dental treatment
• Enhance communication and patient cooperation
• Aid in treatment of the mentally/ physically disabled or medically compromised
patient
• Reduce gagging
22. Write various techniques of sedation
A. Various techniques can be employed for inducing sedation.
Non Titrable Techniques
▪Oral Sedation
▪Rectal Sedation
▪Intra-muscular Sedation
▪Sub-mucosal Sedation
▪Intra-nasal Sedation
Titrable Techniques
▪Inhalational Sedation
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▪Intra-venous Sedation
23. What are the various drugs that can be used for sedation
A. Benzodiazepines
Diazepam
Lorazepam
Midazolam
Opioid Analgesics
Fentanyl
Morphine
Ketamine
Choral hydrate
Propofol
24. What is diffusion hypoxia
A. Diffusion hypoxia may occur as the sedation is reversed at the termination of the procedure.
The nitrous oxide escapes into the alveoli with such rapidity that the oxygen present becomes
diluted; thus the oxygen–carbon dioxide exchange is disrupted and a period of hypoxia is
created.
To minimize this effect, the patient should be oxygenated for 3 to 5 minutes after a sedation
procedure.
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25. Define general anesthesia
A. An induced state of unconsciousness or complete loss of protective reflexes, including the
inability to continually maintain an airway independently and respond purposefully to physical
stimulation or verbal command and that is produced by a pharmacologic or nonpharmacologic
method or combination thereof.
26. What are the advantages of inhalation all sedation or Nitrous oxide sedation
• No irritation to mucous membranes
• Potent Analgesic effect even at sub-anesthetic doses
• Non-toxic to Liver & kidneys
• Mild Euphoria
• Excellent titratibility
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Pediatric endodontics
Dr Chandana
1. Indications of indirect pulp capping
History:
• Mild pain associated with eating
• Negative history of spontaneous,. extreme pain
Clinical Examination:
• Deep caribou’s lesion which are close to, but not involving the pulp in vital primary and young
permanent tooth.
• No mobility
• When pulp inflammation is seen as normal and there is a definite layer of affected dentin after
removal of infected dentin.
Radiographic examination:
• Normal lamina dura and PDL space
• No radiolucency of bone around the spices of the roots or in the furcation.
2. Indications of direct pulp capping
• Small mechanical exposure surrounded by sound dentin in asymptomatic vital primary teeth or
young permanent teeth.
• Exposure should have bright red haemorrhage that is easily controlled by dry cotton pellet with
minimal pressure.
3. Materials used for pulp capping.

Ca(OH)2:
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• Simulates reparative dentin bridge formation due to high alkalinity, which leads to enzyme
phosphotase being activated and thus releasing of inorganic phosphate(calcium phosphate)
leading to dentin bridge formation.
• It also has anti bacterial property
Corticosteroids and antibiotics:
• These agents include Neomycin and Hydrocortisone.
• Ledermix- mixture of Ca(OH)2 and prednisolone is used in pulp capping
• Other combinations used are pencillin or Vancomycin with Ca(OH)2.
Collagen fibers:
• Collagen fibers influence mineralisation and are less irritant than Ca(OH)2 with dentin bridge
formation in 8 weeks.
Denaturated albumin:
• It has calcium binding properties.
• When pulp capping was done with it, it forms a matrix for calcification.
MTA(Mineral trioxide aggregate)
• Ash coloured powder
• Hydrophilic in nature
• Initial pH is 10.2 and set pH is 12.5
• Low cytotoxicity
• It has ability to simulate cytokine and interleukins release from bone cell, indicating that it
actively promotes hard tissue formation.
• Composition is tricalcium aluminate, tricalcium silicate, silicate oxide, tricalcium oxide and
bismuth oxide.
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Lasers
• Andreas Meritz reported the effect of laser on direct pulp capping and reported 89% success.
Bone morphogenic protein
• Demineralised bone matrix could stimulate new bone formation when implanted to ectopic
sites such as muscles.
• It is also capable of inducing repetitive dentin.
• Recombinant human osteopenia protein-1 in a collagen carrier matrix appeared to be suitable

as bioactive capping agent for surgically exposed dental pulp.
4. MTA as pulpotomy agent
• MTA is used in regenerative type of pulpotomy.
• This type is also called reperative and inductive type of pulpotomy
• So called because it induces reperative dentin bridge formation
• Ash coloured powder
• Hydrophilic in nature
• Composition is tricalcium aluminate, tricalcium silicate, silicate oxide, tricalcium oxide and
bismuth oxide
• Initial pH is 10.2 and set pH is 12.5
• Low cytotoxicity
• It has ability to simulate cytokine and interleukins release from bone cell, indicating that it
actively promotes hard tissue formation.
5. Limitations of direct pulp capping in primary teeth.
• Caries process or pulp capping material may stimulate the undifferentiated mesenchymal cells
to differentiate into odontoclasticcells rather than odondoblastic cell formation which further
lead to internal resorption
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• High cellular content, abundant blood supply and consequently faster inflammatory response
and poor localization of infection are some of the reasons that direct pulp capping is
contraindicated in primary teeth.
6. Pulpotomy
• According to Finn- It is defined as the complete removal of coronal portion of the dental pulp,
followed by placement of suitable dressing or medicament that will promote healing &
preserve vitality of the tooth
Types of pulpotomy
 Vital pulpotomy:
1. Devitalisation(mummification or cauterisation)- mummify the vital tissue
Single sitting- Formocresol, laser, electrosurgery.
Two stage- GysiTriopaste, Easlick’s formaldehyde, paraformdevitalising paste
2. Preservation(minimal devitalisation, noninductive)- maintains maximum vital tissue, with
no induction of reperative dentin.- zinc oxide eugenol, glutei aldehyde,ferric sulphate
3. Regeneration(inductive, reperative)- has formation of dentin bridge- Ca(OH)2, bone
morphogenic protein, mineral trioxide aggregate, enriched collagen, freezes dried bone,
osteogenic protein
 No vital pulpotomy: done in compromised cases- Beechwood creosol, formocresol.
7. Indications of pulpotomy:
• Pulp exposure in primary teeth
• Teeth showing a large carious lesion but free of radicular pulpit is
• History of only spontaneous pain
• Haemorrhage from exposure sites bright red and can be controlled
• Absence of abscess or fistula
• No interradicular bone loss
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• No interradicularradioleucency
• Presence of at least 2/3rd of root length
• In young permanent teeth with vital exposed pulp and incompletely formed spices.
8. Formocresolpulpotomy
• Devitalisation type
• Formocresol was introduced by Buckley in 1904
Composition:
 creosol- 35%
 Glycerol- 15%
 Formaldehyde-19%
 Water-31%
3parts of glycerin(90ml)+ 1part distilled water(30ml)= Diluent(120ml)
4parts diluent(120ml)+ 1part Buckley’s Formocresol (30ml)= 150ml Formocresol of 1/5th
strength
Mechanism of action:
Prevents tissue autolysis by bonding to proteins.
Bonding ispeptide group of side chain aminoacids and is reversible process.
9. Classification of pulpotomy
Types of pulpotomy
 Vital pulpotomy:
1. Devitalisation(mummification or cauterisation)- mummify the vital tissue
Single sitting- Formocresol, laser, electrosurgery.
Two stage- GysiTriopaste, Easlick’s formaldehyde, paraformdevitalising paste
2. Preservation(minimal devitalisation, noninductive)- maintains maximum vital tissue, with
no induction of reperative dentin.- zinc oxide eugenol, glutei aldehyde,ferric sulphate
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3. Regeneration(inductive, reperative)- has formation of dentin bridge- Ca(OH)2, bone

morphogenic protein, mineral trioxide aggregate, enriched collagen, freezes dried bone,
osteogenic protein
 No vital pulpotomy: done in compromised cases- Beechwood creosol, formocresol.
10. Pulpectomy
It is defined as complete removal of the necrotic pulp from the root canals of primary teeth and
filling them with inert resorbable material so as to maintain the tooth in dental arch.
Indications:
 Tooth previously planned for pulpotomy that shows either dry pulp chamber or
uncontrolled haemorrhage
 Any primary tooth in the absence of permanent successor
 Any deciduous tooth with severe pulpal necrosis provided there is no radiographic
contraindication
 Primary tooth with necrotic pulps and minimum of root resorption
 Pulpless primary tooth with stomas
 Pulpless primary tooth in haemophiliacs
 Pulpless primary anterior teeth when speech, aesthetics are a factor
 Pulpless primary anterior molars holding orthodontic appliance
 Teeth with adequate periodontal and bony support
 Incipient internal resorption in the occlusal portion of the root canal
Method
 Anesthetise the tooth and isolate
 Access cavity preparation
 Deroofing of pulp chamber
 Coronal and radicular pulp tissue is removed with broaches
 Irrigation with saline
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 Trial working length radiograph is taken

 Canals enlarged
 Irrigation with irrigating solutions
 Drying with paper points
 Obutation
 Final restoration and stainless steel crown
Materials used for pulpectomy:

 Zinc oxide eugenol, calcium hydroxide, iodoform, vitapex, walkhoff paste, KRI paste,
Maistone paste, MTA, Endofloss.
11. Importance of H files in pulpectomy

 Also called hedstroem files.
 Made from round stainless steel wire to produce spiral flutes resembling cones
 Has higher cutting efficiency than K files
 They are inserted up to apex presssed laterally against one side of the wall and with
drawn with pulling motion.
 Kennedy strongly recommend the usage H files in primary teeth since they remove hard
tissue only on withdrawal, which prevents pushing the infected material through the
spices.
12. Materials used for obturation of primary teeth

 Zinc oxide eugenol- available as zinc oxide powder and eugenol liquid
 Calcium hydroxide
 Iodoform- derivative of iodine
 Vitapex- calcium hydroxide + iodoform + oil additives
 Walkhoff paste- parachlorophenol + camphor + menthol
 KRI paste- iodoform + camphor + parachlorophenol + menthol
 Maidstone paste- zinc oxide eugenol+ iodoform + thymol+ chlorphenolcamphor +
lanolin
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 Mineral trioxide aggregate- tricalciumaluminata + tricalcium silicate + silicate oxide +

tricalcium oxide + bismuth oxide
 Endofloss- barium sulphate + calcium hydroxide + iodoform+ zinc oxide eugenol
13. Apexogenesis:
It is defined as treatment of a vital pulp by capping or pulpotomy in order to permit continued
growth of the root and closure of open apex.
Indications:
 Traumatised or pupally involved vital permanent teeth when root apex is incompletely
closed
 No history of spontaneous pain
 No sensitivity on percussion
 No hemorrhagic
 Normal radiographic appearance
Procedure
 Application of rubber dam followed by local Anesthesia
 Removal carious tooth structure followed by opening of pulp chamber
 Removal of coronal pulp tissue with excavator not damaging the radicular pulp
 Rinsing all the residual debris followed by placement of wet cotton pellet over the
amputee pulp
 Ca(OH)2 mixture is placed over the amputee pulp stumps, followed by temporary
restoration
 Follow up radiographs for monitoring root canal development are taken
 Once root development is completed conventional root canal treatment is done
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14. Apexification
It is defined by Cohen as a method of induced development of the root apex of an immature
pulpless tooth by formation of osteocementum/bone like tissue.
Indications
 No vital permanent tooth with open apex(blunderbuss canals)
Procedure
First visit
 Pre operative assessment includes clinical evaluation of colour, mobility, tenderness and
swelling
 Periapical radiograph evaluated
 When acute signs and symptoms are absent, instrumentation is recommended
 Application of rubber dam followed by local Anesthesia
 Access is gained in the pulp chamber
 Barbed broach used to remove debris necrotic pulp tissue from the canal
 Irrigation is performed with saline
 Working length determined
 Circumferential filling done followed by irrigation
 Canal dried with paper points
 Ca(OH)2 is used to fill 2mm short of radiographicapex
 Barium sulphate added for radio opacity
 Temporary restoration
Second visit
 After 6- 24 months
 Tooth re entered apexification verified
 If apex is formed RCT is done
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15. Ca(OH)2
 Simulates reparative dentin bridge formation due to high alkalinity, which leads to enzyme
phosphotase being activated and thus releasing of inorganic phosphate(calcium phosphate)
leading to dentin bridge formation.
 It also has anti bacterial property
 Used as indirect, direct pulp capping agent , also for apexogenesis and apexification procedure
16. Formocresol
 Used in devitalisation type of pulpotomy
 Formocresol was introduced by Buckley in 1904
 Composition: creosol- 35%
 Glycerol- 15%
 Formaldehyde-19%
 Water-31%
3parts of glycerin(90ml)+ 1part distilled water(30ml)= Diluent(120ml)

4parts diluent(120ml)+ 1part Buckley’s Formocresol (30ml)= 150ml Formocresol of 1/5th
strength
Mechanism of action:
Prevents tissue autolysis by bonding to proteins.
Bonding is peptide group of side chain aminoacids and is reversible process.
17. Techniques of obturation in primary teeth

Aim of obturation is to prevent recontamination of canal from either apical or coronal leakage.
 Endodontic pressure syringe: This apparatus has syringe barrel, threaded plunger, wrench
and threaded needle. Needle is placed 1 mm barrel, short of apex and with slow with
drawing motion the needle is with drawn 3mm with each quarter turn of the screw until
the canal is visibly filled at the orifice
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 Mechanical syringe: cement is loaded into the syringe with 30 gauge needle as per the
manufacturers recommendation and expressed into canal. Press using continuous pressure
while withdrawing the needle.
 Tuberculin syringe: Has 26 gauge, 3/8th inch needle
 Jiffy tube: Material was expressed into the canal by slow finger pressure on the plunger
until the canal was visibly filled at the orifice
 Incremental filling technique: Endodontic plunger corresponding to the size of the canal
with rubber stop is used to place a thick mix of cement into the canal
Thick mix was prepared into a flame shape corresponding to the size and shape of the
canal and then tapped gently into the apical area with the help of plugger
 Lentulospiral technique: They are dipped into the canal to its predetermined length and
rotated in the canal.
 Other techniques: Amalgam plugger, paper points, wet cotton pellet.
18. Pulp vitality test

 Thermal test- heat test: Rotating dry prophylaxis cup, heated water bath, hot burnisher,
hot Guttapercha and hot compound.
 Cold test: stream of cold air, cold water bath, ethyl chloride, Co2 ice stick, pencil of ice
 Electric pulp testing: depends on vital sensory fibers present in the pulp.
False positive: pulp is necrotic still the the signals the sensation of tooth. This may be
due to electrode contact with metal restoration or the gingiva, patient anxiety,
liquefaction necrosis, failure to isolate before testing.
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False negative response: pulp is vital but still the patient feels unresponsive to electric
pulp tests. It is due to inadequate contact of electrode and enamel, recently traumatised
tooth, calcification of root canal, recently erupted teeth with immature apex, partial
necrosis.
 Other tests are anaesthetic testing, test cavity, physiometric tests,
photoplenthysmography, thermography, pulp haemogram, dual wave length
spectrometry, laser Doppler flowmetry, pulse oximetry.
19. laser Doppler flowmetry:

It is a new method of measuring the pulp vitality by measuring the velocity of RBC in
capillaries. A near infrared with a wavelength of 632.8nm is produced by 1mw helium neon laser
within the flow meter and is transmitted along a flexible fiber optical conductor inside a specially
designed round dental probe with a diameter of 2 mm. Enamel prisms and dentinal tubules guide
light to the pulp, where it is scattered both by static tissue by moving RBC’s. A fraction of back
scattered light from the tooth is returned to the flow meter along a pair of afferent optical fibers
within the probe. The scattered light beam from moving RBC’s will be frequently shifted while
those from static tissue is unshifted indicating non-vital pulp.
20. Pulse oximetry:

It is a proven a traumatic method of measuring vascular health by evaluating oxygen saturation.
Pulse oximetry is based on placing arterial blood between light source and detector. Light source
diode emits both infrared and red light, which is received by a photo- detector diode. Blood
pulsating through the vessel changes the light path, which modifies the amount of detected light.
This determines the pulse rate. To determine the oxygen saturation, pulse oximetry measures and
compares amplitudes of the ratios of transmitted infrared with red light.
21. Mention different irrigating solutions.

 Chemically non active: water, saline, local anaesthetic
 Chemically active: Enzyme; streptokinase, streptokinase, papain, trypsin, enzymol.
 Acids; 30% hydrochloride acid, 50% sulphuric acid, citric acid.
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 Alkalis; sodium hydroxide, potassium hydroxide, urea, sodium hypochlorite

 Chelating agents: ethylene diamine tetra acetic acid
 Oxidising agents; hydrogen peroxide, carbamide peroxide
 Antibacterial; chlorhexidine
 Detergents: sodium lauryl sulphate.
22. Electro surgical pulpotomy:

Marks reported 99% success rate for electro surgical pulpotomy for primary tooth.
 Rubber dam isolation followed by local Anesthesia

 Caries removal with large round slow speed bur
 Sterile cotton pellet in contact with pulp and pressure applied to abstain hemostasis
 The Hyfrecator plus is set at 40% power and the 705A electrode is used to deliver the
electrical arc
 Cotton pellet is quickly removed and the electrode is placed 1-2mm above the pulpal
stump.
 Electrical arc is allowed to bridge the gap to the pulpal stump fo r 1 sec, followed by a
cool down period of 5 sec.
 When the procedure is properly performed, the pulpal stumps appear dry and completely
blackened.
 Pulp chamber is filled with ZoE placed directly against the pulpal stumps.
 Final restoration is then placed.
23. Infected Vs affected dentin:
Infected dentin Affected dentin
Softened and contaminated with bacteria Demineralised but not yet invaded by bacteria
Contains irreversibly denatured collagen stained Contains reversible denatured collagen

by caries detecting dye
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Infected dentin Affected dentin
Requires removal Doesnot require removal
24. KRI Paste:

 KRI paste- iodoform + camphor + parachlorophenol + menthol
 It is used for obturation of primary teeth after pulppectomy.
25. Four contraindications of direct pulp capping:

 Severe toothache at night
 Spontaneous pain
 Tooth mobility
 Radiographic appearance of pulp, peri radicular degeneration
 Excess of hemorrhage at the time of exposure
 Serous exudate from the exposure
 External/ internal resorption
 Swelling/ fistula.
26. Gluteraldehyde:
 It was suggested by S. Gravenmade.
 It produces rapid surface fixation of underlying pulpal tissue.
 A narrow zone of eosinophilia, stained and compressed fixed tissue is found beneath the
area of application, blends into vital normal appearing tissue apical. With time
gluteraldehyde fixed zone is replaced by macrophagic action with dense collagen opus
tissue, thus the entire root canal tissue is vital.
27. Sweet Formocresol pulpotomy:
 Pulpotomy is defined as the complete removal of coronal portion of the dental pulp ,
followed by placement of suitable dressing or medicament that will promote healing &
preserve vitality of the tooth.
 Sweet Formocresolpulpotomy is multi visit pulpotomy.
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Traumatology
Dr Devi V
1) Ellis and Daveys classifications of traumatic injuries?
Class I- Simple fracture of crown involving only enamel with little or no dentin
Class II- Extensive fracture of crown involving considerable dentin but not exposing dental pulp
Class III-Extensive fracture of crown involving considerable dentin and exposing dental pulp
Class IV-The traumatized tooth that becomes nonvital with or without loss of crown structure
Class V-Total tooth loss - avulsion
Class VI-Fracture of the root with or without loss of crown structure
Class VII-Displacement of tooth with neither crown not root fracture
Class VIII-Fracture of crown en masse and its displacement
Class IX-Traumatic injuries of primary teeth
2) Treatment of root fractures?
Horizontal root #
• The principle of treatment of permanent teeth is reduction of displaced coronal fragments and firm
immobilization.
• Immobilization of teeth with root fractures is achieved with rigid fixation with an acid etch splint.
• The fixation period should be 2 to 3 months to ensure sufficient hard tissue consolidation.
• Following treatment modalities are recommended based on the fracture line:
– When fracture is present in middle third —extraction
– When fracture is in apical third —obturation till the possible working length and apical surgery to
remove the fragment.
When fracture is near to gingival margin—orthodontic or surgical extrusion of the fragment followed by
immobilization and later crown fabrication.
Vertical root fracture.
Single rooted teeth—extraction
- Multi rooted teeth—hemisection and the remaining
tooth is endodontically treated and resorted with crown.
140
3) classification of root fractures?
Classification of Root Fractures

A)Based on direction of fracture line with long axis of tooth:
– Horizontal: Fracture perpendicular to long axis of tooth.
– Oblique: Fracture is at an angle to long axis.
– Vertical: Fracture parallel to long axis.
B)Based on location
– Cervical third.
– Middle third.
– Apical third.
C)According to number of fracture lines:
– Simple: Only one fracture line dividing root into two
fragments.
– Multiple: When root is divided into more than two
fragments.
– Comminuted: Multiple fracture lines.
D)According to extension of line of fracture:
– Partial: Fracture involves a portion of root.
-Total: Entire root is involved with fracture line.
E) Position of root fragments:
– Without displacement: Segments face each other.
– With displacement: When fracture segments are not
aligned.
4) Subluxation?
An injury to tooth supporting structures with abnormal loosening but without clinically or
radiographically demon- strable displacement of the tooth.
Clinical Features
• Tooth is tender on palpation.
• Mobility.
• Evidence of hemorrhage at gingival margin.
Radiographic Features
141
• Widening of periodontal ligament space.

• Reduction in size of pulp after few months.
Treatment
• Slight adjustment of opposing tooth to relieve occlusion.
• Splinting for 10 days.
• Soft diet for 10 to 14 days.
• Follow-up the tooth clinically and radiographicaly.
5) Avulsion
Traumatic Injuries to Anterior Teeth. Term used to describe complete displacement of tooth from its
alveolus. It is also called as exarticulation and most often involves the maxillary teeth.
Clinical Features
Bleeding socket with missing tooth.
Radiographic Features
• Empty socket.
• Associated bone fractures.
• If the wound is recent then lamina dura is visible otherwise
it is obliterated.
Treatment
• Reimplantation depends on extraoral time.
• If apical foramen is not closed—endodontic therapy is
delayed till first signs of apical closure are seen.
• If apical foramen is closed—endodontic therapy is done after 1 to 2 weeks depending on type of
reimplantation.
Prognosis
Tooth survival: 51 to 89 percent
• PDL healing: 9 to 50 percent
• Pulp healing: 4 to 15 percent.
6) Hank’s balanced salt solution:
142
– It is a standard saline solution that is widely used inbiomedical research to support the growth of
manycells types.
– This solution is nontoxic, it is biocompatible withperiodontal ligament cells, pH balanced at 7.2 and
hasan osmolality of 320 mOm/kg.
– It is composed of 8 g/L sodium chloride; 0.4 g/L of D-glucose; 0.4 g/L potassium chloride; 0.35 g/L
sodium bicarbonate; 0.09 g/L sodium phosphate; 0.14 g/L potassium phosphate; 0.14 g/L calcium
chloride, 0.1 g/L magnesium chloride and 0.1 g/L magnesium sulfate. It containsingredients, such as
glucose, calcium and magnesium ions which can sustain and reconstitute the depleted cellular
components of the periodontal ligament cells.
– It is the best solution for storing avulsed teeth since it does not require refrigeration and it can be kept
on the shelf for 2 years and it has been recommended and used successfullyas a storage medium by
clinicians and researchers.
– It is commercially available as Save-A- Tooth [Pottstown, PA], which has an inner net to receive the
avulsed tooth and to minimize cell trauma during transport.
7) Types of splinting?
According to Ross, Wiesgold and Wright (1968):

• Temporary stabilization
– Removable extracoronal splints
– Fixed extracoronal splints
– Intracoronal splints
– Etched metal resin-bonded splints,
• Provisional stabilization
– Acrylic splints
– Metal-band-and-acrylic splints
• Long-term stabilization
– Removable splints
– Fixed splints
– Combination removable and fixed splints
2. According to Grant (1988) • Temporary
– External (extracoronal)
■Ligature splint
143
■Enamel bonding material
■Welded band splints
■Continuous splints
■Night guards
– Internal (intracoronal)
■ Acrylic splints
8) sequelae of dental injuries?
• White or yellow brown discoloration of enamel.

These lesions appear as sharply demarcated stained enamel opacities most often located on the facial
surface of the crown. Their extent varies from small spots to large fields.
White orYellow Brown Discoloration ofEnamel with Circular Enamel Hypoplasia
These lesions are a more severe manifestation of trauma sustained during the formative stages of
permanent tooth germ.
Typical finding in this group, which distinguishes these lesions from those in first group, is a narrow
horizontal groove, which encircles the crown cervically to the discolored areas.
Crown Dilaceration
These malformations are due to traumatic nonaxial displacement of already formed hard tissue in relation
to the developing soft tissues.
Odontoma like Malformations
The type of injury affecting the primary dentition appears to be intrusive luxation or avulsion. These cases
show a conglomerate of hard tissue having morphology of complex odontoma or separate tooth element.
Root Duplication
This is a rare occurrence seen after intrusive luxation of primary teeth. The pathology of these cases
indicates that a traumatic division of the cervical loop occurs at the time of injury resulting in formation
of two separate roots.
Lateral Root Angulation
These changes appear as a mesial or distal bending confined to the root of the tooth. In contrast to
vestibular angulation most teeth with lateral root angulation or dilacerations erupt spontaneously.
Partial or Complete Arrestof Root Formation
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A number of teeth with this type of root malformation remain impacted while others have inadequate
periodontal support.
In some instances, a typical calciotraumatic line separating hard tissue formed before and after injury is
seen. In these cases, trauma directly injures HERS thus compromising normal root development.
Sequestration of Permanent Tooth Germs
In case of jaw fractures infection can complicate healing sometimes leading to spontaneous sequestration
of involved tooth germs.
Disturbances in Eruption
The eruption of succeeding permanent incisors is generally delayed after premature loss of primary
incisor. Early loss of primary incisors causes ectopic eruption of permanent incisors due to lack of
eruption guidance otherwise offered by primary dentition.
9) What are the healing reactions after avulsive injury?

Healing with a Normal PeriodontalLigament
• Histologically, this is characterized by complete regeneration of PDL, which usually takes place 2
to 4 weeks to complete. This type of healing will only occur if innermost cell layersalong the root
surface are vital.
Healing with Surface Resorption
• Histologically, this type of healing is characterized by localized areas along the root surface,
which show superficial resorption lacunae repaired by new cementum.
• This surface resorption presumably represents localized areas of damage to PDL or cementum,
which is healed by PDL, derived cells.
• Clinically, the tooth is in normal position and a normal percussion tone can be heard.
Healing with Ankylosis (ReplacementResorption)
• Histologically ankylosis represents a fusion of the alveolar bone and the root surface and can be
demonstrated 2 weeks after reimplantation.
• The etiology of replacement resorption appears to be related to the absence of vital PDL cover on
the root surface.
• After some time little of tooth substance remains, at this stage the resorptive process are usually
intensified along the surface of the root canal filling a phenomenon known as tunneling
resorption.
145
Healing with Inflammatory Resorption
• Histologically inflammatory resorption is characterized by bowl-shaped resorption cavities in

cementum and dentin associated with inflammatory changes in the adjacent periodontal space.
• Pathogenesis is that minor injuries to PDL and cementum due to trauma or contamination with
bacteria induce small resorption cavities on the root surface.
10) Reimplantation?
• Case history should include exact information on the time interval between injury and
reimplantation as well as conditions under which the tooth has been stored (e.g. saline, saliva,
milk, tap water or dry environment). The following conditions should be considered before
replanting a permanent tooth:
• •The alveolar socket should be reasonably intact in order to provide a seat for the avulsed tooth.
• The extra-alveolar period.

Short extra-alveolar storage: This is done if the tooth since the time of injury has been placed in a
suitable medium and the extra-alveolar time elapsed is short.
Tooth is placed in saline
• If visibly contaminated, the root surface is cleaned with a stream of saline until visible
contaminants have been washed away.
• No efforts should be made to sterilize the root surface as such procedure will damage or destroy
vital periodontal tissues and cement.
• The socket is then examined for the evidence of fracture and alveolus is cleaned with a flow of
saline to remive contaminated coagulum.
• The tooth is replanted using slight digital pressure.
• Suture gongival lacerations
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• Apply splint for 1 week only as prolonged splinting of replanted mature teeth increases the extent
of resorption
• Proper repositioning is evaluated by the occlusion of tooth.
• Verify position radiographycally
• If apical foramen is closed then perform endodontic therapy 1 week reimplantation, prior to
removal of splint.
11) Etiology of traumatic injuries in children?
Following factors can be attributed:

• Falls in infancy
• Child abuse—battered child syndrome
• Sports injuries
• Horse riding
• Automobile injury
• Assault torture
• Mental retardation, epilepsy
• Drug related injuries
• Developmental defects of enamel and dentin like
dentinogenesis imperfecta.
147
12) Management of avulsed tooth?

13) storage media for avulsed toothSaline solutions
Saline solution
Tap water
Milk
Saliva
Viaspan
Gatorade
Propolis
Contact lens solution
Emdogain
Egg white
Eagles media
L-Dopa
Coconut water.
148
REQUIEMENTS OF STORAGE MEDIUM FOR AVULSED TOOTH
14) complicated crown fractures?
Clinical Features
• This occurs when there is a fracture of enamel, dentin along with exposure of pulp.
• This usually presents as a fractured segment of tooth with frank bleeding from the exposed pulp.
Treatment
• The type of treatment will depend upon the extent and time of pulp exposure.
• When the exposure is small and pulp has not been exposed for more than 4 to 5 minutes then it is
advisable to do pulp capping.
– When the exposure is large and pulp has been
exposed for more than 5 minutes then it is ideal to do pulpotomy/RCT.
149
15) classification of mouth guards?
3types of mouth guards.

Type I: stock mouthguards
Type II: mouth-formed mouth guards
Type III: custom-fabricated mouth guard.
Stock mouth guard

Stock mouth guards are not adapted to the dentition of the athlete,so that they must be held in place by
biting the teeth togeather. Because they are the least retentive and often bulky, stock mouthguards
interfere most with the athlete’s ability to breath and speak and often cause the athlete to gag.stock
mouthguard are generally made of polyethylene.
Mouth-formed mouth guard

Mouth-formed mouthguards are intermediate between the stock and custom fabricated types.mouth
formed mouthguards come in two varieties:shell lined and boil and bite.
Custom-fabricated mouthguard:
Custom fabricated mouth guards are made professionally over a dental cast of the athlete’s arch (
maxillary arch for patients with class I or class II malocclusion. Mandibular arch for patients with class
III malocclusion.
16) Mechanism of dental injuries in children
Direct trauma: Occurs when tooth itself is struck, e.g. against table or chair.
Indirect trauma: Seen when the lower dental arch is forcefully closed against upper, e.g. blow to chin.
The extent of trauma can be assessed by four factors given
by Hallet in 1954
1. Energy of impact:
• Energy = Mass × Velocity.
• Hence, if the impacting object either has more mass
or has high velocity, the impact will be more.
2. Resilience of impacting object:
• This can be either hard or soft.
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• More injury is bound to occur in the case of former

and less in case of later.
3. Shape of impacting object: The nature of wound depends
on whether the object is sharp or blunt.
4. Direction of impacting force: Type of fracture will directly
depend on direction.
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STAINLESS STEEL CROWNS
Dr KS Roja Ramya
1. WHAT ARE THE INDICATIONS OF STAINLESS STEEL CROWNS
•Extensive caries: caries is involving three or more surfaces.
•Extensive decalcification: On any one surface like proximal
• Rampant caries
• Recurrent caries
• After pulp therapy
• Inherited or acquired enamel defects, e.g. hypoplasia, amelogenesis imperfecta (permanent and
primary teeth)
• Severe bruxism
• Abutment teeth to prosthesis
• As part of a space maintainer
2.WRITE THE CONTRAINDICATIONS OF STAINLESS STEEL CROWNS
• Primary molars close to exfoliation.
• Primary molars with more than half the roots resorbed.
• Teeth that exhibit mobility.
• Teeth which are not restorable.
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• Patients with known nickel allergy.
3.Write the classification of stainless steel crowns
According to trimming
• Untrimmed crowns: These crowns are neither trimmed nor contoured e.g. The Rocky
Mountains
• Pretrimmed crowns: These crowns have straight, noncontoured sides They still require
contouring and some trimming, e.g. Unitek, 3M Co
• Precontoured crowns: These crowns are festooned and are also precontoured e.g. Uniter
stainless steel crowns
According to composition:
• Stainless steel crowns—188 Austenitic stainless steel (67% iron, 18% chromium, 8% nickel),
e.g. Unitek stainless steel crowns
• Nickel-chromium crowns—Nickel chrome Alloy (70% nickel,15% chromium,10% iron) e.g.
NiChro Ion crowns
4. Write the composition of stainless steel crowns
Iron – 67%
Chromium - 17 to 19%
Nickel–– 10 to 13%
Minor elements – 4%
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5. Write the composition of Nickel base crowns
Nickel– 76%
Chromium – 15%
Iron– 8%
Carbon – 0.08%
Manganese – 0.35%
Silicon– 0.2%
6. Advantages of Stainless Steel Crown
• Can be completed in a single appointment.
• Less time consuming than cast restorations.
• No need for laboratory procedures.
• Less prone to fractures.
• Longevity.
• Durable as compared to multi-surface restorations
• Cost effective.
7. What are the Disadvantages of Stainless Steel Crowns
• Significant amount of tooth structure is removed.
• Unesthetic.
• Poor marginal adaptation may cause gingivitis.
• Gingival inflammation due to excess unremoved cement.
• Overhanging distal margins may cause impaction ofpermanent 1st molars.
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8. What is hall’s technique
A. This is the technique of placement of stainless steel crown without any caries removal
and tooth preparation.
This technique was developed by Dr Hall.
9. What are the indications of hall’s technique.
A. Class I—cavitated or noncavitated lesions where in the child is unable to accept caries
removal or conventional restoration.
Class II—cavitated or noncavitated lesions.
10. What are the contraindications of hall’s technique.
• Signs or symptoms of irreversible pulpitis.
• Clinical or radiographic signs of pulp exposure.
• Unrestorable crowns.
• Patient at risk for bacterial endocarditis.
11.What are the advantages of hall’s technique.
• Quick and noninvasive.
• No tooth preparation is needed.
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• No need for caries removal.
• No need for local anesthesia and rubber dam.
• Acceptable to dentist, parent and child.
12. What is the procedure of hall’s technique.
A. The six stages of crown placement are
1. Size: The smallest crown that covers all the surfaces is selected.
2. Fill: Dry the crown and fill with glass ionomer cement.
3. Locate and seat: Seat the crown by using finger pressure and ask the child to bite on it.
4. Wipe: Excess cement has to be wiped off with a cotton wool roll.
5. Seat further: Ask the child to bite on the crown firmly for 2- 3minutes.
6. Clean: Remove excess cement by means of a scaler.
Note : Halls technique is also an important 4 marks question. If given for 4 marks you need to
write 8,9,10,11,12 questions together.
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MINIMAL INVASIVE DENTISTRY, SEALANTS, PRR, ART

Dr P.Chaitanya
1) Define MID. What are the principles of minimal intervention?

Definition: Minimum (or minimal) intervention dentistry (MI) can be defined as a philosophy of
professional care concerned with the first occurrence, earliest detection and earliest possible cure
of disease on micro (molecular) levels, followed by minimally invasive and patient-friendly
treatment to repair irreversible damage caused by such disease.
There are four basic principles that must be applied to fulfill the description of minimal
intervention dentistry.
1. Recognition – to identify and assess any potential caries risk factors & early diagnosis,
through lifestyle analysis, saliva testing and using plaque diagnostic tests
2. Reduction – to eliminate or minimize caries risk factors, through altering fluid balance,
reducing the intake of dietary cariogenic foods, addressing lifestyle habits such as smoking,
and increasing the pH of the oral environment.
3. Regeneration – to arrest and reverse incipient lesions, regenerating enamel subsurface
lesions using fluorides , CPP-ACP
4. Repair – cavitation is present and surgical intervention is required, tooth structure is
maintained by using conservative approaches to caries removal. Bioactive materials are used
to restore the tooth and promote internal healing of the dentine.
2) What is Mount & Hume Classification of cavity preparation?

This is a new system that identifies the site as well as the complexity of the lesion.
Site I: Pits and fissure on occlusal surfaces
Site II: Proximal areas just below the contact point
Site III: Cervical 1/3rd of crown
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Size I: Minimal involvement of dentin

Size II: Moderate involvement of dentin but remaining tooth structure strong enough to support
restoration
Size III: Large cavity with weakened tooth structure
Size IV: Extensive caries with loss of bulk of tooth structure
3) What is the philosophy and recommendations of MID?

Philosophy:
The ultimate goal of minimal intervention is to extend the life of restored teeth with as less
intervention as possible. When operative care is indicated, it should be aimed at “PREVENTION
OF EXTENSION”rather than “EXTENSION FOR PREVENTION”.
Recommendations:
1) Always follow the philosophy of minimally invasive dentistry.
2) Never remove more tooth structure than is absolutely required to restore teeth to their normal
condition.
3) Always use dental materials that conserve maximal tooth structure over time.
4) Use only the strongest and longest lasting materials to reduce the need for future repair and
replacement.
5) Use only restorative materials that do not wear opposing teeth more than enamel.
4) Explain the design of tunnel cavity preparation.
• This is indicated if the cavity is small and if placed 2 to 2.5 mm below the marginal ridge.
• The aim is to develop an access via the occlusal aspect so as to preserve the strength of
marginal ridge and also to prevent formation of proximal
• Access to the lesion through the occlusal surface should be limited to the extent required to
achieve visibility and should be undertaken from an area that is not under direct occlusal load.
• Fossa immediately next to mesial marginal ridge is the most suitable position for entry.
• Glass ionomer is the best suited for such cavities as it readily flows into a small cavity and has
the ability to remineralize the enamel margins and any dentin on axial wall.
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Steps:
• Start the cavity preparation in the direction of the lesion
• After lesion is spotted use a slow speed round bur to remove remaining caries
• Donot fracture the proximal wall if it is not involved
• Remove remaining caries with spoon excavators
• Restore using glass ionomer cement
5) What is slot cavity preparation?
• As the name denotes it is creation of small slot on the proximal aspect of posterior teeth.
• Indicated if there is a small lesion involving the area of or below the marginal ridge only in
deciduous teeth.
• The outline form will be dictated entirely by the extent of the breakdown of the enamel,
removing only that which is friable and easily eliminated without applying undue pressure.
Retention will be through adhesion, so it is only necessary to clean the walls around the full
circumference of the lesion, leaving the axial wall because it will be affected by dentin only.
• Cavity preparation is done only on the proximal aspect after establishing entry over marginal
ridge and the extent of cavity is defined by the extent of the lesion with the intention to
preserve as much tooth as possible.
• The material of choice is glass ionomer but resin composite may be a useful material
because on many occasions there will be an enamel margin around the full circumference.
6) What is proximal approach of cavity preparation?
• This is a very conservative approach used when the proximal surface of a tooth becomes
accessible at the time of cavity preparation in an adjacent tooth. The lesion may have been
revealed through radiographs or it may be noted only during cavity preparation.
• The larger cavity in the adjacent tooth will normally need to be of reasonably generous
proportions to allow room to maneuver, but when such an approach is possible, it leads to
considerable conservation of natural tooth structure. It is only necessary to remove enamel that
is broken down beyond remineralization. There will often be a residual area of demineralized
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enamel around the circumference of the lesion and this should be retained because it is quite
capable of being remineralized.
• As this entire restoration will be hidden by adjacent tooth, it is essential to use a radiopaque
material. Glass ionomer is preferred because the limited access will make it difficult to assure
full polymerization of the resin through light activation.
7) Define ART and describe operator and patient position for ART.
Definition: The Atraumatic Restorative Treatment (ART) is a procedure based on removing
carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive
restorative material. Another terminology used for ART is Alternate Restorative Treatment.
Operator posture and position:
• The work posture and the position of the operator should provide the best view of the inside of
the patient’s mouth. At the same time, both patient and operator should be comfortable.
• The operator sits firmly on the stool, with straight back, thighs parallel to the floor and both
feet flat on the floor. The head and neck should be still, the line between the eyes horizontal
and the head bent slightly forward to look at the patient’s mouth.
• The height of the stool must then be adjusted so that the operator can see the patient’s teeth
clearly.
• The distance from the operator’s to patient’s tooth is usually between 30 and 35 cm. The
operator should be positioned behind the head of the patient. The exact position will depend on
the area of the patient’s mouth to be treated.
Patient Position:
As with any other oral treatment, ART requires correct patient and operator positions. A patient
lying on the back on a flat surface will provide safe and secure body support and comfortable
and stable position for lengthy periods of time
8) What is the armamentarium and materials used for ART?

ART INSTRUMENTS: Centre for Oral health services research of WHO have developed
an
instrument set a total of 8 instruments are supplied in form of kit. It contains;
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1. Mouth mirror
2. Explorer
3. Tweezers
4. Spoon excavators (small, Medium, Large)
5. Enamel Hatchet
6. Double ended carver
7. Enamel access cutter.
8. Instrument tray
Material used:
• Glass ionomer cement that leach fluoride is material of choice as it also minimizes the onset of
secondary caries. High viscosity Glass Ionomer Cement (Fuji IX) is used as it simplifies the
restorative process and enable dentine-pulp complex to react against carious process.
• GIC creates a chemical bond between the cement and the remaining enamel and
dentine. This adherence provides an adaptive seal, and, as the material slowly leaches fluoride
ions into the adjacent tooth tissue, GICs are capable of halting or slowing the progression of
carious-lesions.
9) Explain the procedure of ART.

The following are steps involved in ART
STEP I: ISOLATION :
1. Reasonable light source weather natural or artificial should be available.
2. Isolate the operating area with cotton rolls.
3. The cavity is cleaned with moist cotton and dried using small cotton pellets or a chip
blower.
STEP II: EXCAVATION OF THE CAVITY
1. The caries is excavated depending on its size with a suitable spoon excavator.
2. Only soft carious infected is removed.
3. Remove all the unsupported enamel with an enamel hatchet.
STEP III: FILLING WITH GIC :
1. Glass Ionomer Cement is mixed as per manufactrers instructions and carried to the
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cavity using blunt end of the applier.

2. Put small of cement at a time in the cavity. This will ensure complete filling of the cavity
without any air voids which would ultimately be detrimental to the strength and
integrity of the restoration.
3. Use round surface of a medium excavator to push the mixture into deeper parts of cavity or
under any over hanging enamel.
4. The cavity is finally filled by press finger technique [13]. The finger is moved side ways
with pressure to remove excess of GIC which is then removed by sharp end of carver.
5. Cavity is restored and the adjacent fissures are sealed with GIC at the same time. This is
called sealed restoration.
6. Give appropriate setting time for the GIC which is as per manufacturer instructions.
7. Then check the bite using articulating paper and remove any excess cement if needed.
8. Remove the cotton rolls
9. Advise the patient not to eat or bite hard objects at least for one hour.
10) What are the advantages & disadvantages of ART?

Advantages of ART
• Easily available inexpensive hand instruments are used rather than the expensive electrically
driven dental equipment.
• As it is almost a painless procedure the need for local anesthesia is eliminated or minimized.
• ART involves the removal of only decalcified tooth tissues, which results in relatively small
cavities and conserves sound tooth tissue as much as possible.
• Sound tooth tissue need not be cut for retention of filling material. The retention is obtained by
the microtags produced due to etching and also because of the chemical adhesion of glass
ionomer restorative material with cavity walls.
• A practice of straight forward simple infection control is used without the need to use
autoclave hand pieces.
• The leaching of fluoride from glass ionomer probably remineralizes sterile demineralized
dentin and prevents development of secondary caries.
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• The combined preventive and curative treatment can be done in one appointment.
• Repairing of defects in the restoration can be easily done.
• It is less expensive and less time consuming, in one sitting several fillings can be done.
• One of the greatest advantages of ART is that it enables oral health workers to reach people
who otherwise never would have received any oral health service.
Disadvantages of ART:
• ART restorations are not long standing.
• The average life is two years depending upon the rate of caries activity of the individual oral
cavity.
• As fundamental principles of cavity preparation are not followed all oral health workers may
not accept it.
• Because of the low wear resistance and low strength of the existing glass ionomer materials
their use is limited to small and medium sized one surface cavity only.
• The continuous use of hand instruments over long period of time may result in hand fatigue.
• A relatively unstandardised mix of glass ionomer may be produced due to hand mixing.
11) What are pit and fissure sealants? What are the various morphological types of pits &
fissure on teeth?
Pit and fissure sealant (Simonsen RJ, 1978): Term used to describe a material that is introduced
into the occlusal pits and fissures of caries-susceptible teeth, thus forming a micro mechanically
bonded, protective layer cutting access of caries-producing bacteria from their source of
nutrients.
There are five types of pits and fissures according to Nagano (1961)
1. V – type (34%)
2. U – type (14%)
3. I – type (19%)
4. IK – type (26%)
5. Inverted Y – type (7%).
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12) Classify pit & fissure sealants

Pit and fissure sealants are classified into five types:
1. According to chemical structures of monomers used:
• Methylmethacrylate(MMA)
• Triethyleneglycol dimethacrylate(TEGDM)
• Bisphenol dimethacrylate(BPD)
• Bis-GMA is the reaction product of BisphenolA and glycidylmethacrylate (GMA) with a

methyl methacrylate monomer
• ESPE monomer
• Propyl methacrylate urethane(PMU)

2. Based on generations
• First generation sealants: Polymerized with UV light with wavelength of 356 µm.
- Had excessive absorption and incomplete polymerization of sealant at its depth.
Eg., Nuva-lite (Caulk/Dentsply).
• Second generation sealants: Self cure or chemical cure resins

- Based on accelerator catalyst system. Example: ConciseWhite(3M)
• Third generation sealants: Light cured with visible (blue) light of 430–490 µm. Eg., Helioseal
• Fourth generation: Fluoride releasing sealants. Eg., Seal right (Pulpdent).

3. Based on filler content:
• Unfilled: Advantages include better flow and more retention but, abrade rapidly
• Filled: Advantages include resistance to wear but, may need occlusal adjustments.
4. Based on color:
• Clear: Esthetic but difficult to detect in recall visit. Eg., Helioseal (changes from green to
white)
• Tinted/opaque: Can be identified, Eg., Delton
• Colored: Based on color change technology,.

Easy to see during placement and recall. Eg., Clinpro pink (changes to pink on setting)
5. Based on curing:
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• Autopolymerizing
• Light cure.
13) What are the indications & contraindications of pit & fissure sealants?
Indications:
• Newly erupted both primary molars and permanent bicuspids and/or sticky grooves and
fissures.
• Stained pits and fissures with minimum decalcification of opacification and no softness at
the base of the fissure.
• A tooth in question should have erupted less than four years ago.
• A deep or regular fissure, fossa or pit is present, especially if it catches the tip of the
explorer.
• The fossa selected for sealant placement is well isolated from another fossa with a
restoration present.
• An intact occlusal surface is present where the contra-lateral tooth surface is carious or
restored.
• If there is no radiographic evidence.
• Patient at moderate or high risk of developing dental caries for a variety of reasons.
• Patients with incipient caries.
• Patients who have sufficiently erupted permanent teeth with susceptible pits and fissures.
• Patients who have existing pits and fissures that are anatomically susceptible.
• Use of other preventive treatment such as systemic or topical fluoride therapy, to inhibit
interproximal caries formation.
Contraindications:
• Well established cavitated caries lesion.
• Proximal caries, existing on the other surfaces of the tooth with definitive caries diagnosis.
• A large restoration is present on occlusal surface.
• If pits and fissures are self-cleansing.
• Life expectancy of primary tooth is very less.
• When a patient is allergic to sealant material.
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• Pit and fissure that has remained caries-free for four years or longer.
• An individual with no previous caries experience and well coalesced pits and fissures.
• In children who are too young to cooperate during the procedure.
• Synthetic porcelain restorations, veneers, amalgam restorations, gold foil restorations,
inlays, onlays, or crowns.
14) Describe technique of pit & fissure sealant placement

The technique of sealant placement involves the following steps:
Isolation of the tooth:
• The tooth should be from salivary contamination by use of rubber dam or by cotton rolls and
suctioning.
• Rubber dam should be used in fully erupted teeth and cotton rolls can be used where that is not
possible.
• This procedure is very technique sensitive, so moisture control is essential to achieve optimum
bond strength.
Acid etching:
• Most frequently used: 37% orthophosphoric acid (gel/liquid)
• Gel applied either directly with special application tips or with a small disposable brush
• Liquid etchant: brush or small cotton pledget
• Should be applied to all the susceptible pits and fissures and extend up to cuspal inclines
• Etch for 15 seconds for permanent molars, 15 to 30 seconds for primary teeth. Fluorosed
teeth require additional etching time.
• If glass ionomer cement is being used, etching is not required: surface conditioner may be
used.
• Etching produces micro porosities: resin extends into these porosities and forms tags: these
retaining the sealant on to the surface of the teeth.
• Rinse well with air water spray for 30 seconds.
• Dry tooth surface for 15 seconds with uncontaminated compressed air.
Sealant placement and curing:
• Many sealant kits have their own dispensers and own set of steps, they must be followed.
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• Apply sealant, allow to flow into pits and fissures.

• In mandibular teeth, apply sealant to the distal aspect, allow to flow mesially.
• In maxillary teeth, apply sealant to mesial aspect,allow to flow distally.
• Use a fine brush, mini sponge, and carry sealant material up to the cuspal inclines.
• Air bubbles should not be incorporated.
• After sealant has set, wet cotton pellet- wipe surface so that air inhibited layer of non-
polymerized resin is removed and failure of this step leaves an objectionable taste in the
patient's mouth.
Visible light cured sealant:
• 10 to 20 seconds: exposure to visible light
• Tip of curing light should be held 3 mm to 5 mm from the surface of sealant.
Evaluate the sealant:
• Visually and tactically
• Take the explorer and attempt to dislodge it
• After evaluation, remove isolation and let the patient rinse.
Evaluate the occlusion of scaled tooth surfaces
• Check the occlusion with articulating paper – round with finishing bur
• Annual recall: 5% to 10% of sealants require repair or replacement annually
15) What is the scientific basis of acid etching & What are the various etching patterns?
Scientific basis of acid etching:
• It was given by Silverstone.
• Acid etching on the surface enamel has shown to produce a degree of porosity.
• First, a narrow zone of enamel is removed by etching. In this plaque and pellicles are
dissolved. Fully reacted inert mineral crystals in the surface of enamel are also removed,
resulting in a more reactive surface, increase in surface area and decrease in surface tension
that allows the resin to wet the enamel surface more readily. This zone is 10 µm in depth.
• The second zone is qualitative porous zone, which is 20 µm in depth. Because of the porosities
created, this zone may be distinguished qualitatively from enamel by polarized light
microscopy.
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• The third zone is quantitative porous zone with small porosities and is 20 µm deep.
Types of etching pattern:
Silverstone in 1975 identified three basic patterns of etching:
• Type 1: There is a generalized roughening of enamel surface, but with a distinct hollowing of
prism centers and relatively intact peripheral regions.
• Type 2: Prism peripheries appear to be damaged. Prism cores are left projecting towards
original enamel surface.
• Type 3: Show neither type 1 nor type 2 etching pattern but appear, as generalized surface
roughening.
16) What are the functions of resin tag formation?
• Provide mechanical means for retention
• Surround the enamel crystals and provide resistance to demineralization by acid products from
plaque
• Bis–GMA sealants are resistant to acid dissolution and provide protection against caries
along enamel resin interface
• Creates a protective barrier against bacterial colonization of sealed fissure.
17) What is air abrasion/ Kinetic cavity preparation/ Micro abrasion. Write the principle
and advantages.
The study of the use of air abrasion technology for dental applications initiated by Dr Robert
Black of Corpus Christi Texas in the 1940’s was successfully introduced in 1951 with the
Airdent air abrasion unit (SS White). Air abrasion can be described as a pseudomechanical,
nonrotary method of cutting and removing dental hard tissue.
Advantages: There are many advantages to the patient when the dentist uses air abrasion:.
• It is painless.
• Local anesthesia is rarely needed.
• It works quickly and the tooth with a small lesion is ready to restore in seconds.
• It works quietly without the whine of dental headpiece.

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• There is no vibration or pressure to cause micro fractures that weaken tooth.
• There is no production of heat to damage the dental pulp.
• Lesser sound tooth structure is removed.

Principle:
• Air abrasion for restoration preparation removes tooth structure using a stream of aluminium
oxide particles generated from compressed air or bottled carbon dioxide or nitrogen gas. The
abrasive particles strike the tooth with high velocity and remove small amounts of tooth
structure.
• Efficiency of removal is relative to the hardness of the tissue or material being removed and
the operating parameters of the air abrasion device.
18) Explain the procedure of air abrasion.

The steps in air abrasion include:
• Take a pre operative radiographs to determine if interproximal caries is present
• Isolate preferably with rubberdam
• Use caries detection dye to know the caries lesion
• Use air abrasive unit with high volume evacuation placed in the proximity of the tooth to
prepare cavity
• After a few seconds of initial preparation examine the preparation for decay
• Re-apply caries detecting dye
• Complete the preparation using the caries detecting dye until all caries is removed
• Apply the etchant for 20 sec and rinse with water spray
• Disinfect the cavity preparation with chlorhexidine or other materials
• Within 10 sec apply the dentin-bonding agent
• Immediately place the correct shade of composite and photopolymerize the material for 40 sec.
• Use a carbide bur for initial shaping
• A flexible polishing cup point or disc will provide the final polish for the restoration
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• Remove the rubber dam and check occlusion
19) What is Chemomechanical caries removal (CMCR)? What are it’s advantages?
Chemomechanical method is an effective alternative for caries removal because it brings
together atraumatic characteristics and bactericide/bacteriostatic action. The method was created
so as that an active ingredient would soften the predegraded collagen of the lesion without pain
or undesirable effects to adjacent healthy tissues.
Advantages:
• It’s proven effectiveness
• Safe method
• Elimination of local anesthesia and bur
• Lower anxiety built up in patients
• Conservation of sound tissue
• Only demineralised dentin containing denatured collagen is affected
• Gel consistency simplifies control of the application and reduces the risk of spillage.
20) Mention various systems for CMCR. What are the constituents of carisolv?
Various systems used for chemomechanical caries removal include:
• Caridex
• Carisolv
• Papain gel
Constituents of Carisolv:
The formulation of Carisolv® is isotonic in nature and consists of the following:
• Available in single mix or multi mix syringes.
• Syringe one: Sodium hypochlorite (0.5%)
• Syringe two:Three amino acids (glutamic acid, leucine, lysine)
• Gel substance: Carboxymethyl cellulose
• Adjunct: Sodium chloride/sodium hydroxide
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• Vehicle: Saline solution
• Colouring indicator: Red
21) What are conservative adhesive resin restorations? Write the classification.
Preventive Resin Restorations (PRR) introduced by Simonsen in 1978 are presently referred to
as ‘Conservative adhesive restoration’.
Types of PRR:
Based on extent and depth of the carious lesion, there are 3 types of PRR
1. Type A:Comprises suspicious pits and fissures where caries is limited to enamel
2. Type B: Comprises incipient lesion extending into dentin that is small and confined.
3. Type C: Characterised by the presence of deep caries and need greater exploratory
preparation in dentin.
22) Explain the procedure of Preventive Resin Restoration.

Type A PRR:
Comprises suspicious pits and fissures where caries is limited to enamel.
Steps involved are:
• Isolation after surface cleaning of tooth.
• Remove the decalcified pits & fissures with a speed round bur.
• Apply acid etchant over entire occlusal surface followed by washing and drying of the tooth
• Apply sealant in the preparation site avoiding air entrapment and light cure for 20sec.
• Adjust the occlusion if needed with a finishing bur.

Type B PRR:
Comprises incipient lesion extending into dentin that is small and confined.
Steps involved are:
• Thorough prophylaxis of tooth surface followed by rubber dam placement.
• Remove the carious pits & fissures with a slow speed round bur.
• Acid etch the entire occlusal surface followed by washing and drying.
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• A coat of bonding agent should be applied on the walls of the preparation and then the
preparation is to be filled with composite material.
• Sealant should be applied over the entire occlusal surface and all the layers are to be
simultaneously cured.
• Adjust the occlusion and finish and polish the surface.

Type C PRR:
Characterised by the presence of deep caries and need greater exploratory preparation in dentin.
Steps involved are:
• Thorough prophylaxis followed by isolation of the tooth.
• Carious pits and fissures should be removed with a slow speed round bur. Since it involves
deep caries local anaesthesia may be required.
• A bevel should be placed on the cavosurface margin of the preparation.
• Fast setting calcium hydroxide should be placed over the exposed dentin.
• Acid etch the entire occlusal surface followed by washing and drying.
• A coat of bonding agent should be applied on the walls of the preparation and then the
preparation is to be filled with composite material.
• Sealant should be applied over the entire occlusal surface and all the layers are to be
simultaneously cured.
• Adjust the occlusion and finish and polish the surface.

23) What are smart burs?
• These are polymer burs with shovel-like straight cutting edges.
• The polymer material has been designed to be harder than carious, softened dentin but softer
than healthy dentin.
• It is claimed to remove carious dentin selectively; whereas, healthy dentin is not affected
(minimally invasive excavation); the cutting edges wear down in contact with harder materials.
• SmartPrep burs are available in three ISO sizes 010, 014, and 018 and are meant for single-use
only (self-limiting action).
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• They should be used with light pressure and excavation should be done from the center to the
periphery to avoid contact with the harder dentin.
24) What are smart materials?
• Smart behavior generally occurs when a material senses some stimulus from the environment
and reacts to it in a useful, reliable, reproducible, and usually reversible manner. The most
important key feature of smart behavior includes its ability to return to original state even
after the stimulus has been removed. These properties have a beneficial application in
various fields including dentistry.
• Traditionally materials used in dentistry were designed to be passive and inert, that is, to
exhibit little or no interaction with body tissues and fluids. Materials used in the oral cavity
were often judged on their ability to survive without interacting with the oral environment.
• As there was no single material in dentistry that is ideal in nature and fulfills all the
requirements of an ideal material, the quest for an “ideal restorative material”continued and a
newer generation of materials was introduced. These are termed as “smart’’ as these materials
support the remaining tooth structure to the extent that more conservative cavity preparation
can be carried out. Some of these are also “biomimetic” in nature as their properties can mimic
natural tooth structures such as enamel or dentin.
• The current dental materials were improvised make them smarter. The use of these smart
materials has revolutionized dentistry which includes the use of restorative materials such
as smart composites, smart ceramics, compomers, resin-modified glass ionomer, amorphous
calcium phosphate releasing pit and fissure sealants, etc. and other materials such as
orthodontic shape memory alloys, smart impression material, smart suture, smart burs, etc.
25) What is CPP-ACP?
• Casein phosphopeptide - amorphous calcium phosphate (CPP-ACP), milk derivative helps in

remineralization of the carious lesion by replenishing lost minerals like calcium, phosphate
ions into the tooth structure.
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• CPP-ACP is useful in the treatment of white spot lesions, early childhood caries, dental
erosion, root caries, and dentin hypersensitivity.
• CPP-ACP is delivered in the form of oral hygiene products such as chewing gum, tooth cream,
and even incorporated in dental restorative materials also.
ORAL HABITS
Dr P Ahalya
1. Define habit and classify them.
“Habit is defined as tendency towards an act”- By Boucher.
Classifications: refer Q2,Q3,Q4,Q5.
2. Brief out Morris and Bohanna’s habits classification with examples. Or
What are pressure and non-pressure habits? Give examples.
Morris and Bohanna’s habits classification:
Habit Example
Nonpressure habits Mouth breathing
Pressure habits A. Sucking habit
Lip Sucking habit
Thumb and digit Sucking habit
B. Biting habits
Nail biting/needle holding
Pillow rest
Postural habit Chin rest
Miscellaneous Bruxism
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3. What are useful and harmful habits? Give examples for each. Or Classify habits
according to James.
Useful habits: are those habits of the normal function e.g: correct tongue posture,proper
respiration and deglutition.
Harmful habits: are those which exert perverted stress against teeth and dental arches. E.g:
mouth breathing, tongue thrusting.
4. What are meaningful and empty habits?Give examples for each.
Meaningful: habit with deep-rooted psychological problem.e.g: respiration.
Empty habit: meaningless habit that can be treated using reminder therapy. e.g: thumb/digit
sucking.
4. What are compulsive and non-compulsive habits?give examples for each. Or Write
about Finn’s classification of habits.
Finn’s classification of habits:
compulsive- acquired as a fixation in the child to the extent that he retreats to the practice
whenever his security is threatened. Non-compulsive habits :- children undergo
behavioural modifications continously from birth wherein there will be cessation of
undesirable habits and form new ones which are socially acceptable.
5. What is thumb/digit sucking habit? Or Classify thumb sucking habit according to
subtelny.
Thumb sucking is defined as the placement of thumb or digits in varying depths into the
mouth.
According to Subtelny, it is of following types :
Type A- accounts to 50% of cases wherein the whole digit is placed inside the mouth with
the pad of the thumb pressing against the palate, while simultaneously maxillary and
mandibular oral contact is maintained.
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Type B- accounts to 13-24% of cases wherein the thumb is placed inside the mouth, while
simultaneously maxillary and mandibular oral contact is maintained.
Type C- accounts for 18% of cases wherein the thumb is placed into the mouth just beyond
the first joint and contacts hard palate and maxillary incisors but without any contact with
mandibular incisors.
Type D- seen in 6% of cases wherein only a little portion of the thumb is placed into the
mouth.
6. Enumerate briefly the theories or concepts of thumb sucking.
The causes of thumb/ digit sucking can be explained by the following theories :
a) classical Freudian theory - according to sigmund Freud’s psychoanalytic theory
whenever a child is deprived of placing or taking things to his oral cavity during his oral
phase of psychological development, it results in the development of this habit.
b) oral drive theory - according to Sears and wise it is not the frustration of weaning but it
is the prolonged nursing that causes the development of this habit.
c) rooting reflex : according to Benjamin, it is the rooting reflex that involves movement
of the infant’s head and mouth towards an object which touches the cheeks results in the
development of thumb sucking in the first 3 months of life.
d) sucking reflex : according to Ergel babies who are restricted from sucking due to
disease or other factors becomes restless and irritable as a result they suck thumb/digit for
additional gratification.
d) learning theory : according to Davidson infant associates sucking with feelings like
pleasure and hunger, and these situations are expressed by sucking available objects like
thumb/digit by an infant.
7. Mention causes for thumb sucking habit.
Causes :
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a) socioeconomic status: in high socioeconomic status mother fulfills baby’s hunger so
there is less incidence while in low socioeconomic group as they may be deprived of
feeding so there is greater incidence of this habit. It is more in industrial areas than rural
areas.
b) working mother: as the child is away from mother and brought up by caretaker an
insecure feeling is created resulting in development of thumb sucking habit.
c) number of siblings : as the number of siblings increase the attention seeked by every
baby is decreased and when the child feels neglected develops sucking habit to compensate
for the insecure feeling.
d) order of birth of child
8. What are the clinical features of thumb/ digit sucking habits.
Clinical features of thumb/ digit sucking habits:
Effects on maxilla and mandible Proclination- maxillary incisors, increased

maxillary arch length, forward placement of
maxillary apical base, increased clinical crown
length of maxillary incisors, high palatal arch,
atypical root resorption in primary central incisor,
trauma from occlusion for maxillary incisors,
retroclination of mandibular incisors, retrusion of
mandible.
Effects on interarch relationship Increased over jet, decreased overbite, posterior

cross bite, anterior open bite.
Effect on lip placement and function Development of tongue thrust , lower tongue
position, hypotonic upper lip, hyperactive lower
lip.
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9. Mention different methods for treating thumb sucking habit.
treatment for thumb sucking habit: management is initiated as soon as identification of the habit
or when there is a family history of habit.
Preventive therapy a) feed immediately when the child is hungry b)

he should be allowed to eat how much ever he
wants c) habit practice to be stopped at the time
of inception only.
Psychological therapy Beta hypothesis or Dunlop’s hypothesis- here the

child is made to be conscious during the habit by
sitting in front of the mirror after explaining
about its adverse effects.
Three alarm system Used when the child is willing to discontinue the
habit. The bandage tied to the digit acts as a first
alarm, the long pin placed at the elbow is the
second alarm, but still if the child involves in the
habit then tightening of the bandage is done
which acts as third alarm for reminding to quit
the habit.
Chemical treatment Bitter and sour chemicals are applied to the digit
involved in sucking. E.g. quinine,
asafoetida,pepper, castor oil, femite,
thumbup,antithumb etc.
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Mechanical or remainder therapy a) extraoral approach b) intraoral approach c)

removable /fixed palatal crib d) oral screen e) hay
rakes f) blue grass appliance and its modified
version
Current strategies Thumb home concept, Thumb sucking book,

increasing the length of the night suit.
10. What is tongue thrusting habit? Classify tongue thrusting habit.
Tongue thrusting habit: is the forward movement of the tongue tip between the teeth to meet the
lower lip during deglutition and in sounds of speech, so that the tongue lies interdentally.
Classification:
Physiologic It is the normal tongue thrust during infancy.
Habitual Habit exists even after the correction of

malocclusion
Functional It is an adaptive mechanism developed to achieve

oral seal
Anatomical It is due to enlarged tongue
Type Classification
1 Nondeforming tongue thrust
2 Deforming anterior tongue thrust
3 Deforming lateral tongue thrust
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4 Deforming anterior and lateral tongue thrust
10. Mention causes for tongue thrusting habit.
Causes are :
genetic influence tongue size(macro gloss is and micro gloss is) ,

high palatal vault
Presence of thumb sucking This habit changes the tongue position and
palatal vault depth which increases the chances of
development of tongue thrusting habit.
Mixed dentition When anterior space is created with loss of

primary anteriors it may cause protrusion of the
tongue through these spaces and may lead to
development of tongue thrusting habit
Allergies Causing respiratory disturbances followed by

development of mouth breathing and tongue
thrusting.
Sleeping habits Those who sleep with their mouth open may
develop tongue thrust due to change in tongue
position.
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Oral trauma Of longer duration results in change in

swallowing pattern.
13. Briefly explain the clinical features of tongue thrusting habit.
Simple tongue thrusting 1) anterior open bite

2) normal posterior contact
3) contraction of lips, mentalis, and mandibular
elevators
Complex tongue thrusting 1)generalised open bite 2) absence of contraction

of lips and oral muscles.
Lateral tongue thrusting Posterior open bite with lateral tongue thrust
Other features 1)proclination of anterior teeth

2) anterior open bite
3) midline diastema
4) posterior crossbite.
14. What are the treatment modalities for tongue thrusting habit? treatment is by either
of the following ways:
Myofunctional therapy Guiding the patient to keep tip of tongue in

contact with rugae for 5min and then swallow.
Orthodontic elastics 5/16” elastic is held against the palate followed

by swallowing
Lemon candy exercise Instead of orthodontic elastic lemon candy is held
against palate
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4S exercise It is identifying the spot, salivating, squeezing the

spot and swallowing with the tongue held at the
identified spot.
Lip exercises Tug of war and button pull exercise
Mechanotherapy Removable and fixed appliances can be used :

1) preorthodontic trainer 2) modifications of
Hawley’s appliance 3) tongue crib 4) oral screen
15. What is mouth breathing habit?
It is the habitual respiration through mouth instead of nose. Classified by Finn as habitual,
obstructive and anatomical types.
Mention causes for mouth breathing habit.
a) developmental and morphological anomalies - abnormal nasal cavity, nasal turbinates
and short upper lip.
b) partial obstruction due to deviated nasal septum, localised benign tumors.
c)infection and inflammation of nasal mucosa, chronic allergic stomatitis, chronic atropic
rhinitis, enlarged adenoids and tonsils, nasal polyps.
d)trauma to nose
e) genetic- ectomorphic faced children.
16. What are the clinical features of mouth breathing?
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General features- pigeon chest, speech with nasal tone, patient having sleep apnea
syndrome.
Appearance-adenoid faces, lips wide apart,short upper lip,long narrow face.
Dental and skeletal features- low tongue position, narrow maxillary arch with deep palatal
vault, anterior open bite, high risk of caries, chronic marginal gingivitis for anterior due to
drying of gums during mouth breathing, protrusion of maxillary and mandibular anteriors.
17. Write briefly about tests for diagnosing mouth breathing.
Various tests are as follows.
a)Mirror/fog test: 2 surfaced mirror is placed on upper lip and observed for the fogging effect
on the mirror. If fog appears on mirror towards nasal side then he is nasal breather and if on oral
cavity side it indicates mouth breathing.
b)Massler’s water holding test: ask patient to hold mouth full of water for some time in
case of failure to do so indicates mouth breathing.
c) jwemen’s butterfly test: place some cotton fibers just below the nasal openings if it
flutters downwards he is nasal breather if flutters in upward direction then he is a mouth
breather.
d) Rhinometry :using inductive plethysmograph the total airflow through nose and mouth
are quantified. If the quantity is more through mouth he is a mouth breather.
18. How do you treat mouth breathing habit?
Management is mainly dependent on a) identifying the underlying cause and its
prompt treatment b) cessation of habit: deep breathing exercises, lip exercise for
months, oral screen.
19. What is lip biting habit? Classify lip biting habit.
It is a habit that involves manipulation of lips and perioral tissues. Classification:
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Lip licking Wetting of lip by tongue

Lip sucking Pulling of lips into the mouth between the teeth
21. Write the causes, clinical features and treatment for lip biting habit?
Lip biting habitEtiology: malocclusion, emotional stress, in conjunction with other habits.
Clinical features: protrusion of upper incisors, retrusion of lower incisors,lip trap, muscular
imbalance, lower incisor crowding lingually, chapped area below the vermilion border,
attenuated mentolabial sulcus.
Treatment : is directed towards correction of the etiology and later use of appliance therapy
(lip protector, lip bumper, oral screen).
22. What is bruxism and mention its causes.
It is the habitual grinding of teeth when an individual is not chewing or swallowing
(Ramfjord).
It is of two types daytime and night time bruxism.
Causes: a) CNS- as a manifestation of dental lesions.e.g. Cerebral palsy. b) psychological
factors- in case of inability to express emotions or in case of feelings like anger and
aggression may result in this habit.c) occlusal discrepancies d)genetics e) systemic factors-
magnesium deficiency, chronic abdominal distress, intestinal parasites.f) occupational
factors- over enthusiastic student, compulsive overachievers.
23. What are the clinical features and treatment options for bruxism ?
Clinical features: depends on frequency, intensity and age of the patient.
The abnormal forces thus generated are absorbed to some extent while remaining are
transmitted to structures of masticatory system causing
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a) occlusal trauma like tooth ache, mobility
b) tooth structural changes- abnormal wear facets resulting in extreme sensitivity, pulp
exposure and sometimes even fractured teeth.
c) muscular effects- muscular fatigue,muscle tenderness, hypertrophy of masseter.
d)TMJ effects- pain, crepitation, clicking and restricted mandibular movements.
Others- headache.
Treatment: a) occlusal adjustments of premature contacts b) occlusal splints/ nightguards
c) restorative treatment d) relaxation training e) physiotherapy f) drugs-local anaesthetic
agents, tranquillizers, muscle relaxants g) biofeedback h) electrical method-
electrogalvanic stimulation for muscle relaxation I) acupuncture j) orthodontic correction.
24. What are masochistic habits?
Masochistic habits are also known as sado-masochistic habits, self mutilating habits.
They are repititive acts that result in physical damage to the individual which are more
common in mentally retarded patients (20%) and children with psychological disturbances.
Clinical features: frenum thrusting, picking of gingiva, insertion of sharp objects into the
oral cavity, biting of fingers,knees, shoulders, banging of head to wall, window or any
other hard object available nearby in an attempt to gain attention, love, affection.
25. Classify masochistic habits. Or what is the etiology/causes for masochistic habits.
According to etiology classified into
1. Organic a)Lesch-Nyhan disease

b)De-Lange’s syndrome
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2. Functional ( Stewart and Kernohan ) Type A: injuries superimposed on pre-existing

lesion.
Type B: injuries secondary to another established
habit e.g. rotation of thumb during thumb sucking
habit.
Type C: injuries of unknown or complex etiology
which has greater psychogenic component.
26. Name any two sadomasochistic habits
a) Frenum thrusting
b) Bobby pin opening.
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INTERCEPTIVE ORTHODONTICS
Dr.Ch.Devi
1. Define Preventive and Interceptive orthodontics

Ans. Preventive orthodontics defined as procedures undertaken prior to the onset of a developing
malocclusion in anticipation of a developing malocclusion.
Interceptive orthodontics defined as the elimination of the existing interferences with the key factors
involved in the development of the dentition
2. Write various procedures of Interceptive orthodontics?

Ans. Procedures that comes under interceptive orthodontics are:
● Serial extraction
● Correction of developing crossbite
● Control of abnormal habits
● Space regaining
● Muscle exercises
● Interception of Skeletal malrelation
● Removal of soft tissue or bony barriers to enable eruption of teeth
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3. Define crossbite and write the classification of crossbite

Ans. Crossbite is defined as a condition where one or more teeth may be abnormally malposed
buccally or lingually or labially with reference to the opposing tooth or teeth.
Classification: Based on location
Anterior Crossbite: single tooth
Segmental
Total
Skeletal
Posterior crossbite: unilateral
Bilateral
Based on Nature of Cross Bite
 Skeletal
 Dental
 Functional
4. Anterior crossbite
Ans: Definition; Anterior cross bite can be defined as upper frontal primary or individual permanent
teeth lingual position in relation to the lower incisor teeth.
This is a condition where reverse overjet is seen in mandibular anterior teeth overlapping the
maxillary anterior teeth.
Classification;
Individual: Due to a malposed incisor or canine displaced towards palate.

Total: Caused by an anterior displacement of the mandible.
Skeletal: Due to an over growth of the mandible, retarded maxilla or a combination of these.
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Simple anterior dental crossbite
Functional anterior crossbite
True skeletal anterior crossbite
5. Management of Anterior crossbite
Ans. Dentoalveolar anterior crossbite treated by using removable appliances like tongue blade
therapy, cataln's appliance, Hawley's appliance with z spring etc.
Skeletal anterior crossbite might be due to maxillary retrognathism or mandibular prognathism

treated by using orthopedic appliances like face mask and functional appliances like F. R lll
respectively.
6. Serial extraction
Ans. Serial extraction defined as the correctly timed, planned removal of certain deciduous and
permanent teeth in mixed dentition cases with Dentoalveolar disproportion in order
- To alleviate crowding of incisor teeth
- Allow unerupted teeth to guide themselves into improved position
- Lesser the period of active appliance therapy.
various methods to follow the order of extraction are:
Dewel's method - CD4
Tweeds method - D4C
Nance method - D4C
C- primary canine, D-primary first molar, 4 - permanent first premolar
7. Cataln's appliance
Ans. Introduced by Catlan, 150 years back. This type of appliance, if properly constructed, can
correct a cross bite in a matter of days.
Indications
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 Normal or excessive overbite and adequate space in the arch to bring the incisor into
correct anteroposterior relationship with the opposing mandibular incisor .
 Used only in cases where cross bite is due to palatally displaced maxillary incisor.
Contraindications
 When cross bite is due to true mandibular prognathism.

 If there is an end to end over bite or an open bite
Advantages
 Ease of fabrication
 Rapidity of correction, using functional and muscle forces.
 Lack of soreness or looseness of the teeth during movement.
Disadvantages
 Patient has problems in speech during the therapy.

 If used for long time (>6 weeks), leads to anterior open bite and TMJ problem.
 It can’t be used for more than 4 weeks.
 Exact amount of labial movement is unpredictable and uncontrolled.
8. Management of anterior single tooth crossbite
Ans. Tongue blade therapy: Tongue blade therapy can be used successfully in a developing single
tooth anterior cross bite. This technique is useful when child is co-operative and have proper
encouragement and guidance at home.
 A tongue blade is a flat wooden – stick similar to an ice – cream stick.
 Mac Donald – the child is instructed to place the stick behind the locked tooth and using the
chin as a fulcrum, exert pressure on the tooth toward the labial.
 The patient is advised to bite with a constant pressure on the wood incline and at the same
time to exert a slight but constant pressure with his hand on the blade so as to prevent blade
displacement.
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 The proper use of the tongue blade for 1 or 2 hr/day for 10 to 14 days.
9. Write various methods of space regaining
Ans: various methods of space regaining are

 Proximal stripping
 Expansion
 Extraction
 Distalization
 Uprighting of molars
 Derotation of posterior teeth
 Proclination of anteriors
10. Open bite

Ans: Open bite is defined as a malocclusion that occurs in vertical plane, and is
characterized by lack of overlap between maxillary and mandibular posterior teeth.
Classification of open bite: 110
1. Based on the location
 Anterior open bite
 Posterior open bite
2. Based on the components involved
 Skeletal open bite
 Dental open bite
11. Write about the management of open bite

Ans; Management of Open Bite:
 Removal of the cause (use of habit breaking appliances)
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 Myofunctional therapy – eg: activator, twin block, vertical chincup etc

 Orthodontic therapy
 Surgical correction
 Combination of two or more of the above
Management of posterior open bite:
 The primary aim of the treatment is to remove the etiology.
 Use of lateral tongue spikes
 Extrusion of posteriors
 Treatment of ankylosed teeth.
 Fixed appliance with elastics
12. Posterior cross bite
Definition: Posterior cross-bite is defined as any abnormal bucco- lingual relation between
opposing molars, premolars or both in centric occlusion.
TYPES
 SEGMENTAL
 SINGLE TOOTH
 UNILATERAL
 BILATERAL
 BUCCAL NON – OCCLUSION
 LINGUAL NON – OCCLUSION
13. Management of Posterior cross bite
192
Ans: For single tooth /dental crossbite ; Cross- Bite Elastics {correction in 4-8 weeks}.
Dento alveolar contraction / crossbite:
 Removable plate with jackscrew and Adams clasps


Soldered W-arch (Porter appliance)

Quad helix

Coffin spring

Arch expansion using fixed appliances
Gross disharmony between osseous bases/skeletal crossbite
Numerous appliances have been used for rapid maxillary expansion. They are broadly classified
1) Removable appliances : Eg; A split acrylic plate with a midline screw
2) Fixed appliances
a) Tooth borne: Derichsweiler type and Hass type.
b) Tooth and tissue borne: Isaacson type and Hyrax type
14. Coffin spring
Ans;
 This was designed by Walter Coffin. It is a removable appliance capable of slow

dentoalveolar expansion.
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 The appliance consists of an omega shaped wire of 1.25 mm thickness placed in the mid
palatal region. The free ends of the omega wire are embedded in the acrylic covering.
 The spring is activated by pulling the two sides apart manually. This brings about
dentoalveolar expansion.
15. Quad helix appliance
Ans; One of the appliances used to expand a narrow maxilla is quad helix.
 The quad helix incorporates 4 helices that increase the wire length. Therefore the
flexibility and the range of action of this appliance is more.
 Constructed using 0.038 inch wire and is soldered to bands on the first molar.
 The quad helix consists of a pair of anterior helices and a pair of posterior helices. The
portion of the wire between the two anterior helices is called the anterior bridge and the
wire between the anterior and posterior helices is called palatal bridge.
 The free wire ends adjacent to the posterior helices are called outer arm. They rest against
the lingual surfaces of the buccal teeth and are soldered to the molar bands lingually.
 The quad helix brings about a slow dentoalveolar expansion but in primary dentition a
skeletal mid palatal splitting can be achieved.
16. Midline diastema and its management?

Ans; Midline diastema is a space or gap between the maxillary central incisors.
194
Management of mid-line diastema : Treatment according to its cause
Active treatment; Removable or fixed appliances./ Restorative Treatment
Removable appliances:
i) Finger springs ii) Split labial bow.
Fixed appliance: Fixed appliances incorporating elastics or springs
1) Closed coil springs
2) Elastics
3) Elastic chain
4) M shaped springs
Retention: Midline diastema is often considered easy to treat but difficult to retain.
Retainer use for mid-line diastema are
1. Lingual bonded retainer
2. Hawley’s retainer
17. Myotherapeutic Exercises?
Ans; Myotherapy is the creation of normal orofacial muscular function to aid growth and the
development of normal occlusion
Exercises of masseter musle; Clenching of teeth
Exercises of the tongue: One elastic swallow
Tongue hold exercise
Two elastic swallow
The hold pull exercise
Exercise for the lips (circum oral muscles)
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18. Myotherapeutic tongue exercises?
Ans; These are done to correct any aberrant tongue swallow patterns.
One elastic swallow:
A 5/16th inch orthodontic elastic is placed on the tip of the tongue and the patient is
asked to raise the tongue to rugae area and swallow.
Two elastic swallow:
Two 5/16th inch elastics are used. One is placed on the tip of the tongue whereas the
other is placed on the dorsum of the tongue in the midline and asked to swallow.
Tongue hold exercise:
A 5/16th inch elastic is used and the patient is asked to place the same on a
designated spot over a definite period of time with the lips closed. The patient is asked to
swallow with the elastic in the designated position and lips apart.
Hold pull exercise:
The tip of the tongue is made to contact the palate in the midline and the mandible is
gradually opened. This allows the stretching of the frenum to relieve a mild tongue-tie.
19. Circum oral muscles exercise?
Ans: Stretching of upper lip - hold a piece of paper between the lips.
 Holding and pumping of water back and forth behind the lips
 Massaging of the lips
 Button pull exercise
 Tug of war exercise
20. 4S exercises.
Ans: This includes
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 identifying the spot by tongue,

 salivating,
 squeezing the spot
 swallowing.
First exercise is spotting exercise. Spot should be the rest position of the tongue. Next is the 2
S exercise. Place the tongue on the spot results in salivation. It should be followed by
squeezing the tongue vigorously with the teeth closed against the spot. 'Squeeze' is done by
squeezing followed by relaxing. This is 3S exercise. This should be followed by 4S exercise.
The patient should practice the new swallowing pattern at least 40 times a day. After learning
the new swallowing pattern at conscious level, it is necessary to reinforce it subconsciously
for transforming the control of the reflex from conscious to unconscious level. Citric acid
tablet with bi concave surface is used for the above said transformation.
21. Arch Expansion ?

Ans: Maxillomandibular expansion is the most common non extraction approach for treating
mild-to-moderate tooth size arch length deficiency. Maxillary expansion is a well-established
approach for correcting of transverse malocclusion.
Appliances can be classified as rapid or slow.
Rapid palatal expansion (RPE) appliances produce large forces at the sutural site over a short
period. These heavy forces maximize skeletal separation of the midpalatal suture by
overwhelming the suture before any dental movement or physiologic sutural adjustment can
occur. Eg: HYRAX
Slow-expansion appliances, such as the quad-helix and Coffin spring, have been shown to
allow for more physiologic adjustment to sutural separation with less potential for relapse.
22. Myofunctional appliances?

Ans:
A functional appliance harnesses the natural forces which it transmits to the teeth and
alveolar bone in a predetermined manner
Basically functional appliances can be classified { Proffit}
197
 Tooth borne passive appliances- Myotonic appliances: these appliances do not have
intrinsic force generating components such as springs or screws. They depend on the soft tissue
stretch and muscular activity to produce the desired treatment results.
E.g.: Activator, Bionator, Herbst appliance.
 Tooth borne active appliances- Myodynamic appliances: they include modifications of
activator and bionator with expansion screws or other active components like springs to provide
intrinsic force for transverse or anteroposterior changes.
 Tissue borne passive appliances: they are mostly located in the vestibule and have little
or no contact with the dentition.
E.g. Functional Regulator of Frankel.
 Tissue borne active appliances: appliance is located in the vestibule and has little or no
contact with the dentition and transmit forces through some component of the appliance.
E.g. lip bumper, oral screen.
23. Oral Screen?

Ans; The oral screen is a simple functional appliance that takes the form of a curved shield of
acrylic placed in the labial vestibule. It was first introduced by Newell in 1912.
Principle:
The oral screen can be used either to apply forces of the circumoral musculature to certain teeth
or relieve those forces from the teeth thereby allowing them to move due to forces exerted by the
tongue. Thus it works on the principle of both force application as well as force elimination.
Indications:
1. This appliance can be used to intercept oral habits such as thumb sucking, mouth
breathing, tongue thrusting, lip biting, cheek biting.
2. It can be used to perform muscle exercises to help in correction of hypotonic lip and
cheek muscles.
3. It can be used to correct mild anterior proclination, mild disto-occlusion.
24. Lip Bumper?
198
Ans:The lip bumper is a combined removable- fixed appliance. It can be called a modified
vestibular screen that is used for muscular force application or force elimination. The appliance
can be used in both the maxilla and mandible to shield the lips away from the teeth.
Uses of lip bumper:
1. They are used in patients exhibiting lower lip habits such as lip sucking and it shields the
lower lip away.
2. They are also used in patients exhibiting hyperactive mentalis activity that causes
flattening or crowding of the lower anteriors.
3. Lip bumper can be used to augment anchorage. The muscular force transmitted on to the
molars in a distal direction would discourage the forward movement of the molars.
4. Distalization of the first molars can be achieved by use of lip bumpers. The degree of
distal movement can be very limited, especially where the second molars are erupted.
5. It can be used as a space regainer if the lower molars have drifted mesially due to early
loss of deciduous molars.
25. Write about the managemnt of Skeletal Malrealtion in growing children?
Ans; Interception Of class II malocclusions
Maxillary prognathism – head gear to restrict maxillary growth
Maxillary prognathism and mandibular retrognathism - head gear and myofunctional therapy
Mandibular retrognathism - myofunctional therapy
Interception of class III malocclusions
Maxillary retrognathism – face mask to protract maxilla
Mandibular prognathism and maxillary retrognathism - face mask followed by chin cup/
myofunctional appliances for class II
Mandibular prognathism - chin cup therapy to restrict mandible growth
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SPACE MANAGEMENT
Dr.Ch.Devi
1. Define space maintenance and space maintainers?

Ans: Space maintenance can be defined as the prevention of space left by primary incisors,
primary canines, primary molars and sometimes the primate spaces.
J.C. Brauer in 1941 defined as the process of maintaining a space in a given arch previously
occupied by a tooth or a group of teeth.
Space maintainers are fixed or removable appliances used to preserve arch length following
the premature loss or elective extraction of a tooth/teeth.
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2. Classify space maintainers?

Ans; Hinrichsen (1962) classified space maintainers as
A) Fixed appliances
Class I - a) Nonfunctional : i) Bar type ii) Loop type
b) Functional types : i) Pontic type ii) Lingual arch type
Class II - Cantilever type (Distal shoe, Band and loop)
B) Removable: Acrylic partial dentures Space
3. Define space regaining and space regainer?

Ans; SPACE REGAINING: The process of gaining the space lost by drifting of adjacent
teeth following premature loss of deciduous teeth/tooth.
SPACE REGAINER: A fixed or removable appliance capable of moving a displaced

permanent tooth into its proper position in dental arch.
4. Space regainers?
Ans: Space regaining can be accomplished by using either

A} Intraoral appliances: Removable - Appliances with helical coils or loops,
Split acrylic dumbbell spring
Screw type space regainer
Sling shot type space regainer
Fixed - Hotz lingual arch, Pendulum appliance

Open Coil Springs, Herbst space regainer
Gerber Space regainer, Lip bumper
B} Extra oral appliances: Extra oral molar-distalizing appliances.
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5. What is space analysis and Mention Mixed dentition analysis?

Ans: Space analysis is performed to predict the amount of space available for the unerupted
permanent teeth in the mixed dentition
Three basic approaches for estimating the size of the unerupted permanent teeth are
1. Measurement of teeth on radiographs.
2. Estimation from probability tables.
3. Combination of radiographs and prediction table methods.
MIXED DENTITION ANALYSIS:
 Moyer’s
 Tanaka Johnston
 Hixon and Old father
 Staley kerber
 Huckaba’s
 Ballard and Willie
6. What are the ideal requirements of a space maintainer?
Ans: Requisites of space maintainer
1) Should maintain mesio-distal width of tooth
2) Simple, easy to fabricate and cost effective
3) Should restore function and prevent over eruption of opposing teeth
4) Should be strong enough to withstand the functional forces
5) It must permit maintenance of oral hygiene
6) It must not restrict normal growth and development which take place during the transition
from deciduous to permanent dentition
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7. What are radiographic and non –radiographic space analysis?

Ans: Non –radiographic space analysis Radiographic analysis
 Moyer’s Nance’s
 Tanaka Johnston Huckaba’s
 Ballard And Wylie
Combination of Radiographs and Prediction Charts
 Hixon and Old father

 Staley kerber
8. Tanaka Johnston Analysis?

Ans: They simplified the Moyer’s results and gave regressive equations of the form
Y = A + B (X)
Where Y = sum of the mesio distal widths of the unerupted canines and premolars
X = sum of the mesio distal widths of the lower incisors , A & B are constants.
For the maxillary arch, Y = 11 + 0.5 (X) For the mandibular arch, Y = 10.5 + 0.5 (X)
Advantages: Non-radiographic, uncomplicated, convenient, flexible, relatively accurate and

non-invasive. However, tooth sizes vary significantly between different populations and different
races. This method is less accurate for other population groups and appears to have systematic
errors for specific race and gender.
9. Moyer’s Mixed Dentition Analysis?

Ans: The best known prediction tables for estimating the required space of unerupted
permanent canines, first and second premolars is that of Moyer’s. It is done as follows.
Determination of the sum of the mesio distal widths of the lower permanent incisors. The
probable space requirement for the permanent canine and the two premolars is read off from
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the prediction table [space required}.The difference between the space available and the
space required is expressed as the space situation in mm as space excess or space discrepancy
with a negative sign.
This method is advocated for the following reasons.
 It has minimal systemic errors and the range of such errors is known
 It can be done with equal reliability
 It is not time consuming, simple and easy to perform.
 It requires no special equipment or radiographic projections
10. Enumerate the effects of premature loss of primary teeth?

Ans: Delayed or early eruption of the succedaneous teeth.
o Tilting of tooth adjacent to the extraction space.

o Creation of arch length inadequacy.
o Encouragement of deleterious habits, Psychological trauma.
o Extrusion and rotation of opposing teeth.
o Unilateral tooth loss can lead to arch asymmetry and shifting of midline.
o Succedaneous teeth may become impacted due to bony crypt or mucosal barrier.
o Development and aggravation of malocclusion affecting physical, social and
psychological health, TMJ disorder, pain, etc.
11. What are the factors to be considered for Planning a Space Maintainer?
Ans; The following considerations are:
1. Time elapsed since loss- Space closure occurs usually during the first 6 months after the
extraction. it is best to insert an appliance as soon as possible after the extraction.
2. Dental age of the patient- Permanent teeth erupt when three-fourths of the root is
developed, regardless of the child’s chronologic age.
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3. Amount of bone covering the unerupted tooth - if there is bone covering the crown, it
can be readily predicted that eruption will not occur for many months, a space-maintainer is
indicated.
4. Sequence of eruption of teeth- the dentist should observe the relationship of developing
& erupting teeth adjacent to the space created by the untimely loss of a tooth.
5. Delayed eruption of the permanent tooth- in case of impacted permanent tooth, it is

necessary to extract the primary tooth, construct a space maintainer.
6. Congenital absence of the permanent tooth- if permanent teeth are congenitally absent,
the dentist must decide whether it is wise to hold the space for many years until a fixed
replacement can be provided or it is better to allow the space to close.
7. Presentation of problems to parents - Explain existing conditions & discuss the

possibility of the development of a future malocclusion if steps are not taken to maintain the
space or to guide the development of the occlusion.
12. Band and loop space maintainer?

A n s : It is used for preserving space created by premature loss of single primary molar. It
consists of a band cemented commonly to the tooth posterior to the edentulous space and a
loop of wire across the edentulous space abutting the anterior tooth. The loop should be
fabricated wide enough so that the succedaneous tooth can erupt into it. The crown and loop
is a variation of the band and loop appliance, and is used where stainless steel crown therapy
is necessary on the abutment teeth. Another approach to the crown and loop appliance is to
place a band and loop appliance over the crown.
13. Lingual arch space maintainer?

Ans: It is a mandibular, fixed, bilateral, nonfunctional, passive space maintaining appliance.
The classical mandibular arch wire consists of two bands cemented to the first permanent
molars or sometimes 2nd deciduous molars, which are joined by a stainless steel wire butting
against four incisors.
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Lingual arch fabrication;
Archwire should rest on cingulae of incisors 1-1.5 mm above gingival margin

Solder joint should be in mid-third and parallel to band
Archwire should be below plane of occlusion posteriorly
Indications: Bilateral single or multiple tooth loss in mandible,
Not recommended when primary incisors still present
14. What are the Modifications of band and loop space maintainer?
Ans:1.The loop can be made only on one side, but it is less stable {Mayne Space Maintainer}.
2. Crown and loop
3. Band and bar
4. Reverse Band and Loop
5. Band and Loop appliance with occlusal rest.
15. Distal shoe space maintainer?

Ans; Intra-alveolar appliance- Introduced by Gerber and extended by Croll. The fixed
distal shoe space maintainer was first proposed by Willets. Roche advocated the Crown and
band appliance with a distal intragingival extension. It is used to maintain space or influence
the active eruption of first permanent molar in distal direction. The depth of the intragingival
extension should be about 1-1.5 mm below the mesial marginal ridge of the molar, or just
sufficient to capture its mesial surface as the tooth erupts and moves forward. After the molar
has erupted, the intragingival extension is removed. Before final placement of the space
maintainer in the mouth, the radiograph of the appliance should be made to determine
whether the tissue extension is in the proper relationship with the unerupted first permanent
molar.
Indications: loss of second deciduous molar before the eruption of first permanent molar.
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Contraindications: Certain medical conditions such as blood dyscrasias, immune-

suppression, congenital heart disease, rheumatic fever, diabetes, generalized debilitation.
16. Nance palatal arch appliance?

Ans: This is a maxillary custom-made fixed appliance developed by H.N. Nance in 1947,
consisting of a heavy gauge stainless steel wire soldered to the palatal aspect of the first
permanent molar bands. The wire is directed from the molars anteriorly and is attached to an
acrylic button, about 0.5 inches in diameter. It is used in situations where premature bilateral
loss of maxillary primary teeth is present or when leeway space must be preserved.
17. Transpalatal arch?

Ans - Described by Robert Goshgarian in 1972, the transpalatal arch is a maxillary fixed
appliance consisting of a heavy gauge stainless steel wire that extends from one maxillary
first permanent molar, along the contour of the palate, to the contralateral first molar. It is
adapted to the curvature of the palatal vault, so that it lies 2-3 mm away from the palatal
mucosa, and an omega loop is usually incorporated midway across the span. The original
design included a straight bar extending across the palate. It is referred as transpalatal bar.
Maximum pressure was obtained when the loop of the Transpalatal arch (TPA) was placed at
the middle of the palatal mucous membrane between the right and left second molars.
18. Gerber Space maintainer?

Ans: This type of appliance is fabricated directly in the mouth. It has a “U” assembly which
is soldered or welded in place and fitted into tube. The appliance placed and wire section
extended to contact the tooth mesial to the edentulous area. The kit is used for space
maintenance or space regaining. In case of space regaining, a compressed coil spring or open
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coil spring is introduced between the tube and the wire. Once the space is regained, the
assembly is left behind as the space maintainer
19. Space Maintenance in Anterior Segment?

Ans; 1) Removable partial denture – indicated for cooperative young children
2) Fixed Appliances - If a fixed appliance is required, one approach is to attach the

anterior replacement teeth to a 0.040 or 0.045 inch stainless steel wire frame work
retained with bands or crowns on the second primary molar.
3] Groper Appliance - similar to Nance holding arch, but with acrylic teeth processed to
the wire instead of a palatal acrylic button in the rugae area. The round wire should be
attached to either the first or second primary molars with either SS crowns or SS bands.
The acrylic teeth are attached to metal cleats that have been soldered to the palatal wire
bar.
20. Mayne Space Maintainer?

Ans: Designed by W R Mayne, is a type of non-functional space maintainer. Gellin in 1990
described a technique where banding the first primary molar for guidance, which can be used
in cases where the second molar is lost before the eruption of the first permanent molar.
From a band, a 0.036” stainless steel wire is soldered buccally, extended till the distobuccal
surface of the tooth anterior to the edentulous area, then bent lingually at the distal surface of
first bicuspid.
Disadvantage: Non-functional, over eruption of opposing tooth.
21. Glass Fiber-reinforced Composite Resin?

Ans : GFRCR is a translucent colored, semi manufactured product made of glass fibers,
thermoplastic polymer, light curing resin matrix for reinforcing dental polymer. It is made of
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unidirectional fibers which increases the strength and stiffness of the final product
perpendicular to the direction of the fibers.
Indications: 1.Unilateral loss of 1 or 2 teeth in maxillary or mandibular arch.
2. In case of metal allergy.
Advantages: Time saving,Single sitting procedure. Do not come in contact of periodontal

tissue therefore no periodontal problems, Need for lab procedure is eliminated, Easy to apply
, Reliable adhesive bonding , Easy to clean, esthetic
Disadvantages: Cost, Invasive technique for tooth preparation
22. Removable space maintainers?

Ans: 1. Simple acrylic plate: Non-functional space maintainer
2. Removable partial denture/ Functional space maintainer: It helps in mastication in the

posterior region, improves esthetics in the anterior region, prevent abnormal speech and
tongue habits.
Advantages: Functional in true sense as it replaces the missing teeth. Maintains or restores
vertical dimension. Facilitates chewing and speaking. Easy to fabricate and requires less
chair side time.
Disadvantages: Patient compliance is necessary and mandatory, Appliance may be lost or

broken, It restricts the lateral growth of the jaw if clasps are incorporated, It may irritate the
soft tissue.
23. Hotz lingual arch space regainer

Ans: Hitchcock in 1974 introduced a modification of lingual arch – “Hotz lingual arch” with
U loops which is used for moving molars distally. Indicated in situations where the
permanent tooth moves mesially rather than distal movement of mesial teeth and also in
cases where sufficient space is present for eruption of permanent second molar. The lingual
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arch provides compound anchorage from all the other teeth which the lingual arch touches. A
horizontal spur can be soldered perpendicular to the arch wire contacting the distal surface of
the premolar or canine. This compounds the anchorage additionally. The loop on the active
side is adjusted periodically once a month.
Pedodontic clinic setup

Dr Chandana
1. Location of front desk in pedodontic clinic

The reception should be adjoining the play area so that not only the receptionist keeps a watch
on behaviour of child but also is able to engage them in conversation thereby alleviating their
dental anxiety. The receptionist should possess communication skills to deal with children
effectively. He/she must call each and every child by his/her name and converse about the topics
of his/her interests.
2. Instructions given to parents and children in pedodontic clinic

The notice boards in the consultation room must carry instructions for parents before dental visits
of children as well as certain post-treatment instructions. Also, a booklet or a brochure as a
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pretreatment communication can be mailed to parents beforehand or delivered to them soon as

they enter.
Certain instructions need to be given to parents;
• Do not tell your child about pain, blood, injections, etc. in the first place.
• Do not tell him/her something like “... because you do not brush your teeth properly, doctor
will give you an injection ...” or “because you eat chocolates, your spoiled teeth will be
removed by doctor”.
• Do not voice your own fears about dentistry (pain, blood, etc.) in front of children.
• Do not insist on starting the treatment in the first visit itself.
• Do not promise him/her in advance about the time the doctor would take to treat, the pain
he/she might get, etc. which can mislead him/her. Simply say you do not know.
• Report to the doctor any past negative experience.
• Any discussion regarding the treatment has to be taken place in the absence of children.
3. What is team approach

The whole team should work with a plan for each visit of a child. The initial visits are usually
sufficient for getting the child cooperation and diagnosis and treatment planning. Plan for the
subsequent visit - if an uncooperative child is to be scheduled for his first restorative work, have
his/ her appointment after a cooperative child whom you can model for a certain procedure. Plan
procedures requiring minimal cooperation initially and the complicated ones, later. It is a good
idea to have a separate session of pediatric patients in a busy general practice. The team should
work with a flexible approach, learn communication skills to deal with children effectively and
be positive.
4. Design of equipment in pedodontic clinic

Very accessible sterilization to meet the needs of the fast and large volume of patients in an
office. Large size of multiple units for ultrasonic dugmat, steam or chemical mat sterilization. A
sufficient number of instruments, mouth drops and such to treat a large patient volume. Storage
in every conceivable spot under holding benches in the operatory wall cabinets and under
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counter cabinets, etc. Brush up sinks at graduated heights. Hard surface floor under operatory
chairs; carpeted trash disks. Foot controlled or automatic faneets for operatorysinks. Trash
container in the operatory out of sight and out of reach of children’s hands. A colorful towel to
cover the restrained child. A camera to take first examination photograph—an excellent
marketing activity that phases point. The equipment must be accommodated to the child not vice
versa.
5. Play area in pedodontic clinic

Children require free, empty spaces to move around.They usually do not sit in one place. They
often stand near a window, move around reception or table or keep looking for interesting things
around. Therefore, it is necessary to provide some empty space for them to move around. A fish
tank or a slide may be kept in such a vacant area. Also, it is better to engage them in some
interesting activity to relieve their anxiety before their turn comes for dental check-up or
treatment
6. How the attire of dentist influences children in pedodontic clinic

A typical attire of dental staff comprising cap, apron, mask and gloves is certainly not child-
friendly. In case of children, it is especially recommended to try and work with alternatives to
apron as they have white coat anxiety. Make an attempt to meet a child casually, and preferably
not around the dental chair. The dentist first meets the child casually in the consulting room,
takes a brief history, assesses the behaviour and then directs the child to dental chair after
showing around the clinic and meeting other staff.
7. Importance of waiting area in pedodontic clinic

This is especially useful for children, who are big enough for the play area and would like to
show their intellect and engage in smarter games. This can comprise of books and games for
elder children and waiting parents. It is necessary that the waiting time of a child in the dental
clinic is made pleasant. Often, children having to wait for long are bored by the time they are
taken in for treatment. Also, 5 to10 minutes of waiting time spent in playing can distract them
from the fact that they have been brought for some treatment and is ‘refreshing ’for them.
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8. Role of colour smells on the behaviour of children

Often clinics have roof-to-floor tiles for easy maintenance and cleanliness, and colors projecting
office ambience. Children imagine and accept bold, bright fresh colors such as yellow, red, blue,
green, orange, pink and may dislike gray, black and white, wooden, brown, etc. Also, smell of
spirit, eugenol, acrylic, waxes may not really go well with children. The noise of an air-rotor
handpiece, suction apparatus, a compressor or an ultrasonic cleaner can be disturbing too. Hence,
it is best to mask these sound by use of light instrumental music.
9. Gifts and rewards to children

Give a child a token of appreciation for good work with a small gift at conclusion of a visit such
as cars, dolls, pencil, medals, etc. Even calling a child a ‘goodboy’or a ‘goodgirl’or drawing a
‘star ’on his/her hand can work like rewards and excite children and leave with them fond
memories of dental visits. Never bribe the child before treatment.
10. Use of Audio visual aids in pedodontic clinic

Children forget themselves while watching cartoon films. The TV set in front of dental chair can
distract the child enough to forget the dental treatment while that being carried out. Also, once a
child is cooperative, it reduces the need of talking on the part of the dental team. It is a good idea
to have a camera attached to a TV set displaying the child on the chair as children do love
watching themselves.
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MEDICAL EMERGENCIES IN DENTAL OFFICE
Dr Chandana
1. Management of syncope
General considerations:
• Position of the patient: Made to lie own in supine position with legs raised to improve venous
return.
• Loosening of the clothes: Tight clothing should be loosened.
• A patent airway should be maintained.
• Any foreign body should be removed manually or with suction apparatus.
• Inhalation of the aromatic spirit of ammonia or application of cold sponges to the face helps in
securing reflex stimulation.
• 100 percent oxygen should be administered
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• If bradycardia atropine injection 0.6 mg in 5 mL of water should be given slowly given

intravenously.
• If hypotension persists, drugs like phenylephrine should be administered.
Dental treatment considerations:
• Delay further dental treatment 24 hours especially if the patient lost consciousness.
• If the patient lost consciousness- they must not be permitted to leave unescorted or drive a
motor vehicle.
• Determine the cause of the syncopal episode prior to completing further treatment. Stress is
the major cause of syncope in the dental practice.
• Use stress management protocols, morning appointments, consider sedation.
• Ensure that patients do not miss meals prior to treatment.
2. Management of epileptic patient in dental office

This is a central nervous system disturbance involving convulsions followed by loss of
consciousness.
Most seizures last < 2 minutes
• EMS activated.
• Assure patient and staff safety.
• Administer oxygen.
• Manage airway.
• Monitor vitals, pulse oxymetry.
• Suction available.
If seizure is lasting > 2 minutes,
• establish IV, administer medicines.
• Diazepam Pediatric: 0.2 to 0.5 mg/kg IV/IM
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• Midazolam 0.05 to 0.1 mg/kg IV 0.2 mg/kg IM (Max 10 mg)
EMS not arrived > 5 minutes
• Pediatric: 2 mL/kg 25 percent dextrose solution.
• Evaluate airway maintenance.
• Evaluate cardiac rhythm.
3. Hypochlorite Accident
It is due to expelling of an irrigant such as NaOCl beyond the apex.This happens only by locking
the needle of the irrigating syringe in the canal and forcefully injecting the irrigant.
 Allow the bleeding to continue.
 If the body rids itself of toxic fluid healing may be faster.
 If the treated tooth is pulpless consider prescribing an antibiotic and an analgesic for 5
and 3 days respectively.
 Since this may be hypersensitive reaction consider prescribing an antihistaminic.
4. Drug overdosage for local Anesthesia

 ABC’S
 Activate EMS
 Administer oxygen by mask at 10–15 L/minute
 Start IV if available (18 gauge catheter with normal saline)
 If needed and available administer anticonvulsant, versed 2 mg, then 1 mg/min to effect
(Monitor respiration)
 Monitor and record vital signs
5. Management of Diabetic emergencies in dental office

Hypoglycaemia:
• In a conscious patient administer 20 gm of oral glucose
• In an unconscious patient 50 cc 50 percent glucose given IV
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• Adrenalin: 0.5 cc of 1:1000 adrenalin is given subcutaneously.
• It stimulates hepatic gluconeogenesis and counteracts hypoglycemia
• Glucocorticoid: 100 mg of hydrocortisonehemisuccinate IV
• Glucagon: 1–2 mg IM raises blood sugar.
Hyperglycaemia:
• Circulating insulin present is ineffective because of poor tissue perfusion. Hence, tissue
perfusion must be improved.
• One liter of fluid can be given in the first half hour and subsequently 1 liter per hour till
dehydration is corrected
• Insulin therapy forms the main stay of hyperglycemia.
• It not lowers the blood sugar but also prevents further lipolysis thereby preventing
accumulation of ketones and hydrogen ions.
6. Management of foreign body aspiration

May occur due to
• Pathology in airway
• Dental instruments
• Tongue
Management
• Re-establishement of airway
• Non-invasive procedures
• Forceful coughing
• Back blows
• Hemlichmanoeuver
• Chest thrust
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• Finger sweeps
Prevention
• Rubber dam
• Chair position
• Dental assistant
• Magills intubation foreceps
7. Anaphylaxis
This is a severe systemic type allergic reaction and is a medical emergency.
Treatment
General treatment
• ABC’s
• Maintain airway,
• administer oxygen, and
• determine possible need for intubation or surgical airway
• Monitor vital signs
• If in shock put patient in a horizontal or slight Trendelenburg position
Mild reactions
• Antihistamines usually effective. (Benadryl 50–100 mg or Chlorpheniramine maleate 4–12 mg

PO, IV, or IM)
• Identify and remove allergen
• Follow-up medications in 4–6 hours
Severe reactions
• If available start IV fluids
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• Epinephrine is drug of choice.
• Usually prepackaged 1:1,000 in 1 mg vials or syringe
• If drop in blood pressure is minimal, start with 0.5 mL (0.5 mg)
• If drop in blood pressure is severe start with 2 mL (2 mg)
• Repeat after 2 minutes if needed
• If no IV use 1:1,000 (1 mg/CC) IM 0.3 to 0.5 mg (0.3–0.5 CC)
• If the patient is intubated can give epinephrine endotracheally
• If asthma, edema or pruritus (itching) are present, can use Corticosteroids. Hydrocortisone
sodium succinate (Solution cortef) 100–500 mg IV or IM.
• Dexamethasone (Decadron) 4–12 mg IV or IM
• Repeat dose at 1, 3, 6, and 10 hours as indicated by severity of symptoms.
8. Classify allergic reactions

It is an unwanted response of the body to a complete dose of the drug. It is as the result of
immunological response by the individual.
Gel and Coombs classification
• Type 1 (IgE – mediated hypersensitivity) most life threatening few minutes
• Type 2 (cytotoxic/cytolytic antibody mediated) IgM or IgG antibodies mediated
• Type 3 (Immune complexmediated) 1–4 weeks, IgM – IgG soluble metabolite
• Type 4 (Delayed hypersensitivity) sensitized T cell lymphocytes.
9. Shock in pediatric clinic

It is a phenomenon marked by circulatory deficiency which is either cardiac or vasomotor in
origin exhibiting marked hypotension.
Treatment:
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• Position: Put the patient in a shock position with head at the lower level than feet 15 degree
trendlenbergpostion
• Maintain the body heat by covering the patient with blanket and keep a hot water bottle
between the thighs
• Check for any airway obstruction and patency of airway be maintained
• Control the loss of blood in hemorrhage shock by pressure packs
• Restore the lost body fluids. Infusion with plasma expanders or Ringer’s lactate solution
should be carried out to maintain the intravenous line and restore the volume loss
• Administer 100 percent oxygen
• The blood pressure, pulse rate and respiratory rate should be constantly monitored to assess the
vitals
• Injection hydrocortisone sodium hemisuccinate 100 mg in 5 mL of water intravenously as

stress bearing factor of the body
• Injection mephentermine to raise BP
• Injection atropine is given for bradycardia
• Broadspectrum antibiotics
• Narcotic analgesic to relieve pain.
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DENTAL CARE FOR SPECIAL CHILD

(Including CLEFT LIP & PALATE)
Dr P.Chaitanya
1) Define handicapped child & dental handicapped child.

Handicapped child (WHO): One who over an appreciable period of time is prevented by
physical or mental conditions from full participation in the normal activities of their age group
including those of social, recreational, educational and vocational nature.
Dental handicapped child:A person should be considered dentally handicapped if pain, infection or
lack of functional dentition,
1. Restricts consumption of diet adequate to support growth and energy needs.
2. Delay or otherwise alters growth and development.
3. Inhibits performance of any major life activity, including work, learning, communication
and recreation.
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2) What are different handicapping conditions?

Frank and Winter (1974)
• Blind or partially sighted
• Deaf or partial deaf
• Educationally subnormal
• Epileptic
• Maladjusted
• Physically handicapped
• Defective of speech
• Senile
Nowak (1976)
• Physically handicapped—polio
• Mentally handicapped—retardation
• Congenital—cleft palate
• Convulsive—epilepsy
• Communication—deafness
• Systemic—hemophilia
• Metabolic—juvenile diabetes
• Osseous-disorders—rickets
• Malignant disorders—leukemia
New Classification
• Developmentally disabled
• Medically compromised.
3) What are the preventive measures for handicapped child?

Oral hygiene measures:
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• Meticulous tooth brushing is essential for maintaining oral hygiene. If child cannot be
trained to perform or cannot perform due to cognitive or physical impairment, then the
parent or primary caretaker is trained to brush child’s teeth. Positions most commonly used
for children requiring oral care assistance are as follows:
1. The standing or sitting child is placed in front of the adult so that the adult can cradle the
child’s head with one hand while using the other hand to brush the teeth.
2. The child reclines on a sofa or bed with the head angled backward on the parent’s lap.
Again, the child’s head is stabilized with one hand while the teeth are brushed with the
other hand.
3. The parents face each other with their knees touching. The child’s buttocks are placed on
one parent’s lap, with the child facing that parent while the child’s head and shoulders lie
on the other parent’s knees; this allows the first parent to brush the teeth.
4. The extremely difficult patient is isolated in an open area and reclined in the brusher’s lap.
The patient is then immobilized by an extra attendant while the brusher institutes proper
oral care. If a child cannot be adequately immobilized by one person, then both parents and
perhaps siblings may be needed to complete the home dental care procedures.
5. The standing and resistive child is placed in front of the caregiver so that the adult can
wrap his or her legs around the child to support the torso while using the hands to support
the head and brush the teeth.
Diet counselling: Low sugar and high fibre diet diet should be advised. Cariogenic stuff,
sticky solid foods and frequent snacking should be avoided.
Fluoride exposure: Tooth brushing with a Fluoride dentifrice and annual topical fluoride
application is recommended for caries prevention.
Sealant application: Pit & Sealant application on first molars between 6 1/2 and 7 1/2 years of
age and on second molars between 12 and 13 years of age would be appropriate.
4) What are the indications of Physical restraints/Protective stabilisation?

Indications:
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• A patient requires immediate diagnosis and/or limited treatment and cannot cooperate
because of lack of maturity or mental or physical disability.
• A patient requires diagnosis or treatment and does not cooperate after other behavior
management techniques have failed.
• The safety of the patient, staff, parent, or practitioner would be at risk without the use of
protective stabilization.
5) What are the contraindications of Physical restraints/Protective stabilisation?

Contraindications:
• A cooperative nonsedated patient.
• Patients who cannot be safely stabilized due to medical or physical conditions.
• Patients who have experienced previous physical or psychological trauma from protective
stabilization (unless no other alternatives are available).
• Non-sedated patients with non emergent treatment requiring lengthy appointments.
6) Classify physical restraints

Physical restraints involve restriction of movement of child’s head, hands, feet’s or body.
It can be ,
 Active restraints: performed by the dentist, staff or parent without the aid of a
restraining device.
 Passive restraints: with the aid of a restraining device.
Types of restraints:
For body:
• Papoose board
• Pedi wrap
• Triangular sheet
• Bean bag dental hair insert
• Towel and tapes
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• Safety belt
For extremities:
• Velcro-straps
• Posey straps
• Towel and tape
• Extra assistant
Head:
• Head positioned
• Forearm body support
• Plastic bowl
• Extra assistant
Mouth:
• Mouth-blocks: Ferguson bite blocks, McKesson bite blocks, Molt mouth prop.
• Banded tongue blade and open wide mouth props
7) What is IQ and mental retardation?

Mental retardation translates an intelligent quotient (IQ) which is calculated as:
IQ = (MA/CA) × 100
MA–mental age CA–chronological age.
Mental retardation (MR) is defined as an overall intelligence quotient lower than 70,
associated with functional deficit in adaptive behavior, such as daily-living skills, social
skills and communication. Three levels of impairment were identified:
1. Idiot, individuals whose development is arrested at the level of a 2 years old
2. Imbecile, individuals whose development is equivalent to that of a 2 to 7 years old at
maturity
3. Moron, individuals whose mental development is equivalent to that of a 7 to 12 years old
at maturity.
IQ Classification guide
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IQ range Grade
140 and above Very superior

120-139 Superior
90-119 High Average
80-89 Low Average
70-79 Borderline
<69 Mentally retarded
8) Classify Mental Retardation.
Degree of mental SB(Stanford WISC(Weschler Communication Special

disability –Binet Intelligence Scale for requirements for
Intelligence children) dental care
Scale)
Mild 67-52 69-55 Should be able to Treat as a normal

speak well child; mild
enough for most sedation or
communication nitrous oxide-
needs oxygen analgesia
may be beneficial.
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Moderate 51-36 54-40 Has vocabulary Mild to moderate

and language sedation may be
skills such that beneficial, use
the child can restraints and
communicate at a positive
basic level with reinforcement;
others general anesthesia
may be indicated
in cases of severe,
generalized dental
decay.
Severe or 35 and below 39 and below Mute or Same as for

profound communication in moderately
grunts; little or no retarded
communication
skills
9) Describe clinical features of Down’s syndrome child

 Trisomy 21 accounts for nearly 95 percent of all patients with Down syndrome.
 It is the most common autosomal abnormality and occurs in approximately 1 in 700
live births.
Clinical features:
Skull:
 Small head (brachycephaly)
 Flat facies with increased interocular distance(hypertelorism)
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 Flat occiput
 Depressed nasal bridge
Ocular anomalies:
 Narrow , upward and outward slanting of palpebral fissures
 Medial epicanthal folds
 Strabismus
 Cataract
 Retinal detachment
Ears:
 Small and misshapen ears with anomalies of the folds.
Neck:
 Broad, short neck
Skeletal anomalies:
 Short stature
 Broad and short hands, feet ,digits
 Single transverse palmar crease on the hand(Simian crease)
 Short curved fifth finger(dysplasia of the mid phalanx)
 Dysplasia of the pelvis
 Joint laxity
 A wide gap between first and second toes
 Atlanto- occipital instability
 Muscle hypotonia in new borns with decreased response to normal stimuli has been
reported.
Intelligence Quotient (IQ):
Mental retardation which can be mild to severe with an IQ of 25-50.
Other features:
 Protuberant abdomen(with or without umbilical hernia)
 Hypogenitalism
 Hypospadia
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 Cryptorchism
 Delayed and incomplete puberty
 Congenital defects of the heart (40%)
 Duodenal atresia
 Polydactylia
 Syndactylia
 Recurrent respiratory infections
 Leukemia(1%)
 Epilepsy(10%)
 Hypothyroidism(3%)
 Presenile dementia
10) Describe oral manifestations of Down’s syndrome.

Oral manifestations:
 Small mouth with protrusion of the tongue (macroglossia) with difficulty in eating and
speech.
 Scrotal tongue
 Hypoplasia of the maxilla
 Delayed tooth eruption
 Partial anodontia
 Enamel hypoplasia
 Juvenile periodontitis
 Cleft lip and palate
 Bifid uvula
 Fissuring and thickening of lips with angular cheilitis.
11) What are the dental treatment considerations of Downs Syndrome?

Dental treatment considerations:
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 When treating children with Down syndrome, the primary concerns are to determine the
need for sub acute bacterial endocarditis prophylaxis and the child’s ability to co –
operate.
 If a child has had a surgery to repair a congenital heart defect, they may not need sub
acute bacterial endocarditis prophylaxis depending on when the surgery wasperformed
and the presence of any residual defect.
 This should be confirmed with the child’s cardiologist.
 Children are generally affectionate, co-operative and present no special problems during
management.
 Most of the children can be managed with Tell, Show, Do technique.
 Nitrous oxide analgesia can be used in mildly apprehensive patients.
 The patients with Down syndrome are more susceptible to periodontal disease.
 The dentist should make it clear to the parent and should stress on the early development
of good oral hygiene habits including thorough,supervised daily tooth brushing with a
fluoridated tooth paste, flossing and when necessary ,use of an antibacterial mouth rinse
such as 0.12%chlorhexidine.
12) Autism
Autism is a complex neurobehavioral disorder with the following diagnostic criteria.
 Impairments in social functioning
 Deficits in communication
 Restricted interests
Characteristics of autistic individuals include,
 Repetitive behavior
 Languagedisorders
 Sleep disturbances, social problems
 Seizures, attention disorders,
 Allergicreactions,
 Cognitive changes involve IQ, reasoning, verbal and language disorders
Considerations for dental care
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 People with autism need will exhibit a wide variation in their level of understanding and
ability to co-operate during dental treatment.
 Several appointments are required just for introduction to dentistry. It is important for the
patient to meet the same dentist and preferably same assistant or hygienist to know the
personnel and be able to trust them.
 Presence of parents in the operatory is helpful and appears to comfort the patients.
Compliance is further enhanced by use of the tell-show-do technique and by giving short,
clear commands and positive and negative verbal reinforcement.
 Children and adolescents with autism use pictures or photographs as an aid in
communication.
 Photos of an open mouth symbolizing ‘open your mouth’; a tooth brush, mirror,
operatory lamp, and dental chair are useful.
13) Management of visually impaired child
 Pre appointment interview
 Complete medical history
 Explain in detail office settings, treatment procedure
 Physical contact for reassurance
 Do not suddenly grab or move the pt
 Children use auditory, tactile and olfactory senses
 Highly verbal
 More interested in listening stories
 Avoid any signs, expressions of pity
 Audio and Braille pamphlets
14) Management of hearing impaired child
 Substitute communication procedures must be employed
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 Remain in the child’s view to maximize visual communication
 Use Magic Slate, Chalk Board or writing Pads in elder children
 Allow use of tactile sense
 Use of Desensitization
 Such patients are impatient with delays , so avoid them
 They are hyperactive, so allow them to explore
 Avoid the element of surprise
 Avoid changing the environment/ setup
 Positive Reinforcement
 Tell-show-feel-do
 Non verbal communication
 Adjust hearing aid
15) Learning disability
• Learning disabilities are neurological conditions that interfere with the individual’s
ability to store, process, or produce information. They can affect a person’s ability to read,
write, count, speak, or reason. In addition, they may affect memory, attention,
coordination, social skills, and emotional maturity.
• Example: Minimal brain dysfunction, Dyslexia, Developmental aphasia
• Learning disabilities affect between 3% and 15% of the population. They occur four times
more frequently among boys than among girls. Learning disabilities may run in families,
indicating a possible genetic factor, and are sometimes confused with intellectual
disabilities, autism, deafness, and behavioral disorders.
• They include conditions that have been referred to as perceptual handicaps, brain injury,
minimal brain dysfunction, dyslexia, and developmental aphasia. The cause of learning
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disabilities remains unclear. Physiologic factors, such as minimal brain injury or damage to
the central nervous system, have been implicated.
• The possibility exists that severe emotional disturbances can develop as a result of
learning disabilities. This potential has prompted the early diagnosis and treatment of
affected persons.
• Most children with learning disabilities accept dental care and cause no unusual
management problems for the dentist. If a child is resistant, behavioral management and
conscious sedation techniques may be used with success.
16) Define celebration palsy and explain its different types. What are the oral
manifestations of a patient with cerebral palsy?
Cerebral palsy is a severe childhood disability, characterized by a non-progressive motor
disorder of posture & movement due to a lesion in the developing brain.
Types of cerebral palsy
Based on anatomical involvement
Primarily it is a disorder of voluntary movement, which results in a wide spectrum of
disability ranging from virtually unnoticeable physical impairment.
 Monoplegia - affecting only one limb
 Hemiplegia – one upper & one lower limb
 Paraplegia - both lower limbs
 Quadriplegia - all the four limbs
Based on neuromuscular involvement
1. Spasticity: increased motor tone resulting in stiffness & difficulty in moving limbs.
Increased deep tendon & stretch reflexes. Involvement of cerebral cortex.
2. Athetosis: involvement of basal ganglia, uncontrolled voluntary muscle contraction.
3. Ataxia: involved muscles unable to contract completely, involvement of cerebellum.
4. Rigidity: involvement of basal ganglia, resistance to passive movements, voluntary
movements are slow.
5. Mixed: combination of characteristics of more than one type of cerebral palsy.
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Oral manifestations:
 Dental caries: this may be due to their inability to maintain good oral hygiene.
 Periodontal disease: difficulty in chewing & swallowing, children tend to eat soft
foods that are high in carbohydrates. They may also be on phenytoin to control
seizure activity which is cause of some degree of gingival hyperplasia.
 Malocclusion: occurs twice as often than in average population. Commonly noticed
protrusion maxillary anterior teeth, excessive over jet & overbite, open bites &
unilateral cross bites, the cause being the disharmonious relationship b/n intraoral &
perioral musculature. in spastics, class II div2 malocclusion is observed , along with
constricted maxillary & mandibular arches
 Bruxism: commonly seen in athetoid cerebral palsy resulting severe attrition, loss of
vertical dimension & TMJ disorder.
 Trauma: due to nature of this disorder these children are susceptible to trauma,
especially maxillary anterior teeth.
 Children may have excessive drooling & difficulty in swallowing.
17) Management of child with cerebral palsy

The following suggestions are offered to the clinician as being of practical significance in
treating a patient with cerebral palsy:
1. Consider treating a patient who uses a wheelchair in the wheelchair. Many patients
express such a preference, and it is frequently more practical for the dentist. For a young
patient, the wheelchair may be tipped back into the dentist’s lap.
2. If a patient is to be transferred to the dental chair, ask about a preference for the mode of
transfer. If the patient has no preference, the two-person lift is recommended.
3. Make an effort to stabilize the patient’s head throughout all phases of dental treatment.
4. Try to place and maintain the patient in the midline of the dental chair, with arms and
legs as close to the body as feasible.
5. Keep the patient’s back slightly elevated to minimize difficulties in swallowing. (It is
advisable not to have the patient in a completely supine position.
6. When the patient has been placed in the dental chair, determine the patient’s degree of
comfort and assess the position of the extremities. Do not force the limbs into unnatural
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positions. Consider the use of pillows, towels, and other measures for trunk and limb
support.
7. Use stabilization judiciously to control flailing movements of the extremities.
8. For control of involuntary jaw movements, choose from a variety of mouth props. Patient
preference should weigh heavily because a patient with cerebral palsy may be very
apprehensive about the ability to control swallowing. Such appliances may also trigger
the strong gag reflex that many of these patients possess. Allow frequent time-outs for
the patient to regroup, relax, and breathe normally.
9. To minimize startle reflex reactions, avoid presenting stimuli such as abrupt movements,
noises, and lights without forewarning the patient.
10. Introduce intraoral stimuli slowly to avoid eliciting a gag reflex or to make it less severe.
11. Consider the use of the rubber dam, a highly recommended technique, for restorative
procedures.
12. Work efficiently and quickly and minimize patient time in the chair to decrease fatigue
of the involved muscles.
13. Sedation or general anesthesia may be an option for more complex patients.
14. Management of haemophilic child
MANAGEMENT :
 Consultation with the child patient’s physician and severity of the condition should be
assessed before the procedure.
 Minor injuries like lacerations due to slippage of instruments, placement of matrix band,
scaling etc. must be avoided.
 For patients requiring deep scaling, initially supragingival scaling is done and then
repeated 7-14 days after proper healing.
 Minor bleeding should be controlled with pressure packs and hemostatic agents.
 In all cases the patient should be prescribed tranexamic acid which can be started one
night before the procedure: 250mg for a child and 500mg for an adult for 2 times daily.
 Continue for 5-7 days after the procedure.
 Use of local anesthetics, especially nerve block is contraindicated.
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 Dental pain can usually be controlled with a minor analgesic. The use of any non-
steroidal anti-inflationary drug (NSAID) must be discussed beforehand with the patient’s
haematologist because of their effect on platelet aggregation.
 Surgical treatment, including a simple dental extraction, must be planned to minimize the
risk of bleeding, excessive bruising, or hematoma formation.
18) Dental considerations for management of an epileptic child

Seizure: It is an episode of neurologic dysfunction caused by abnormalities in electrical
activity of the brain.
 If seizure occur in dental chair, chair is lowered to a supine position
 Patient should be taken away from any sort of equipment or sharps that could cause
injury
 Wrapped tongue blade is placed to prevent tongue biting. A mouth prop or rubber or
plastic should be inserted into oral cavity to prevent tongue biting.
 Suction may be useful to avoid aspiration of secretions, but if it is not available the
head should be turned to the side.
 If convulsions don’t stop in few minutes then administer anticonvulsants like
diazepam (most commonly advised1mg/kg IV slowly up to 10 mg)
 Give oxygen
 Throughout the seizure the airway needs to be maintained.
 If condition does not improve admit to the hospital
19) Antibiotic prophylaxis for children with congenital cardiac disease
 Situation  Agent  Regimen
 Standard  Amoxicillin  Adults: 2g

general prophylaxis  Children: 50mg/kg orally 1 hour
before procedure
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 Unable to  Ampicillin  Adults: 2g IM or IV

take oral  Children : 50mg/kg IM or IV 30 min
medication before procedure
 Allergy to  Clindamycin  Ad: 600mg; ch: 20mg/kg Ad: 2g;

penicillin  ch: 50mg/kg
 Cephlexin or  Ad: 500mg; Ch: 15mg/kg orally
cefadroxil 1hour before procedure
Azithromycin/Clarithromycin
 Allergy to  Clindamycin  Ad: 600mg; ch: 20mg/kg IV

penicillin and  cefazolin  Ad: 1g; children: 25mg/kg IM or IV
unable to take oral within 30min before procedure
medication
20) Management of AIDS in children

Prevention
• Barrier techniques
• Proper sterilization– HIV is sensitive to autoclaving at 121°C for 15 min at 1 atmospheric

pressure
• Dry heat of instruments up to 170°C– Virus can be inactivated by heating lyophilized factor
at 68°C for 72 hours.
Disinfectants for innate objects:
• Calcium hypochlorite
• 0.2 percent sodium hypochlorite
• 6 percent hydrogen peroxide for more than 30 minutes
• 2 percent glutaraldehyde and 6 percent hydrogen peroxide
• Sodium dichloroisocyanate
• HIV is inactivated by treatment for 10 minutes at room temperature with 10 percent

household bleach, 50 percent ethanol and 3 percent hydrogen peroxide
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• Gloves may be disinfected by immersing them in boiling water for 20 minutes and
alternatively overnightsoakingin1percentsodiumhypochlorite
Drugs used for AIDS:
• Acyclovir 1 to 2gm daily orally or IV
• Zidovudine(AZ7), Which attacks the virus through the enzyme reverse transcriptase
• Others inhibitors available: Dideoxycytosine (ddc), Dideoxyinosis (dd I), Stavudine (d4 T)
• Protease inhibitors: sanquinavir, indinavir and ritonavir.
21) Classify cleft lip & palate

Classification of cleft lip and palate
Many classifications have been proposed .these classifications can be broadly categorised
into
1. Morphological classifications
2. Embryological classifications
Morphological classification -
Veau classification (1931)
Group I - cleft of the soft palate only
Group II - cleft of the hard and soft palate till the incisive foramen
Group III - complete unilateral cleft of the soft palate, hard palate, alveolar ridge and lip on
one side
Group IV- complete cleft of the soft palate, hard palate the alveolar ridge and the lip on both
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side
Embryological classification
Kernahan and Stark Classification (1958)
Group I - cleft of primary palate only
· Unilateral - total , subtotal
· Bilateral – total , subtotal
Group II - cleft of the secondary palate only
· Total
· Sub total
· Submucous
Group III - cleft of both primary and secondary palate
· Unilateral - total , subtotal
· Median - total , subtotal
· Bilateral - total , subtotal
22) Treatment protocol for a cleft lip palate child

Protocol is developed to provide comprehensive treatment in alliance with other experts to
attain optimal treatment in cleft lip and palate patient
At birth
 Attend referral
 Predental treatment: feeding plate, presrugical orthopedics
 Make study records by photographs, models
3-5 months
 Introduce the parents to dental care for the primary teeth
 Alignment of primary teeth and palatal expansion
 Lip repair by a plastic surgeon.
 Audiology/ENT surgeon first assessment
 Suction myringotomy for “glue ear”
12 months
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 Pedodontic review
 Explain possible eruption abnormalities
 Palatal repair by a plastic surgeon.
 Speech assessment by speech pathologist.
 Review by the Audiologist and ENT surgeon
2-6 years
 Pedodontist review-facial growth and development
 Preventive measures for caries-sealants, fluorides
 Restorative care if needed
 Plastic surgeon to review 12 monthly
6-7 years
 Pedodontist review-mixed dentition
 Preventive or early orthodontic intervention
 Radiographicevaluation
 Orthodontic consultation
8 years
 Combined coalescence with team members
 Suitability about bone grafting
 Dental bone assessment (OPG, wrist x-ray, lateral cephalogram)
 Review by plastic surgeon ,speech pathologist and ENT surgeon
 Pedodontist review
9 years
 Combined orthodontist and pedodontist coalescence
 Review by other expert if required.
 Bone grafting alveolar cleft.
10-12 years
 Pedodontist to plan future treatment
 Orthodontic consultation
 Monitoring changing dentition and growth
 Preventive measures with a review of dental health
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12-15 years
 Orthodontic treatment
 Pedodontic review
 Oral surgeon to assist if the orthodontist requires
 Review by plastic surgeon
 Speech pathologist review
23) Role of Pedodontist in management of cleft lip & palate
• A key member who sees the baby and the parent at the time of repair of the lip
• Provides presurgical orthopaedic treatment for the baby
• To maintain perfect oral health
• To guide the occlusion and facial growth
• Motivates the parent and the child to cooperate with the treatment
24) What are the dental procedures that require antibiotic prophylaxis in children?
• Dental extraction
• Periodontal surgery, scaling, root planning, probing and recall maintenance
• Placement of dental implants
• Reimplantation of avulsed tooth
• Endodontic instrumentation or surgery beyond the apex of the tooth
• Sub gingival placement of antibiotic fibers/strips
• Initial placement of orthodontic bonds but not brackets
• Intraligamentary local anesthetic injections
• Prophylactic cleaning of teeth or implants where bleeding is anticipated
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25) Enumerate the considerations for prevention of oral diseases in special children?
Prevention of oral disease is of paramount importance for individuals with disabilities, not least
to prevent disease and complications such as pain but also to obviate the need for operative
intervention.
Prevention programmes must be started at an early age as feasible and reinforced on a long-term
basis, incorporating them into other daily programmes such as rehabilitation, education and
occupational therapy.
 Dental recalls should be planned in accordance with the individual patient’s needs:
people with severe dental disease or a predisposition to it (e.g. xerostomia predisposing to
caries) may need to be seen every 2–3 months.Patients should be involved in maintaining
their own oral hygiene as much as possible, but caregivers may need to assist.
 Education of the family members, partner or other care providers may be critical for
ensuring regular and appropriate supervision of diet and oral hygiene. Caregivers may
well need dental health education, and should be shown how to properly position the
person for oral hygiene care. Chairs, pillows, head rests, bean bags, and other devices
may be helpful.
 Dietary counselling is crucial, to avoid caries and erosion. Ideally, patients should brush
their teeth after each meal and before bedtime, but at least twice daily is acceptable.
 Brushes can be modified to assist people with physical disabilities to brush their own
teeth. Electric toothbrushes may improve patient compliance in patients with physical or
mental disabilities.
 Other aids helpful to many people include:
Fluoride toothpastes, mouth rinses or gels, which may be beneficial in controlling
caries. Patients who might swallow a rinse can benefit from application with a
toothbrush, cotton bud or sponge-sticks. Additional topical fluorides such as professional
applications of varnish are indicated when the caries rate is high.
Chlorhexidine mouth rinses or gels, which may be beneficial in controlling gingivitis
and periodontitis. Patients who might swallow a rinse can benefit from application with a
toothbrush, cotton bud or sponge-sticks.
Intermittent use (e.g. weekends or every other day) may help to minimize problems with
staining.
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Where cooperation is good:

o Tooth flossing is recommended daily, although a second person may need to
assist.
o Disclosing solutions may be beneficial in promoting behavioural changes.
o Fissure sealants may be beneficial.
Child abuse & neglect
Dr KS Roja Ramya
1. Define Child abuse.
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A. According to Gill, it is defined as the ‘nonaccidental physical injury, minimal or fatal,
inflicted upon children by persons caring for them’. It is an overt act of commission of a
caretaker—physical, emotional or sexual.
2. Define Neglected child
A. Neglected child: It is one who shows evidence of physical or mental health primarily due to
failure on the part of the parent or caretakers to provide adequately for child’s needs.
3. Define Dental neglect
A. The failure by a parent or guardian to seek treatment for visually untreated caries, oral
infections and/ or oral pain, or, failure of the parent or guardian to follow through with
treatment once informed that the above condition(s) exists.
4. What are the characteristics of child abuse
A. Some of the identifying features of the abused child are:
• Unduly afraid or passive child
• Evidence of prolongedconfinement like delay in speech
• Evidence of repeated skin orother injuries
• Child is undernourished andis given inappropriate food ordrink
• Evidence of poor overall care.
• Child is cranky irritable or crieseasily.
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5. Write the various types of child abuse and neglect
1. Physical abuse
• Sexual abuse
• Failure to thrive
2. Intentional drugging or poisoning
• Munchausen syndrome by proxy
• Health (Medical) care neglect
• Dental neglect
• Safety neglect
3. Emotional abuse and neglect
• Physical neglect
6. Write various indications of physical abuse based on the location of bruises.
A. Location of bruise - Indication of abuse
• Genital or inner thigh. - Toilet mishaps or sexual abuse
• Cheeks - Slapping of child
• Earlobes. - Pinching or pulling
• Upper lip/labial frenum. - Impatient or forceful feeding
• Neck. - Strangulation
• Circumferential bruises on ankles/wrists. - Placement of restraints
• Corners of mouth - Gagging of child
7. Write various marks Seen in Physical Child Abuse
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• Human hand marks: Grab marks which is oval-shaped bruise that resemble fingerprints due to
holding of child in violent shaking
• Strap marks: sharp-bordered, rectangular bruises of various lengths, often caused by a belt.
• Lash marks: bruises or scratches caused by thrashing with tree branch or switch.
• Loop marks: These are secondary to being struck with a doubled-over lamp cord, rope or fan-
belt.
• Bizarre marks: These are always inflicted when a blunt instrument is used in punishment
• Circumferential tie marks: These are present on the ankles or wrists and are caused, when a
child is restrained.
• Gag marks: Seen as abrasions that appear near the corner of the mouth. Children may be
gagged because of screaming or yelling.
8. Mention the features that are noted in sexually abused child.
– Emotional effects
– Functional disturbances such retention of feces
– Frequent masturbation
– Preoccupation with the genital area
– Regression in behavior
– Guilt and anxiety.
9. Write various types of neglects
A. Nutritional Neglect
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Healthcare Neglect
Safety Neglect
Emotional Neglect
Dental Neglect
Physical neglect
10. MUNCHAUSEN SYNDROME BY PROXY
•InMunchausen syndrome by proxy, a parent or caretaker attempts to bring medical attention to
themselves by injuring or inducing illness in their children.
• This describes children who are victims of parentally fabricated or induced illness. The
fabricated symptoms and signs lead to unnecessary medical investigations, hospital
admissions, and treatment.
• Factitious symptoms are often of bleeding from various sites.
• Factitious signs include recurrent sepsis from injecting contaminated fluids, chronic diarrhea
from laxatives, fever from rubbing thermometers, or rashes from rubbing the skin or applying
caustic substances.
11. Write about battered child syndrome.
A.Definition: Battered child syndrome (BCS) refers to non-accidental injuries sustained by a
child as a result of physical abuse, usually inflicted by an adult caregiver.
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Symptoms : Physical examination detect injuries such as broken or fractured long bones, bruises,
burns, swelling, retinal hemorrhages, internal damage such as bleeding or rupture of an organ,
spiral-type fractures that result from twisting, and fractured ribs or skull.
Shaking an infant can cause bleeding in the brain ( subdural hematoma ), resulting in permanent
brain damage or death.
12. ROLE OF PEDODONTIST IN CHILD ABUSE AND NEGLECT
. The dentist’s role in identifying and preventing child abuse is as follows:
• To observe and examine and record any suspicious evidence.
•To treat any dental injuries.
• To establish and maintain a professional therapeutic relationship with the family.
• To transfer the child to a physician or hospital for proper care.
13. Role of Pedodontist specifically in Intervention and Prevention of child abuse
• Primary level: screeningchildren at a higher risk of maltreatment.
– Parents at risk for abusing children need to be screened and counselled.
• Secondary level: Concerns directed to thosewho are especially at high-risk.
– enhance parentingcapabilities to avoid possible maltreatment.
• Tertiary level: It refers to intervention after the condition is already identified.
• goal isto prevent recurrence of the condition.
– Pedodontist should ensure that child is referred to adesignated child protection agency.
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14. Write definition and classification of Bite marks
Definition:
Bite marks are defined as marks caused by teeth alone or in combination with other oral parts.
These can be on the skin or on inanimate objects like foods, cigarette, etc. and can also be
differentiated as human or animal bite marks.
Classification:
• According to causative agent

Human - Children, Adults
Animals - Mammals, Reptiles, Fish
Mechanical - Full denture, Saw blade tooth marks, Electric cords, belt marks
• According to the degree of biting

Definite marks - Tissues damage due to direct application of pressure by the biting edge
Amorous marks - These are made in amorous circumstances, slowly with the absence of
movement between teeth and tissue
Aggressive marks - These show evidence of scraping tearing or avulsion of tissues and
may be difficult to interpret
15. What are the characteristics of human bite marks.
Characteristics of human bite:
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A human bite mark is usually of elliptical or ovoid pattern; consists of tooth marks producedby
antagonist teeth; arch mark may indicate the shape of their incisal or occlusal surfaces.
• The puncture marks of incisors are narrow rectangular in shape, canines leave triangular-
shaped lesions, premolars leaveovoid marks.
• Bite marks left by maxillary teeth tend to be more diffuse, while those left by mandibular teeth
are more distinct.
16. Bite mark analysis
Examination of bite marks for analysis :
• History: Obtain a thorough history of any dentaltreatment carried out
• – Photography: Extraoral and intraoral photographs
• – Extraoral examination: Record and observe soft and hard tissue factors that may influence
biting dynamics.
• – Intraoral examination: Salivary swabs should be taken. The tongue should be examined to
assess size and function.
• – Impressions: Take two impressions of each arch. The occlusal relationship should be
recorded.
• – Sample bites: sample bites should be made into an appropriate material.
• – Study casts: Casts should be prepared using Type II stone.

Procedure for bite mark analysis
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• involves visualization, description of bite marks, collection of evidence from victim
andsuspect, comparison and analysis of evidence, formation of the opinion and often court
testimony.
• Note : Bite marks is also an important 4 marks question. If given for 4 marks you need to write
14, 15 & 16 questions together.
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First dental visit and Infant oral Health care
Dr Malathi
1.Common procedures carried out during the first dental visit
• Ans:If the child is frightened, uncomfortable or non -cooperative a rescheduling may be necessary
• Patience and calmness on the part of the parent and reassuring communication with your child are very
important in these instances.
• Short, successive visits are meant to build the child’s trust in the dentist and the dental office, and can
prove invaluable if your child needs to be treated later for any dental problem.
• Appointments for children should always be scheduled earlier in the day, when the child is alert and
fresh.
• For child under 2 yrs the parent may have to sit in the dental chair and hold the child during the
examination where as for older patients, parents may be asked to wait in the reception area so a
relationship can be built between the child and dentist.
• Apart from taking history better to polish few teeth by dentist.
• If radiographs required better to take in first visit.
• Attend to any of the emergency present and treat for pain if present.
• Topical fluoride application or any non traumatic procedure.
2.Define Infant oral health care

Ans:Professional intervention within 6 months after the eruption of the first primary tooth or no later than
12 months of age directed at factors affecting the oral cavity, counselling on oral disease risks and
delivery of anticipatory guidance.
3.importance of infant oral health care

Ans:-To identify , intercept and modify the potentially harmful parenting practices that may adversely
affect the infants oral health.
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-Parent education right from the prenatal period highlighting the importance of their role in the prevention
of dental diseases for their child.
Periodic evaluation of the pro facial development and oral health by the clinician.
4.Define Dental Home

Ans:It is defined as the ongoing relationship between the dentist and the parent where accessible and
coordinated oral health care can be delivered comprehensively while actively involving family
participation.
5.Requirements of Dental Home

Ans:-Comprehensive oral health care including acute care and preventive services in accordance with
AAPD periodicity schedules
-comprehensive assessment for oral diseases and conditions
-Individualized preventive dental health program based upon a caries risk assessment and a periodontal
disease risk assessment.
-Anticipatory guidance about growth and development
-Plan for acute dental trauma
-Information about proper care of the child’s teeth and gingiva
-Dietary counselling
-Referrals to dental specialists when care cannot be directly be provided within the dental home.
-Education regarding future referral to a dentist knowledgeable and comfortable with adult oral health
issues for continuing oral health care.
6.Define Anticipatory guidance

Ans:The process to provide practical, developmentally appropriate information about the children’s
health to prepare parents for the significant physical, emotional and psychological milestones.
7.Aims of Anticipatory guidance

Ans:-Delivery of appropriate information
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-Discussion based counselling

-AAPD has identified three developmental age ranges associated with specific milestones.
-Each age range has six specific entities called ‘content areas’
• Oral development
• Fluoride adequacy
• Oral hygiene
• Diet and nutrition
• Habits
• Injury prevention
8.Window of infectivity
Ans:It is defined as the time of initial colonisation of the infants oral environment with the cariogenic
bacteria mutans streptococci.
-Earlier the colonisation of a young child’s mouth, greater is their caries risk.
Early studies reported that the window of infectivity for MS occurs at a mean age of 27 months.
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School dental health program

Dr Devi Ch
1. Define school dental health program?
Ans: Definition- school health services are defined as the procedures established
 To appraise the health status of pupils and school personnel

 To counsel pupils, parents and others concerning appraisal findings
 To encourage the correction of remediable defects
 To assist in the identification and education of handicapped children
 To help prevent and control disease
 To provide emergency service for injury or sudden sickness
2. What are the aspects of school dental health service?
Ans; Aspects of school dental health service
 Health appraisal
 Health counselling
 Encourage to correct the remedial effects
 Emergency care and first aid
 School health education
 Maintenance of School health records
 Curative services
3. What are the objectives of school dental health service?
Ans: Objectives of school dental health service are
 To help every school child appreciate importance of a healthy mouth.
 To appreciate the relationship of dental health to general health & appearance
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 To encourage dental health care practices, including personal care, professional care,
proper diet and oral habits.
 To enlist the aid of all groups and agencies interested in promotion of school dental
health services
 To correlate dental health activities with total school health program.
4. What are the Guidelines for school dental health service?
Ans ; Guidelines
 Administratively sound
 Available to all children
 Provide facts about dentistry & dental care – self care preventive measures
 Aid in development of favorable attitudes towards dental health
 Include primary preventive programe- Oral Prophylaxis,Fluoride programs and Pit and
Fissure sealants.
 Provide screening method for early identification & referral to pathology.
 Ensure that all discerned pathology is expeditiously treated.
5. What are the Advantages and Disadvantages of school dental health service?
Ans: Advantages
 Less thereatening
 Availability of children
 Miss less time from school
 Provides central education on dental subjects
 Supplements the nursing services
 opportunity for positive peer modeling
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Disadvantages:
 little face time with parents
 disruption in the school day
 comprehensive care - may be controversial
6. What are the Elements/components of school dental health programme?
Ans; Components are
 Improving school community relationship
 Conducting dental inspections
 Conducting dental education
 Performing specific programmes
 Referral for dental care
 Follow up of dental inspection
7. Name some specific programmes performed in school dental health programme?
Ans; specific programmes like
 Tooth brushing programmes

 Classroom-based fluoride programmes
 School water fluoridation programmes
 Nutrition as a part of school preventive dentistry programmes
 Sealants placement
 Science fair
8. Blanket referral
Ans: Referral for dental care - in few schools dental care is provided at the school itself.
However if only emergency treatment is provided then the parents should be informed and
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made to understand that such emergency treatment is not a cure and they have to visit the
dentist for proper treatment.
Blanket referral – “A program that has proved to be effective in many schools is blanket
referral of all children to their family dentists. In this program all children are given referral
cards to take home and subsequently to the dentist, who sign the cards upon completion of
examination, treatment, or both. The signed cards are then returned to the school nurse, or
classroom teacher, who plays an important role in following up the referral with the child and
parents”.
9. Mention various types of school dental health care Programs?
Ans; they are
o Learning about oral health
o Tattle tooth program
o North carolina state wide preventive dental health program
o Askov school dental health program
o Preschool denatl health programme
o New zealand progrmme
o Incremental dental care
o Comperhensive dental care etc.
10. Name few existing School Oral Health Programs in India?
Ans; 1. “Young India” bright smiles, bright futures - A collaborative effort of IDA and
Colgate- Palmolive started in 1976 to deliver oral health education to children. Status -
Running
2. Chacha Nehru Sehat Yojna - school health scheme - Government of Delhi. The dental
component of school health scheme is looked after by two government hospitals, namely.
Maulana Azad Institute of Dental Sciences and DDU hospital which conducts regular
screening programs and also serves as referral centers. Status - Running
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3. Neev - School Oral Health Program by Government of NCT of Delhi in Delhi State as a
Pilot Project. Mobile Dental Van would be utilized after drafting a district plan, and public
schools will be covered round the year. Status - Unknown
4. Trinity Care Foundation - Bengaluru conducts outreach programs and school health
programs in Bengaluru and nearby areas. It harbors the vision of Health Promoting Schools
and provides pre-screening of students for height, weight, skin, eye, dental, cardiac, caries,
oral lesions, facial deformities, etc. Status - Running
5. National Oral Health Program- AIIMS - Pit And Fissure Sealant Pilot Project. Status –
Running
11. Incremental dental care?
Ans; Definition - “Periodic care so spaced that increments of dental disease are treated at the
earliest time consistent with proper diagnosis and operating efficiency in such a way that
there is no accumulation of dental needs beyond the minimum”
Advantages:
 Applicable where incidence of new dental disease is to be expected each year

 Dental diseases intercepted at or near the beginning
 Topical and other preventive measures can be maintained on a periodic basis
 Reduce loss of teeth & inculcate habit of periodic return to dental office
 Avoiding high expenditure for the initial care
 Bills for dental services are equalized and regularly placed
Disadvantages:
 Time consuming
 Attention to deciduous teeth
 Likelihood of interruption in children's dental health programmes
 Inertia towards seeking private dental care
12. Comprehensive dental care?
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Ans: Definition - “meeting of accumulated dental needs at the time a population group is
taken into the programme (initial care) and the detection and correction of new increments of
dental disease on a semiannual or other periodic basis (maintenance care)”.
Advantages:
 Restore serviceable teeth to good functional form

 Replace missing teeth
 Provide maintainenece care for the control of early lesions dental disease
 Provide preventive measures and education
 Good quality work using best of modern restorative techniques
13. Tattle tooth programme?
Ans; Texas state wide preventive dentistry programme
Developed by Texas Department of Health, Texas Education Agency (1974 -76}. In 1989 the
bureau of dental health developed – Tattle tooth II- A new generation for grades K-6.
Teaching material - 3 videotapes, Separate lesson plans, training package for teachers
The first video tape familiarizes the teachers with the lesson format and content.
The second video tape,“ brushing and flossing” was developed for the dental purpose of
teacher training and as an educational unit to be used by the teacher with students.
The Third video tape provides teachers with additional background information as a means of
preparing them to teach the lessons.
14. Askova dental demonstration?
Ans: Askova is a small farming community, showed very high dental caries in the intial
surveys made in 1943 and 1946.
o 1949 -1957 dental heath of minnesota –implemented a school dental programme
o All methods used for preventing caries were used with exceptional of communal
water supply
o Dental care was rendered by a group of 5 dentist
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o 10 year period findings include-28% reduction in caries-3-5 year, 34% in permanent

teeth
o Increased filled tooth ratios, but Cost more than water fluoridation
15. SHARP?
Ans: School Health Additional Referral Programme: A programme called SHARP was
instituted in Philadelphia where the lowest rate for correction of physical defects prevailed.
The purpose of the programme was to motivate parents into initiating action for correction of
defects in their children through effective utilization of community resources. The project was
carried out by the district nurses with the cooperation of all school personnel. The nurses
made daytime visits to families in which the mothers were at home. Working parents were
contacted by phone. The one-to-one basis of health guidance between parent and health
worker establishes better rapport between school and home.
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Pediatric Pharmacology
Dr P. Ahalya
1. GENERAL PRINCIPLES of PEDIATRIC PHARMACOLOGY
• The metric rather than the Apothecary system should be used to determine dosage.
• The younger the patient, the more atypical is the therapeutic and toxicological response to drug
therapy.
• The younger the patient, the more atypical is the disease manifestation. For example, seizures
in infants and young children differ clinically from those in adults. In infancy, motor seizures
appear as limited tonic stiffening or partial movement of the face and limbs.
• Prolonged therapy with agents that affect the Endocrine system retards growth. For example,
large doses of corticosteroids impairs skeletal growth.
• Childhood is a time of high water turnover when fever, vomiting and diarrhea contribute to
variable and oftentimes dangerously high drug level
• The excessive use of syrups should be avoided especiallyat night. These medicinal vehicles
have high sugar content and are highly cariogenic.
• General anesthesia should be discussed with the parent as part of the hospital admission
program.
• During anesthesia, concentration of the oxygen supply for induction and maintenance should
never be less than
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20 percent because it can cause cerebral hypoxia and irreparable brain damage.
• Allergenicity is greatest during childhood. More than half of all allergens appear, first during
childhood.
• To obviate tetracycline staining of permanent incisors, canines and 1st premolars the antibiotic
should be administered sparingly.
• Genetic inheritance can influence drug responsiveness. For example, hepatic
porphyria, Barbiturates are contraindicated in these patients because they increase porphyrin
synthesis and provoke acute attacks.
2. Formulas for drug dosage calculation
Clark’s rule
This is based upon the relative weight of the child as compared with the weight of the average
adult. The average weight of the adult is taken to be 150 pounds. The rule is to divide the weight
of the child in pounds, by the average weight of the adult, 150, and to take this fraction of the
adult dose.
Child dose = Weight (pounds)/150 × Adult dose
Young’s rule
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This rule is based upon the age of the child, regardless of the weight. It is to divide the age of the
child by the age plus 12, and the resulting fraction is the portion of the adult dose, which is to be
used.
Child dose = Age of child/Age + 12 × Adult dose
Cowling’s rule
It is also based upon the age of the child. In this fraction of the adult dose, which is to be used, is
obtained by dividing the age at the next birthday by 24.
Child dose = Age at next birthday/24 × Adult dose
Dilling’s rule
He made a new analysis of extensive weight statistics of children and found that Young’s
formula is sufficiently accurate up to the 11th year and Cowling’s is accurate until the 15th year,
but that thereafter, it is very inaccurate and wholly unsatisfactory. It consists of dividing the age
by 20, to obtain the fraction of the adult dose, which is required.
Child dose = Age of child/20 × Adult dose
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3. Principles for prescribing analgesics.
The American Academy of Pediatric Dentistry (AAPD) recognizes that children with inadequate
pain management may have significant physical and psychological consequences for the patient.
• Recognize and assess pain,documenting in the patient’s chart;
• Use nonpharmacologic and pharmacologic strategies to reduce pain experience preoperatively
Be familiar with the patient’s medical history to avoid prescribing a drug that would be
otherwise contraindicated;
• Comprehend the consequences, morbidities, and toxicities associated with the use of specific
therapeutics;
• Consider nonopioid analgesics as first line agents for postoperative pain management;
• Utilize drug formularies in order to accurately prescribe medications
• Consider combining NSAIDs with acetaminophen to provide a greater analgesic effect than the
single agent alone.
4. Use of Antibiotic Therapy for Pediatric Dental Patients (AAPD Guidelines) or
indications of antibiotics
The widespread use of antibiotics even in minimally required scenarios has led to misuse of
antibiotics can lead to development of resistance to drugs and hence these guidelines are framed.
a) Oral Wound Management
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• Factors related to host risk and type of wound must be evaluated when determining the risk for
infection and subsequent need for antibiotics.
• Facial lacerations may require topical antibiotic agents.
• Open fractures and joint injuries should be covered with antibiotics. The drug should be
administered as soon as possible for the best result and the minimal duration of drug therapy
should be limited to five days.
• Pulpitis/Apical Periodontitis/Draining Sinus Tract/Localized Intra-oral Swelling
If a child presents with acute symptoms of pulpitis, treatment(i.e. pulpotomy, pulpectomy, or
extraction) should be rendered. Antibiotic therapy usually is not indicated if the dental infection
is contained within the pulpal tissue or the immediately surrounding tissue.
b) Acute Facial Swelling of Dental Origin
A child should receive immediate dental attention and the treatment should be initiated
immediately with antibiotic coverage for seven days to contain the spread of infection.
c) Dental Trauma
d). Local application of an antibiotic to the root surface of an avulsed tooth with an open apex
and less than 60 minutes extraoral dry time has been recommended.
• Systemic antibiotics have been recommended as adjunctive therapy.
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• Tetracycline is the drug of choice, but consideration must be exercised in the systemic use of
tetracycline due to the risk of discoloration in the developingpermanentdentition and hence
Penicillin V can be given as an alternative.
e) Pediatric Periodontal Diseases
Antibiotic therapy is advised after culture and susceptibility testing of isolates from the involved
sites.
f) Viral Diseases- Conditions such as acute primary herpetic gingivostomatitis should not be
treated with antibiotic therapy unless there is strong evidence to indicate that a secondary
bacterial infection exists.
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Minor oral surgical procedures
Dr P.Ahalya
1. Indications for extraction of primary teeth
• Teeth affected by periodontal disease
• Extraction of healthy teeth to correct malocclusion
• Over-retained teeth
• Trauma to the teeth or jaws may cause dislocation of a tooth from its socket (avulsion)
• Extraction of teeth for esthetic reasons
• Extraction of teeth for prosthodontic reasons
• Impacted and supernumerary teeth
• Extraction of decayed 1st or 2nd molars to prevent impaction of 3rd molars
• Teeth involved in fracture line
• Teeth involved in tumors or cysts
• Tooth as foci of infection
• Teeth affected by crown, abrasion, attrition or hypoplasia
• Teeth affected by pulpal lesions e.g. pulpitis, pink spot or pulp polyp
• Teeth in the area of direct therapeutic irradiation.
2. Contraindications for extraction of primary teeth:
• Presence of acute oral infections such as, necrotising ulcerative gingivitis or herpetic gingival
stomatitis.
• Pericornitis (difficult surgical procedure involving bone removal is anticipated).
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• Extraction of teeth in previously irradiated areas (atleast 1 year should be allowed for maximal
recovery of circulation to the bone).
• There are number of relative systemic contraindications to the tooth extraction, e.g.
– Uncontrolled diabetes
– Acute blood dyscrasias
– Untreated coagulopathies
– Adrenal insufficiency
– General debilitation for any reason
– Myocardial infarction (wait for 6 months period).
3. Principles of extraction:
a) Expansion of the Socket
The extraction of a tooth requires the separation of its attachment to the alveolar bone via the
crestal and principal fibers of the PDL which involves a process of expansion of alveolar socket.
This is achieved by using the tooth as the dilating
Instrument with the help forceps, to permit the removal of the tooth.
b) Use of a Lever and Fulcrum:
This basic principle is used with elevators that force a tooth or root out of the socket along the
path of least resistance.
c) The Insertion of a Wedge:
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This is done between the tooth root surface and the bony socket wall to help the tooth to rise in
its socket.
4. EXODONTIA TECHNIQUES
The following techniques may be used for tooth removal:
• The forceps technique — closed method
• The elevator technique — open
• Transalveolar technique — open method
• Odontotomy.
5. OPERATIVE COMPLICATIONS OF EXTRACTION
The most frequent operative complication that encounter during the extraction of teeth are:
• Fracture of the tooth
• Injuries to adjacent teeth
• Fracture of the alveolar bone
• Fracture of the tuberosity
• Extraction of the wrong tooth
• Root displaced in the sinus
• Maxillary sinus perforation
• Root displaced in the submandibular space
• Gingival and mucosal lacerations
• Injury to the inferior alveolar nerve
• Hemorrhage and hematoma
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• TMJ trauma
• Damage to permanent successor.
6. Postoperative instructions of extraction
• The patient should be warned that sucking the wound, investigating the socket with tongue and
rinsing during the first day disturbs the blood clot and may cause dry
socket.
• Patient should be directed to remain quiet for several hours, preferably sitting in a chair or if
lying down, keeping the head elevated.
• Only liquids and soft solids should be advice on the firstday. They may be warm or cold but not
extremely hot.
• The teeth should be brushed as usual and on the day after surgery rinsing of the mouth should
begin. A warm saline solution is best for this purpose.
• Some degree of postoperative pain accompanies many exodontia procedures and begins after
the effects of the anesthetic have left. So, it is better to take some analgesic before the effect of
anesthetic wears off.
• Prevention of swelling after extensive or difficult operation adds to the comfort of the patient.
The degree of swelling is generally in direct proportion to the degree of surgical trauma. The
application of cold to the operated site is beneficial in reducing the amount of postoperative
swelling. Pressure dressings are also beneficial in limiting the postoperative swelling.
• Smoking should be avoided after tooth extraction as it increases the incidence of alveolar
osteitis and should be discontinued for five days.
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7. Enumerate minor oral surgical procedures in pediatric dentistry.
Management of the following is considered under minor oral surgical procedures.
• 1) LESIONS OF THE NEWBORN- include Epstein’s pearls( 75 to 80 percent) dental lamina
cysts, Bohn’s nodules, and congenital epulis.
• Epstein’s pearls are found in about of newborns. They occur in the median palatal raphe area
as a result of trapped epithelial remnants along the line of fusion of the palatal halves.
• Dental lamina cysts, found on the crests of the dental ridges, most commonly are seen
bilaterally in the region of the first primary molars. They result from remnants of the dental
lamina.
• Bohn’s nodules are remnants of salivary gland epithelium and usually are found on the buccal
and lingual aspects of the ridge, away from the midline.
• No treatment is required, as these cysts usually disappear during the first 3 months of life.
2) LESIONS OF ERUPTING DENTITION - includes eruption cyst, eruption hematoma, natal
and neonatal teeth.
• The eruption cyst is a soft tissue cyst that results from a separation of the dental follicle from
the crown of an erupting tooth.
• Natal teeth have been defined as those teeth present at birth, and neonatal teeth are those that
erupt during the first 30 days of life.
• The clinical manifestation and treatment for all these conditions has been dealt in detail earlier
(Teething).
8. MUCOCELE
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• An oral mucocele is a cavity of mucus that develops in salivary glands. It may be retention
cyst or extravasation phenomena, depending on etiological and histopathological features.
• The most common benign salivary gland problem inchildhood.
• The lesion is a pseudocyst and does not have an epithelial lining.
Etiology
• Trauma causing rupture of a minor salivary gland excretory duct, with subsequent leakage of
mucin into the surrounding connective tissues that later may be surrounded in a fibrous capsule.
• When the duct is totally or partially obstructed, and there is accumulation of saliva behind the
obstruction, a retention cyst develops. This collection of mucus is
surrounded by duct epithelium, and is therefore by definition a true cyst.
Clinical Features
• Well-circumscribed bluish translucent fluctuant swellings that are firm to palpation.
• Color ranges from normal to whitish keratinized surface.
• Mucoceles most frequently are observed on the lower lip, usually lateral to the midline
followed by buccal mucosa, ventral surface of the tongue, retromolar region, and floor of the
mouth (ranula).
• Superficial mucoceles are short-lived lesions and heal within a few days.
• Many lesions, require treatment to minimize the risk of recurrence.
Technique of Removal
• The size of the mucocele should be considered before removing it in the cheek, lip or palate.
• Unroofing - larger ones, dissection for moderate-sized.
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• The mucocele is excised in an elliptical fashion where the dissection is continued in the plane
adjacent to the capsule down to the muscular layer and all of the marginal
glands and associated gland tissue are removed before primary closure.
Complications
• Recurrence is a common complication.
• Excision in the lower lip may be harmful to the labial branches of the mental nerve.
9. RANULA
• Ranula is a mucocele in the floor of the mouth.the word being derived from the Latin, Ranula
Pipiens meaning frog. Elevation of the tongue by fluid filled pseudocyst is reminiscent of the
appearance of a frog’s tongue.
Etiology
• These are most commonly pseudocysts originated in the deeper portion of the sublingual gland,
but may be retention cyst from the ducts of Rivini ( superficial portion of the sublingual gland)
or the Wharton’s duct of the submandibular gland.
Clinical Features
• Ranulas appearing in infants and toddlers are congenital, a result of dilatation of sublingual or
submaxillary gland ducts in the floor of the mouth whereas those appearing in older children are
usually traumatic.
• located in the sublingual space between the mylohyoid muscle and the lingual mucosa.
• extend into the submental or submandibular spaces by perforating through the mylohoid muscle
and are then called as “Plunging ranula”.
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Technique of Removal
• Small ranulas - excised, large ones - observed for several months until the lining is mature
before we any treatment.
• Plunging type requires excision of the sublingual gland to prevent recurrence.
10. MAXILLARY FRENUM / MAXILLARY FRENECTOMY
• The superiorlabial frenum is a triangularfold of tissue originating in the lip and inserts into the
attached gingiva at the maxillary midline.
• Frenectomy is the complete excision of the frenum and the term frenotomy indicates a partial
removal (a relocation).
Clinical Features
• A prominent maxillary frenum in children is often a concern especially when associated with a
diastema.
• Interference with oral hygiene measures, esthetics, and psychological reasons are contributing
factors that relate to treatment of the maxillary frenum.
Diagnosis
• An abnormal frenum is excessively wide and attached close to the gingival margin.
• A lack of apparent zone of attached gingiva along the midline may be observed, and stretching
of the upper lip and observing the movement and ischemia/blanching of interdental and/or
palatal tissues may be helpful.
Indications for Removal
• When the frenum restricts lip movement
• prevents closure of a midline diastema.
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• prevents mechanical tooth cleaning
Technique
two methods viz. simple frenectomy and Z-plasty.
• The Z-plasty involves excision of the frenum and making two oblique incisions down to
periosteum and the resulting triangular flaps are raised and sutured with
interrupted sutures in a reverse position.
11. ANKYLOGLOSSIA
• Ankyloglossia is a developmental anomaly of the tongue characterized by a prominent lingual
frenum attached high on the lingual alveolar ridge, the thick lingual frenum resulting in
limitation of tongue movement (partial ankyloglossia) or by the tongue appearing to be fused to
the floor of the mouth (total ankyloglossia).
• It is also called as Tongue-tie
• The reported prevalence is 0.1 to 10.7 percent of the population.
Clinical Features
• There is a higher prevalence of nipple pain in mothers feeding infants with ankyloglossia
• Some difficulties in articulation are evident, e.g.rolling an “r” and pronouncing certain
consonants and sounds.
• Other problems - reduced tongue mobility , difficulties with licking the lips, keeping the teeth
clean, etc.
• Because of intense pulling, ankyloglossia has been associated with gingival recessions.
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• It has also been hypothesized that a tongue that is in low position may predispose for maxillary
hypodevelopment
and mandibular prognathism, typical features of class III malocclusions, and that ankyloglossia
indirectly can cause malocclusion.
• Frenal attachment may interfere with denture stability, dislodging the denture when the tongue
is moved.
Diagnosis
• Clinical observation and patient anamnesis should be sufficient to diagnose the condition. The
frenum is often abnormally short and thick and with decreased mobility.
• A heart-shaped tongue may be seen during protrusion.
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GENETICS
Dr Devi Ch
1. GENETIC COUNSELING?
Ans: Genetic counselling is a communication process between health ‑ care specialist and
individual or families affected by or at risk for a genetic disorder. The goals of the process
include spreading awareness of the medical facts for the condition and understanding the
contribution of heredity in the expression of the condition, its risk for recurrence. It also includes
discussion of the options available for dealing with disorder and assisting families in choosing
the option which are most appropriate for them
Function of genetic counselor:

 Counselor must supplement the information with a full discussion of psychological implication
for the patients and his or her family. Counselor must know almost all of the potential outcomes
of the patients with craniofacial malformation relative to major and minor malformations,
treatments and longevity.
 When trait is inherited with multifactorial inheritance, genetic counseling usually can be
provided only in terms of the empiric risks that it will recur, that is, on the basis of past
experience with the behaviour of the trait within families.
2. HOMEOBOX GENES?
Ans: “Homeobox” is a stretch of DNA sequence found in genes involved in the regulation of the
development (morphogenesis). It contains 180 base pair sequence in the DNA. It was first
detected in fruit fly drosophila.
Homeobox genes have the following properties
o They contain within them a DNA sequence known as the homeobox.
o They are organized in a sequential cluster in the order of their expression pattern along
the cephalo-caudal (head to tail) axis of the organism.
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Homeobox genes involved in the formation of craniofacial units
 Lim homeobox genes- earliest mesenchymal markers for tooth formation.
 Fgf-8 homeobox genes- determine the position of tooth germ formation.
 Pax-9 homeobox genes- location of tooth germ.
 Activin – A – tooth germ initiation.
 Ssh genes- initiate tooth formation and stimulate epithelial cell proliferation.
 Lef – 1 genes – dental epithelial thickening and bud formation.
 Barx – 1 & Dix – 2 – bud stage to cap stage transition
3. GENE?
Ans: A gene can be defined as a segment of DNA which contains the information for
synthesis of one complete polypeptide chain.
EXONS: Portion of genes that are eventually spliced together to form MRNA.
INTRONS: Spacing regions between the exons that are spliced out of precursor RNA’S
during RNA processing.
They are 2 types:
• Structural genes- synthesize specific proteins.
• Control genes- regulate the activity of structural genes.
Functions of Genes: Genes accomplish their function
1. Through replication that result in more units like themselves
2. Through transcription and translation, whereby proteins that function as determiners in

metabolism of cell are synthesize
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3. Genes act by determining the structure of proteins, which are responsible for directing cell
metabolism through their activity as enzymes
4. STRUCTURE OF DNA?
Ans: The basic unit of genetic function is the gene, the chemical basis for which is the DNA
molecule. DNA consists of a pair of strands of a sugarphosphate backbone attached to a set
of pyrimidine and purine bases. The strands are held together by hydrogen bonds between
adenine and thymine bases and between guanine and cytosine bases. Together these strands
form a double helix. The strands separate during DNA replication, and the base sequence of
the newly synthesized strand is dictated by the complementary of adenine with thymine and
guanine with cytosine. DNA therefore contains within its structure the information necessary
for its replication.
 It is mainly found in chromosomes and also in mitochondria.

• It is a long chain polymer formed by linkage of nucleotides.
• Each turn of DNA measures 3.4nm and contains 10 pairs of nucleotides.
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5. MENDEL’S LAWS {OR} LAWS OF INHERITANCE?

Ans: they are
• The law of uniformity
• The law of segregation
• The law of independent assortment
The majority of traits don’t follow these rules but Mendel’s laws are nevertheless crucial to
understanding almost all principles of genetic inheritance.
law of uniformity: When plants with two contrasting characters are crossed, the characters do
not blend. If any character doesn’t express in the first generation, it may reappear without change
in subsequent generation.
The law of segregation: Two members of a gene pair segregate from each other in the formation
of gametes; half the gametes carry one allele, and the other half carry the other allele. each gene
has two copies (alleles) and a parent will give only one copy to a child. The other parent will
give another copy, and thus the child will receive two copies (alleles) – one from each parent.
The law of independent assortment: Members of different gene pairs assort independently at
the time of gametogenesis. This produces new combination of characters in the off spring.
6. CHROMOSOME ABNORMALITIES?
Ans; Three types
• Numerical abnormalities
• Structural abnormalities
• Different cell lines(mosaicism / chiamerism)
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1. Numerical abnormalities; Abnormal chromosome number. Increase or decrease

Ex: Monosomy – Turner’s syndrome(45 XO), Trisomy - Down syndrome(trisomy 21)
2. Structural abnormalities:
a) Deletion: Breakage occurs in a part of the chromosome and the broken part is subsequently
lost as it has no centromere.
b) Inversion: involves a single chromosome which breaks at two points and the broken segments
rearrange in a inverted position
c) Ring chromosome: Rare abnormality, where a chromosome forms a closed circle (ring). The
broken, sticky ends subsequently fuse with each other.
d) Isochromosome: Incorrect splitting of centromere. There will be duplication of one
chromosome arm and deletion of another arm.
e) Translocation: The transfer of genetic material from one chromosome to another.
3.Different cell lines;
a). Mosaicism: Presence of two or more cell lines i.e.,one chromosome constitution while other
cell different constitution.
b). Chiamerism: An individual having two or more genetically distinct cell lines which are
derived from more than one zygote.
7. PEDIGREE ANALYSIS?
Ans: A pedigree is a family tree or chart made of symbols and lines that represent a patient's
genetic family history.
Pedigree analysis helps in identifying a genetic condition running through a family, aids in
making a diagnosis, in determining who in the family is at risk.
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8. TWIN STUDIES?
Ans; The classic Twin studies are for separating the effects of genetic and environment involves
comparing identical (monozygous[MZ]) twins and nonidentical (dizygous[DZ]) twins.
 Differences between MZ twin pairs reflect environmental factors.

 Differences between DZ twin pairs are due to both genetic and environmental factors.
9. MODES OF INHERITANCE?
Ans: It is a mechanism by which many genetic characters are transmitted from one generation to
the next generation.
There are two major classifications in the mode of inheritance.
- Autosomal inheritance - Autosomal dominant inheritance
Autosomal recessive inheritance
- Sex linked inheritance - X- linked dominant inheritance
X-linked recessive inheritance
Autosomal dominant inheritance: It is due to defect in at least one gene out of a pair of genes
on autosomes. Males and females are equally affected. Trait or disorder seem in every generation
without skipping. e.g – Achondroplasia, Osteogenesis imperfect etc.
Autosomal recessive inheritance; It occurs when both the genes on the autosomes are affected.
The disease appears in male and female children of unaffected parents. Trait is seen in same
generation, among siblings. e.g- dentin dysplasia, hereditary amelogenesis imperfect.
X-linked dominant inheritance: Occurs due to presence of a mutant gene on X-chromosome.

Both sexes are affected, but males are more severely affected. Absence of father to son
transmission. e.g. vitamin D resistant rickets, X-linked amelogenesis imperfect
284
X-linked recessive inheritance: Affected males transmit the defective genes only to daughters.
Skip- generation transmission is seen. An affected female equally transmits the disease to her
children. e.g: Duchenne muscular dystrophy, Hemophilia, colour blindness.
10. GENE MAPPING?

Ans: Gene mapping’ is the locating of one or a few genes of particular interest, within the
framework of a more global ‘genome map’.
 Genetic maps are species-specific and comprised of genomic markers and/or genes and
the genetic distance between each marker. These distances are calculated based on the
frequency of chromosome crossovers occurring during meiosis, and not on their physical
location on the chromosome.
 Genetic maps are a necessary tool for mapping of disease genes or trait loci, a method
also commonly known as linkage mapping. Integrating genetic mapping and disease gene
mapping with next-generation sequencing has proven to be a powerful strategy in genetic
research.
Types: Genetic linkage mapping,
Radiation hybrid mapping,
Happy mapping
Fluorescence in situ hybridisation.
11. GENE THERAPY?

Ans; Gene therapy is a process by which small DNA or RNA sequence are transferred to cells or
tissues to correct a genetic defect or treat a disease.
Gene therapy can be somatic gene therapy or germline gene therapy.
285
Somatic gene therapy involves modifications of the genes in selected cells which are not gametes
or undifferentiated cells.
Germline gene therapy, on the other hand, introduces permanent inheritable changes to the
genome of the individual, by targeting gametes.
The state of gene therapy research is confined for ethical and technical reasons almost in its
entirety to somatic cell gene therapy. Typically, therapeutic genes are identified, isolated, and
cloned and introduced into a vector. A vector is a vehicle that is used to deliver the gene of
interest to the target tissue. A vector should deliver accurate amount of material into the target
cell.
12. DNA VACCINATION?

Ans; A direct injection of plasmid DNA encoding an antigenic protein enables expression of
protein intracellularly. This leads to surprisingly strong responses, involving both humoral and
cellular branches of the immune system.
• It is a technique for protecting an animal against disease by injecting it with genetically
engineered DNA so cells directly produce an antigen, resulting in a
protective immunological response
• As of June 2015 only one human DNA vaccine has been approved for human use, the
single-dose Japanese encephalitis vaccine called IMOJEV, released in 2010
13. DNA PROBES?

Ans; single stranded small DNA or RNA segments of known sequences.
• Used to detect DNA or RNA fragments having same nucleotide sequences.
• Labelled either with radioactive isotopes or non radioactive
Uses:
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• Helps to recognize complementary sequence in DNA or RNA, isolate & identify specific
DNA
• Helps in diagnosis of infectious disease
• Identify stains of an organism
• Used in forensic test
14. RECOMBINANT DNA TECHNOLOGY (RDNA)?

ANS; Recombinant DNA technology comprises altering genetic material outside an organism to
obtain enhanced and desired characteristics in living organisms or as their products. This
technology involves the insertion of DNA fragments from a variety of sources, having a desirable
gene sequence via appropriate vector. Manipulation in organism’s genome is carried out either
through the introduction of one or several new genes and regulatory elements or by decreasing or
blocking the expression of endogenous genes through recombining genes and elements.
Applications of recombinant DNA technology;
 Preparation of chromosome maps and analysis of DNA sequence
 Drugs – insulin, somatostatin,blood clotting factor, growth harmones
 Synthetic vaccines – antirabic, anti-malaria, anti-hepatitis, cholera
 Production of monoclonal antibodies
 Diagnosis of genetic disease
 Gene therapy
15. GENETIC SCREENING?
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Ans; Genetic screening indicates the assays undertaken on a population wide basis to identify at-
risk people. Genetic testing means assays for definitive diagnosis, these are performed due to
positive screening results, family history, ethnicity, physical stigmata, or other reasons.
Different types of screening:
a. Newborn screening: used after birth to identify genetic disorders which can be treated early in
life
b.Diagnostic testing: used to diagnose or rule out a specific genetic or chromosomal condition
c. Carrier testing: It is used to identify people who carry one copy of a genetic mutation that
when present in double number causes a genetic disorder
d. Prenatal testing: used to detect alteration in the fetus genes or chromosomes before birth
e. Predictive and presymptomatic testing: They are used to detect gene mutations associated with
disorders occur after birth or in later life
16. BIOCHIPS?
Ans; A DNA chip is an array of DNA sequence embedded in a gel that layers over a silicon
surface. It provides a medium for matching the known and unknown DNA samples based on
base printing rules and automating the process of identifying the unknowns.
An array of experiment can be created by hand or make use of robotics to deposit the sample.
Grafting of DNA sequences on a silicon chip for a rapid and accurate diagnosis of a variety of
diseases: e.g, breast cancer.
17. CLONING?
Ans: A clone is a group of genetically identical cells for example, tumors are clones of cells
inside an organism because they consist of many replicas of one mutated cell. Another type of
clone occurs inside a cell, such a clone is made up of groups of identical structures that contain
288
genetic material, such as mitochondria and chloroplasts. Some of these structures, called
plasmids, are found in some bacteria and yeasts. Technique of genetic engineering enables
scientists to combine an animal or plant gene with a bacterial or yeast plasmid. By cloning such a
plasmid, geneticists can produce many identical copies of the gene.
18. STEM CELL THERAPY?

Ans: Stem cells are undifferentiated cells, capable of renewing themselves via differentiation,
they have the potential to develop into many different cell lineages. There are different kinds of
stem cells, depending on the type of cells they can create and the location in the body.
Classification according to their origin :
 Embryonic stem cells,

 Somatic or adult stem cells,
 Induced pluripotent stem cells
Characteristics
1. Totipotency: generate all types of cells including germ cells (ESCs).
2. Pluripotency: generate all types of cells except cells of the embryonic membrane.
3. Multipotency: differentiate into more than one mature cell (MSC).
4. Self-renewal: divide without differentiation and create everlasting supply.
5. Plasticity: MSCs have plasticity and can undergo differentiation.
Dental stem cells:
 DEFPCs - Dental Follicle Precursor Cells

 DPPSCs - Dental Pulp Pluripotent like Stem Cells
 DPSCs - Dental Pulp Stem Cells
 PDLSCs - Periodontal Ligament Stem Cells
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 PDLPs - Periodontal Ligament Progenitor Cells

 SCAP Cells- Stem Cells From Apical Papilla
 SHED Cells - Stem Cells From Human Exfoliated Deciduous Teeth
19. WHAT ARE THE POTENTIAL APPLICATIONS OF STEM CELLS IN

DENTISTRY?
Ans; The regenerative potential of adult stem cells obtained from various sources including
dental tissues has been of interest for clinicians over the past years and most research is directed
toward achieving the following:
• Regeneration of damaged coronal dentin and pulp
• Regeneration of resorbed root, cervical or apical dentin, and repair perforations
• Periodontal regeneration
• Repair and replacement of bone in craniofacial defects
• Whole tooth regeneration.
20. TISSUE ENGINEERING OF STEM CELLS?

Ans: Tissue engineering approach requires the three main key elements that is termed as tissue
engineering triad.
Triad of Tissue engineering :
a. Signaling molecules
b. Stem cells
c. Scaffolds
But a conductive environment is equally important for successful engineering of any tissue
and/or organs. Promising result have been shown by Dental tissue engineering using dental stem
290
cells which can be considered as a novel approach to treat diseases like periodontitis, dental
caries or to improve dental pulp healing and the regeneration of teeth.
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Department of Pedodontics & Preventive dentistry

DEPARTMENT OF PEDODONTICS & PREVENTIVE

VISHNU DENTAL COLLEGE, BHIMAVARAM.

PEDODONTICS BRIEF NOTES

1. Define pediatric dentistry.

2. Give a brief history of pediatric dentistry.

3. What are the aims and objectives of pedodontics?

4. What are the attitudes/responsibilities of a pedodontist ?

e) Willingness to adopt, after a critical assessment, new methods and techniques of

5. Importance of primary teeth in oral cavity.

6. Explain the concept of pedodontic triangle

7. Who is the father of pedodontics

8. Who is the Father of Pedodontics in India

9. Who is the father of Children’s Dentistry organizations ?

10. Who published first book on children’s dentistry ?

12.What is pediatric dentistry treatment model ?

13. What is the scope of pedodontics?

DIFFERENCES BETWEEN PRIMARY AND PERMANENT TEETH

1. Enumerate differences between primary and permanent teeth

Dentin : a) Dentinal tubules are less regular.

cusps would indicate. 

2. Enumerate histological differences between primary and permanent teeth

Reparative dentin formation is less.  Reparative dentin formation is more

Density of innervations is less because of which Density of innervations is more. 

Localization of infection and inflammation is poorer in Infection and inflammation in pulp is

Neural tissue is the first to degenerate when root

Eruption and shedding

1) Nolla stages of tooth development?

2) Natal teeth and neonatal teeth?

Clinically, eruption cyst appears as a dome shaped raised swelling in the

6) Sequence of primary and permanent tooth eruption?

For permanent tooth:

Permanent maxillary latral incisor: 8-9 years.

8) Shedding pattern of anterior and posterior teeth?

9) write the anatomic stages of eruption?

10) Theories of tooth eruption?

 Growth of periodontal tissues theory

11) Factors affecting development of dentition?

12) what is dental age? How to estimate dental age?

Estimation of dental age:

The four teeth recommended for this purpose:

13) Importance of 1st permanent molar.

Largest and strongest teeth in the dental arch

14) What are the causes of delayed eruption?

15) Riga-fede disease?

Developmental anamolies of teeth

• More often in permanent dentition than primary dentition

• Situated between maxillary central incisors

• Resulting in a single large tooth structure

• Well delineated additional cusp

• Joined along the root surfaces by cementum

• May occur before or after the teeth have erupted

• Affects both primary and permanent dentition

• Mutation in dentin sialophosphoprotein

• Have blue to brown discolouration

• 3 types type I-occurs in families with osteogenesis imperfects

• Etiology: remains undetermined

• Inflamed pulp: pulpotomy / root canal therapy based on extension

Etiology:Focal growth retardation