Contents

1. The little patient’s psychology………………………………………………………………9

(Michaela Mesaroș, Cristina Iosif)
2. Examination in pediatric dental medicine………………………………………………….15
(Michaela Mesaroș, Anca Mesaroș)
3. Odontogenesis……………………………………………………………………………...48
(Michaela Mesaroș, Alexandra Botoș)
4. Dental eruption……………………………………………………………………………..57
(Michaela Mesaroș, Alexandra Botoș)
5. The normal occlusion relations evolution………………………………………………….67
(Michaela Mesaroș, Alexandra Botoș)
6. Dental anomalies…………………………………………………………………………...79
Numerical abnormalities…...……………………………………………………………………………79
Size abnormalities……………………………………………………………………………………….83
Shape abnormalities……………………………………………………………………………………..84
Structure abnormalities………………………………………………………………………………….92
Color abnormalities……………………………………………………………………………………...98
(David Angelescu)
7. Treatment plan elaboration for children and teenagers…………………………………...103
(Alexandrina Muntean)
8. The dental cavity in children and teenagers………………………………………………108
The temporary teeth cavity……………………………………………………………………………113
The complicated temporary teeth cavity……………………………………………………………….124
The permanent young teeth cavity……………………………………………………………………..138
Dental sealing…………………………………………………………………………………………..158
The complicated permanent young teeth cavity………………………………………………………..163
(Michaela Mesaroș, Carmen Costea, Meda Simu)
9. The dental cavity prophylaxis…………………………………………………………….173
(Michaela Mesaroș, Meda Simu, Carmen Costea)
10. Dental trauma……………………………………………………………………………200
Temporary teeth trauma………………………………………………………………………………..203
Permanent teeth trauma………………………………………………………………………………...208
(Alexandrina Muntean)
11. Dental extraction in pediatric dental medicine…………………………………………..215
(Alexandrina Muntean)
12. Periodontal afflictions…………………………………………………………………...223
(Alexandrina Muntean, Meda Simu)
13. Oral mucosa afflictions in children and teenagers………………………………………232
(Michaela Mesaroș, Alexandrina Muntean)
14. Prosthetic treatment in children and teenagers…………………………………………..238
(Alexandrina Muntean)
15. Pain in pediatric dental medicine………………………………………………………..243
(Michaela Mesaroș)
16. Parafunctions and vicious habits………………………………………………………...258
(Meda Simu)
17. Dento-maxillary abnormalities prophylaxis……………………………………………..266
(Meda Simu)
18. Medication for children………………………………………………………………….271
(Alexandrina Muntean)
19. Dental treatment for children and teenagers with general afflictions………………..….281
(Alexandrina Muntean)
20. Treatment for patients with labio-maxillo-palatal clefts...………………………………290
(Alexandrina Muntean)
21. Emergency treatment in pediatric dental medicine……………………………………...295
 1. The Little Patient’s Psychology

Painful or unpleasant experiences had in the childhood at the dentist can have negative
influences over the psychic, going as far as developing phobias, anxiety episodes and even
panic attacks.
The ‘dental’ experience represents a challenge for the child, one that they can pass
harder or easier, depending on their personality, their mental development or the socio-
cultural environment they come from.
To allow the ‘little patient’ to familiarize himself with the white coat, with the smell of
the office or the dentist’s tools, it is recommended their first visit is made at a young age,
before the first dental problems come and implicitly, the pain.
The majority of the children suffer from an intense fear of the dentist, fear that can
have multiple causes: previous traumatizing experiences, shame in front of the doctor in case
of a poor oral hygiene, fear of the pain, acquired fear after the experiences of the people
around them or as a reaction that appears when they face a new situation, unknown to them.
Fear of the dentist does not come without results and will have negative consequences on the
health state of the oral cavity and on the general developing of the child. In some cases, the
teeth-brushing alone can make the children remember their dental problems and the necessity
of the treatment, so they come to avoid respecting basic hygiene rules.
However, if some children do not manage to go to regular checks or treatment it’s not
the fear intensity to blame, but rather a weak motivation or some lacks in education. A vicious
circle is thus created which will have unpleasant consequences on the everyday life of the
little patient.
Exacerbation of the dental pain will determine a continuous state of fatigue for the
child, who will not be able to eat properly and will always be in an uncomfortable state.
Children do not understand their new emotional state correctly, do not know what to expect
and thus resulting in a weak capacity to face the new created situation.
For this reason, in the ‘little patient’ anxiety prophylaxis, parents play an essential
role. They are the ones who must prepare the child and thus the first visit to the dentist can
become a pleasant experience.
The parent must explain to the child by his way of understanding what is going to
happen to him next, using familiar terms (sting, pinch). If it will be the case, the tooth will be
put to sleep by the dentist, so the pain will go away and then he will probably feel a small
pinch. It is to be avoided to tell the child that he will feel nothing, when in fact, he will feel
many things (not necessarily pain). It is the duty of the adults to try to mask their emotions,
because a child can feel all the anxiety forms that parents exhibit.
Not infrequently the children who exhibited an excessive fear when they were
accompanied by parents or grandparents proved to be more cooperative and more
understanding in the organized visits in school or kindergarten.
At the same time, the doctor must figure if the parents’ interest is occasional,
following painful phenomena and/or infectious or if they show a real interest for the oral
health of their child.
A special category is represented by those who particularly want that the treatment is
done under general anesthesia, In this case, personal comfort being above their child’s
interest, not knowing fully the risks that this procedure imposes.
It is indicated that at the first visit, at least one parent to be present. This will make
them feel safe and much more comfortable. The parent, in this case, gets an observer role and
will let the child answer to the doctor’s questions. This happens because the majority of the
children (especially the really young ones) cannot pay attention to two people at the same
time. However, next sessions, it is preferable that the little patient comes in the doctor’s office
without parents.
Besides collecting information, anamnesis has the role of establishing a good doctor-
patient relationship, understanding the reason for the excessive fear and maybe the way the
anxiety can be countered regarding the personality of every different child.
For children, the unwanted behavioral palette showed in these situations is much more
complex because of their vulnerability in stress conditions.
The doctor must find all the ‘fears’ the little patient developed and has the job to
change his perception over the dental treatment, to give them information which will help him
form a correct image on what is going to happen. Without a doctor-patient alliance there will
be no successful treatment. (Img. 1.1)
Img. 1.1 Moral support for countering the anxiety state of the child is offered by both the
dentist and the parents
So, the success of the therapy depends on both the doctor-caregiver relation and the
little patient approach. For this, the doctor must consider a few aspects:
1) The doctor will explain the patient the next things that are going to happen to them
using simple words and instructions. Some children want a detailed explanation, others want
to know less and even refuse to look at the tools. To win their trust, the doctor should ask the
child when they can start the treatment and to set a ‘code’ together, a sign which will tell the
doctor to stop. If that ‘pact’ will not be complied, the child will lose the trust, will feel lied to.
A good doctor-patient relationship is based on this kind of approach. The child’s anxiety
increases when they feel they are losing control, when they feel vulnerable in a certain
situation.
‘Tell-show-do’ is a method used to present the tools to the kid, it is shown to them
how they work, followed by beginning the treatment. (Img. 1.2)
Img. 1.2 The doctor must adopt a firm attitude when doing the therapeutic act.
2) Voice control: The voice must always be warm, but firm. The doctor continuously -
gives information on the sensations that are going to be felt.
3) Small rewards (diplomas, stickers, compliments) may stimulate the child.
4) The child’s attention is distracted with short tales.
5) Non-verbal communication: most times it is more important for the children than
the verbal communication. A simple smile, a light touch have the role of reassuring the little
patient, they make them feel safe. Some call this approach type ‘iatrosedation technique’.
6) Pain management: The first visit must be only for a checkup, and the treatments
made in the next sessions should be minimum-invasive, as less traumatizing as possible.
7) The sessions must be carefully organized from the point of view of the schedule,
treatment duration and the way of progress. The child best learns the ‘rules’ in the dentist
office by playing games or inventing small experiments adapted to his age.
The child’s stress can be countered by distracting his attention, so he doesn’t forget his
patient status. This can be done by:
 Installing a TV set in the waiting room or even in the office. The child watches his
favorite cartoons, becomes a viewer and forgets about problems.
 Setting up the office and the waiting room in neutral colors.
o Neutral colors help the patients become calmer, to relax, they play an essential
role in keeping the good-mood. Having these effects on the psychic and
emotions, they reduce anxiety, induce optimism and stimulate focusing.
 Pieces of art, magazines in the waiting room or even a fish tank can have a role in
distracting attention and decreasing anxiety.
 Plants bring extra color in the waiting room, keep the air fresh and implicitly a more
pleasant atmosphere.
 Music: is not a safe solution for uncooperative children, but reduces the anxiety
climate which now becomes friendlier.
 Therapy through music is a psychotherapy or reeducation form which uses music as a
mean to communicate or to structure relationships.
One of the objectives of using therapy through music in pediatric dentistry is that it
helps the difficult children to overcome their emotions and benefit from a corresponding
treatment. The music ‘masks’ the noise made by the tools, distracting the child’s attention
towards something more pleasant.
Acting on the neuro-muscular system lets the patient keep his mouth open for a much
longer time without exhausting them. Inducing a decrease in the heart rate and the blood
pressure, the music implicitly determines a decrease of anxiety. At the level of the oral cavity
it determines a decrease of the salivary glands secretion and allows a little more control over
the hemorrhaging phenomena.
Even the relaxation is very important and the means to relax are multiple, there is a
category of children whose negative attitudes make the dental treatment impossible or affects
their quality and durability.
The uncooperative behaviors are originated in excessive fear and the doctors attitude
will be adapted according to the child’s personality, to their general state and to the socio-
cultural status.
The fear of the dentist can show in different ways:
 Verbally (the child tells the dentist he is afraid)
 Vegetative reactions (tremors, sweating, muscle tension, cutaneous reactions)
 Behavioral effects (cannot adapt to the treatment, aggressive motor effects)
Excessive fear is linked to the psychological state in general. It is not a simple fear, it
is a complex answer with multiple causes.
A special category is represented by the children with serious behavioral problems
(ADHD, autism, etc.). Because of the weak cooperation that is obtained with these children
they will be more prone to complications and relapse. The success of the treatment depends
on a correct evaluation of the child’s behavior, on a psycho-pedagogic attitude adapted to the
respective case. In the cases, a mild sedation of the child is imposed.
Sedation method election criteria:
a) general state of the child (age, associated general afflictions, cooperation level)
b) oral cavity state (the type and number of afflictions, emergency state)
c) the socio-cultural background (socio-economic level, the cooperation and responsibility of
the parents).
 The sedation techniques are for diminishing anxiety, discomfort and pain during the
treatment. The effects depend on the used pharmacological agent, way of administering but
also on the child’s state.
Sedative pre-medication favors the child’s relaxation. It is obtained with anxiolytic
medication administered by different ways (oral, rectal, intravenous).
For children older than 4 years, whose understanding and cooperation capacity is
higher a profound sedation with M.E.O.P.A. can be used (Oxygen and nitrogen protoxide
mixed equally). During these sedations a verbal contact is always maintained with the child to
explain him what is going to happen next and to see his level of consciousness. Far from
being the perfect choice, this technique is a precious help for doing the dental treatment on
uncooperative children.
Nitrogen protoxide is a painkiller, sedative, anxiolytic and euphorising. The sedative
effect is obtained quickly (3 minutes) and goes away right after the inhalation is stopped. It
shows as a little safer because the respiratory function is not suppressed.
A child who categorically refuses to open his mouth, to have a conversation with the
doctor, refuses to look at the doctor or the tools, will tip the balance towards general
anesthesia. Only general anesthesia will allow a complete and correct treatment in the absence
of full cooperation from the child.
Any other treatment method implies a doctor-patient interaction and minimal
cooperation.
Fearful or not, the patients wish the ‘ideal’ dentist, from both a professional point of
view and psycho-pedagogic point of view, so they can obtain pain and anxiety management.
The doctor’s competence covers all the psychological and pharmacological intervention
methods which he uses with empathy to help the ‘little patient’ access a corresponding dental
treatment in good conditions.
 2. EXAMINATION IN PEDIATRIC DENTAL MEDICINE

Examination is an essential step in achieving any medical act and has the following
objectives:
1. Obtaining data in order to:
 Set a complete diagnosis of dental, periodontal, oral mucosa or
dento-maxillary afflictions, which:
- shall cover all the pathological aspects (local or
general) of the patient’s state
- allows the establishment of a complex treatment,
pointed towards the oro-maxillo-facial manifestations, as
well as complications and distant manifestations.
 Trace the affliction’s evolution and treatment possibilities.
2. Finding the patients that present a risk for certain interventions or risk of
contaminating the medical staff or other patients.
The examination differs according to certain factors as the child’s age, psychic
development and cooperation possibility.
In order to reach a complete and complex diagnosis, the examination must be done in
several steps; thus we can differentiate anamnesis, the actual clinical examination, which in
the cervico-facial region is composed of exo- and endo-oral examination and lastly, but just as
important, come the complementary examinations which have the purpose to bring extra
information to confirm the diagnosis.

1. Anamnesis
According to the explanatory dictionary, anamnesis is the doctor-patient dialogue
conducted with the purpose of obtaining information regarding the health state.
The information obtained during anamnesis can be classified this way:
1. Personal data
2. Reason for coming
3. Personal history
4. Hereditary and collateral history
5. Present condition history
 Anamnesis must take place in a quiet and pleasant atmosphere of the doctor’s office,
which allows the patient to present the medical problems, without becoming exhausting and
in the case of using surveys the terms used must be according to the understanding level of the
patient, however avoiding influencing the answers.
Personal data refers to obtaining the patient’s identification data: first and last name,
age, date and place of birth, street address, the school they go to, phone number, parents’
occupation, as well as data about the number of siblings or anything else useful.
Reasons for which the patients come to the dentist are varied, as follows: pain,
physiognomic disorders, phonetic disorders, masticatory disorders, traumatic lesions,
inflammatory processes, abnormal growths, eruption disorders, TMJ (temporo-mandibular-
joint) dysfunctions, examinations for finding and sanitation of dental infections sources before
a surgical intervention, periodic individual or collectivity organized controls, consisting of
school or kindergarten children.
Present condition history must contain data referring to:
 The moment the affliction occurred: pain, swelling, dysfunction, abnormal growths, bone
deformations;
 The type of start: sudden or insidious
 Followed treatments and their effects
 Pain localization
 Character of pain: caused or spontaneous
 Triggering factors
 Intensity of pain (discomfort, strong pain)
 Type of pain: sting, tension, stabbing
 Irradiation and the area of irradiation
 Duration: intermittent, continuous, attacks followed by rest
 General associated disorders: loss of appetite, feverish, fever, asthenia, weight loss
 Localized associated disorders: tearing, hyper-salivation, face congestion, swellings
 Factors which reduce the pain: physical (heat, cold), medication
 Functional caused disorders: physiognomic, masticatory.

Hereditary and collateral history refer to familial afflictions determined by general,

genetic, neuro-endocrine, metabolic, environmental factors, chronic infections as well as
afflictions the mother suffered from during pregnancy (viral infections, toxicosis which could
have influence the child’s development), familial dental cavities predisposition, periodontal
pathologies or some dento-maxillary abnormalities (covered occlusions, open occlusions,
mandibular prognathism, numerical variations).
Personal history is divided in two subtypes:
Physiological – consist of writing down information regarding birth moment (term,
premature, facilitated, etc.), diet (natural, mixed, artificial), teeth eruption age and puberty
onset.
Pathological – regarding certain congenital malformations, trauma, surgical
interventions in the cervico-facial region, the presence of eating disorders in the first year of
life, rickets, infectious/contagious diseases, malfunctions of the endocrine system, cardiac,
renal, hepatic afflictions, nervous disorders, epilepsy, allergies, TB, arthritis, etc.
Medication treatment taken as well as allergic reactions to certain medication or
substances (penicillin, aspirin, local anesthetics).
Nose/pharynx afflictions (adenoid vegetation, recurrent tonsillitis, deviated septum, or
surgical interventions in the oro-maxilo-facial region) are also important to write down, as
they might have a major relevance over the actual diagnosis of an abnormality.
Certain bad habits such as oral breathing, thumb, lips sucking, tongue interposing,
putting objects between the dental arches, bad postural attitudes might be etiological factors
for dento-maxillary abnormalities.
Dental treatments followed as well as prophylactic fluoridation programs must be
written down in the actual patient’s chart.
Before doing the actual objective examination, the doctor must find out about the
child’s psychic development, either by asking the parents or caregivers about the child’s
grades in school or by trying a dialogue with the little patient, the latter being the better
option. This way, the doctor can appreciate the possibility to cooperate with the child.
Regarding adults, we can talk about a psychological profile, but in children’s case this aspect
cannot be evaluated easily as the child’s psychic is still developing. Also, there are certain
reactions and attitudes regarding the developing stage the child is in and the mood they are in
while doing the consult. This way, there are more attitudes and reactions in different stages:
1) Under 3 years old, children do not have focusing capacity, they always feel the need for
continuous movement and the obligation to sit still in the chair exhausts them, thus making
cooperation difficult. If the doctor shows patience and understanding, by trying to get their
attention with toys the compliance can be improved.
2) After 3 years of age, with the preschool period doctor-patient communication comes into
discussion. At this age, children become much more communicative, often ask questions and
the positive attitude and patience on the doctor’s side as well as explaining the medical
procedures so they can understand will improve cooperation. They are very receptive to
praising and as they get older their personality will sketch, accepting to remain in the doctor’s
office without their parents.
3) In the school period, once the thought process is developed, the children start rationing and
controlling themselves.
4) The pre-pubertal period is one of the most difficult because they can change from one
moment to another and negligence trends might appear, especially in the boys’ case, while the
girls will be, sometimes excessively, preoccupied by their image.
1. Objective examination
A complete examination requires going through more steps. (Img. 2.2)
1. General clinical examination: Appreciation of the general status.
2. Localized examination: Exo-oral
3. Endo-oral examination:
a. Assessing the oral hygiene
b. Examination of the oral mucosa, the bone structures and endo-oral muscles.
c. Dental examination
d. Periodontal examination
e. Static and dynamic examination of occlusion.

Img. 2.1 Child patient in the waiting room

Img. 2.2 Putting a patient in the dental chair
GENERAL CLINICAL EXAM has the role to assess the health state of the child by
looking at: postural attitude, behavior, somatic development, regarding age, gender,
constitutional type. (Img. 2.1 and 2.2)
Clinical assessing is done by measuring: height, weight, thorax and cranial perimeter which
can be compared with average values for our country. According to these measurements the
child can be classified in one of these 3 typologies: hyposomic, normosomic or hypersomic.
LOCALIZED EXAM – EXO-ORAL consists of examining the cervico-facial region using
classical examination methods: inspection, palpation and auscultation.
Face examination
INSEPCTION
Direct or indirect observation of the normal or modified aspect of the anatomical
structures of the face. (Img. 2.3)
Img. 2.3 Exo-oral examination: front and profile
Inspection can be facilitated by using the auxiliary tools (facilitates access, enlargement and
lighting):
- spreaders
- mirrors
- light sources
Facial exam is done from both front and profile.
The inspection will offer information regarding:
- face shape: oval, round, triangular, square.
- symmetry or asymmetry adding the cause: hemiparesis, chin deviation, septum deviation,
scarring, tumors, inflammatory processes.
- facial trenches aspect: shallow, pronounced.
- tegument aspect: smooth, rough, dry, color changes, congestion, paleness, integrity.
- lips and dermic part (high, medium, short).
- labial slot: closed, open, semi-open.
- stomion position: tall, low.
- lips relationship, positive or negative step.
- face floors relationship (inferior floor from the superior floor).

Profile examination consists of analyzing the relative positions in the sagittal of some
reference points localized at the level of: glabella, nasal pyramid, superior lip, inferior lip, and
chin.
The patient has a straight position, Frankfurt plane (imaginary plane between the Au-
auricular and Or – infra-orbital points) is parallel to the floor, the doctor situated laterally
assesses the relative positions of:
- the superior lip
- inferior lip
- chin
Profile analyzing is done by assessing the face aspect from the profile (Img. 2.4). For this
purpose we assess the position of the superior lip, the inferior lip and the chin in the profile
field. This is obtained by drawing two perpendicular imaginary lines on the Frankfurt plane:
- from the nasion (N) – naso-frontal plane (Dreyfuss plane)
- from the infra-orbital (Or) the orbito-frontal plane (Simon plane)
Img. 2.4. Examples of straight, convex and concave profile
The space delimitated by the three plans is called the profile field. There are 3 possible
versions:
- straight profile (normal)
- convex profile
- concave profile
The straight profile implies that:
- The superior lip is positioned in the anterior third of the profile field.
- The inferior lip is positioned in the middle third of the profile field.
- The chin is positioned in the posterior third of the profile field.
Convex profile implies that the superior lip surpasses the Dreyfuss plane and/or the chin is
drawn posterior to the Simon plane, and in the case of a concave profile, the superior lip is
localized in the middle third and/or the chin advances towards the anterior third of the profile
field.
Palpation is done bimanually, comparatively; the following are analyzed:
- face tegument and soft tissue.
- bone outlines specifying the possible presence of some level oscillations, mobility, abnormal
growths (dimension, shape, consistency, sensitivity, adherence):
- Orbital edges
- Zygomatic arches
- Nasal pyramid
- The gonion
- Basilar edge of the mandible
- Posterior edge of the ascending branch of the mandible
The emergence points of the sensitive branches of the trigeminal nerve are palpated by applying a
pressure in the following points:
The ophthalmic branch – supra-orbital point
The maxillary branch – infra-orbital point
The mandibular branch – chin point
The cervico-facial nodal groups would benefit of a special attention because their reactivity is known
in the case of dental diseases. For this, we will check:
Palpating possibility
Volume
Consistency
Adherence
Lymph nodes mobility on the subcutaneous plans
Associated pain sensibility
The pre-auricular nodal group will be palpated anterior of the external auditory canal, the retro-
auricular posterior of the ear lobe and anterior of the mastoid apophysis.
The submandibular and subangulomandibular and the submental will be palpated alongside of the
internal face of the mandibular body, where the gonion is, in the anterior extremity of the mouth floor.
The palpation of the genian nodules is done in the width of the musculo-adipose mass of the cheek,
and the superficial and deep lateral-cervical nodes alongside of the anterior and posterior margin of the
sterno-cleido-mastoid muscle.
The functional examination of the muscular groups estimates:
 Rest position
 Tonus
 Behavior of the oro-facial muscles in mimics
The directional growth of the alveolar processes and the positioning of the teeth on the arches depends
on the balance between the labio-jugal muscle forces (dental lane). Since the first consult, the doctor
evaluates the muscular tonus correlated with the general physical aspect, postural attitude and the
patient’s walking, so an atheltic constitution corresponds to a well developed constitutional type while
a cifotic posture corresponds to a thin type.
The orbiculary muscle of the lips, when in relaxed position determines the rapport of the lips as well
as the rapport between lips and the dental arches, position of the edge of the lower lip in relationship to
the free edge of the superior incisors (the stomion). When we are dealing with a tall stomion (the
inferior lip is larger than the incisal third) the superior retro-dent.
The lip appearance: thick, thin, tight.
Palpation offers information on tone.
Functional tests for the internal and external orbiculary muscle (Netter produres) (Img. 2.10):
For the internal fascicle of the orbiculary – the examiner pulls laterally on the oral comissures of the
patient and appreciates the opposition force and the possibility of closing the labial slit.
For the external fascicle we ask the patient to puff up their cheeks and the examiner exerts pressure on
the external surface of the cheeks, appreciating the patient’s capacity to maintain the air in their oral
cavity under these conditions.
Img. 2.10. Functional tests for the orbicular muscles of the lips
In orbiculary hypertonia we find reduction of the perimeter of the arches and crowding of the frontal
teeth; in hypotonia – protrusion because of the predominance of the musculature of the tongue.
Parafunctions with aspiration or sucking the lower lip determine the retro-dent of the inferior frontal
teeth and the pro-dent of the superior frontal teeth.
The tongue also exerts force at dental arch and the alveolar processes leve, thus during the
examination we must appreciate its volume, its rest position if it fits into the inferior arch, if it
overflows and maintains the impressions left by the teeth on the lateral edges (macroglossia), the
position of the tip of the tongue (low/high, anterior/posterior) and of the lateral edges, if it herniates
near the breaches, in case of inocclusion, if the inocclusion space is occupied producing vertical dento-
maxillary anomalies.
The tone of the tongue musculature is appreciated during the funcionality tests when the patient is
asked to execute movements to which the examiner opposes with a finger applied either on the dorsal
face or the tip:
Lifting (the child should move their tongue to the base of their nose)
Propulsion
Left and right laterality
Rolling, gutter tongue (cannot be done by patients that while in rest interpose their tongue
between arches in the lateral areas).

Cheeks – following the aspect and tonicity of the facial musculature. For the buccinator muscle we
appreciate the capacity of the patient to aspire the cheek mucosa from the internal face of the cheeks,
the examiner must create a light traction of those from the exterior.

The lifter muscles

The masticatory muscle may be palpated during contraction, we usually prefer that palpation should
be done simulatenously, bilaterally, which requires an isometric contraction (Img. 2.11). Palpation is
done for the superficial fascicle, the superior insertion on the postero-inferior extremity of the
zygomatic arch, the inferior insertion on the basilar edge of the mandible and intra-orally we can also
palpate the inferior insertion of the deep fascicle, in the inferior vestibule, distally of M3 (wisdom
tooth).
Img. 2.11. Functional tests for the buccinator. Examination of the masticator muscle.

The internal pterygoid muscles may be palpated exo-orally on the internal face of the
ascending arch of the mandible and of the basilar edge and endo-orally on the internal faces of the
ascending branch of the mandible, by the gonion behind the wisdom tooth.
The temporal muscle (Img. 2.12) may be palpated along the three fascicles: anterior, middle
and posterior having the superior insertion on the temporal bone, wide, fan-shaped, the fascicles being
thus situated: the anterior, slightly anterior to the TMJ having a vertical orientation, the middle above
TMJ being slightly oblique, the posterior, almost horizontal, posterior to TMJ.
The inferior insertion may be palpated endo-orally, mouth wide open while the patient executes a
slight laterality motion on that side, along the ascending edge of the mandible, in the superior
vestibule, at the level of the coronoid apophysis.
Img. 2.12. Exo-oral examination of the temporal muscles. Functional test for the lifting muscles.
Palpation of the inferior insertion of the external pterygoid muscle.

For the appreciation of lifting muscles tone we invite the patient to open their mouth while the
examiner opposes (hyper-, normo- and hypotonia).

The lowering muscles: supra- and subhyoid muscles, the inferior fascicle of the internal pterygoid: we
follow the opening motion by opposing.

Propulsion muscles: the exernal pterygoid may be palpated in the superior vestibule, peri- and
retrotuberositary. (Img. 2.13)

The anterior fascicle of the temporal muscle: the child sitting in dorsal decubitus is invited to execute
propulsion motions, then laterality motions while the examiner opposes.

Retropulsion muscles – the posterior fascicle of the temporal, suprahyoid muscles: the
retropulsion motion is examined in inverted occlusions.
Examination of temporo-mandibular joint is done by inspection, palpation and auscultation
(Img. 2.14).
Palpation is done bilaterally and symmetrically in one or two points. One point palpation is less used
and done by applying the index finger on a pretragian point and thus palpating the lateral surface of
TMJ. Two point palpation is done by positioning the thumb in a pretragian position and inserting the
index in the external acoustic canal, thus allowing the palpation of the posterior surface of the condile.
The limitations of the second method lie in the fact that by compressing the external acoustic canal we
can induce articular sounds.
The patient is asked to execute ample open-close motions.
Img. 2.13. Functional test for propulsion muscles.

Auscultation should highlight the presence of articular sounds, if they exist, using a
stethoscope, however this is most often unnecessary, the articular sounds may be discerned without it.
The crackles are similar to distinct clicking, with short duration and meaning the existence of
functional incongruences between the articular disc and the mandibular condile, and certain reducible
disc movements.
Img. 2.14. Examination of TMJ.
Crepitations are similar to the noise of ‘walking on snow’ or ‘hair strands rubbed with each
other’ and reveal an organic condition of the articular components (e.g. osteoarthritis of the articular
surfaces). It is important to say that if they are uni- or bilateral and the moment they occurred: at the
start of the lowering motion, at the end of the lowering motion, at the start of the lifting motion and at
the end of the lifting motion.
While examining the TMJ, the examination of the mouth opening is done as well. In the
lowering motion of the mandible a maximum opening of the mouth is required. The appreciation of
the amplitude is followed. Also the trail of a mandibular reference point is described in relation to the
medio-sagittal plane (the inferior inter-incisor point, the inferior lip frenulum, chin point).
The amplitude of the opening is appreciated as being the distance between the two inter-incisor points
in the moment of the maximum opening minus the incisor over-covering degree. Average values are
4-4.5 cm in women and 4.5-5 in men. An opening smaller than 4 cm is considered to be pathological,
exceptions being children or elderly people. The limitation of the opening is called trismus and can
have multiple causes:
 Muscular – mobilizing and mandible muscle spasms
 Submandibular and subangulomandibular regions inflammation
 Expression of the M3 mandibular molar eruption pathology (pericoronaritis)
 Mandibular constrictions
 TM arthrosis
 Tumors in the TM articular space
 Fibrous scars.
The mandible trail in relation to the medio-sagittal plane should be a symmetrical trail, without
deviation from the medio-sagittal plane.
An asymmetric trail may appear pathologically under different forms, with varied etiologies:
The initial deviation followed by the come-back of the point in the medio-sagittal plane: the
sinusoid trail is caused by the dislocation of the articular disc.
Deviated trail in which the deviated position is kept until the final position caused by some
muscular spasms which affect the masticatory muscle, deviating the mandible on the same side
(ipsilateral) or the intern pterygoid muscle, deviating the mandible towards the opposing side (counter-
lateral).
TMJ afflictions determine an ipsilateral deviation.
The amplitude of the movements in a horizontal plane is also appreciated between the inter-incisors
points, the propulsion having a normal value of 9mm, value which is considered normal in the left and
right laterality movements as well.
Normally, in a healthy patient, while examining the TMJ we should find the symmetrical, continuous,
condile movement, without interruptions, without articular sounds, asymptomatic and the movement
of the inter-incisor points must be continuous, uninterrupted, symmetrical and with an amplitude of
5cm.

Pathologically, we could highlight:

Articular pain associated with mandibular movements
The amplitude of the movements: limited – trismus or excessive – subluxation
Asymmetric mandibular trail
Deviation and come back
Deviation without come back
Articular jump
Articular sounds
Crackles
Crepitations
Mouth opening amplitude
Normal 4-5cm
Limited
Blocked
Opening movement: - circle arch (normal)
- abrupt (TMJ dysfucntions)
Chin and inter-incisor line excursion from opening to closing
The correlation between the superior and inferior inter-incisor line
Condiles excursion: symmetry, movement amplitude, crackles, crepitations, articular jumps,
pain, malformations, subluxations, ankylosis.

ENDO-ORAL EXAM
Soft tissue examination refers to examining the mucosa: gingival, labial, palate floor, oro-
pharynx and jugal mucosa.
The mobile mucosa is the mucosa that covers the musculo-fat walls or the oral cavity:
the mouth floor, the internal surface of the lips, the labial mucosa, the internal surface of the
cheeks, the genian or jugal mucosa, the palate veil mucosa, the mucosa of the ventral surface
of the tongue. The normal aspect of the mobile mucosa is red-colored, the epithelium is
transparent because of the rich capillary vascularization and the surface is smooth.
The fixed (attached) mucosa covers the bone components of the oral cavity, the bone
palate and the alveolar processes of the maxillary bone and the mandible. It has a more pale
color, pink, firm constitution, rougher surface, compared with ‘orange peel’ and might present
colored melanic spots. The height of the fixed mucosa strip is wider in the anterior vestibular
region and narrower in front of the canines and premolars – sometimes only 1 mm.
The fixed gingival fibro-mucosa is the mucosa which covers the vestibular and oral
ridges of the maxillary and mandibular alveolar processes, having the following limits:
towards the tip it is limited by the alveolar mucosa and the passive-mobile mucosa of the
vestibular and para-lingual sack bottoms; the coronary limit is the free gum, situated around
the dental cervix on which it is inserted.
Img. 2.15 Examination of the oral mucosa, frenum and of the oro-pharynx.

Particular mucosal elements we look for are:

- lips frenum (superior and inferior) for which we analyze the position, consistency, insertion
localization in relation to the free gum and mobility (Img. 2.15).
- bridele de mucoasa – the insertion is perpendicular on the alveolar processes in the canines
area.
The aspect of the lingual mucosa is also checked in order to look for infectious and
contagious diseases specific lesions: fissured, saburala, geographic tongue (Img. 2.16).
Img. 2.16 Geographic tongue

Salivary glands may be examined by inspection and palpation of the excretion orifices of the
salivary glands ducts as well as evaluating the quantity and quality of the saliva.
The Stenon canal papilla for the parotid gland – situated by the second maxillary molar and
the salivary caruncule of the Wharton canals for the submandibular and sublingual glands,
situated one both sides of the lingual frenum.
The quantity of the saliva can be abundant, rich in mucina – hypersialia; watery, reduced
quantity – hyposialia or absent – asialia. The quality of the saliva is givn by the macroscopic
aspect: clear or murky, presenting fibrin clots or not.
Oral hygiene is appreciated by inspection regarding the quantity of bacterial plaque and tartar
presented by the patient. For quantifying the use of certain epidemiologic evaluation
indicators is recommended.
The requirements of a correct plaque indicator are the following:
- must be easy to apply
- must allow examining large number of patients in a short time
- must be clinically objective
- must be used by more examiners – recognized by the scientific community.
Dental plaque indicators are divided in more categories:
1. without coloring the bacterial plaque
2. coloring the bacterial plaque

OHI-S indicator (oral hygiene index simplified), the most used, requires the examination of 6
teeth following the next figure:
1.6 1.1 2.6

4.6 3.1 3.6

Evaluation is made on the vestibular surface and for each of these teeth a score is given:
0 – no plaque or tartar
1 – bacterial plaque or tartar in the cervical third
2 – bacterial plaque or tartar in two thirds
3 – bacterial plaque or tartar in more than two thirds
DI (Plaque indicator) = the sum of all the numbers corresponding to each tooth divided by 6
CI (Tartar indicator) = the sum of all the numbers corresponding to each tooth divided by 6
OHIS = DI + CI
The palatal arch is examined, evaluating the shape, width, depth, rugae’s and torus aspect.
The palatal arch can be: low, flat, medium, deep, etc.
By reverberation of the lips the apical base can be appreciated: the curve described by the
radicular apex of the frontal teeth. The relationship between the apical base and the coronary
base, given by the vestibular surfaces of the dental crowns is: for the maxillary arch the
coronary base must be equal or greater than the apical base with a maximum of 15 degrees,
while for the inferior arch the coronary base must be smaller than the apical one with a
maximum of 5 degrees.
MORPHO-FUNCTIONAL FEATURES OF THE TEMPORARY TEETH
General features:
 Number: they are 20, opposing to 32 (the number of permanent teeth)
 Volume: smaller than the volume of the permanent teeth, except for the temporary
molars, which have a higher volume than their successors, premolars.
 Shape: the crown is globular with a narrowing at the cervix level because of the
sudden end of the enamel, with a protuberance of the enamel at the level of the
vestibular face of the first superior molar.
 The resistance of the hard dental tissue is decreased (this explains the increased
abrasion)
 The thickness of the hard dental structures is decreased
 Pulp room is bigger compared to the hard tissue and the dental canals are larger, thus
facilitating the rapid evolution of the dental cavity towards pulp complications
 Pulp horns are situated superficially, thus the accidental openings of the pulp room are
frequent
 Roots are weak with narrow canals
 The mineralization is superior in quality in the pre-natal period and inferior post-natal,
separated by the neo-natal line
 Pulp defense capacity is reduced
Group features
Incisors
1. similar shape to the permanent homologue ones
2. they are small in size
3. the M-D diameter is larger than the V-O one
4. the vestibular surfaces are slightly convex
5. the palatal surfaces are slightly concave
6. the cingulum is well-marked
7. the roots are singular, long, oval-section
Canines
1. their size is smaller compared to the permanent canines
2. the crown aspect is globular
3. incisal edge protrudes by a cusp
4. the vestibular surface has 3 un-even lobes, the central one being the largest
5. the palatal surface has a protruding cingulum
6. the inferior canine has the proximal slopes and the cingulum are less remarked
7. the canine root is long, strong, triangular section
Temporary molars
1. similar shape to the permanent molars
2. occupy the place of the permanent premolars
3. are pluri-cusped
4. the superior molars have 3 roots, 2 vestibular and 1 palatal root.
5. The inferior molars have 2 roots, 1 mesial and 1 distal
6. The roots are thin, divergent and the finishing part of it turned towards inside

The first superior molar

1. Premolar aspect
2. The occlusal face with 3 or 4 cusps

The second superior molar

1. Larger than the first temporary molar
2. Similar morphology to the one of the 6 year molar, but it’s smaller than it, more
globular
3. 2 vestibular cusps, 2 sulci and 3 fossets
4. The biggest cusp is the mesio-palatal one
5. The palatal surface can present a tubercle

The first inferior molar

1. Molar aspect
2. Narrowed towards vestibule-lingual direction
3. 4 cusps, the biggest one being the mesio-vestibular one

The second inferior molar

1. Similar morphology to the first permanent molar, but smaller volume-wise
2. 5 cusps, 3 vestibular and 2 lingual
3. On the occlusal surface there are 2 primary fossets (mesial and distal) and three
secondary, at the intersection of the 4 sulci
The roots’ aspect - varies depending on the evolution state of the tooth
 The young tooth period – after eruption the apex is wide open
 The mature tooth period – completely defined thin roots
 In the radicular resorption the root regains its truncated, sectioned shape

TEETH CALL
We will begin with the superior arch, from the median line towards right and left, then going
to the inferior arch from the median line towards left and right, in the quadrants’ order. Thus
the dental formula is noted with Arabic numbers for the permanent teeth and with Roman
numbers for the temporary teeth, either by using 1, 2, 3, 4 prefixes for the permanent teeth and
5, 6, 7, 8 for the temporary teeth in the FDI system.
Temporary and permanent dentition:

V IV III II I I II III IV V
V IV III II I I II III IV V
8765432112345678
8765432112345678
Teeth call allows us to specify the dentition type: temporary, mixed or permanent, as well as
the dentition according to the child’s age: late or early.
There are also noting systems of the different changes which can appear on an arch:
The presence of the breaches is noted: - 0 if a temporary teeth was extracted around the
replacement time or if it takes less than 1 year until the permanent successor erupts.
- X premature extraction of a temporary or
permanent tooth
Shrunk breach – accolade ∩
Closed breach – double accolade
Trema or diastema – 
Erupting tooth is marked between brackets: e.g. (3) or (4.3)

Dental examination requires examination through inspection and palpation of every dental
surface in order to detect any dysplasia, dental caries, obstructions, traumatic lesions (Img.
2.17). Favored spots for dental caries are the sulci, fossets, fissures, proximal surfaces. The
following are specified:
- the lesion’s topography
- the lesion’s type: acute or chronic
- the depth degree of pulp affecting (hyperemia, pulpitis)
- periapical tissues state
The axial and paraxial percusssion controls the sensitivity of the apical periodontal.
Img. 2.17 Dental examination

Dental mobility: must be also appreciated: it is considered normal in the replacing period of
the temporary teeth and otherwise pathological. (except for the situations in which a treatment
results in changing the respective tooth position).
In the case of extraction, the type of dentition and the breach status (shrunk, unmodified) are
specified.
The abrasion (physiological or pathological) is specified as well as all the uni-dental position
changes: versions, gressions, rotations specifying the movement direction and the presence or
absence of space regarding dental recovery.

Periodontal examination follows the aspect of the papillae, marginal and attached gum, the
level of the epithelial insertion, the depth of the gingival sulcus, the presence of the tartar:
supra- and sub-gingival, the presence of congestions, edema, bleedings, purulent secretions,
gingival retractions, false or real bags, with the depth and localization being specified, dental
migration.
Mono-maxillary examination follows on both the superior and inferior arch the presence of:
- uni-dental position changes, versions, rotations, specifying the change direction as well as
the presence or absence of the space.
- dental group modifications in the 3 reference directions.
Sagittal Transversal Vertical
Frontal Protrusion/retrusion Crowding/spacing Infraposition/suprapositio
Group n
Lateral mesialization/shortening Uni/Bilateral symmetrical Level oscillation of the
Group /interruption of a or asymmetrical occlusion plane,
hemiarch. narrowing Left > Right specifying the cause
- change in the arch shapes

Static occlusion examination is done with the mandible being in centric relationship and the
arches in MI (Maximum intercuspidation) (Img. 2.18). If the two positions do not coincide the
habitual static occlusion will be analyzed. The examination is done in all the 3 directions
(sagittal, transversal, vertical) for all the 3 important marks. In the case of mixed or permanent
dentition, the marks are the first permanent molars, canines and incisors and in the temporary
dentition we are talking about occlusal relationships at the level of the post-lacteal plane,
canines and incisors. The examination begins in the right molar region, along the arches
towards the opposing direction. If at the level of other teeth major changes appear in one of
the 3 directions and these changes are not deduced from presenting the changes near the
important marks, they must also be specified.
Img. 2.18. Static occlusion relationship examination
In order to discern the changes, normal occlusion relationships must be defined:
Molars Canines Incisors
Sagittal Angle’s Key (the The cusp of the The circumscription
mesio-vestibular cusp superior canine of the vestibular
of the first superior comes in contact with surfaces of the
molar in the the canine and the inferior incisors by
intercuspidal sulcus first inferior premolar the palatal surfaces of
between the mesio (first temporary the superior ones.
and centre-vestibular molar) The presence of a
cusp of the first sagittal level of 1-
inferior molar) 2mm.
Transversal The vestibular cusps Contact between the Median inferior line
of the first inferior palatal face of the corresponds to the
molar are superior canine and superior median line.
circumscribed by the the vestibular faces
vestibular cusps of of the inferior 3 and
the first superior 4.
molar
Vertical Cusp-fossa or cusp- 1/3 covering The superior incisors
marginal ridge cover the incisal third
 relationships of the vestibular
surface of the inferior
incisors.

Img. 2.19. Normal occlusal relationships

Abnormal relationships:
Molars Canines Incisors
Sagittal Mesialization or Distalization or Sagittal level greater
distalization (half or mesialization of a than 1-2mm.
one full cusp) half or full cusp Reversed gearing
(one or two incisors)
Reversed frontal
occlusion (all the
incisors)
Transversal - crossed occlusions - level (mm) Median line
- lingualized occlusion - reversed gearing deviation towards
right or left by 1-2
mm or more
Vertical - open occlusion Deep or open Deep occlusion if the
- unstable occlusion occlusion covering is greater
Cusp – ridge than 2/3 or full.
- collapsed occlusion Open occlusion –
(occlusal-articular lack of contact before
blocks) superior and inferior
incisors.

Occlusal relationships in temporary dentition

The incisor and canine mark is analyzed the same way as in the permanent dentition, but the
posterior mark is represented by the post-lacteal plan. The post-lacteal plane (Img. 2.20) – the
line which links the distal faces of the superior and inferior temporary molars 2 (M2). This
can be straight (normal until 5 years), in mesialized level (normal after 4-5 years because if
facilitates installing the neutral relationships in the 6-years molars), or in distalized level
(abnormal).
Img. 2.20. The post-lacteal plane

Dynamical occlusion examination requires doing the mandibular limit-movements, starting

from the rest position of the mandible. The patient is seated so the Frankfurt plane is parallel
to the floor and they are asked to count or pronounce words which contain the ‘v’, ‘f’ and ‘s’
letters. Normally, a lips contact is obtained while resting without muscular contraction, the
frontal over-covering is reduced and lateral inocclusion is around 2-4mm. The closing trail is
analyzed from this position until MI, following the chin position and the inferior inter-incisal
point.
If at the first dental contact the intercuspidation is complete it is considered that MI coincides
with the centric relationship, so we have a centric occlusion characterized by a neuro-
muscular harmony. If at the first inter-dental contact there is a premature contact which causes
a mandibular deviation and a 2 steps closing, the chin and the inferior inter-incisor points
deviate anterior or laterally, a habitual MI position is reached which is not in balance with the
neuro-muscular centric relationship position and condile guidance. This way, mandibular
lateral deviations, crossed occlusion, frontal reversed occlusion and mesialized occlusions can
appear.

Mandibular movement examination:

The propulsion (Img. 2.21) – the patient is asked to do gliding moves of the inferior incisors
on the palatal surface of the superior ones until the head-to-head position. Physiologically this
anterior guidance is done on the superior central incisors and sometimes on the lateral ones
with the concomitant desocclusion of the lateral teeth. The normal guidance is straight in
medio-sagittal plane. If the median line is deviated in the occlusion, it is checked if it corrects
itself in resting positon.
The lateral areas desocclusions depends on the over-covering degree and the size of the
sagittal level. A large over-covering and low sagittal level will lead to an immediate and
important lateral areas desocclusion.
Propulsion movement examination can show the presence of interferences. If the guidance is
supported by only one incisor this is called active propulsive interference. If there are dental
units posteriorly where the desocclusion doesn’t occur these are called passive propulsive
interferences. Keeping the dental contacts at the level of the interferences and at the end of the
gliding movement is called premature active propulsive contact, respectively passive.
Keeping the median lines and the concordance of the two arches in transversal plane is
checked. Premature contacts and interferences require correction because they can lead to
mandibular deviations, muscular spasms, periodontal lesions, TMJ disorders.
In the frontal open occlusion, the propulsive movement is taken over by the lateral teeth and
in the reversed frontal occlusion the possibility of executing the retropulsion until head-to-
head position of the incisors is acquired by the patient is checked.

Laterality (Img. 2.22): the patient is asked to do gliding movements towards right and left,
keeping the dental contacts. The side towards which the movement is done will be called
active side and the counter-lateral side becomes passive side. It is preferred that the laterality
guidance is done on the canines: thus the inferior canine will slide on the palatal face of the
superior canine, phenomenon called canine protection or canine guidance. If besides the
canines, other lateral teeth on the active side take part as well, we are talking about a lateral
group guidance. If another tooth takes over the laterality guidance it will be called active
lateral interference which causes an occlusal trauma in the respective tooth. If another tooth
takes part in the laterality movement with the canine, regarding the tooth localization we are
talking about a lateral active or passive interference.
Img. 2.22 Laterality movement examination

FUNCTIONS EXAMINATION
It follows the behavior of the facial and lingual musculature in the moment of the dento-
maxillary apparatus functions development and in the moment of breathing, swallowing,
mastication, phonation, physiognomy and self – maintenance.

BREATHING
Breathing examination will show the breathing type (nasal, oral or mixed). Oral breathing can
be caused by a nasal respiratory deficiency, initially caused by disorders appeared in the aerial
passage: rhinitis, adenoid vegetation, septum deviation. In these situations, the child keeps his
mouth open or sleeps this way, exhausts after effort and in the case there is no respiratory
tract obstructions because it was surgically removed and the oral breathing persists, we are
talking about a habitual breathing. The characterizing aspect of the oral breathers is adenoid
facies, characterized by an elongated face, narrow nostrils, dark circles around the eyes, labial
slit open while in resting position, lips are dry, fissured, teeth may present cervical caries.
In order to appreciate the permeability of the nasal fossa the following tests were invented:
 Wool flake test implies alternative clamping of the nostrils while a wool flake is held
in the clamp in front of the other nostril;
 Steaming of the mirror test – dental mirror is applied successively while exhaling in
front of each nostril (Img. 2.23).
When the wool flake is not moved or the steaming areas are asymmetrical the respective
nostril obstruction can be assumed.
Gudin nostril reflex implies pressing the nostrils on the nasal septum for one second. Right
after stopping the compression, in the case of an nasal breather, a large opening appears
because of the fact that the nostril musculature is well developed. The oral breather lacks this
aspect.
Rosenthal test consists of executing 20 breaths with both nostrils, followed by 20 with each
nostril successively in a normal rhythm. Children who have a decreased nasal flow have
increased pulse and open the mouth before the 20th breath.
Img. 2.23 Appreciation of the nasal fossae permeability.

DEGLUTITON
It is an extremely important function for the dento-maxillary apparatus because of more
factors:
- participation of multiple muscular groups;
- the high frequency of occurrence.
It implies 3 closing circles: lips contact, dental arches contact and the dorsal face of the
tongue in contact with the palate and the tip of the tongue is resting on the superior retro-
incisor region.
In order to examine the deglutition, the child is asked to swallow saliva or some water
checking if the deglutition occurred. The masticator and mylohyoid muscles are palpated and
it is checked if there is an extra lips or cheeks contraction. The lips are gently detached with
the fingers and we check: if the dental arches are in contact in the moment of deglutition and
the possible interposing of the tongue in the frontal or lateral region. The projection of the
tongue between the incisors shows an atypical infantile deglutition, close to the tongue
movement while sucking. The consequences of persistent infantile deglutition are: open
occlusions, protrusions, pathological trema and diastema and in the case of adults it is an
etiological factor for dental pathology.

MASTICATION
From the anamnesis, information about food preferences will be obtained: food consistency
(soft, pasty, consistent) which will determine the masticatory stereotype – active or lazy.
The number of masticatory units must be appreciated for the evaluation of the health state of
the teeth, of the occlusion relationships which can facilitate of aggravate mastication. In the
case of an unilateral unbalanced mastication inactivity gingivitis occurs. The presence of a
toothache can determine avoidance of the mastication on the affected side, self-cleaning will
no longer be done and tartar deposits and plaque appear, accompanied by gingivitis.
Among the masticatory function indicators information about the muscular tone, self-cleaning
degree and physiological abrasion are also present.

PHONATION
Along the phonation disorders which disturb the sound quality of the dyslalia, rhinolalia,
sigmatism type changes in the oro-facial musculature during phonation may appear.
Phonation disorders can determine, aggravate or maintain certain abnormalities and vice-
versa, the dento-maxillary abnormalities can determine phonation disorders.

THE PHYSIOGNOMIC FUNCTION

When changes in the physiognomic function occur and they are noticed by the patient at
certain ages and in relationship with the behavioral type of the patient, they can lead to the
appearance of inferiority complexes. The examination of the physiognomic function is done
by inspection in both resting position and while talking, when smiling, in order to detect
certain tics, grimaces or parafunctions. It is assessed if the patient has an active or passive
mimic.

SELF MAINTAINING FUNCTION

It ensures the health state of the dento-maxillary apparatus and it’s disturbance will affect:
- the teeth by the occurrence of pathological migrations, abrasions.
- the dentition by gingival retractions, inflammatory processes.
- the musculature by pain or contractions.
- TMJ by pain, crackles, jumps and crepitations.

3 COMPLEMENTARY EXAMINATIONS
In order to complete the objective clinical exam and in order to offer the patient a certain
diagnosis, complementary examinations are required. Among these, the most frequent are the
following:
Radilogic examination
Photostatic examination
Study models examination

The photostatic examination consists of doing and analyzing photos from the front and side.
The purpose of these examinations is:
- assessing the facial changes caused by the increase and dental, periodontal, prosthetic and
therapeutic effects.
- determination of a dento-maxillary abnormality diagnosis.
- determination of a therapeutic plan.
- following the development of the case.
The photos are done from a 60-70 cm distance from the patient, the Frankfurt plane must be
parallel with the floor and points can be applied with the eyeliner on the patient’s face
corresponding to some bony points. (Img. 2.24)
Trichion (Tr) – median point at the frontal insertion of hair
Ophryon (Oph) – median point on the tangent to the eyebrows line
Nasion (N) – point situated at the nose’s root
Sub-nasal point (SN) – corresponds with the nasal anterior spine
Pogonion (Pg) – the most pronounced point on the chin
Sub-orbital point (Sor) – the most inferior point of the orbit’s edge
Auricular (Au) – at the level of the tragus
Gnation (Gn) – the lowest on the inferior edge of the mandible
Gonion (Go) – at the level of the mandible angle
Superior Labial (S.L.) – at the level of the superior lip filtrum
Inferior Labial (I.L.) – median on the inferior lip
Stomion (St) – median on the contact line of the lips
Img. 2.24 Front and profile images with the anthropometric points
Photostatic analysis from the front checks the evaluation (Img. 2.25):
- face shape
- symmetry
- face floors proportionality
- facial sulci aspect
- lips aspect and their relationship
Symmetry = the bilateral disposition of the organs with the same origin and morphology
which correspond on both sides of a reference plane.
From a physiological point of view, absolute symmetry is very rare.
Dissymmetry = physiological condition of bilateral organs which do not have an alike special
disposition.
There is a natural and normal dissymmetry of the face, a harmonious difference of the 2 parts
of the face while resting and while executing functions.
Asymmetry = pathological situations in which the bilateral organs have a completely different
disposition on each side of the reference plan. Only the amplitude of the difference between
the 2 halves of the face make the difference between dissymmetry or asymmetry.
Asymmetry = malformations
Dissymmetry = anomalies
E.g. in lateral deviations of the mandible we are talking about dissymmetry
Img. 2.25 Photostatic symmetry analysis
Horizontal lines which help evaluating the symmetry:
- above the eyebrow’s line
- Frankfurt plane
- Bi-commissural line and the bi-goniac line.

Photostatic analysis from the front:

The median line of the face – linking the Oph-N-Sn points. It is elongated. It is checked if
S.L., I.L., Pg, Gn points are on the extension of the median line or not (symmetry or not).
Through Tr, Oph, Sn, Gn perpendiculars on the median plane are drawn.

The proportionality of the three floors of the face:

Superior (Trh-Oph)
Middle (Oph-Sn)
Inferior (Sn-Gn)
- the middle and inferior floors are normally equal
- a perpendicular on the median plan which goes through the stomion divides the inferior floor
in two sub-floors Sn-St (smaller) and St-Gn (larger), the two normally being in the golden
proportion. (the golden proportion = 61.82%)

Photos taken while laughing have the role to show the teeth, gums aspect, the incisor line trail
and its’ relationship with the laughing line, the bi-commissural line, the free edge of the
inferior lip, the degree of visibility of the teeth while laughing, negative lateral spaces, the
number of visible teeth while laughing.
The photostatic analysis from the lateral (Img. 2.26) has the role of facilitating doing the
profile analysis by assigning the inferior floor’s elements in the profile field.
Img. 2.26 Photostatic analysis of the profile field
The profile field:
- delimitated by two perpendiculars from the nasion and suborbital on the Frankfurt plane.
The Frankfurt plane formed by linking the Au point with the sub-orbital point (Or).
The Frankfurt plane must be parallel to the floor.
Straight profile:
- the superior lip in the anterior third of the profile field
- the inferior lip in the middle third
- the chin in the posterior third
Convex profile:
- the superior lip exceeds the naso-frontal plane and the other elements keep
their position
- the chin is retraced behind the orbital-frontal plane
- the superior lip and the chin are not situated in the profile field
Concave profile:
- the superior lip is retracted in the middle third
- the chin advances towards the anterior third
- the association of the position changes of the superior lip and the chin
Img. 2.27 Photo montage for the photostatic examination
The tangent of the mouth is an angular measurement method introduced by Schwarz and it
assess the inter-maxillary sagittal relationship.
Sn and Pg points are linked. This line normally forms a 10 degree angle with the naso-frontal
plane. If the value decreases, the Pg point is more anterior and a mandibular prognathism is
suggested. If the value increases, the Pg point is retracted, so it will be a mandibular
retrognathism.

A complete photomontage also contains photos of the arches and the arches while in
occlusion (front, lateral, right and left). The 3D photo is a modern investigation, the facial
coordinates are calculated using the computer in all 3 dimensions.

Radiological examination offers us a large palette of investigations:

- radiographs with retro-alveolar film
- radiographs with retro-coronary film (Bite-Wing)
- radiographs with occlusal film (bitten)
- panoramic radiographs
- orthopantomographs
- teleradiographs
- carpal radiographs

Radiographs with retro-alveolar film (Img. 2.28).

Img. 2.28 Retro-alveolar radiography
Indications:
- the dental and periodontal lesions
- dental numeric, position and volume abnormalities
- endodontic treatments control
The major advantage of these radiographs type is the exact reproduction of:
- cavity processes extending
- dento-perdiodontal structures
- relationships with the pulp room
- root length
- formation degree
- radicular canal aspect
- relationship of the temporary teeth with the permanent underlying teeth buds
- the relationship of the teeth with the neighboring anatomical structures (sinus, nasal fossae)
- the presence of peri-apical or radicular processes.
The disadvantages of this technique consist of the fact that these radiographs reproduce
exactly the status of only one tooth or only one teeth group; more films are needed for a full
arch and the irradiation in the classical technique was rather important. With the development
of the digital techniques the problem of the irradiation is not the same.

Retro-coronary film radiographs (Bite-Wing) (Img. 2.29) present a median wing which
interposes between the occlusal surfaces of the molars and premolars and allow the
reproduction of the coronary image of both the superior and inferior teeth.
The indications for this technique are as follows:
- coronary structures analysis
- early proximal clinically undetectable caries diagnosis
The disadvantage of the technique is: limited inclusion of the roots on the film
Img. 2.29 Bite-Wing radiography

Occlusal film radiographs (bitten), for which the technique implies that the film is kept
horizontally between the two arches in occlusion (Img. 2.30).
Indications:
- completing another two radiography type
- assessing the correct vestibule-oral position of misplaced, supernumerary and
included teeth.
Img. 2.30 Palate axial radiography (with bitten film)

Orthopantomography (Img. 2.31)

Includes both maxillaries on the same film and the following can be analyzed:
- the two alveolo-dental arches in habitual occlusion
- bony bases
- maxillary sinuses
- the whole mandible
- the TMJs
Img. 2.31 Orthopantomography
Disadvantage: masking of the incisor region because of the technique as well as overlapping
the cervical spine.
Study model examination
Study models allow checking and completing clinical data, making extra measurements,
following the development of the case over time and they represent a medical and legal
precious document.
On the study models the following can be executed:
- teeth call and writing down the position change
- dentition diagnosis corroborating with anamnesis and orthopantomography
- monomaxillary analysis like the one presented in the clinical examination
- analysis of dental group changes
- static occlusion analysis
- specific measurements in orthodontia (Pont Index, Bolton Index, Perimetry,
Symmetroscopy, Tweed-Merrifield total space analysis)
- diagnostic set-up.
 3. ODONTOGENESIS

Odontogenesis is the tooth development process, which begins during the intrauterine
life and continues until the age of 14-15 years.
Each tooth undergoes several developments stages, same for all the teeth, but do not
coincide over time:
- proliferation
- histo-differentiation
- morpho-differentiation
- calcar apposition and calcification

PROLIFERATION
Starting with the 6th intrauterine week the basal cells of the stomodeal epithelium
proliferate in the underlying mesenchyme and form the dental lamina.
Temporary teeth buds appear on the free margin of the dental lamina, 10 for each
maxillary in the 6th week of the intrauterine life. They are linked to the dental lamina through
a pedicle. At the pedicle level, through a rapid cell proliferation the permanent replacement
teeth buds will develop. The first which start developing are the central incisors buds in the
20th intrauterine week, followed by the rest of the replacement teeth
Img. 3.1 Section through the maxillary at the start of the dental development
Starting with the 16th intrauterine week, completing teeth buds start developing at the distal
extremity of the dental lamina. The first which start this process are the first permanent molar
buds. Then in the 8th postnatal month the second molar buds will develop and around the age
of 4-5 years the wisdom teeth buds will develop.

HISTO-DIFFERENTIATION

Continuing the development, on the internal surface of the buds a small depression
appears, marking the capsule phase (Img. 3.2) of their evolution. Then, by the invagination of
the mesenchymal tissue, the bud goes into the bell phase.
Img. 3.2 Capsule phase of the dental bud
 The dental-epithelial bud will be surrounded by mesenchymal tissue, confirming the
mesodermal origin of the dental organ. The two types of tissue, ectodermal and mesodermal,
will act in a reciprocal manner, being by turn inductor and receptor.
In the bell phase the following will develop (Img. 3.3):
- enamel organ of ectodermal origin
- dental papilla out of which dentine and dental pulp will develop, having a
mesodermal origin
- follicular sack out of which the cement, alveolar bone, alveolo-dental ligaments will
develop, having a mesodermal origin
Img. 3.3 Bell phase of the dental bud

a) enamel organ (Img. 3.4) is made of multiple cell layers:

- adamantine external epithelium – made of a single layer of cubic cells which form a
convex protective wall;
- adamantine internal epithelium – surrounds dental pulp, being made of tall cells
which will differentiate in hexagonal cells, called preameloblasts. When their activity
will begin they will be called ameloblasts or adamntinoblasts.
- stellar network or enamel pulp – separates the adamantine external epithelium from
the internal one. It is made of stellar cells and mucous tissue and has a nutritive and
protective role.
- intermediate layer – is situated between the ameloblasts and the stellar network. It
contains cubic cells having the role of distributing the fluid inside the ameloblasts and
by the enzymatic intake also has a role in enamel forming.
- basal membrane – separates the amelobasts from the dental papilla, being the future
amelo-dental junction.

At the bell’s base the adamantine external and internal epithelium merge at the level of
the future dental cervix. These form a sharp angle in the mesenchymal tissue where they will
proliferate and invaginate forming an epithelial sheath which surrounds the tooth and is called
Hertwig’s Sheath – Hertwig’s Sheath has an important role in modeling the root.
Img. 3.4 Enamel organ
 b) dental papilla (Img. 3.5)
- it is made out of the condensed mesenchymal tissue in the invaginated portion of
the enamel organ.
The peripheral cells actively multiply (2 areas appear)
- the central area (future pulp area)
- the peripheral area (future dentino-genetic area)
The mesenchymal papilla fibroblasts will differentiate in odontoblasts because of
some mechanisms which resulted from the interaction between the epithelium and
the mesenchyme, separated by the basal membrane.
Img. 3.5 Dental papilla, Hertwig’s Sheath

c) follicular sack
It is formed by condensing the mesenchymal tissue around the dental bud. Through
this process, specialized cells will develop for the forming of the cement (cementoblasts),
alveolar bone (osteoblasts) and the sustaining elements of the tooth (fibroblasts).
The dental lamina and the buds’ links with it progressively disappear because of the
proliferation of the mesenchymal tissue.
The follicular sack of the temporary teeth will be directly inserted on the oral mucosa
membrane currently developing. In the case of permanent teeth, their link to the oral mucosa
is done by a fibrous cord called Individual gubernacular ligament. Permanent molars have a
follicular sack and a common gubernacular ligament.

MORPHODIFFERENTIATION

The cells formed in the histo-differentiation stage become functional and will form the
organic matrix of the enamel and dentine. The matrix generation process is called dentino-
genesis, respectively amelogenesis. Then this matrix will be mineralized with calcic salts.
a) Dentinogenesis (Img. 3.6)
The peripheral cells from the dental papilla are organized in order to secrete the dental
matrix.
These changes include:
- orderly disposition of the cells.
- nucleus migration to the basal pole.
 - the development of the organelles involved in protein synthesis, divided between the
nucleus and the future secretive pole of the cell.
- around the odontoblasts alkaline phosphatase, adenosine triphosphatase and lactate
hydrogenase were identified, according to the increased energetic needs of the cell.
Predentine looks like an homogeneous layer which separates the odontoblasts in the
secretive stage from the ameloblasts in the differentiation stage.
Img. 3.6. Dentinogenesis

Dentinogenesis stages:
- cellular stage in which the odontoblasts synthetize and secrete the organic components
precursors.
- extracellular stage in which biochemical changes and enzymatic reactions of the secreted
materials appear.
In the functional stage, the odontoblast looks like a uni-polar cell having the cell body
at the periphery of the pulp and a cytoplasmic extension towards the internal adamantine
epithelium, Tomes fiber. Around the cytoplasmic extensions and between them, Van Korff
fibers appear, which together with the matriceal substance will form the first dentine layer.
Van Korff fibers are spiral-shaped and will be embedded in dentine.
The major protean element of the dental matrix is the collagen which is organized as
fibers with variable thickness.
The inter-fiber fundamental substance is made of:
- glycosaminoglycan
- glycoconjugate
- proteoglycan
- phospholipid complexes, phosphoproteins

b) Amelogenesis (Img. 3.7)

After the dentinogenesis start, with the forming of the first predentine layer the cells of
the internal adamantine epithelium start differentiating towards becoming secretive cells. The
phenomenon is called retour induction of the odontoblasts on the internal adamantine
epithelium. A similar phenomenon takes place at the level of the epithelium on the
odontoblasts which earlier started their activity.
Img. 3.7. Amelogenesis
The cellular phenomena which transform the preameloblast into ameloblast are:
 - the Golgi apparatus migration towards the nuclear pole;
- mitochondrial enrichment;
- the development of the endoplasmic reticulum in the secretive pole area;
- appearing of vacuolar inclusions.
Also an extension of the cellular body appears which extends towards the deposited
predentine layer, Tomes process. At the dentinal extremity of the ameloblasts, the inter-cell
substance condenses forming the terminal bars network having the role of forming the inter-
prismatic enamel. At the opposing pole of the ameloblasts calcospherites which fusion
forming the enamel prisms.
As the matrix is deposited the ameloblasts will retreat towards a centrifuge direction,
pushing the intermediate layer outwards and decreasing the area of the stellar network. From
all the layers described at the enamel organ an epithelial cover is formed, Nasmyth cuticle.

CALCAR APPOSITION AND CALCIFICATION

By depositing the inorganic components on the organic matrixes of the enamel and
dentine, developed in the other stages the tooth forming is finished.
a) dentine mineralization
It starts at the level of cusps or the incisor edges, the predentine being transformed in
dentine as the mineralization ends.
After the end of a dentine layer mineralization another predentine layer depositing
starts, thus resulting the growth of the dentine layer. As the dentine layer grows in thickness,
the odontoblasts retreat in centripetal direction, leaving the Tomes fibers in the dentinal
canals. At the end of the mineralization process, the dentine will be 70% mineral, 18%
organic and 12% water.
Intense cellular activity and rest periods successions are observed in dentinogenesis.
These are materialized through the OWEN outlines.
Dentine apposition overlaps the mineralization with a rate of 5 microns/day dentine
depositing. This rate determines the VON EBNER growth lines.
From a structural point of view 2 types of dentine are distinguished.
 - peripheral dentine – a thin dentine layer underlying the enamel and the cement,
atubular and with a reduced mineralization degree. It is assumed to be the first secretion
product of the odontoblasts.
- circumpulpal dentine formed by joining of dentinal metabolic units perpendicular on
the ceiling of the pulp room.
The dentinal metabolic unit is constituted of:
- the Tomes fiber – the cytoplasmic extension of the odontoblast
- the surrounding pericytoplasmic space
- the dentinal canal which contains it
The Tomes fiber comes from the secretive pole of the odontoblast. This elongates as
the odontoblast seems to retreat behind its secretion product. The Tomes fiber has a bi- or tri-
fidate extremity and also lateral extensions which come in contact with the lateral extensions
of the neighboring extensions through secondary canals.
The pericytoplasmic space is contained between a cytoplasmic extension and the canal
wall. It contains polysaccharide complexes, collagen proteins, collagen fibers. It also contains
nerve terminals (Weil intradentinal nerve fibers).
The dentinal canal contains the cytoplasmic extension and it covers the dentine from
the pulp to the amelodentinal junction. Its diameter decreases as it gets further from the pulp
because of the progressive mineralization. The dentinal canals are connected through
secondary canals and are surrounded by the peritubular dentine. Between two neighboring
metabolic units there is intertubular dentine.
Dentine types
- primary dentine – appears in the forming stage of the tooth;
- secondary dentine – it is formed afterwards through processes that continue as long
as the pulp is alive; it contributes to the uniform reduction of the pulp room volume, having a
structure similar to the primary dentine;
- tertiary dentine (reaction dentine or irritation) – it is produced as a defense reaction
to the irritation of the odontoblasts (caries, trauma).
- sclerosus dentine – appears in old people or in chronic caries being characterized by
salt depositing and obstruction of the dental canals.
b) enamel mineralization
It is done by progressive and continuous depositing of mineral salts in both the
secretive stage and in the maturation stage. The crossing stage from the matrix secretion is
translated by the decrease of the protein proportion. The mineralization gets to values around
92-93% for the temporary teeth and 95-96% for the permanent ones.
The enamel mineralization starts from the cusp tips, respectively the incisors edges
towards the cervix and from depth towards surface (centrifuge) while the dentine
mineralization takes place from the surface towards depth (centripetal). The mineral crystals
contain: hydroxyapatite, octo-calcic, di and tricalcic phosphate. Through ionic trades other
mineral elements can be present: Mg, N, K, F, Cu, Zn, Mn.

Root forming
It contains the radicular dentino-genesis and the cement-genesis, desmodontium and
the alveolar process building.
After finishing the crown size and implicitly the enamel and dentine layers a new
epithelial spurt triggers the radicular organogenesis. At the cervix level, the internal and
external adamantine layers fusion in order to form a tissue collar which clogs into the
conjunctive and then it tries to encapsulate the mesenchymal papilla.
Similar to a diaphragm which progressively reduces its diameter, the epithelial collar
persists over all the root formation period. This formation is known as Hertwig’s Sheath (Img.
3.8)
Img. 3.8. Hertwig’s sheath
While in contact with the pulp mesenchyme, the epithelial sheath cells induce
preodontoblastic organization processes in the mesenchyme and then they are expelled in the
follicular sack. The radicular predentine aggregates to the coronary dentine continuously.
Along the external radicular wall isles from the epithelial sheath are observed, which are
called Malassez epithelial remains.
At the multi-radicular teeth’s level, the epithelial tissue ring issues two or three langets
which grow and form a sheath for each root.
Cementogenesis
After the extinction of the epithelial sheath, the radicular dentine comes in contact
with the follicular sack formed of fibroblasts and well vascularized fundamental substance.
This contact produces a tropism on the fibroblasts which aggregates around the dentine layer
and secrete a non-matrix granular layer which after mineralization will form the acellular,
fibrous cement. The thickness of the acellular cement is reduced in the coronary third of the
root, but it grows towards the apex.
 Towards the end of the root forming the last cell population involved in
odondtogenesis, the cementoblasts, differentiates. They will grow numerous filiform
extensions which will extend especially in the apex area and will include themselves in their
own collagen matrix, the cell cement.

Desmodontium forming
It is formed in the same time as the cement.
The collagen fibers from the follicular sack will incorporate one of their ends in the
cement edge where they will be fixed by mineralization and the other end will fix in the
alveolar wall which is currently developing, forming the Scharpey fibers.
Img. 3.9. Overview over the dental bud development
 4. DENTAL ERUPTION

The dental eruption is the last stage of the odontogenesis, a complex physiological
process, strongly linked to the general development of the body; it is influenced by genetic,
metabolic and local-regional factors.

The eruption is a complex process which involves the teeth as well as surrounding
tissues.

The dentition is the corresponding dynamic process of the tooth forming process and
of their eruption process. This complex process determines through incompletely discovered
mechanisms the movement of the teeth from their intraosseous position in their functional
position on the arch. The dentition is part of the cranio-facial growth process of the child.

Dental eruption stages

The eruption begins when the tooth crown is mineralized.

Stages:

- preeruptive stage: crown forming

- pre-functional eruptive stage:

o Intraosseous stage (root development) – coincides with the root

development; the eruption track is axial, along the gubernacular canal.
M2 and M3 make exception of this rule; their gubernacular canal is not
directly linked to the gum, it is linked to the M1 gubernacule. For this
reason, M2 will grow towards M1, its distal face guiding its crown
towards the gum and eventually correcting its eruption axis.
o Mucosa eruption stage – it is done when the root forming reached a half
or two thirds of its final length. The peri-coronary epithelium fusions
with the gingival epithelium close to it, moment in which a dehiscense
is produced and the tip of the crown appears in the oral cavity.
o Preocclusal eruption stage – lasts a few months until the tooth reaches
the occlusal plane and comes into contact with the antagonist.

- post-occlusal functional stage – axial movement and alveolar growth continue after
teeth placement in functional occlusion, but at a slower rate. A mesial migration also
takes place which accompanies the inter-proximal attrition of the teeth. The post-
occlusal stage ends with the disappearance of the tooth from the arch.

The root continues to grow after the eruption and in parallel the periodontal
elements form from the follicular sack.
 If in its eruption, the tooth does not meet its antagonist, either because its eruption is
late or it was extracted, it continues its evolution overcoming the occlusion plane. This
evolution can be produced through 2 mechanisms:

- dental eggresion – the tooth is accompanied by a parallel growth of the alveolar

process while keeping the relationship between the clinic and anatomic crown. The
phenomenon is observed especially in young patients.

- dental extrusion – the tooth moves accompanied by the bone depositing at the alveole
base, phenomenon which determines the growth of the clinical crown size.

The eruption mechanism is not completely discovered, several theories being

discussed:

- the root forming – would determine the movement of the crown towards to surface of
the alveolar ridge.

- pulp elongation – consecutive to the growth of its basal extremity, level at which the
proliferative pulp area is separated by peri-apical tissue through the diaphragmatic epithelium
of the Hertwig’s sheath.

- Sicher’s hammock ligament – a fibrous formation at the base part of the follicular
sack which would have the role of absorb the pressures exerted by the pulp volume growth,
transforming them in pressure forces of the tooth towards the surface.

- sanguine pressure from the periodontal and radicular pulp area vessels

- bone apposition from the apical area

- epithelial remains from gubernaculum dentis – this formation, which links the bud to
the dental lamina, is considered to be a guiding trail of the dental movement based on the
minimum resistance principle, towards the gingival tissue.

- ‘Iter dentis’ – the trail covered by the tooth in its bone eruption.

The epithelial insertion results from the fusion of the reduced adamantine epithelium
and the gingival epithelium which covers the tooth. As the crown continues its ascension, the
insertion lowers, so when it reaches the occlusal plane, it is located at the level of the amelo-
cemental junction. Thus the gingival sulcus is formed.

Factors which influence dental eruption:

- the general factors influence the odont development, including the buds position as
well as the intraosseous stage of the eruption process. The buds position can be influenced by
the neighboring teeth and their state.

- masticatory factors influence the intra-oral stage of the eruption.

 - the final position of the teeth on the arch is dictated by the balance between the intra-
and extra-oral muscle groups (tongue, cheeks and lips musculature) – dental lane. An
unbalance between these muscle groups could determine teeth position abnormalities.

- in the functional or occlusal stage the influence of the muscles is done by

intercuspidation, thus the tooth also has a role in the development of the dento-maxillary
apparatus, the periodontal proprioceptors being a very sensitive self-regulating system.

- the eruption mechanism of the temporary and permanent complementary teeth

evolves without problems, but for the permanent replacement teeth a few particularities
intervene; these particularities are linked to a longer and more sinuous guberancule and on
another hand to the obstacle represented by the temporary teeth.

TEMPORARY TEETH RIZALISIS

It is a physiological process which begins approximately 2 years before the

replacement period with a certain chronology for each dental group.

Factors which influence the rizalisis:

- the permanent tooth in eruption, which by the exerted pressure determines a

transformation of the peri-coronary cells into cells with lytic capacity (osteoclasts,
cementoclasts) which produce the resorption of the neighboring tissues, including the
temporary teeth.

- temporary teeth pulp would contribute to auto-resorption, the odontoblasts being

dissociated by the fiber elements.

Clinical observations which support the interaction of the two factors:

- the long persistence on the arch of a temporary tooth in the case the successional
permanent tooth is not formed

- occurrence of rizalisis in a persistent temporary tooth but at a slower rate

- intervention of general factors in temporary teeth rizalisis in the case of permanent

teeth aplasia.

- prolonging of a temporary tooth’s presence on the arch by doing a pulpectomy even

until adult age

- accelerating the rizalisis after a pulp inflammation and especially peri-apica

inflammatory processes.
 Rizalisis mechanism:

- the process starts on the surface which comes into contact with the permanent tooth

- the root completely disappears

- the tooth stays in position with the support of circular periodontal fibers

- the resorption is not uniform and it depends on the relationship with the successional
tooth or radicular fragment can remain unresorpted.

ERUPTION PARTICULARITIES

The permanent incisors have a more oralized position than the temporary ones. The
eruption takes place on a trail towards forward and downward on the maxillary and towards
forward and upward on the mandible. So the temporary teeth root is resorbted from oral
towards vestibular. The permanent teeth will be situated on a larger arch than the temporary
ones, thus widening the arch perimeter.
If the rizalisis is not properly done, the incisors will erupt more orally than the
temporary ones. This situation is called double occlusion (Img. 4.1).
Img. 4.1. Double occlusion caused by the lingual occlusion of the central inferior incisors.
Because the premolars buds are situated between the roots of the temporary molars, their
rizalisis will start in the inter-radicular area. The vestibular roots resorb faster because of the
migration trend towards vestibular direction of the premolars. In the majority of the cases the
rizalisis in the temporary molars is done obliquely or even vertically in the root axis.
The rizalisis rate is not continuous, there are also slowing periods, when the tooth
seems to be refixed.
The reinclusion of a temporary tooth – after osteosclerosis or radicular-alveolar
anchylose (especially in the temporary M2).
The pathological rizalisis of the temporary teeth – when it starts faster than the usual
time, for instance the rizalisis of the lateral incisor can occur at the same time as the central-
temporal when the eruption of the central permanent incisor takes place or the canine together
with the lateral-temporal when the eruption of the lateral one takes place. These rizalises are
considered to be precocious signs of dento-maxillary disharmonies secondary to permanent
teeth macrodentition.
 The permanent teeth rizalisis is always pathological. The causes can be:
- changes of the mesenchyme produced by the eruption of other permanent teeth – the
rizalisis of the lateral incisor at the same time as the canine eruption.
- trauma
- peri-apical infections
- intraosseous tumors
- idiopathic rizalisis.

ORDER AND AGE OF ERUPTION

The eruption of one tooth takes place in a certain succession and at a certain age. It can be
influenced by the racial, regional, constitutional types and pathological factors.

Temporary teeth
Eruption of temporary teeth takes place between 6 and 30 months (2.5 years), erupting
one dental group every 6 months.
The order is:
- incisors: 6-12 months
- first molars: 12-18 months
- canines: 18-24 months
- secondary molars: 24-30 months
The sequence is: I, II, IV, III, V
The inferior teeth precede the superior ones, the exception being the lateral incisor.
Eruption can start earlier, 4-5 months, or later, 8 months, but at 30 months the process
is usually concluded. For the permanent complementary teeth, the time interval is 6 years, the
first molar at 6 years, the second molar at 12 years and the third molar at 18 years.
The eruption order is different in the maxillary than the mandible.
The most frequent eruption sequences are:
Maxillary: 6, 1, 2, 4, 5, 3, 7 or 6, 1, 2, 4, 3, 5, 7
Mandible: 6, 1, 2, 3, 4, 5, 7 or 6, 1, 2, 4, 3, 5, 7 or 1, 6, 2, 3, 4, 5, 7
The replacement of the temporary teeth is done in two stages:
Stage I: replacing the incisors 6-9 years
o Central inferior incisor 6-7 years
 o Central superior incisor 7-8 years
o Lateral inferior incisor 7-8 years
o Lateral superior incisor 8-9 years
Stage II: replacing the support are: 9-12 years
 III inferior, IV superior at 9 years
 IV inferior, V superior at 10-11 years
 V inferior, III superior at 11-12 years

The clinical importance of the replacement process

The size differences between the temporary and permanent teeth
- the permanent incisors: the sum of the mezio-distal diameters is 4mm greater on the
mandible and 5.5mm greater on the maxillary than the one of the temporary teeth
- occurrence of the physiological diastema and trema: expression of maxillary growth. This
way, the space for permanent teeth alignment is assured
- the inferior incisors keep their lingual position in eruption as well, then their position is
corrected at the same time with the maxillary growth through the pressure exerted by the
tongue.
- the dimensional relationships in the area of the temporary molars are inversed: the mezio-
distal diameters are greater than the ones of the premolars by 1.5mm on the maxillary and
2.5mm on the mandible (lee-way space)
- III, IV and V are the support areas (the support the vertical dimension until the eruption of
the first permanent molar)
- maintaining the integrity of the support zone until their physiological replacement – the
integer teeth maintain the lee-way space
- compromising the support area with caries -> eruption disorders, lack of eruption space for
the replacement teeth: superior canines and the two inferior premolars.
DENTATION AND DENTITION

Dentation is the dental formula observed in the moment of the examination.

It can be:
- temporary: 6 months – 6 years
- mixed: 6 years – 12 years
- permanent: after 12 years

Dentition is the progressive process of forming and eruption (dental age).

It can be:
- concordant with the chronological age
- early
- late

ACCIDENTS AND ERUPTION DISORDERS

The temporary teeth eruption can be accompanied by:

- hypersalivation
- local gingival congestion
- gingival pruritus (fingers in the mouth, unrest state)
- hematoma, gingival inflammations
In these cases rigorous oral hygiene and applying of sedative gel is recommended.
Eruption accidents and dental eruption complications in the temporary teeth can
aggravate other diseases the child might also have. Complications susceptibility depends on
the terrain, the infections and on the irritation of nerve endings.
Eruption accidents can be local, regional or general.

Local accidents
- congestive pericoronaritis – an intense redness appears at the level of the erupting
tooth as well as abundant salivation, indisposition state and refusal to eat.
- festered pericoronaritis – swollen aspect of the gum as well as pain, a sero-
purulent secretion, fever, restlessness and insomnia.
 - gingival-stomatitis – when a festering process localized at the level of a single
tooth extends towards the oral mucosa, having erythematous or ulcerous forms.
- expulsive folliculitis – the infection spreads and gets to the follicle, determining a
tooth infection.

Regional accidents
- secretory and vasomotor reactions by irritation of the trigeminal nerve
o Hemifacial erythema
o Nasal hydrorrhea
o Conjunctive hyperemia accompanied by tearing and photophobia
o Can associate with conjunctivitis, herpes, eczema.
General accidents
- nervous disorders
- restlessness
- seizures
- digestive disorders
- loss of apetite
- vomiting
- diarrhea
- weight loss
- respiratory disorders
- irritative cough
- dyspnea
In these situations a pediatrician consult is required to rule out general afflictions.
General treatment implies rigorous hygiene and diet associated with sedatives.
The local treatment is symptomatic: weak antiseptic solution washings, anesthetic
solutions applying (anesthizine – resorcine), avoiding trauma.

Permanent teeth eruption accidents

The eruption of the permanent teeth is usually without problem. Only the wisdom
teeth (especially the inferior ones) may cause:
- infectious accidents (congestive or suppurative pericoronaritis, accompanied by
trismus, stomatitis) (Img. 4.2)
 - mechanical complications (pressure exerted on the mesial teeth): pathological
rizalisis, caries, retrograde pulpitis in the M2, crowding of the frontal teeth, relapses of some
treated dento-maxillary abnormalities,

Tooth eruption disorders:

They can concern:
- eruption age
- eruption order
- eruption rate
- eruption position of the teeth

Img. 4.2. Eruption cyst of a permanent tooth

Eruption age disorders

Early eruption is the emergence of a tooth or a group of teeth long before the normal
eruption period (more than 6 months in temporary teeth, 1 year in permanent ones).
- in temporary dentition – the presence of the temporary teeth at birth (called neo-natal
teeth). Their roots disappear quickly. These teeth are either from the normal series or
supernumerary.
- pathological early eruption is called Cap de Point expulsive folliculitis (or baby
osteomyelitis).
- in permanent dentation the early eruption in the premolar region is linked to dental
caries complications in the temporary teeth, called Turner tooth (usually inferior PM2, with
shape, volume and structure changes).
In early dentition, general risk factors can be:
- environment factors (urban environment)
- gender
- STH hypersecretion
- hyperthyroidism
- hypercortisolism
Early calcifications and root forming are observed using radiology.
 Later eruption concerns an isolated tooth or a group of teeth, overcoming the time
periods considered average for the race, regional or socio-economical types. For example: an
8 year old child who was only temporary teeth or a 12 year old one who has not changd the
teeth from the support area.
Late eruption can be a symptom for certain general afflictions: hypothyroidism,
hypopituitarism, cleidocranial dysostosis, Down syndrome, metabolic diseases, vitamin
deficiencies, psychic disorders, pre-natal disorders (food deficiencies, rubella, mother older
age), temporary teeth rizalisis disorders.
Local factors which can determine late eruption:
- early extraction of temporary teeth
- posttraumatic osteosclerosis
- rizalisis disorders following pulp mortifications
- temporary teeth persistence (sometimes, the permanent teeth erupt
outside the arch, avoiding the obstacle)

Eruption order disorders

The causes can be local or general factors, like cleidocranial dysostosis or
hypothyroidism.
It is seldom met in temporary dentation.
In the permanent dentation it is observed in the first and second stage of teeth
replacement. For example: central incisors eruption asymmetry – eruption of the laterals
before the centrals, the eruption of the first premolars before the eruption of the lateral
incisors, etc.
The radiological examination will show either:
 the presence of an obstruction (supernumerary tooth which hinders the normal
evolution of permanent teeth)
 a cystic formation
 late rizalisis
 dental buds position changes consecutively to temporary dentition trauma
 dental buds agenesis, more frequently in the superior lateral incisor, inferior central
incisor, associated or not with the persistence of the temporary teeth.
 The post-extraction osteosclerosis or osteofibrosis can delay the eruption of PM2 with
the neighboring teeth migration and space closing, the ectopic eruption of the premolars or
their inclusion.

Eruption rate disorders

Normally, the chronological, bone and dental age coincide.
The dental eruption depends on general growth factors.
If there are gaps between the dental and the bone age, frontal crowding occur, because
of the rate gap.

Position disorders
- misplacements (ectopies, versions, gressions, rotations) – usually in the last
replacement teeth
- dental transpositions – two neighboring teeth switch their places on the arch
- heterotopies – the tooth is localized at a great distance from its normal eruption place
- retentions or inclusions – the presence in the maxillary of the completely or partially
formed permanent tooth, after a period of at least 2 years after it should have erupted on the
arch. (Img. 4.3)

Img. 4.3 The inclusion of 2.1 and the 6.1. persistence on the arch
 5. THE DEVELOPMENT OF THE NORMAL OCCLUSION
RELATIONSHIPS

Even since the prenatal period, the sagittal relations between the maxillary and the
mandible start being set up, relations which change during the various stages of the dento-
maxillary apparatus development.
In the second intrauterine month, there is a common oro-nasal cavity, the tongue
filling the whole space. The hard palate is not yet formed. In this period, the maxillary
overcomes the mandible on a sagittal direction – embryonic maxillary prognathism.
In the third intrauterine month the hard palate and the two cavities are formed, the
nasal and oral cavities, which separate progressively. In the palate formation process, the
tongue is pushed towards the oral cavity, thus lowering its position. The new exerted pressure
will stimulate the sagittal development of the mandible, so it will eventually overcome the
maxillary on a sagittal direction – embryonic mandibular prognathism.
Once the facial bones are developing, the growth rate of the maxillary is higher. This
phenomenon explains the physiological prognathism of the maxillary or the physiological
mandibular retrognathia at birth.
The physiological retrognathia is characterized by an antero-posterior gap between the
maxillary and mandibular alveolar ridges of about 5-6 mm. in the frontal area, the mandibular
alveolar ridge reaches the superior incisors plane (Img. 5.1.).
Img. 5.1 The antero-posterior relationship between the maxilla and the mandible. A.
Embryonic mandibular prognathism. B. Physiological maxillary prognathism at birth. C. The
head-to-head sagittal relationship of the temporary incisors at the moment of the eruption.
A.M. Schwarz defined the relationship between the mandible and the maxilla
according to the incisors plateau inclination:
- horizontal – the superior alveolar plateau has a plain surface which touches the edge of the
inferior alveolar ridge,
- inclined – the superior plateau includes the inferior alveolar edge like a ‘box cap’
(Schachtelbiss); this type of relationship can later evolve towards deep covered occlusion,
abnormality which is considered to be hereditary (Img. 5.2)
Img. 5.2 The relationship between the maxilla and the mandible according to the incisors
plateau inclination. A. Horizontal B. Inclined.
 In case the alveolar ridges relationship is head-to-head at birth, the later evolution can
be towards progenic occlusion.
In the lateral areas, the alveolar ridges are in contact on the whole stretch.
In the later development of the occlusion relationships, an important role is played by
the natural feeding of the child, because it stimulates the rhythmic propulsion of the mandible,
consecutively reducing the sagittal step between the maxilla and the mandible. This
phenomenon is called the first physiological mesialization of the mandible, at 5-6 months
after birth, the frontal alveolar ridges have a head-to-head relationship which will facilitate a
correct eruption of the temporary incisors.
The consecutive growth of the maxillaries depends on the general growth, on the
dental buds from the temporary and permanent series presence and on the dental eruption
process.
The eruption of the temporary teeth starts at the age of around 6 months. This age is
only indicatively because it can be subjected to changes, either towards an accelerated
eruption (more frequently nowadays) or towards a late eruption (genetic, hormonal, general
afflictions).
Temporary teeth eruption starts with the incisors: inferior central incisors, superior
central incisors, superior lateral incisors and inferior lateral incisors. At the age of 12 months,
the incisors group is present. The first occlusal relationships are the circumscription of the
inferior incisors done by the superior ones (Img. 5.3). The existent over-covering is large
because in the lateral area there is no dental support yet, the areas with no teeth coming into
contact.
Img. 5.3. The temporary incisors relationship after the end of their eruption
Between 12 and 18 months the first temporary molars erupt, first the inferior ones and
then the superior ones. They change occlusal relationships vertically between the maxillary
and the mandible through a physiological elevation of the occlusion – the first physiological
elevation of the mandible. In this context (of occlusion elevation) the incisor over-covering
degree will decrease (Img. 5.4).
Img. 5.4. Occlusal relationships after the eruption of temporary M1.
Between 18 and 24 months, the temporary canines erupt and between 24 and 30
months the temporary M2s erupt. These will finish the occlusal relationships of the temporary
teeth (Img. 5.5).
Img. 5.5. Occlusal relationships of the temporary teeth at the end of the temporary teeth
eruption.
CHARACTERISTICS OF THE ARCHES AND OCCLUSION IN 3-YEAR OLD
TEMPORARY DENTATION

 dental arches have half-circle shapes

 contiguity relationship of the teeth, with trema or crowding
 pronounced occlusal landscape
 straight occlusal plane
 the coronary and apical bases are equal in the mandible, the apical base is larger than
the coronary one in the maxilla
 the distal face of the maxillary M2 at the level of the tuberosity, the distal face the
mandibular M2 at the level of the ascendant branch of the mandible
 the maxillary arch circumscribes the mandibular arch
 reduced over-covering relationship or even head-to-head occlusion
 every temporary teeth has 2 antagonists, except for the central mandibular incisor and
the maxillary M2
 the superior and inferior inter-incisor lines are in the same plane
 neutral report in the canine – the inferior canine comes into contact with the maxillary
lateral incisor and with the maxillary canine
 the post-lacteal plane – the distal faces of the temporary M2s are in the same vertical
plane.

CHARACTERISTICS OF THE ARCHES AND OCCLUSION IN THE 4-6

YEAR OLD PERIOD DENTATION (FUNCTIONAL PERIOD)

This period is called the functional period because this is the maturity period of the
temporary dentation: the presence of all the temporary teeth on the arches, having inter-
proximal contact and stable occlusion relationships. In this period, certain changes will appear
which will prepare the transition to mixed dentation:
 Physiological abrasion – is determined by the hard food eaten, by the active
mastication, the free movements of the mandible in all directions. The abrasion
maintains the occlusal plan straight and determines a decrease in the frontal covering.
 The physiological trema and diastema – they are the expression of the maxillaries
growth under the influence of the general growth and under the influence of the
 stimuli exerted by the permanent teeth buds which are situated intraosseous, which
follow their eruption track, getting close to the oral cavity.
 The retro-molar field – appears distally from the temporary M2 through resorption and
bone apposition, because of the maxillary bones growth. Thus, the alveolar arches
elongate and a distal space is create for the eruption of the permanent M1.
 The second physiological mesialization of the mandible – it is possible because of the
physiological abrasion which disbands the occlusal landscape and allows the mandible
to slide towards anterior direction.
Consecutively, the post-lacteal plane becomes uneven mesially and makes the neutral
occlusion relationship forming possible at the level of permanent M1.

THE DEVELOPMENT OF THE OCCLUSION RELATIONSHIPS IN THE

MIXED DENTATION

The mixed dentation period is between the age of 6 and 12. In this time interval the
permanent replacement teeth erupt (incisors, canines, premolars) and the permanent
complementary ones (the 6 years molar, the 12 years molar).
Replacement of the temporary teeth takes place over two stages:
Stage 1 – 6 – 9 years – incisors replacement
Stage 2 – 9 – 12 years – the replacement of the teeth from the support area.
Aligning the permanent replacement teeth in the space delimited distally by the first
permanent molar depends on the maxillaries growth and very importantly, on the order and
age of teeth eruption.
The dento-alveolar ligaments become growth centers, each erupting tooth forming its
own socket (alveolus) and thus contributing to the alveolar ridge development.
On the eruption track, until reaching the occlusion plan, each tooth is guided mesio-
distally by the neighboring teeth and vestibule-orally by the lingo-labio-jugal musculature.
From the crowded intramaxillary position, the teeth will reach a harmonious alignment on the
arch.
THE IMPORTANCE OF THE 6 YEARS MOLAR

The mixed dentation usually starts with the first molars, the first inferior permanent
molar is the on which erupts first, followed by the first superior molar.
Determining the neutral occlusion relationships of the permanent M1 is very important
for the occlusion, meaning that the mesio-vestibular cusp of the first superior molar to be in
contact with the vestibular sulcus between the mesio and central-vestibular cusps of the first
inferior molar.
The occlusion relationship can be obtained in more ways:
 Achieving a neutral relationship in the moment of the eruption – possible when the
post-lacteal plane is uneven (mesially)
 By closing the primate tremas – if the post-lacteal plane remained straight until the
eruption of the first permanent molar; while erupting, this tooth can determine a
mesialization pressure on the temporary teeth on the arch with closing the primates’
tremas. The primates’ tremas are larger on the mandible, situated distally and for this
reason the inferior molar can mesialize itself more in order to achieve the neutral
occlusion relationship with its antagonist.
 By using the lee-way space – in case the post-lacteal plane remained straight and the
mesialization impulse was not sufficient, the first permanent molars will initially be
obliged to achieve a head-to-head occlusion relationship, totally unstable. This may be
corrected when the temporary molars will be replaced by the smaller premolars. The
mesio-distal size difference between the temporary molars and the premolars will
provide a space surplus, called lee-way space. The lee-way space is larger on the
mandible. Thus, a more increased mesialization of the inferior molars will be allowed,
with their sliding into the neutral and stable position.
The second physiological heightening of the occlusion takes place once with the
eruption of the 6 years molars.
THE INCISOR REPLACEMENT

The permanent incisors are larger than the temporary incisors and they cannot fit in the
space provided by the arches in the moment of their eruption. The surplus space which is
necessary appears through the primates’ tremas which can compensate the mesio-distal
diameter of the incisors group (with a limit of 4 mm) difference. If the tremas are missing and
the size difference is small, the discrepancy can be solved by the growth of the maxillaries
concomitant with the dental eruption and through the pressure of the lingual and labial
musculature.
The central incisors’ buds have a divergent eruption axis which is situated above and
behind the roots of the temporary incisors. To reach a correct position on the arch, they do a
rotation movement. If they erupt before the rotation, a space will form between them, called
transitory diastema; it will disappear with the eruption of the lateral incisors which will push
the central incisors and will force the position correction.
If the permanent central incisors eruption is done orally from the temporary incisors
without the elimination of the temporary incisors, the double occlusion will occur. This is
more frequent on the inferior arch and is spontaneously corrected after the extraction of the
temporary incisors.
The intraosseous position of the lateral incisors’ buds is more oral than the one of the
permanent central incisors. Because of the intra-maxillary crowding of the dental buds, this
position is kept during the eruption; it will be corrected by the muscular pressure of the
tongue and the lips. If the space on the arch is not sufficient, reversed gearing may appear at
this level.
The occlusion in the frontal zone settles with the eruption of the lateral incisors. If the
sagittal development of the two maxillaries was a harmonious one and the time interval
between the eruption of the inferior and superior incisors is short, the vertical occlusion size
determined by the 6 years molar will not be changed by the replacement of the incisors, which
will settle a correct occlusal relationship of 1/3 over-covering.
If the mandible grows insufficiently compared to the maxillary, the vertical occlusion
size lowers and a frontal over-covering will occur.
If the time interval between the eruption of the inferior and superior incisors is short,
they will meet at the level of the occlusion plan determined by the 6 years molar. If there is a
gap in the incisors eruption, the inferior incisors may egress until reaching the superior
alveolar arch, thus determining total over-covering or reversed gearing relationships. So, the
frontal covering degree also depends on the time interval between the eruption of the superior
and inferior incisors.

REPLACING THE SUPPORT AREA

The canine, the first and the second temporary molars are considered to be support
area because of their functional and prophylactic role. The functions of these areas are:
 Facilitating the mastication in the time interval of the frontal area replacement
 Maintaining the vertical occlusion size
 Maintaining the eruption space for the canine and the premolars, plus the space
reserve – lee-way space.
The mesio-distal sizes of the canine and premolars are smaller than the ones of the teeth in
the support area. The space surplus known as the lee-way space is about 1.5 mm on the
maxillary and 2.5 mm on the mandible. If the occlusion relationships of the first molar are
neutral, this space can be used by the crowded incisors. If the occlusal relationships of the
first molar are singular antagonist cusp-on-cusp, the lee-way space will be used by the 6 years
molar in order to slide in a mesial relationship towards a neutral relationship.
The eruption order in the support area is very important for the use of the lee-way
space. In the inferior arch the ideal order is 3, 4, 5 while in the superior one it is 4, 3, 5.

THE ERUPTION OF THE 2ND PERMANENT MOLAR

At the age of 12-13 the second permanent molar erupts; it is a complementary tooth,
which determines the physiological heightening of the occlusion may contribute to the
improvement of the frontal over-covering.

THE ERUPTION OF THE 3RD PERMANENT MOLAR

The third molar (the wisdom tooth) presents an eruption period which becomes more
and more varied. It erupts on the arch around the age of 18, the inferior limit being as low as
15 years old. Being the last complementary tooth and the bud being situated in an area which
is subjected to numerous bone reshuffles in the growth process, this tooth presents the most
frequent eruption accidents. Among these, there are the inclusion because of the insufficient
space with all the possible consequences, the eruption in an unfavorable position (ectopia), the
eruption accompanied by marked inflammatory phenomena – trismus and even general state
alteration.

THE CHARACTERISTICS OF THE ARCHES AND OF THE EUGNATIC

OCCLUSION IN THE PERMANENT DENTATION

The permanent dental arches have certain characteristics:

 The maxillary arch has elliptical shape, the tooth axes being inclined so as the apical
base is smaller than the coronary one by 15 degrees,
 The mandibular arch has a parabolic shape with the apical base being larger than the
coronary one by 5 degrees,
 The teeth on each arch determine the proximal contact,
 The occlusion plane is straight or slightly inclined in a sagittal and transversal
direction,
 The maxillary arch’s teeth are situated in a more vestibular direction than the ones of
the mandibular arch
 Each tooth has 2 antagonists, except for the central inferior incisors and the 3rd
superior molar,
 The homonymous antagonist tooth is the main antagonist and the second tooth with
which the contact is determined is the secondary antagonist.
 The lateral teeth determine a tight gearing, both sagittal and transversal.

NORMAL OCCLUSION RELATIONSHIPS

At the level of the incisors

 Sagittal direction – the sagittal physiological step if 0-2 mm – the incisors edge of the
mandibular incisors comes into contact with the palatal surface of the maxillary
incisors.
 Transversally – the inter-incisors mandibular line corresponds to the superior one.
 Vertically – 1/3 over-covering of the mandibular incisors by the maxillary ones.
 At the level of the canines
 Sagittal direction – neutral relationship – the inferior canine cusp is situated between
the lateral maxillary and maxillary canine cusp
 Transversally – the superior canine circumscribes the inferior canine
 Vertically – 1/3 over-covering of the mandibular canine by the maxillary one
At the level of the first molars
 Sagittal direction – neutral relationship – Angle’s key – the mezio-vestibular cusp of
the first superior molar is situated between the mseio-vestibular and center-vestibular
cusps of the first mandibular molars
 Transversally – the circumscription of the vestibular cusps of the first inferior molar
by the vestibular cusps of the first superior moars
 Vertically – cusp-fossa or cusp – intercuspid sulcus relationship.
In the next images (Img. 5.6, 5.7, 5.8, 5.9, 5.10, 5.11) the development of the occlusal
relationships is illustrated, from arches with no teeth of a baby until the permanent
complete dental arches of a young adult.
Img. 5.6. the mandible-maxillary relationship right before and during the eruption period
of the temporary teeth (Van der Linden, 1976)(3)

A, B. Lateral and frontal sight of the arches before the eruption of the temporary teeth;
C, D. Lateral and frontal sight of the arches during the eruption of the temporary incisors;
E, F. Lateral and frontal sight of the arches during the eruption of the first temporary
molars;
G, H. Lateral and frontal sight of the arches during the eruption of the temporary canines;
I, J. Lateral and frontal sight of the arches during the eruption of the second temporary
molars;
K, L. Lateral and frontal sight at the end of the eruption period of the temporary teeth –
the complete temporary arches – the start of the functional period;
Img. 5.7 The relationship between the permanent successional teeth buds with their
homonymous temporary teeth. To be observed: the palatal position of the permanent
lateral maxillary incisors’ buds; the superior position of the permanent canines (Van der
Linden, 1976).
Img. 5.8 The eruption period of the first permanent molar; the replacement period of the
incisors group (Van der Linden, 1976).
A, B. Lateral and frontal sight of the temporary arches after the eruption of the first molar
and before the replacement of the incisors group;
C, D. Lateral and frontal sight of the mixed arches in the replacement period of the
inferior central incisors;
E, F. Lateral and frontal sight of the mixed arches in the replacement period of the
superior central incisors – frontal transitory edentation of children;
G, H. Lateral and frontal sight of the mixed arches in the replacement period of the
maxillary incisors;
I, J. Lateral and frontal sight of the mixed arches in the replacement period of the lateral
maxillary incisors;
K, L. Lateral and frontal sight of the mixed arches in the replacement period of the
incisors group. To be observed: the correction of the lateral maxillary incisors axis.

Img. 5.9 The permanent replacement and complementary teeth buds relationship with
their temporary predecessors (Van der Linden, 1976).
Img. 5.10. The replacement period of the support area (Van der Linden, 1976).

A, B. Lateral and frontal sight of the mixed arches in the replacement period of the
mandibular canine and first maxillary premolar;
C, D. Lateral and frontal sight of the mixed arches after the eruption of the first maxillary
premolar and of the maxillary canines and first mandibular premolar;
E, F. Lateral and frontal sight of the mixed arches in the replacement period of the
maxillary canines;
G, H. Lateral and frontal sight of the mixed arches after the eruption of the maxillary
canines;
I, J. Lateral and frontal sight of the mixed arches after the eruption of the second maxillary
and mandibular premolars. The eruption of the second molar.

Img. 5.11 The aspect of the permanent dental arches (Van der Linden, 1976).
 6. DENTAL ANOMALIES

The dental anomalies are a rather frequent situation for children, which if it is not
treated will lead to sever dysfunctional occlusions. Given that most anomalies are developed
at the level of the premaxilla, the esthetical prejudice caused by these is extremely big,
especially in children which are at the age of puberty. The treatment is complex and it implies
the intervention of the pedodontal, ortodontal doctors, the surgeon and the genetics specialist,
who is responsible for the genetic counseling of the families with this pathology.

NUMBER ANOMALIES

They appear during the formation, initiation and proliferation period of the dental lamina as
an effect of a genetic defect which is either inherited or acquired.

Hypodontia

The hypodontia or oligodontia is the congenital absence of one or more teeth and can occur
on itself or as part of a syndrome.

The isolated hypodontia or non-syndromic is relatively frequent; it may appear spontaneously

or familial. In the majority of the cases, the absent teeth are the last in each series. So, on the
first place there is the wisdom tooth, followed by the lateral maxillary incisor and the second
mandibular premolar (Img. 6.1). on the other hand, the most resistant teeth to hypodontia are
the first in each series: the central incisors, the canine and the first molar.

The agenesis of the temporary teeth buds is associated with the agenesis of the
permanent teeth buds in 75-85% of the cases. The congenital absence of one or more wisdom
tooth is also associated with an increased trend of dental agenesis.

Img. 6.1. Clinical and radiological aspect of a 13 year old girl diagnosed with non-syndromic
hypodontia. The agenesis of 1.2, 1.4, 1.5, 1.8, 2.2, 2.5, 2.8, 3.2, 3.5, 3.8, 4.5, 4.8 is observed
(case from the Orthodontia-pedodontia Clinic from Cluj-Napoca).

There are over 120 syndromes of the head and neck which also present with congenital
absences of multiple teeth. The most important are: ectodermal dysplasia, oro-facial clefts,
Down Syndrome, Ellis van Creveld Syndrome or condroectorermal dysplasia, Reiger
Syndrome, incontinentia pigmenti and the type I and II oro-facial-digital Syndrome. For this
reason, it is important to analyze the other systems as well, especially those which derive from
the ectoderm, in order to diagnose as complex and correct as possible.

The absence of the third molar does not present any clinical sign, often being
diagnosed during other treatments.

The absence of the second premolar leads to the persistence on the arch of the second
temporary molar. In some cases, the rizalisis process continues, alternating with the radicular
repairing periods, which leads to bone anchylose of the second temporary molar. Clinically,
this is observed because of the position of the molar crown under the occlusion plane.

The absence of the superior lateral incisors presents clinically by the occurring of a
diastema at the level of the central incisors which, after the eruption of the canines, may
spontaneously close itself.

Anodontia. Ectodermal dysplasia

The anodontia is a dental anomaly, quite seldom met, which is characterized by the congenital
absence of temporary or permanent dentation. It is almost always associated with the sever
forms of ectodermal dysplasia.

The ectodermal dysplasia is a term used for a group of syndromes (117, described by
Freieere-Maria and Pinherio), which affect the structures deriving from the ectoderm: skin,
nails, hair and teeth. Because of the multiple forms of this affliction, it was decided that, in
order to diagnose with ectodermal dysplasia, at least 2 anomalies which regard the anteriorly
mentioned structures are necessary.

Clinical:

The most frequent form is X linked hypohidrotic ectodermal dysplasia which manifests by:

1. The forehead is curved

2. The ears are prominent
3. The inferior face floor is decreased because of the alveolar processes aplasia and the
vertical hypo-development of the maxillaries.
 4. The lips are prominent and the face sulci are increased; thus the patient has an elderly
aspect.

The hair is soft, scanty and blonde (hypertrichosis) and the nails are small and have the
shape of a teaspoon. Onicodysplasia occurs in 75% of the cases and can vary from
keratinization anomalies until the total absence of the nails.

At the endo-oral exam the congenital absence of a large number of teeth is noticed, which
does no respect the anteriorly mentioned frequency rule. The present teeth are small, conical
and are associated with the absence of permanent dental buds (Img. 6.2). There always is a
large anterior diastema and a hypoplastic superior labial frenulum. The alveolar processes are
aplastic because they develop only under dental eruption conditions.

Img. 6.2 the radiologic aspect of a patient with ectodermal dysplasia. The presence of two
conical superior incisors, of the temporary second molars and the 6-year molars on the right
side is noticed. The treatment started with re-doing the morphology of the two incisors by
composite and acrylic partial prosthetics restorations for the edentated areas (case from the
Orthodontia-pedodontia Clinic from Cluj-Napoca).

Genetical

The genetic transmitting is autosomal dominant, autosomal recessive and X linked. In the X
linked transmission, the heterozygote women present a less severe form than the men, because
the genetic defect is present only in 50% of the cells; the other cells have normal phenotype.
In men, the genetic anomaly is present in all cells (Lyon’s hypothesis) (A. Cameron 1997).

Treatment

The treatment follows the restoration of the dento-maxillary apparatus’ functions and starts
around the age of 2-3 years old by making partial acrylic prosthetics and restoration of the
conical teeth with composite, facets or crowns (Img. 6.3). as the child grows, the treatment
assumes a orthodontic interdisciplinary approach – surgical prosthetic for the space
management, uncovering and pulling of the included teeth, implants and prosthetic
restorations.

Img. 6.3. A. Incisor-like supernumerary tooth. B. Mesiodens tooth with tubercular

morphology.
Hyperdontia

Hyperdontia is the presence of a higher number of teeth than normal on the arch. They can
appear isolated or within a syndrome, like the cleidocranian dysostosis, Gardner syndrome or
oro-facial clefts. The genetic transmission is autosomal dominant or X linked, which makes
the men be twice as affected as women. 98% of the supernumerary teeth are found at the
level of the maxillary, out of those, 75% in the area of the anterior palate.

The supernumerary teeth appear following the complete division of a dental bud or following
the excessive organized burgeoning of the dental lamina.

Clinical

The supernumerary teeth are classified from a morphological point of view in supplementary
teeth and rudimentary teeth (Primoch, 1981).

Supplementary teeth have the same shape as normal teeth and for this reason the
differential diagnosis between the two types of teeth is very difficult. They appear more
frequently in the permanent dentation and develop in the incisors, premolars and rarely in the
molar areas (Img. 6.3 A).

Rudimentary teeth are the most frequent type of supernumerary teeth. They are
dysmorphic and easily diagnosed. There are 2 distinct shapes: conical and tubercular.

The conical shape is the most frequent and occurs on the median line between the two
central incisors, reason for which it is called mesiodens. The root is completely formed and it
erupts at the same time as the superior incisors, except for the times its eruption axis is
inversed.

The tubercular shape has a coronary morphology similar to the one of a ‘barrel’ and
the root is incompletely formed or even absent. They form in the anterior palate and in the
majority of cases it stays included, thus blocking the eruption of the superior incisors (Img.
6.3 B).

Treatment

The treatment follows the extraction of the supernumerary teeth as early as possible in order
to avoid eruption disorders which they may cause.
SIZE ANOMALIES

Macrodontia

Macrodontia refers to any tooth which is bigger than normal and it can be generalized or
localized.

Generalized macrodontia is very rare and occurs in the following pathologies: hypophyseal
gigantism, oto-dental syndrome and facial hemi-hypertrophy or Crouzon disease.

Localized macrodontia is more frequent and occurs after a disturbance in the mopho-
differentiation stage of odontogenesis.

Treatment

The treatment is tightly linked to the orthodontic treatment and implies: reducing the dental
mass by stripping or extraction and prosthetic use. In the case of a space deficit and the
mactodontia is asymmetrical the counter-lateral incisor is cosmeticized after the model of the
macrodontal incisor.

Microdontia

Microdontia refers to any tooth which is smaller than normal and also presents in two types:
generalized and localized.

Generalized microdontia is very rare and occurs in the following pathologies:

hypophyseal nanism, ectodermal dysplasia, condroectodermal dysplasia, Down Syndrome,
Crouzon disease and hemifacial microsomia.

Localized microdontia is more frequent and affects one or two teeth. It occurs,
especially, in the permanent dentation and it concerns the teeth that are usually congenitally
absent, the last in each series (Img. 6.4 B, Img 6.5). It also frequently affects the
supernumerary teeth.

Img. 6.5 Microdontia – localized at the level of 2.1, associated with multiple agenesis (1.8,
1.5, 2.8, 3.8, 3.7, 3.5, 4.4, 4.5, 4.8) confirmed using radiology.

Treatment

The treatment implies composite restoration, with facets or crowns of the afflicted teeth.
SHAPE ANOMALIES

Gemination

The gemination is a coronary-radicular dysmorphism which results after the incomplete

division of a dental bud. In some situations this phenomenon can lead even to total cleaving of
the dental bud, resulting in the occurrence of a supernumerary tooth on the arch.

Clinical

The geminated tooth presents a bifid crown and only one pulp room (Img. 6.6). In the frontal
area, it presents a sulcus on the vestibular surface, which ends at the level of the incisors edge
by a notch. In the lateral area, the occlusal surface morphology is changed, supplementary
cusps being easily observed. The number of teeth on the arch is normal, this being the only
clinical parameter in the differential diagnosis from the teeth merging.

Img. 6.6 The endo-oral aspect of the geminated incisor and of the supplementary
supernumerary tooth. On the laterals there are the development diagrams of the two dental
anomalies (case from the Orthodontia-pedodontia Clinic from Cluj-Napoca).

Treatment

The cosmeticizing of a geminated tooth is impossible in most cases because of the large
volume of the pulp room. For this reason, the extraction and prosthetic restoration through
implant or bridge is the only viable solution.

Merging

The merging is a coronary-radicular dysmorphism resulted by merging of two dental buds at

the level of the enamel, dentine or pulp.

The clinical aspect of the coronary morphology is identical with the one of the geminated
teeth. When the merging is between two normal dental buds, the number of teeth on the arch
is smaller by 1 (Img. 6.7). In most cases, the merging is with a supernumerary tooth and then
the number of teeth on the arch is normal. In these situations the differential diagnosis
between gemination and merging is very difficult and for this reason the two anomalies come
under the name of double tooth in the specialty literature.
Img. 6.7 A. Inferior central and lateral incisors merging. The number of mandibular incisors
is lower by 1. B. The radiologic aspect of the 2 merged incisors.

The merging of two temporary teeth is frequently associated with localized hypodontia in the
permanent dentation. So, the merging of the temporary canine with the temporary lateral
incisor is associated with the agenesis of the permanent lateral incisor in 50-75% of the cases
(Img. 6.8). In the case of merging between the permanent central and lateral incisors, the
agenesis of the permanent lateral incisor was noticed in only 20% of the cases (Hall, 1994).

Img. 6.8. A. Merging between the temporary lateral incisor and canine. B. They radiologic
aspect confirms the agenesis of the permanent lateral incisor.

Treatment

The treatment implies the separation of the two merged teeth and the creation of space with
the help of orthodontic tools for the coronary restoration.

Concrescence

The concrescence is a type of merging which appears after the end of the root development
and consists of the merging of two or more adjacent teeth through cement (Img. 6.9). It may
occur either before or after the teeth eruption and has the following causes: trauma, dental
misplacements or sever crowding. It is more frequent in the lateral area at the molars’ level or
between the supernumerary teeth and the permanent ones because of the radicular proximity.

Img. 6.9 Concrescence between the first and second mandibular molar (A. Pasler 1993).

Dens invaginatus

Dens invaginatus is a tooth which presents the calcified layers invaginated in the dental pulp.
This will form a new teeth inside the tooth itself, thus called ‘dens in dente’, pregnant
odontoma or dilated odontoma (Img. 6.10).

Img. 6.10 Dens invaginatus at the level of the right lateral maxillary incisor (Dunlap, 2004).

The dental pulp communicates in most cases with the oral cavity through a very
narrow constriction situated at the cingular level. In other cases, it is separated from the oral
cavity by a hypoplastic dentine and enamel layer which is easily decayed (afflicted by caries),
affecting the dental pulp.
Clinical

Dens invaginatus usually occurs bilaterally, the most affected tooth being the lateral maxillary
incisor. The vestibular face of the lateral incisor is normal, the anomaly can be detected only
in a thorough clinical examination of the palatal face in the sub-cingular area. The diagnosis is
set only after the radiological examinations.

Treatment

The treatment implies the sealing of the defect to prevent pulp complications. In case the
patient presents pulp pathology, then canal treatment is elected or the tooth is extracted in
case the canal treatment cannot be done.

Dens evaginatus

Dens evaginatus is a tooth which presents a tubercle made of enamel, dentine and pulp tissue,
localized at the level of the occlusal surface (Img. 6.11).

Img. 6.11 Longitudinal section through a molar with dens evaginatus. Dental pulp presence is
observed at the level of the extra cusp (R. M. Browne 1995).

A few years after the dental eruption, dens evaginatus is easily fractured or abrased
because of the occlusal interferences which exhibit the pulp to the septic environment from
the oral cavity, which will infect it.

Treatment

The treatment is prophylactic or symptomatic depending on the moment the patient presents
himself at the doctor. Thus, the tooth which has not yet reached the level of the occlusal plane
the enamel tubercle is reduced with the dental drill, which beforehand has its edges reinforced
with composite. If it is already fractured or abrased and the pulp is exhibited, then the
endodontic treatment is started for the said tooth.

Spur cusp

The spur cusp is a type of dens evaginatus which occurs on the oral surface of the temporary
and permanent incisors (Img. 6.12). the cups extends at least until the half of the distance
between the amelocemental junction and the incisor edge of the tooth. From a structural point
of view, it is made of enamel, dentine and pulp tissue, which does not appear constantly. In
75% of the cases, the spur cusp occurs at the level of the permanent maxillary incisors, more
frequently in the lateral incisor than the central one (Img. 6.12). in the temporary dentation,
the anomaly has a predilection for the central maxillary incisor.

The spur cusp is frequently associated with other dental anomalies: dens evaginatus,
microdontia, gemination, merging or complex odontoma. At the beginning of the eruption, the
cusp may appear like a supernumerary tooth and thus leading to a serious diagnosis and
treatment error. Once erupted, it decays very easily and favors food retention. It interferes
with the occlusion and leads the vestibular-version of the incisors.

Img. 6.12 The spur cusp is present at the level of the left lateral maxillary incisor (case from
the Orthodontia-pedodontia Clinic from Cluj-Napoca).

Treatment

The treatment is not necessary as long as it does not interfere with the occlusion. In case there
are occlusal interferences these are eliminated by grinding the spur cusp.

Taurodontia

Taurodontia is the term used for a molar with enlarged pulp room. The distance between the
amelo-cementary junction and the radicular furcation is larger than the roots’ length, which
makes the tooth have long anatomical crown and short roots (Img. 6.13).

Img. 6.13. Clinical and radiological aspect of a taurodont tooth (Dunlap, 2004)

From a clinical point of view, the taurodont tooth is identical with the normal one. The
anomaly is discovered by chance, in the course of other treatments. The diagnosis is set using
paraclinical examinations which highlight the enlarged pulp, with rectangular aspect and short
roots.

Taurodontia may occurs isolated or within syndromes: tricho dento osseous syndrome,
otodental syndrome, ectodermal dysplasia, amelogenesis imperfect, dentinogenesis imperfect,
Klinefelter Syndrome, Down Syndrome or orofaciodigital syndrome.
Odontoma

The odontoma is a development anomaly (hamartoma) of the dental tissues, not a neoplasm,
because once it is calcified it does not grow further. It occurs during the odontogenesis and
may vary from one supernumerary tooth to an odontogenic tumor.

The odontoma is made of enamel, dentine, pulp and cement, among which there are normal
anatomical relationships, despite the increased coronary-radicular dysmorphism. It has an
eruption tendency like any other tooth, even if in the most cases it stays included. If the
odontoma erupts, it decays very fast and the infection spreads in the subjacent structures
forming abscesses. In other cases, the odontoma moves the neighboring teeth, blocks their
eruption or degenerates.

The odontoma is classified in two types: compound odontoma and complex odontoma.

The compound odontoma is formed of more denticles comprised by a fibre-conjunctive

capsule. These are structures similar to teeth, which appear by multiple and localized
burgeoning of the dental lamina, which can form hundreds of dental buds (Img. 6.14 A).

Img. 6.14. A. Mandibular compound odontoma with a characteristic radiological aspect of

‘marble bag’ (Charles Dunlap, 2001). B, C. Clinical and radiological aspect of a complex
odontoma which erupted in the oral cavity (Manoj Vengal, March, 2007).

Clinical

The compound odontoma usually occurs in the anterior part of the maxillaries where an
unpainful deformation is observed. Radiological, a radiotransparency is observed, which is
clearly delimitated from the alveolar bone, which contains many radio-opaque structures
which are separated one from the other.

The complex odontoma is an irregular mass of dental tissues surrounded by a fibrous

tissue. Histological, the dental tissues have a disorganized arrangement, even if frequently
these can be radially arranged when the odontoma has a cauliflower-like morphology (Img.
6.14 B, C).

The complex odontoma occurs more frequently in the posterior part of the maxillaries as an
unpainful deformation. It may erupt and infects very quickly or it can remain included and
degenerate. Radiological, a radio-opaque mass is observed, surrounded by a radio-transparent
halo, which can block or move the eruption trajectory of the neighboring teeth.

Dilaceration

Dilaceration is a deviation of the root from the dental axis which occurs during the eruption
and radicular development. The anomaly usually results after a traumatic episode in the first
years of life or after radicular disorders. The most traumatized tooth is the temporary central
maxillary incisor. The intrusion or sever dislocation of it leads to the dilaceration of the
permanent incisor.

The permanent incisor bud develops in a palatal direction from the temporary incisor’s
root. Any trauma in this period can lead to enamel hypoplasia in the traumatized area or to
dilaceration of the permanent incisor’s crown (Img. 6.15).

Img. 6.15. Trauma around the age of 2-3 (R. J. Andlaw, 1996).

After 4-5 years, when the amelogenesis is finished, the permanent incisor’s crown is in
a vestibular position from the temporary incisor’s root. Consequently, the trauma from this
period cannot cause enamel hypoplasia, only dilacerations of the root in the coronary half
(Img. 6.16).

Img. 6.16. Trauma around the age of 4-5 (R. J. Andlaw, 1996).

If the root presents an angulation in the apical half, it means that the trauma is directly
upon the permanent incisor, having happened around the age of 8-10 (Img. 6.17).

Img. 6.17. Trauma around the age of 8-10 (R. J. Andlaw, 1996)

The non-traumatic dilaceration has a characteristic morphological aspect. The root

presents a slight angulation at the level of the amelo-cementary junction and the enamel is
normal (Img. 6.18).

Img. 6.18. Non-traumatic radicular development anomaly (R. J. Andlaw, 1996).

SHAPE ANOMALIES

Structure anomalies of the enamel

The anomalies that regard the enamel structure can be divided into two categories: acquired or
inherited.

Acquired enamel anomalies

These anomalies occur during life as a result of the interaction between the exogenous factors
and the ontogenesis process. Depending on the nature of the etiological agent the can occur
either localized or generalized as hypo-mineralization defects (opacities) or hypoplastic
defects.

Localized hypoplasia and hypo-mineralization of the enamel with infectious or

traumatic etiology is known as Turner hypoplasia (Img. 6.19 A). The most affected teeth are
the permanent maxillary incisor, because of the frequent trauma of the little child, and the
second mandibular premolar because of the periapical infections of the temporary molars or
the trauma associated to their extraction.

Generalized hypoplasia and hypo-mineralization can occur as a result of nutritional

deficiencies (lack of vitamin A, C, D or a low intake of Calcium or Phosphorusus), severe
infections in the first years of the childhood (congenital syphilis, rubella, measles, varicella),
premature birth, neurological defects or fluorosis.

Congenital syphilis has 3 clinical signs which are essential for the diagnosis: syphilitic
keratitis, syphilitic labyrinthitis and Hutchinson teeth. Treponema pallidum afflicts the
incisors and molars, which present a characteristic dysmorphism which is observed only in
this pathology. Thus, the incisors are small, conical, with the incisor edge being cared in a
semilunar shape (Img. 6.19 B) and the molars have a characteristic occlusal aspect, which is
similar to a blackberry.

Excessive fluoride ingestion causes generalized opacities of the enamel in lighter

forms or hypoplastic defects in sever forms (Img. 6.19 C). Fluorosis occurs after ingesting an
excessive amount of fluoride only between the age of 6 months – 5 years and has different
clinical manifestations depending on the quantity of fluoride and the duration of the treatment
(Table 6.1).
Img. 6.19 A. Post-traumatic Turner hypoplasia at the level of the right central incisor. B.
Hutchinson teeth in a child with congenital syphilis (Dunlap, 2004). C. Sever fluorosis
(Wikipedia).

Table 6.1. DENTAL FLUOROSIS. CLASSIFICATION by H.T. Dean 1942 (American

Dental Association, 2005).
Classification Clinical characteristics of the enamel
Normal Smooth, translucent enamel – white color
Intermediate Several white opaque spots
Very mild Opaque white spots which cover less than 25% of the tooth surface
Mild Opaque areas which cover less than 25% of the tooth surface
Medium All the tooth surfaces are afflicted; brown pigmentations of the opacities may
occur; marked abrasion at the level of the contact surfaces of antagonist teeth
Severe All the tooth surfaces are afflicted; brown pigmentations of the opacities;
dimples

Inherited enamel anomalies

Amelogenesis imperfecta (A. I.)

Amelogenesis imperfecta represents a large group of structural anomalies of the enamel

transmitted autosomal dominant, autosomal recessive or X linked. In the most cases, the
anomaly afflicts both the temporary dentation and the permanent one, having a prevalence of
1:14000 children in America and 1:800 children in Sweden (A. Cameron, 1997).

From a clinical point of view, there are 2 types of amelogenesis imperfect: hypoplastic
and hypo-mineralized.

1. Amelogenesis imperfecta – hypoplastic form

The hypoplastic form is observed in around 60-70% of the cases, women being afflicted more
often than men. The enamel is thin, normal hardness and with different aspects: smooth,
rough or with dimples. Because of the reduced quantity of enamel, there are tremas and
diastemas observed clinically (Img. 6.20). Many teeth remain included, erupt late or resorb.
More than half the cases present anterior open occlusion.

Img. 6.20. A. I. – smooth hypoplastic form with autosomal dominant transmission

Amelogenesis imperfecta – hypo-mineralized form

From the quantity point of view the enamel is normal, but quality-wise the organic
matrix is insufficiently mineralized. In these conditions, the enamel is soft and can be
penetrated with the periodontal probe when palpating. Initially the enamel has a normal
thickness, but after the eruption of the teeth it easily becomes abrased, it fractures or can even
detach in pieces revealing the dentine, which is very sensitive to the stimuli from the oral
cavity. The color of the enamel varies from chalky-white to dark yellow and even brown,
depending on the hypo-mineralization degree. The more sever the hypo-mineralization is, the
darker the color of the enamel. Beside the anteriorly described signs, some patients may
present massive tartar deposits in the supra-gingival area. In a paraclinical examination the
enamel has the same radio-opacity as the dentine, so the radiography cannot differentiate the
two dental tissues (Img. 6.21).

Img. 6.21. A. I. – hypocalcified form – clinical and radiological aspect (case from the
Orthodontia-pedodontia Clinic from Cluj-Napoca).

Structure anomalies of the dentine

Dentinogenesis imperfecta (D. I.)

Dentinogenesis imperfect is a hereditary structural anomaly of the dentine which occurs in the
histo-differentiation period of the odontogenesis. The anomaly is based on a defect in the type
I collagen molecule synthesis, which is one of the primary components of the pre-dentine and
bone matrix. The genetic defect is transmitted autosomal dominant and results in forming
atubular, amorphous dentine with a high concentration of organic substances and with inter-
globular calcifications (Img. 6.22).

Img. 6.22. Histological atubular and amorphous aspect of the dentine in D. I.

The anomaly affects both dentations, especially the temporary teeth, incisors and first
permanent molars and presents 3 types described by Shields.

Dentinogenesis Imperfecta Type I and II have the same clinical signs. Type I is always
associated with Osteogenesis Imperfecta and Type II occurs isolated. For this reason, patients
with this pathology must be investigated further for Osteogenesis Imperfecta, which is a
genetic anomaly of the conjunctive tissue characterized by bone fragility, multiple fractures
and blue sclera. Clinically, the teeth have a characteristic opalescent aspect, which can vary
from blue-violet to yellow-brown. Dyschromia is caused by the pathological changes in the
dentine which can be seen through the enamel. The crowns are small and bublous because of
the cervical constriction and the roots are short and thin with pulp rooms and radicular canals
partially or fully obliterated (Img. 6.23. C). After the eruption of the teeth the enamel is lost,
revealing a soft dentine which quickly becomes abrased to the gum (Img. 6.23. B).

Img. 6.23. A. Typical opalescent coloration of the teeth with dentinogenesis imperfect
(www.usc.edu, 2006) B. Sever abrasion of the temporary dentation in a patient with D. I. –
type II. C. The radiological examination reveals the total obliteration of the dental pulp. The
roots are short and thin and the crowns are bublous (www.marquette.edu/dentistry).

Dentinogenesis Imperfecta – type III is a rare form, described in an isolated group of people
from Maryland known under the name of ‘Brandywine people’. The clinical aspect is similar
to the one from D. I. types II and III, except for the circumpulpar dentine which is very thin,
fact that made these teeth to be called ‘shell teeth’ (Img. 6.24 A).

Dentinal dysplasia

Dentinal dysplasia represents another group of hereditary structural anomalies of the dentine –
transmitted autosomal dominant. Shield & co divided it into two types: radicular dentinal
dysplasia or type I and coronary dentinal dysplasia or type II.

Type I: Radicular dentinal dysplasia. Clinically, both dentations have a normal crown
(aspect and morphology). The diagnosis is set after the paraclinical examination, where the
short, conical or even absent roots are noticed, which makes the teeth from this pathology be
called ‘teeth with no root’. The pulp is totally obliterated in the temporary dentation and
partially in the permanent dentation. So, at the level of the permanent molars a coronary pulp
with semilunar shape reminiscence is observed on the radiography. The periapical radio-
transparencies present at teeth without carious or traumatic lesions are important signs in the
diagnosis of the anomaly (Img. 6.24 B). The prognostic is severe because of the radicular
morphology and the periapical resorbs which lead to exaggerated mobility and premature
exfoliation of the teeth.

Type II: Coronary dentinal dysplasia. The clinical and radiological aspect is different
in both dentations. The temporary teeth have the same clinical signs as the Dentinogenesis
imperfect – type I or II, except for the fact that the coronary morphology is normal. The
permanent teeth have a normal clinical aspect, but they present a flame-shape pulp room on
the radiography (Img. 6.24 C). Different from the coronary dentinal dysplasia, the root of the
teeth have a normal length and thickness and the periapical transparencies are absent.

Img. 6.24. A. Shell teeth from the dentinogenesis imperfect, type III. The reduced (almost
inexistent) thickness of the circumpulpar dentine is observed (Dunlap, 2004). B. Dentinal
dysplasia type I. The short roots with periapical transparencies and almost fully dental pulp
obliteration are observed. C. Dentinal dysplasia type II characterized by normal roots and
pulp room having flame shape. In the 4.4 a pulpolit is observed (Chussid, 2007).

Regional odontodysplasia

Regional odontodysplasia is an anomaly in which the tooth development is blocked due to a

regional vascular defect. The afflicted tooth present severe enamel and dentine hypoplasia, the
pulp room is large with diffuse calcifications and the roots are short and dysmorphic. The
dental eruption is late or even prevented because of the enamel organ anomaly and the
gingival hyperplasia. The first sign of the odontodysplasia is the presence of acute abscesses
in the dysplastic teeth before the eruption period. The teeth that erupt have an irregular dental
surface with dimples, fissures and sulci and the color is yellow-brown, depending on the
hypo-mineralization degree. Usually, the pulp communicates with the exterior through enamel
fissures, which explains the abscesses from the pre-eruptive period of the teeth.

Radiological, the teeth present a reduced radio-opacity because of the hypo-

mineralization of the hard dental tissues, reason for which they are called ‘ghost teeth’ as well
(Img. 6.25). The pulp room and the radicular canals are large, the roots are short with open
apexes and periapical transparencies are often noticed.

Img. 6.25. The radiologic aspect of the ‘ghost teeth’ form the right inferior quadrant in a 7
years old child (Dunlap, 2004).

Structure anomalies of the cement

The cement structure anomalies are very rare and the present only within some syndromes
(cleidocranial dysostosis, dystrophic epidermolysis bullosa) or metabolic diseases. They do
not occur isolated, they always associate with other dental tissues dystrophies.

Cleidocranial dysostosis is a hereditary disease, transmitted autosomal dominant,

characterized by the aplasia or hypoplasia of the clavicles, later ossification of the fontanels,
supernumerary teeth and late teeth eruption. On the extracted supernumerary teeth the total or
partial absence of the cement is observed and on the histopathological examination the
amorphic structure of the remaining cement is observed.

Dystrophic epidermolysis bullosa is also a hereditary disease characterized by the

presence of an extremely fragile tegument and mucosa. The cement which is formed is hypo-
mineralized. The acellular cement has a fibrous structure and the cellular cement is
hypoplastic.

Hypophosphatasia is a rare metabolic disease which implies a poor mineralization of

the bones because of the low serum level of alkaline phosphates. The main clinical signs are
osteoporosis, bone fragility and premature loss of the temporary teeth.

Premature exfoliation of the teeth occurs because the quantitative and qualitative failure in
forming the cement, which becomes unable to sustain the tooth in the alveole (Img. 6.26).

Img. 6.26. The orthopantomography of a 5 year old patient with hypophosphatasia in which
premature exfoliation of the temporary teeth is observed (XUAN Kun, Mar. 2007).

COLOR ANOMALIES

Extrinsic colorations

Dental dyschromia with extrinsic cause occur after an interaction of the enamel or the
exhibited dentine with chromogenic agents from the oral cavity. The teeth color is specific
depending on the chemical particularities of each etiologic agent:

 Greenish coloration, usually present in the cervical third of the teeth is caused by
chromogenic bacteria.
 Yellow coloration, with the same topography as the one above mentioned, is caused
by the bile pigments present in the crevicular fluid.
 Black coloration, which affects all dental surfaces, occurs after administering the
ferrous sulfate in the anemia treatment (Img. 6.27 A).
 Chalky-white coloration is characterized by the demineralized enamel.
 Gray-black coloration occurs in teeth with large silver amalgam obturations.
Intrinsic colorations

Because of the high concentration of organic substances, the dentine is capable of

incorporating any chromatic substance from the blood flow. After the mineralization process
the enamel has an almost negligible organic component. For this reason, the enamel
pigmentation an appear only in the calcification stage of the odontogenesis or in the hypo-
mineralization defects. The most frequent form of intrinsic pigmentation occurs in the hypo-
mineralized enamel areas and can vary from chalky-white to dark brown, depending on the
hypo-mineralization degree. The Turner teeth, dental fluorosis or amelogenesis imperfecta –
the hypo-mineralized form are only a few examples of pathologies with clearly or diffusely
delimitated opacities which absorb chromatic substances like a sponge.

A classic example of intrinsic dyschromia occurs after administering tetracycline to

children under the age of 7. Today, these case are rare because of the knowledge of secondary
effects of tetracycline and the development of a large range of antibiotics. Dyschromia may
vary from yellow-orange to gray-brown, depending on the type of administered tetracycline
and the duration of the treatment (Img. 6.27 B).

Congenital porphyria is a synthesis and excretion of porphyrins dysfunction; they

give the temporary teeth crown a red-brown color.

Hyperbilirubinemia may occur in a child for diverse causes: fetal erythroblastosis,

bile duct atresia, internal hemorrhaging or hemolysis following a sanguine group
incompatibility. The bilirubin accumulates at tegument level, mucosa and temporary or
permanent teeth, which get a gree-blue color. The clinical aspect is increased in the temporary
teeth where the bilirubin is inglobated in the dentine and enamel, differing from the
permanent teeth, where it is only in the dentine (Img. 6.27 C).

Img. 6.27. A. Extrinsic dyschromia caused by the iron excess in the saliva. B. Intrinsic
dyschromia in a patient treated with tetracycline (A. Cameron, 1997). C. Intrinsic gray-green
dyschromia of the teeth in a patient with hyperbilirubinemia in the neo-natal period (Hall,
1994).
 7. ELABORATING THE TREATMENT PLAN IN CHILDREN
AND TEENAGERS

The treatment plan in the case of children or teenager patients must include all the
dento-maxillary apparatus elements and must harmonize all the treatment means with the
growth processes that are characteristic for this stage. To achieve these goals, the patient’s
examination must be done respecting a specific algorithm.

THE TREATMENT PLAN respects the following succession:

 Emergency treatment – removal of the pain complaints, the instituting of a specific

treatment for the donot-periodontal afflictions which were diagnosed;
 Preventive treatment – using prevention means for dental caries motivates the patient,
improves the collaboration and ensures an adequate stability of conservative
treatments applied in time;
 Restoration treatment – according to the patient’s age, the necessity of the orthodontic
treatment, skeletal and facial typology, growth;
 Surgical treatment – extraction of the irretrievable teeth, facilitation of the
successional teeth eruption;
 Orthodontic treatment;
 Individualized recommendations for the prophylaxis of the dental caries, periodontal
afflictions, muscular and TMJ dysfunctions, etc;
 Periodic examination. (1,3)

ORAL HEALTH represents a component of the general health state. In order to ensure an
adequate oro-dental health state, the following are imposed:

 First check in the dentist’s office is recommended to be done after the eruption of the
first temporary teeth, between 6-12 months;
 Phrasing individual recommendations in order to prevent the dental caries and dento-
periodontal trauma;
 Ensuring an efficient collaboration between the pediatrician – dentist – family;
  Setting the periodic examinations. (4)

THE FIRST CONSULT follows the examination of the following elements:

 Family history – evaluating the importance of the oro-dental health for the family;
 Personal history – general affliction, associated medication;
 Psycho-somatic development – fitting in the standard criteria specific for that age.
Evaluating the individual cognitive capacity allows the dentist to set up a direct
communication relationship with the child or teenager patient, which will have a
positive long-term effect which concerns the individual involvement in keeping an
adequate health state;
 Evaluating the caries risk – this index has a dynamic character and can change under
the influence of general and individual factors. Appreciating the individual caries risk
is recommended in the periodic examinations;
 Development of the dento-maxillary apparatus, dentation, dentition. (3,4)

6-12 MONTHS. The specific elements that are recommended to be analyzed in this period
are represented by:

 Appreciating the correlation between dental and chronological age;

 Oro-dental hygiene – this has to be done by the mother, once the first tooth erupts;
 Adequate food – avoiding drinking of sweet drinks using the child’s bottle, sweets
eating, etc.
 Individualized prophylaxis of the dental caries by administering fluoride. Setting the
dose will be done together with the pediatrician according to the individual exogenous
fluoride intake, the general health state of the child, family history;
 Dental trauma prophylaxis by preventing the playing accidents or those associated
with walking learning process;
 Controlling the vicious habits – finger sucking, inferior lip para-functions, etc;
 The treatment of the accidents caused by the temporary teeth eruption;
 Periodic examination setting. (2,4)
12-24 MONTHS. The specific elements which are recommended to be analyzed in this
period are represented by the following:

 Caries prophylactic food – adequate diversification of food to allow an active

mastication;
 Oro-dental hygiene – done by the parents;
 The specific prophylaxis of the dental caries;
 Odontal afflictions treatment (incipient lesions in the temporary incisors, etc.);
 Periodic examinations. (3, 4)

2-6 YEARS. The specific elements which are recommended to be analyzed in this period
are represented by the following:

 Specific dental caries prophylaxis – sealing of the temporary molars, topic

fluoridation;
 Odontal afflictions treatment – morpho-functional restoration of the teeth crowns in
order to ensure the normal functionality of the dento-maxillary apparatus and space
maintaining;
 Dental trauma treatment – conserving the afflicted teeth, space maintaining and
prevention of dental migration;
 Orthodontic evaluation in order to diagnose the skeletical gaps, muscular
dysfunctions;
 Periodic examinations;
 Eruption of the 6 year old molar – respecting the eruption age, specific prophylaxis of
the dental caries (sealing, fluoridation) (4,5).

6-12 YEARS. The specific elements which are recommended to be analyzed in this period
are represented by the following:

 Oral hygiene – motivating the patient, adequate teeth-brushing technique. It is

recommended that the parents supervise the oral hygiene program at least until the age
of 8;
 Dental cavity prophylaxis for the young permanent teeth;
 The 6 year old molar – specific dental cavity prophylaxis;
 Odotnal lesions treatment respecting the tissue economic criteria and using the bio-
compatible dental materials;
  Support area – the treatment of the odontal lesions and maintain the space according to
the eruption order;
 Incisors area – preventing dental trauma, teeth alignment in the frontal area and
ensuring correct occlusal relationships;
 Radiological evaluation – the presence of the permanent replacement and
complementary teeth buds, eruption order;
 Periodic examinations (3,4).

12-18 YEARS. The specific elements which are recommended to be analyzed in this period
are represented by the following:

 Periodic examinations – frequent motivation in order to respect the oro-dental hygiene

and the caries prophylactic food;
 The specific prophylaxis of the cavities – premolars, the 12 year old molar;
 Evaluating the wisdom tooth – preventing of the orthodontic treatment and residual
dental crowding regression;
 Food – food unbalances that are characteristic for this age, sweets excess and
carbonated drinks, chaotic feeding schedule;
 Behavioral disorders – neglecting one’s self, peer pressure which is opposite with the
family recommendations;
 Orthodontic treatments – the patient wants to correct the dento-maxillary anomalies,
especially from esthetical points of view;
 Pre-prosthetic orthodontic treatments in order to correct the negative effects of dental
migration consecutively to the dental extractions and in order to facilitate the complex
rehabilitation at the adult age (2,4).

TREATMENT STAGES which are characteristic for the pediatric dental medicine are as
follows (this succession):

 Emergency treatment – the pain control allows setting a climate in which the
collaboration with the patient is adequate;
 Making provisional restorations to allow reducing the level of microbe contamination
at the oral cavity level. Moreover, the collaboration with the patient improves and the
individual and family involvement in respecting the oral hygiene recommendations
will be appreciated;
 Caries risk evaluation – dynamic index evaluated on each periodic examination;
 Preventive treatment – food, oro-dental hygiene, specific prophylaxis of the caries;
 Surgical treatment – irretrievable teeth extraction by conservative means, orthodontic
purpose extraction;
 Orthodontic treatment – done after the sanitation of the oral cavity;
 Definitive restoration treatment using dental materials and methods according to the
patient’s age and the physiological development stage of the tooth (2,3,4).
 8. THE DENTAL CAVITY IN CHILDREN AND YOUNG

The dental cavity is one of the most frequent conditions of the modern people, being
able to appear at all ages, in children with temporary dentition, in teenagers but even in adults.
The dental cavity is a disease of bacterial etiology, Streptococcus mutans and
Lactobacilii being the bacteria that have a leading role in destroying of the hard dental tissues.
The dental cavity is the main cause of loss of teeth and if it isn’t treated in the early
stages, in short time the pulpal complications will lead to the extraction of the tooth, if this
was not diagnosed early and treated accordingly.
In this chapter we will talk about some aspects about the dental cavity, in children as
well as in the young adult. For knowing the mode of evolution of this condition in children
and adolescent, the particularities of the temporary and permanent teeth, the etiology of this
condition and the clinical forms but as well as the treatment of the simple and complicated
cavity will be described in more detail.

THE DENTAL CAVITY

The dental cavity represents a pathologic localized process, multifactorial, that appears
after the dental eruption. It is a destructive process that affects all the hard dental structures,
that can be localized on all the dental surfaces and affecting the temporary teeth as well as the
permanent ones. Many authors tried different classifications of the dental cavity meant to ease
the dialogue between doctors, all of these being detailed lower to help the differentiation of
the cavity types and choosing the plan of treatment.

THE ETIOLOGY OF THE DENTAL CAVITY

The dental cavity is characterized by the demineralization and destruction of the hard
dental tissues, with the ulterior appearance of the cavity defect. Taking in consideration of the
multifactorial etiology is essential for the efficient stopping of this condition. The dental
cavity appears as following of a prolonged imbalance between the factors that favors the
enamel demineralization (bacterial plaque and hydrocarbons) and the factors that intervene in
the remineralization of this (hygiene, fluorine, natural protective factors).
Individual risk factors associated with the forming of the dental cavity are:
- oral breathing
- dental malpositions
- poor dental hygiene
- orthodontic prosthetics owners must accord a special attention to the means of maintaining
hygiene because the orthodontic prosthetics limit the dental hygiene maneuvers.
- low levels of fluorine reduces the remineralization process and so the risk for forming of the
dental cavity rises.
- some medications like anti-histaminics, antidepressants, corticoids.
- in patients that have paraplegia, arthritis or other diseases that cause coordination problems.
- low socio-economic status reduces interest for oral hygiene and a corresponding diet.
Besides the factors that were listed, three primary etiology factors stand out:
a) environment (quality of the enamel and saliva)
b) cariogenic bacterial flora
c) fermentable food substrate
a) Enamel resistance is conditioned by its structure, this being determined by the
influences that were exercised on the teeth in the development period, but on the exogenous
and endogenous influences after the dental eruption too.
The metabolic disorders produced by irrational eating or chronic diseases can have
consequences on the dental germ in the fetus (in the case of the pregnant) or on the
mineralization and development of permanent teeth (in the case of the child). The
consequence will be a poor structuring of the dental tissues, an arrangement of hydroxyapatite
crystals with a modified architecture compared to the normal (dysplasia) or the decreasing
content of mineral salts along with the increasing of organic tissue (hypoplasia).
Dysplasia and hypoplasia are part of the dental dystrophies that are able to favor the
forming of the carious process or to increase its evolution by accumulation of oral acidogenic
microorganisms and fermentable hydrocarbons in the structural defects of the enamel.
The severity of the dystrophies depends on:

- the moment of debut of the metabolic disorders (the earlier, the greater severity).
- intensity of harmful factors
- metabolic dysfunctions duration
- the accumulation of different metabolic dysfunctional factors along the different stages of
development of dental tissues.
 The structural particularities of the temporary teeth, (more sensible and less resistant)
determine the forming of a particular type of cavity ‘baby bottle decay’.
Besides the structural resistance of the enamel, a specific role in the prevention of the
cavity belongs to the salivary secretion. The salivary secretion flow, varies from one person to
another, influences the time in which food and bacterial produced acids are in contact with the
dental surfaces.
Saliva, through the minerals that it contains and that inhibit the spontaneous
precipitation of calcium phosphate, has an important role in re-mineralization. More, it
contains a series of substances that act as buffer solutions with a role in neutralizing the
bacteria produced acidity, reducing thus the level of acidity in the oral cavity, especially on
the dental surfaces.
Saliva contains organic and inorganic substances. A part of the organic constituents,
come from food, others are produced through a series of metabolic processes, at the level of
the oral microbial flora. Thus, some organic constituents are transitory, others stay in the
saliva enough to influence the microbial flora. Saliva contributes in the antibacterial
unspecific defense (provided by lactoferrin, lysozyme, peroxidase and glycoproteins), and
specific (through the significant content of proteins). Thus, in the absence of saliva, the
mucosa of the oral cavity ulcerates and infects and at teeth level the susceptibility for dental
cavity rises. The dental surfaces covered by saliva are protected from an immunologic point
of view, by the only class of immunoglobulins that is actively secreted in the oral cavity, the
secretory Ig A.
Certain fermentable hydrocarbons go through saliva and become accessible to
pathogenic microorganisms from the oral cavity. This microorganisms will metabolize them,
thus resulting acids that determine an immediate decrease of the pH at the level of dental
surfaces with 2-4 units. The decrease of pH depends on the thickness of the bacterial plaque,
the type and number of microorganisms and on the efficiency of the salivary buffer solutions.
The leveling of pH to normal values depends on the type of food and the individual
predisposition to dental cavities. An increased salivary flow can get the pH fast to neutrality,
while local sticky food retention can delay the raising of the pH to its dissolving and removal.

b) In the oral cavity there are normally different types of bacteria, but some of those
can colonize the dental surfaces forming the dental plaque. The more frequent are
Streptococcus Mutans and the Lactobacilli.
 Dental plaque is responsible for the fermentation of the hydrocarbons from food and
drinks, with forming of acids on dental surfaces. The saliva buffering efficiency of those acids
is inversely proportional with the thickness of the plaque. Consistent dental plaque is kept in
deep cracks, interproximal spaces, especially in the interdental contact areas and on the rough
surfaces of the fillings. The dental hygiene mechanical methods are not always efficient
enough in the removal of the plaque of this area, so that these areas will represent areas for the
initiation of dental cavities.
c) The cariogenic potential of the food is conditioned by the quantity and quality of the
nutrients. The action of the food manifests pre/post resorbtive. The nutrients interact with the
local and general metabolic processes, influencing the development of hard dental tissues.
There is a demonstrated interrelation between metabolic processes from the organism and the
metabolism of dental tissues.
So the character of the food is important for the teeth, influencing their forming and
development and determining their receptivity and resistance to cavities.

Hard food stresses the dento-maxillary apparatus, stimulates the salivary secretion and
activates local circulation and metabolism, facilitating self-cleaning.
Soft and sticky foods determine the hypo-function of the dento-maxillary apparatus,
decreases the salivary flow and favors the growth of the microbial flora on their fermentable
substrate. The most dangerous are the sticky sugars, candy and pastry products because those
adhere for a long time on the dental surfaces.
The quantity of proteins found in the food influences the mineral part of the teeth and
maxilla: in case of a lower protein intake, the calcium concentration and forming of the
apatite is decreased.
Carbohydrate diet determines structural dysfunctions in the forming of hard dental
tissues. Carbohydrates are kept for a long time after ingestion in the oral cavity, adhere on the
dental surfaces and enter easily in the microbial plaque. The frequent intake of carbohydrates,
favor the development and multiply of pathogenic germs, which determines a growth of the
quantity of acids which determines enamel demineralization.
It’s proven that the ‘key factor’ that produces the dental cavity is the frequency and not
quantity of fermentable hydrocarbons consumed. Acids resulted are weak organic acids and in
the majority of cases they determine dental cavities with a slow evolution. Dental cavities will
evolve faster if sugar is consumed frequently or if there is a deficiency in the natural
protective factors of the human body. Strong acids are resulted from extremely varied sources
(drinks, fruit juices or even gastric reflux). Prolonged exposure or frequent to those factors
determines a quick demineralization and can transform a slow evolution dental cavity into
aggressive attacks.
In the first years of a newborn, microelements have a particular importance. The decrease of
microelements in newborns is balanced by the reserves that have been stored in the body over
the intrauterine life. Mineralization of the temporary teeth and some of the permanent ones is
made in the intrauterine life, that’s why a special role belongs, of course, to the health and
quality of food the pregnant woman ingests.
Macro-elements (calcium, phosphorusus) are elements of the bones and dental tissues,
but participate in the formation of salivary buffer systems too.
The forming of enamel and dentine processes, are influenced by calcium, phosphorus
but fluorine too. It’s been demonstrated that the fluorine intake in the time of dental growth,
provides a resistance to dental cavities over a long time, because this participates in the
forming of fluorapatite, more resistant to acid attacks.
Chronic diseases, metabolism dysfunctions (pregnancy toxicosis) or endocrine
diseases of the pregnant, determines in children the development of multiple carious processes
with fast and progressive evolution.
Toxicosis in the first half of pregnancy is the cause of the development of structural
damaged tissues. Teeth formed in such conditions have a lower resistance to dental cavity.
Toxicosis in the second half of pregnancy favors the development of hypoplasia, and has
lesser influence on the development of dental cavity.
In artificially fed children and those with a lower immunity it’s been observed a higher
rate of carious processes.
The majority of children with mothers that have lower levels of vitamin D, present a
higher frequency of dental cavity, vitamin D being a major factor in calcium and phosphate
ions concentration. Recent studies discovered that there is a less lower frequency of dental
cavity in the areas with higher quantity of UVB radiations, that determine the synthesis of
vitamin D. Some authors consider even more important the role of Vitamin D in the
prevention of dental cavity than the fluorine.
Early damage of the teeth and their progressive destruction has been observed
frequently in premature born children, those that have suffered trauma during birth, that have
rickets disease, rheumatism and cardiac dysfunctions. The carious process has a faster
evolution in those, with an extended demineralization of the dental tissues with the frequent
development of pulpal complications. In children with collagen diseases, chronic pneumonia,
 mental impairment, endocrine diseases or from the E.N.T. sphere can be observed a multitude
of dental problems, recurrent or complicated dental cavities. Children with T.B. present an
atypical localization of carious processes, an active evolution with high rate and intensity.
Children that were treated with corticoids have a certain fragility of the hard dental tissues,
forming of multiple and recurrent dental cavity.
So, the child’s body is very sensible to an irrational feeding, at an unsatisfactory
lifestyle. Disturbing their lifestyle can even lead to shortage of body reactivity, problems in
general development that will influence the eruption and evolution of the teeth on the dental
arches.
For ease of communication between doctors, different authors tried to make a
classification of the dental cavity based on certain criteria: depth, location, evolution rhythm.

TEMPORARY TEETH DENTAL CAVITY

The temporary teeth evolution is a long term process, these going through a series of
stages during their evolution. It is important to know the evolution stage in which a temporary
tooth is at the moment of examination so that an adequate treatment can be followed. The
temporary tooth has 3 stages of evolution.
Img. 8.1. Temporary teeth in stage III of development
 stage 1: the young temporary tooth
o it is the growth and development stage, until the forming of the root.
o this process of development starts intrauterine, the second month and continues until after the
eruption time of teeth
o the eruption of temporary teeth begins from 6-30 months
o the root continues to develop after the eruption, for 1-2 years more

 stage 2: mature temporary tooth

o Inferior post-natal mineralization
o large dental canals
o big pulpal room in comparison to the width of the hard dental tissues
o weak divergent dental roots, hold between them the replacement permanent teeth buds
o the radicular canals are narrower
o the pulp is big in volume, well vascularized, the pulp horns are located superficially
o the pulp-periodontal communication, is done through various accessory canals, radicular as
well as the pulpal chamber floor
 stage 3: temporary teeth with resorbtive root
o risalysis starts at 4-5 years for incisors, 6-7 years at molars, 8 years for canines
o risalysis is a physiological process determined by general and local factors (temporary tooth
pulp and the eruptive permanent tooth) that are involved in this process
o the root shortens in length, the apical orifice gets bigger, increasing the pulp-periodontal
communication.
o risalysis can be found also at the joint with the permanent tooth
o there are multiple communication canals with the periodontal space, even at the level of
bifurcation, determining diffuse osteolysis.
o the pulp suffers a process of involution with the decreasing of cells, the defensive and
reparatory potential, degenerative fibrous modifications and intra-pulpal calcifications.
o masticatory pressures, lead to modifications in the conjunctive tissue, which transforms into
granulation tissue, invading the pulpal chamber.
o risalysis is increased by pulpal or periodontal inflammatory processes

The consequences of the particularities of temporary teeth

 the fast evolution of the carious process
 exposure to the accidental opening of the pulpal chamber
 the reparatory property is less intense
 the pulpal action time is reduced
 the presence of chronic dental cavities and those stopped in evolution prove the property of
forming of the reaction dentine
 the innervation and sensibility is lesser than in the permanent teeth
 the marginal periodontium has a representative papillary area
 the globular shape of the crown and the interdental contact surface, as well as the papillary
zone is representative – those are important protection factors against occlusal trauma

The cavity classification of the temporary teeth

Simple dental cavity is that which affected the enamel in a certain proportion or which
in its evolution has reached the dentine, but whose depth did not result in painful symptoms.
A deep cavity, which caused pain, determined or spontaneous is a complicated cavity.
 The simple dental cavity of the temporary teeth can be divided into more classifications, as
following:
- Black’s morphological classification which divides the cavities into 5 classes:
1. Ist Class
2. IInd Class
3. IIIrd Class
4. IVth Class
5. Vth Class
- Classification by depth of the lesion:
1. Superficial cavity: affects enamel to the enamel-dentinal limit
2. Deep cavity: the carious process affects the dentine too, and if it isn’t treated
on time it will determine the forming of complicated cavity
- Classification by evolution:
1. Acute cavity
2. Chronic cavity
3. Cavity stopped in its evolution
4. Circular cavity

The complicated cavity is that which in its evolution gets in the proximity of the
pulpal chamber and determines the cause of pulpal problems and finally the opening of the
pulpal chamber along with the invasion of microbial flora from the mouth and endodontic
space.

Complicated cavity of the temporary teeth is classified like this:

-Pulpitis (is the form in which the condition of pulpal tissues debutes):
Pulpitis classification:
 by evolution:
o acute
o chronic
o reversible
o irreversible
o symptomatic
o asymptomatic
 by topography
o with open pulpal chamber
o with closed pulpal chamber
1. acute serous pulpitis, partial or total
2. acute purulent pulpitis, partial or total
3. chronic pulpitis can be:
 Chronic pulpitis with open pulpal chamber
 Chronic pulpitis with open pulpal chamber: ulcerous chronic pulpitis
 granulomatous chronic pulpitis (polyp)
- Pulpal necrosis
- Pulpal gangrene, which can also be classified in:
1. Simple gangrene (periodontal tissues are not involved)
2. Complicated gangrene (with the affecting of the endodontic system and involvement of the
periapical periodontal tissues), with the possibility of evolution towards:
o Acute apical periodontitis, serous or purulent
o Chronic apical periodontitis

Diagnosis and treatment of the temporary teeth simple cavity

Temporary teeth cavity can appear more frequently in this areas:
- areas with no self-cleaning possibility
- at the prime inferior molar (most frequently affected) and second molar: fissure and
occlusal cavities
- in the proximal areas
- on the incisors proximal and vestibular surfaces (circular cavity)

Occlusal cavities appear in general at age 3-4 and the proximal ones at age 5-6 (at
approximately 70-80% children). Carious processes, depending on evolution, have the
following properties:

1. Acute cavity
Carious cavities can be of different sizes, with a limited opening in the enamel, but
have rapidly progressed in the dentine, determining a certain depth of the cavity. Enamel is
fragile, undermined at the carious process surface and can be fractured in the masticatory
 process for example. Characteristic for the acute cavity is the evolution speed, thus the pulp
cannot maintain to form the dentine at the same rhythm and in 1-2 months this cavity can
become penetrant or complicated.
2. Chronic cavity
It is characterized by a bigger opening to the surface of the cavity and reduced depth
expansion. Has a slow evolution, 1-2 years from the start until the opening of the pulpal
chamber. Thus, the dental pulp has the possibility of forming reactive dentine in large
amounts. Affected dentine on the pulpal wall of the carious process is hard, brown, darkened.
This long evolution stage is because of the large opening to the surface which favors self-
cleaning and so slowing the destructive chemical processes.

3. Cavity stopped in its evolution

It is that cavity that is formed on the proximal surfaces of the teeth, most of the times.
Originally, this cavity has been, for example, an acute cavity, but because of the extraction of
the neighboring tooth. Thus, the remineralization processes replace the demineralization ones
and the cavity stops in its evolution. The surface of the enamel is of hard, brown, rough shape,
similar to the chronic cavity. The difference between the two types is just theoretical.
4. Circular cavity
It is also called ‘the baby bottle decay’. It appears more frequently in children that fall
asleep with their baby bottle still in their mouths, the drinks being sweetened with honey. It is
considered a dystrophy and appears more frequently in the superior frontal teeth, superior
prime molars and inferior canines. Inferior incisors are rarely affected. The determining factor
of this lesion is the ingestion of those sweetened drinks while sleeping, with the decrease of
salivary secretion and so the decrease of the oral pH. Thus, acidic bacteria will determine the
fast progression of carious lesions and their multifactorial development. Circular cavity starts
as pigmentation in the cervix area, on the vestibular side, then proceeding circular, more on
the surface than in depth. If serious oral-dental and food hygiene measures aren’t applied fast,
those lesions will progress rapidly, towards the fracturing of teeth.

The diagnosis of the simple cavity

Diagnosing a carious process can be difficult at many times, because of a lack of

massive coronary damage or forming of an serious dental cavity, a doctor without experience
 can easily overlook some subtle signs of cavity, like a color modified marginal ridge or
occlusal or cingular pigmentations. In children, diagnosis of the cavity becomes more difficult
because those cannot state clearly the pain location or symptomatology, the information given
by them or parents being most of the times in contradiction.
The subjective symptoms are those that the patients or family tells us.
The objective symptoms are those that the dentist observes during dental check-up.
The subjective symptomatology of the simple cavity:
- Erased pain symptoms, inconsistent, without a classical pattern (sensibility is reduced along
with the pulpal organ involution in case of the temporary teeth)
- Child complains of a sensibility during ingestion of sweets
- Child refuses to feed (if there are many deep cavities or gingival polyps that could provoke
pain while masticating)
- Patient complains about the presence of sensibility during contact with chemical and thermal
agents
The objective symptomatology of the simple cavity:

Will be observed by the dentist while the dental check-up (through inspection, palpation,
percussion, thermal tests, radiologic examination) and will consist of:
While inspecting the dentist will observe:
 loss of enamel translucency
 the presence of a chalky white spot
 brown-darkened pigmentations at the level of some cracks/fissures
 continuity solutions with a lack of substance
 carious cavities containing food scraps
 on the proximal surfaces, ‘mirror-like’ cavities, just a color change under the marginal ridge
or undermined marginal ridge associated eventually with a papillitis. Many times the proximal
surfaces cavities cannot be diagnosed without the help of dental radiography, retro-alveolar or
bite-wing.
Palpation is done with the dental probe. The probe will pass all dental surfaces, any
crack or discontinuity in the enamel being thus identified. So, the probe will ‘grab’ existent
cavities. If it is an acute cavity, the probe will have access easily in the undermined tissues, in
the damaged dentine. If it is a chronic cavity or stopped in its evolution, the dentinal tissues
 will be harder but rougher. Palpation also, with a Black spoon can take off the damaged
dentine on the bottom of the cavity, thus easily exfoliating in layers.

Percussion is done with the probe or dental mirror’s handle. Axial positive percussion
will indicate a peri-apical pathology, a total serous or purulent pulpitis which in evolution
affects also the peri-apical tissues or a chronic apical periodontitis for example. Paraxial
percussion may reveal lesions of endodontic cause (in case of presence of high caliber lateral
canals) or of periodontal cause.
In the case of temporary teeth, percussion does not reveal, in general, pain or it isn’t
conclusive.
Thermal tests in children aren’t conclusive because the poor collaboration with the
patients, because they get scared while applying any pressure or change of temperature in the
oral cavity. Still, it has to be known that thermal tests can be done with cold stimuli (ethyl
chloride spray) as well as with warm stimuli (gutta percha stick heated and applied in the
cervical 1/3). These tests won’t be applied unexpected, known being the fact that in the
etiology of pulpal conditions, physical factors can cause the start of a pulpal suffering).
Radiologic examination is represented by the ortopantomography type radiographies,
the retro-alveolar and bite-wing radiography. Premature extractions of temporary teeth,
absence of permanent teeth after the eruption stage will indicate the use of a OPT,
supplemented by a bite-wing or retro-alveolar radiography to diagnose a cavity suspicion
from a precise area. The radiologic examination will highlight:
 Proximal carious lesions
 Depth of the carious processes and proximity of the pulpal chamber
 Radicular rizalisis degree of the temporary tooth
The differential diagnosis of the simple cavity in temporary teeth is done with:
 Dental dysplasia (for chronic and early acute simple superficial cavity)
 Complicated cavities with chronic pulpitis with open or closed pulpal chamber can be painless
 Complicated cavities with necrosis and pulpal gangrene (when pulpal chamber can be closed
or apparently closed, with a carious process apparently non-penetrative)
Prognostic of a simple cavity in temporary teeth
Prognostic of a simple cavity in temporary teeth is favorable, as well as any other
carious lesions given that it is treated early and right. Thus, the necessity of periodic check-
 ups, on time carious process discovery, dental prophylaxis, patient and family compliance is
imperative for a proper odonto-periodontal status.

TREATMENT OF TEMPORARY TEETH SIMPLE CAVITY

Carious lesion treatment of temporary teeth is necessary because of their importance
in:
- Ongoing of the dento-maxillary apparatus functions
- Proper growth and development of the child
In treating the carious lesion of temporary teeth, our conduit stands for their morpho-
structural particularities, the behavior and age of our patient. We’ll treat one way a 4 year old
with a temporary tooth simple occlusal cavity and another way a temporary molar with
aggravated rizalisis at age of 9. We must know the particularities of the temporary teeth
corresponding to their development stage, to know the eruption age of permanent teeth, to
make the difference between a prime permanent molar for example, early erupted, at age 5,
and a temporary second molar decayed.

Treatment indication will be made by the following elements:

- child age
- dental age
- frontal group – up to age 5
- support area – up to age 10-11 (up to age 8 all of the support area, after age 8
especially second molar and superior temporary canine).
The difficulties we will meet in treating the simple cavity of temporary teeth are tied to the
particularities reminded, the decreased thickness of dental tissues, the big volume of the
pulpal chamber and superficial location of the pulpal horns.

Times for preparing the cavities, after Black:

1. Creating access
2. Removal of the cavity affected areas – cleaning
3. Ensuring resistance
4. Ensuring retention => undergo changes
5. Preventive extension
6. Edge processing
7. Cavity check
Attention:
- we do not do edge bevel, just a polishing of the cavity edges
- we ensure the retention through enlarging of the surface of the filling

CLASS I
First and second molars:
- shall include all fissures and cracks
- two fissures can exist and so two cavities can be created if the diagonal ridge is
resistant enough

CLASS II
- Gingival threshold is prepared
- Occlusal retention is placed
- The isthmus is created
Particularities in proximal cavities treatment:
- Superficial position of the pulpal horns, so that while removing the carious process
we can accidently open the pulpal chamber
- Creating the occlusal retention, that has to be big enough to ensure the retention and
maintaining the filling but not to be too big, so that would undermine the tooth’s resistance
- Extended MOD preparations (mesio-occlusodistal), when sometimes it’s hard to
collaborate with the patient for long term treatments, the difficulty in placing the matrix or
interdental wedges are other impediments in realising a good filling.

CLASSES III AND IV

- simple holes are made
- we will do the opening, cleaning of the cavity and smoothing the edges in incisors
- palatal retentions are rarely done
- in superficial cavities, fluoridation and polishing is recommended
- in canines, palatal retentions can be filled with amalgam too
- in canines, covering crowns can be applied too

CLASS V
- all decalcified areas are included
- the depth of the cavity must not be bigger than 1.5-2mm
- difficulties in treating those carious lesions are tied to how close those are to the gum and
difficulties in obtaining a dry area, required for applying a filling

After the age of 3-4 the frequency in dental cavity of children is high. Thus, while
treating a simple cavity, temporary or permanent tooth, we’ll keep in mind about the
expansion of the lesion. If we have a superficial cavity, only extended to the enamel, as we
clean the infected tissues and the cavity, we can put in the material needed for coronary
restore. But, in the case of a deep cavity, which penetrated all the way to the dentine, during
treatment we will focus on the remaining dentine aspect and the proximity to the pulpal
chamber.

SUPERFICIAL SIMPLE CAVITY TREATMENT

In the case of a superficial simple cavity, treatment is about removal of damaged

dental tissues and applying a long term filling material, good enough for treating temporary
teeth.
Removal of the carious process will be done with diamond, turbine drills because the
vibrations are decreased and the removal speed is high, so the child won’t get scared by the
vibrations emitted by the angular drills and won’t get bored by the long duration of the
treatment. We will check if we removed the infected tissues by using a cavity indicator. If the
cavity is clean, we can start washing the cavity, if not, the cleaning stage will be resumed and
we will remove the damaged areas which were indicated by the cavity indicator.
After we removed the carious process, following Black’s principles adapted to the new
filling materials, we are required to isolate the created cavity to be able to put in the filling
material. Having in mind that our patients are small children, with whom we cannot have an
excellent collaboration, we won’t always be able to do a perfect isolation using the rubber
dam procedure. If we won’t be able to use the rubber dam procedure we will use cotton rolls
and saliva vacuum, helped by the nurse.
Rubber dam system is 15/15cm rubber foil, that can be smooth, rough or extra-rough,
that is maintained at tooth level with the help of some metallic clips, specific for every dental
group. Others accessories of this system are the plastic frame on which the rubber foil is
placed, the adjustable perforator, with which different size holes are made depending on the
size of the teeth of interest, the applier for clams and dental floss thread.
Advantages of the rubber dam system are:
- increased visibility
- keeping a dry area, aseptic conditions
- prevents swallowing or aspiration of materials accidents
- dentist ease of access
- comfortable and safe way of isolation for children
Once we are done with isolating the tooth/teeth we can go to the next step in treating
the dental cavity, the washing of the cavity. This consists of washing the cavity with saline,
chlorhexidine or other modern substances especially made for degreasing and eliminating
remaining scraps in the cavity. We will not use irritating substances such as peroxide or
alcohol. Then, we dry the cavity with the air spray, moderately.
Materials used for filling this type of cavity are:
- Silver amalgam, rarely used nowadays
- glassionomer cement, especially made as long term filling material
- Compomers, modern materials, photopolymerizable, eventually colored.
After placing the filling material, we check the occlusal adapting of the filing and we do the
polishing of it with the fine diamond drill, rubber or disks for finishing.

DEEP SIMPLE CAVITY TREATMENT

Deep cavity, penetrating in depth the dental tissues and in its evolution reaching the
dentine, will benefit of another stage in the course of filling, the cleaning of the dentinal
wound. After we removed the infected tissues in a good proportion and permanently checked
the infected areas with the cavity indicator, we will face the next possibilities, tied to the
appearance of the pulpal wall dentine:
- Hard and normal colored
- Hard and colored
- Hard with the presence of a limited area of soft dentine
- Hard dentine and a dot-like opening of the pulpal chamber
Based on the evolution stage of the temporary tooth the next treatment schemes will be
applied:
- indirect pulp capping if:
 cavity base is hard, normal colored or pigmented
 pulpal inflammatory changes are absent or limited
 tooth is young or mature
If there is a limited area with soft dentine, it will be removed, with the risk of pulpal chamber
opening and then direct pulp capping is made. Another way is keeping that soft infected zone
and applying an indirect pulp capping with zinc eugenol.
-Accidental opening of the pulpal chamber is treated by direct pulp capping, in small children
in the immature or young tooth stage (rare situations)
-in the majority of cases the accidental openings are treated like pulpitis. If the cavity base is
hard, normal colored, but we suspect the damage of the integrity of the pulpal organ, an
endodontic treatment is applied, just like in the case of pulpitis.

Filling materials used in deep simple cavity treatment of temporary teeth can be:
- Silver amalgam with zinc eugenol base or zinc eugenol with quick setting
- Because decreased sizes, three layers of filling material cannot be applied, like ZnOE
+ cement + finishing filling)
- Cement is only used over ZnOE, because it can provoke necrosis
- Calcium hydroxide, with quick setting or photopolymerizable will be used in deep
cavities
- Silicophosphate cements are used only with the ensurance of an indirect pulp
capping and cement base
- Glassionomer cements, in class I and II cavities, with pulpal protection based on
calcium hydroxide
- Compomers, materials that combines the glassionomer qualities with those of
compounds, can be used in all types of cavities, disposing of a good resistance and esthetic
properties. In order to apply them we need a very good isolation of the area (rubber dam).
- Composite materials can be applied with a good pulpal protection and using the
rubber dam system for a good isolation.
Other treatment solutions for the deep simple cavity are:
- encrusting, in the temporary molars
 Advantages:
o Avoiding the danger of damaging the pulp
o Reducing the danger of breaking at isthmus level
o Creating contact points
 Disadvantages:
o High cost
o Requires the development of some laboratory steps
o Requires patience from the child while adapting and realizing the printwill
o Cannot be widely applied
- prefabricated crowns coating
- Requires minimal polishing for adapting
- Restoring contact points and the vertical dimension

TEMPORARY TOOTH COMPLICATED CAVITY

In its evolution, carious process advances in depth and will determine the appearance
of painful processes. Often, in practice, we face with complicated cavities in the temporary
teeth because in many cases parents won’t bring children to the dentist if they have simple
cavities in temporary teeth until dental pain appears. Thus, after a few nocturnal painful
episodes, the patient is brought to the dentist and we are in front of a complicated temporary
teeth cavity treating situation.
In conclusion, the most frequent causes for developing complicated cavities are:
- early development of carious process, which is neglected and thus quickly advancing
in depth
- neglecting simple cavity treatment
- using the turbine, non-stop drilling, use of irritating substances and filling materials
with no pulpal protection, the existence of accidental pulpal chamber openings which are not
observed or treated wrong
- accidental trauma, which created accidental openings of the pulpal chamber
Clinical forms of the complicated cavity:
- Pulpitis
- Gangrene and necrosis

PULPITIS
It is a pulpal condition that appears when the carious process exceeds the enamel-
dentin limit and advances towards the pulpal chamber. Under the aggression of microbial
germs, the protection and repairing potential of the dental pulp decreases and dental pulp
regressive changes appear. The stages of pulpal inflammation are quickly succeeded, without
the possibility of being identified, most of the time, only in late stages, when pain is increased
and cannot be overlooked by the patient. Because of the temporary tooth rizalisis, with a large
apical opening area which compensates the congestive processes and determine an intra-
pulpal pressure decrease and favors the inflammation becoming chronic, these pulpal
phenomena have a very decreased symptomatology until late stages.
Pulpitis can be:
- Serous pulpitis, partial or total
- Purulent pulpitis, partial or total
- Chronic pulpitis, with open or closed pulpal chamber
The pulpitis diagnosis is based on the painful symptomatology. In children, the pain is
many times decreased because of the involution of the pulp. Another difficult element in
diagnosing a pulpitis is the fact that the little patients cannot give information about the
intensity of the pain, its form, or pain triggering elements. Thus pain can vary from the simple
discomfort of masticating (in pulpal hyperemia, stage of pulpal condition before the
developing of a pulpitis and chronic pulpitis with open pulpal chamber) until the continuous,
stabbing, unbearable pain.
The vitality tests are inconclusive in children, most of the times they are scared only if they
see the probe or the dental mirror. Applying a spray for vitality testing or just cold water can
cause the occurrence of high intensity pain and can damage the future collaboration between
the patient and the dentist.
Differential diagnosis of pulpitis is done with:
- Acute apical periodontitis
- Marginal periodontitis
- Pericoronitis
- Tonsillitis
- Otitis
- Faked pain
The inspection distinctive sign, if there are more teeth affected, is the gingival congestion
around the affected tooth.
SEPTUM SYNDROME
It is due to a septum compression, a gingival papilla compression especially in a case of
proximal cavity when the point of contact between the two teeth is no more and food
fragments compress this area.
Subjective: spontaneous live pain, located between the two teeth, increased during meals,
which does not respond to analgesics.
Objective: proximal cavity, usually in molars, with gingival papilla congested and painful
Differential diagnosis will be made with pulpitis.
Septum syndrome treatment consists of freeing the dental papilla, anti-inflammatory treatment
and remaking of the contact points through crown rebuilding.

ACUTE SEROUS PULPITIS

Acute serous pulpitis is the first stage in the evolution of a pulpal condition and many
times, especially if it affected the organ only partial, will pass by unobserved or will be
ignored by the patient. The patient will not come to the dentist only when pain become of so
high intensity that regular painkillers will not work anymore (this symptomatology appears
when pulpitis is in the acute total stage).
Subjective: pain is spontaneous or provoked, with diurnal or nocturnal character, the painful
crisis varies in intensity.
Objective: carious cavity of different depths, rich in damaged dentine deposits and food
fragments on the bottom of the cavity; at the opening of a pulpal horn, there is a drop of blood
and the patient states the increase of pain. The pulp, thus uncovered, is touch-sensitive. In
case of total serous pulpitis, pain can no longer be relieved by usual painkillers, it’s
continuous and of high intensity, axial percussion sensibility being present as well.

PURULENT ACUTE PULPITIS

Subjective: pain is spontaneous and pulsating, long term and diffuse. Pain gets worse
or is triggered especially during night, because of the pillow heat for example. Patient can also
tell us that pain is relieved by cold liquids kept in the oral cavity.
 Objective: we observe the presence of a deep cavity, with rich damaged dentine
deposits. When removing the dentine, the pulpal chamber is easily open, a drop of puss will
be freed, followed by the progressive relief of pain. In total purulent pulpitis, pain is present at
axial percussion.

CLOSED PULPAL CHAMBER CHRONICAL PULPITIS

It is an asymptomatic pulpal condition or with discrete signs of pulpal suffering. The

patient can tell us of a painful discomfort while masticating which is inconstant. It occurs
more frequently under old massive fillings with secondary cavity.

OPEN PULPAL CHAMBER CHRONICAL PULPITIS – ULCER FORM

This type of pulpal condition occurs when in its evolution the carious process opened
the pulpal chamber, the elimination terms of harmful substances at pulpal level have been
made and the pulpal lesion hasn’t proceeded towards the pulpal gangrene stage. At this
opening, in response to the continuous aggression, granulation tissues have appeared.
Subjective: mastication sensibility occurs, when food fragments press on this granulation
tissue. Objective: we observe the open pulpal chamber, while palpating with the probe the
granulation tissue bleeds and it is sensible. This lesion can turn acute anytime and will
determine the occurrence of a continuous painful symptomatology, similar to that from serous
or purulent pulpitis.

OPEN PULPAL CHAMBER CHRONIC PULPITIS –

GRANULOMATOSE (POLYP) FORM

Typical for this chronic pulpitis type is the fact that at the pulpal chamber opening
orifice a pulpal polyp will form. This can be mistaken with a gingival polyp and this is why
we will check its implantation base always for the right diagnosis. The patient will tell us
about the presence of subjective symptoms like discomfort while masticating or bleeding if
the polyp has been damaged. Objective, the dentist will observe the pulpal chamber widely
open, the polyp made of granulation tissue, lax, well vascularized, red, separable, that bleeds
 when touched. In the superficial areas the polyp is insensitive to palpation because of nerve
endings absence at this area. Differential diagnosis is made with other pulpal affections and
with the gingival polyp, like mentioned before.

Objectives for treating this lesion are:

- Fighting pain
- Pulpal lesion treatment, removal of the carious process and morpho-functional
rebuilding of the tooth if rizalisis isn’t increased and we have at least one year until the
normal exfoliation time of the tooth on the dental arch.

Treatment of these lesions will follow:

 Not to influence the rizalisis
 Ensure the resuming of tooth functions
 Ensure its hold on the dental arch until its physiological replace

Temporary teeth pulpitis treatment particularities:

1. Anatomical and physiological, related to the complexity and variability of the endodontic
system
2. Pathophysiological, related to the etiology of the condition (pulpitis occurred because of a
carious process or trauma), the evolution of the inflammation in the pulpal territory, the
defense capacity of the pulp (varies depending on the stage of evolution)
3. Succession germ closing in
4. Related to patients age, his collaboration capacity: anamnesis is difficult and often
information that we receive are in contradiction. Often the family isn’t conscious of the
involvement of temporary teeth untreated cavities and so they overlook these lesions.

Temporary teeth pulpitis treatment difficulties:

1. While diagnosing: clinical diagnostic and vitality tests (depend on the collaboration with the
patient), retro-alveolar or bite-wing radiographies (frequently superpositions occur, the patient
cannot maintain the film/sensor in the right position), panoramic radiographies also have
overlaps and imperfections that make diagnosing the problem harder.
2. Techniques, related to depth of cavity and pulp closeness determination, trepanation at the
interest location, radicular pulp stage of inflammation determination, and determination of the
radicular canals.
3. Child and family behavior.

Options for possible pulpitis treatment:

1. Indirect pulp capping: consists of conserving the pulp, it is done when there are no deep
cavities in temporary teeth with roots in development.
2. Direct pulp capping: in accidental pulpal chamber openings, teeth with root in development
3. Vital amputation (pulpotomy): in accidental pulpal chamber openings but of bigger sizes
4. Vital removal (pulpectomy): in case of total pulpitis in teeth with already formed root
5. Non-vital amputation: deep cavities, accidental pulpal chamber openings, pulpitis.
6. Non-vital removal: in case of pulpitis in temporary young teeth, with completely formed roots
or non-absorbable roots
7. Dental extraction, if the tooth has its roots in an advanced stage of rizalisis and time until
physiological exfoliation is less than one year.
Facing this many therapeutic options, the dentist must decide if an endodontic treatment of a
dental extraction will be followed.

Treatment indications of a pulpal damaged tooth are:

- Existence of a deep cavity, with loss of proximal wall
- Radiologic proof of the cavity, extended to more than half the distance between the
enamel and the pulp
- Clinical sign presence of pulpal necrosis or gangrene
- Medical indications (hemophilia, diabetes, hemostasis disorders)
- Extraction related anxiety
- Maintaining space
- Agenesis of the successor tooth
- Maintaining the function
- Esthetics
The extraction indications of a tooth with an affliction of the pulp are:

- Medical risk (cardiac immunological, oncological treatment, grafts)

- Multiple cavities with multiple extractions
 - Crowded mixt dentation
- Massive coronal destruction, so that the teeth loses all its functions
- Cavity that penetrates the floor
- Radicular resorbtion of more than 2/3 of the root
- Advanced pathological radicular resorbtion

Common endodontic treatment of temporary teeth may be:

1. INDIRECT PULPAL CAPPING = favorable prognostic

2. DIRECT PULPAL CAPPING = not indicated
3. PULPOTOMY = favorable prognostic
4. PULPECTOMY = difficult to achieve

Preparing the patient is done by psychological counseling, dental anesthesia (either by plexus
anesthesia, or by inhaling sedation) and preparation of the operative field for endodontic
treatment (removing the carious lesion and isolating the operative field with the rubber dam).

1. INDIRECT PULPAL CAPPING

It has the objective of maintaining the vitality of the pulp. It can be applied in case of
early afflictions of the pulp, pulpal hyperemia, partial serous pulpitis (which is hard to
diagnose and treat in this stage because the symptomatology is very sparse and is often
overlooked by the patient). After removing the largest possible quantity of altered dentine,
with the aim of not opening the pulpal chamber, we will apply a material with anti-microbial,
sedative properties that also stimulates the build-up of tertiary dentine to the pulpal wall of the
cavity. One of these materials may be: calcium hydroxide, zinc eugenol, covered by
protective cement to increase its resistance. Recent studies show that dentinal adhesives could
be used as indirect pulpal capping materials. The prognosis of this treatment is good, if
applied in good time, the amount of affected dentine was reduced and the defense capacity of
the dental pulp is good.
2. DIRECT PULPAL CAPPING
It consists of the accidental discovery of the inflamed dental pulp and placing a bio-
material at this level. The purpose of direct pulpal capping is to preserve pulpal vitality, which
cannot be fulfilled if the dental pulp is inflamed and infected with pathogen germs. Thus, the
 prognosis is unfavorable, and it shall not be used in the treatment of pulpitis. Direct pulpal
capping can only be used in case of accidentally opening the pulpal chamber, when the dental
pulp is not inflamed, asymptomatic. We will treat some pulpal lesions, by pulpotomy, when a
tooth that is temporarily vital shows signs of early pulpal suffering and requires endodontic
treatment.

We will treat a pulpal lesion by pulpectomy:

 when treating an emergency of a temporary tooth with a cavity and acute or chronic parulic
abscess
 when applying endodontic treatment of a temporary tooth with partial or total necrosis and or
parulic abscess.

3. PULPOTOMY
It consists of removing the coronal pulp that we assume is altered, wholly eliminating
the inflamed and infected tissue, and maintaining the vitality of the radicular pulp. The
prognostic of this treatment is favorable if it was correctly applied clinically and
diagnostically.
The indications of pulpotomy:

- Temporary tooth with deep cavity of the dentine (more than half of the thickness of
the dentine) or accidental pulpal discovery.
- Temporary tooth that requires coronal remodeling because of malocclusion,
significant abrasion.
- Traumatic pulpal discovery (emergency)

Contraindications of pulpotomy:
 Local:
- Periapical or interradicular lesions
- Fistulized abscesses
- Terminal stage 3 of evolution of the tooth
- Inflammatory radicular resorbtion
 General: children at risk
Working technique
- Pre-operatory X-RAY
- Local anesthesia
- Constructing the operative field (rubber dam)
- Removing the cavity and creating the access towards the pulpal chamber
- Total evaluation of the pulpal chamber (with care for the retention areas): with Black
sterile drills and spoons
- Hemostasis: sterile cotton roll with formo-cresol, applied compressively on the
bottom of the cavity (2-3 min.)
- Preparing and filling the pulpal chamber with fast setting ZnOE, applied on the
pulpal wall of the cavity
- We can also apply calcium hydroxide paste, to the pulpal wall of the cavity, over
which we apply the ZnOE cement.
- Control retro-alveolar X-RAY
- Coronary rebuilding for the tooth in question can be done by multiple methods:
Method 1: if the patient is unavailable (behavior and time) = apply a fast
setting ZnOE filling  permanent resolution after 15 days if pain is absent.
Method 2: if the patient is available (behavior and time) = remove the access
ZnOE and obtain clean dentinal walls and apply a permanent filling (inlay, filling or
preformed crown)

Post therapeutic indications:

- advice after anesthesia: we will warn the patient about the cheek or tongue biting risk
- pharmacological treatment indication prescribed for: analgesics and or mouth wash,
if the patient exhibits gingivitis or associated gingival lesions
- 1 month check-up and clinical exam, when we check for possible necrosis of the pulp
remaining in the radicular canals: inflammation, pain on percussion
- retroalveolar X-RAY for comparison with the post operatory X-RAY
- Regular three month check-ups for patients with multiple cavities or children with
increased risk of cavity or six months check-up for children with good hygiene or low risk of
cavities.
4. PULPECTOMY
It is a maneuver that consists of removing the coronal and radicular pulp, from
temporary tooth with irreversible pulpal affliction.
 Contraindications of pulpectomy:
 local:
- stage 3 terminal rizalisis
- pathological radicular resorbtion
 general:
- In children with general associated health problems.

Working technique

To do the pulpectomy of a temporary tooth with irreversible pulpal affliction we will need:

- A pre-operative dental X-RAY to be able to see the relation between a temporary

tooth and a permanent one and the stage of root rizalisis.
- Dental anesthesia. We can apply a topic anesthesia at the level of the mucosa to
relieve the patient’s discomfort, inhalo-sedation is good as well.
- We apply the rubber dam at the interest tooth
- We will then proceed with the removal of the carious process and closing of the
pulpal chamber. We carefully remove the roof of the pulpal chamber. With the Black spoon or
with the angular drill we remove the coronary pulp and then the radicular one with the Kerr
needles. The maneuver will be done while constantly washing with sodium hypochlorite, 2.5-
5%. We must identify then the length of the radicular canals with the apex locator. It is very
important to do the mechanical treatment only on the length of the radicular canals and not to
pass over this length thus hurting the permanent tooth bud.
- After we removed the entire radicular pulp and we widened the canals we will dry
the radicular canal with sterile cotton cones by entering with the 25 Kerr needle, 2% taper up
to the root and do a control X-RAY to check the length of work is good (if the treatment was
done at a tooth that its pulp suffers from pulpit phenomena and the 25 Kerr needle didn’t
reach the apex from the start of the treatment).
- If the length of work is right, we will transfer this length on a lentullo needle and
we’ll apply at the radicular canal level the ZnOE paste of a creamy consistency.
- We then do the cement coronary filling, to seal the endodontic system and avoid
entry of saliva and microbial flora from the oral cavity.
- We can prescribe the patient some painkillers
 - The patient will then be rescheduled for check-up after a month, searching for
clinical periodontitis signs (inflammation, pain to percussion) and radiologically check the
endodontic treatment
- If there are no pain signs, we can do a complete long-term coronary rebuild, like a
composite material filling, amalgam, preformed metallic or in-lay crowns.

Gangrene and necrosis

The aseptic death of the dental pulp is called necrosis. Dental pulp necrosis can appear
after a dental trauma, consecutive to physical or chemical aggression, after applying an
excessive orthodontic force in case of treatment with fixed or mobile dental apparatus, after
continuous occlusal trauma. The pulp necrosis will appear slowly, often the only objective
sign being the color change of the tooth. Dental necrosis can only be diagnosed on a
devitalized dental pulp, but which has no continuity with the outside, so that a microbial
invasion in the endodontic space exists. Once a trauma or cavity exhibited the necrotic pulp to
the outside and filled by the microbial germs, this dental necrosis will turn into gangrene, this
being a septic death of the pulp.
Gangrene is a septic process located in the pulpal tissues, tissues that lost their vitality
prior to the endodontic system infection with pathogen germs. So gangrene is developed on a
devitalized pulp or with previous pulpal suffering and it is a septic infection. The microbial
flora that is present in a pulpal gangrene is aerobic or anaerobic. The devitalized pulp
becomes thus headquarters for fermentation and putrefying processes, proteolysis and
dissolution of the pulp. At the same time the dentine walls are demineralized and damaged.
In conclusion, a necrosis or gangrene will not be present at the level of a vital tooth.
Those pathological processes are specific for the devitalized teeth.

Pulpal gangrene etiology:

- Deep cavity, with pulpal chamber opening

- Pulpal necrosis, infected through a continuity solution
- Direct microbial invasion on a healthy pulp after trauma (the pulp will rapidly pass
through the stages of pulpitis and the tooth will become devitalized tooth, the microbial
invasion determining the gangrene of the pulpal tissue)
 Clinical forms of pulpal gangrene:

- Simple gangrene:
 the septic mortification of pulpal tissues, without the involvement of the periodontal tissues
-Complicated gangrene:
 the septic mortification of pulpal tissues, in its evolution the infectious process including the
periapical tissues and the periodontal ones.
 it is favored by the pronounced rizalisis of the dental roots, thus exists an open way to germs
to infect the periapical tissues. The communication between the roots and the inter-radicular
spaces, the bone tissue less mineralized, lax conjunctive tissue and the reduced defense of the
body are just elements the favor the rapid evolution of the gangrene towards a complicated
form and towards its frequent complications.

Treatment of the gangrene consists of:

- conservative treatment
- extraction
- compromise measures

The therapeutic attitude will vary so, by:

- Clinical form
- Coronary destruction degree
- Radicular resorbtion degree
- Alveolar bone grade of implication
- The importance of the tooth in maintaining the space for permanent tooth in relation
with the dental and chronological age
- Dental and general health of the child
- The possibility of the patient to come to repeated sessions.

If we will decide that this tooth must be maintained on the dental arch, then we will do a
conservatory treatment, such as endodontic treatment, like:

 Mechanical treatment:
 - Removing of the carious process and creating access to the pulpal chamber
- Removing of the scraps in the pulpal chamber
- Opening the canals with endodontic instruments, with constant irrigation using disinfectant
chemical substances (chemical treatment)
- we will do gentle maneuvers, trying not to push infected scraps behind the dental apex and
to favor the distribution of germs.

 Chemical treatment

- In case of a microbial invasion in the endodontic space, the simple mechanical treatment to
remove the dental pulp will not suffice. This will be combined with a chemical treatment, of
irrigating the endodontic system with disinfectant substances. Large-scale washes with
peroxide or chloramine, chlorhexidine, or sodium hypochlorite can be done. The sodium
hypochlorite is the disinfectant agent chosen in the case of advanced pulpal afflictions. It is
the only chemical agent capable of neutralizing all endodontic system pathogens. The only
disadvantage of using it or the only need will be the use of the rubber dam, many times
impossible in case of a small or uncooperative child.
After all the painful phenomena and swelling have decreased, we can try applying a
canal filling. Speaking of a temporary tooth, this filling will consists of either Walkoff paste,
either iodoform resorbable cement or simple calcium hydroxide. The filling will not be done
with gutta percha cones, because those aren’t resorbable and will affect the natural process of
rizalisis. We’ll then do the coronary filling using glassionomer cement, an inlay, a preformed
crown.

Temporary tooth extraction will be done if:

- The tooth does not have functional importance
- The teeth at which the repeated problems, may affect the permanent teeth buds
- When the patient presents a focal disease
- When there are serious complications like repeated abscesses
- In previous treatment failure
- If there was a premedication in children with bacterial sub-acute endocarditis,
nephritis, leukemia, tumors, idiopathic cyclic neutropenia.
 Compromise measures are indicated when:

- Conservatory treatment cannot be realized

- If the extraction doesn’t have a certain indication
Compromise measures consist in the amputation of the coronary pulp, than the tooth is left
open. This measure is taken in the following cases:
- Mentally unstable child, those with whom collaboration is impossible
- When there is complex radicular canal morphology
- Teeth with serious coronary disruption
- When occlusal conditions are unfavorable to apply the space holder, when the 6 year
molar hasn’t erupted yet

Complications of the gangrene are:

A) Acute apical periodontitis

It is an inflammatory diffuse process. Evolution stages of an acute apical periodontitis
are: endosseous stage, subperiostal stage 0 and the submucosa stage. Those are quickly
succeeded and they externalize at 2-3 mm under the gingival ridge in molars (the bifurcation
area) and in the apical area of the incisors.
Subjective: spontaneous pain, high intensity, children can no longer tell the type of
pain.

Objective:
 carious process with open pulpal chamber or apparently closed, sensibility on axial
percussion, loss of sensibility while probing the pulpal chamber
 Congestion, gingival swelling, vestibular and lingual, neighboring edema, fistulized or
collected abscess, parulic abscess.
Differential diagnosis is done with: otitis, tonsillitis, supra-infected tumors, periodontal
abcess.

Treatment of the acute apical periodontitis:

Treatment has, as objective, the relieving of the pain, suppression of the infectious
focus and of the inflammatory process. This is done by:
 - Endodontic drainage: opening of the pulpal chamber, radicular canals dissection,
apex trepanation, washing with disinfectant. The tooth remains open a couple of days, with
maintaining hygiene. It is indicated the application of a cotton swab in the pulpal chamber on
the course of the day, because while feeding the food fragments not to close the radicular
canals.
- In case of abscess, it is completed by the incision at the level of the purulent
collection.
- It can be completed by drug treatment, represented by antibiotics and painkillers.
Emergency treatment of a temporary tooth with cavity and acute parulic abscess:

Diagnosis

Anamnesis: the patient will tell us about the presence of an acute permanent pain or
provoked by pressure in mastication. Some patients will tell us about the presence of
spontaneous nocturnal pain that is not relieved by painkillers
At clinical exam we’ll see:
 A deep cavity with an important loss of substance, a penetrating cavity
 The presence of an acute parulic inflammation (gingival inflammation in course of
fistulization)
 Increased pain by percussion
 Constant mobility of the tooth is present
The radiologic exam will indicate:

 Inter-radicular and or apical extended resorbtion

 Rizalisis stage indicates the conservation possibility of the tooth or its extraction after the
remission of the acute phenomena.

The decision of keeping a tooth with parulic abscess:

- temporary tooth that can be kept (stage 1-2 of development), with limited loss of
hard dental substance  will be treated immediately.
- temporary tooth without possibilities of keeping (stage 3) and or not restorable (very
important loss of substance, subgingival cavity limits) and if anesthesia is possible.
Thus, if we keep a temporary tooth, we can start endodontic conservatory treatment:
pulpectomy.

B) Diffuse chronic apical periodontitis

Can evolve from the start in this clinical form or this affliction can be caused by the
chronicling of an acute form. The affliction is characterized by the resorbtion of bone
structures and replacing them with granulation tissues.

Subjective: asymptomatic evolution of the lesion or with erased pain, ignored by the patient.

Objective: we can observe the presence of a fistula or a congestive area of 4-5 mm in the
apical area of the tooth.

Evolution: could get worse and can present the symptomatology of an acute apical
periodontitis. In its evolution it can undermine the bone vestibular wall completely.

In radiologic exam we’ll observe an inter-radicular radio-transparency represented by existing

granulation tissue and bone resorbtion.

Treatment in case of reacutization is the same as in acute apical periodontitis. In case in which
chronic apical periodontitis remains asymptomatic, treatment will be correlated with the stage
of radicular rizalisis and the physiological time of exfoliating on the dental arch. Thus, if the
tooth presents frequent episodes of reacutization it can lead to dental extraction and placing a
space holder if its permanent successor is not in the physiological time of eruption.

YOUNG PERMANENT DENTAL CAVITY

Morphological histological particularities of the permanent tooth in the growing stage:

Enamel:
 - it is a semipermeable membrane that allows the permanent changes between salivary and
pulpal metabolic processes
- allows the substitution of ions from the structure of the hydroxyapatite crystals, followed by
inducing of a good defense capacity against cavities.
- the intensity of the ionic changes between the enamel and oral environment as well as the
enamel permeability are reduced with aging.
- recent erupted teeth, grab the inorganic ions from the oral liquid about 10-20 times more
pronounced than the adult tooth

Dentine:
- reproduces the tooth form
- limits towards interior the pulpal chamber, in which the pulp resides
-dentine possesses reaction capacities towards physiological and pathological stimuli that can
determine the forming of secondary functional dentine, tertiary dentine or sclerotic dentine.
- the thickness of the dentine is lower than that in the mature teeth and the dentinal canals are
wider.
- dentinal genetic activity continues lifelong, new layers of dentine being deposited in time,
along with the growth in thickness of the dentinal tissues and aging.

Dental pulp

- it is the central organ of the tooth

- has a role in forming and developing of the tooth and its nutrition, as well as in the defense
processes against irritating or toxic local and general factors
- the pulpal organ is located in the pulpal chamber, surrounded by dentine and communicates
with the apical periodontium and the rest of the organism through the apical foramen and
accessory canals.
At pulpal level we will find a multitude of cellular elements like:
 odontoblasts, pulpal highly specialized cells, of which primary function is that of producing
dentine
 Macrophages
 Mastocytes
 Plasmocytes
 Mesenchymal undifferentiated elements, with multiple transformation possibilities in highly
differentiated cells, of repairing or defense.

- Fibrillar element is lesser than in the pulpal adult tissue

- Fundamental substance of the pulp represents the ‘internal environment’ in which all normal
or pathological pulpal phenomena is done. The high grade of hydration of the fundamental
substance in the growing phase, allows the rapid pass of nutrients towards the cells and
elimination of the inflammation and catabolic products, contributing to maintaining a intra-
pulpal constant pressure.
-Rich vascularization of the pulp, assures:
 the cellular metabolism
 dentino-creating capacity
- It is the area where anti-inflammatory and anti-infectious reactions take place
- Capillary network is higly developed, being in a permanent reshuffling and regeneration.
- Innervation of the pulp is done by sensitive and vegetative fibers, with vasomotor role.

In young permanent tooth, because of the open apex, in the apical area there is a large
contact area between the radicular pulp and periapical tissues, which allows unhindered
circulation at this level and avoidance of intrapulpal pressure raise in course of inflammatory
processes

YOUNG PERMANENT SIMPLE CAVITY

Morphological structural particularities of the immature, young permanent teeth

These teeth have immature enamel, with porous surface, which determines a more
important adherence of the bacterial plaque and a higher difficulty in removal of it by the
patients. They aren’t always motivated to do a right brushing of the teeth, or they don’t know
how because they don’t have enough dexterity and parents don’t actively involve in children
teeth brushing. Enamel will suffer post-eruptive maturation for 18-24 months after the
eruption of the tooth in the oral environment, critical stage which corresponds to a powerful
susceptibility to cavity of the young permanent tooth. Dentine is also immature, with wide
dentinal canals, that represent penetration and diffusing ways for bacteria and their toxins,
 favoring thus the progression of the carious process without a significant loss of occlusal hard
substance (enamel) in a first phase.
Dental pulp is also immature, so are the roots that have a wide open apex. Cemento-
dentinal junction is not finished only after 4 years from the eruption. Because of these
particularities, the child cannot feel any pain, even if the cavity is deep until the moment
where there are pulpal complications.
 Enamel mineralization is weaker, especially in those with early eruption
 Occlusal surface is very bumpy
 Nonfunctional stage, until the teeth reach the level of the plan of occlusion can take a couple
of months
 Pulpal chamber is big in volume relative to the hard tissues
 Pulpal horns are superficially exhibited
 Dentinal canals are wide
 Root is in course of development, with open apex
 Formative capacity and of defense of the pulp is raised

Young permanent teeth pulp particularities

 Fundamental substance
o It is a colloidal gel, rich in water and mucopolysaccharides, being the internal environment
through which metabolites go towards the cells and catabolites are eliminated
o Has a high degree of hydration
o Favors fast pass of the nutrients from general circulation in dental cells
o Ensures the elimination of inflammation products
o Maintains constant the intra-pulpal pressure
 Cell element
o Fibroblasts are present in high numbers, big in volume, with capacity of changing into
odontoblasts
o Odontoblasts (highly specialized cells), form an uninterrupted palisade (a group of
uninterrupted cells) at the edge of the pulpal organ)
o Link cells, located in the subodontoblastic zone have an intermediate form between the
fibroblasts and odontoblasts, participate in forming of collagen and the fundamental
substance, have the capacity to transform into odontoblasts
o Cells involved in the anti-infectious or anti-inflammatory defense are represented by
macrophages, mastocytes, plasmocytes, undifferentiated mesenchymal cells, capable of
transforming into highly differentiated cells with a role in defense or repairing.
 Vascularization
o It is rich, ensures the cell metabolism, dentino-forming capacity, antiinflamatory and
antiinfectious reactions
o Capillary network is plenty in all the pulp, but prevails in the subodontoblast area
o Blood vessels anastomose in curls and terminal loops
o Blood vessels have regenerative capacities, by burgeoning
o Arterial-venous anastomosis allow the adjustment of sanguinary flow and isolation of
microlesions
o Lymph vessels are present too, with importance in the anti-inflammatory reactions
 Innervation
o Nervous filaments reach the mesenchymal papilla only later, unmyelinated filaments reaching
early the dentino-genic zone
o Nervous filaments have importance in the induction phenomena that precede odontoblasts
cito-differentiation
o Nervous filaments can be either sensitive or vegetative
o Nervous endings present at odontoblasts level enter in predentine and tjam come back to the
pulp, while others enter in the dentinal tubes and surround the odontoblastic extensions that
are present here.

Apical zone characteristics in teeth with root still in development or finished, but with wide
open apex are:
 Open dental apex, the advantage of this fact is that the pulpal tissue isn’t exhibited to
pressures determined by a tight dental canal like in mature permanent teeth
 Rich vascularization allows the metabolic changes and fast elimination of the degrading
products and toxins
 Abundance of young cell elements, gives autonomy to this region and facilitates the healing
of the inflammatory process
 Maintaining the vitality of this region allows the further forming of the root.
Cavity predisposition of those young teeth is because of:
- morphological and functional characteristics
 - oral environment:
- cavities from temporary teeth level
- dento-maxillary abnormalities and wearing orthodontic apparatus with
neglecting the oral hygiene
- ingestion of carbohydrates and sticky foods
- neglecting the periodic check-ups
- general factors, like puberty
Young permanent cavity topography, ordered by frequency, is:
 6 year molar (occlusal and proximal cavities)
 Superior incisors (10-11 years)
 Pre-molars (13-14 years)
 Canines are in general resistant to cavities
 Secondary permanent molars
Classification of young permanent teeth cavities:
- by topographic criteria: cavities will be ordered by Black, in classes I,II,III,IV,V
- by depth criteria, there are cavities:
- Superficial: located at enamel level
- Medium: in evolution have passed by the enamel-dentinal limit
- Deep: close to the pulpal chamber
- by evolution criteria, the cavities are:
- Acute
- Chronic
- Stopped in evolution
Many times problems in diagnosing permanent teeth may appear, if their morphology
isn’t well known, comparative with that of temporary teeth. Problems may also appear when
diagnosing fissure cavities and proximal cavities located beneath the contact point. It is
mandatory the examination of the homonymous tooth on the other side (symmetric cavities).

Differential diagnosis of the simple permanent teeth is made with:

1. Dystrophies, in superficial cavities
2. Open pulpal chamber chronic pulpitis
3. Gangrene and necrosis, in deep cavities.
 Simple cavity symptomatology:
Simple cavity of the young permanent teeth has a similar symptomatology with that of adult
permanent teeth.
Deep cavities present the next characteristics:
- Clinically, subjective signs are attenuated. Sensibility appears to chemical agents
(sweet) or physical (cold), this stopping once the stimulating factor is removed. Axial
percussion of the tooth is negative.
- Objective, we can observe a lack of extended substance. According to the depth of
the cavity there can be a simple cavity located at the level of the enamel, or a medium or deep
cavity, with abundant damaged dentine(wet cavities), with fast evolution and persistency of a
thin layer of dentine above the pulpal chamber.

Treatment of the young permanent teeth simple cavity:

It must be done as soon as possible, otherwise these carious lesions will rapidly
penetrate the hard dental tissues (which have a lower resistance to the carious attack
comparative with a mature permanent tooth) and so will become complicated cavities.

Treatment objectives are:

 Eliminating the irritating and favorable factors
 Ensuring the favorable conditions that the pulp will continue its dentinogenetic function and
forming the root
 Rebuilding the morphology of the tooth, so that this can still do its physiognomic function,
phonics, masticatory, occluzal, self-cleaning and growth area.
Times for dental cavity treatment are:
1. Surgical: which consists of excision of the affected tissues, preparing the cavity
2. Drug stage, which consists in treating of the dentine wound
3. Prosthetic stage, rebuilding the morpho-functional structure of the crown

The preparation of the cavity will be done by respecting Black’s principles, adapted to
modern filling materials. We will conserve the hard dental tissues because of the properties of
modern filling materials, which don’t need mechanical retention anymore, at the level of the
prepared cavity. We will have in mind the big size of the pulpal chamber at these teeth as well
as the big sized dentinal canals.
 Dentinal wound treatment has as objectives, removal of the dangerous factors,
protecting the dentinal surface, protecting the pulp from the affection of physical and
chemical factors from the oral environment or from the filling materials and stimulating the
pulpal defense and neo-dentino-genesis mechanisms. We will avoid irritating substances like
peroxide or alcohol and we will use distilled water, saline, then easily drying the cavity.
According to the aspect of the dentine from the pulpal wall, in deep cavities, as well as in
temporary teeth there will be 3 possibilities:
 Dentine is hard and with normal aspect: we can apply long-term filling from the first session.
On the pulpal wall we can apply a material like calcium hydroxide, and over it we’ll apply a
layer of cement with corresponding properties. According to the degree of destruction of the
tooth we could use other long time rebuilding methods, keeping in mind that we are speaking
about a permanent tooth.
 Dentine is hard, but pigmented: we will disinfect the dentine, applying a temporary filling
material like Zn eugenol, and then we do the final filling after 2-3 weeks of observation in
which the patient will tell us about the absence of painful phenomena.
 Dentine is hard, with a dot-like area of altered dentine at the level of a pulpal horn ( we will
do the natural pulp capping, Zn eugenol or calcium hydroxide bandage, minimum 6 weeks,
followed by some vitality tests, radiologic exam and then if the tooth is vital and there are no
signs of pulpal suffering we can continue with the final treatment of the cavity with a long-
term filling).
 Accidental opening of the pulpal chamber: direct pulpal capping with calcium hydroxide,
applying a base of cement glass ionomer and then a long-term filling. Periodic check-ups will
be made, vitality tests, radiologic exams, to check the continuity of root forming and absence
of pulpal suffering.

Materials with which final filling of the permanent young teeth is done can be either
plastic materials that will harden the carious cavity or non-plastic materials, made in the lab
and cemented in the cavity. In posterior areas, it is still used even today in some offices, the
silver amalgam. Other materials will be used also, which are at our disposition for the long-
term cavity treatment like compomers or compound materials (some components used in the
compound filling can be pulpal toxic and can determine the apparition of pulpal necrosis, that
is why some authors recommend the use of a liner under the filling of compound material in
case of deep cavities). From the dental materials that are used for temporary filling, in case in
 which we are required to do an indirect or direct pulpal capping, we can use Zn eugenol, Zn
phosphate cement, Poly-carboxylate cement or glass ionomer cement.
Further we will discuss about some of the primary proprieties of the filling materials
that are used today.

a. Silver amalgam
It is a non-physiognomic rebuild material, used on a restrained scale today. Dental
amalgam is an alloy of mercury with other metals such as silver, tin, copper or zinc. By the
content of copper, the dental amalgams are classified into conventional amalgams (with low
content of copper, 2-5%) or modern amalgams, with high content of copper( 12-30%) or non-
gama 2.

Advantages:
 simple and fast use
 cheap
 long-term
Disadvantages:
 unaesthetic
 It isn’t adherent and so needs the achieving of retention and preventive extension ( removing
of excess dental healthy tissues)
 There is a rumor regarding the toxic properties of the mercury and the negative effects it has
on the human body.
Clinical protocol
 Removing of the cavity and isolating the operative field
 If the cavity is proximal and is more deep, requires an occlusal cavity of retention, and the
angle between the two cavities must be rounded (we will do a class II typical cavity)
 If the cavity is deep it is preferred to apply a base of glass-ionomer
 If the carious cavity is very deep it is used some Calcium Hydroxide (Dycal, Kerr-Life) on the
bottom of the cavity followed by the appliance of a proper glass-ionomer base and then
amalgam filling
 If we have a Class II cavity to fill, we’ll place a circumferential matrix, fixed proximally with
a wooden cone, and filling it with filling material starts with the proximal cavity and ends
with the occlusal extension.
 The occlusion is verified with joint paper
 Then, the amalgam filling must be polished with some special drills, to obtain the specific
shine and to perfect the marginal closing.
b. Glass ionomer cement
Glass ionomers are hybrids resulted from silicate cements and poly-carboxylate
cements. Researcher’s intention was to make dental cement having the properties of silicate
cements (translucence and fluorine release) as well as the poly-carboxylate cements (ability to
chemically bond with the structure of the tooth and be non-irritating to the dental pulp).

Advantages:

 Resistance to compression is higher than the Zn oxy-phosphate cements

 Cario-prophylactic effect – because of the concentration of fluorine
 Higher adherence
 Very good sealing
 Good bio-compatibility
 Easy to use
 Holds on even in conditions in which an increased humidity persists (isolation is not
corresponding or teeth are partially erupted)
Disadvantages:
 Decreased durability (under 2 years)
 It degrades in acid environment
 Has weak mechanical qualities
 Usable only in cavities that are less extended
 Inferior esthetic than in compounds
Glass-ionomer cements are condensable (rich in inorganic filling), Fuji IX (GC) for example,
it is indicated
- In proximal rebuilding of small volume or for patients with carious risk increased
(releases more F than CGI modified with resins)
- As base filling in all cavities that have a pulpal wall that is deeper than 0.5-1 mm
towards the enamel-dentine junction
CGI resin modified, photo-polymer, Fuji II LC (GC), Photac-Fil(3M ESPE) it is indicated:
- for temporary teeth, in occlusal and cervical restoring, for superficial cavities.
 Glass-ionomer cement adheres better to the dentine than the enamel. Thus, the primary
indication of glass ionomers is the sandwich technique, as base or a compound or amalgam
filling as much as temporary as permanent teeth.

Clinic protocol

 Removing the cavity and isolating the operatory field

 Optional, demineralization with poly-acrylic acid to raise adhesion (10-20 sec)
 Easy moderate washing of the dentinal wound (can remain a slight moisture)
 Applying the glass-ionomer and or photo-polymerization according to the cement type
 Occlusal control and adjusting
 Applying a photopolymerizable polish for the protection of the glass-ionomer until the
complete adhesion (Fuji Coat LC or any other photopolymerizable adhesive polish)

c. Compomers

Compomers are modern materials, that come from glass ionomer cement and composite
materials, aiming to combine the qualities and benefits offered by these 2 materials

Indications:

- For treatment of temporary or young permanent teeth

- For treatment of small cavities
- Material of choice in treatment of class III and class IV cavities in temporary and
young permanent teeth
- Cervical erosions treatment (cuneiform gaps)
- Radicular cavities treatment
- Class II – mixt restores (compomer + composite resin)
- Abutments restore – crown still has ½ of its walls
- Crown repair of the fractured teeth
- Cavity repair for a term of maximum 4 years, after this time being able to be replaced
with a composite material, for example
 If the remaining enamel is in insufficient quantity, the adhesion will be unsatisfactory, the
contact surface being too small. The compomer does not need acid demineralization (only
when we use adhesives from the composite kit, acid etching will be made prior, when on top
of the compomer we will apply a composite material). Instead, the cavity is conditioned
through applying a primer and it polymerizes 10-20 seconds. This stage facilitates and grows
the adhesion of the compomer.

Present available materials: Compoglass F (Vivadent), Dyract AP (Dentsply), Elan (Kerr),

Twinky Star (Voco) which is a colored compomer, used for temporary teeth rebuilding.
Advantages
 those are adhesive systems, but does not require the separated demineralization (adhesive
system is also auto-demineralizing)
 have a good esthetic
Disadvantages:
 Limited durability, under 4 years
 Mechanical qualities inferior to resin compounds and fluorine release inferior to glass
ionomer cement
Clinic Protocol
1. Choosing the tint of the compomer
2. Preparing or not the cavity ( in erosions and cuneiform gaps the cavity is mechanically
cleaned with a brush and prophylaxis paste)
3. The primer is applied on the enamel and dentine for 30 seconds. The surface is not dried
immediately but only at 5-10 seconds after appliance. Photopolymerization for 10 seconds.
4. Applying of the compomer and photopolymerization for 40 seconds
5. Finishing, processing with bands/disks (SOFT – LEX). (2)

d. Composite materials

Those are modern cavity lesion repair materials, with which maximum esthetic results
can be obtained. Those are used for all classes of cavities, able to restore with those the
carious lesions, dental cracks, surface/form defects, can close the direct diastemes and facets,
can improve the loss of interdental papilla, periodontal immobilization and ceramic crown
repairing can be made also. Composite materials have lower resistance than the amalgam,
 gold or ceramic, using them being limited to the size of the lesion to be restored and the forces
that act on it.
Dental composites and their adhesive systems allow the maximal preservation
of the hard dental structures, ensuring their resistance. These are materials with a good
quality/price ratio and give superior esthetical results. Proper clinical situation use, the
procedure is minimal invasive, which tests the efficiency of these materials. The adhesive
techniques ensure retention and adequate resistance, requiring a minimal preparation. It
requires an adhesive system because these have no adhesive potential of their own to the hard
dental tissues, like glass ionomers, adheres better to enamel than the dentine and requires a
very good isolation. (3)

Microhybrid and nanohybrid composites

Microhybrid composites are material composites with special esthetic properties,
indicated for frontal area cavities restoring (very good esthetics, but lower mechanical
resistance).
- Advantages
 Adhesive system, esthetic
 Satisfying mechanical properties
- Disadvantages:
 Hard to obtain contact point
 Very sensitive protocol to any contamination
Condensable composites:
These are composite materials with mechanical resistance increased, indicated
especially for posterior restoring.
- Advantages:
 Adhesive system, esthetic
 Increased consistency, mechanical resistance
- Disadvantages:
 Hard to obtain contact point
 Very sensitive protocol to any contamination
 Lack of long-term clinical evaluation, these being relatively new composite materials
 Fluid composites:

Are composite materials characterized by a reduced viscosity, being indicated

especially for the following maneuvers:
 Enlarged sealing (when we remove with the drill the superficial coloring from occlusal ditch
 Cervical lesion treatment
 As base material we will use a more resistant composite in cavities of permanent teeth for that
its properties allow it to get in areas in which a solid compound cannot enter (class II cavities)
 Very narrow lesion treatment, found on the proximal faces, treated by tunneling or other
minimum invasive methods of cavity removal, in permanent teeth
 Sealing the temporary or damaged permanent teeth
- Advantages
 Adhesive system, esthetic
 Usable in micro-cavities
- Disadvantages:
 Protocol sensible to any contamination
 High viscosity
Clinic protocol
1. Rigorous isolation (with the rubber dam)
2. Demineralization for 15-30 seconds
3. Washing with water for 30 seconds, to neutralize the acid used for etching the cavity
4. Applying the adhesive by friction with the cavity walls, for minimum 10 seconds, so that can
penetrate as deep as possible. Then very easy drying up the cavity so that the adhesive will
distribute in an even way and photopolymerizes in 20 seconds. We won’t use high power
drying for not to clog the dentinal tubes, thus reducing the adherence surface.
5. Applying of composite resin and photopolymerise it for 20-40 seconds depending on the
product indications
6. After we applied the composite material in successive layers, rebuilding the coronary
morphology, we will finish the filling with finishing gums, disks, diamond pastes.

The adhesive systems that are the most used and with better marginal closing are those we
talked about previously, those with successive times of making the adhesion
(demineralization, washing, applying the adhesive system and then a composite material).
 Systems that reduce the number of steps, such as acid and adhesive are contained in a single
product, are faster and much more sensible to strict following of all technical details and
haven’t yet proven their durability in time, those being relatively new materials.

e. Preformed metallic crowns

These are industrial made metallic crowns, in series, used especially in the treatment
and rebuilding of temporary tooth (this method is discussed in this subchapter because all the
therapeutic measures used while treating dental cavities to be grouped like this, makes it
easier to remember). Those allow the keeping of the temporary tooth on the arch until its
physiological replacement, thus continuing its, functional as much as space holder, role.
Allows the complete reconstitution of the coronary crown, including the inter-proximal and
occlusal contact points, which in case of temporary teeth is difficult to rebuild with
conventional filling measures. (Img. 8.2, 8.3)
Img. 8.2 Preformed metallic crowns
Img. 8.3. Preformed metallic crowns at the level of 7.5
In case of permanent teeth, individualized metallic crowns are indicated, which are
created in the laboratory after a print was taken before of the prepared corresponding
permanent tooth.

Advantages:
 Long-term resistance
 Protects the teeth with coronary increased destruction
 Space-holder in a mezio-distal way and keeping of DVO
Disadvantages:
 unaesthetic
 prosthetic preparation which requires removal of healthy tissue
 requires a very good cooperation from the child
Indications:
 important coronary destruction of temporary teeth
 structure abnormalities (dystrophies, dental dysplasia)
 in case of fracture of an entire wall of the temporary tooth
Contraindications:
 chrome or nickel allergy
 when temporary tooth will be removed in the next months because of the rizalisis.
Principles for applying preformed crowns

Preformed crowns can be done on vital teeth and on those on which a pulpotomy or
pulpectomy has been done. Before we apply the preformed crown, we check that the carious
lesion has been treated well and the canal treatment has been finished correctly. A sealed
coronary reconstruction with amalgam or glass ionomer is indispensable for realizing the
protection of the present treatment, in case of de-cementation of the preformed crown.
We can observe the convexity of the vestibular and oral anatomy of the temporary tooth, these
will be used for crown retention because of the elasticity of the metal and we will reduce from
the tooth at proximal and occlusal level only what needed. Occlusal almost 1.5 mm with an
olive-type drill, proximal we take contact points and polish without threshold, with smooth
drill. The crown margins are shortened with curved scissors, it adapts very well to the level of
the ridge and then it is finished.

f. Restoring frontal teeth with the help of celluloid capes

These are utilities used in dentistry to ease the reconstruction of large scale dental
lesions. These are capes made from a transparent material which allows thus the
photopolymerization of composite materials. Those are found in adaptable sets to any tooth.
Indications:
 Coronary fractures
 Structure abnormal teeth
 Allows the esthetic and quick restoring of frontal teeth with extended destruction
Clinical Protocol
1. Removal of decayed tissues (‘baby-bottle syndrome’) or of irregularities of surface (surface
abnormalities)
2. Adjusting the capes and testing them
3. Acid apply + wash, adhesive + dry + photopolymerization
4. Cape is filled with microhybrid composite
5. Cape is inserted on the tooth and the excess that comes out must be removed
6. Photopolymerization, 40 seconds on each face
7. Cape is then removed and restoring is adapted in occlusion
8. Finishing isn’t generally required, only at cervical level

g. The inlay and onlay

These dental restores are the alternative to a normal dental filling, a modern and much
greater solution. These keep and restore contact points of the tooth with neighboring ones,
protect the interdental papilla from the masticatory pressures and restore the morphology of
the affected tooth and carious process.
Img. 8.4. Ceramic inlays at the level of 3.6 and 4.6

Indications:
1. On proximal cavity teeth, because of the accuracy and perfect adapting at the gingival
threshold;
2. In proximal cavities with difficult access for applying a composite filling, especially when the
contact point is hard to do
3. When we have a maximum 60% loss of the crown of a vital tooth
4. For rebuilding the occlusal and proximal morphology in big cavities, MOD.

Materials

Dental inlay can be made of ceramics, composite resins or even precious metals (gold).
Because those can be done from materials that mimic the natural color of the tooth, ceramic
inlays and onlays are preferred by the patients to replace amalgam unaesthetic fillings, with
the purpose of obtaining a much more natural aspect. Ceramics remains the material of choice
in prosthetics and dental cosmetics because of the natural esthetic aspect and its multiple
qualities based on durability, resistance and bio-compatibility. There are no differences
whatsoever between metallic and ceramic inlays except esthetics. To remember that patients
with low cario-activity and good oral hygiene, inlays from noble alloys can have a durability
of even 25-40 years.
The type of material used will depend on the following factors: esthetics, resistance, durability
and cost. In treating temporary teeth this type of dental restoring isn’t indicated, but in case of
permanent teeth with big coronary destruction, this is the ideal therapeutic alternative. These
will combine the esthetic qualities of dental ceramics with resistance and longevity.(4)
h. Dental Facets

Dental faceting represents a restoring procedure that fits in the category of dental
esthetics, because can improve the form, position, aspect and color of the teeth. Faceting can
be indirect – facets are done in the dental laboratory, time in which (2-3 weeks) the patient
wears temporary facets, or direct – the facets are done in the dentist’s office, from composite
materials.
Dental facets can be done from ceramic as well as composite resin physiognomic
materials. Ceramic facets are more resistant, more expensive and have a longer life span (up
to 15 years, keeping translucence and shine of the natural enamel) than those made of
composite (up to 2 years, composite quickly losing the esthetic qualities)
The faceting success depends on the dentist’s experience and the handiness of the
technician that does the ceramic facets.

Indications for ceramic faceting

Faceting can be done on a single tooth or on multiple teeth, even on the entire portion
of the visible arch while we smile – often until pre-molars 2 on each hemi-arch.
Ceramic facets can be used to solve:
- Spacing and diastemas
- incisal angle fractures in the enamel and cracks of the teeth
- discoloration provoked by endodontic treatment, drugs and fluorine deficit
- enamel erosions
- cosmeticizing the malpositioned teeth, rotated
- cosmeticizing big unaesthetic fillings on anterior teeth
- cosmeticizing enamel hypoplasia, imperfect enamel genesis
- cosmeticizing short teeth, conic or with other form abnormalities

Contraindications for ceramic facets

-patients with para-functions: ceramic facets can crack or easily break if they are
applied to a patient that suffers from bruxism
 - the existence of an inappropriate or insufficient quantity of enamel: ceramic facets
are cemented only over the dental enamel
- periodontal active diseases: teeth that are to be applied with facets must have a
healthy periodontium
- if the patient has poor oral hygiene
- if coronary morphology is unfavorable
In conclusion we can use dental facets only on permanent teeth, when we have coronary
destructions or development defects of the teeth from the frontal area. We must know that
applying a fixed orthodontic apparatus later will be much harder and will damage the facet.
That is why, we prefer the orthodontic treatment before, in the adolescent time so that then,
when in adult age to do the prosthetic restores that will finish a complete and correct dental
treatment occlusal as well as esthetic.
Choosing the filling material of the temporary or permanent cavity treatment will be
done following the aspects that are schematized below.

Therapeutic indications for temporary teeth

In temporary teeth the restoring materials are chosen by:
 expansion of the carious process
 time until the physiological replacement (for anterior area 6-9 years and for lateral
area 9-12 years)
Ordering the materials by these criteria can be illustrated like a pyramid that has at its base the
materials that can be used on all lifespan of the temporary tooth, more resistant in time, and at
the top the materials that have a limited lifespan and that are used thus only for a limited time.
 Physiological fall of the temporary tooth
deep cavity
condensable GI
resin modified GI -
<2 years until replacement I
Compomer C-
Condensable composite, CPP R
<4 years until replacement +
Micro-hybrid composite, amalgam, CPP

Fluid composite, compomer, resin modified GI

superficial Supplementary hygiene methods, fluorinated polishes

cavity
Tooth eruption on the arch. Medium lifespan: 7 years
after F. Courson and M-M. Landru
Therapeutic indications can be modified by the carious individual risk, the higher the
risk the more usage of highly resistant materials.
For example: if a tooth that has 4 years until replacement and a superficial cavity, for which
normally a compomer would suffice, if the patient has high ICR (individual carious risk), will
be better filled with a micro-hybrid composite for this is more time resistant and has a better
marginal enclosure.

In children that have no possibilities to come to regular check-ups every 3 months, we

will prefer using these highly durable materials.

Therapeutic indications for permanent teeth

1. cavity free notches, less breakable:
Noninvasive treatment will be done with:
 fluorinated polishes immediately after eruption
 composite applying for sealing after the tooth has erupted and can thus obtain a
corresponding isolation of the operatory field
2. Deep colored notches or microcavities located superficially in the enamel:
The limited dot-like access will be done towards the decayed notches (fissure drills can be
used, very smooth or non-abrasion or micro blast). Materials used will be: compomer and
over it a protective polish or fluid composite, depending on the respective tooth’s age.
3. Enamel located cavity, near the enamel-dentinal limit
The carious lesion and the colored notches are removed. Materials used are composite
materials, chosen from the wide palette of consistency, depending on the location of the
carious process.
4. Medium cavity, located 1/3 externally of the dentine
The carious lesion is removed but we will inspect the notches and fissures apparently healthy.
Materials used can be represented by, depending pm depth of the carious process and age of
the permanent tooth: a liner (calcium hydroxide) and a composite material used for
morphological and functional rebuild, a liner protected by a cement or glass ionomer and
composite base, in big sized cavities or just a corresponding composite material if we talk
about a permanent tooth that is already mature.
5. Deep cavity, located in the para-pulpal dentine
Access to this lesion is done, undermined enamel and infected dentine is removed. It is
good that beginners used the cavity indicator all along the removal of altered tissues, this
being proved to be of help. Materials used will be the ones necessary for an indirect pulp
capping: calcium hydroxide applied in a thin layer at the level of the pulpal wall, this is
covered with a glass ionomer base and over this base we will apply the composite material,
long term filling.

6. Very deep cavity, near the pulp, on a young permanent tooth, with pain
symptoms

a) Accidental exposure of the pulp, with spontaneous located pain, short duration:
The direct capping will be done with the purpose of maintaining the pulpal vitality: we
apply pure calcium hydroxide (preferable in the form of dust that is mixed with saline, or it is
used just the base from the paste products) , over this we apply calcium hydroxide for base,
then glass ionomer and then the composite material to perfectly isolate the area o pulpal
exposure. We will ask the patient to come to regular check-ups, in which we will test the tooth
vitality and in consequence the direct capping.
b) Pronounced pain symptomatology, with irradiating spontaneous pain:
 In these conditions in which these painful symptoms appear, we will do the
endodontic treatment of the respective tooth, pulpectomy. If it is about a permanent young
tooth then we will apply the technique of apexification in a first stage, and if it is about a
mature tooth with closed apex, we will do right and final endodontic treatment.

Dental Sealing

This technique is used in prophylactic purposes and it has been more detailed in the dental
prophylaxis chapter.
In permanent teeth we can recommend other sealing types, called enlarged sealing and
extended resin filling (preventive resin filling =PRF)

I. Enlarged sealing (PRF type 1)

Minimal invasive techniques are a new concept in dental pediatric medicine, which
combines the early diagnosis with the ultra-conservative preparations. Enlarged sealing (ES)
is part of the modern treatment techniques (sealing fillings), ultra-conservative.

ES consists of creating a minimal cavity, obtained by strictly removing only the

colored part of the enamel through a minimum invasive technique called enameloplasty.
Then, this cavity is filled with sealant (a fluid composite resin)

Indications
- In patients with medium/high risk for cavity
- In case that we observe the presence of occlusal malformations/demineralizations.

Technique

1. Local anesthesia if it is the case (generally unnecessary)

2. Rubber dam isolation
3. Surface cleaning by professional brushing
 4. Enameloplasty of the suspected affected crack with a small ball turbine
drill
5. Excision of all cavity areas and unsupported enamel prisms
6. Cavity washing
7. 1. PRF type II:
i. the difference between PRF type III is just about the cavity
resulted. PRF II treats a medium carious cavity, PRF III the
cavity is deeper in the dentine, treatment requiring the
appliance of a liner of calcium hydroxide for example.
Technique
 it will be done by removal of the carious lesion with
small sized drill. We will try not to remove healthy
enamel, undermined but we will not let either enamel
prisms that are dentinal unsupported
 after we have checked with the cavity indicator the total
removal of the carious process, we will wash the cavity
and do its isolation with the rubber dam
 at the level of the pulpal wall we will apply a liner/ a
base if the depth of the lesion is big enough.
7) 2. PRF type III
This type of filling treats a deeper carious cavity, extended over the enamel-dentinal joint,
over 1 mm depth in the dentine.
- if the cavity resulted is medium, we apply a base of CIS/FOZ up to the JSD
-if the cavity resulted is deep we apply a layer of calcium hydroxide liner and over it a
base of CIS/FOZ up to the enamel-dentinal joint (laminated filling)
- photopolymerization of each layer will be done for 40 seconds.
We then finalize the coronary restore like so (common for both types of preventive fillings):
- acid demineralization of enamel margins of the cavity and the occlusal/fissural
system remaining, in general 15 seconds:
- neutralizing the acid with water, under isolation
- applying a thin layer of primer + bonding, in the cavity with the help of an
applicator. Photopolymerization of the bonding is done for 20 seconds
- applying a hybrid composite in the cavity, rebuilding the occlusal morphology. The
material is polymerized layer by layer.
 - applying a liquid sealant, opaque, over the composite filling and over the entire crack
system and occlusal remaining holes, photopolymerization of the sealant. Not required to
demineralize the occlusal surface before placing the sealant.
8) filling check-up
9) oclusal checkup and isolation removal
10) finishing and polishing the filling

Type of Indications Lesion level Treatment

sealing
Simple - Patient with high risc for cavity - no cavities Only sealant
sealing - Crack system retentive but healthy - questionable lesion,
- without proximal cavities colored occlusal
- fresh erupted teeth notches
- patient with lower risk for cavity,
having though maximum one cavity
- Rx bitewing excludes dental cavity
Enlarged - colored and demineralized notch -lesion stops in the Enameloplasy,
sealing - patient with medium and high risk enamel (superficial applying the composite
of cavity having 2 or more cavities cavity) flow + sealant material
PRF I - superficial cavity, located in the - lesion stops at JSD Enameloplasty +
enamel of up to the JSD level (class I composite material +
superficial cavity) sealant
PRF type - medium or deep cavity, extended in - lesion is localized at - Enameloplasty
II , III the dentine, with lateral expansion different dentine levels followed by CIS base +
somewhat bigger - class I medium composite + sealant
- cavity margins are in contact with - class I deep - Liner Ca(OH)2 + CIS
the antagonist + Composite + sealant
Amalgam - extended to dentine big lateral - lesion is located in Enameloplasty
or cavity, along JSD the dentine ±Ca(OH)2 +
composite - cavity margins are in contact with (medium/deep cavity) Composite+ sealant
filling for the antagonist - less cracks remain
the around the unaffected
posterior carious cavity
area

Permanent young teeth complicated cavity

Many times, being mistaken by the parents with temporary teeth, permanent teeth
suffer advanced cavity lesions and are brought in the dentist’s office too late for treatment.
This happens often after a nocturnal pain. Many times we will diagnose a deep cavity, with a
rich deposit of altered dentine and with previous painful phenomena.
Pulpal affliction particularities of the permanent teeth in growing stage are determined
by characteristic aspects of the young dental pulp and the stage of root forming. The large
contact between the radicular pulp and the periapical area, because of the open apex has the
following consequences:
 prevents the increase in intrapulpal pressure during inflammatory
phenomena
 rich blood perfusion facilitates intense metabolic exchange and rapid
toxic and metabolites elimination

Permanent tooth pulpitis

Pulpitis classification:
 by evolution:
o acute
o chornic
 by topography:
o with open pulpal chamber
o with closed pulpal chamber
 by pathology:
o serous
o purulent
 o ulcerative
o granulomatose

Diagnosing pulpitis in permanent teeth

Subjective exam:
The patient visits the dentist most often due to pain. They will tell us about the
presence of painful episodes in the past, most often overlooked if analgesics would be
effective. They will indicate a tooth with large cavity or a healthy tooth, not the tooth in
cause, in late stages of pulpal inflammation when the tooth in cause cannot be identified by
the patient. The pain may be triggered or spontaneous, the duration may be seconds up to
hours or days. Often the patients cannot locate the pain, they will tell us that their eye or ear or
half of their face hurts. Other times if the pulpal suffering is in an early stage, the patient will
tell us correctly the problem tooth. In children, the absence of pain does not mean the lack of
pulpal affliction or inflammation (it is an asymptomatic form or a chronicled affliction). The
pain perception mechanisms are different in children and the intensity of the lesion is not
correlated to pain intensity.

Objective exam

In objective exam the dentist will observe often an extended carious cavity, with a rich
deposit of altered dentine. In other situations, we will notice an older, incorrect filling, with
secondary cavity and altered color of the enamel. There is also the possibility of identifying a
deep carious cavity, on its pulpal wall we notice altered dentine, granulation tissue, a pulpal
polyp (present in chronic pulpitis with open pulpal chamber) that bleeds abundantly on probe
palpation. Axial percussion sensibility is present in all phases that follow total serous pulpitis.
This signifies involvement of the periapical tissues. The viability tests may be useful but are
not always conclusive.

Clinical forms of pulpitis

 pulpal hyperemia
  acute serous pulpitis - partial
- total
 purulent pulpitis - partial
- total
 chronic pulpitis - with closed pulpal chamber
- with open pulpal chamber
Young permanent teeth pulpitis treatment
Treatment objectives:
 Ensuring conditions for future root forming
 Partial or total pulp conservation
 Removal of pulpal irritants
 Relieving the pain
 Stimulating the defense capacity of the pulp

Treatment methods:
 vital amputation
 pulpectomy

Vital amputation (pulpotomy)

Indication: in acute and chronic pulpitis
 Technique: anesthesia
 Rubber dam isolation
 Preparing the cavity
 Opening the pulpal chamber
 Ablation, removing the coronary pulp
 Hemostasis
 Saline washing, using only sterile rolls
 Applying the quick setting calcium hydroxide paste on the radicular
abutments
 Applying a cement base then the final filling

Periodic clinical and radiological check-up until root is formed.

Img. 8.5 Schematic representation of pulpotomy stages
Endodontic treatment of young permanent teeth

In the case of these young developing teeth, whose apex is still open, our main
objectives during endodontic treatment is to suppress the patients pain, to remove the dental
pulp under perfect isolation conditions, to remove as many microbes as possible from the
endodontic system and last but not least to allow the tooth to mature, thus aiding the
apexification process. If the tooth has a closed apex, then we will not need to do more than the
correct endodontic treatment.

APEXIFICATION

Definition

Apexification is a treatment technique that stimulates the continue of root forming at a young
devitalized permanent tooth (after a pulpal suffering), through with the radicular canal
diameter is reduced with the purpose of obtaining apical enclosing and achieving the right
conditions to do a correct and definitive endodontic treatment.

Indication: in permanent young teeth, with open apex, with one or more roots.

APEXO-GENESIS is, by contrary, the physiological process of apical region forming and of
tooth maturing in its apical zone.

The apexification technique will be detailed later, this being a technique that is used in
treating pulpitis and necrosis, gangrene or apical periodontitis from young permanent teeth,
with immature apex. Endodontic treatment of a permanent tooth with closed apex will be
made as in the case of an adult permanent tooth, following the same steps.
Img. 8.6 Apexogenesis (Ingle)

Pulpal necrosis

Definition
Pulpal necrosis represents the pathological process of aseptic mortification of the pulp
under the action of dangerous factors of different natures.

Etiology of the necrosis:

1. local factors, determined: mechanical, chemical, thermal
2. general factors, favoring, that cannot provoke pulp mortification but creates right
conditions so that normal stimuli to become dangerous.

Pulpal gangrene

Definition
Pulpal gangrene represents the pathological process of pulpal septic mortification,
with or without the interest of periapical tissues, as following to the action of mixt microbial
flora, aerobic or anaerobic.

It is a complication of the pulpal afflictions, which determine the loss of tooth vitality, as
following of evolution of an acute purulent pulpitis, of a chronic pulpitis or a pulpal necrosis,
infected afterwards.

Evolution:
 Towards an acute or chronic apical periodontitis
 Can favor the appearance of a crown-apical fracture
 Can be an active focus of infection or potential, with negative involvements on the
entire organism.
Treatment
Necrosis and pulpal gangrene are two entities of which treatment is the same and can be:
- conservative
- surgical
Conservative treatment of the gangrene and pulpal necrosis:
  In teeth with completely formed root treatment is the same as in adults
 In teeth with root still in development, with open apex, there are difficulties related to:
o Mechanical treatment: Protecting the apical zone is a must, and we will accord
a special attention to isolating the tooth, deciding on the work length,
instrument we use
o Antiseptic treatment: appears the danger of drug diffusion through the wide
open apex and supplemental irritation of the periapical periodontium.
o Radicular filling: serous or purulent secretion may persist on the canal and can
be difficult to get a dried canal, prepared for filling
In the wish to be more conservative, we will try in a first stage to disinfect as well as
possible the endodontic canal and then, using drug substances with biological effects on the
tooth and periapical tissues we will try to stimulate the closing of the apex and do a complete
and correct canal filling.
To do this we apply the apexification technique, described lower in more detail, applicable in
case of treatment for pulpitis, necrosis or gangrene as well as in an apical periodontitis.

Apexification – Frank technique

 Objectives:
 Eliminating the necrotic or gangrened content from the endodontic
system
 Achieving a mechanical treatment and preparing the radiculary canal
 Achieving the partial radicular filling, with calcium hydroxide paste
(biologic activator), in a first phase.
Technique
 Obtaining a retroalveolar radiography to better know the position of the tooth on the
arch and the radicular anatomy
 Rubber dam isolation
 Obtaining a wide and correct access into the pulpal chamber
 Irrigating the canal with sodium hypochlorite constantly, to remove dentinal scraps
 Determining the roots length with the apex locator and confirming this with the
‘needle in canal’ radiography (Img. 8.7)
 Achieving mechanical treatment with Kerr needles series I or II depending on the size
of the canal, under constant irrigation with sodium hypochlorite
  Drying the canal with paper sterile cones
 Inserting the calcium hydroxide paste without pressure, to avoid supra-filling
 Applying a sterile cotton swab over which glass ionomer cement or a composite
material will be added to ensure a better sealing
 If inflammatory phenomena are appearing, the process is repeated insisting more on
the mechanical and disinfection treatment
 Over 6 months, the apexification process is appreciated, radiological.
 The procedure is repeated until we notice a tightening of the canal in the apical zone.
 The healing process has a duration that varies between 6 and 24 months
 After the dental apexification has been made, we will do endodontic definitive
treatment on that tooth.
The result of the apexification is favorable if:
1. The root elongated, canal tightened, apex closed
2. Apex closed, without changes in size of the radicular canal.
3. There is the presence of a calcified, radio-visible bridge under a closed apex
4. Apex funnel formed, but closed by a hard bridge, invisible radiologic but manually check-
able, with a needle introduced in the radicular canal without pressure, up to the apical zone. If
this meets an obstacle in the apical zone, a barrier, means that the calcium hydroxide bridge
has formed and the treatment was right.
After the formation of the calcified bridge, the radicular filling is made, to prevent the
calcified zone resorbtion.
Img. 8.7 Needle canal radiography at the level of 1.7; at its level there is also a
supplementary canal, MV2
Img.8.8 Radiologic evaluation of the apexification efficiency
Img. 8.9 Different stages of the apexification process
Img. 8.10 Schematic representation of the apexification process

Surgical methods used in treating complicated gangrene:

 Apical resection is not indicated in the growing stage, because reduces even more the
length of the root
 Dental re-implantation, which isn’t used nowadays
 Dental extraction
The moment and extraction indication of a tooth will be done by those aspects:
 if it is about the permanent molar one, we will keep in mind about his role in keeping
the occlusal relations
 The presence or absence of DDMs that are crowded
 The dental age
 Dental migration of neighboring teeth or antagonists
o By moving of the teeth (gression, version)
Permanent molar one extraction can be:
 Early extraction, 7-9 years, will have as consequences:
o Ample migration to distal of the premolars, with spaces between them and the
canine
o Egression of the antagonist (blocking sagittal movements)
o Occlusal dysfunctions
 Extraction at 10-11 years with the following consequences:
o Biological closing of the breach from posterior, through migration of the
permanent molar two.
 Extraction after the eruption of the permanent molar two
o The version of the neighboring teeth, decrease of edentate breach, fact that
favors the installation of occlusal disfunctions

Apical periodontitis

Clinical forms of apical periodontitis are:

- Acute
- Chronic
- Congestive
- Exudative

Diagnosis

Acute apical periodontitis have a rich symptomatology, subjective and objective

Chronic apical periodontitis are characterized by an olygosymptomatic clinical picture, even
absent for a long time or, with excruciating pain, unbearable that cannot be relieved with
regular painkillers in the acuting phases

Subjective: axial percussion, simple touch of the tooth or while talking, masticating
determines pain.
Objective: color change of the tooth, gingival congestion, dental mobility, presence of the
fistula (in chronicle forms)

Radiologic exam: Diffuse bone processes, areas of periapical radio-transparency of different

sizes.

Treatment

Acute apical periodontitis are considered emergencies and are treated like so:

 Endodontic drain
 Abscess incision, if this is big in size and drainage by canal isn’t possible or
insufficient
 Antibiotics therapy
After the painful and inflammatory symptoms ceased, treatment of the tooth will be done
respectively, which will also be conservative (endodontic treatment) or surgical (apical
resection, dental extraction)
Img. 8.11 Fistulized chronic apical periodontitis
 9. THE DENTAL CAVITY PROPHYLAXIS

Primary prophylaxis represents the measures for increasing hard dental tissues
resistance and removal of favoring or determining of dental tissue destruction factors.
Secondary prophylaxis represents the early treatment measures of the carious lesions
and decreasing the disease rate of healthy tissues
Prophylaxis of the dental cavity is done throughout the entire life, but can be
influenced by life stage:
- in babies and little children: educated by the parents firstly for establishing the right
hygiene measures and then the child, when it is capable to follow our instructions.
- in children in the permanent teeth eruption stage: the measures for dental hygiene are
increased, erupted permanent teeth are sealed
- in teenagers: periodic professional check-ups are done, applying topical fluorinating
substances depending on the cario-receptivity, prophylaxis and motivational measures for a
very good dental hygiene and a healthy aspect of the soft tissues of the oral cavity.
- in adults: regular check-ups and professional hygiene, topic application of fluoride
compounds depending on the cario-receptivity, individualization of prophylactic program,
professional activity/existing odontal afflictions.
- in old people: regular check-ups and professional hygiene, in case of xerostomia we
apply treatment (because of organic afflictions or pharmacological treatments) we utilize
artificial saliva if need be, we may recommend electric brushes (because of decreased
dexterity or different afflictions which prevent up to par hygiene).
The patients must realize that dental prophylaxis measures must be pursued and
perfected all throughout one’s life. The dentist have a duty to constantly motivate the patients,
children and adults for a healthy way of life, while maintaining oral hygiene and a healthy and
cario-prophylactic nutrition.
Primary prophylaxis consists of:
 increase in hard tissue resistance by general fluoridation
 control of dental cavity by oral hygiene
 counseling on cario-genetic and cario-prophylactic nutrition
 sealing the notches and cracks
Secondary prophylaxis consists of the prevention of formation of the dental cavity
and early action against early lesions, to prevent the progression of the afflictions:
  early diagnosis and treatment of carious lesions in early stages
(remineralization, extended sealing)
 measures to decrease the rate of healthy tissue alteration
Tertiary prophylaxis consists of therapy of established lesions in order to avoid their
progression or appearance of complicated lesions and reoccurrence, as well as all cavity
treatment:
 treatment of dental cavities, rebuilding fillings with overflowing
edges or with secondary cavities
 prevention of recolonizing the teeth with bacterial plaque,
professional hygiene.
The prophylaxis of the dental cavity is done individually as well as collectively.

Collective prophylaxis is done at collectivities level and consists of prophylactic measures

with maximum efficiency and minimum investments, in large population groups. It is about
organized actions that are controlled by doctors and helped by teachers, parent, local and
national authorities:
 Fluoridation of the water and kitchen salt
 Radio/TV campaigns for informing about dental hygiene measures
 Social programs addressed to disadvantaged categories of the
society

Individual prophylaxis consists of using some diagnostic and therapeutic measures, adapted
to the carious risk of every patient, following the prevention of carious pathology forming
through:

I. Evaluating the carious risk of every patient

II. Prophylaxis measures done by every patient (dental brushing, using mouthwash and
dental floss)
III. Prophylaxis measures done by the dentist, individualized, regarding the needs of every
patient and periodic control

I. Evaluating the carious risk of every patient is done by:

1. Medical survey
 The medical survey contains personal data of the patient, physiological and
pathological history of the patient, food and drug allergies, information about drug
treatments followed by the patient (chronic/ on the moment), if the patient eats
between meals or not, consumes sweetened or carbonated drinks, takes supplements
of fluorine or uses fluorine tooth pastes, mouthwash with clorhexidine.
2. Clinical exam
Must contain data referring to:
 Hygiene ( OHI-S index)
 CAO index and the date of last fillings
 Chalky stains
 Dystrophies and discoloring present
 Dental morphology characteristics (notches with irregularities,
more prominent cingulum in lateral superior incisors)
 Inappropriate restores
 Malposition
 Periodontal exam

3. Food analysis
It is indispensable to evaluate the carious risk. The sugar intake leads to significant
drop of pH at the level of dental plaque and in consequence the demineralization of the hard
dental tissues appears. The studies have shown that not the quantity of sugar is important, as it
is the number and frequency of the sugar intake.
Food analysis has the following purpose:
Informing the child about the negative influence that permanent snacks between meals have
on dental health
Orientates the practitioner on the measure he must take in order to fight against a frequent
cariogenic food intake.
It is recommended to the patients:
- food with harder consistency
- reducing the frequency of carbohydrates (with low molecular mass) between meals
- reducing the quantity of sucrose in meals in general, knowing the sucrose containing
aliments under masked form (ketchup, dried fruits)
- between meals it is recommended: milk and milk products (yoghurt, cattle cheese), fruits,
vegetables, nuts, as long as these products are not supplemented with sugar (sweetened
yoghurts, candied fruits)
- at the end of the meal we can eat a fruit or a fresh vegetable as desert (celery, carrot, apple,
orange) which removes a part of the new plaque deposits on the teeth.
- chewing sugar-free gum after meal (if there is no brushing possibility) because, stimulant
saliva, rich in carbs and phosphates, has a very good buffer capacity and helps in the
remineralization of the early enamel lesions.

4. Evaluating oral-dental hygiene

Two copies of the patient’s record are completed, one for the patient, which serves to
his motivation. Records are completed at every check-up thus being able to objectively
appreciate if the patient improved his oral hygiene. We can watch different dental hygiene
indexes like: OHI-S or OHI, the plaque Index Silness and Loe, the retention of bacterial
plaque index Loe.

OHI-S index (Oral Hygiene Index – Simplified)

We will check the following teeth:
-1.1, 1.6, 2.6, 3.1 on vestibular sides
- 3.6, 4.6 on lingual sides
The values of the plaque index (DI- Debris Index) are the following:
0= absence of the plaque
1= supra-gingival plaque in 1/3 cervical part of the tooth, at the ridge
2= plaque in 1/3 middle part of the tooth
3= plaque in 1/3 occlusal and incisal of the tooth, so the whole tooth is covered by muco-
bacterial plaque

Tartar index values (CI – Calculus Index):

0= absence of the tartar
1= supra-gingival tartar in 1/3 cervical part of the crown
2= supra-gingival tartar even in 1/3 middle part of the crown, sub-gingival tartar isles
3= supra-gingival tartar even in 1/3 occlusal/incisal part of the tooth, sub-gingival tartar in
tape
Img. 9.1 OHI-S evaluation
The sum of the plaque deposits (DI) and mineralized deposits(CI) is calculated at the level of
the 6 teeth, on the mentioned surfaces
Expression can be done in 2 ways:

1. No. of surfaces with plaque (tartar) / No. total dental surfaces*100

Hygiene is considered ok when the total surfaces with plaque don’t pass 15%

2. After calculating plaque and tartar deposits these are compared to the following
values:

0-4 => good hygiene

4-6 => acceptable hygiene
>6 => poor hygiene
18 => maximum value, disastrous hygiene

Silness and loe plaque index

It is an easy to do index and can be done in epidemiologic studies also, in kindergartens,

schools.

Values of the plaque index are the following:

0= absence of plaque
1= plaque is not observed freely only after its removal with the probe
2= dental plaque can be observed freely, like a fine film-like deposit
3= thick layer of plaque is accumulated, covering all of the gingival notch from the gingival
free edge until the dental surface
Interpretation of the values is similar to that for the OHI-S index.

Values of the tartar index are:

0= absence of cavities, tartar or irregular edged fillings near the gum

1= supra-gingival tartar, cavities, irregular edged fillings
2= sub-gingival tartar, cavities, irregular edged fillings
3= abundant tartar supra and sub-gingival, deep big cavities, fillings with big retentive
marginal defects

Interpretation of the values is similar to that for the OHI-S index.

Salivary flow exam and salivary buffering capacity

CRT test – Caries Risk Test (Vivadent), measures the flow, buffering capacity and
Streptococcus Mutans and Lactobacillus colonies from subject’s saliva.
Test protocol asks the patient not to eat anything for at least an hour and half, not to use any
oro-pharyngeal antiseptic at least twelve hours before the test is done and not to take any
antibiotics the last two weeks.
a) Salivary flow measure:
Salivary flow:
- Reflects the quantity of saliva that is produced
- Decrease of salivary flow determines the increased forming of dental plaque, decrease of
antibacterial activity, discomfort sensation.
- Salivary flow is continuous during time and almost stopped during sleep.
- Normal rest flow is 0.25-0.35 ml/min (15-19 ml/h)
- Stimulated salivary flow is between 1-2 ml/min (60-120 ml/h)
- The interest is represented by measuring the rest flow, which is on the most part of the day,
but the stimulated flow is easier to measure and the two flows are direct proportional.
 Salivary flow (ml/min)

1.6

1.2

0.8

0.4

0
while sleeping non-stimulated stimulated saliva
saliva

b) Salivary buffer system capacity

- Salivary pH has a normal 6.7
- Enamel demineralization starts at a pH value of 5.3
- fermentable sugars intake provoke the pH drop (decomposing of sugar by bacteria that lead
to rapid increase of acids that pass in saliva), this acidity being favorable for the initiation of
the carious process by maintaining a favorable environment for acidophil bacteria and dental
tissues demineralization.
- pH drop depends on the type of carbon hydrate, its retention in the oral cavity, food acidity,
frequency of ingestion, etc.
- Saliva, because of the carbonated ions, phosphates as well as proteins, has the capacity to
buffer the acidity created by bacteria, progressively raising the pH level towards the normal
value.
c) Sepsis estimation of Streptococcus mutans (SM) and Lactobacilli (LB)
It raises the quality of the carious risk diagnosis and the prognostic on long term of the
affliction. Testing saliva proprieties towards the dental plaque gives a more general
information, in relation with the sampling of a bacterial plaque quantity form a focus, and
reveals information only about that specific focus of the oral cavity.
Conclusions:
The results of these tests will be written in the patient’s record, these may lead to
further analysis and certain recommendations:
- a decreased salivary flow will lead the doctor towards the cause, that may have
slipped during anamnesis (>400 drugs can lower the salivary secretion)
- drop of salivary flow can require the prescription of salivary stimulants or some
salivary substitutes (Programme BioExtra Medicadent), regular humidifying of the mouth
with water, mastication of a chewing gum with xylitol or fluorine (Freedent, Tonigum,
Fluogum), special diet recommendations.
- Tests point towards some individualized therapeutic actions (if a lowered salivary
flow exists, fluoridations are recommended as well as protection of the root in gingival
retractions, more insistent brushing in carious risk areas).
- Salivary tests can allow the following of risk factors evolution and prevention
efficacy, through redoing and comparing of tests at different times.

5. Radiologic exams
Radiologic exams that we use are the classic ones:

- Retroalveolar radiographies
- bite-wing radiographies
- orthopantomography

These radiologic investigations are indispensable to identifying:

- Cavities located under the point of contact

- Radicular cavities
- Secondary cavities and cavity relapses
- Pulpal affliction
- Periapical dental focuses.

Once we did those examinations, we can assess the carious risk of the patient and so, we can
focus on prophylaxis methods that we can adapt, individualize and apply.
RISK FACTORS RISK INDEXES
 HIGH MODERATE LOW
1. History (parent interrogation)
1.1 Child needs special care, has general health Yes No
problems
1.2 Child has a reduced salivary flow or a poor Yes No
saliva composition
1.3 Child is in dispensary care Never Irregular Regular
1.4 Time from the last cavity forming <12 months 12-24 months >24 months
1.5 Child wears fixed or mobile orthodontic Yes No
apparatus
1.6 Child’s mother presents active cavities Yes No
1.7 Social-economical level of parents Lowered Medium Raised
1.8 Daily exposure to sweets/ cariogenic foods, Minimum 3 1-2 times Just during
sweetened juices/carbonated drinks, between times meals
meals

1.9 Child exposure to fluorine Fluorine Fluorine Fluorine

toothpaste is toothpaste is toothpaste is
not used; used; used;
Drinking Drinking Drinking
water is not water is not water is
fluoridated, fluoridated, fluoridated
no fluorine no fluorine or fluorine
supplements supplements supplements
taken taken are taken

Patients can thus be ordered in 3 categories: with low, moderate or high risk.
Children with high risk will present, depending on age, the dental afflictions that are detailed
in the following:
1. Early cavities of the young child, under 3 years
b) Baby bottle syndrome

It is characterized by multiple cavities that appear frequently in very young children, who
constantly sleep, during the day as well as night, with sweetened liquids (tea, fruit juice, milk)
in their baby bottle.
At first the maxillary incisors are affected (rapidly evolving multiple cavities appear), second:
maxillary, mandibular molars and mandibular incisors are affected. At incisors level the
carious lesions appear on the vestibular surface at start, where the salivary flow is lower and
sweetened substances stay for long time in contact with the vestibular surfaces.
Then the proximal surfaces of the incisors are affected, and finally the cavity will progress on
all surfaces, leading many times to the fracture of these temporary teeth. At molars level the
occlusal cracks and fissures are affected at first and then the proximal faces. Untreated, this
pathology ends up with a severe coronary destruction, leading to dental cavity complications
and extractions.

Baby bottle syndrome appears to every neglected child, not depending on socio-economic
status, in children whose parents cannot impose dental and food hygiene according to age and
don’t have time enough to tend the child. These cavities may occur in children who are breast-
fed after teeth eruption, with same symptoms and clinical picture.

c) Early cavities that are not because of the sweetened baby-bottle

These cavities develop very quick, after teeth eruption when more predisposing factors are
present: socio-economic and unfavorable cultural status, low level of interest and health
education of the parents, lack of hygiene measures, lack of fluoride supplements, frequent
sweets consume, the presence of Streptococcus Mutans in high quantities.

Consequences of these early afflictions:

- Oral cavity rehabilitation of these very young children afflicted by early severe
multiple cavities, requires complicated caring, frequent extractions. When teeth are very
afflicted and cannot keep collaboration with the patient these interventions are under general
anesthesia or with the help of inhalo-sedation.
- Premature loss of temporary teeth, not compensated by a space holder or juvenile
prosthetic, has influence on the dento-maxillary apparatus, phonation, swallowing,
mastication, development and further growth of the dental arches and of the face.
- There are frequent modifications of feeding behavior (which requires a re-education of
the feeding ways), as well as psychiatric disorders because of the absence of teeth from the
frontal zone.

Mechanical processes

These are key major processes in the anti-infectious fight. Consists of:

- Mechanical or manual dental brushing

- Dental floss, interdental cones/stimulators, toothpicks, interdental brushes (auxiliary ways of
oral hygiene)
- The hydropulsor or oral douche.

Chemical processes

These are auxiliary processes to the mechanical processes, so that it completes those.
Chemical substances that are more frequently used:

- Chlorhexidine
- dental gels and polishes with chlorhexidine

Mechanical hygiene processes

Dental brushing

It is the base element for the oral-dental hygiene

The toothbrush must be adapted to the particular anatomical configuration of the mixt
teeth of the young child as well as the permanent adolescent and adult teeth. In children, the
hair of the toothbrush must be supple, with round head, and not to cause trauma in covering
tissues. The head of the brush must be small (for access in posterior areas) and round, to have
an easy-to-hold ergonomic handle. The modern brushes have cartoon inspired designs and
portrays children favorite characters, another element that can make the toothbrush to be
loved and used by the little patient.
The minimal frequency of dental brushing after every meal or, in its absence we can
still use the auxiliary ways of hygiene. Brushing done by the parents until the moment the
child gets the required manual dexterity (at about 7-8 years) and can do the brushing right and
alone.

Brushing begins since the appearing of the first temporary teeth.

The duration of the brushing is at best for 3-4 minutes. It can be associated to the
length of a favorite song for example or with a hourglass in the bathroom, that will guide the
patient on the optimal duration for brushing.
There are many brushing techniques, but whichever will be the most used, two rules
are imposed: The brushing will be vertical and every tooth will be brushed.
Electrical brushing can substitute the manual one. The electric toothbrush was built
initially for patients with disabilities, but its utility sphere extended a lot, nowadays electric
brushes that satisfy all the needs exist (for patients with fixed orthodontic apparatus, for
patients with periodontal problems or patients without patience or dexterity).

Mistakes of the dental brushes:

- The active head of the toothbrush isn’t positioned horizontally, thus traumatizing the
gum, mechanical irritation and insufficient removal of dental plaque.
- Placing the brushes hair only on the gum or only the dental surface, results in a
unsatisfactory hygiene of the cervical zone.
- Using the hard brushes and doing an unexpected brushing (with a duration and high
frequency, exaggerated), producing cervical enamel lesions, especially in the canine and
premolar, as well as gingival retractions.
- Using abrasive tooth pastes, popular hygiene/whitening methods like brushing with
sodium bicarbonate, kitchen salt or lemon salt.

Dental Floss
 While brushing ensures the removal of dental bacterial plaque from vestibular,
occlusal and oral level, it is almost inefficient in the case of proximal surfaces.
Dental floss is the most efficient method of removing bacterial plaque off the proximal
surfaces, allowing the passing over the interdental contact point.
Many types of dental floss exists, may be waxed or not waxed, packed in rolls or
applied on a support, ready for use. There exists even waxed impregnated dental floss, which
is more resistant and easily passes through tight contact points or over proximal filling
insufficient finished.

Method of utilization:

- 20-40 cm of dental floss are rolled on the medius or index finger

- Approximately 1.5-2 cm are left between the two fingers and it is stretched well
- The thread is inserted with a controlled force, through combined antero-posterior
moves
- The thread is curved, thus being smoothly adapted on one of the dental surfaces of the
interdental space
- Carefully inserted until the base of the interdental papilla
- Clean dental floss is always used, unused in the previous cleaned space

The Hydropulsor
Is a device used for the completion of oral hygiene, having as principal purpose the
stimulation of the gingival blood circulation. It may be used for elimination of food scraps,
especially if the patients wear an orthodontic apparatus. It doesn’t replace the daily dental
brushing.

Chemical processes of hygiene

These processes are represented by maneuvers of microbial flora removal through

chemical antimicrobial agents. These agents have different actions, either reduce the existing
bacterial plaque either control the formation of the new bacterial plaque.

Clorhexidine
 It occupies a privileged position between the bacterial plaque inhibitors, because of its
efficiency and relative reduced toxicity for the organism in its usual dose. It is an antibacterial
agent with broad spectrum, acting on Gram positive bacteria as well as on Gram negative, on
yeasts, even in low concentrations. In high concentration (100µg/ml) has bactericide effects,
producing the destruction of the bacterial cell walls. In low concentrations (0.1µg/ml) has a
bacteriostatic effect, determining the coagulation of the cytoplasmic proteins. This molecule is
capable of reducing the oral flora and to block the bacterial colonization at the dental surfaces
level on which it was absorbed. In the last 30 years, different methods of applying
chlorhexidine were studied: mouthwash, toothpaste, sprays, gels, chewing gum.

Chlorhexidine mouth rinses still hold as the antiseptic of choice in some periodontal
pathologies, cases of pre-pubertal and pubertal gingivitis and periodontitis. It requires to be
doubled by a right and regular dental brushing.

B. The diet

The frequent consume, of sweets snacks and carbonated drinks, between meals is
around the causal cavity factors. The habit of respecting the three main meals of the day and
with completing them with snacks that consists of fruit or yoghurt must be acquired by the
patients. We can analyze the feeding habits if the patients with the help of the Feeding
Journal. This journal consists of writing down all the food ingested in one school day for
example or in week-end, eventually the hour of the ingestion or the quantity of food. Thus, the
practitioner will have a means of observing the feeding habits of the patient and will be able
to indicate and correct the mistakes in the diet. These problems are involved not only in dental
health but general too, known being the fact that feeding is an important element in
maintaining our health.

Feeding habits that must be corrected are:

- high carbohydrates intake

- sugar intake in indirect form (candy, cakes, ice-cream, chocolate, drinks) has raised from
40% to 55% in the last quarter of the century, with a continuous ascending rate. If sweets are
ingested in the course of the main meals, even in high quantities, won’t do important damage,
while in low quantities on all course of day will create a good environment for cariogenic
bacteria. Thus, it is recommended the replacement of cariogenic sugars (sucrose, fructose,
glucose) with non-cariogenic sugars like xylitol, reducing the sugar intake and products in
which this is contained.
- ‘crunching’ between meals
This habit is never practically followed by brushing, maybe eventually the use of a chewing
gum. Thus, sweets and other carbohydrates ingested between meals will keep on the whole
course of the day a favorable environment for producing and developing of carious processes.
It is recommended: avoiding sweets between meals because those subject the teeth to long
terms of demineralization and favoring the raise of salivary flow through the use of the sugar-
free chewing-gum.
- Soft food, mashed preferential intake,
There are children who are preponderant fed with soft foods, mashed, which does not
stimulate at all the dento-maxillary apparatus and its harmonious development. They are not
used thus to correctly chewing the food, do not develop their maxillary and masticatory
muscles, do not stimulate the self-maintenance and trophicity of the oral tissues. It is
recommended: diversification of food, harder foods intake that allow the self-cleaning of the
surfaces, the physiological abrasion of the triturated faces and stimulates the salivary flow.
- Frequent use of pediatric syrups, sweetened drinks (milk, tea, juice) in the evening, before
bedtime.
These habits create multiple cavities (baby bottle cavities) that handicaps the child on esthetic
and functional plans. Untreated multiple cavities create favorable conditions on appearing of
early carious lesions on permanent teeth and will influence the grow of the maxillary and
establishment of harmonious dento-alveolar reports. It is recommended: replacing milk and
other sweetened liquids with the unsweetened version, or with water in the evening before
bedtime and using the pediatric syrups that contain non-cariogenic sweeteners (in children
with chronic diseases, asthma for example, that consumes these syrups on long term).

C. The fluorine

This chemical element was discovered by Joseph Henri Moissan in year 1886. Has a
cubic crystal structure, density at 293K: 1696 g/ cm3, greenish color and is part of the halogen
group. Fluorine is more electronegative than any other chemical elements and cannot be
found in free state in nature, but is present in the soil for example, in the form of fluorides.

Commercial products: FLUOGUM ®

- these have a systemic and topic action

- stimulates salivary secretion, facilitating the removal of the food scraps from
interproximal spaces
- the tablet releases 0.113mg F
At two hours after meal, in the absence of dental brushing, at the proximal plaque a
drop of pH can observed. The simple chewing of two chewing-gums (sugar-free) after meal,
for 20 minutes, is enough to get the pH back to normal values. The chewing gum can be
removed after the disappearance of the sweet taste, and the number of chewing gums should
be limited to 6 per day.
Current research reaffirms the fact that fluorides in the form of topical appliances with
slow release, are essential to patients with high carious risk.

Harmfulness of the fluorine

Products with high concentration of fluorine will have to be applied only by the
dentist, not to be applied in excessive quantities, and patients require not to swallow the
topical applied products. Patients must be watched in the course of treatment, overdosing with
fluorine can induce acute or chronic intoxications.

Acute intoxication

It is rare in adults and appears especially through accidental ingestion of insecticide

with fluorine or in children after ingesting toothpaste with fluorine.

Clinical picture of the acute intoxication (appear after a few minutes after ingestion):

- Nausea
- Throw-ups
- Abdominal pain
General intoxication symptoms may appear like increased salivary secretion, tearing, tetanus
and spasms, headache. In a couple hours death may intervene.
- under 5 mg/kg body is sufficient the ingestion of high quantities of milk.
- over 5 mg/kg body it implies the emergency admission in the hospital for gastric
lavage.

Chronic intoxication

It interests the teeth through dental fluorosis – from mate white coloring to brown in
the form of striations at enamel level. It occurs frequently by not following the dentists
indications in which interests the dosage of fluorine tablets or combining systemic treatment
with fluorine toothpaste brushing.

General recommendations for children:

 Before 3 years it is not recommended the use of fluorine toothpaste because of

ingestion risk.
 3 years to 6 years, the brushing must be done after every meal with fluorine toothpaste
under the watch of an adult to limit the toothpaste ingestion. Toothpaste will have to
have a reduced concentration of fluorine: 250 – 600 ppm fluorine. Brushing will be
done with a very small quantity of toothpaste, the size of a small pea.
 After 6 years, can be utilized a familial toothpaste that contains between 1000 and
1500 ppm F.

The intake of fluorine must not get over 2ppm/day to avoid the fluorosis risk. The
lethal dose administration of 2500-5000 mg (5-10 sodium fluoride), are preceded by signs of
acute intoxication. The role of fluorine in dental cavity prophylaxis is extremely important,
but must be given only under surveillance and following a practitioner’s indications,
considering an individualized fluorine balance and particular predisposition of each person to
carious pathology.(1)
 E. Prevention sealing

High prevalence of occlusal cavities, the impossibility of a perfect mechanical

cleaning of the occlusal surfaces as well as the limited benefit at this level through
fluoridation, has imposed the finding of new treatment methods in these areas. Sealing is a
cavity prevention method from notches and cracks, on occlusal surfaces of the molars and
premolars, on the vestibular surfaces of the molars and premolars and on the oral surfaces of
the superior incisors. These aspects can be synthesized in the following observations:
- Using fluorine reduces carious lesions especially on smooth surfaces, but ensures
only a weak protection of the anfractuous areas of the enamel.
- Notches, fissures and cracks are morphological entities of the tooth that are the most
exhibited to cavities (85% of the carious afflictions)
- Contrary to the cusps that are synthesis areas of the enamel, dental notches are areas
of enamel fusion, that is why coalescence defects appear which are fragile areas that are more
vulnerable thus to cavities.

2. Fluoridated gels and solutions

Fluoridated gels

Commercial products: Fluocal Gel, Fluoridin Gel N5, FluorOpal, GEL-KAM®

The best moment for their use is the eruption of the tooth, applying the gel being done with
the help of trays.

- the gel quantity placed in the trays must be limited to maximum 2.5 ml
- the time of fluoridation must not be over 4 minutes, because over this interval, active
F can no longer penetrate the enamel, because the impermeable calcium fluoride is formed
- after removing the tray the child is recommended for 30 minutes to not eat, drink,
rinse or wash their teeth

The frequency of use for the cavity prophylaxis is: 1-2 sessions/year/tooth
Fluoridated solutions

Commercial products: Fluocal solution, Fluoridin, Elmex

Their concentration is 2% NaF.

It is applied on each tooth for 3-4 minutes with the help of an applicator, after professional
sanitation and tooth drying and isolation. After its application the patient is invited to spit and
30 minutes won’t rinse, eat or wash their teeth.

3. Dental materials that contain fluorine

- Products for dental hyperaesthesia therapy: Fluocal Solution, Izodan

- Sealing products: Fissurit F, Helioseal F
- Cleaning and polishing paste for teeth after professional sanitation: Detartrine with
fluorine
- Filling materials with fluorine releasing: liners, glass ionomer cements made of glass,
compomers, enamel-dental adhesives, composite materials.

Patient applying of fluorine preparations

a) Fluoridated tooth paste

- allows the reduction of 20-30% of the carious lesions frequency

- the most used fluorides are:

1. sodium fluoride: SANOGYL SYSTEME®, FLUOSALYL®,

2. sodium monofluorophosphate: SIGNAL +®,
3. combination of the two fluorides: FLUOCARIL BIFLUORE® 180 or 250
4. fluoridated amines: ELMEX®
In countries that belong to the European Community it is regulated the distribution of
fluoridated toothpastes like so:
- toothpastes with under 150mgF/100g (under 1500ppm), are called toothpastes with low
content of fluorine and can be sold in the vast distribution
- toothpastes with over 150mgF/100g (over 1500 ppm), are called toothpastes with high
content of fluorine and can be sold only in pharmacies.

b) Fluoridated mouthwash

Commercial products: ELMEX®, FLUOCARIL®, FLUOSEPT®

Rinsing with fluorinated mouthwash is a simple and efficient method of prevention of

the school aged child carious pathologies (the preschool children risk to ingest the solution).
These solutions raise the level of fluorine in saliva immediately after rinsing and thus allow
the maintaining of a high fluorine concentration for more hours. These are indicated:
i. high or moderate carious risk groups, along with fluoridated toothpastes
ii. children that are undergoing orthodontic treatment
fluorinated solutions can be used in the following concentrations:
 0.05% NaF for daily rinsing
 0.2% NaF for weekly rinsing

c) Xylitol and fluorine chewing gum

Fluorine represents one of the most important known microelements nowadays of having an
important role in cario-resistance obtaining. The first observations were done in the 19th
century by Maginot who drew attention on the spotted teeth’s cario-resistance in areas with
high concentrations of fluorine in the water, observations confirmed by Black and McKay
(1914). Water contains fluorine but in variable concentrations, and in food exists in different
forms. Food content of fluorine is influenced by industrial or domestic processes also, used
for their preparing.

Fluorine content of some vegetal Fluorine content of some animal foods

foods (mg/kg of dry matter): (mg/kg of dry matter):

tea (dry) in 100g……………. 120-190 calf (muscle)………………0.8-0.9

coffee……………………….. 0.2-1.6 cattle (liver)……………….2.3
cocoa………………………... 0.5-2.0 pork (muscle)……………...0.8
honey………………………... 1.3 sturgeon……………………5.0
sugar………………………….0.3 salmon……………………...9.3
raisins…………………………0.6 tuna (can) ………………….0.6-1
nuts…………………………...7.8 sardines…………………….1.8
peanuts………………………..0.3 shells………………………..0.6-1.5
cherries………………………..0.6 milk…………………………0.1-0.7
bananas………………………..0.6 butter………………………..1.5
pineapple………………………0.9 cheese……………………….1.6
apple…………………………...2.0 egg (white)…………………..1.1-1.4
mushrooms…………………….0.2-1 egg (yolk)…………………….0.4-2
salad…………………………...5.6-6.7 lamb…………………………..1.2
tomatoes……………………….1-2.4
potatoes………………………..0.8-1.3
beans…………………………...1-2
carrots/spinach………………….1-8
rice……………………………...0.5-0.8
bread……………………………0.5-1
flour…………………………….0.3-1.3
grain…………………………….0.2-1.7

Fluorine assimilation
Comparative to the fluorine contained in water, which is quickly and almost all
absorbed, fluorine present in food passes slowly and in low quantity the gastro-intestinal
barrier. Because of the connection with other elements, its bio-availability is mediocre, being
lesser especially when fluorine is combined with dairy products, which because of the
coagulation of the milk in the stomach creates the calcium fluoride, less soluble. The drinking
water can be an important source of fluorine intake. Other fluoridation programs have been
tried and are still functional, of the kitchen salt in France for example, since 1985. Salt
fluoridation is an economical measure of prevention, easy to put in practice and respects the
consumer’s freedom of choice, the big disadvantage being that we cannot control individual
intake. Salt is supplemented with fluorine with 250 mg/kg, in the form of potassium fluoride.
On the wrap is labeled as fluoridated salt or iodized and fluoridated salt and it is mentioned
not to consume if drinking water in the area contains more than 0.5 mg/l fluorine.
 Drinking water can be an important source of fluorine intake. Fluorine concentrations
in water are variable (not allowed to go over 1.5mg/l) and under 0.3 mg/l can be administered
by systemic means.

Cariostatic mechanism

Cariostatic mechanism of fluorine acts on the dental substance at first with the
decrease of enamel solubility at the acid attack. The fluorine fixing in dental tissues is done on
the behalf of a ionic exchange at hydroxyapatite crystals level, by replacing hydroxyl groups
with fluorine ions and forming of fluoroapatite. It was found that only 10% of the hydroxyl
ions are substituted in the pre-eruptive stage. Alas the forming of fluoroapatite while the pre-
eruptive stage development of teeth contributes in a smaller measure to the cariostatic effect.
The biggest part of the existent fluorine in and on the enamel, is because of the post-eruptive
mineralization and local applications of fluorine. Fluoroapatite is 10 times less soluble than
hydroxyapatite, thus enamel is more resistant to acid attacks. Another important effect of the
fluorine is the decrease of demineralization periods because minerals precipitate faster.

Fluorine exercise antibacterial effects and simultaneously decreases the forming of

polysaccharides intra and extra cellular; it blocks the degrading of carbon hydrates
degradation at bacterial plaque level through enzymatic inhibition; reduces the superficial
tension at enamel level and thus reduces the microbial adherence followed by decrease of acid
production.

Ways of administration of fluorine

Administration of fluorine occupies a very important role in dental cavity prophylaxis.

It can be administered on systemic as well as topic applications on teeth. Systemic
fluoridation influences the pre-eruptive forming and maturing of the enamel acting
simultaneously with the help of saliva on recent erupted teeth too, having a topic effect too.
Also the topic applications of fluorine can have a systemic effect if the product is ingested.
The topical fluorine applications have a beneficial effect on the remineralization process of
the afflicted dental surfaces at the carious process level, it shortens the demineralization
stages, decreases enamel solubility at the acid attack and negatively influences the metabolism
of streptococci and lactobacilli from the dental plaque.
 Systemic administration of fluorine

In the case of fluoridation with fluorine tablets will be taken into interest of the following
criteria:

- Fluorine administration with tablets starts at the age of 6 months, but is indicated after the
eruption of the first teeth
- Fluorine efficiency administered prenatal is reduced
- The majority of authors consider the postnatal and pre-eruptive administration presents a
significant efficacy, because saliva contains fluorine provided by systemic administration as
well as the local one.
- the fluorine tablets will be dissolved in a spoon with water or tea. It will not be dissolved in
milk. Once the temporary molars appeared, tablets can be sucked or grinded on temporary
molars by the child.
For a systemic fluoridation, we can use fluorinated tablets like:4
- ZYMAFLUOR (potassium fluoride, 1 tablet=0.25 mg)
- FLUOR MONAL (calcium fluoride)
- FLUOR IN (potassium fluorine)
Or we can use solutions (drops)
- ZYMAFLUOR (0.25 mg = 4 drops)
- FLUOREX

Recommendations of the systemic fluoridations must keep account of:

- If in the respective area the water is naturally of artificially fluoridated.

- If the patient uses fluoridated kitchen salt
- If the dentist recommends vitamin D for the rickets prophylaxis, because those tablets can
contain fluorine supplements.
- If the patient uses mineral waters that contains fluorine
- It is recommended only one type of systemic fluoridation
- Local applications that are associated will take account of the child’s age, possibilities of
removing the fluorine excess.
 Drinking water concentration of F
Age of the child Water <0.3 ppm F Water >0.3 ppm F
0-6 months Not administered Not administered
> 6 months – 3 years 0.25 mg/day Not administered
> 3 – 6 years 0.50 mg/day Not administered
>6-16 years 1.00 mg/day Not administered

Topical application of fluorine

Fluorine application of fluorine can be done by the medic, and by the patient, through
toothpastes with fluorine or mouthwash.
Application by the dentist

Local application methods of fluorine impose the prior teeth preparing:

- removing the tartar, abrasive dusts brushing and perfect isolation on one side and on the
other side the circulation of fluorinated substances in all areas of the dental arch as well as in
the interdental spaces.
- the purpose of topic applications is to transform the hydroxyapatite crystals in fluoroapatite
more resistant to acid attacks.
- Topical applied fluorine favors and remineralizes the decalcified enamel
Prepared with high fluorine concentration, for professional use:
1. Fluoridated polishes:
Commercial products: Duraphat, Fluor Protector
- Adheres to enamel surface a longer time and slowly releasing fluorine
- Polishes application will be done after a careful professional brushing, followed by
drying the surfaces
- Polish application will be done by turn in the 4 areas
- The patient must not drink or eat in the first 45 minutes after applying of the polish
and dental brushing is not recommended until noon
- The frequency and number of the applications depend on the type of polish used:
- FLUOR PROTECTOR®: it is applied twice a year
 - DURAPHAT®: it is applied every 2 days for a week, and applications are resumed
twice a year.
- In the moment of eruption, the first permanent molars have an immature, porous
enamel => in the mineralization stage of the enamel, the first permanent molars are very
vulnerable to the carious attack
- Cracks diameter of the newly erupted tooth is less than that of the toothbrush’s hair,
their inaccessibility to brushing facilitating the development of bacteria
- First permanent molars through their complex architecture consists real ‘traps’ that
hold very easy the bacterial plaque, but molar one is often neglected because it erupts in a
context less favorable:
 Presents a complex architecture
 Enamel is immature
 Sometimes presents malpositions
 Positioned very posterior in the oral cavity
 Hygiene skills are not fully developed at the age of those teeth eruption

We will continue with the notches, fissures and occlusal and vestibular cracks sealing at the
following teeth:
- Permanent molars, at occlusal and vestibular levels
- Premolars
- Permanent incisors, at the cingulum level
- Temporary molars, in patients with high carious risk

Sealants have three important effects

- Mechanically fill the cracks and deep notches
- Blocks the preferred place of Streptococcus mutans and other cariogenic micro-
organisms
- Eases the cleaning maneuvers of the notches and cracks.

Before we realize any prophylactic act we must consider the following factors:

- Must examine with care the occlusal, vestibular and oral face and identified all fissures,
notches and cracks.
- In case of suspicioning a carious lesion, it is preferred to open minimally the fissure and to
realize a preventive filling with a fluid or amalgam composite.
- It is necessary the ensuring of an optimal control of the operatory field, isolation must be
very good, preferable with the rubber dam.
- It is important that the sealing is done quick, after the eruption of the tooth because in this
stage the carious risk is higher.
- Sealant agents do not apply once forever, sealing must be checked (at least twice a year) and
completed or rebuilt if that’s the case.
Sealing technique

Dental sealing is a dentist maneuver relatively safe and with predictable results,
provided the compliance of the working stages and respecting the utilization indications
communicated by the producer.

Working technique is composed of 3 important stages: Bacterial plaque removal off the dental
surfaces that will be sealed, preparing the dental room and applying the sealant. Sealing with
composite resins presumes:

1. Cleaning the dental surface, to remove the bacterial plaque and food scraps on the dental
surface. It is done by professional brushing with an adequate toothbrush a paste for
professional brushing without fluorine (prevents the demineralization process). Then, the
toothpaste that will remain in the notches will be removed with the Air-flow system, with
sodium bicarbonate. Air-flow can replace the professional brushing, its effects being the same
as in brushing.
2. Tooth isolation is an essential step in any collage technique. Isolation is ideally done with
the rubber dam, if we cannot collaborate with the child or if on the tooth cannot be applied a
corresponding clip, we can obtain good results by carefully isolating with cotton rolls. If we
cannot do a corresponding isolation (teeth in eruption): glass ionomer cements can be used,
because of the lower sensibility to wet environment (their retention rate is inferior to
composite resins) or other solution is applying a fluoridated polish in waiting for the complete
eruption of the tooth.
3. Surface enamel preparing is done only if highly colored notches are present of cavity is
suspected. The opening of the notches is done with a very smooth drill or globular very small
drill. In this case it is recommended that the enamel fissures are filled with a fluid compound.
These aspects are widely detailed in the chapter dedicated to dental cavity treatment, where
enlarged sealing and preventive resin filling are presented.
4. Acid demineralization, with orthophosphorusic acid 30-40%. Time of demineralization
differs from a stage to another, but is considered that 15-60 seconds (30 sec. in average) are
sufficient.
5. Washing for 20 seconds to stop the acids action, the tooth being isolated so that the
demineralized surface is no longer in contact with the saliva
6. Dry, enamel must present a white-chalky aspect.
7. Applying and photopolimerizing the sealant ( some sealing materials do not need
adhesive). If we will use fluid, modern, colored composite materials before we apply the
sealant we apply also the adhesive system.
8. Sealing control in occlusal relation, to remove the excess.
9. Periodic check-ups are done 2 times/ year in case of low carious risk or 3 times/year in
case of high carious risk. Sealing resin loss is estimated to 5-10%/year, this prophylactic
technique has an efficiency of up to 90% in the first year and up to 70% in 5 years.

Sealing notches and cracks, alongside of the general and local fluoridation, food
hygiene and oral-dental hygiene, these are methods recommended by WHO for the prevention
of the dental cavity. Only by using all the four methods can we hope for a carious disease
control and of a corresponding prevention.
It is not sufficient that the medic realizes correct maneuvers technically speaking, to
recommend the diet modification and fluoridation dental cavity prophylaxis, if the patient
does not follow the advices and does not continue at home the efforts from the dentistry.
 10. DENTAL TRAUMA

Dental and dento-periodontal trauma, interest both dentitions and are more frequent in
children and teenagers.
In terms of location it can be observed a high incidence of traumatic lesions in the
anterior region of the dental arches, the incisor canine area, especially if a tooth or a group of
teeth presents modifications (vestibule-version, vestibule-gression, protrusion). (1,2)
Systematization of traumatic lesions can be done using different criteria:
 Patients age and dentition type;
 Tooth stage of evolution;
 Structures interested by the traumatic lesion: enamel, dentine, pulp, cement,
periodontium;
 Associated lesions;
 Gravity of the lesions;
 Time of the presentation, time since the trauma. (1,2,3,4)

Dental trauma – clinical forms

Clinical forms of the dento-periodontal trauma can be differentiated by: gravity,

neighboring interested tissues, intensity and direction of the force, etc. Using these criteria,
the following entities can be described:
 Concussion;
 Dislocation;
 Fracture;
 Associated forms. (1,2,4)

Concussion
It implies the crushing of ligament fibers and periapical tissues, in which inflammatory
phenomena of traumatic origins is associated. Post traumatic desmodontal space becomes
insufficient between two hard elements, incompressible (dental root and lamina dura). (1)
 In terms of the subjective signs the concussion may not be observed by the parents and
child and frequently the diagnostic is late, together with the appearing of associated
complications: tooth loss of vitality, abscesses, pathologic rizalisis, etc(1,4)

Dislocation
It is a more serious trauma that implies the movement of the articular surfaces with the
modification of the anatomical reports between the alveolar wall and radicular cement. (1)

In terms of intensity and direction of the traumatic agent, the edification stage of the
root and laxity of the ligamentous system there can be differentiated two clinical forms of
dislocation:

 partial – tooth is mobile in the socket and has suffered position modifications more or
less aggravated;
 total – the impact force determines the loss of contact between the tooth an socket,
which is determined by expulsion or clogging.

Fracture

Represents the traumatic lesion in which a continuity solution is resulted at the hard
dental tissue level. Dento-periodontal fracture classification can be done on topographical
criteria, like so:

 crown;
 radicular;
 crown-radicular; (1,3,4)

Ellis – classification of coronal fractures include four classes:

 Class I – enamel is interested with or without minimal damage of the dentine;

 Class II – dentine is interested without the affecting of the pulpal chamber;
 Class III – dentine is interested with the affection of the pulpal chamber
 Class IV – complete loss of the crown

Systematization of the coronal fractures allows the creating of correlations between the
diagnosis and treatment methods. (1)

Garcia Godoy Classification assigns a code system meant to ease the diagnosis and
therapeutic orientation in dento-periodontal trauma:

 0 - enamel crack
 1 – enamel fracture
 2 – enamel fracture with dentine damage but without affliction on the pulpal
chamber
 3 – enamel fracture with dentine and pulpal chamber damage
  4 – enamel fracture with dentine and cement damage but without pulpal chamber
affliction
 5 – enamel fracture with dentine, cement and pulpal chamber damage
 6 – radicular fracture
 7 – subluxation – percussion reaction
 8 – dislocation
 9 – lateral movement
 10 – intrusion
 11 – extrusion
 12 – expulsion (3)

WHO classification differentiates the dento-periodontal trauma by the interested tissues to

ease the choice of therapeutic conduit

 enamel fracture (Img.10. A)

 simple coronal fracture (Img. 10.1 B) Img.10.1 WHO
classification
 complicated coronal fracture (Img. 10.1 C); of dental fractures.
 crown-radicular fracture without
pulpal exposure (Img.10.2 D);
 crown-radicular fracture with
pulpal exposure (Img.10.2 E); Img.10.2 WHO
classification
 radicular fracture (Img.10.2 F). (3) of dental fractures.

Dento-periodontal trauma may include a single or multiple clinical forms, depending on the
intensity and direction of the traumatic agent. Most frequently is associated with the following
entities:
 Radicular fractures and dislocation
 Coronal fractures and dislocation
 Soft parts lesions
 Alveolar processes fractures. (1)
Dental trauma in temporary dentition

The time of the temporary dentition, associated to the young childhood, is

characterized by an accelerated psycho-somatic development, that determines a raised
curiosity of children in exploring the surrounding environment. Plus the defense reflexes are
insufficient and the incapacity to correctly analyze dangers determines a raised frequency,
over 51%, of dento-periodontal trauma that affects temporary teeth. (3,4).
In terms of incidence by sex there exists a predominant raise of this trauma in boys –
64%. (3)
Affected topographic area in 95% of the dento-periodontal trauma is represented by
the anterior area of the dental arch. (3,4)
Etiologic factors involved in dento-periodontal trauma appearing in temporary
dentition are extremely varied: learning to walk, playing accidents in first years of life, etc.
The laxity of the bone tissues and growing processes that are characteristic for this
stage determines the appearance of dislocation, as the most frequent clinical form. (1)

Check-up
Dental and dento-periodontal trauma, are emergency situations. The main preoccupy
of the parents is compromising the esthetic aspect of the little patient. The dentist’s attitude in
this case must be balanced – to try to calm down the parents and make a check-up as fast as
possible.
The success of any treatment method applied depends on patient’s collaboration and
the parents’ also. Main objective of treatment must be the decrease of adverse consequences
of the trauma on the permanent tooth bud from under the temporary one, and on the second
plan the conservation of the temporary tooth to restore physiognomic aspect and phonation.(2)
Treatment objectives are in direct relation with the evolution stage of the temporary
tooth. Main elements that therapeutic approach that are proposed, include the reduction of
inflammation and control of the infection. Still temporary teeth have a limited existence in
time at dental arches level, the conservative or the extraction option must be based on the
clinical exam in which complementary examinations are added, especially radiologic exam.
Main elements that are implied to be analyzed in temporary teeth trauma are
represented by:
  Permanent tooth bud – the presence or absence of this, intra-osseous position, degree
of development and mineralization;
 Maintaining space – the time until the physiological exfoliation of the temporary
tooth, possibility of neighboring and antagonist teeth migration, occlusal-articular
blocks;
 Orthodontic treatment necessity;
 Associated para-functions, can determine an uncertain prognostic for some
therapeutical maneuvers. (1,3,4)

Treatment recommendations are differentiated by the gravity of the trauma and

interested structures.
Coronal fracture of temporary teeth, depending on the affected dental tissues, implies
a distinct therapeutic approach.

Coronal fracture with exclusive affliction of the enamel requires the smoothing of the dental
surface followed by fluoridation, in a dispensary system context of the patient with respecting
oro-dental hygiene rules and a cario-prophylactic diet. (3,4)
Coronal fracture with enamel and limited dentine affliction presumes the restoring of the
dental crown with a filling that ensures the pulpal protection. Parents will have to be informed
on the necessity of periodic check-up-clinical exam necessity that will be completed with
vitality tests and retro-alveolar radiographies. (3,4)
Coronal fracture that affects the enamel, dentine and the pulp presumes a complex treatment.
Depending on the evolution stage of the temporary tooth, the time since the trauma, the level
of collaboration with the patient, conservative treatment techniques can be applied
(pulpotomy, pulpectomy followed by dental crown restoring) or surgical techniques
(extraction). (3,4)
Crown-radicular fracture of the temporary teeth affects all dental tissues (enamel-dentine-pule
dental-cement) which determines the choice of a radical therapeutic conduit – extraction –
followed by the evaluation and maintaining the space left to prevent negative consequences of
the dental migration. (3,4,5)
Radicular fracture of the temporary teeth presumes a different therapeutic approach depending
on the line of fracture level, displacement of radicular fragments and degree of mobility.
These elements will be evaluated by clinical exam and radiologic exam done from different
incidences. Treatment will be influenced by the collaboration of the patient and the family.

If the radicular fracture is not followed by fragment displacement, and mobility degree
is low and so we can choose to keep the tooth on the arch, in the context of periodic check-
ups and monitoring the patient, at which we add the oro-dental hygiene rules and cario-
prophylactic diet with avoiding active masticatory movements, of high intensity in the first
days after the trauma. (2,4)
If the displacement of the radicular fragments is important or the mobility degree is
increased, we can extract the coronary fragment with the keeping of the radicular fragment, in
case in which endodontic treatment can be done and an adequate cooperation with the family
will be possible. Contrary the tooth will be extracted, and post-extraction space will be kept
using space-holders. Before applying the space-holders it is imposed a radiologic exam to
estimate the state of the permanent tooth underneath and an orthodontic evaluation of the
patient. (4,6)

The subluxation of the temporary tooth, can be associated or not with dental mobility
but in general, position modifications are absent. The treatment implies oro-dental hygiene
rules keeping and a diet that will not put pressure on mastication, with avoiding hard or sticky
foods. To prevent the negative consequences on the underlying permanent tooth, patient’s
admission in a dispensary is recommended, clinical exam being thus completed with
retroalveolar radiographies in different incidences.
The dislocation of the temporary tooth is associated with
dental mobility and position modifications (Img.10.3). Treatment
follows the repositioning of the tooth to avoid occlusal interferences,
respecting oro-dental hygiene rules and a diet that will not put pressure
on mastication, with avoiding the hard and sticky foods.
Img.10.3 palatal dislocation 6.2

The extrusion of the temporary tooth is the result of a high intensity trauma.
Treatment may include repositioning and immobilization or extraction of the tooth if the
mobility is increased. Tooth repositioning can be done by easy digital pressure, in conditions
of local anesthesia or using orthodontic apparatus. Monitoring the patient represents an
important element for ensuring the adequate prognosis on long-term of the treatment methods
applied. (4)

The intrusion of the temporary tooth frequently represents a consequence of trauma

occurred while playing or while learning to walk. Treatment will be conditioned by the
progressive stage of the temporary tooth and the report with the successional permanent tooth
bud, evaluated with the help of retroalveolar radiographies. Low consistency food intake,
avoiding incision and an adequate oro-dental hygiene can determine the spontaneous resume
of eruption, which certifies the success of the treatment (favorable evolution is often found in
case of temporary teeth in evolution stage I). If spontaneous eruption is not noticed or trauma
direction has determined the evolution towards palatal respectively lingual of the root of the
temporary tooth, to prevent negative consequences on the permanent tooth bud, it is
recommended the extraction of the temporary tooth, and post-extraction space evaluation.
The avulsion of the temporary tooth requires the confirmation of the clinical diagnosis
with radiologic examinations. Even if the time since the trauma was short, and parents come
with the recovered tooth that was adequately kept, its reimplantation must be avoided because
it determines complications (necrosis, accelerated resorbtion, dento-osseous anchylose) with
negative effects on the mineralization and eruption of the permanent underlying tooth. The
post-extraction space will be evaluated because the avulsion of the temporary tooth can delay
with almost a year the successional permanent tooth eruption. (4,5)

Temporary teeth trauma complications affect the temporary tooth as well as the
permanent tooth bud.
At the level of the temporary tooth the traumatic dental complications are represented
by: coloring at crown level, accelerated resorbtions, dento-osseous anchylose.
Temporary teeth discoloration represents frequent consequences of the dental trauma
and is often the retrospective diagnosis of minor traumatic lesions. These colorations are
reversible if the tooth affected is in evolution stage I or beginning or stage II. Late colorations
are associated in the majority of cases with pulpal mortification. Radiologic exam will reveal
the existence or not of periapical inflammatory lesions. Depending of the temporary tooth
stage and complications associated, the treatment will be conservative (endodontic treatment
followed by coronary restoring) or the temporary tooth extraction will be done not to affect
mineralization of the permanent tooth bud. (1,3,5).
 Pulpal obliteration is a frequent post-traumatic reaction. Clinically it is observed the
change of tooth color that becomes yellow or opaque. In the absence of periapical
complications, the temporary tooth will be kept on the arch and monitored through periodic
and radiologic exam, because the rizalisis is normally developing. If periapical complications
appear the temporary tooth will be extracted, (2,4)
Accelerated resorbtion determines the temporary tooth exfoliation in a couple of
months after the trauma and appears as a frequent complication in case of dislocations. To
avoid the accelerated resorbtion, endodontic treatment of the temporary teeth in evolution
stages I and II is recommended immediately after the trauma. (2,4)
Late resorbtion is consecutive to dental trauma that has determined the intrusion of the
temporary tooth. Because of the dento-osseous anchylosis processes a limitation of the
alveolar bone grow is produced or successional permanent tooth eruption perturbing, with the
developing of isolated dental malpositions (ectopia, inclusion). (2,4)

The consequences of temporary tooth trauma on the permanent tooth bud are in direct
relation with the patient’s age, intensity and trauma direction, evolution stage of the
temporary stage and report between the apex of the temporary tooth and the permanent tooth
bud.
The bud is certainly affected if the trauma interests the temporary tooth around the age of 3.
Temporary teeth trauma determines at the level of the permanent tooth the following:
 white or brown-yellowish colorations of the enamel (Img.10.4);
 Enamel hypoplasia;
 Coronal dilacerations;
 Odontoma;
 Coronary angulations;
 Radicular angulations;
 Radicular edification disturbance; Img.10.4 Chromatic and position
 Position disturbances; modifications at the level of 2.1

 Successional permanent tooth inclusion (1,3) consecutive of 6.2 trauma

The success of the treatment and adequate prognosis in case of temporary teeth trauma
depend on:
  State of the temporary tooth prior the trauma
 Patient and family cooperation
 Trauma amplitude
 Contention range
 Periodic check-up. (1,4)

Dental trauma in permanent dentition

In terms of frequency the dental and dento-periodontal trauma in permanent dentition

affect in average 1/3 children and teenagers, and in topographical terms in 80% of the cases
the incisors area is affected (Img.10.5). (2)
Anatomical and structural particularities of the maxillary bones and of the permanent
young teeth, associated with the force and impact direction generated by trauma, determining
as clinical form the most frequent diagnosed to be the coronary fracture.

Img.10.5 11- coronary fracture with incisor angle interest

Check-up

Dento-periodontal trauma represents a medical emergency. Affection of teeth in

anterior area of the dental arch, with direct involvement in talking and smiling, in preschool
age, represents an important emotional impact on the parents and on the child.
In case of important trauma, coming to the professional service is immediately which
implies using an emergency treatment.
If the trauma was less important the patient comes late to the dentist, moment in which
retrospective treatment of the traumatic lesion is done and treatment for consequences and
complications of the trauma. (1,2,3)

Anamnesis represents a very important element for choosing the therapeutic approach
and must not get past the emotional moment, to allow the dentist to obtain adequate info
regarding:
  the place and circumstances of the accident;
 time since the trauma until the moment of presentation at the dentist
 traumatic lesions associated changes: altering the general state, head-ache,
ocular disturbances, consciousness disturbances;
 the existence of some traumatic lesions associated in the oro-facial sphere.
(2,4)

Exo-oral exam will be done as systematic as it can to allow the identification of some lesions
associated to dento-periodontal trauma:

 fractures of the face bones

 concussions
 lesions at the TMJ level or particular articular noises. (6)

Endo-oral exam must contain the whole dental arches, not to limit just the trauma affected
area.
Each tooth will be evaluated through inspection and palpation with the dental probe,
without putting exaggerated pressures. For the traumatized tooth or teeth, the substance loss is
appreciated, aspect of the remaining dental tissues, mobility, aspect of the gingival edge.
Immediate post-traumatic results obtained in axial and lateral percussion as well as
vitality tests are inconclusive. Tooth color gives us information on the prior to trauma odontal
status. (4)

Radiologic exam is a must for a complete diagnosis. To obtain an overview on the

traumatic lesion effects the radiographies must be done from more incidences. With the help
of the radiography the following elements will be evaluated:
 Dental fracture focus
 Associated alveolar fractures
 The fracture line report with the dental pulp
 The forming degree of the root and apex aspect. (1,4)

Choosing the therapeutic approach and long term favorable evolution in case of permanent
teeth that have suffered traumatic lesions are determined by:
  time since the trauma to the presentation to the dentist
 dental state of the permanent tooth prior to the trauma
 patient and family cooperation
 following the dental hygiene recommendations
 patient’s periodic check-ups
 conservation possibilities of pulpal vitality
 root edification degree
 periodontal tissue damage degree. (2,4)

Traumatic lesions treatment of the permanent young teeth requires a very good
collaboration between the dentist, patient and family, and the recommendations are specific
for every clinical entity.

The coronal fracture of the permanent tooth. The main treatment objective is
represented by the conservation of the pulpal vitality, because of the special esthetic and
functional importance of these teeth (Img.10.6). The trauma-treatment emergency time period
represents the main factor of decision in choosing the therapeutic approach. To this the stage
of development of the permanent tooth is added and the amplitude of affected dental tissues.
(1,4)
Coronal fractures that superficially affects the enamel requires only the
smoothing of the fracture surface and applying of polishes and gels with fluorine. If dental
mobility is minimal, a contention system is not imposed. Avoiding incision and a diet that
does not put pressure on mastication, as well as keeping an adequate dental hygiene are
recommendations that must be followed. In case of an enhanced morbidity, a contention
system may be used, that will not be kept for more than 7 days. (3,5,6)
Coronal fractures that interest only the enamel, but are more extended, impose
the morphological restoring of the crown with a filling. The material used for coronary restore
will be chosen by biological criteria. (5,6,8)
Coronal fractures that affect the enamel and dentine require a coronary restore
that will follow the principles of hard tissues economy and evolution stage of the permanent
tooth. For emergency coronary restoring if the tooth was with no cavities, we can try the
reattachment of the fractured coronary fragment. In case of direct pulp capping it is
recommended that a check-up and vitality tests will be done after 7 days; if these are positive
then the prognosis is favorable. (3,5,6,8)
Loss of fractured tooth vitality can intervene after a variable time (3 weeks-2
years). (1,4)
If pulpal affliction has imposed pulpotomy, the 4-7 weeks radiologic exam
must show the presence of a dentinal bridge, to ensure a favorable evolution. Treatment
success is materialized by continuing the root’s edification and closing of the apex. (4,7)
The biological principles that follow the dental vitality conservation are not
always in agreement with the parents’ and the patient’s aesthetic requirements that wish the
immediate remake of the aesthetic aspect with a composite filling.

Img.10.6 11-coronary fracture with pulpal chamber damage. Initial aspect and after
pulpotomy (it can be observed that the radicular edification is complete at the traumatized
tooth).

Crown-radicular fracture of the permanent tooth requires a complex therapeutic

approach regarding:
o the direction of the fracture line
o the state of the marginal periodontium
o the radicular anatomy
o the root-crown report
o the radicular canal diameter
o the patient and family cooperation
o the dental hygiene of the patient

The prognosis is in correlation with the sub-gingival localization of the fracture line,
and the treatment methods are conservative (endodontic treatment, coronary restoring) or
extraction. (1,2,4)
Permanent tooth dislocation can present many clinical forms regarding the intensity
and direction of the traumatic agent:
 Partial dislocation in which the anatomical reports between the tooth and
socket are modified
 Total dislocation – expulsion (Img.10.7), intrusion (Img.10.8)
 Dislocated permanent teeth treatment depend on the traumatic lesion intensity, root
forming degree, uni-dental position changes,

Img. 10.7 Total dislocation with expulsion 1.1.

Img. 10.8 Intrusion 1.1, 1.2.

 Partial dislocation requires the tooth repositioning and vitality control in course
of the periodic control 6 to 6 months;
 Total dislocation with expulsion – treatment may include reimplantation or
extraction depending on different factors: general state, time since the trauma,
tooth keeping conditions, etc.
 Total dysplasia with intrusion of the tooth – if spontaneous eruption isn’t
observed after a couple of days from the trauma, extraction is recommended.

The space thus resulted after extractions will be evaluated regarding the ortodontic
treatment necessities and dental migration criteria. (1,5,6,7)

REIMPLANTATION is a therapeutic approach method that is recommended to be done

immediately after the trauma. Maneuver success depends on the way in which the keeping
and transport of the traumatized tooth was done, the aspect of the root, the degree of apex
forming, the socket and soft tissues aspect. If the patient came right after the trauma, and the
apex is open, the replantation will be done without the previous endodontic treatment. If the
patient came late (hours or days posttraumatic), endodontic treatment is necessary before
replantation, to prevent infectious complications.
The contention is recommended to be 7-10 days, maximum 2-8 weeks. On all
contention time period the dental hygiene rules will be followed together with an adequate
diet that will not put pressure on mastication.
Adjunctive medication will include non-steroid anti-inflammatory drugs at which we
can add, regarding the general state of the patient, antibiotics. (1,3,5)

Consequences of the permanent teeth trauma depend on the severity of the traumatic
lesions and emergency therapeutic measures that were applied. The most frequent
complications are:
  pulpal necrosis
 classic degeneration
 radicular resorbtions
 chromatic changes
 Altering the bone support. (3)

CONTENTION STAGE represents a very important element for the favorable evolution in
case of young permanent teeth trauma.
Contention methods must be done immediately and without trauma. Through these a
physiological position of the tooth must be ensured, with periodontal trauma avoidance and
occlusal interferences. Plus, the access for an eventual endodontic treatment must be easy. For
the patient the contention system must be acceptable esthetically and to allow an adequate
dental hygiene keeping. (4,5)

Img.10.9 A. Orthodontic mobile apparatus used as contention measure. B Fixed orthodontic

apparatus used as contention measure. C. thermal formed tray.

The most known content systems are: wire ligatures, trails, elements that are components of
fixed orthodontic apparatus, mobile orthodontic apparatus, acrylic and thermal formed trays.

If the dental trauma intervenes in case of a patient currently undergoing orthodontic

treatment the orthodontic apparatus can be modified so that it can be used as means of
contention.
Creating the acrylic and thermal formed trays requires the dental printing which
because of the patient’s anxiety, dental mobility or associated lesions cannot be done
immediately post-traumatic. Under these conditions the printing will be done after a day after
the trauma, when the dentist-patient-family collaboration is better. Trays can limit the dental
arch sector affected by the trauma. For conserving the vitality of the dental pulp and reducing
the discomfort determined by the dental mobility the tray can be cemented for 7 days using
glass ionomer cements.
In patients that cannot follow the isolation conditions and collaboration the stitched trails with
composite material can be used. It is preferred the stitching on the vestibular face not to
determine occlusal interferences and to allow the access for a following endodontic treatment.
The contention system will be kept for 7-10 days.
Treatment of the dental trauma that interests the young permanent teeth must represent
a balance between esthetic and functional because frequently an incorrect applied treatment
proves to be more dangerous than the trauma.

Img.10.10 Contention system – immobilization tray

 11. DENTAL EXTRACTION IN PEDIATRIC
DENTISTRY

DENTAL EXTRACTION of temporary or permanent teeth in childhood and adolescence

constitutes a treatment method that has advantages and disadvantages:
 Simplified therapeutic sequences
 Setting orthodontic treatment results, by making a balance between the dental system
and bone structures
 Favorable evolution of the wisdom teeth, prevention of dental-maxillary disharmony
with topographical crowding in the posterior area of the dental arch
 Unfavorable dental migrations of teeth adjacent to the post-extraction space if it isn’t
chosen the right moment for extraction or dental movements are not done under
control, though gression movements.
 Occlusal dysfunctions or of TMJ determined by the dental migration
 Contact points absence or inadequate dento-dental contacts forming. (1,2)

TEMPORAL TEETH EXTRACTION is recommended in the following situations:

 Dental trauma that don’t allow conservative approach of the affected temporary tooth
 Conservative odontal therapy failure
 General state of the patient imposes the removing of dental focuses
 Dento-alveolar anchylosis, re-inclusion
 Supernumerary temporary teeth
 Uni or bilateral aplasia of the permanent teeth
 Dental migration favoring of the permanent teeth
 Trauma of the soft parts determined by temporary teeth. (1,2)
Temporary teeth extraction requires individual evaluation of every patient to allow the
continuity of the growing processes and forming of stable oclusal relations, in a esthetic
and functional context.
 Conducted extraction

It is a method that favors the fitting of permanent teeth on the dental arch, without the
need of systemic appliances of an orthodontic apparatus. The method implies a long term
monitoring and requires a very good collaboration between dentist-parents-patient. (1,2)
Conducted extraction starts at age 7-8 and stops at age 10-11.
The steps of conducted extraction, by Hotz, are the following (Img.11.1)(1):

Img. 11.1. conducted extraction steps

 age 7 - lateral temporary incisors extraction to favor the alignment of the

central permanent incisors (Img. 11,1-1)
 age 8 – temporary canines extraction to favor the alignment of the lateral
permanent incisors
 age 9 – extraction of the first temporary molars to facilitate the eruption of
the first premolars (Img.11.1-3)
 age 10 – extraction of the first premolars to favor the alignment of the
permanent canines (Img. 11.1-4,5).
Conducted extraction is recommended if the following conditions are followed:
 Temporary teeth in the support area to be whole or restored with respecting
the morphological criteria
 Neutral occlusal relations, in sagittal plan, at the 6 years molar
 The presence of all replacement permanent teeth buds
 The eruption order of successional teeth is in correlation with the
conducted extraction steps
 The occlusion relation, in vertical plan of the incisors is with normal
covering (1/3)
Dental extractions must be made symmetric to prevent the appearing of some asymmetries or
the inter-incisive line deviation determined by dental migrations. (1,3)

PERMANENT TEETH EXTRACTION is recommended in the following situations:

 Conservative dental therapy failure
 Making a balance between the arches
  Keeping symmetry of the dental arch
 Ectopical and atypical teeth
 Trauma of the soft parts determined by permanent teeth
 Supernumerary teeth
 Teeth situated on bone fractures
 Indications about the general health state of the patient, for eliminating dental focuses
 Dental extraction in orthodontic means. (1,2)

Permanent teeth extraction in childhood and adolescence has to be the result of a

complete and complex analysis of every case in particular. There are some general
recommendations for permanent teeth extraction depending on the topographic situation at the
level of the dental arch.

THE 6 YEARS OLD MOLAR is extracted frequently when its odontal state does not allow
anymore the conservative treatment (Img.11.2A,B,C). Modifying the order of eruption, with
the appearing of the first permanent molar at age 5, its evolution in completing the dental
arch, existence of odontal untreated lesions at temporary teeth level, neglecting periodic
controls and insufficient apply of the specific prophylaxis methods of the dental cavity are
just a few of the causes that can explain the early affliction with cavity of the 6 year old
molar.

Img. 11.2 A. mandibular DDM with secondary crowding. Extraction is recommended 3.6,4.6
odontal compromised to create the space needed for dental alignment. B. Radiologic aspect
of the dental arches before the orthodontic treatment debut. C. Clinical aspect of the
mandibular arch towards the end of the endodontic treatment.
Img. 11.3 A. First superior premolar extraction in orthodontic means – occlusion in frontal
area before and B. after treatment

The moment of extraction must be chosen according to the patient’s age, the direction
of dental displacements and the relative conduit to the post-extraction space (keeping or
biological closing of the space). If the biological closing of the post-extraction breach is
wanted, preponderant through displacement towards mesial of the 12 year old molar, the 6
year old molar extraction will be done at the age of 8-9 depending on the radiologic aspect of
the second permanent molar’s roots (the roots must be 2/3 formed). If the 6 year old molar is
extracted to do the prophylaxis for dental crowding secondary to the wisdom teeth eruption or
to make enough space to align the teeth in case of DDM with crowding, then the extraction
will be done after the eruption of the second permanent molar. (1,3)

MAXILAR PREMOLARS are teeth that are the most frequent chosen for extraction in
orthodontic purpose, because it is situated close to the crowding focus in the anterior area of
the dental arch (Img.11.3A,B). Superior premolars present a poor mineralization, following
complicated odontal afflictions of the temporal molars, which develops intro a raised
predisposition for cavities. Plus, prime premolars can present long thin roots, difficult to deal
with for the endodontic treatment.
Secondary premolars, because of the numeric modifications represent a frequent choice for
orthodontic extractions. (Img. 11.4A,B,C).

Img. 11.4 A,B Agenesis 25, inclusion 15, clinical and radiological aspect C Frontal area
occlusion after germectomy 15 and orthodontic treatment.

Secondary maxillary molars are recommended to be extracted when the DDM with
crowding is localized in the posterior area of the dental arch or when occlusal relations of
Class II from the prime permanent molar level are the consequence for migration towards
mesial. (1,3)

Lateral Superior Incisors are not a frequent choice for dental extraction, in general, or the
dental extraction in orthodontic purposes. In some particular situations the extraction can be
recommended:
 unilateral aplasia (Img. 11.5A,B)
 shape modifications
 pathologic rizalisis following the evolution towards mesial of the permanent
teeth. (1,2)
Img. 11.5 A,B Aplasia 2.2. Extraction is recommended 1.2 as following the
pathological rizalisis determined by the eruption of 1.3 towards mesial and 2.2
agenesis.

Superior canines are selected for dental extractions in well determined conditions:
  Tooth erupted at distance from the normal arch position, impossible to bring back in
position with orthodontic or surgical measures, especially if the arch presents a
continuous aspect, with adequate contact points between the lateral incisor and the
first premolar and the occlusion relations are functional and stable
 volume, shape, structure changes that cannot be corrected by prosthetic means. (1,3)
Central superior incisors are considered an exceptional choice for dental extraction:
 Shape changes that cannot be corrected with prosthetic means.
 Trauma with the avulsion of the central incisor. (1,3)

Mandibular premolars are recommended to be selected for the dental extractions in the
following conditions:
 Orthodontic extraction, as following of a situation close to the crowding focus from
the anterior dental arch. In the majority of cases the first mandibular premolars will be
extracted (Img.11.6 A,B)
 Correcting the occlusal relations by repositioning the 6 year old molars – in this
situation the secondary mandibular molars will be extracted. (1,3)

Img. 11.6 A Prime mandibular premolars extraction in orthodontic purpose - the aspect of
the mandibular arch before and B after treatment.

MANDIBULAR INCISORS will be chosen for dental extraction in particular conditions:

 Tooth with ectopic or entopic position and afferent space completely closed (Img.
11.7A,B)
 Odontal state does not permit the recovering by conservative means
 Favoring the inferior canine eruption, if this has the root and apex mesial oriented.
(1,3)

Img. 11.7 A 3.2 entopic extraction - the aspect of the mandibular arch before and B after
incisor extraction.

Mandibular canines will be extracted in particular conditions:

 Tooth erupted at distance from the normal arch position, impossible to bring back in
position with orthodontic measures;
  Tooth impossible to bring back in position with orthodontic surgical measures,
especially if the apex if oriented to mesial (Img.11.8)
 Volume, shape, structure modifications. (1,3)

Img. 11.8 Extraction recommended 4.3 ectopic – the aspect of the mandibular arch before
treatment.

Secondary mandibular molars are recommended to be extracted when odontal lesions do

not allow a conservative approach or when the DDM with crowding is localized in the
posterior area of the dental arch, to favor the eruption of the wisdom tooth (Img. 11.9 A,B).

Img. 11.9 A,B the extraction of 4.7 for the purpose of favoring 4.8 eruption

Img. 11.10 A bi-maxillar DDM with secondary crowding – relapse determined by wisdom
tooth eruption – clinical aspect B and radiological aspect.

Wisdom teeth are recommended to be extracted to prevent the crowding of the teeth from the
frontal area or to reduce the risk for relapse of the orthodontic (Img.11.10 A,B).
The extraction recommendation must not be done systematic – this implying a complete and
complex analysis of every case in particular. (1,3)

The moment of the extraction will be chosen according to the general state of the
patient, teeth migration rules, the attitude toward the post-extraction space and the necessity
of further orthodontic treatments.

THE DENTAL EXTRACTION of temporal and permanent teeth implies the succession of
the following steps:
 Patient preparation - explaining the maneuver in simple terms, adapted by age;
 Preparing the required instruments, so that the patient can see as less as possible from
the specific tools.
 Topical anesthesia using sprays or gels to reduce the discomfort of the proper
anesthesia
 Anesthesia by infiltration – will be used small sized needles, and injecting the
anesthetic will be done slowly
  Extraction
 Post-op indications – avoiding food with extreme temperature and dairy products. No
food allowed for at least 2 hours after the extraction to prevent the lesions by biting on
the soft parts, because the post anesthetic sensation does not allow a good control over
the masticatory movements and an adequate sensibility
 Post-op check-up after 24-28 hours for patients with risk or in case of more difficult
maneuvers. (1,2,4)
Used substances for the infiltration anesthesia, in case of temporary or young permanent teeth
extraction:

LIDOCAINE
It is presented in the form of hydrochlorhydric solution
It is recommended for infiltration anesthesia and ensures a profound anesthesia and on
a more extended area then procaine.
The allergic response to parenteral administration is extremely rare, but can present a
higher toxicity than procaine.
Adverse reactions manifest like faintness, shock.
Liver metabolism implies precautions in patients with hepatic afflictions.
Hydrochlorhydric lidocaine is compatible with epinephrine. Products used contain
1:100.000 epinephrine, and the maximum dose of anesthetic admitted is 4.4g/kg. (2,3)

EPINEPHRINE

It is an adrenergic product, anesthetic adjuvant, bronchodilator.

Indications – anaphylactic reactions, bronchospasm, cardiac arrest.
Contraindications – cardiovascular affections, atherosclerosis, diabetes.
 12. PERIODONTAL AFFECTIONS IN CHILDREN AND
TEENAGERS

Periodontal afflictions include clinical entities of multiple factors etiology, with

progressive evolution, that determines the destruction of the support and fixing elements.
These pathologies can clinically manifest in childhood, but more frequently in this stage
predisposing factors act, and periodontitis intervenes in adolescence or in adults. (1)
In terms of structure and functionality, the following types of periodontal tissue are
differentiated in children and teenagers: coating periodontium and sustain periodontium. (1)

COATING PERIODONTIUM is made of:

 free marginal gum that surrounds the dental cervix and contributes
to the forming of the deep gingival notch of 0.5-1.5 mm
 interdental gum is located in the interdental spaces area with
protection role against periodontal trauma
 Attached gum that continues the marginal gum and is fixed with
fibrous dense tissue in underlying alveolar bone. (1)

SUSTAIN PERIODONTIUM is made of:

 radicular cement that covers the surface of the root and whose
thickness grows with age. Cement is produced continuous and
allows functional restructuring of the alveolo-dental ligaments
 alveolar bone that is developed at the same time with the hard
dental tissues and it is a young bone in the childhood
 desmodontium which is a tissue complex: Lax conjunctive tissue,
blood and lymph vessels, alveolo-dental ligament fibers that are in a
continuous functional restructuring. (1)

ETIOPATHOGENESIS OF PERIODONTAL AFFECTIONS in children and teenagers is

varied and includes:
 general factors
 regional factors
  individual factors
 genetically modified terrain
General factors that determine the periodontal affections are:
 Endocrine affections (thyroid dysfunctions, etc.)
 Metabolic disturbances (diabetes)
 Vitamin deficiencies (vitamin C)
 Hematologic diseases
 Autoimmune diseases
 Drug products (anti-epileptics). (1)
Regional factors that determine the periodontal affections are:
 Muco-bacterial plaque
 Muscular dysfunctions and parafunctions
 Masticatory inactivity
 Labial frenulum with abnormal insertion
 dento-maxillary abnormalities
 Occlusal dysfunctions.

Img. 12.1 Periodontal tissues affection induced by muco-bacterial plaque, tongue

parafuncitons and dento-maxillary abnormalities

PERIODONTAL AFFECTIONS CLASSIFICATIONS in children and teenagers can be

done after different criteria like so:

 Inflammatory forms
 superficial
 profound
 Dystrophic forms
 dystrophic
 atrophic
 Proliferative forms
 hypertrophic
 hyperplasic
 Acute progressive forms
 gingivitis
  papillitis
 Chronic progressive forms
 inflammatory
 dystrophic
 mixt (1)

CLINICAL ENTITIES FREQUENTLY DIAGNOSED in children and teenagers are:

 odontiasis gingivitis
 unspecified marginal gingivitis
 septum syndrome = localized gingivitis
 pulpal gangrene with periodontal affection
 ectopic evolution of the permanent teeth
 asymmetric rizalisis of the temporary teeth
 Pubertal gingivitis
 Gingival recessions
 Gingival hyperplasia
 Oral manifestation of some general manifestations
 Acute juvenile periodontitis. (2,3)

ODONTIASIS GINGIVITIS

It is a clinical entity that can accompany the dental eruption (Img.12.2)

Temporary teeth eruption allows the penetration of microorganisms at the underlying
periodontium level and regarding the immune response of the child may or may not appear
local uncertain inflammatory phenomena.
Permanent teeth eruption, because of the proximity with the temporary teeth already
affected by cavities as well as poor oral hygiene, can determine pericoronitis or false
periodontal bags.
Treatment implies a rigorous oral hygiene with specific toothbrushes for teeth that are
in eruption and mouthwash rinsing.

Img. 12.2 Odontiasis gingivitis

NONSPECIFIC MARGINAL GINGIVITIS
The incidence of this clinical form is frequent in the childhood, according to
professional literature 18% of the children age 5, 40% of the children age 7, 54% of the
children age 11 and 49 % of the teenagers age 15, have still presented specific manifestations
of this clinical entity.
In terms of expansion this gingivitis form can be localized or generalized.
Nonspecific marginal gingivitis etiology implies: poor hygiene, oral breathing,
temporary and permanent teeth eruption, extended carious lesions, inadequate restores with
overflowing edges, etc. (Img. 12.3)
Treatment implies a rigorous dental hygiene, a brushing instructing preceded by
markers with the help of plaque revealers of the areas that need a more careful approach.

Img. 12.3 nonspecific marginal gingivitis

Odontal lesions were treated according to the progressing stage of the tooth, and
parafunctions will be approached by conviction methods or by restraint methods. For the
patient’s accountability learning and adequate brushing technique a check-up is recommended
after 15 years (Img.12.4)

Img. 12,4 Revealing the muco-bacterial plaque to explain and motivate the correct technique
for dental brushing
SEPTUM SYNDROME = LOCALISED GINGIVITIS

It is noticed frequently while consulting as pain symptomatology that appears during

meals. At interdental level a gingival polyp can be noticed and an abscess at the papilla level
(12.5)
Septum syndrome etiology includes:
 Extended coronary destructions with the marginal enamel crest disappearance
 overflowing fillings.
Treatment implies the coronary restoring of proximal mirrored cavities, respecting the
morphological and functional particularities of the teeth, using amalgam, glass ionomer
cements or pedodontic preformed crowns. (3,4)

PULPAL GANGRENE WITH PERIODONTAL AFFLICTION

 Represents a frequent complication in case of temporary teeth gangrene, and in a lot of
cases it is the manifestation of the radicular bifurcation pathology of the temporary teeth.
Signs and symptoms are characteristic to the odontal base affection.
Therapeutic conduit depends on the progressive state of the temporary tooth:
 Conservative treatment – on the retroalveolar radiography pathologic resorbtion
and apical radio-transparency is not observed:
 Surgical treatment – extraction with or without the applying of the space-holder
depending on the period of time until the successional permanent tooth eruption,
the status of the neighboring and antagonists teeth, occlusal relations, dento-
maxillary associated abnormalities

ECTOPIC EVOLUTION OF THE PERMANENT TEETH

Permanent teeth eruption at distance from the afferent topographic zone from the level
of the dental arch, may determine periodontal manifestations, especially in the case of
permanent canines and the premolars. Frequently, the tooth does not erupt on the middle of
the alveolar crest and must pass a thick bone tablet or in case of early extraction of temporary
teeth a well distributed keratinized tissues. Under these conditions at the erupting tooth level,
characteristic to the unspecific marginal gingivitis phenomena appear. Treatment implies a
rigorous dental hygiene (Img. 12.6)

Img.12.6 ectopic evolution 4.5

Temporary teeth asymmetric rizalisis can determine the ectopic eruption of the permanent
tooth associated with the stalling in developing the periodontium. (Img. 12.7)

Img. 12.7 Asymmetric rizalisis of temporary teeth

Treatment implies elimination of the temporary tooth or of the remaining root and
respecting the rules of oral hygiene.
PUBERTAL GINGIVITIS
The clinical aspect is that of a hypertrophic marginal gingivitis, the interdental papilla
are swollen and easily bleeding (Img.12.8).
Etiological main factors are represented by the dental plaque and tartar, prebupertal
and pubertal period, frequently representing moments of neglecting the self and negating the
rules of adult’s authority.
Aggravating factors of periodontal affliction are: oral respiration, dento-maxillary
abnormalities or lingual dysfunctions.
Treatment implies teenagers motivation for a rigorous dental hygiene, bacterial plaque
removal and recommending auxiliary methods for oral hygiene.(3,4).

Img.12.8 Pubertal gingivitis

GINGIVAL RECESSIONS

Gingival recessions etiology (Img.12.9) includes:

- labial frenulums are highly inserted
- Dento-maxillary abnormalities
- Parafunctions. (1,4)

Treatment of the gingival recessions must follow at first the removing of the causal factor.
Patient will be instructed over a right brushing technique to keep an adequate dental hygiene.
To compensate the defect, fixed gum grafts will be used after the stopping of growing
processes. (1,4)

GINGIVAL HYPERPLASIA

It implies a volumetric augmentation of the marginal gum which is inflamed, and with
smooth non-swollen aspect.
Gingival hyperplasia etiology includes drug products (diphenylhydantoin – anti-
epileptic) or may have a genotypic determination (Img.12.10).
General treatment implies the administration of a medication that does not determine
periodontal response.
 Local treatment includes rigorous oral hygiene respecting an adequate brushing
technique. (1,3,4)

Img. 12.10 gingival hyperplasia of drug etiology (5)

ORAL MANIFESTATIONS OF SOME GENERAL AFFLICTIONS

Periodontal tissues may represent indicators for general health state. Thus, before the
pre-pubertal period we can diagnose generalized afflictions of the marginal gum which in the
biggest part are reversible with an unspecific treatment. In young children during infectious
diseases a marginal gingivitis can be observed. The swollen tonsils represent a germ pool for
the oral cavity and can favor the appearing or exacerbation of the periodontal afflictions. In
teenagers an ulcero-necrotic gingivo-stomatitis may be present in the context of a altered
general state and poor oral hygiene.

ACUTE JUVENILE PERIODONTITIS

It may present two distinct clinical forms: localized and generalized form (Img.12.11).
The localized form is more frequent in teenagers. Etiological agent is Actinobacillus
actinomicetemcomitans. Lesions are in general symmetric and periodontal localized bags and
bone destructions may appear. (prime molars, incisors).
The generalized form may appear at an older age and may represent the starting point
of a rapidly progressing periodontitis in the young adult. Early diagnosis, before the age of 10,
may be done with the help of retroalveolar radiographies. Early treatment allows the obtaining
of favorable results.
 13. AFFLICTIONS OF THE ORAL MUCOSA IN
CHILDREN AND TEENAGERS

ORAL MUCOSA OF CHILDREN AND TEENAGERS present the following

particularities:
 Reduced tissue density
 Rich vascularization
 High regeneration capacity
 Defense capacity in the conditions in which it realizes a biological balance of the oral
environment.
The resistance decrease of the organism determines the trophicity of the oral mucosa witrh
the saprophyte flora transformation to pathogen flora or exacerbation of some pathogene
microbial species. (1,2)

AFFECTION CLASSIFICATION OF THE ORAL MUCOSA can be done using

different criteria:
1. Type of lesion: erythematous, vesiculobullous, ulcerous
2. Etiology: microbial, viral, systemic
3. Topographic disposition: tongue, lips, etc. (1,2,3)

ELEMENTARY LESIONS OF THE ORAL MUCOSA regarding their aspect:

 Erosions
 Ulcerations
 Vesicles
 Pustules
 Others – macules, papules, nodules. (1,2)

Erosion implies a loss of substance with superficial localization, without the necrosis of
underlying tissues (lichen plan).
Ulceration characterizes as a deep loss of substance, with the interest of underlying
conjunctive tissues (aphthae).
The vesicle is an intra-dermal formation that stands out, bumpy, with frequent liquid content,
serous (herpes simplex).
The pustule is an intra-dermal formation that stands out, bumpy, with purulent content
(impetigo). (4,5)
Clinical entities that frequently in children are represented by: aphthae, herpes simplex
and oral candidiasis.

Aphthae
These are lesions of the oral mucosa that present under the form of erosion or
ulceration at whose periphery a reddish ring can be seen. The stages of macula and vesicle are
short and often pass unobserved.
Topographically, aphthae can be located at lip, tongue or vestibule level and lesions
can be isolated or generalized. Lesions are not contagious but are very painful.
Aphthae etiology is undetermined, but around the favoring factors are: dento-
periodontal trauma, vitamin deficiency, low immunity, infectious diseases, hematologic
affections, AIDS, stress, etc.

Local treatment is preponderant symptomatic:

 rigorous dental hygiene
 preponderant liquid diet with avoiding extremes of temperature, of condiments, etc.
 treating the lesions with specific products to isolate them from the oral environment
(Plantagingival, glycerine borax)
 applying antibiotic toothpastes or corticosteroids at lesion level in case of
superinfection or to reduce the evolution in time.
General treatment follows the sustaining of the general state and immunity stimulating in
determined cases. (1,4,5)

APHTHOUS STOMATITIS

It is a contagious infectious disease, of viral etiology that can appear isolated or with
the clinical picture of come infectious diseases (measles, pertussis)
General symptoms includes: fever, headache, loss of appetite. At oral cavity level the
mucosa is erythematous and numerous aphthae can be seen.
Prognosis is favorable – disease duration is 7-8 days.
 Local treatment is symptomatic, and general treatment appeals to analgesics, anti-
inflammatory and vitamin therapy. (1,4,5)

HERPES SIMPLEX

The prime infection with Herpes Simplex Virus (HSV) is frequent in children between
1-3 years.
HSV is located at nodules level in patients that have already presented the primary
infection. Reactivation is secondary to fever, stress, solar radiations, hormonal dysfunctions,
etc.
In terms of lesion, the labial herpes simplex can be seen as erosion or ulceration with
reddish ring or associated vesicles in bouquet.
Isolated lesions are located most frequently at the level of the upper lip, but can extend
over to the lower lip or nearby tissues (nasal wing).
Complications include the expansion of the lesions if the vesicles popped and their
liquid content diffuses at lip level, skin or through saliva to the soft tissues from the oral
cavity. Lesions spontaneous heal in 10 days.
Symptomatic treatment of herpes simplex implies sustaining the general health state,
rigorous oral hygiene, dehydration prevention through adequate liquid intake. To reduce the
local discomfort caused by the vesicles it is recommended: Aciclovir®=Zovirax® (200 mg
5x/day/5 days, local treatment). If the product is applied since the forming of the vesicles the
time for healing can be reduced to half. Antibiotic applications are reserved only in cases of
superinfections of the lesions. In the recurrent forms it is recommended the active
immunization with anti-herpetic vaccine.
Img.13.2 Herpes simplex with labial localization
HERPETIC GINGIVAL-STOMATITIS

It may represent the expression of the primal infection with HVS. The affection has
auto-limiting character, complete healing can occur after 10-14 days with or without adjuvant
symptomatic treatment.
Herpetic gingival-stomatitis symptomatology includes: altered general state, raise of
temperature, growth in volume of lymph nodes. At oral cavity level the dryness sensation
precedes the apparition of vesicles whose location interests the tongue and palatal mucosa.
Vesicles confluence, pop and determine the apparition of extremely sensible ulcerations.
 Positive diagnosis implies the creating of viral cultures that will reveal the presence of
HVS.
General treatment is preponderant symptomatic because the affection is auto-limited
and follows especially the prevention of dehydration because the majority of patients refuse to
feed because of the local discomfort it creates. Feeding will not solicit the mastication and so
cold or warm products will be preferred. For discomfort reduction analgesics and anti-
inflammatory drugs may be administered, and for the general state sustain Aciclovir® tablets
200mg/5x day/5 days.
Antiviral topical treatment implies applying some products at the ulceration level that
will isolate those in the oral cavity.(1,3,6)

Img. 13.3. Herpetic gingival-stomatitis

ORAL CANDIDIASIS

It is an infection caused by Candida Albicans, micro-organism that is present in

saprophyte flora of the oral cavity. In particular conditions, its multiplication is extremely
fast, and saprophyte forms turn into pathogen entities.
Oral candidiasis etiology is extremely vast and includes:

 Prematurity
 Immunity deficiencies
 Head and neck irradiation
 Antibiotics therapy
 Imbalanced diabetes
 Xerostomia. (2,3)
Oral candidiasis can present the following clinical forms: Pseudomembranous and
atrophic. Etiological diagnosis is based on microbiological exam.
Oral candidiasis symptoms are in principal the dryness sensation or burn sensation
from the oral cavity level and the metallic taste. Oral mucosa is erythematous, and on this
background white areas appear, prominent that confluence into placards. Initially the lesions
appear at the level of the dorsal face of the tongue and extend on the jugal and palatal mucosa.

Treatment is a systemic and topic approach.

Systemic therapy:
 Ketoconazole (tab.200mg)
o Adult – 1 tab/day
o child – 4-7 mg/kg/day
 Fluconazole (tab. 50mg, 150mg
o Adult – 2 tab./day 1; 1 tab/day/7-14 days
o child – 3-6 mg/kg/1X/day
Topic treatment:
 Nistatin – suspension 100.000 unit/ml (vial 6g dust)
o child – 1ml/4X/day. Product is administered at least 48 hours after
disappearing of local symptoms. (2,3,4)

MANIFESTATIONS AT THE LEVEL OF THE ORAL MUCOSA IN CHILDHOOD

DISEASES

Infectious contagious diseases are characteristic to childhood and can determine specific
manifestations at the level of the oral cavity mucosa that sometime can precede the stage of
general affection.

 Scarlet fever – oral manifestations are like angina or glossitis. Tongue is sabural with
red edges initially, it desquamates from tip to base, and in final it becomes red by
proliferating and pigmenting of the fungiform papillae – raspberry tongue.
 Chicken pox – in the prodromal stage, at the level of oral mucosa macules can be
observed, that transform into yellowish vesicles and lastly in ulcerations. Maculo-
vesicle eruption appears after the symptoms at the oral mucosa are obvious.
 Measles – Koplick sign, characterized by the presence of white micro-papules
disposed on a congestive area at the level of the jugal level or in the vestibular notch).
Lesions are asymptomatic, persists for 2-3 days, and the exanthema appears lately.
 14. PROSTHETIC TREATMENT IN CHILDERN AND
TEENAGERS

Prosthetic treatment presents particularities in children and teenagers comparative to the adult
prosthetic treatment because it must allow the active growing processes. Prosthetic measures
are used to treat the following entities:
 Dental cavity complications that determine the loss of temporary or permanent teeth;
 Extended coronal destructions
 Dental trauma
 Reduced or extended hypodontis
 Shape, structure, color abnormalities
 Dento-maxillary abnormalities, as adjuvant of the orthodontic treatment.
Prosthetic treatment can be applied in every progressive stage of the dentition but has
a temporary character in childhood and adolescence. (1,2)

PROSTHETIC TREATMENT IN TEMPORARY DENTITION

The indications are a function of the topographical area of the dental arch that needs to
be restored: support area or the incisor area.
The choice of restoring method depends on:
 the size of remaining hard dental tissues;
 the patients oral hygiene;
 the time interval to the moment of physiologic exfoliation of the tooth.
 adhesion to periodic check-ups;
 associated dento-maxillary anomalies. (3)

Support area

It includes the temporary canine along with temporary molars one and two. The role of
these dental units is to maintain the vertical dimension of the occlusion and to ensure
masticatory effectiveness until the eruption of the six year molar and premolars.
 The dimensional distances between the mesio-distal diameters of the temporary molars
compared to successional premolars, allow the correction of the sagittal occlusal relations in 6
year molars or certain variations with crowding in the anterior area. (1)

For the support area the prosthetic means of treatment are:

 inlay
 prefabricated or extemporaneously constructed metal rings
 prefabricated pedodontic crowns
 space-holders. (1,2)

Inlays are seldom recommended because they require a laborious work technique for
preparing and printing of the cavity that is contradictory to the patients age.

Prefabricated metal rings allow the reconstruction of the morphology of the proximal,
vestibular and oral faces and to a lesser degree of the occlusal face. Adaptation is relatively
easy by selecting the rings from special kits. Cementing is done with glass ionomer cements.

Prefabricated pedodontic crowns (Img.14.1) allow the morpho-functional reconstruction of

the dental crowns that are extensively damaged and ensure increased durability of the
reconstruction. Because of the odontal lesions frequently advance past the stage of superficial
cavity, before the application of pedodontic crowns we recommend endodontic treatment of
the temporary teeth.

Img.14.1 Preformed pedodontic metallic crown

Space-holders (juvenile prosthetics) will be done after the extraction of irrecoverable

temporary teeth by conservative means to the end of preventing dental migration or the
construction of the components of an orthodontic apparatus if dental maxillary anomalies are
present. Space holders may be mobile (Img.14.2, 14.3) or fixed (more difficult to apply in
case of temporary teeth because of reduced crown dimensions, difficulties in isolating the
operating field and the patient’s oro-dental hygiene ) (Img.14.4).(1,2,3)
THE ANTERIOR AREA

Temporary incisors do not maintain space for successional teeth but their function in
phonation, physiognomy, mastication and parafunction prevention is very important.
Prefabricated pedodontic crowns constructed from acrylic resins allow the morpho-functional
reconstruction of dental crowns and the esthetic aspect of the small patient.
Space holders are done after the extraction of the irrecoverable temporary teeth to prevent
parafunctions. Space holders may be mobile or fixed and require periodic replacement to
prevent perturbation of the growth process. (1,2,4)

PROSTHETIC TREATMENT IN MIXED DENTATION

The indications depend on the topographic area of the arch that needs to be restored:
the support area, the anterior area, prime permanent molar.
Anterior area
Prosthetic treatment in permanent incisors is recommended in the following situations:

 extensive coronary fractures.

 incomplete radicular development
 uni or bilateral aplasia
The objectives of the prosthetic treatment are mainly the restoring of the esthetic and phonetic
functions, ensuring an effective mastication and preventing the parafunctions.
The effective prosthetic means – facets, coating crowns, substitution crowns, inlay, onlay,
dental bridges – must be chosen with respect to biological criteria (dental tissue saving),
especially in young permanent teeth that are vital. The parent’s requests for immediate
esthetic restore may compromise the tooth’s vitality for this reason the dentist is obliged to
establish a balance between functionality and esthetics until the completion of dental post-
eruptive maturity (1,2).
Img.14.2 Mobile space holder
Img.14.3 Mobile space holder

Support area
Prosthetic restoring in case of temporary teeth from the support area can be done with:

 Metallic rings
  Prefabricated pedodontic crowns
 Space holders. The presence of the 6 year molar ensures better morphological
conditions for applying a fixed space holder that will be periodically replaced to not
interfere with growth processes.
Before applying the space holder it is required a radiologic exam to verify the
presence of the successional teeth buds and an orthodontic evaluation of the case. (1,2)

The 6 year molar requires the applying of some means of prosthetic treatment
because of the high predisposition for cavity and the difficulties of the restoring treatment
(extended coronary destructions, incomplete formed roots, etc.). The functional importance of
this tooth implies its keeping on the arch to ensure adequate occlusal relations and to prevent
the dental migrations.
The prosthetic means used are more frequently the coating crowns, inlays, onlays and
rarely substitution crowns. (1,4,5)

Img.14.4 Fixed space holder

Img.14.5 Imperfect dentino-genesis – onlay 1.6,2.6

PROSTHETIC TREATMENT IN PERMANENT DENTITION

It has the following objectives:

 Restoring the DM Ap. functions
 Respecting the bio-mechanical, bio-functional principles
 Respecting the growing directions from the level of the facial massive
 Ensuring some optimal conditions for a prosthetic treatment after age 18-20. (1,2,5)
Means of prosthetic treatment that allow the realization of these objectives are:
 Coating crowns
 Substitution crowns
 Dental bridges
 Faceting.

Coating crowns are applied on vital teeth and represent an exceptional treatment option,
because of the raised sacrifice of hard dental tissues. If the permanent tooth is devitalized,
prosthetic therapy respects the criteria applied in case of adult patients.
Faceting done on vital teeth are contraindicated formally until over age 18, but in case of
devitalized teeth it represents a adequate therapeutic option.
Dental bridges must be done so that it won’t stall the growing and developing processes.
Bone growth continues 1-2 years after the stop of the dental eruption, and the lateral
development of the dental arches continues until after 21 years. To respect these criteria the
dental bridges will be temporary and will be replaced periodically.
Dental implants will be applied after the stop of the growing processes. The implant is acting
like an anchylosed tooth that does not allow the exact evaluation of effects on which growing
will have on the relative position of the implant. To reduce the risks it is recommended the
applying of implants and realizing prosthetic rehabilitation after the stop of the growing
pubertal processes. (2,5)
 15. PAIN IN PEDIATRIC DENTISTRY

HYSTORY

Fighting pain in the treatment of different dental affections and surgical interventions
quietly for the patient and for the doctor are major objectives for the medical practice.
Considerable progress in anesthesiology lately, were possible because of the pharmacological,
physiopathological and clinical research that have allowed not only the discovery of new
substances with individualized actions with high efficiency and reduced toxicity but also a
more correct indication, that will predict and treat efficiently local and general accidents. In
dentistry, doing some maneuvers without pain holds to the particularities of this domain, in
which therapeutic interventions are extremely diverse as amplitude, length, intensity, from the
treatment of a simple cavity to a large-scale surgical intervention at maxillary bone level or
soft tissues from the face area.
The majority of the interventions are done in the dental office the people who come
here for other affections, undiagnosed, general and so in consequence it is uncompensated and
most of the times cannot be monitored post-op. Thus the dentist will have to choose the type
of anesthesia regarding on the type and length of the intervention, the affection for which the
intervention is for, the patient’s general state and the place where the specific dental
intervention is being done, an isolated medical cabinet or a clinic with an emergency service.
For usual dental treatments, done in the isolated office, the big majority of cases, local and
regional anesthesia is used. Local anesthesia is preferred by the majority of the dentists, being
more precise, and easy to administer without special preparing, does not require special
instructed personnel or special tools and offers the possibility of a permanent collaboration
with the patient while the operatory act is in course, thus being very important. There are
however situations in which local and regional anesthesia is no longer indicated even for a
simple dental maneuver, when patients present inflammatory processes that blocks access to
the place of local anesthesia applying, when respective patients have psychiatric disorders, in
very young children with whom we cannot collaborate. At present, the therapeutic arsenal
used in dentistry allows the developing of a large variety of specialized therapeutic
interventions know being the fact that a good anesthesia gives operatory quietness to the
doctor and psychic and physical comfort to the patient. (1)
 Pain is a sensorial experience that each one of us have lived it along the course of life,
a signal of warning, a signal if dysfunctions.
Pain is defined by the international media, as a sensorial experience and emotionally
unpleasant, determined or in relation with some real or potential tissue lesions. (2)
‘Anesthesia’ means the complete abolishment of all sensations, including the pain.
Local anesthesia is the loss of painful sensation in limited regions and can be induced by local
applying, local infiltration or regional injection of anesthetic substances. It is obtained usually
by placing an analgesic substance near the sensitive nerves, so that temporarily blocks the
nervous impulses towards the central nervous system.
The trigeminal nerve is the Vth pair of cranial nerves. It is a mixt nerve, but in
sensitive terms it is the most important pain receptor from the face level, cranium, and its
annex cavities. The trigeminal nerve also innervates the masticatory and mandible raisers
muscles. It is the nerve that ensures almost exclusively the sensibility of the facial cranium
and of the face, is the neuro-vegetative secretor nerve for the lacrimal, salivary glands and
glands of the rhinosinusal mucosa. Has a vasomotor and trophic role. Actually, almost all oral
and maxilo-facial pathology is linked more or less to the trigeminal nerve, fighting the pain
and obtaining anesthesia at this level cannot be done without knowing the anatomy of this
nerve. (2)
Dento-periodontal pain represents the most frequent oro-facial pain. The dentinal pain
is a type that is often met and appears any time the dentine is exhibited to the external
medium. It is known that the dentine is isolated by the external environment through the
enamel or cement. Loss of those protective layers is possible because of the carious processes,
pathological abrasions, periodontal reactions with the disappearing of the necrotic cement,
fractures of the enamel and dental cement and frequently because of cavities evolutions.
Pulpal pain differs regarding the pulpal lesion of the respective tooth. In normal
situations, pulpal pain irradiates towards the corresponding nerve branch that innervates the
diseased tooth. Pain intensity varies a lot, depending on the nature of the stimuli and can
progress to a discrete disturbance, to moderate pain or insupportable pain. Pain duration can
be intermittent, with quiet periods of time between the painful spikes or continues to irradiate
in all half of the face
In the majority of cases, our patients present to the dentistry after an acute painful
episode. If the patient is a child, the diagnosis and treatment of that pain will be stalled
because of the more difficult collaboration with the little patient. That is why it is very
important for the dentist to know very well the dental anesthesia techniques, anesthetic
substances used and even accidents and complications possible.

With the purpose of fighting pain, most of the times it is sufficient to inject the
anesthetic in the vicinity of the sensitive nerves, thus temporary blocking impulse conduct
towards the CNS. In dentistry the local anesthesia is obtained by two main ways:
1. Topic anesthesia
2. Infiltration anesthesia
We use local anesthesia in dentistry to eliminate pain. It is used in usual dental
treatments like extractions, cavity treatment, endodontic or prosthetic treatment. In oral
surgery we use it to remove cysts, for a preprosthetic treatment or for dental implants. If a
local anesthetic is applied, patients relax and treatment is done easier. For the same reason we
will apply many times the local anesthesia to anxious patients even if the procedure is
painless. Local anesthesia is used in diagnostic purpose too because if a nervous branch from
a certain region is anesthetized the pain stops, and a conclusion can be made that the causing
lesion is in the area that is innervated by this nerve and the cause of pain can be detected
easier. Usually local anesthesia contains a vasoconstrictor substance, its role being to keep
hemorrhage under control, and to prevent the rapid removal of the anesthetic from the area by
the blood flow. More agitated patients can relax if we use sedative techniques like the
inhaling of an equimolar mix of oxygen and nitrous protoxide (MEOPA) or using intravenous
techniques under premedication form, if the maneuver is painful following the injection of a
local anesthetic. With these techniques, patients remain conscious and cooperative, with all
protection reflexes maintained. (1)

ANESTHETIC SUBSTANCES

For anesthesia, a relatively reduced quantity of local anesthetic is injected in the

vicinity of the nervous fibers. The fat and muscular fibers as well as blood absorption reduce
the quantity of anesthetic available to diffuse in the nervous tissue. Once absorbed in the
blood flow the anesthetic substances will be metabolized in the liver into compounds that will
be eliminated by the kidneys. About the chemical composition, local anesthetics can be esters,
amides (Lidocaine, Mepivacaine, Articaine) or quinolones. There is a wide variety of
anesthetic substances available today, but in modern dentistry we use anesthetic substances
with superior qualities, especially created for dental use.
 1. Lidocaine (Xiline)
Lidocaine is commercialized in the form of sterile solutions, that contain an anesthetic
agent, with or without adrenaline and it is administered parenteral by anesthetic infiltration.
The solution contains many times a preservative, metilparaben, guilty of possible allergic
effects. Of course, the Xiline type products with adrenaline may contain sodium
metabisulphite, also a preservative that can induce severe reactions to allergic people or
asthmatic episodes to susceptible patients. One vial of 2ml of Xiline, concentration 2%
contains 40 mg of lidocaine chlorhydrate (20mg/ml). It is recommended the injection of a
minimal dose of anesthetic, the usual dose for local anesthesia being 20-100 mg Lidocaine, so
1-5 ml solution 2%. The maximum dose for a session in healthy adults will be:

- Lidocaine without adrenaline, 4.5 mg/kg-body, without passing 300 mg

- Lidocaine with adrenaline, 7 mg/kg-body, without it passing 500 mg
- In children over 3 years the maximum dose of Lidocaine without adrenaline is
3-4 mg/kg-body

From the commercial products, injectable products are: Xiline 1%, 2%, 4%,
Lifnospam or in the form of spray 10% (Lidocaine) and gel 2% (Tropicain Gel).

2. Mepivacaine

It is also a local amidic anesthetic, chemically and pharmacologically related with every other
amidic anesthetic. The rate of anesthesia installation is short, 2-3 minutes, and the duration of
the efficient anesthesia is high, 2-3 hours. The rate of local anesthetic absorption is depending
on the dose, concentration and presence/absence of the vasoconstrictor adjuvant (they do not
significantly prolong the anesthesia with Mepivacaine). Mepivacaine will be administered in
reduced doses to old patients or with cardiac hepatic or renal problems. The maximum dose
for a session in healthy, normal weight, without general affections is 400mg (1 ml injectable
solution contains 30 mg Mepivacaine chlorhydrate). There have been administered doses of
up to 7 mg/kg-body without adverse effects but this dose is not recommendable. The total
dose for 24 hours will not pass over 1000 mg. In children aged 4-15 years the maximum
dose is 0.5 mg of mepivacaine chlorhydrate/kg body, which does not correspond to
0.0167 ml mepivacaine solution simple/kg body or 0.025 ml solution of mepivacaine with
adrenaline 1/100.000 kg body.

3. Articaine
It is an amidic local anesthetic; it is commercialized in isotone sterile solution form,
for administration by infiltration. Articaine is indicated only for local regional anesthesia in
dentistry or oral surgery and is shipped only with adrenaline 1/200000 (‘simple’) or 1/100000
(forte). Has a higher anesthetic potency than other anesthetic substances and a reduced
toxicity. The duration of anesthesia installation is short, 2-3 minutes, and the duration of the
efficient anesthesia is 60-70 minutes for those with vasoconstrictor. It is recommended the
injection of a minimal dose, 1.7-1.8 ml of anesthetic solution being sufficient for nodal
anesthesia and 1-2 doses for truncal anesthesia. It is recommended that the solution is slowly
injected, 1ml/minute, with the prior aspiration to avoid intravascular injection. In adult
patients, normal weight, the maximum dose is 7 mg/kg-body without it passing 500 mg in one
session, the equivalent of 12,5 ml articaine with adrenaline 1/100000 (1 ml injectable solution
contains 40 mg of articaine chlorhydrate and 0.012 epinephrine chlorhydrate). Maximum dose
in ml is 0.175 ml/kg-body. In children under 4 years articaine administration is
contraindicated. In children over 4 years with:

- medium weight of 20-30 kg 0.25-1 ml injectable solution doses/session are

sufficient
- medium weight of 30-45 kg 0.5-2 ml anesthetic solution doses/session are
sufficient

Injectable anesthetic substances are administered to the children too, depending on

age, weight and general health state. It isn’t realistic that in our days not to make anesthesia to
a child and do complex dental treatments without anesthesia or with topic anesthesia. (3)
In children as well as adults, if they didn’t had any contact with a local anesthetic
before we will do a prior allergist test to the substance we want to use and if the test was
negative we will be able to do the dental anesthesia in the next treatment session.

The duration of the anesthetic block depends on the following factors:

- individual variations of the answer to the drug

 - anesthesia point precision
- the status of the tissues at the anesthesia puncture place (vasodilation, pH)
- anatomical variations
- type of anesthetic blockage (super-periostal infiltration, periferic troncular, etc.).

TYPES OF LOCAL ANESTHESIA

Local anesthesia acts directly on the receptors and nervous endings, the disappearance
of the sensibility being strictly limited to the area of intervention.

1. Local anesthesia by refrigeration

It is a type of anesthesia used in small scale interventions, superficial, like extraction

of temporary teeth with increased rizalisis, extraction of periodontics mobile teeth, drainage
of superficial abscesses. As anesthetic, kelen is used, ethyl chloride, that pulverizes in the
wanted area.

2. Topic local anesthesia

It is based on the property of the mucosa to be permeable to some substances, whereas

some anesthetics. Applying the anesthetic is done by embrocation, imbibition or pulverizing.
More frequently is used the pulverizing method because of the ease of application and lack of
administrating risks (Img.15.1).
Img. 15.1 Lidocaine Spray 10%
3. Local anesthesia by infiltration

Consists of injecting the anesthetic, in the tissues at which level we will intervene (or around
it). As anesthetics, xiline and other modern substances are used. Anesthesia by direct
infiltration consists of injecting the anesthetic substance in the mucosa, in the skin, in
submucosal and subcutaneous tissue. The injection will be done slowly the recommended
speed should not go over 1 ml solution/minute. We will constantly check, especially in
troncular anesthesia, through repeated aspirations, the lack of a blood vessel.
  Plexus anesthesia (Img.15.2, Img.15.3)
o Anesthetic is disposed in the immediate vicinity of the area we will try to
intervene on
o Target area for the depositing of the anesthetic is given by the apex of the tooth
of interest
o many times in cases in which it is associated endodontic pathology too
(infection), so the plexus anesthesia is not efficient, being necessary the use of
other techniques
o Plexus anesthesia is not efficient only seldom in the adults mandibular arch
because of the thick cortical.
o In children, plexus anesthesia has a better effect at the mandibular bone level,
especially in temporary teeth. When a permanent tooth is treated, the plexus
anesthetic efficiency drops in children too.
o Sometimes a pain control cannot be obtained through the plexus anesthetia
even in the case without a pulpal pathology because of the depositing of the
anesthetic at distance from the apex, in case of malpositioned teeth or a wrong
technique. More frequently involved in these situations, the superior canine
and superior central incisor. Prime and secondary maxillary molars, may
sometimes have vestibular oriented roots, they are oriented towards the
zygomatic arch where the bone is thicker or palatal roots can be had which
extend over to the median line of the palate.
 Periferic troncular anesthesia

Img. 15.2 Plexus anesthesia at the central temporary incisor

Img. 15.3 Plexus anesthesia of the temporary canine

This type of local anesthesia follows the placement of the anesthetic around the
vicinity of a nervous trunk, at distance from the tooth/teeth we want to intervene on.
It is used when a plexus anesthesia isn’t indicated or cannot be done in the respective
area either when we want that with a single anesthetic puncture to anesthetize more teeth.
Troncular periferic anesthesia is used in dentistry especially for the anesthetic blockage of
infraorbitar nerve ( Img.15.4), of the superior alveolar nerves, of the big palatal nerve or the
inferior alveolar nerve for example. Eficacity of the technique is maintained even in the case
of pulpal affliction because the tissue where the punction will be done is healthy.
 - anesthetic blockage of the posterior superior alveolar nerve leads to
insensitivity of the dental pulp and the corresponding covering tissues of the maxillary molars
- in 28% of the cases the mesio-vestibular root of the molar 1 is innervated by
the upper-middle alveolar nerve; in this case an anesthetic infiltration in the vestibule is used,
anterior by the prime molar
- Blocking the antero-superior alveolar nerve will be done at the infra-orbitary
fossa.
- the palatal nerve anesthesia offers the insensitivity at palatal level containing
the bone as well as the soft tissues. Interested area are extended to the prime molar, distal and
up to molar 3
- naso-palatal nerves are distributed to the palate mucosa after they pass
through the incisor canal, located immediately posterior of the incisive papilla. Ensures
sensibility of the bone and soft tissues of the pre-maxilla up until the mesial face of the prime
premolar where it anasotmoses with the great palatal nerve.

Img. 15.4 Infraorbitary fossa anesthesia

Img. 15.5 Spina Spix anesthesia.

- Periferic troncular anesthesia of the inferior alveolar nerve, Spina Spix

anesthesia (Img.15.5), does the blocking for the soft parts and mandibular bone from the
respective hemi arch. Exception does the mucosa of the alveolar vestibular process, distal
from the second premolar, which is innervated by the oral nerve.
- the two anterior thirds of the lingual nerve are anesthetized together with the
alveolar inferior nerve, resulting the anesthesia of the floor and muco-periostium on the
lingual face of the mandible.

 Intra ligament anesthesia (15.5)

It is a anesthesia done by infiltration in the dento-alveolar space, rarely used in practice.

- it is used only when at the tooth level there are insufficiently anesthetized areas
- although it can be used on any tooth, IL anesthesia is used at first at mandibular
molar level when other techniques are inefficient
 - an advantage of IL anesthesia is the obtaining of a deep pulpal anesthesia with a
minimum volume of anesthesia (0.2-0.4 ml)even the absence of anesthetized tongue or
lower lip
- it is efficient in teeth with endodontic pathology
- the main contraindication is that IL is given by the presence or inflammation or
infection at the piercing(needle) place.

Intra osseous anesthesia

This type of anesthesia follows the infiltration of the anesthetic directly into the spongious
bone matter, by cortical passing. It is used exceptionally in current practice, because of the
hardness with which one pierces the cortical bone matter + the microbial growth which is
at high risk

PAIN MANAGEMENT PROTOCOL

1. Pre-op administration of an non-steroid anti-inflammatory drugs with an hour before

the beginning of the treatment and eventually a sedative
2. The chosen local anesthesia will be practiced
3. After the end of the intervention, the patient will be treated with bupivacaine or
etidocaine for pain control in the following hours (prolonged anesthesia)
4. Anti-inflammatory therapy is continued at home, at the dentists indications
5. Patient will confirm by phone his state at the end of the respective treatment day.

ACCIDENTS AND COMPLICATIONS OF THE LOCAL/REGIONAL

ANESTHESIA

It is assumed that local or local/regional anesthesia presents a minimum risk of

inducing accidents or local complications, appreciated risk by the specialists of under 1%.
Many times we are forced to intervene in decompensated patients or insufficient
compensated patients because of an emergency.
 Ordinarily, accidents or complications of the local anesthesia are because of the local
action of administered substances, traumatic lesion of the tissues or errors regarding the
technique. Accidents can be the following:
 Piercing the nervous trunk or the nervous sheath
 Piercing or traumatizing the tissues
 Sudden distension or dilacerations of the tissues
 Anesthesia in inflamed tissues
 Substance errors
o Vascular lesions, that appear in the moment in which we pierce the
blood vessels with the needle and can produce hematomas
o Facial transitory paralysis
o Transitory paralysis of the nervous trunks
o Ocular disturbances in case of infraorbital fossa anesthesia
o Breaking the needle in tissues.
Local complications of the local anesthesia and loco/regional anesthesia:
 Epithelial scaling and ulcerations of the mucosa
 Mucosa necrosis
 Post-anesthetic inflammation
 Persistent lockjaw
 Persistent paresthesia
 Post-extraction alveolitis

Complications and general accidents of the local and regional anesthesia

These general accidents, post-anesthetic the most frequent found in the dentistry are
represented by respiratory manifestations, vaso-vagal syncope, pectoral angina, allergic
accidents and orthostatic hypotension. Other accidents like the hypertensive accident, the
hyperthyroid crisis have a lower incidence.

ANXIETY MANAGEMENT IN THE DENTISTRY

In the dentistry we meet very frequently anxious patients, the cause of anxiety being
the most frequently associated with pain and fear of the dentist. Painful pathology is the most
frequently met in endodontics, pulpal complications being the most frequent cause of the
patient’s coming to the dentistry. Children, because of their lack of inhibition of the adults, do
not present statistically a similar incidence of the emergency cases met in adults
(hyperventilation, passing out). The child has its typical reaction: does noise, cries, bites,
kicks, moves in the chair. Rarely there are incidents like passing out to normally children.
Patients that present CV, respiratory, neurological or metabolic disorders are considered as
having 0 stress tolerance, having an increased risk during dental treatment if they are
exhibited to pain. Many adults don’t admit the fear they go through while the dental
treatment, thus the signs for affective states must be searched elsewhere. With this purpose we
can use dental history of the patient. Anxious patients history can reveal a big number of
canceled appointments from different reasons. A raised number of emergency treatments can
also be suggestive, this patient being one that calls the dental medical services only when the
pain is unbearable, when he cannot postpone the treatment anymore. Patients posture in the
dental chair is also significant. Patients with low anxiety sit comfy in the chair while the
anxious patients have a non-relaxed, rigid, ‘ready to leave’ posture, gripping tight the handle
of the chair. The medical questioning represents a utility in order to identify the patient’s
attitude before starting the treatment. Corah and Gale have used a form that determines the
anxiety level of the patient:

You feel nervous when you know you will undergo a dental treatment?
Have you had any traumatizing experiences while undergoing dental treatments?
The behavior of the dentist was proper?
Are there any aspects of the dental treatment that bothers you?

Many patients that do not verbally admit their anxiety state, but are left to answer in
writting to a questioning that will be then read only by the dentist, answer honestly at those
questioning.
The maneuvers that imply anxiety control are vast from processes that do not imply
drugs to general anesthesia, this in the last is used only in oral and maxilla-facial surgeries or
in case of patients with psyche affections or children that need laborious interventions and
these cannot be done in the simple dental office. In principal, two motives have generated this
situation: using conscious sedation in dentistry and the appearing on the market, 20 years ago,
of anxiety control, efficient drugs.
Conscious sedation is defined as a lack of the minimum level of the patient that allows
the patient to breath independently and continuous, and to respond to physical stimuli and
verbal commands, being obtained through pharmacological, non-pharmacological or
combined means.
We distinguish two important criteria for sedation:

Iatrosedation consists of the techniques that do not require medication for anxiety
control (hypnosis, biofeedback, acupuncture, electro-anesthesia as well as the behavior of the
doctor towards the patient who is seated in the chair). Before choosing the medication
techniques, the non-medication techniques must be taken into consideration as well as
creating a pleasant atmosphere. A relaxed and pleasant doctor-patient relationship facilitates
the patients accommodation with the office and reduces the fear and anxiety which are so
frequent in our field.
Drug sedation consists of the sedation and relaxing techniques with the help of
medication. Even if iatrosedation is the origin of all the anxiety diminishing procedures it can
prove insufficient for most patients, thus being unable to control their high degree of anxiety.
The drug sedation techniques have the following goals:
- The patient must be conscious
- His psychic status will be changed
- The patient must be cooperative
- All the defensive reflexes must remain active and integer
- The vitals must be stable and within normal limits
- The pain threshold of the patient must be high

Types of drug sedation

1. Oral sedation
The oral route is the most frequently used route for drug sedation; its disadvantages are more
than its advantages. The indications for oral sedation are:

- High level of anxiety, one day before the treatment. In this situation a sedative will
be administered to the patient one hour before going to bed.
- High level of anxiety on the day of the treatment. In this situation a sedative will be
administered to the patient one hour before the treatment.
Benzodiazepines are used for oral sedation: Diazepam, Oxazepam, Midazolam, Triazolam,
Flurazepam. The Triazolam and Flurazepam are indicated the day before the treatmen, while
the rest of them are recommended on the day of the treatment in order to control the anxiety.
Sedation for patients under the age of 13 proved to be risky and so in these cases must pay
more attention to the little patient.
Advantages of oral sedation:
 It is a universally accepted method
 it is safer
 adverse reactions are less frequent
 when they occur they are less severe
Disadvantages of oral sedation:
 time before the effect occur is long
 the effects are maximum after approximately 60 minutes
 the sedation cannot be efficiently controlled
 prolonged action (3-4 hours)
 impossibility to increase or reduce the sedation level in a short time
 because of the prolonged effect the patient must always be joined by a parent.

2. Intramuscular sedation
It is rarely used in the dentist’s office. Like the oral sedation, the muscular sedation has the
disadvantage of lacking an efficient sedation control and for this reason the sedation level
desired to be obtained by intra-muscular sedation is low to medium. The most efficient IM
sedative proves to be the Midazolam. Its use is associated with amnesia which is desired
under this circumstances.

Advantages of intramuscular sedation

 shorter time before the effect occur (10-15 minutes)
 it is safe
 less frequent adverse reactions
 efficient absorption
Disadvantages
 the sedation cannot be very efficiently controlled
 the maximum effect is obtained after 30 minutes
 impossibility to increase or reduce the sedation level in a short time
 prolonged action (3-4 hours)
 because of the prolonged effect the patient must always be joined by a parent
 the necessity of punction.

3. Inhaling sedation
It is a frequently used technique, being used by approximately 35 % of the dentists from USA
because of the safety the technique guarantees and the fact that it is very controllable. Even
though this technique is almost perfect, just like in the other cases there are situations when
desired effects do not occur. Approximately 70% of the patients who were sedated this way,
receive a mix in which the nitrous oxide represent 30-40% (Img. 15.6). 15% of the patients
need a concentration <30% and 15 % need a concentration >40%. 5-10% cannot be sedated
with nitrous oxides in a concentration lower than 70%.

Advantages
 quick onset of the effects (approximately 20 seconds)
 reaching a desired level of sedation with maximum precision
 the possibility of increasing or decreasing sedation level
 patients recovery after the sedation is extremely short (3-5 minutes)
 the patient can leave the office without escort
Disadvantages
 expensive
 large equipment
 requirement for supplementary medical personnel training
 risk of complications
 chronic exposure of the medical personnel
 the possibility of overcoming the desired doses

4. IV sedation
The IV sedation is the only method through which the effect’s onset occurs in a comparable
time with the inhaling sedation’s one, because of the direct contact between the gas and the
pulmonary alveoli. The required time for obtaining the ideal level of sedation depends on the
utilized technique: Diazepam or Midazolam IV administering offers an onset time of the
effect of four minutes, while other techniques require 10 minutes to obtain the sedation effect.
Once the IV access line was set, the IV administering of the drug is easy. The sedation degree
may vary from mild to moderate or deep. IV conscious sedation is frequently used for the
endodontic therapy especially when using benzodiazepines that have a reduced onset time
(Midazolam or Diazepam)

Advantages:
 quick onset of the effects (9-30 seconds)
 reaching a desired level of sedation with maximum precision
 the possibility of increasing or decreasing sedation level
 patients recovery after the sedation is extremely short (3-5 minutes)
 the patient can leave the office without escort

Disadvantages:
 the risk of possible complications indicate a strict monitoring of the patient
 requirement for supplementary medical personnel training
 the necessity of a venous punction.

5. Combined anesthesia techniques

Frequently the patient who needs inhaling sedation or IV sedation also needs oral
sedation either the evening before the treatment of right before the treatment! This
combination does not have any contraindications, as long as the level of the oral sedation is
not excessive and the IV or inhaling sedation medication is carefully dosed. If in these
situations the patient sedated prior to this using oral sedation in the actual sedation, ‘medium’
doses will most likely cause an overdose. The mix of nitrous oxide and oxygen can be used in
the cases when the patient required IV sedation but he does not want venous punctions. The
advantages of using nitrous oxide and oxygen during venous punction are:
 vasodilator effect
 anxiety reduction
 analgesic properties
After obtaining the IV line the patient will receive oxygen 100% until the inhaling
sedation effects will disappear. Only after that the indicated sedative will be administered to
the IV line.
 Other types of used analgesia in dental medicine are:

- acupuncture analgesia
- audio analgesia
- cold air anesthesia
- hypnosis
As doctors we have to understand that coming to a dentist is frequently a stressing
moment for the patient, associated with the worries before coming and general pressing
feeling. Despite the modern techniques and substances used nowadays the treatment is still
felt by the patient as being aggressive and painful.
The feeling of guilt for neglecting the health is a frequently invoked theme in the
discussions with the patient, as they consider themselves responsible for the situation they are
in right now. This feeling of guilt determines the patient to neglect the regular visits to the
dentist, thus a vicious circle is formed – the dental lesions progress.
So we must know the cognitive and behavioral dimension of the pain the patient feels
as well as minimum human psychology knowledge in order to determine the patient to regain
their self-esteem and their trust in us as doctors. Besides the human component, we have to be
able to apply the anesthesia techniques correctly in order to control pain and make the dental
treatments without trauma.
In pedodontia the dimension of pain is exacerbated, children being much more
sensitive to painful stimuli. But with patience and skill, mixing both psychology and dentistry
knowledge we will be able to successfully finish the treatments and win our patients’ trust.
 16. PARAFUNCTIONS AND VICIOUS HABITS

The most frequent functional alterations which are also responsible for the occurring
and aggravating many dento-maxillary anomalies we will talk about: tongue dysfunctions,
respiratory dysfunctions and vicious habits.

Between the muscular intraoral forces (tongue) and the extraoral ones (buccinators and
orbicular muscles) normally there is a balance; they also delimitate the dental lane in which
the dental arches are positioned (Img. 16.1, Img. 16.2). Disturbing this balance, in which one
of the muscles groups becomes hypotonic or hypertonic or makes abnormal movements, has
direct consequences over the dental arches and occlusion.

Img 16.1 A. Dental lane – lateral aspect (Vanni) B. Dental lane – frontal aspect (Vanni).

Img. 16.2 The aspect of the arches of a patient with atypical deglutition

The tongue plays an important role in functions as deglutition, phonation and also the
tongue’s posture while resting has significant consequences over the development of the
dento-maxillary apparatus.

A high position of the tongue favors the development of the superior maxillary on
transversal direction, whilst a low and posterior position of the tongue favors a narrow
maxillary and maintains the mandible in a posterior position, thus facilitating the occurring of
a class II anomaly. The tongue may be kept in a distal position also by a short lingual frenum
which restricts its movement.

The tongue can be positioned in the lateral breaches which occurred after the
premature loss of temporary teeth, fact that can favor an asymmetrical posture of the tongue,
crossed occlusion, mandible lateral deviation, etc.

The tongue position re-education creates the premises for maintaining the results
obtained after the orthodontic treatment, this aspect having a major importance especially in
the case of anomalies with functional etiology.
ATYPICAL OR INFANTILE DEGLUTITION

During the adult type deglutition the dorsal face of the tongue comes into contact with
the palate and its tip gets in the retro-incisor papilla area. The dental arches come into contact,
concomitantly, thus realizing the lips contact as well. In babies, the tongue interposes between
the alveolar ridges in order to allow suction. The persistence of this deglutition type in the
older child, teenager or even adult is called infantile deglutition and it is not considered to be
physiological. In case the deglutition runs applying pressure on the superior incisors, it is
called atypical deglutition (Img. 16.2). These abnormal types of deglutition favor the
protrusion of the incisors and the occurrence of an open functional occlusion.

The most indicated device for this would be a palatal arch which would be fixed on
two rings and which presents a lingual shield in the retro-incisor area (Img. 16.3). This has the
advantage that it has to be worn permanently and cannot be removed by the child. There is
also the alternative of adding an acrylic lingual shield to a palatal nice.

Img. 16.3 Fixed lingual shield

Img. 16.4 Palatal nice with an acrylic lingual shield

SIGMATISM

The sigmatism is represented by the tongue interposing between the dental arches
while pronouncing certain phonemes like ‘S’ or ‘Z’, resulting modified sounds.

ORAL BREATHING

The normal type of breathing is the nasal breathing. The oral breathing or mixed
breathing (oral and nasal) may have different causes, such as: adenoid vegetation, tonsil
hypertrophy, nasal septum deviation, asthma, respiratory allergies, etc. Whenever we find
ourselves in front of a patient who presents oral breathing we also have to send the patient to a
ENT consult.

Oral breathing determines, over time, changes in the facial aspect, the so called:
‘adenoid facies’ (Img. 16.5), with a prolonged face, prominent check, clamped nostrils
(because of not using the nasal breathing), dark circles around the eyes because of the poor
sanguine irrigation of this area, open labial slit, dry and cracked lips, hyperplastic superior
gum and favoring the caries on the vestibular face of the frontal teeth. These people are more
susceptible to respiratory afflictions and have lower stamina; the air will reach the lungs being
unfiltered and unheated – roles usually belonging to the nasal cavity. Because of the poor
brain oxygenation the patients will present restless sleep, they wake up tired and can also
present difficulties when focusing during school.

Img. 16.5 Adenoid facies associated with deep palate and narrow maxillary.

The dento-alveolar arches are usually narrowed, the maxillary presents a deep palate
because the patient, having an open labial slit, there will be an unbalance between the perioral
musculature which becomes dominant and the tongue, usually with a low position which
allows the muscles of the cheeks to exert a continuous pressure on the superior maxillary,
limiting its development in a transversal direction, thus resulting in a narrow maxillary.

Frequently, after removing the obstacle which caused the respiratory dysfunction, the
patient will keep breathing through the mouth, as this was his habitual type of breathing. This
is why reeducation is very important and making the patient and the parents aware of the
importance and benefits of nasal breathing.

Exercises for encouraging nasal breathing are recommended.

One of these exercises is the one-nostril breathing, which implies having the labial slit
perfectly closed and one nostril to be plugged. E.g. The left nostril plugged, breathing in
through the right nostril, then plugging the right one and breathing out through the left nostril,
followed by breathing in through the next nostril and breathing out through the right one. It is
recommended to start with 10 reps 2 times/day, continuing to progressively increase the
number of reps.

Also wearing a vestibular shield (Img. 16.6) or a functional educator (Img. 16.7) is
recommended during nights and at least for 4 hours during the day, at home, when the child
does his homework or has any other activities that do not require speaking. The functional
educator, besides reeducating the breathing also favors tongue positioning on the palate,
allows easy dental alignings and facilitates a correct position of the mandible in relation to the
maxillary.

Img. 16.6 Silicon vestibular shield.

Img. 16.7 Functional educator

VICIOUS HABITS

1. Bruxism
The bruxism is represented by the contraction of the masticatory muscles outside
mastication and deglutition, having a high intensity and long duration, usually nocturnal,
which in time leads to neuromuscular excitation which overcomes the proprioceptive control
and causes progressive damage to the hard dental tissues, to the periodontal structures and the
TMJ (G. Vanni).
The causal factors are considered to be: local factors (occlusal interferences), systemic
factors (intestinal parasites, food deficiencies, allergies, endocrine dysfunctions) or
psychological factors (increased stress, personality disorders, etc).
The treatment must start with simple measures to check the occlusion and the
adaptation of already existent blocks in order to eliminate the interferences and premature
contacts. Also, the patient will be sent to a specialty control in order to detect and systemic or
psychological factors. In order to protect the teeth against abrasion and relaxing of the TMJ
and masticatory muscles soft silicon trays can be applied or functional educators.
2. Thumb sucking
The thumb sucking (or any other fingers) represents one of the most frequent vicious
habits practiced by children. The changes over the dental arches and maxillary are different
depending on the support point of the finger/fingers, the intensity of the suction force and
pressure, duration and frequency. Of these factors, the duration is the most important factor.
Clinical experience suggests that a minimum of 4-6 hours/day is required in oder to cause
dental movements.
The classical consequences of this habit concern all the 3 spacial planes:
a) Vertical – open frontal occlusion.
b) Sagittal – the vestibule-version of the superior incisors and lingual-version of the
inferior incisors, leading to an increase in the sagittal step.
c) Transversal – narrow maxillary’
The treatment usually starts around the age of 4-5, offering the child the opportunity to
give up this habit before the eruption of the permanent incisors. 3 different types of approach
are recommended:
a) Therapy through awareness and reminding: an adhesive bandage will be worn on the
said finger, until the child quits the habit. This bandage can be an adhesive textile
bandage which will degrade and deteriorate fast to discourage the child. In the night
 time a glove or a pajamas with long sleeves (which will be sewn) can be worn, these
becoming obstacles that will wake up the patient and make him aware. Frequent
awakenings are tiring and in order to avoid them the child will progressively reduce
the frequency of the habit.
b) The second way is using the reward system. A deal will be made between the parent
and child or between the dentist and child which stipulates that if the child will stop
doing that for a certain amount of time he will receive a previously set reward. The
reward doesn’t have to be extravagant; it must be special enough in order to motivate
the patient. Daily progresses can be noted by using stickers on a calendar in which
each day the child did not suck his finger is marked.
c) If the first two approaches did not work, an orthodontic apparatus will have to be
applied, along with trying to solve a possible psychological cause which may be the
basis of the habit. This device will create a physical obstacle which will prevent the
finger’s contact with the palate. The dentist will explain the child that this is not a
punishment, but a help which will permanently remind him to not put his finger in the
oral cavity.

The fixed lingual shield is indicated in this case too, as it cannot be removed by the
child and it represents an uncomfortable obstacle for the finger. Even though the lingual
shield will prevent the thumb suction immediately, there are usually another 6 months needed
before completely giving up this habit, for this reason the device has to be worn for 6 months.

Another fixed device which can be helpful is the quad-helix which is used when along
with discouraging the suction habit a crossed occlusion is also present and needs to be
corrected. The anterior helixes will be the ones who will prevent the contact with the palate.

Img. 16.8 Quad-helix

The patient and the parents will be informed about the occurring of some speaking and
deglutition difficulties which will disappear in 3 days – 2 weeks. Another problem will be the
hygiene, as the quad-helix and the lingual shield easily retain food and in the absence of an
efficient hygiene halitosis and soft tissue inflammation will occur.

There is also the possibility of a palatal nice with acrylic lingual shield, but wearing
this will depends very much on the patient’s cooperation.
 3. The pacifier
The changes caused by the pacifier over the dento-maxillary apparatus are similar to
the one described at the thumb sucking, but ameliorated. There are also orthodontic pacifiers
which have a special shape which diminishes the unfavorable effects even more.
Theoretically, giving up the pacifier is easier than giving up the thumb sucking habit, as the
pacifier can be given only for a limited time or can be ‘lost’ at a certain point.
4. Interposing objects between the dental arches
Most times this is about interposing different writing tools (pencils, pens), usually
supported on an inferior incisor which will then be dislocated – with gingival recession and
may even present increased mobility. The mobility is usually spontaneously reduced after
stopping this traumatizing habit for the support teeth.
5. Inferior lip aspiration

This habit determines the occurring of a lingual force on the inferior incisors and of a
vestibular force on the superior incisors. The result is superior protrusion, inferior retrusion
and increase of the sagittal step. Also, the inferior lip is permanently cracked and inflamed, as
a consequence of continuous damping (Img. 16.9).

Img. 16.9 Facial aspect and endooral aspect of a patient who aspires her inferior lip.

For giving up the habit, besides awareness and determining the child to wish to give
up this habit it is also recommended to wear a device similar to the acrylic or silicon
vestibular shield or a functional educator if we wish to also correct another dento-maxillary
anomaly.

6. Sulks twitch

Occurs mostly in small children as a reaction to frustration – the propulsion of the

mandible and achieving a negative lips relationship, with the inferior lip being reflected,
covering the superior lip. This twitch, in time, can favor the occurrence of a class III anomaly.

7. Nails chewing (onicophagia)

This habit usually leads to the superior incisors protrusion with a tendency towards
open frontal occlusion. In order to quit, the same methods as for thumb sucking are
recommended.
 The parafunctions and vicious habits may interfere with the normal face growth
typologies. For these reasons, they must be identified and corrected as early as possible, in
order to take advantage of the residual growth quantity. Early functional reeducation is
necessary, thus allowing a faster correction of occlusion dysorders and reaching a new
functional balance.
 17. DENTO-MAXILLARY ANOMALIES PROPHYLAXIS

The dento-maxillary anomalies determine dysfunctions of the dento-maxillary

apparatus (DM Ap), with direct consequences over the oro-dental health state, self-respect
and even social acceptance.

By preventing the dento-maxillary anomalies the dental and facial esthetics will be
improved, a rebalancing of the DM Ap, stable and functional occlusal relationships ensuring
and oro-dental health state amelioration will be achieved. (1)

The dento-maxillary anomalies prophylaxis has the goal of optimizing the DM Ap

elements and the facial esthetics in a stable muscular context by removing the dysfunctional
factors. In order to achieve these objectives, the prohpylaxy of the dento-maxillary anomalies
must be started in the prenatal period and continued throughout childhood and teenage years.

PRENATAL PROPHYLAXIS of the dento-maxillary anomalies implies examining

the parents in order to individualize the presence of hereditary anomalies. Supervision of the
prenatal period and doing specific tests allows the diagnosis of congenital anomalies, thus
making the preparing and psychological counseling for parents possible.

POSTNATAL PROPHYLAXIS of the dento-maxillyary anomalies includes the

recommendations for the mother about the feeding methods of the new-born. Natural food is
preferred because the functional movements during sucking will determine the first
physiological mesialization of the mandible. If this is not possible, special devices are to be
used. The oral hygiene of the alveolar ridges will be done by the mother.

POST-ERUPTIVE PROPHYLAXIS of the dento-maxillary anomalies includes

instituting of oro-dental hygiene means after the eruption of the first tooth. Also, the food
must allow a normal functionality of the DM Ap and must respect the caries prophylaxis
criteria. Controlling the parafunctions ensures an adequate muscular balance, a harmonious
bone growth and development. Following the dental eruption processes allows setting stable
occlusal relationships.
 PARAFUNCTIONS CONTROL represents an essential element for ensuring a
harmonious growth and development of the cranial-facial complex. In childhood, the
following parafunctions are recommended to be dropped, using constraint or persuasive
methods:

 Thumb sucking;
 Habitual oral breathing;
 Postural position of the tongue;
 Defect postures of the head and body;
 Abnormal tongue position;
 Lip aspiration/biting;
 Sulks twitches;
 Phonation disorders;
 Associated dysfunctions/parafunctions.
o The means by which the functional reeducation can be instated include:
miogymnastics, logopedia, kinetotherapy, functional orthodontic
devices.

INTERCEPTIVE ORTHODONTIC TREATMENT can be applied in all evolution stages of

the temporary, mixed or permanent dentation and it implies catching a phenomenon and
changing its course in order to reduce to a minimum or even remove the consequences of the
DM Ap. Interceptive therapy implies preventing the occurrence of aggravating of dento-
maxillary anomalies, by balancing the functions and controlling the parafunctions.

NORMAL OCCLUSION IN TEMPORARY DENTATION is characterized by:

 The incisors relationship – the circumscription of the inferior incisors by the superior
once, with minimum covering on vertical direction or even head-to-head contact;
 The retrusion of the maxillary frontal group;
 Straight post-lacteal plane;
 Occlusal antagonism relationship – each tooth presents two antagonists, except for the
central mandibular incisor and the second maxillary molar.

3-6 YEARS OLD PERIOD is the functional period of the temporary dentation. The
characteristic elements for this period are:

 Growth processes of the maxillary bones – the appearance of tremas and diastemas;
  Attrition of the temporary teeth which allows the correct development of occlusal
relationships;
 The post-lacteal plane becomes uneven in a mesially, in order to allow the correct
sagitta occlusion relationships at the level of the 6 year old molar;
 The eruption of the 6 year old molar.

IN THE TEMPORARY DENTATION the following anomalies are recommended to be

therapeutically approached:

 Reversed occlusion (Img. 17.1);

 Crossed occlusion;
 Open occlusion;
 Sucking protrusion.

Img. 17.1 Frontal reversed occlusion in the temporary dentation.

6-9 YEARS OLD PERIOD is the first stage of the mixed dentation, in which the permuting
of the teeth from the anterior sector of the dental arches takes place. In order to allow a correct
dental alignment and articulation controlling the parafunctions and correcting the eruption
axes of the teeth is recommended (Img. 17.2). Balancing the growth processes will be done by
functional orthodontic or dento-facial orthopedic means. The odotnal lesions of the temporary
teeth from the support area treatment allows maintain the lee-way space, mean that can help
obtaining the necessary space for aligning the frontal tooth in mild DDM.

Img. 17.2 The eruption of the inferior central incisors in lingual gression consecutive to a gap
between the dental age and the bone age (absence of growth tremas).

9-12 YEARS OLD PERIOD is the second stage of the mixed dentation, in which the
permuting of the teeth from the support area of the dental arches is done. The active growth
processes – the pubertal spurt – allow this period to be considered the optimal period for
orthodontic treatmet. Unfortunately, the intrinsic motivation of the patient is not always
enough to accept and follow a complex orthodontic treatment. In order to ensure the stability
of the results and to avoid regression, the dispensary of the patient is required until the end of
the growth processes (Img. 17.3, 17.4). (1,3)

Img. 17.3 Bi-maxillary DDM with crowding. 1.3, 2.3 ectopy – initial aspect;

Img. 17.4 Bi-maxillary DDM with crowding. 1.3, 2.3 ectopy – occlusal balancing stage.
TEENAGER YEARS is the stage in which the intrinsic motivation dominates and the patient
regrets not following an anterior orthodontic treatment. Treatment soliciting is very large; the
patient wants the results to be obtained in a short time. In this stage, the prevention of dento-
maxillary anomalies regressing can be achieved; also prevention of late position of the
incisors changes due to wisdom tooth development can be achieved (Img. 17.5, 17.6).

Img. 17.5 Position changes determined by the development of the wisdom teeth.

Img. 17.6 Position changes determined by the development of the wisdom teeth – radiologic
aspect.
 18. CHILDREN MEDICATION

The medication recommended in pediatric dental medicine must be complementary to

the local treatment and directly correlated with the affliction diagnosis. In order to achieve the
desired therapeutic effect and the maximum decrease in adverse reactions, the
pharmacological forms utilized will be coordinated with the patient’s age and the treatment
objectives.

Administration route represents the mean through which the pharmacological product
enters the body and it can be:

 Oral;
 Intramuscular;
 Intravenous;
 Rectal.

The administration route will be chosen so the therapeutic effect of the administrated
product is maximal and the adverse reactions are minimal or even non-existent. For child
patients, oral administration is preferred whenever it is possible.

Administered dose

Childhood and teenager period is characterized by growth, development, adapting and

maturation processes which concern the digestive system, the enzymatic apparatus, the
metabolic processes and excretion mechanisms.

In order to avoid the occurrence of toxic effects, following absorption and excretion
processes (particularly in children), the administered dose must be an individualized element,
set according with the weight and age of the child. The formula is the following:

Adult dose * weight * K / adult weight

K – is a correctional coefficient which has different values depending on the child’s

age; it is as follows:
  2 – children younger than 1 year;
 1.5 – children 1-12 years old;
 1.25 – children 12-18 years old.

For the situations in which the child’s weight is unknown, the administered dose can
be calculated depending on the age, starting from the adult dose this way:

 1-3 years old – 1/6 adult dose;

 3-7 years old – 1/3 adult dose;
 7-12 years old – 1/2 adult dose;
 12-17 years old – 2/3 adult dose.

The oro-dental maneuvers which can be triggering factors for bacteremia are represented
by:

 Teeth brushing during the oro-dental hygiene;

 Professional brushing;
 Restoration procedures;
 Applying fixed orthodontic devices;
 Extractions (40-50% of the cases);
 Anesthetic infiltrations (96.6% of the cases).

From a microbiological point of view, in 50% of the cases the bacterial species which is
identified is Streptococcus viridans.

The majority of the maneuvers which are done in the pediatric dentist’s office do not
represent a potential danger for bacteremia for clinically healthy patients. Evaluation of the
infection risk is done during the anamnesis and depends on the general state of the patient and
their medical history.

The recommended pharmacological products in pediatric dental medicine are:

antibiotics, analgesics, anti-inflammatory medication, antifungal medication, antiviral
medication, sedatives, etc.
ANTIBIOTICS (AB)

AB recommendation in pediatric dental medicine must be based on a complete

diagnosis of the dental affliction which is associated with a general complex diagnosis of the
general pathology of the patient. AB prescription must be adequate, according with the
affliction etiology and is always an adjuvant element of the local treatment.

The primary recommendation for AB use is preventing local infections and microbian
spreading following oro-dental treatments.

AB administration must be reasoned – beneficial effects must be superior to the

immediate or late adverse effects!

AB administration will NEVER compensate for the absence of oral and dental hygiene
or aseptic measures.

ANTIBIOPROPHYLAXIS is an adjuvant element of the oro-dental treatments and

implies AB administration before potential bacterial contamination, in risk situations. The
recommendation will be done according with the patient’s history and the efficiency of the
administrated product over the pathogenic germs (Table I, II).

Table I – general recommendations of AB administration – clinically healthy patient

Maneuver Infection Risk Antibioprophylaxis

Local anesthesia - -
Pulpitis treatment - -
Gangrene treatment + +, -
Dental extraction -, + -, +
Orthodontic treatment - -
Table II – general recommendations of AB administration – patient with risk

Maneuver Infection Risk Antibioprophylaxis

Local anesthesia -, + +
Pulpitis treatment -, + +
Gangrene treatment + +
Dental extraction -, + +
Orthodontic treatment - +
 In order to give an example about the specific course of action, several antibiotics
which are frequently recommended in the pediatric dental medicine will be presented.

PENICILLIN

Indications – moderate or severe bacterial infections with sensitive germs.

Contraindications – anterior hypersensitivity which was proved for this antibiotic.

Adverse reactions – nausea, vomiting, diarrhea, cutaneous eruptions.

Recommended does:

 Children < 12 years old: 20-50mg/kg/day

 Adult: 1-2g/day

Maximum recommended dose: 3g/day

Number of doses per 24 hours: 3 or 4

TETRACYCLINE

Indications – infections with sensitive bacterial species (acne, chronic bronchitis, syphilis),
patients who are allergic to penicillin.

Contraindications – children younger than 8 years old because of the risk of enamel
dyschromia and dysplasia occurrence.

Adverse reactions – nausea, vomiting, stomatitis, glossitis, photosensitivity, hepatotoxicity.

Recommended dose:

 Children < 8 years old: forbidden

 Children > 8 years old: 25-50 mg/kg/day
 Adults: 250-500 mg/4X/day

Maximum recommended dose: 3/day

Number of doses per 24 hours: 3 or 4.

AMOXICILLIN

Indications – infections with sensitive bacterial species (acne, chronic bronchitis, syphilis),
patients who are allergic to penicillin.

Recommended dose:

 Children <12 years old: 20-40 mg/kg/day

 Adults: 250-500 mg/3X/day

Maximum recommended dose: 2-3 g/day

Number of doses per 24 hours: 3.

AUGMENTIN

Indications – infections of the respiratory tract, otitis, sinusitis, cutaneous afflictions.

Contraindications – hypersensitivity, conocmitent Disulfiram administration.

Adverse reactions – they occur when the Augmentin is associated with pharmacological
products which contain allopurinol, Disulfiram.

Recommended dose:

 Children – 20-40 mg/kg/day

 Adults – 250-500 mg/ 3X/day

Maximum recommended dose: 2 g/day

Number of doses per 24 hours: 3

ERYTHROMYCIN

Indications – respiratory afflictions, medium otitis.

Contraindications – hepatic dysfuncitons.

Adverse reactions – the erythromycin determines the increasing of the sanguine level of
digoxin and cyclosporine if it is administered concomitantly.

Recommended dose:
  Children <12 years old– 30-50 mg/kg/day; maximum dose: 2 g/day
 Adults – 250-500 mg/3X/day; maximum dose: 4 g/day

Number of doses per 24 hours: 4

CLINDAMYCIN

Indications – infections with sensitive germs (streptococcus, staphylococcus), acne treatment.

Contraindications – hypersensitivity, hepatic dysfunctions

Adverse reactions – severe diarrhea, colitis, thrombophlebitis, hypotension, thrombocytopenia

The clindamycin increases the curare derivatives effects.

Recommended dose:

 Children <12 years old – 10-20 mg/kg/day

 Adults – 600-1800 mg/ 3X/day

Maximum recommended dose: 4-8 g/day

Number of doses per 24 hours: 3

In the case of patients with a general specific pathology the AB are recommended to
be administered as a prophylactic measure before starting the oro-dental treatments in order to
reduce the risk of infection (Table III).

Table III – Antibioprophylaxis – general recommendations

Antibiotic Dose Administration route Time before the treatment

Amoxicillin 50 mg/kg
Oral 1h
(max 2 g)
Clindamycin 20 mg/kg
Oral 1h
(max 600 mg)
Cephalexin 50 mg/kg
Oral 1h
(max 2 g)
Clindamycin 15 mg/kg
IM or IV 1h
(max 600 mg)
ANTI-INFLAMMATORY MEDICATION AND ANALGESICS

IBUPROFEN

Non-steroidal anti-inflammatory drug, antipyretic, anti-rheumatoid

Indications – mild and moderate pain, antipyretic

Contraindications – anteriorly detected ibuprofen hypersensitivity, ulcer

Adverse reactions – dyspepsia, abdominal pain, ulcer

Recommended dose:

 Children <12 years old – 20 mg/kg/day

 Adults – 400-800 mg/day

Maximum recommended dose: 1.2-2 g/day

Number of doses per 24 hours: 3

ACETAMINOPHEN

Non-opioid analgesic, antipyretic.

Indications – moderate pain, fever

Contraindications – hepatic dysfunctions

Recommended dose:

 Children <12 years old – 65 mg/kg/day

 Adults – 325-650 mg/day

Maximum recommended dose: 4 g/day

Number of doses per 24 hours: 6

SEDATIVES

Oro-dental treatments determine an increased level of anxiety in some patients.

Localized and regional anesthesia contributed significantly to the improvement of the doctor-
patient relationship, but in the case of extremely anxious patients it is insufficient.
 In order to reduce anxiety and to ensure a pre-operator calm state sedative medication
can be used. Because of the multiple adverse effects, the sedative medication will be
administered with care, strictly under medical control. Even if they allow an easier approach
of the patient, the sedatives cannot substitute the patient’s cooperation, they only help
overcoming the individual anxiety step.

DIAZEPAM

It is a benzodiazepine derivative. It has multiple and complex effects: sedative, hypnotic,

anticonvulsive, musculature relaxing.

Indications – anxiety management

Contraindications – hypersensitivity, uncontrollable pain with unknown etiology

Adverse reactions – respiratory rate reduction, apnea, confusion, hypotensions

Recommended dose:

 Children – 0.12-0.8 mg/kg/day; IM every 6-8 hours.

 Adults – 2-10 mg/2-4 times/day

Maximum recommended dose: 1-2 mg/min (child); 5 mg/min (adult).

MIDAZOLAM

It is a benzodiazepine derivative with sedative and hypnotic effects.

Indications – preoperative sedation, conscious sedation.

Contraindications – Midazolam hypersensitivity, undiagnosed pain, shock.

Adverse reactions – reduction of respiratory rate, nausea, vomiting, apnea, cardiac arrest, pain
at the infiltration spot.

Recommended dose for children is set depending on the administration route:

 0.07-0.08 mg/kg – IM, 30 minutes – 1 hour before the intervention

 0.035 mg/kc – IV (maximum dose – 0.1-0.2 mg/kg)
 0.25-1 mg/kg – oral administration (maximum dose – 20 mg).
ANTI-FUNGI MEDICATION

It is frequently recommended as an adjuvant in case of AB administration in order to

prevent the negative consequences determined by the disturbing of the bacterial flora balance
from the oral cavity.

Mycotic etiology afflictions may exist as unique entities in patients with immune
system deficiency or with general afflictions which impose a specific medication. The
products which can be used in pediatric dental medicine are extremely varied:

 Nystatin – suspension 100 000 UI/ml – administered 1 ml/4X/day – 7-10 days (the
treatment is prolonged with by at least 48 hours after the extinction of the symptoms).
 Nystatin – tablets 500 000 UI – administered 1 000 000 – 4 000 000/day divided in 4
for older children and in 6 for younger children (the treatment is prolonged with by at
least 24 hours after the extinction of the symptoms).
 Chlorhexidine gluconate – tablets (2 mg Chlorhexidine gluconate/tablet). It is
administered to children with ages 6-8, perilingually (1 table, 2-3 times/day, 2 hours
after eating and eating again is avoided for the next 2 hours). The treatment is
prolonged with by at least 24 hours after the extinction of the symptoms.
 Ketoconazol – tablets, 200 mg – for children 4-7 mg/kg/day the treatment is prolonged
with by at least 24 hours after the extinction of the symptoms.
 Fluconazol – tablets, 50, 150 mg – administered 50-100 mg/day 14 days for the
treatment of buccal candidiasis or a unique does of 150 mg/day (preventive) in case of
AB treatment.

ANTIVIRAL MEDICATION

It is recommended in the case of afflictions with a viral etiologic agent, mainly with the
herpetic virus.

 Vidarabine – ophthalmic ointment 3% applied in case of labial Herpes simplex;

 Acyclovir (Zovirax®) ointment 5% - applied 6X/day for 7 days;
 Acyclovir – tablets 200 mg. Recommended dose for adults is 200-800 mg/4X/day 5-7
days. For children, the daily does is divided in 4 and depends on the age: >6 years old
– 3.5 g/day, 2-6 years old – 1-1.6 g/day and <2 years old – 500-800 mg/day. Adequate
hydration is important in case of acyclovir administering.
CONTRAINDICATED MEDICATION IN PEDIATRIC DENTAL MEDICINE

The pharmacological products included in this category cause adverse effects in the
child’s body during the growth, development and maturation processes:

 Chloramphenicol – in children, it leads to normal functioning of the bone marrow cells

affliction, aplastic anemia, leucopenia, thrombocytopenia;
 Tetracycline – administering to children younger than 8 years old determines intrinsic
dental coloration and dental dystrophies. Administration indications are limited to the
cases which have a reserved prognosis;
 Sulfonamides – are contraindicated in children because it causes: allergies, bone
marrow afflictions, hemolytic anemia, reduced number of leucocytes,
thrombocytopenia;
 Phenylbutazone – contraindicated in children because it causes: gastric mucosa
affliction, hemorrhages, anemia, increases the effect of oral anticoagulants.
 19. ODONTAL TREATMENT OF CHILDREN AND
TEENAGERS WITH GENERAL AFFLICTIONS

The patients with a compromised health state, following contagious afflictions or

chronic diseases, require frequent odontal treatments.

Correct anamnesis and in some cases, the pediatrician agreement are the primary
elements that allow the dentist do the required maneuvers in maximum security conditions for
both the patient and the medical team. If this information is unknown, the oro-dental
treatments can become elements that trigger or cause the aggravation of existent afflictions.

In order to facilitate choosing the therapeutic behavior several clinical pictures will be
present with the observation that every patient is a unique entity.

ACUTE RHINOPHARINGITIS

It is a cold-season affliction. The etiology of acute rhinopharingitis is viral; it can be

caused by over 150 viral serotypes, mostly rhinoviruses. The bacterial complications occur
only secondary, on the basis of the immune system affliction and the decrease of the
defensive capacity of the body; they are more frequent in children.

The infectivity period lasts from several hours before the symptoms until 1-2 days
from the stationary stage. The way of transmitting is mostly respiratory.

The treatment implies non-specific therapy: rest, balanced food, adequate hydration,
acetaminophen (aspirin is contraindicated because of the possible vascular complications).

Odontal treatments must be put on hold until the disappearance of the symptoms. In
case the odontal treatment is imposed, rotating tools are to be avoided and general protection
rules for the medical team are to be respected. (1)
VARICELLA

The varicella (chicken-pox) is an infectious and contagious disease specific for the
childhood (90% of the patients are younger than 10) who etiologic agent is Herpes Virus
Varicellae.

The transmission of the viral agent is aerial or through saliva.

The infectivity period is considered to be 24 hours before the cutaneous eruption until
the appearing of crusts (7-8 days). The incubation period of the virus is 13-17 days.

The rash begins as red papules which will later become vesicles and will finally be
covered with crusts. The cutaneous lesions appear initially at the level of the trunk, they later
extend on the face and on the scalp. Generally, the distal extremities of the limbs are
exempted from these lesions. The cutaneous lesions are associated with intense pruritus and
the trauma of the lesions or not respecting the personal hygiene rules will lead to the over-
infection of these lesions.

The general treatment is symptomatic, sustaining the general state and adequate
hydration of the body. The febrile spurts are characteristic for the first days and can be treated
by administering acetaminophen.

Odontal treatments must be put on hold until the disappearance of the lesions. In case
the odontal treatment is imposed, general protection rules for the medical team are to be
respected in order to avoid spreading the viral agent (the treatment will be started after the
appearance of the crusts). (1)

HEPATITIS B

Highly contagious viral affliction.

The transmission of this disease is sanguine, by direct inoculation and the incubation
period is 2-5 months. During childhood, it can determine severe complications: active chronic
hepatitis, aplastic anemia, renal complications.

Active immunization can be done by complex vaccination schemes.

The odontal treatment imposes reducing the infectious risk both for the patient and for
the medical team. The complete anamnesis and knowing the medical history of the patient
allow a correct approach. In these cases there is the possibility of spreading the infection from
the dentist’s office, which imposes respecting and supplementing the disinfection, antisepsis
and asepsis measures.

Scheduling the patients at the end of the schedule, using one-use-only tools, avoiding
hemorrhaging maneuvers, respecting individual criteria for the protection of the doctor and
the nurse represent essential parts of the infection spreading risk reduction.

THE FLU

It is an infectious and contagious disease which presents 3 types of serological

categories. The transmission is frequently aerial or through direct contact with an infected
person and the incubation period is 2-3 days.

The start of the disease is sudden in children and young adults; they present an altered
general state, fever, loss of appetite. The high temperature persists for 2-3 days and the
respiratory symptoms (cough, rhinorrhea) become more intense starting with the 2nd – 4th days
of the stationary stage. The altered general state may persist 1-2 weeks after the remission of
the acute stage of the disease.

Prevention can be done by active immunization with Infuenza vaccine for the risk
groups: patients with general afflictions, children, elderly, etc.

The general treatment is symptomatic, sustaining the general state: rest, crowds
avoiding, adequate hydration, vitamin rich food, reducing fever (acetaminophen). The
antibiotic treatment is not necessary only if bacterial over-infections occur.

Odontal treatments must be put on hold until the disappearance of the symptoms. In
the case of pain or emergency situation, the rotating tools are to be avoided and the general
rules for protection of the medical team are to be respected. (1, 3)

THE DIABETIC PATIENT

Diabetes is characterized by a glucose metabolism imbalance which determines, as

main symptoms, hyperglycemia and glycosuria. The diabetic patient presents a symptomatic
triad: polyphagia, polydipsia, polyuria – associated with a significant weight loss.

Approximately 0.2% of the school children have diabetes.

 The complications of diabetes are: vascular afflictions, peripheral neuropathies,
infection risk (oral cavity, skin).

The odontal treatment in the case of a diabetic patient impose in the first place the
reduction of the operative stress by setting short treatment sessions, by using local anesthesia
and sedation techniques.

In order to reduce the hypoglycemia risk the patient will follow a strict diet before a
treatment session.

In order to reduce the associated infection risk, the specialist physician agreement is
recommended and balancing the biological constants values before treatments. In the case of
diabetic patients, frequent period examinations are preferred in order to allow the odontal
afflictions diagnosis in incipient evolution stages, prophylaxis measures for the dental caries
and periodontal afflictions, pre and post-operatory antibiotherapy (when it is necessary).

ASTHMA PATIENT

Bronchitis asthma is a syndrome which is characterized by dyspnea, coughing and

wheezing caused by bronchospasms; it occurs based on the hyperirritability of the
tracheobronchial tree.

5-10% of the children may present during the childhood, symptoms or signs which are
characteristic to asthma.

Among the triggering factors of an asthma attacks are the following: emotional stress,
cold air, respiratory infections, aspirin, etc.

The extreme complications are represented by the asthmatic status or even death of the
patient in particular situations.

The general treatment targets the desensitization for allergens. The pharmacological
products used for this purpose are beta-adrenergic medication and corticosteroids.

The odontal treatments in cases of patients which are diagnosed with asthma imply
respecting the following rules:

 In order to prevent asthma attacks the patient will have an inhaler upon him;
 Avoiding local epinephrine anesthetics – relative contraindication;
  Avoiding topic anesthetics in the form of sprays excessively pulverized;
 Reducing the psychological stress, shorter treatment sessions;
 Patient sedation. (2,3)

INFECTIOUS ENDOCARDITIS

The infectious endocarditis is present in 1 out of 2000 cases and it may represent a
cause of death during childhood and teenager years.

The symptoms of this affliction are: weight loss, fever, nocturnal sweating, anorexia,
arthralgia, etc.

The complications which may occur if the infectious endocarditis is not diagnosed and
treated adequately are hemorrhaging and congestive cardiac failure.

The oro-dental treatments represent infectious-risk maneuvers for these patients; for
this reason the agreement of the cardiologist is required before starting any treatment.

Infectious endocarditis prophylaxis is imposed for the following maneuvers:

 Dental extraction;
 Reimplantation;
 Periodontal therapy;
 Endodontic treatments;
 Applying antibiotic filaments;
 Applying orthodontic rings;
 Local anesthesia.

Infectious endocarditis prophylaxis is not imposed only in particular cases for these
maneuvers:

 Restoration treatments;
 Rubber dam applying;
 Sutures removing;
 Mobile prosthetic works;
 Dental radiography;
 Mobile orthodontic devices;
 Fluoridations;
  Orthodontic control.

The recommendation of an antibiotic for the endocarditis prophylaxis must be based on the
following criteria:

 General state of the patient;

 The microbe species which could determine the infectious complications;
 Dose and treatment duration.

The pre- and post-operatory antibiotherapy will be recommended in order to prevent

bacteremia which can be triggered by certain therapeutic processes. Moreover, hemorrhaging
manuervers are to be avoided. (1, 2, 3)

CHRONIC RENAL FAILURE

The oro-dental manifestation which are frequently diagnosed in the case of a patient
renal failure are the following: intrinsic and extrinsic dental colorations, enamel hypoplasia,
late dental eruption, stomatitis.

Penicillin is the election antibiotic to prevent the odontogenic infections in these

patients. The contraindicated pharmacological products for these patients are: aspirin and
tetracycline.

Because of the frequent perfusions and dialysis procedures, the patients who suffer
from chronic renal failure also present a high risk for hepatitis B.

In order to ensure a favorable prognostic for the restoration treatments and to prevent
the occurring of complications prophylaxis measures of the dental caries and frequent
examinations are recommended.

The patients who recently had dialysis require permission from the physician for any
oro-dental treatment. The odontal treatments are recommended to be made the day after
dialysis (favorable electrolytic balance, reduced anticoagulant medication effects). Preventing
the infectious complications will be done through antibiotherapy.

In the case of patients who will benefit from renal transplant the following are
recommended:

 Dental focus removal – precursory condition to the surgical intervention;

  Supplementing the steroid therapy in order to compensate the operative stress
induced by the oro-dental treatments;
 Pre and post-operatory antibioprophylaxis.

The cyclosporine treatment can determine gingival hyperplasia which imposes

individual specific measures of oro-dental hygiene. Post-transplant, because of specific
medication, the caries risk increases and for this reason more frequent periodic examinations
and specific measures to prevent periodontal afflictions are recommended.

THE PATIENT WITH ONCOLOGIC AFFLICTIONS

They present complications consecutive to chemo-therapy: infections, hemorrhages,

agenesis, enamel hypoplasia, facial growth changes, stomatitis, xerostomia, trismus,
dysphagia, caries predisposition, etc.

In order to prevent the severe compromise of the general state, before that start of
chemo and radiotherapy a full clinical and radiological exam of the head and neck will be
made and the dental focuses must be removed.

The family will be informed about the long term effects of the therapy. The caries
prophylactic dietetic recommendations will be settled together with the oncologist and the
family.

The patient will be instructed about the oral hygiene and any dental treatment will be
done with the permission from the oncologist when the general state is adequate. The
maneuvers which impose an infection risk impose antibiotherapy. In order to make an
efficient prophylaxis and to diagnose periodontal afflictions early, the periodic examinations
must be done each 3 months.

ANEMIA

The anemic syndrome implies the volume reduction of the red blood cells or
hemoglobin concentration diminishing.

The etiology of this disease includes: insufficient red blood cells production,
distruction of red blood cells, extracellular factors, etc.
 There are more types of anemia:

 Congenital anemia;
 Anemia associated with chronic renal afflictions, infections,
inflammations and cancer;
 Megaloblastic anemia;
 Anemia secondary to iron deficit;
 Spherocytosis;
 Thalassemia;
 Infectious mononucleosis;
 Systemic Lupus;
 Sanguine transfusion reactions.

The oro-dental treatments require besides evaluating the odontal status the risk degree
of the patient. If the general state, confirmed by the blood work, is considered to be balanced,
the treatment will undergo under normal conditions respecting the general criteria for the
patient’s approach. Contrary, these patients will be treated in hospital conditions, with an
adequate control of the hemorrhagic and infectious risk.

COAGULATION DISORDERS

They represent varied clinical entities with diverse etiologies which depend on the
following factors:

 Coagulation factors deficit – congenital or acquired;

 Thrombocytopenia;
 Functional alterations of the thrombocytes.

A detailed anamnesis is compulsory for these patients, paying attention to the evaluation
of personal and hereditary history.

The clinical examination highlights, in most cases, petechiae, hematomas or spontaneous

gingival hemorrhaging. The clinical examination will be completed with the specific
laboratory test: bleeding time, coagulation time and prothrombin time.

Depending on the data obtained from the clinical examination, adding the hematologist
recommendations, the following risk categories can differentiate:
  Reduced risk – normal values of the bleeding time, prothrombin time,
thrombocyte count – in these cases, a standard approach is recommended for
the dental treatments;
 Moderate risk – the recommendation, documentation and the notice from the
physician and the hemorrhagic risk;
 High risk – hematologic consult, admitting in a specialized unit.

HIV INFECTION

In the etiology of this syndrome (in children and teenagers) there is the type 1 HIV and
rarely type 2.

The infection is transmitted by blood from the mother to the fetus, in 6-30% of the
mothers positively diagnosed with HIV. In the case of a perinatal infection, the prognostic is
reserved. The surviving rate is higher if the infection occurs after the age of 2.

The oral manifestations of this disease include: mycosis, viral and bacterial infections,
non-Hodgkin lymphoma, Kaposi sarcoma, etc.

HIV patients are under active antiretroviral treatment which can be associated with
recurring afflictions specific medication.

For these patients, sustained prevention and prophylaxis of the dental caries and
periodontal afflictions measures are mandatory in the context of frequent periodic
examinations. The invasive oro-dental treatments impose infectious risk and hemorrhagic
control and are recommended to be done in specialized units.
 20. TREATMENT OF PATIENTS WITH LABIO-MAXILO-
PALATAL CLEFTS

DEFINITION

The labio-maxillo-palatal clefts represent congenital anomalies caused by the absent

merging or incomplete merging of the facial buds.

ETIOLOGY

The etiology of these complex dysmorphisms is incompletely discovered, varied and includes
the following factors

 Genetic predispositions;
 Mother’s treatment with cortisone derivatives during pregnancy;
 Radiation during pregnancy;
 Mother’s virus infections during pregnancy.

The diversity of the etiologic factors and clinical aspects determined the occurrence of
numerous classifications which have applying the treatment protocols specific to each
case as the main goal.

VEAU CLASSIFICATION

 Class I – palate cleft;

 Class II – hard and soft palate cleft;
 Class III – complete unilateral clefts;
 Class IV – complete bilateral clefts.

ANATOMICAL AND CLINICAL CLASSIFICATION

 Anterior, posterior and associated labio-maxillo-palatal clefts;

 Complete and incomplete labio-maxillo-palatal clefts;
 Unilateral and bilateral labio-maxillo-palatal clefts. (Img. 20.1, Img. 20.2)

Img. 20.1 Complete unilateral labio-maxillo-palatal cleft (left)

Img. 20.2 Complete bilateral labio-maxillo-palatal cleft

LAHSAL CLASSIFICATION

It systematizes the labio-maxillo-palatal clefts depending on their topography and on the

anatomical structures involved (Img. 20.3)

Img. 20.3 LAHSAL Classification

Treatment

These children’s treatment requires a very good interdisciplinary collaboration and a

prolonged monitoring in order to realize the specific therapeutic procedures in accord with the
individual growth and development. The main objectives are:

 Psychological counseling for the family;

 Surgical treatment;
 Dental caries and periodontal afflictions prophylaxis;
 Dental treatment;
 Orthodontic treatment;
 Logopedic treatment;
 General afflictions treatment.

DENTAL CARIES PROPHYLAXIS must represent an essential objective for this category
of patients:

 Caries-prophylactic food: it has to stimulate mastication, self-cleaning phenomena and

physiological abrasion;
 The oro-dental hygiene must be done by the parents once the first teeth erupt. The
dental dystrophies are often part of the complex clinical picture of these afflictions,
along with the numeric dental anomalies. Recommendations for a correct teeth
brushing technique, adapted to the age and supplementary means of oral hygiene must
be made during each examination;
 Sealing the sulci and fossets, specific prophylactic method for caries of the occlusal
surfaces is recommended for both the temporary molars and for the permanent ones;
 The administered fluoride significantly contributes to reducing the individual caries
risk for these patients. Also the topic fluoride applying can be included in the
individual prophylactic plan;
  Periodic examinations are recommended to e made at short time intervals – 3 months
or depending on the caries risk.

DENTAL TREATMENT respects the diagonosis and therapeutical approach criteria with a
general validity. Collaboration difficulties with these patients is because of the general
pathology, psychological problems, familial situation. The oral and dental health is not a
priority in the general context and for this reason the treatment of the dental lesions is put on
hold; the patient presents at the doctor only in case of emergency.

ORTHODONTIC AND ODF TREATMENT

Covers more stages which are specific for the oro-dental system development:

 Stage I – birth – 18 months old

 Stage II – temporary dentation
 Stage III – mixed dentation
 Stage IV – permanent dentation

STAGE I – II – SMALL CHILD

The orthodontic treatment goals are the following:

 Repositioning of the maxillary segments;

 Crossed occlusion correction;
 Facilitating feeding in order to ensure a normal somatic growth.

STAGE III – MIXED DENTATION

The orthodontic treatment is facilitated by the active growth processes and follows the
reducing of the development gap between the maxillary and mandible. In order to ensure an
adequate eruption of the permanent incisors incisor and canine grafts will be made.

STAGE IV – PERMANENT DENTATION

The orthodontic treatment has the following objectives:

 Correcting the inter-arch gaps using orthodontic and orthopedic means;

 Maintaining the space and ensuring a normal functionality of the dento-maxillary
apparatus during the teenager years;
  Pre-prosthetic treatment – ensuring adequate positions of the teeth so the prosthetic
restorations are possible at the age of 18-20, according with the functional and esthetic
principles.

SURGICAL TREATMENT

It is an important element in the complex rehabilitation of these patients.

In order to obtain the desired esthetic results and a normal functionality of all the DM Ap
elements orthodontic and esthetic surgery interventions are required.

ASSOCIATED TREATMENTS

Multidisciplinary treatment of these patients reflects the complex etiology of these

dysmorphisms:

 Logopedic treatment – it is recommended along with the orthodontic treatment in

order to achieve a functional reeducation of the perioral muscles which will ensure the
adequate stability of the obtained results;
 Postural corrections – inadequate postures lead to incorrect muscular behaviors which
can change the growth and development directions of the oro-facial system;
 Psychological counseling – the complex and prolonged treatment of these patients
implies the active implication of the family for very long time. Any discontinuity in
the multidisciplinary therapy of these patients will reflect negatively in the quality and
stability of the results.
 21. EMERGENCY TREATMENT IN PEDIATRIC DENTAL
MEDICINE

Emergency situations can be avoided by doing a complete anamnesis of the patient

and by knowing their medical history. Moreover, the medical team must be prepared to act
promptly when such a complication occurs.

In the case of a medical emergency the following principles must be respected:

 Adequate approach of the patient;

 Ensuring the vitals;
 Resuscitation maneuvers.
The main clinical entities which can be emergencies in the doctor’s office are:
syncope, lipothymia, hypoglycemia, asthma attack, allergic reactions and obstructions of the
upper airway.

SYNCOPE

It represents a temporary loss of conscience. The etiology of the syncope includes fear
and stress associated with the oro-dental treatments, changing the patient’s position in the
chair, metabolic alterations with anxiety basis.

Preventive attitude implies reducing the stress by psychological preparation of the

patient, sedative medication, local anesthesia, and adequate food before starting the treatment.

The treatment of the syncope implies the correct positioning of the patient in the chair
in order to give them a comfort and trust state, freeing the upper airways, cold compresses,
ammonium inhaler and in particular situations, transporting the patient in a medical unit.
HYPOGLYCEMIA

It is characterized by reducing the level of glucose in blood under 50 mg/100 ml.

The etiology of the hypoglycemia attack includes: diabetes, fear and anxiety,
metabolic alterations, etc.

The symptomatology includes: loss of conscience, palpitations, confusion, headache,

sweating, paleness, hypotension and bradycardia.

Prevention imposes knowing the medical history of the patient, psychological

approach before and during the treatment session.

The treatment for a hypoglycemic attack implies the correct positioning of the patient
in the chair, dextrose or glucose administration, specific individual medication administration
in the case of patients with chronic afflictions, sending the patient to a medical unit for
specialty treatment.

ASTHMA ATTACK

The asthma is characterized by the hyperactivity of the airways associated with their
irreversible obstruction. 10% of the children under the age of 5 present manifestations of
asthma (more or less severe).

The etiologic agents that can cause an asthma attack are: allergens, infections of the
upper airways, stress, anxiety and sulfites that are present in the anesthetics with adrenaline.

Asthma attack symptoms are: chest pain, irritative cough, wheezing, dyspnea, anxiety.

Preventive attitude imposes knowing the medical history of the patient, reducing the
stress in relationship with the treatment, careful usage of triggering substances (vapors,
sprays), adequate medication. In order to ensure the psychological comfort for the patient he
will have his regular medication upon him (inhaler).

Specific approach requires stopping the treatment and the administration of bronchi-
dilators, oxygen, epinephrine or sending the patient to a specialized medical unit.
ALLERGIC REACTION

It is a possible complication and reaction to products used during the treatment.

The pseudo-allergic or allergic reaction in its mild forms, determines redness at the
level of the face teguments associate with pruritus.

The most severe form – the anaphylactic shock – determines local and fast reactions
associated with dyspnea, tachycardia and in the most severe cases, cardiopulmonary arrest.

Preventive attitude implies knowing the patient’s medical history. Also, in the case of
children, the allergy tests must be done before the first anesthesia – even though they are not
100% accurate.

The treatment implies the vitals management, specific medication (epinephrine 0.01
mg/kg) and transporting the patient to the ER.

DRUG ABUSE

The absence of an adequate legislation allows the teenagers to have access to certain
substances included in the category of drugs and frequently, the use of those is denied by the
patient. In case of unsupervised children, they can accidentally ingest medication.

Drug abuse can be classified in absolute or relative. The frequent entities are narcotic
overdose and anesthetic overdose.

Narcotic overdose

Symptoms of narcotic overdose are: unconsciousness or sleepiness, hypoxemia,

cardiac arrest.

The preventive attitude implies knowing the medical history and anamnestic data of
the patient as well as the interaction between the patient’s regular medication and the one he
received during treatment.

The treatment implies managing the vitals, oxygen administration, naloxone 0.01-0.1
mg/kg IV and sending the patient to a specialized medical unit (ER).

Anesthetic overdose
 Symptoms observed in the anesthetic overdose are: excitation followed by depression
of the CNS, unconsciousness, cardiac arrest.

The preventive attitude implies complete anamnesis (correlating the anesthetic does
with the age and weight of the patient), general medical history directly related to the dental
treatment, respecting the recommended anesthetic dose and using an adequate anesthetic
technique (slow injection of the substance). The treatment implies managing the patient’s
vitals, possible administration of Diazepam 0.1-0.3 mg/kg IV, sending the patient to the ER.

OBSTRUCTION OF THE UPPER AIRWAYS

It is a possible complication in the case of pediatric dental medicine especially when

the isolating foil is not used.

The mechanic obstruction may be caused by a foreign body or adjacent soft tissue.

The mechanic obstruction secondary to the sedation is associated with hypoxemia,

ample and difficult respiratory movements and cyanosis.

The mechanic obstruction secondary to the action of a foreign body determines:

coughing, ample and difficult respiratory movements, cyanosis and shock state.

The preventive attitude in the case of upper airway obstruction implies: administering
the correct does of sedatives, monitoring the vitals, sustaining the shoulders during the
treatment, etc.

The treatment for the upper airway obstruction includes: managing the vitals, stopping
the sedative medication administration, sending the patient to a specialized medical unit (ER).