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QUICK REVIEW SERIES for

BDS
PAEDODONTICS
4th Year
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QUICK REVIEW SERIES for

BDS
PAEDODONTICS
4th Year

J Jyotsna Rao, BDS, MDS, PGCOI (MAHE), F ISOI


Director
SRS Dental Exams Academy, Bengaluru
Ex-professor, Department of Oral and Maxillofacial Surgery
The Oxford Dental College, Hospital and Research Centre
Bengaluru, INDIA

ELSEVIER
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Quick Review Series for BDS 4th Year: Paedodontics
Rao

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ISBN: 978-81-312-3733-5

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Dedicated to

My lovely son

Master K Raghasai

(whose understanding and cooperation made all this possible)


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Foreword

I am extremely happy to pen a few words about this conscientiously written book. It is a common knowledge that books play
a major complementary and contributing role in any educational process, where they are envisioned to facilitate self-learning
beyond classroom exercises.
This book of Quick Review Series for BDS IV: Paedodontics, authored by Dr J Jyotsna Rao, is presented with such a systemic
approach that it demonstrates her consummate skill in preparing students for examinations. It is good to see that she has
shared her vast experience in academics with the students through this book.
While going through the pages of this book I found that the author has made a sincere attempt to present the subject of
paedodontics as per the syllabus of Dental Council of India to fulfil the long-term need of a concise quick review book with
best standards, simple language and required depth of explanation of the subject through questions and answers of various
university examinations.
Designing such a book is a challenging task, especially if it has to be concise and comprehensive in scope. Such a version
demands wise sifting, prudent pruning and meaningful condensing of the enormous and variegated knowledge base of the
subject.
This outstanding resource is perfect for those studying in BDS IV year. The easy-to-understand text material serves as both
preparatory tool at the start of study course providing road map of the subject to be learnt and at the course end helping rapid
review and recapitulation of what has been learnt.
I am confident that this book is undeniably appropriate for exam-going undergraduate students craving for a thorough
review of subjects in a short period of time.
Regards

Dr Murali Mohan
Principal, Professor and Head of the Department
Department of Conservative Dentistry and Endodontics
Government Dental College and Hospital
Vijayawada, Andhra Pradesh
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Preface

This book is a result of my close interaction with the students. There is a lot of information available to students in various
textbooks, which are not only voluminous but also time consuming and daunting to read. This book is not only a replacement
of any paedodontics textbook, but is written keeping the needs of students in mind and their expectations from a book for the
purpose of excelling in the exams.
To excel in a subject one has to not only understand the same but also remember and present it in a systematic way in the
examinations. The subject like paedodontics includes concepts of conservative orthodontics and oral surgery, etc. All these
need to be condensed into a simple and comprehensible text.
The book is planned in a meticulous manner and I have endeavoured comprehensively to refer and include relevant in-
formation from the standard textbooks. Though written in a question and answer format, this book is arranged in a logical
sequence for the purpose of better recapitulation. This makes it easy for the students to rapidly review the entire subject and
also recollect whatever they had studied during the final year of BDS.
This book is primarily intended for undergraduate students, but can also be used as a quick reference book by postgraduate
students to recollect the subject.
J Jyotsna Rao
drjjrao@gmail.com
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Acknowledgements

First of all I thank the Almighty for his blessings, without which this work would not have been possible.
I would like to thank my father Mr J Sudharshan Rao, who is the key person behind all my successful endeavours. I am
thankful to my mother Mrs S Sujatha Laxmi for her unforgettable sacrifices and choicest blessings. My warmest regards to my
husband Mr K Vinayak Rao for his constant support to enhance my software skills in operating computers. My thanks and
love to my son Master K Raghasai, without whose cooperation this work would not have been possible. I am thankful to my
brother Mr J Jayakrishna for his valuable, constructive suggestions.
I wish to thank Dr BK Reddy, Ex-Principal, Government Dental College, Hyderabad and Meghna Institute of Dental
Sciences, Nizamabad, Andhra Pradesh for his support, blessings and advice. I would like to especially thank Dr P Bal Reddy,
Principal, Professor and Head of the Department, Department of Oral and Maxillofacial Surgery, Government Dental College,
Hyderabad, Andhra Pradesh, for his contribution of four topics in this book; and Dr Murali Mohan, Principal, Professor and
Head of the Department, Department of Conservative Dentistry and Endodontics, Government Dental College and Hospital,
Vijayawada for his contribution of five topics in this book.
My sincere thanks to Dr Bhaskar Y, Dr P Chidambar and Dr Laxmikanth for their invaluable support in collecting previous
years’ question papers from various universities. I would also like to specially thank Dr Shravani B, Dr Keerthi Yamini and
Nethravathi P for their valuable contribution in preparing this script.
Thanks to Elsevier India, especially Ms Ritu Sharma along with her team for active contribution in publishing of this book.
I would like to take this opportunity to thank all those people who, directly or indirectly, were instrumental in successfully
bringing out this book.
Last but not the least, I acknowledge all my friends and colleagues for their best wishes to boost my morale.

Dr J Jyotsna Rao
drjjrao@gmail.com
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Contents

Foreword .....................................................................................................................................................vii
Preface .........................................................................................................................................................ix

Section I: TOPIC WISE SOLVED QUESTIONS OF PREVIOUS YEARS

Topic 1 Introduction to Paedodontics ................................................................................................... 3


Topic 2 Examination, Diagnosis and Radiographic Techniques............................................................ 8
Topic 3 Theories of Child Development .............................................................................................. 20
Topic 4 Parent Counselling and Child Behaviour ................................................................................ 28
Topic 5 Behavioural Science and Psychologic Management of Children’s Behaviour ....................... 40
Topic 6 Therapeutic Management ....................................................................................................... 63
Topic 7 Management of Handicapped Children.................................................................................. 73
Topic 8 Management of Children with Systemic Diseases and HIV Infection ..................................... 79
Topic 9 Management of Children with Cleft Lip and Palate (Dr P Bal Reddy) ...................................... 89
Topic 10 Growth and Development of the Face and Dental Arches (Dr P Bal Reddy) ........................... 91
Topic 11 Development and Morphology of Primary Teeth and Occlusion ............................................ 99
Topic 12 Acquired and Developmental Disturbances of the Teeth and Associated Oral Structures .. 119
Topic 13 Developing Malocclusion, Its Management and Preventive Measures ................................ 133
Topic 14 Oral Habits ............................................................................................................................ 159
Topic 15 Gingival and Periodontal Diseases in Children ..................................................................... 172
Topic 16 Home Oral Hygiene for the Child and Adolescent................................................................ 181
Topic 17 Dental Caries in Child and Adolescent (Dr Murali Mohan) .................................................. 192
Topic 18 Pit and Fissure Sealants (Dr Murali Mohan) ........................................................................ 217
Topic 19 Atraumatic Restorative Treatment ........................................................................................ 224
Topic 20 Fluorides and Oral Habits ..................................................................................................... 227
Contents
xiv

Topic 21 Paediatric Restorative Materials and Rubber Dam Application (Dr Murali Mohan)............. 244
Topic 22 Restoration of Primary Carious Teeth (Dr Murali Mohan) .................................................... 261
Topic 23 Paediatric Endodontics (Dr Murali Mohan) .......................................................................... 272
Topic 24 Traumatic Injuries of Anterior Teeth and Management (Dr P Bal Reddy) ............................... 287
Topic 25 Local Anaesthesia and Oral Surgery for the Child Patient (Dr P Bal Reddy) ......................... 302
Topic 26 NSAIDS, Antimicrobial Drugs and Miscellaneous ................................................................ 308

Section II: MULTIPLE CHOICE QUESTIONS

Multiple Choice Questions ....................................................................................................................... 313

Section III: QUESTION BANK OF VARIOUS UNIVERSITY EXAMS

Question Bank of Various University Exams ............................................................................................ 321


SECTION I
TOPIC WISE SOLVED
QUESTIONS OF
PREVIOUS YEARS
Topic 1 Introduction to Paedodontics ................................................................................................... 3
Topic 2 Examination, Diagnosis and Radiographic Techniques............................................................ 8
Topic 3 Theories of Child Development .............................................................................................. 20
Topic 4 Parent Counselling and Child Behaviour ................................................................................ 28
Topic 5 Behavioural Science and Psychologic Management of Children’s Behaviour ....................... 40
Topic 6 Therapeutic Management ....................................................................................................... 63
Topic 7 Management of Handicapped Children.................................................................................. 73
Topic 8 Management of Children with Systemic Diseases and HIV Infection ..................................... 79
Topic 9 Management of Children with Cleft Lip and Palate ................................................................ 89
Topic 10 Growth and Development of the Face and Dental Arches ..................................................... 91
Topic 11 Development and Morphology of Primary Teeth and Occlusion ............................................ 99
Topic 12 Acquired and Developmental Disturbances of the Teeth and Associated Oral Structures .. 119
Topic 13 Developing Malocclusion, Its Management and Preventive Measures ................................ 133
Topic 14 Oral Habits ............................................................................................................................ 159
Topic 15 Gingival and Periodontal Diseases in Children ..................................................................... 172
Topic 16 Home Oral Hygiene for the Child and Adolescent................................................................ 181
Topic 17 Dental Caries in Child and Adolescent ................................................................................. 192
Topic 18 Pit and Fissure Sealants ....................................................................................................... 217
Topic 19 Atraumatic Restorative Treatment ........................................................................................ 224
Topic 20 Fluorides and Oral Habits ..................................................................................................... 227
Topic 21 Paediatric Restorative Materials and Rubber Dam Application ........................................... 244
Topic 22 Restoration of Primary Carious Teeth ................................................................................... 261
Topic 23 Paediatric Endodontics......................................................................................................... 272
Topic 24 Traumatic Injuries of Anterior Teeth and Management ......................................................... 287
Topic 25 Local Anaesthesia and Oral Surgery for the Child Patient ................................................... 302
Topic 26 NSAIDs, Antimicrobial Drugs and Miscellaneous ................................................................. 308
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SECTION I

Topic wise Solved


Questions of Previous Years

Topic 1 INTRODUCTION TO PAEDODONTICS


LONG ESSAYS

Q.1. Define paediatric dentistry. Explain paediatric  The office should be decorated according to the fantasies
practice management. of children because a child patient is often fearful when
he/she comes to a dental clinic for the first time.
Ans.
 Office walls should have posters of circus, nursery rhymes,
Paediatric dentistry is defined as an age-related speciality etc. If space permits, an aquarium should be installed at
meant for preventive and curative dental and oral healthcare such a place so that it should be visible from the recep-
of infants and children up to the age of 15 years. tion and also from the dental chair. With such decoration
a child’s fear can be reduced to a great extent.
Paediatric Practice Management  For parents or accompanying persons who bring the
 The main aim of paediatric practice management is devel- child to a dental clinic, good reading material should be
oping management skills to achieve a good practice, har- available, like different types of magazines, newspapers
monious staff, satisfied patient and good income. etc.
 Success of the dental practice depends on the office staff,  Good, soft and mild music always has a soothing effect on
patients and the entire operational system. children and parents, so clinic should have a good music
 Some important things to be considered for a good pae- system.
dodontic practice are as follows:
i. Situation and office decoration ii. Ancillary Personnel
ii. Ancillary personnel  To save the precious time of the paedodontist, he/she
iii. Health education room should have a hygienist, assistant or secretary. These ancil-
iv. Introductory information to patient lary personnel should work under the direction of the
v. Patient history paedodontist.
vi. Preliminary examination and consultation  The importance of these ancillary personnel is as fol-
vii. Recalls. lows:
❍ Paedodontist can work more rapidly and efficiently.
i. Situation and Office Decoration ❍ The assistant keeps the working area and all the neces-
 Paedodontic clinic should be situated in an area where sary equipment ready for the work.
economic and social condition or status of the people ❍ The appointment time can be reduced; hence more
living is good. number of patients can be attended.
 Access to the clinic from the schools and residential area ❍ Paedodontist’s income may increase.
should be good. ❍ More complicated treatments can be undertaken.
Quick Review Series for BDS 4th Year: Paedodontics
4

For smooth and efficient working  On subsequent visits for minor work, a child above 12
 The proper positioning of patient, years of age can come alone.
 Assistant's position and  Paedodontist should also record the name of the person
 Paedodontist's position are very important. who had referred the patient to him and should send an
Position of child patient appreciation card to that person.
 Child’s body should be parallel to the floor and legs
v. Patient History
slightly elevated.
 Paedodontist’s hand should be slightly above the patient’s  Chief complaint and past medical and dental history
chest. should be recorded.
 The instruments should be out of the child’s vision to  If the chief complaint needs emergency, a thorough and
lessen the apprehension of the child patient. revealing past history should be taken to avoid any unto-
ward incident during the treatment.
Assistant’s position
 A child avoids eating if his/her teeth get hurt during treat-
 Assistant should be seated opposite to the paedodontist.
ment; palliative or corrective treatment should be done.
 His or her level should be slightly above the paedodon-
Proper restoration, correct occlusion should be given on
tist’s level from the floor. the first visit.
 Everything should be within the reach of the assistant  All the records should be signed by the person who has
without leaving the chair. given the history.
Paedodontist’s position
 The paedodontist should be comfortably seated on an vi. Preliminary Examination and Consultation
operating stool.  After preliminary examination, the patient and parent
 His back should be straight; he/she should not lean on the should be taken into the treatment room. A thorough
patient. His feet should rest on the floor and thighs should examination of the oral cavity should be done.
be parallel to the floor.  If required, full-mouth X-ray is done and impressions are
Four-handed dentistry taken; topical fluoride is applied and instructions about
proper brushing technique are given.
 In four-handed dentistry, two hands of the paedodontist
 After all these information and examination, a diagnosis
and two hands of the assistant are consistently used. All
and treatment plan can be made.
four hands must be utilized.
 On next appointment, problems can be presented in front
 The exchange of instruments should be very smooth. The
of parents more accurately and alternate treatment plans
assistant exchanges the instruments as and when required, may be suggested.
using one hand to give and take instruments simultane-  A good first appointment experience provides the foun-
ously. dation for enjoyable long-term relationships with the
patients and parents.
iii. Health Education Room
 In the paediatric dental office, there should be a health Recalls
education room, where instructions about preventive  Recall check-up appointments should be given for better
procedures should be given and demonstrated to the par- results.
ents.  Hygienist or assistant should explain the importance of
 Proper toothbrushing technique should be demonstrated periodic examination to keep teeth and gums in good
to the patient. Educating the parents is necessary so that health.
they can guide their child at home.
 Children and parents can be educated with the help of Operational Systems
slides, posters, models, films, pamphlets, etc.
 For smooth functioning of the dental clinic it is very
 Children should be educated on how to brush and floss in
front of a mirror so that they can learn it easily. important to schedule and document all the necessary
activities required.
 Efficient appointment scheduling makes the office func-
iv. Introductory Information
tioning pleasant.
 First visit of a child patient to a dental clinic should be  Patients who miss their appointments should be sepa-
with his parents because a child cannot give all the neces- rately listed and seen that they are not lost. They should
sary information and cannot fully understand what the be contacted periodically and invited to reschedule the
paedodontist or his staff tells him. appointment.
Topic wise Solved Questions of Previous Years
5

Q.2. Define paediatric dentistry. What are the aims and  A paedodontist should have a good relationship with the
objectives of paediatric dentistry? Mention responsibil- paediatricians and physicians practising in the same area,
ities of a paedodontist. so that they can refer the child patients to the paediatri-
cian in case of any medical problems.
Ans.
 If the physician and paediatrician find a child with any
 Paediatric dentistry is defined as an age-related speciality dental problems, they will refer them to the paedodontist
meant for preventive and curative dental and oral health- and that will be helpful for the child also.
care of infants and children up to the age of 15 years.  Whenever a paedodontist opens a clinic, he/she should
introduce himself/herself to the paediatricians, physicians
Aims and Objectives of Paediatric Dentistry and general practitioners practising in the same area. This
 One of the important aims of a paedodontist is preven- will build up mutual respect, understanding and practice.
tion of diseases because it can be very effectively imple-
mented in younger age groups and prevention is always ii. Responsibility Towards Community
better than cure.  paedodontist should think not only about the children
 The general and dental health of a child should be visual- coming to their clinic but also about the other children
ized as a whole and dental health of the child should always who are unable to afford the treatment. They should try
be improved in accordance with their general health. for the betterment of oral health of all children of the
 The developing dentition of the child should be observed community.
and controlled as necessary.  There should be an earnest desire for better dental health
 The parents and patients should be convinced about the of children. The dentist should educate the children and
dental treatment and its importance with respect to pri- parents about dental health through the public dental
mary dentition and young permanent teeth to avoid fur- health programmes.
ther dental diseases.  These programmes should be repeated periodically
 The aesthetics should be maintained or achieved as the to remind the people about the importance of dental
case demands. health.
 Children Dental Health Day (or Week) should be cel-
Responsibilities of a Paedodontist
ebrated once or twice a year. This can help in motivating
 The three main groups of responsibilities or objectives of the people. By this programme, parents can bring their
a paedodontist are as follows: child to a paedodontist for dental check-up.
i. Responsibility towards patient.  Community dental health programmes have two compo-
ii. Responsibility towards community. nents:
iii. Responsibility towards himself/herself and the family. A. Preventive programmes
B. Curative programmes.
i. Responsibility Towards Patient
 The main objective of a paedodontic practice is correct A. Preventive Programmes
diagnosis and proper treatment planning. The paedodon-  Preventive programmes deal with the prevention of ini-
tists should provide the best possible service according to tiation of oral and dental diseases in children and inter-
their knowledge and experience. ception of their progress.
 The paedodontist should know good office and patient  Most dental diseases cause irreparable damage to the
management techniques. They should know how to tissues. By proper planning and implementation of pre-
handle an infant and a child patient to perform high- ventive measures, most of the dental diseases can be pre-
quality paedodontic service. vented.
 Paedodontist should stress on prevention and this will  A paedodontist should teach about the following to the
require knowledge of preventive techniques and func- parents and children:
tions.
a. Oral hygiene and prevention of dental diseases
 A paedodontist should assure the parents of the child
b. Dietary factors for proper health
patient that the money they are spending is not a wast-
age but a wise investment for future dental health of the c. Fluoride prophylaxis
child. d. Pit and fissure sealants
 Good paedodontic practice always begins at home in the e. Prevention of malocclusion
form of proper brushing, diet counselling, and patient f. Soft-tissue treatment
education and motivation, etc. g. Periodic recall check-up.
Quick Review Series for BDS 4th Year: Paedodontics
6

a. Oral hygiene and prevention of dental diseases  The preservation of deciduous dentition till their physi-
 This includes teaching the techniques of proper tooth- ological exfoliation not only prevents malocclusion from
brushing, demonstration on a big model by a big tooth- developing but also makes it less severe.
brush or by audiovisual aids.
 After teaching, they should ask the children and parents to B. Corrective and curative programmes
do what was demonstrated because they can understand  Corrective programmes include the treatment of dental
more quickly by doing than by only observing. caries, habit-breaking appliances, myofunctional appli-
b. Dietary factors ances, etc.
 Some dental care programmes should be started in play,
 The children should be taught proper food habits and nursery and primary schools, religious places, public
about fixed time for meals, and avoiding in-between meals health buildings.
and taking carbohydrates frequently.  If a programme is running on a small scale and cannot
 If caries susceptibility is very high then patient can use treat all the problems of children, then stress should be
artificial sweeteners and must brush teeth after every given on treating and preserving the permanent first
meal. molars because they are the most vulnerable, but most
c. Fluoride prophylaxis important teeth in all respects.
 If a programme is on a large scale, then it should include
 Paedodontist should teach the parents about the impor-
the examination and treatment of both preschool and
tance of fluoride in preventive dentistry.
school-going children. An early school dental treatment
 If a child is living in a fluoride-deficient area, he/she programme up to the age of 12 years is more economical
should be advised fluoride toothpaste and tablets under than teenage treatment programmes.
supervision as home care.
 Periodic topical application of fluoride should be done iii. Responsibility Towards Himself/Herself
on caries-susceptible teeth. Water fluoridation and milk and the Family
fluoridation, wherever required, should be carried out.
 As the ability and experience of the paedodontist increases,
d. Pit and fissure sealants his/her responsibility also increases. Paedodontics is a
The pit and fissure sealants must be applied in appropriate continuously growing profession in knowledge and tech-
time to prevent the decay of young permanent teeth. nique.
 A paedodontist should always try to improve knowledge by
e. Prevention of malocclusion
participating in professional meetings, refresher courses,
 Premature loss of deciduous teeth causes development of lectures, seminars, continued education programmes and
malocclusion. conferences. Paedodontists should also read professional
 The community should be taught about the causes and journals, new textbooks and literature to increase knowl-
consequences of malocclusion through more attractive edge and ability.
educational programmes like the motion pictures, puppet  A paedodontist should try to treat the patients according
shows, newspaper articles, radio and TV programmes, to the best of the knowledge and ability.
posters on vehicles, school projects, talk and slide shows  Paedodontist should have the necessary ability and a good
with projectors. personality to earn livelihood for family and for himself/
 Space maintenance is a widely accepted and practised pre- herself. They should establish good relationship with
ventive procedure. public, private school teachers and administrators.

SHORT ESSAYS

Q.1. Scope of paedodontics. Ans.


 Paedodontics or paediatric dentistry is an age-specific
Or speciality that provides both primary and comprehensive
preventive and therapeutic oral healthcare for infants and
Define paedodontics and write about the scope of pae- children through adolescence, including those with spe-
dodontics. cial healthcare needs.
Topic wise Solved Questions of Previous Years
7

Scope of Paedodontics of other disciplines and in planning and execution of


treatment of cleft lip and palate patients.
i. It encompasses a variety of disciplines, techniques, pro-
cedures and skills that logically share a common basis vi. Paediatric dentistry is the only speciality that has an in-
with other specialities. tensity of knowledge for the management and treatment
ii. To understand the special needs of children and adoles- of the oral health needs of infants, children and adoles-
cents and also of those with special healthcare needs. cents, especially those with special care needs.
iii. Paediatric dentistry concentrates mainly on the inte- vii. The paedodontist can now expand the scope of practice
gration of appropriate didactic and clinical knowledge towards the goal of prevention, endodontic treatments,
from various specialties into a framework of quality oral and high-quality restorative and cosmetic dentistry and
healthcare for children. early treatment of periodontal diseases.
iv. Paediatric dentistry is an age-specific speciality; hence vii. The scope of paedodontics is increasing and its horizon
it encompasses all aspects of dentistry, including some is widening. It is exciting to look ahead as the speciality
aspects of other specialties. evolves, redefines its boundaries and seeks to collabo-
v. They are fortunate enough of being important team rate with other specialities in dentistry and paediat-
members in children’s hospitals to work with members rics.

SHORT NOTES

Q.1. Define paedodontics. prevalence, intercepting and correcting various areas of


malocclusion.
Or
Define paediatric dentistry. According to American Association of Pediatric
Dentistry (1999)
Ans.
Paediatric dentistry is defined as a speciality that provides
The paedodontics is defined in a number of ways as follows:
both primary and speciality, comprehensive, preventive and
therapeutic oral healthcare for infants and children through
According to Stewart, Barber, Troutman and Wei
adolescence, including those with special healthcare needs.
(1982)
Paediatric dentistry is the practice and teaching of compre- Q.2. Scope of paedodontics.
hensive preventive and therapeutic oral healthcare of child
from birth to adolescence. It is constructed to include care of Ans.
special patients who demonstrate mental, physical or emo- Scope of Paedodontics
tional problems.
i. It encompasses a variety of disciplines, techniques, pro-
According to American Academy of Pediatric cedures and skills that logically share a common basis
Dentistry (1985) with other specialities.
ii. Paediatric dentistry is an age-specific speciality. It un-
Paediatric dentistry, also known as paedodontics and as
derstands special needs of children and adolescents and
dentistry for adolescents and children, is the area of den-
those with special healthcare needs.
tistry concerned with preventive and therapeutic oral
iii. Paediatric dentistry concentrates mainly on the integra-
healthcare for children from birth through adolescence. It
tion of appropriate didactic and clinical knowledge from
also includes special care for special patients beyond the age
various specialities into a framework of quality oral
of adolescence who demonstrate mental, physical or emo-
healthcare for children.
tional problems.
iv. Recently, the nature of the paedodontic practice has
changed from predominantly restorative to preventive.
According to Boucher’s Dental Terminology (1993)
v. The paedodontist can now expand the scope of practice
Paedodontics is the branch of dentistry that includes hav- towards the goal of prevention and cosmetic dentistry.
ing a child to accept dentistry, prevention, detection, res- vi. The scope of paedodontics is increasing and its horizon
toration of primary and permanent dentition, applying is widening. It seeks to collaborate with other specialities
preventive measures for periodontal therapy, dental caries in dentistry and paediatrics.
Quick Review Series for BDS 4th Year: Paedodontics
8

Topic 2 EXAMINATION, DIAGNOSIS AND


RADIOGRAPHIC TECHNIQUES
LONG ESSAYS

Q. 1. Write in detail about examination diagnosis in  Accurate information reflecting a child’s learning, behav-
children. ioural or communication problems is especially impor-
tant when the parents are aware of their child’s develop-
Ans.
mental disorder.
 Traditionally a complete examination of the patient is  Behaviour problems in the dental office are often related
performed to develop a treatment plan. to the child’s inability to communicate with the dentist
 It is presented to the patient’s parents, outlining the rec- and to follow instructions.
ommended course of treatment.  This inability may be attributable to a learning disorder. An
 A thorough examination diagnosis of the paediatric dental indication of learning disorders can usually be obtained
patient includes the assessment of the following: by the dental assistant while asking questions about the
❍ General growth child’s learning process. Example, asking a young school-
❍ Behaviour aged child about how he or she is doing in school is a good
❍ General health
lead question. The questions should be age-appropriate
for the child.
❍ Chief complaint, e.g. pain
❍ Extraoral and intraoral soft tissues
General Health
❍ Intraoral hard tissues
❍ Temporomandibular joint  When there is indication of an acute or chronic systemic
❍ Oral hygiene and periodontal health
disease or anomaly, the dentist should consult the child’s
❍ Developing occlusion
physician to learn the status of the condition, the long-
range prognosis and the current drug therapy.
❍ Caries risk.
 In addition to consulting the child’s physician, the den-
 Additional diagnostic aids include:
tist may decide to record additional data concerning the
❍ Radiographs
child’s current physical condition, such as blood pressure,
❍ Study models body temperature, heart sounds, height and weight, pulse
❍ Photographs and respiration.
❍ Pulp tests  Before treatment is initiated, certain laboratory tests may
❍ Laboratory tests. be indicated and special precautions may be necessary.
 If the dentist is aware that a child was previously hospital-
Preliminary Medical and Dental Examination ized or the child fears strangers in clinic attire, the neces-
 It is important for the dentist to be familiar with the med- sary time and procedures can be planned to help the child
ical and dental history of the paediatric patient. overcome the fear and accept dental treatment.
 The dentist’s personal involvement at this early time
 Family history may also be relevant to the patient’s oral
strengthens the confidence of the parents.
condition and may provide important diagnostic infor-
 It is advisable to postpone non-emergency dental care for
mation in some hereditary disorders.
a patient exhibiting signs or symptoms of acute infectious
 Prior to dentist’s examination of the child, the dental
disease until the patient recovers.
assistant can obtain sufficient information to provide the
 The pertinent facts of the medical history can be trans-
dentist with knowledge of the child’s general health and
ferred to the oral examination record for easy reference
can alert the dentist to the need for obtaining additional
by the dentist.
information from the parent or the child’s physician.
 The patient’s dental history should also be summarized
on the examination chart. This should include a record
Behaviour
of previous care in the dentist’s office and the facts related
 Information regarding the child’s social and psychological by the patient and the parent regarding previous care in
development is important. another office.
Topic wise Solved Questions of Previous Years
9

Chief complaints Temporomandibular Evaluation


The reason that prompted the patient to seek dental treat-  One should evaluate TMJ function by palpating the head
ment: of each mandibular condyle and observing the patient
 Most common reasons are pain, swelling and to improve while the mouth is closed with teeth clenched, at rest and
aesthetics. at various open positions.
 May be referred from other practitioner.  Movements of the condyles or jaw that are not smoothly
flowing or deviate from the expected norm should be
Clinical Examination noted.
 A thorough clinical and radiographic examination helps  Similarly, any crepitus that may be heard or identified
in obtaining most facts needed for a comprehensive oral by palpation or any other abnormal sounds should be
diagnosis in the young patient. noted.
 In addition to examining the structures in the oral cavity,  Sore masticatory muscles may also signal TMJ dysfunc-
the dentist may in some cases wish to note the patient’s tion. Such deviations from normal TMJ function may
size, stature, gait or involuntary movements. require further evaluation and treatment.
 The first clue to malnutrition may come from observing a
patient’s abnormal size or stature. Extraoral Examination
 Similarly, the severity of a child’s illness, even if oral in  The extraoral examination continues with palpation of
origin, may be recognized by observing a weak, unsteady the patient’s neck and submandibular area.
gait of lethargy and malaise as the patient walks into the  Any deviations from normal, such as unusual tenderness
office. or enlargement, should be noted and follow-up tests are
 The clinical examination, whether the first examination performed or referrals are made, as indicated.
or a regular recall examination, should be all-inclusive.
 Attention to the patient’s hair, head, face, neck and hands Intraoral Examination
should be among the first observations made by the den-
tist after the patient is seated in the chair. Soft tissues
 The patient’s hands may reveal information pertinent to  The intraoral examination of a paediatric patient should
the comprehensive diagnosis. be comprehensive. The dentist should first evaluate the
 The dentist may first detect an elevated temperature by condition of the oral soft tissues.
holding the patient’s hand. Cold, clammy hands or bitten  The buccal tissues, lips, floor of the mouth, palate and
fingernails may be the first indication of abnormal anxi- gingivae should be carefully inspected and palpated.
ety in the child. A callused or unusually clean digit sug-  Soft tissue should be examined for 3C’s, i.e. change in the
gests a persistent sucking habit. Colour, Contour and Consistency.
 Clubbing of the fingers or a bluish colour in the nail beds  The use of the periodontal screening and recording pro-
suggests congenital heart disease that may require special gramme (PSR) is often a helpful adjunct in children. It is
precautions during dental treatment. designed to facilitate early detection of periodontal dis-
 Inspection and palpation of the patient’s head and neck eases with a simplified probing technique and minimal
are also indicated. Unusual characteristics of the hair or documentation.
skin should be noted.  The tongue and oropharynx should be closely inspected.
 The dentist may observe signs of head lice, ringworm or Enlarged tonsils accompanied by purulent exudate may
impetigo during the examination. Proper referral is indi- be the initial sign of a streptococcal infection, which can
cated immediately because these conditions are conta- lead to rheumatic fever. When streptococcal throat infec-
gious. After the child’s physician has supervised the treat- tion is suspected, immediate referral to the child’s physi-
ment to control the condition, the child’s dental appoint- cian is indicated.
ment may be rescheduled.
 If a contagious condition is identified but the child also Hard tissues
has a dental emergency, the dentist and the staff must take
appropriate precautions to prevent spread of the disease  After thoroughly examining the oral soft tissues, the den-
to others while the emergency is alleviated. Further treat- tist should inspect the occlusion and note any dental or
ment should be postponed until the contagious condition skeletal irregularities. This dynamic developmental proc-
is controlled. ess occurs in all three planes and with periodic evaluation
 Variations in size, shape, symmetry or function of the the dentist can intercept and favourably influence unde-
head and neck structures should be recorded. Abnormali- sirable changes.
ties of these structures may indicate various syndromes or  Monitoring of the patient’s facial profile and symmetry;
conditions associated with oral abnormalities. molar, canine and anterior segment relationships; dental
Quick Review Series for BDS 4th Year: Paedodontics
10

midlines and relation of arch length to tooth mass should Photographs


be routinely included in the clinical examination.
Ideally extraoral and intraoral maxillary and mandibular
 The teeth should be inspected carefully for evidence of photographs are taken.
carious lesions and hereditary or acquired anomalies.
They should also be counted and identified individu- They are useful to assess:
ally to ensure recognition of supernumerary or missing  The symmetry of the face
teeth.  Profile and facial type
 Identification of carious lesions is important in patients of  Serve as a record.
all age groups; but it is especially critical in young patients
because the lesions may progress rapidly in early child- Pulp Tests
hood caries if not controlled. This is not a routine diagnostic aid used in children as their
 The decision whether to place a sealant or to restore a pain perception varies due to the resorbing or developing
defect depends on the patient’s history of dental caries, roots.
the parents’ or patient’s acceptance of a comprehensive
Response to vitality testing is read as follows:
preventive dentistry programme and the patient’s depend-
ability in returning for re-care appointments.  Nil – non-vital pulp or false negative

 In patients with severe dental caries, caries activity tests  Moderate transient – normal

and diet analysis may contribute to the diagnostic process  Painful transient – reversible pulpitis

by helping to define specific aetiologic factors.  Painful lingering – irreversible pulpitis.

Additional Diagnostic Aids Include Q. 2. What is treatment planning in paedodontics?

 Radiographs Ans.
 Study models  Successful dental treatment is based on an accurate diag-
 Photographs nosis and careful treatment planning.
 Pulp tests  The history, clinical examination and laboratory diagnos-
 Laboratory tests. tic aids will provide the essential facts necessary to make
an accurate diagnosis and appropriate treatment plan.
Radiographs  A pattern of sequence serves as a reminder of the phases
of treatment, which must be considered in caring for the
 When indicated, radiographic examination for children
total needs of the child. The following general outline is
must be completed before the comprehensive oral health-
suggested for paedodontic treatment planning.
care plan can be developed.
 Treatment planning can be made based on the following
 Obtaining isolated occlusal, periapical, or bitewing films five different phases:
is sometimes indicated in very young children due to a. Medical phase
trauma, toothache, suspected developmental distur- b. Systemic phase
bances, or proximal caries. c. Preventive phase
 IOPA gives information regarding the presence or absence d. Corrective phase
of permanent teeth, shape and position of the teeth e. Maintenance phase.
present, relative state of development of teeth, extent of
calcification of developing tooth, path of eruption of per- Outline for paedodontic treatment planning consists of:
manent teeth, morphology and inclination of the roots of a. Medical treatment phase:
permanent tooth. a. Referral to a physician.
b. Systemic treatment phase:
Study Models a. Premedication
b. Therapy for oral infections, if any.
 Study models should be neat and record surrounding
anatomical structures like alveolar process. c. Preventive treatment phase:
 When models are in occlusion, the top surface of upper a. Oral prophylaxis
model and lower surface of the lower base should be par- b. Caries control
allel. c. Orthodontic consultation
 In total height of the cast, the anatomic portion should be d. Oral surgery
three-fourth and artistic portion should be one-fourth. e. Endodontic therapy.
 Model analysis is done to detect arch size and tooth size d. Corrective treatment phase:
discrepancies. a. Operative dentistry
Topic wise Solved Questions of Previous Years
11

b. Prosthetic dentistry i. Oral prophylaxis and fluoride treatment


c. Orthodontic therapy.
 After establishment of the medical status and premedi-
e. Maintenance phase: cation regime of the child teeth should be thoroughly
It includes periodic recall examination and maintenance cleaned.
treatment.  The concerned dentist can offer the parent an interesting
The detailed description of ideal treatment plan is as follows: and challenging opportunity to facilitate the reduction of
caries in the child by topical fluoride application or use of
A. Medical Treatment Phase systemic fluorides.

 During this phase patients with positive medical history ii. Oral hygiene counselling
are referred to paediatrician for evaluation and consent.
 It may also be required to modify the dosage or change a  The oral prophylaxis gives the dentist a splendid opportu-
particular drug, etc. as per the requirement of the treat- nity to teach the child toothbrushing and other elements
ment. of home care.
 When the history and examination of the child suggest  Also, much can be learned about the patient’s tempera-
a medical problem, the dentist should consult the child’s ment, apprehensiveness and oral health status during the
physician to ensure/insure the health and safety of the oral prophylaxis and the home care instructions.
child during treatment.
 Blood dyscrasias are often reflected in the oral cavity by iii. Diet counselling
changes in colour, size, shape and consistency of oral
soft tissues. Therefore, the dentist should evaluate tissue  Closely following the initial prophylaxis, an evaluation of
changes and relay any pertinent information to the child’s the caries susceptibility of the child should be made. If
physician or paediatrician. active caries is evident, the child’s mother should be ques-
tioned closely about his diet.
B. Systemic Treatment Phase  With the proper approach, the concerned dentist can offer
the parent an interesting and challenging opportunity to
 This phase includes any medication given to modify dental facilitate the reduction of caries in the child by several
treatment, such as premedication for behaviour manage- means available, like topical and systemic fluorides, diet
ment or antibiotic prophylaxis to a child with congenital substitutions and more regular meals without in-between
cardiac defects. snacks.
 Premedication of apprehensive children, spastic patients,
or those with cardiac problems is frequently necessary and iv. Pit and fissure-sealant application
should be done only after consultation with the child’s
physician. The exact dosages of all drugs to be used should The incidence of caries can be reduced by application of pit
be entered on the treatment plan. and fissure sealants.
 Systemic drug therapy may cause oral tissue changes, Age range for sealant application:
which make restorative work difficult or even impossible.
 3–4 yrs age—for primary molar sealant application
Example: A child taking Dilantin sodium develops severe-
ly hypertrophic gingivae. Such a problem should be dis-  6–7 yrs age—for the first permanent molar
cussed with the physician so that drug substitution may  11–13 yrs age—for the second permanent molars and
alleviate the problem and dental treatment can proceed. premolars.

C. Preventive Treatment Phase v. Orthodontic consultation

 Preventive treatment phase is aimed at providing preven-  When crowding or malalignment is evident, an orthodon-
tive therapy to patient and minimize dental disease. tist should be consulted immediately. Frequently, preven-
 Preventive treatment phase is the first phase of treatment tive orthodontic measures can be performed concurrently
and includes: with restorative procedures.
i. Oral prophylaxis and fluoride treatment  All possibilities of alternate future treatment, such as
ii. Oral hygiene counselling restorative and endodontic procedures, replacement
iii. Diet counselling problems with removable or fixed prostheses, must be
iv. Pit and fissure-sealant application considered from a practical and a dental health point of
v. Orthodontic consultation. view.
Quick Review Series for BDS 4th Year: Paedodontics
12

D. Corrective Treatment Phase  Davis and Vogel emphasized that a force strong enough to
fracture, intrude or avulse a tooth is equally strong enough
 Final corrective treatment can be started only after the
to result in cervical spine or intracranial injury.
medical and preparatory phases have been initiated.
 The dentist must be particularly alert to such potential
 Sequence is important even in this phase of the treatment
problems, be prepared ahead of time to make a neurologic
plan.
assessment and make appropriate medical referral when
Example: Caries should be eliminated from the teeth and indicated promptly.
the restorations polished before orthodontic treatment is  Davis recommends a quick cranial nerve evaluation
initiated. involving the following four areas:
a. Extraocular muscles: If they are intact and functioning
E. Maintenance Phase appropriately then the patient can track a finger mov-
 It includes periodic recall examination and maintenance ing vertically and horizontally through the visual field
treatment. with the eyes remaining in tandem.
 Upon completion of treatment, the wise dentist gives an b. Pupils: Should be equal, round and reactive to light
explicit appointment for the next recall visit. The interval with accommodation.
may vary from 3 months to 6 months. c. Sensory function: Is measured through light contact to
various areas of the face.
Alternate Treatment Plans d. Symmetry of motor function: Is assessed by having the
patient frown, smile, move the tongue and perform
 There is an ideal treatment plan for every child that
several voluntary muscular movements. If they are
should be presented to the parent using models, X-rays,
equal on both sides then it is assumed that symmetry is
and other aids.
present.
 Unlike adult treatment, dental care for children must
 The patient should be assessed for nausea, vomiting,
not be delayed or even spaced over a long period of time.
drowsiness, or possible cerebral spinal fluid leakage from
There are few opportunities for alternate treatment plans
the nose and ears, which would be indicative of a skull
in paedodontics. When an alternate plan is suggested, the
fracture. The patient should be evaluated for lacerations
dentist must be sure that the results will be as beneficial
and facial bone fractures.
as possible and not in any way detrimental to the future
 For practical and especially economic reasons, Andreasen
dental health of the child.
and colleagues have attempted to classify pulpal and peri-
odontal healing of traumatic dental injuries based on the
Advantages of Treatment Planning
effect of treatment delay.
 Repeat-diagnosis at every visit is avoided.  Unfortunately, there is limited knowledge of the effect of
 Instruments can be prepared well in advance. treatment delay on wound healing available in the litera-
 Serial appointments can be given on the first visit. ture.
 Total fee estimation can be done.  Taking a complete dental history can help the dentist
learn of previous injuries to the teeth in the area. The den-
Q. 3. Discuss case taking, clinical examination and di- tist must rule out the possibility of a degenerative pulp or
agnosis of trauma to anterior teeth. adverse reaction of the supporting tissues as a result of
previous trauma.
History and Examination  The patient’s complaints and experiences after the injury
are often valuable in determining the extent of the injury
 The routine clinical evaluation sheet is helpful during and in estimating the ability of the injured pulp and sup-
the initial and subsequent examinations of an injured porting tissues to overcome the effects of the injury.
tooth.  Trauma to the supporting tissues may cause sufficient
 It serves as a checklist of important questions that must be inflammation to initiate external root resorption. In
asked and observations that must be made by the dentist instances of severe injury, teeth can be lost as a result of
and the auxiliary personnel during the examination of the pathologic root resorption and pulpal degeneration.
child.  The clinical examination should be conducted after the
teeth in the area of injury have been carefully cleaned of
History of the Injury debris.
 The time of the injury should first be established.  When a fracture of the crown has resulted due to injury,
 Sometimes the accident is so severe that dental treatment the dentist should observe the amount of tooth structure
cannot be started immediately because other injuries have that has been lost and should look for evidence of a pulp
higher priority. exposure.
Topic wise Solved Questions of Previous Years
13

 Under a good light, the clinical crown should be exam-  Failure of a recently traumatized tooth to respond to the
ined carefully for cracks and craze lines, the presence of pulp test is not uncommon.
which could influence the type of permanent restoration However, the traumatized tooth may be in a state of
used for the tooth. shock and as a result may fail to respond to the accepted
 With light transmitted through the teeth, a severely trau- methods of determining pulp vitality.
matized teeth often appears darker and reddish, although  Laser Doppler flowmetry has been reported to be a signif-
not actually discoloured, which indicates pulpal hyper- icant aid in determining vascular vitality of traumatized
emia. This appearance suggests that at some later time teeth.
the pulp may undergo degenerative change terminating
in pulpal necrosis.
 Historically, the Ellis and Davey classification of crown Radiographic Examination
fractures is useful in recording the extent of damage to  The examination of traumatized teeth is not considered
the crown. to be complete without a radiograph of the injured tooth,
 A vitality test of the injured tooth should be performed, the adjacent teeth, and sometimes the teeth in the oppos-
and the teeth in the immediate area as well as those in ing arch.
the opposing arch should be tested. The best prediction  It may even be necessary to obtain a radiograph of the soft
of continued vitality of the pulp of a damaged or trauma- tissue surrounding the injury site to rule out presence of a
tized tooth is the vital response to electric pulp testing at fractured tooth fragment.
the time of the initial examination.  In young patients, the stage of apical development often
 A negative response, however, is not reliable evidence of indicates the type of treatment.
pulp death because some teeth that give such a response  The presence of a root fracture may not influence the
soon after the injury may recover vitality after a time. course of treatment, particularly if the fracture line is in
When the electric pulp tester is used, the dentist should the region of the apical third. Teeth with root fractures in
first determine the normal reading by testing an uninjured this area rarely need stabilization, and a fibrous or calci-
tooth on the opposite side of the mouth and recording the fied union usually results.
lowest number at which the tooth responds.  If teeth have been discernibly dislocated, with or without
If the injured tooth requires more current than does root fracture, two or three radiographs of the area at dif-
a normal tooth, the pulp may be undergoing degenera- ferent angles may be needed to clearly define the defect
tive change. If less current is needed to elicit a response and aid the dentist in deciding on a course of treatment.
from a traumatized tooth, pulpal inflammation is usually
 The radiographs provide a record of the tooth immediately
indicated.
after the injury. Frequent, periodic radiographs reveal evi-
 The reliability of the electric pulp test depends on eliciting
dence of continued pulp vitality or adverse changes that
valid responses from the patient. It is frequently unreli-
take place within the pulp or the supporting tissues.
able even on normal teeth when apices are incompletely
 When more complex facial injuries have occurred or jaw
formed.
fractures are suspected, extraoral films may also be neces-
 The thermal test is also somewhat helpful in determining
sary to identify the extent and location of all injury seque-
the degree of pulpal damage after trauma. It is probably
lae. Oblique lateral jaw radiographs and panoramic films
more reliable in testing primary incisors in young chil-
are often useful adjuncts to this diagnostic process.
dren than the electric pulp test.

SHORT ESSAYS

Q.1. Intraoral radiographic techniques. A. Paralleling Technique


Ans.  Dr Gordan is the pioneer of paralleling technique.
The various intraoral projection techniques are as follows:  It is also called as right angle technique/long cone tech-
a. Paralleling technique nique/Fitzgerald technique.
b. Bisecting angle technique  Paralleling principle of intraoral X-ray is technique of
c. Specialized intraoral radiographic technique and choice because it is more accurate and produces less dis-
d. Supplementary intraoral radiographic techniques. tortion than bisecting angle technique.
 The paralleling technique and bisecting angle technique  The primary purpose of this is to obtain a true radi-
are two intraoral projection techniques that are used for ographic orientation of teeth and supporting struc-
periapical radiography. tures.
Quick Review Series for BDS 4th Year: Paedodontics
14

 It is based on the principle that central ray should be  Angulations of tube head are different for different teeth.
focused perpendicular to the long axis of the film, with
the X-ray film being parallel to long axis of the tooth. Maxillary
 To obtain parallelism and to reduce distortion, the film
is placed away from tooth; but the use of long source to Incisor: +40°, Premolar: +30°, Canine: +45°, Molar: +20°
object distance reduces the size of the apparent focal spot Deciduous: Anterior: +45°, Posterior: +30°.
and leads to less magnification and increased definition.
 Film holders are used to ensure proper position of the Mandibular
film and to maintain it in position. Incisor: -15°, Premolar: -10°, Canine: -20°, Molar: -5°
 To assure that the periapical areas will be projected onto Deciduous: Anterior: -15°, Posterior: -10°.
the film, it is necessary that the film be positioned away
from the teeth and towards the centre of the mouth, where Advantages
the maximum height of the palate can be utilized.
 For maxillary projections, the superior border of the film i. Positioning of film or film packet is simple, quick
will generally rest at the height of the palatal vault in the and reasonably comfortable for patient in all areas of
midline. mouth.
 For mandibular projections, the inferior border of the ii. If proper angulation is given there would not be any dis-
film is depressed into the floor of the mouth away from tortion of image.
the mucosa on the lingual surface of the mandible.
 In case of children as there is high muscle activity in the Disadvantages
mandible and shallow palate, the film cannot be placed
i. Improper vertical angulations may lead to shortening or
parallel to the long axis of the teeth; but it has been proved
lengthening of image.
that even if the film is placed within 20° parallel to the
ii. Interdental boneless area will be poorly demonstrated.
long axis, with the beam directed to the film, the radio-
graph produced by paralleling technique will be far supe- iii. Shadow of zygomatic bone frequently overlies the roots
rior than bisecting angle technique. of upper molars.
iv. Incorrect horizontal angulation will result in horizontal
Advantages overlapping of crowns and roots.
v. Crowns of teeth are often distorted, thus preventing de-
i. Images obtained are accurate with minimum magnifica- tection of proximal caries.
tion.
ii. Interdental bone levels are very well-represented.
C. Specialized Intraoral Radiographic Technique
iii. Periapical tissue will be accurately demonstrated with
minimal foreshortening or elongation.  Bent film radiographic technique is used exclusively for
children who do not tolerate the placing of a film holder
Disadvantages inside their mouths.
 Size 1 or 2 should be used.
i. Positioning of the film packet is very uncomfortable for
 This technique can be used both with paralleling cone or
patient especially in the posterior aspect of teeth, often
causing gagging. bisecting angle technique.
ii. Anatomy of mouth sometimes makes the technique dif-  This technique works well with young children, requires
ficult. little skill as patient bites down.
iii. Positioning the holders in the lower 3rd molar region  Top portion of the film is bent at right angle and this
can be very difficult. serves as a bite block to hold the film in place. Patient is
instructed to bite the film slowly and radiograph is taken.
Bisecting Angle Technique Care must be taken to straighten the film before process-
ing.
 It is also called as Miller’s right angle technique/short cone
technique/isometric triangulation technique.
D. Supplementary Intraoral Radiographic
 This technique is based on the principal of Cieszynski rule
Techniques
of isometry.
 In this technique the film is placed close to the teeth and
i. Bitewing Radiography
central ray is directed at right angles to the line bisecting
the angle formed by the plane of the film and the long axis  Periapical films are used to record the coronal portions of
of the tooth. both maxillary and mandibular teeth in one image.
Topic wise Solved Questions of Previous Years
15

 Size 1 film is used in children and size 2 films are used in II. Periapical Technique
adults.
 There are essentially two methods of taking periapical
 Used mostly to detect interproximal caries and to check radiographs: paralleling and bisecting angle techniques.
the level of bone.  Each has benefits and limitations when used with the pae-
diatric patient.
ii. Occlusal Radiography  Regardless of which technique is used, film positioning
 Used to take the jaw radiographs of maxilla and mandible for the two techniques is identical. In all cases the identifi-
to detect large lesions, fractures, impactions, supernumer- cation dot is placed towards the occlusal surface.
ary teeth and to localize foreign bodies.
 The film is partially held in-between teeth and partially III. Occlusal Radiography
supported by patient.  Occlusal radiographs are used to take the entire jaw radi-
 The vertical angulation for maxilla is +45° and for man- ographs of maxilla and mandible to detect large bony
dible is −55°. lesions, fractures, impactions, supernumerary teeth and
to localize foreign bodies.
Q.2. Describe briefly about radiographic techniques  The patient’s occlusal plane should be parallel to the floor,
for paedodontic patient. and the sagittal plane should be perpendicular to the
Ans. floor.
 A No. 2 periapical film is placed in the patient’s mouth so
Commonly used radiographic techniques in paedodontic that the long axis of the film is parallel to the floor par-
patients depend primarily on the size of the oral cavity, the tially held in-between teeth and partially supported by
number of teeth present, and patient cooperation. patient.
The procedures commonly used by paedodontic practitioner in-  The vertical angulation for maxilla is +45° and for man-
clude the following: dible is −55°.
i. Bitewing
ii. Periapical IV. Panoramic Radiography
iii. Occlusal  Frequently employed extraoral radiographs include pan-
iv. Panoramic. oramic and cephalometric radiographs.
 Panoramic radiographs aid in visualizing the various
I. Bitewing Technique structures in the child’s developing dentition.
 They are excellent for determining the position of the
 A No. 0 bitewing film is usually the most suitable size unerupted permanent teeth and their likely path of erup-
for the smaller patient, while some children’s mouths are tion. Various pathologic conditions like cysts, tumours,
large enough to receive a No. 2 bitewing film. etc. can also be detected on these films.
 The head is positioned so that the midsagittal plane is per-  Numerous panoramic X-ray units are available to the
pendicular and the ala–tragus line is parallel to the floor. dental profession. The use of a machine with a digital
 The inferior edge of the bitewing film packet is placed in receptor allows a very low dose and means that the opera-
the floor of the mouth between the tongue and the lingual tor, in many cases, may not even need to place an image
aspect of the mandible and the bite-tab or positioning receptor in the mouth. This would be of a great advan-
device is placed on the occlusal surfaces of the mandibu- tage in some cases where the child is not tolerant of an
lar teeth. intraoral image acquisition.
 The anterior edge of the film packet is located as far ante-  It provides an excellent coverage of the structures that are
riorly as possible in the region of the canine so that the viewed during paediatric dental diagnosis. A typical diag-
distal aspect of the canine will be recorded. nostic film or digital panoramic image includes the teeth,
 The dentist holds the bite-tab against the occlusal surfaces the supporting structures, the maxillary region extending
of the patient’s mandibular teeth with an index finger, to the superior third of the orbit, and the entire mandible
and the patient is instructed to ‘close slowly’. The finger is including the temporomandibular joint region.
rolled out of the way onto the buccal surfaces of the teeth  Panoramic radiology can be valuable when disabled
as the patient closes in centric occlusion. patients are examined whether the patient can sit in a
 The central ray enters through the occlusal plane at a chair and hold head in position.
point below the pupil of the eye. The vertical angle is +8  The only inherent drawback to panoramic radiography is
to +10°. lack of image detail for diagnosing early carious lesions.
Quick Review Series for BDS 4th Year: Paedodontics
16

v. Lateral Jaw Technique  The tooth’s mobility should be determined, which, if


present, should warn one about a possibly necrotic pulp.
 A 5 × 7 inch X-ray film is used for the lateral jaw tech-
 Percussion of the tooth should follow, for if any sensitiv-
nique. The film is marked with a right or left lead identi-
ity is registered by the patient, the probable periapical
fication letter placed on the film packet slightly anterior
involvement should make one dubious of pulpal therapy
and superior to the central portion of the film.
success.
 The patient’s head is positioned so that the occlusal plane is
 A vitality test may be made, but the results obtained from
parallel and the sagittal plane is perpendicular to the floor.
primary teeth by this technique have been mostly unreli-
 The long axis of the film, also is perpendicular to the floor,
able.
rests on the patient’s shoulder and against the face. The
patient is instructed to rotate the head towards the film
Radiographic Examination
until the nose rests against it. Then the chin is raised and
the head tilted approximately 15° towards the film.  To complete the diagnosis good radiographs are required
 The patient secures the film with the palm of the hand and subsequent to the choice of treatment and prognosis.
with fingers extended. The cone is positioned so that the  Both periapical and bitewing films are necessary. They
central X-ray beam enters at a point a half-inch behind make it possible to acquire some idea as to the pulp’s con-
and below the angle of the mandible on the side opposite dition.
the film. The vertical angle is 17°.  The radiograph might indicate periapical or bifurcation
 The central X-ray beam is perpendicular to the horizontal involvement that suggests a degenerated pulp.
plane of the film.  The presence of calcified bodies or pulp stones has been
 With advent of specialized panoramic views this tech- reported to be evidence of pulpal degeneration. Such an
nique is slowly becoming obsolete. obvious finding as prematurely resorbed roots would be
detrimental to pulp therapy.
Q. 3. What are the various diagnostic aids in the selec-  In summary, wherever possible, it is desirable to evaluate
tion of tooth for vital pulp therapy? as many diagnostic criteria as possible before proceeding
with pulp therapy and particularly prior to any anaesthe-
Ans.
sia.
 Prior to the selection of primary tooth for initiation of  If the decision to perform pulp therapy has to be made
pulp therapy, a thorough clinical and radiographic exami- after the tooth has been entered, radiographs and obvious
nation must be made. clinical symptoms should be relied upon.

Clinical Examination Q. 4. Radiographic survey in paediatric dentistry.


The clinical examination would normally include: Ans.
 A case history, using the classic format with appropriate  Whenever a new patient is examined at the dental office
alterations as required. and no previous radiographs are available, it may be nec-
 History of present illness (PI), with leading questions like essary to obtain a baseline series of radiographs.
‘Does the tooth hurt now?’, ‘Has it ever hurt you?’, ‘Does it  These series of radiographic examinations include the fol-
hurt when you drink cold water?’, ‘Does it hurt when you lowing.
chew?’ may well-determine whether one is dealing with a
pulpitis or an apical periodontitis. i. Four-film series
 Personal past history (PPH), with questions like ‘Is your  This series consists of a maxillary and mandibular ante-
child in good physical health at this time?’, ‘Has he ever rior occlusal and two posterior bitewing radiographs.
had any serious illnesses—diabetes, rheumatic fever, or ii. Eight-film survey
the like?’, ‘Is he allergic to any drugs?’ will give indications  This survey includes a maxillary and mandibular ante-
as to the condition of his general health and any limita-
rior occlusal (or periapicals), a right and left maxillary
tions on treatment.
posterior occlusal (or periapicals), right and left primary
 Examination of the specific area is best started with an
mandibular molar periapicals, and two posterior bitew-
examination of the soft tissue. Any signs such as discol- ings.
ouration, a draining or quiescent fistula, or inflammation
should cause serious doubts about proceeding with pulp iii. Twelve-film survey
therapy short of endodontics.  This includes four primary molar–premolar periapical
 Then the tooth itself should be examined for clini- radiographs, four canine periapical radiographs, two inci-
cal destruction of the crown and possible presence of a sor periapical radiographs, and two posterior bitewing
hypertrophied pulp. radiographs.
Topic wise Solved Questions of Previous Years
17

 Several techniques commonly used to radiograph a child’s losis, streptococci, staphylococci, and other non-vaccine-
dentition are bitewing, periapical, occlusal and panoramic preventable infections.
views.  As it is impossible to identify all of those patients who
 The technique used depends primarily on the size of the may harbour dangerous microorganisms, it is necessary
oral cavity, the number of teeth present, and choice of to use standard precautions and practice infection control
patient practitioner. procedures routinely to avoid spread of disease.
 The following infection control procedures as described
Q. 5. Sterilization and disinfection techniques used in by Miller and Paienikle are based on those recommended
dental offices. for dentistry by the Centers for Disease Control and Pre-
vention (CDC) in the Public Health Service of the US
Ans.
Department of Health and Human Services:
 Most commonly used methods of sterilization in dentistry i. Always obtain an updated thorough medical history,
are as follows: which includes enquiry about medications, current ill-
i. Steam autoclave nesses, hepatitis, unintentional weight loss, lymphad-
ii. By dry heat in a hot air oven enopathy, oral soft-tissue lesions, or any other infec-
iii. By unsaturated chemical vapour sterilizer (chemi- tions.
clave). ii. Clean all reusable instruments in an ultrasonic cleaner
 Other methods or washer/disinfector, and minimize the amount of
i. Low-temperature steam and formaldehyde (LTSF) hand scrubbing performed.
ii. Use of ethylene oxide iii. Wearing of personal protective equipment like heavy
iii. Irradiation. rubber gloves, mask, and protective clothing and eye-
 Cleaning and disinfection of dental unit and environmental wear to protect against puncture injuries and splashing
surfaces: is required when treating patients.
i. After treatment of each patient and at the completion iv. Sterilize all reusable instruments that penetrate or
of daily work activities, dental unit surfaces should be come into contact with oral tissues or that become
cleaned with disposable towels, using an appropriate contaminated with saliva or blood.
cleaning agent and water as necessary. v. Metal or heat-stable instruments should be sterilized in
ii. Surfaces then should be disinfected with suitable chem- a steam autoclave, a dry heat oven, or an unsaturated
ical germicides such as phenols, iodophors, quaternary chemical vapour sterilizer.
ammonium compounds, household bleach and chlo-
vi. Heat-sensitive items may require up to 10 hours expo-
rine-contained compounds, etc.
sure time for sterilization in a liquid chemical agent/
iii. Laboratory materials and other items that have been
sterilant, followed by rinsing with sterile water.
used in the mouth, e.g. impressions, appliances, pros-
vii. Biological monitoring must occur weekly.
thesis, etc. should be cleaned and disinfected before be-
ing manipulated in the laboratory. viii. Dental instruments must be wrapped before steriliza-
iv. These items also should be cleaned and disinfected tion. Unwrapped instruments have no shelf life.
after being manipulated in the dental laboratory and ix. Barrier protection of surfaces and equipment can pre-
before placement in the patient’s mouth. vent contamination of clinical contact surfaces, but is
v. Single-use disposable instruments (prophylaxis tips, particularly effective for those that are difficult to clean.
saliva ejectors) should be used for one patient only and Barriers include clear plastic wrap, bags, sheets, tubing,
discarded appropriately. and plastic-backed paper or other materials impervi-
 Treatment and disposal technique for healthcare waste ous to moisture
are incineration, safe burying, encapsulation, chemical x. Hand hygiene, e.g. handwashing, hand antisepsis sub-
disinfection, microwave irradiation and wet thermal stantially reduces potential pathogens on the hands.
treatment. Evidence indicates that proper hand hygiene is the sin-
gle most critical measure for reducing the risk of trans-
Q. 6. Infection control. mitting organisms.
xi. For routine dental examinations and non-surgical pro-
Ans. cedures, handwashing and hand antisepsis is achieved
 The dental team is exposed to a wide variety of microor- by using either a plain or antimicrobial soap and wa-
ganisms in the saliva and blood of their patients, which ter. If the hands are not visibly soiled, an alcohol-based
may include hepatitis B and C, herpes viruses, cytome- hand rub is adequate.
galovirus, measles virus, mumps virus, chickenpox virus, xii. Biofilms form quickly and serve as continuous sourc-
human immunodeficiency virus, Mycobacterium tubercu- es of contamination for dental unit water lines water.
Quick Review Series for BDS 4th Year: Paedodontics
18

Flushing of lines temporarily reduces microbial emis- xiv. Routine use of additional chemicals helps retard bio-
sions, but does not remove biofilm. film development.
xiii. Use of sterile water does not reduce the level of micro- As exposure to microorganisms can cause infections, it is
organisms released. The only remedy is to remove ef- the responsibility of dental healthcare practitioners to use
fectively the biofilms through the application of certain water that has the lowest level of microbial contamination.
chemicals.

SHORT NOTES

Q. 1. Bitewing radiographs in children.  Ultraviolet rays


 Infrared rays
Ans.
 Bitewing films are used to record the crowns of maxillary c. Sonic and ultrasonic vibrations
and mandibular teeth in one film.
 These are one of the best amongst the currently available B. Chemical
methods to detect or rule out early interproximal carious
 Ethylene oxide gas
lesions.
 Glutaraldehyde.
Sizes
i. Size 0: For children – posterior (22 × 35 mm) Q. 3. Intraoral periapical radiography in children.
ii. Size 1: For children – anterior (24 × 40 mm)
Ans.
Uses
 Intraoral periapical radiographs are indicated to visualize
i. They are particularly valuable for detecting interproxi-
mal caries in the early stages of development before it the roots, furcation and periapical areas of erupted teeth
becomes clinically apparent. and to assess the developmental status of unerupted per-
ii. Visualize the alveolar crest and assessment of periodon- manent teeth.
 Intraoral films are available in different sizes, i.e. #0, #1,
tal disease in easier way.
iii. They are especially effective and useful for detecting cal- #2. The 0 size ( 22 × 35 mm), which is most comfortable
culus deposits in inter-proximal areas because of projec- to the child patient, should be used.
 Once the film is positioned the X-ray beam should be
tion directly through the inter-proximal spaces.
iv. Useful in periodic checkup of the teeth for detection of directed perpendicular to the film in the vertical plane.
 There are essentially two methods of taking periapical
new caries and of early periodontal change.
radiographs: paralleling and bisecting angle techniques.
 Each has benefits and limitations when used with the pae-
Q. 2. Sterilization methods in the dental clinic.
diatric patient.
Ans.  Regardless of which technique is used, film positioning
 Sterilization is the process by which an article, surface or for the two techniques is identical. In all cases, the identi-
medium is freed of all living microorganisms either in the fication dot is placed toward the occlusal surface.
vegetative or spore state. Q. 4. Orthopantomograph.
Methods of Sterilization Ans.
 It can be achieved by both physical and/or chemical meth-  Orthopantomograph is also called as maxillo-mandibular
ods. radiograph or pantomograph or rotational tomograph.
Indications
A. Physical i. Evaluation of tooth development during (mixed denti-
tion) developmental anomalies, etc.
a. Heat
ii. It is indicated to detect fracture cases, various pathologic
 Dry heat: Hot air oven, glass bead sterilizer conditions like cysts, tumours, etc.
 Moist heat: Autoclaving Advantages
 Panoramic radiographs aid in visualizing broad anatomic
b. Radiation
region exhibiting various structures in the child’s devel-
 Gamma rays oping dentition.
Topic wise Solved Questions of Previous Years
19

 They are excellent for determining the position of the Q. 7. SLOB rule.
unerupted permanent teeth and their likely path of erup-
Ans.
tion.
 Relatively low radiation dose, convenience, speed and  SLOB rule or the buccal object rule is one method of
ease. localizing embedded or unerupted teeth.
 Useful in patients who are unable to open mouth.  SLOB (Same side Lingual – Opposite Buccal) rule states
Disadvantages that the image of any buccally oriented object appears
to move in the opposite direction from a moving X-ray
 Lack of image detail for diagnosis of early carious lesion.
source. On the other hand, the image of any lingually ori-
 Cost of X-ray machine.
ented object appears to move in the same direction as a
moving X-ray source.
Q. 5. Clark’s rule.
Ans. Q. 8. Skeletal age versus dental age.
 Clark’s technique is used to localize the buccolingual posi- Ans.
tion of supernumerary/impacted/unerupted teeth or for-
eign body; there are three techniques. Skeletal age Dental age
 This is also called as SLOB rule (Same side Lingual – It is based on the ossification of It is based on the formation of or
Opposite Buccal), tube shift localization technique or endochondral bone eruption of the teeth
buccal object rule. It can be assessed based on It is assessed on the basis of
 It is based on the principle of parallax which states that the skeletal maturity indicators/ the number of teeth at each
hand–wrist radiographs chronological age or on stages
when an object is viewed from two different positions, the
of formation of crowns and roots
object appears to move in two different directions. of the teeth
 The basic principle is that the relative position of the radi-
The physical maturity of an The physical maturity of an indi-
ographic images of two separate objects changes when individual can be assessed by vidual is not related to dental age
the projection angle at which the projection was made is skeletal age
changed. Assessing the skeletal maturity Dental age can reflect an as-
 Buccal object rule states that the image of a buccally ori- is helpful in treatment planning sessment of physiologic age
ented object appears to move in the opposite direction and response to treatment comparable to age based on the
from a moving X-ray source, and the image of any lin- skeletal development, weight or
gually oriented object appears to move in the same direc- height
tion as a moving X-ray source. There is correlation between the When the last tooth has been
dental age and skeletal age completed, the skeleton is ap-
Q. 6. Digital subtraction radiograph. proaching complete maturation

Ans.
Q. 9. Digital radiograph.
 Digital subtraction radiography is a technique that
Ans.
allows determination of quantitative changes in radio-
graphs.  Digital radiography is a promising technology, which has
 A series of radiographic images are taken before and after revolutionized dental imaging. It has provided new diag-
treatment. The two images are digitalized and compared. nostic procedures that are not available with traditional
The resultant image shows only the changes that have film-based imaging.
occurred and ‘subtracts’ those components of the image  Digital radiography is of two types:
that have not changed. i. Direct digital radiography, e.g. radiovisiography (RVG)
Advantage ii. Indirect digital radiography, e.g. subtraction radiogra-
phy.
 The magnitude of changes that have occurred due to ther-
 In radiography the electronic sensors have gradually
apeutic intervention can be measured.
replaced the radiographic film.
Disadvantage  Charged coupled devices (CCD), complementary metal
 It is difficult to replicate the exact projection geometry oxide semiconductors (CMOS) and photostimulable
and receptor placement, thus the changes in the sub- phosphor plates (PSP) are used for capturing the image
tracted image may demonstrate false changes. in digital radiography.
Quick Review Series for BDS 4th Year: Paedodontics
20

Q.10. Miller’s technique. i. Clark’s technique


ii. Miller’s technique, and
Ans.
iii. Cross-sectional occlusal radiograph.
To localize the buccolingual position of supernumerary/im-  Miller’s technique is also called as right angle technique.
pacted/unerupted teeth or foreign body, there are three tech-  It is used to achieve the same goal as Clark’s technique but
niques: only in case of mandible.

Topic 3 THEORIES OF CHILD DEVELOPMENT


LONG ESSAYS

Q.1. Explain the psychological development of a child  It is present at birth, is impulse ridden and strives for
according to Sigmund Freud. immediate pleasure and gratification without regard to
rules, realities of life or morals of any kind.
Or
Describe the psychological development of child from Ego
birth through adolescent as per Sigmund Freud.  Ego is governed by ‘the reality principle’.
Or  Ego tries to satisfy the Id’s urge of pleasure but only in the
realistic ways that take account on what is possible in the
Describe in detail about psychosexual theory. real world.
Ans.  It is the mediator between id and super ego. It channelizes
id into a socially acceptable way.
 Psychology is the science dealing with human nature,
function and phenomenon of his soul in the main.
Super Ego
 Child psychology is the science that deals with the mental
power or an interaction between the conscious and sub-  It is governed by ‘the moral principle’.
conscious element in a child.  It develops around 5 years. It establishes and maintains
 Sigmund Freud gave two theories: the person’s moral conscious on the basis of a complex of
A. Psychoanalytical theory and ideas and values internalized by parents.
B. Psychosexual theory.  It stems from internalization of feeling good and bad, love
and hate, praising and forbidding, rewards and punish-
A. Psychoanalytical Theory ment.
 This theory helps in understanding intrapsychic process  It is linked to a social consciousness derived in part from
and personality development. the familial cultural restrictions placed on the growing
 This theory was proposed by Sigmund Freud (1905). He child.
compared human mind to an iceberg.
B. Psychosexual Theory
Elements of Psychic Triad  Freud believed that an individual progresses through sev-
i. According to Freud, personality is composed of three eral developmental stages that affect personality.
parts and is known as psychic triad—id, ego and super-  According to Freud development stages are classified
ego. into:
ii. Each system has its own functions, but the three intact a. Oral stage (0–1 year)
are required to govern the behaviour. b. Anal stage (1–3 years)
c. Phallic/Oedipal stage (3–7 years)
Id
d. Latency period (7–12 years)
 It is governed by ‘the pleasure principle’. e. Genital stage (12–18 years)
Topic wise Solved Questions of Previous Years
21

a. Oral stage ii. During this stage the child explores and experiences his
genital organs as pleasurable.
i. The first year of a child’s life is called as oral stage and is
earliest stage of development characterized by passive- Phallic stage is characterized by:
ness and dependency.  Oedipus complex
ii. The oral cavity is the primary zone of pleasure because  Electra complex.
hunger is satisfied by oral stimulation.
iii. In infants oral cavity is the site for the identifying needs. Oedipus complex
Children will put their thumb or anything else they can  The child begins to direct their awakened sexual impulses
reach into their mouths. towards the parent of the opposite sex.
iv. This is a dependent stage, since the infant is dependent  Attachment between young boys and mother, and they
on parents for their oral needs. consider father as their enemy.
v. If the child does not receive the sufficient gratification of  The name oedipal complex (comes from Greek mythol-
pleasure at this age, fixation to this stage occurs, as the ogy). Oedipus the King of Thebes, unwillingly slew this
individual grows older. Example: oral dependency in the father and married his mother.
form of digit sucking in older individuals.
 The little boys strive to imitate their father to gain affec-
vi. If the child’s needs are not adequately met in this age,
tion of mother. Freud also described oedipal complex as a
the following traits may develop: pessimism, demand-
desire to have a sexual relation with the mother.
ism, frustration and jealousy.
vii. Excessive oral gratification leads to excessive optimism Electra complex
or narcissism.  Young girls develop an attraction towards their father and
resent the mother being close to the father.
b. Anal stage  The child realizes the sexual qualities without embarrass-
i. This stage is also known as ‘terrible tows’ that occurs ment. In a phobic child these unconscious, unacceptable
between the 1 and 3 years is marked by the egocentric wishes and feeling associated with Oedipal situation do
behaviour. not enter consciousness.
ii. During this stage, the anal zone becomes the principle  If the characteristic features of this stage are not resolved,
zone of pleasure. Gratification is derived from expelling the balance between male and female roles does not
or with hoarding faeces. develop.
iii. During this stage, neuromuscular control occurs. Con- Clinical significance
trol over the sphincter results in increased voluntary ac-
 Keep the opposite sex during the child management in the
tivity.
iv. This stage is characterized by development of personal dental office/clinic.
autonomy and independence.  Keep mother in case of boy or father in case of baby girl

Child realizes the increased voluntary control that pro- during the child management.
vides him with the sense of independence and autonomy.
v. Child realizes his control over his needs and practices d. Latency stage
with a sense of shame. i. This stage begins with resolution of Oedipus complex
vi. Over-emphasis by adults on toilet training will result in around the age of 5–6 years, ends with the onset of pu-
compulsive, obstinate and the perfectionist behaviour in berty 6–12 years and is a period of consolidation of sex
later life called as ‘anal personality’. roles.
vii. Anal personality is characterized by abnormal behaviour, ii. Maturation of ego takes place and the super ego becomes
like disorderliness, abstinence, stubbornness, willfulness firmly internalized. This stage is quiet as compared to
and frugality. the stages before and after.
viii. Less controlled toilet training results in an impulsive iii. There develops a greater degree of control over instinc-
personality in later life. The transition between the anal tual impulses.
and phallic stage is known as ‘urethral stage’. It is also iv. Child gains better sense of initiative and starts adapting
characterized by competitiveness. Child derives pleasure to the adverse environment.
from exercising control over the urinary sphincter.
v. The goal of this phase is the further development of per-
sonality.
c. Phallic stage
vi. Lack of inner control or excessive inner control results
i. The sex identification, which occurs between 3 and 6 in an immature behaviour and decreased development
years of age, is an important feature of this stage. of skill.
Quick Review Series for BDS 4th Year: Paedodontics
22

e. Genital stage Cognitive Theory


i. It begins with puberty, extends to young adulthood and  The term ‘cognitive’ refers to element of perception,
is characterized by reopening of ego struggle to gain awareness and the ability to comprehend empirical
mastery and control over the impulses of id and super knowledge.
ego.  The cognitive theory was proposed by Jean Piaget (world’s
ii. Child has a material personality. Sense of identity devel- leading theorist in the field of cognitive development of
ops and helps to separate from the dependence of par- children) in 1952.
ents.  He emphasized that childhood development proceeds
iii. He can satisfy genital potency and realizes his goals for from an egocentric position through a predictable step
reproduction and survival. like consistent expansion by incorporation of learned
iv. Fluctuating extremities in emotional behaviour and experiences.
preoccupation with philosophical and abstract thoughts
predominate due to struggle to attain a firm sense of
Concepts of Cognitive theory
self.
v. The individual becomes more matured, and will be able i. Schemata
to make right decision and prepared to face the world. ii. Assimilation and adaptation
iii. Accommodation
Q.2. Classify theories of child psychology. Describe in iv. Equilibrium.
detail about the cognitive development theory.
 Piaget names the major mechanisms that allow children

Or to progress from one stage of cognitive functioning to the


next stage as assimilation, accommodation and equilibra-
Enumerate the different theories of child psychology. tion.
Explain the different stages of Jean Piaget’s cognitive
theory in detail. Schemata
Or  A schemata describes both the mental and physical actions
Classify theories of child psychology. Write in detail involved in knowing and understanding.
about cognitive theory.
Assimilation
Ans.
 Assimilation describes the ability of the child to deal
 Psychology is the science dealing with human nature, with new situations and problems within his age-specific
function and phenomenon of his soul in the main. skills.
 Child psychology is the science that deals with the mental
 The process of taking in new information into the previ-
power or an interaction between the conscious and sub
ously existing schemas is known as assimilation.
conscious element of the child.
Accommodation
Theories of Child Psychology
 Accommodation is an individual’s tendency to modify
 Many theories have been proposed to explain and identify
action to fit into a new situation.
the processes involved in personality development. These
 It is a process that enables him to adapt and change his
theories can be divided into two groups: psychodynamic
way of dealing with the world to handle a problem.
theories and behaviour learning theories.
I. Psychodynamic theories: Equilibrium
i. Psychosexual theory—Freud  Equilibration refers to changing basic assumptions fol-
ii. Psychosocial theory—Erik H Erikson lowing adjustments in assimilated knowledge so that the
iii. Cognitive theory—Jean Piaget. facts fit better.
II. Behaviour learning theories:  As a result of new knowledge, the child is temporarily in a
i. Classical conditioning theory—Ivan Pavlov state of equilibrium or cognitive harmony.
ii. Hierarchy of needs—Abraham Maslow
Merits of Cognitive Theory
iii. Social learning theory—Albert Bandura
 It is the most comprehensive theory of development.
iv. Operant conditioning theory—BF Skinner.
Topic wise Solved Questions of Previous Years
23

 It illustrates that we can learn as much about children’s  Children acquire memory or object permanence at
intellectual development from examining their incor- about 7 months of age. Physical development leading
rect answers to the items as from examining their correct to mobility helps the child to develop new intellectual
answers. abilities.
 The actions of infants are increasingly goal-directed.
Demerits of Cognitive Theory Piaget describes this behaviour as genuinely adaptive and
intelligent at a behavioural level but not totally concrete
 Vagueness about the process of change.
and not accompanied by cognitive awareness of the cau-
 Overestimates age differences in thinking.
sality or outcome of action.
 Underestimates children’s abilities and role of social envi-
 By the end of the 1st year, children will learn to coordinate
ronment.
their sensorimotor skills better to attain an external goal.
Stages of Development According to Cognitive Example: Child will pack up a cover in order to retrieve a
Theory try he saw his father place there earlier.
 Towards the end of the sensorimotor period children
According to Piaget, there are four distinctive periods of cog- learn to invent new schemes through a kind of mental
nitive development under two broad categories: exploration in which they imagine certain event and
A. Sensorimotor period (birth to 2 years) outcomes.
 By the end of sensorimotor stage the child will have
B. Period of conceptual intelligence (2 years and above)
transformed himself or herself from an organism totally
i. Preoperational period (2–7 years) dependent on reflex and other hereditary equipment to a
a. Preconceptual stage (2–4 years) person capable of symbolic thought.
b. Intuitive stage (4–7 years).
Dental applications
ii. Period of concrete operations (7–11 years)
iii. Period of formal operations (11 years and above).  Child begins to interact with the environment and can be

 Each stage is characterized by distinct types of thinking


given toys while sitting on the dental chair.
in which the child successfully relies more upon inter- ii. Preoperational stage
nal stimuli and symbolic thought and less upon external
stimulation.  Preoperational stage is divided into—preconceptual
period (18 months–4 years) and intuitive period (4–7
years).
i. Sensorimotor period
 The essential characteristic of this stage is the manipula-
 It lasts from birth to 2 years of age. Object permanence, tion of symbols or words. This manifests in delayed imita-
primitive beginning of symbolic thought and animism tion and children’s imaginative or pretend play.
are the hallmarks of this stage. Egocentrism
 It is the stage of practical intelligence. During this period
 Egocentrism refers to child’s tendency to conceptualize no
infants are busy discovering relationships between the
point of view other than his own.
body and environment (seeing, touching, sucking, etc).
 The child is incapable of assuming or thinking the role of
 It can be further divided as follows. another person.
 During this stage the child has difficulty in understanding
Substage Period of time Sensorimotor development life from any other perspective other than his own.
i Birth–1 month • Use of reflexes  His thinking is so egocentric that when he covers his eyes
ii 1–4 months • Primary circular reactions he thinks that since he cannot see you, you cannot see
iii 4–8 months • Secondary circular reactions him.
iv 8–12 months • Coordination of secondary sche- Concentrate
mata and their application to new  At the school-age level a child concentrates only one
situations
aspect of a situation and neglects the importance of other
v 12–18 months • Tertiary circular reactions aspects.
v 18–24 months • Invention of means through  During this stage the child’s thinking is self-centred. The
mental combinations child is very ‘me, myself and I’ oriented.
 Sensorimotor stage starts with automatic inform reflexes, Animism
which include the ability of child to suck, cry, move his It means imparting life to inanimate objects. His view of
arms and legs, track a moving object and orient to a world is animistic or artificialistic and he cannot distinguish
sound. Then coordination of these reflexes improves. what is real from what is not real.
Quick Review Series for BDS 4th Year: Paedodontics
24

Example: If the child hurts himself by bumping against the  Thinking becomes quite adult-like, most adult capabili-
door, he may hit the door as he feels that it gets hurt or will ties are thought to be in place by the age of 16 years, hence
be happy if the parents slam at the door. the child should be treated as an adult at this stage.
Dental applications  Adolescents feel that they are constantly ‘on stage’ being
 Constructivism: The child likes to explore things and make observed and criticized by others; this phenomenon is
own observations. Example, child surveys the dental chair, called ‘imaginary audience’.
airway syringe.  The second phenomenon is called ‘personal fable’ in which
 Cognitive equilibrium: Child is explained about the equip- they think they are unique. It is a powerful motivator that
ment or instrument and allowed to deal with it. Example, allows them to cope in a dangerous world.
airway syringe. Dental applications
 Animism: Child correlates things with other objects to  Peer influence and abstract thinking increases. This can
which they are more used to or accustomed. Example, play an important role in orthodontic appliances and
explaining about radiograph as tooth picture. braces.
 Acceptance from peers can be used for motivation for
iii. Concrete operational stage dental treatment.
 During this stage child is about 7–11 years of age and his
thinking is still strongly tied to concrete situation and has Q.3. Classify theories of child psychology. Describe in
limited abstract reasoning. Animism declines. detail about classical conditioning theory.
 During this stage child begins to reason logically and Ans.
organizes thoughts coherently.
 They are able to decanter, i.e. they focus their attention Many theories have been proposed to explain and identify
on several attributes of an object or even understand the the processes involved in personality development. These
relations between dimensions. Example: Same quantity of theories can be divided into two groups: psychodynamic
milk in tall and thin glass, short and broad glass. theories and behaviour learning theories.
 During this stage child has the ability to arrange objects I. Psychodynamic theories:
according to some quantified dimensions such as weight/ i. Psychosexual theory—Freud
size/shape/colour, etc. This is called as serration. Example: ii. Psychosocial theory—Erik H Erikson
arrangement of different sizes of colour blocks according iii. Cognitive theory—Jean Piaget.
to size. II. Behaviour learning theories:
 Child acquires the concepts of time, space, numbers and i. Classical conditioning theory—Ivan Pavlov
logic. He integrates his own experiences with other expe- ii. Hierarchy of needs—Abraham Maslow
riences he has read or observed in others. iii. Social learning theory—Albert Bandura
 The main limitation of this stage is their inability to iv. Operant conditioning theory—BF Skinner.
reason about abstraction, hypothetical propositions or
imaginary events. Classical Conditioning Theory
Dental applications  It is also known as stimulus response theory or Pavlov
 Concrete instructions like this is a retainer; brush, etc. can conditioning theory.
be given to the child.  Classical conditioning is a type of learning in which
 Abstract instructions like wear the retainer every night stimulus acquires the capacity to evoke response that was
and keep clean can be given to the child. originally evoked by another stimulus.
 Child can be allowed to hold the mirror to see what is
being done on his teeth. Pavlov Experiment
 Classic conditioning theory is the result of the classic
iv. Formal operational stage
experiments of Ivan Petrovich Pavlov.
 It begins approximately around the age of 11 years and is  Presentation of food to a hungry dog along with some
continuous through adulthood. The individual is highly other stimulus like ringing bell is done repeatedly. The
versatile and flexible in thought and reasoning. stimulus evoked by sound of ringing bell becomes associ-
 Child acquires ability to deal with abstract concepts and ated with food presentation stimulus.
abstract reasoning. This stage is characterized by the abil-  He trained the dog by sounding the bell and shortly after-
ity to formulate hypothesis and systematically test them to ward presented the food. After few sessions the dog would
arrive at an answer to a problem. This type of thinking is salivate at the sound of the bell. This is the conditioned
important in long-term planning. response what the dog has learned.
Topic wise Solved Questions of Previous Years
25

 The unconditioned stimulus is a stimulus that evokes an experiences, the child learns to discriminate between the two
unconditioned response without previous conditioning. clinics.
Unconditioned response is an unlearned reaction to an
unconditioned stimulus that occurs without previous con- iv. Extinction
ditioning.  The conditioned response gradually disappears when the
 The conditioned stimulus is previously neutral stimu- unconditioned stimulus is removed.
lus that has thorough conditioning, acquired capacity to  Extinction of the conditioned behaviour results if the
evoke a conditioned response. association between the conditioned and the uncondi-
 In Pavlov’s experiment, presentation of food is uncondi- tioned response is not reinforced.
tioned stimulus and salivation is unconditioned response.
Here ringing bell is the neutral stimulus; over a period v. Spontaneous recovery
of time it becomes conditioned stimulus and salivation The reappearance of an extinguished response after a period
becomes conditioned response. of non-exposure to the extinguished stimulus.

Process of Classical Conditioning Dental Applications


 Simple to understand and very applicable on a child in
The processes included under classical conditioning are:
i. Acquisition dental clinic.
 3-year-old child taken to paediatrician—nurse comes
ii. Generalization
with needle—child given injection badly—child cries.
iii. Discrimination
iv. Extinction Next visit—sight of needle—child cries (needle that was a
v. Spontaneous recovery. neutral stimulus has become a conditioned stimulus)
 First visit
i. Acquisition White coat Pain on injection
(Neutral stimulus) (Unconditioned stimulus)
 Acquisition is learning a new response or forming a new
Pain of injection Fear and crying
response tendency due to conditioning.
(Unconditioned stimulus) (Response)
 The acquisition of conditioned response is usually grad-
ual and requires more trials, but once acquired is more  Second visit
strong. Sight of white coat Pain of injection
(Conditioned stimulus) (Unconditioned stimulus)
ii. Generalization
 Generalization means stimuli similar to the original con- Pain of injection Fear and crying
ditional stimulus. It also evokes a conditioned response. (Unconditioned stimulus) (Response)
Example: Development of phobia in children to a specific
environment or action may be due to stimulus generaliza- White coats, hospital atmosphere, etc. (neutral stimuli—
tion most of the time. NS) associated with pain, fear-(unconditioned response)
producing procedures (unconditioned stimulus), will pro-
iii. Discrimination duce fear (conditioned response) in future, even when not
Discrimination is the opposite of generalization. Learning to associated with original unconditioned stimulus. Here, the
discriminate or learning to respond only to certain stimuli but ‘neutral stimulus will become conditioned stimulus’. With
not respond to others. Example: If the child is exposed to clinic repetition, there will be reinforcement of the unconditioned
settings that are different from those associated with painful response (fear).

SHORT ESSAYS

Q.1. What is Oedipus complex and its significance? Or

Or Oedipus conflict and electra conflict.

Oedipus complex. Ans.


Quick Review Series for BDS 4th Year: Paedodontics
26

 According to the psychosexual theory of Freud it was  Keep mother in case of boy or father in case of baby girl
believed that an individual progresses through several during the child management.
developmental stages that affect personality.
 An important feature of phallic stage of development is Q.2. Id, ego, super ego.
the sex identification, which occurs between 3 and 6 years
of age. Ans.

Phallic stage is characterized by: Psychoanalytical theory was given by Sigmund Freud in
1905. This theory of personality was based on the interaction
 Oedipus complex
between three systems called id, ego and super ego within
 Electra complex.
each individual.
Oedipus Complex Psychic structure
 The child begins to direct their awakened sexual impulses
towards the parent of the opposite sex.
 Attachment between young boys and mother, and they Three parts proposed by Freud in psychodynamic theory
consider father as their enemy.
 The name Oedipal complex (comes from Greek mythol-
Id (pleasure Ego (reality Super ego
ogy). Oedipus—the King of Thebes, unwillingly slew his principle) principle) (ethics and
father and married his mother. morals)
 The little boys strive to imitate their father to gain affec- 1. Basic structure of 1. Develops in 2–6 1. It is prohibition
tion of mother. Freud also described Oedipal complex as a personality present months of life when learned
desire to have a sexual relation with the mother. at birth, impulse infant is injured to from environment
ridden and strives for distinguish between (more
Electra Complex immediate pleasure itself and outside from parent and
and gratification world authorities)
 Young girls develop an attraction towards their father and
resent the mother being close to the father. 2. It is governed 2. It is determined by
by reality principle regulations imposed
 The child realizes the sexual qualities without embarrass-
and is concerned on child by parents,
ment. In a phobic child these unconscious, unacceptable with memory and society and culture
wishes and feeling associated with Oedipal situation do judgment (ethics and morals)
not enter consciousness. 3. It develops after 3. It is internalized
 If the characteristic features of this stage are not resolved, birth expands with control that produces
the balance between male and female roles does not age and delays, the feeling of shame
develop. modifies and and guilt
controls id impulses
Clinical Significance on a realistic level. It
is mediation between
 Keep the opposite sex during the child management in the id and super ego
dental office/clinic.

SHORT NOTES

Q.1. Stimulus response theory.  When two stimuli occur together at the same time, result-
ing in a response, this response can be also obtained by
Ans.
stimulating anyone of the original stimuli.
 A theory based on stimulus response reflex given by Ivan
 In dentistry we can use this theory for stimulating the
Petrovich Pavlov is known as stimulus response theory.
development of good habits, breaking old habits, to
 It was developed through experimentation with dogs.
remove fear and to develop positive attitude.
Stimulus response reflex is an involuntary response to an
external stimulus.
Topic wise Solved Questions of Previous Years
27

Q. 2. Super ego. Ego


Ans.  Ego is governed by ‘the reality principle’.
 Ego tries to satisfy the id’s urge of pleasure, but only in the
 Super ego is similar to social conscience.
realistic ways that takes account on what is possible in the
 It is governed by ‘the moral principle’.
real world.
 It develops at around 5 years. It controls id and ego. Super-
 It is the mediator between id and super ego. It channelizes
ego formation continues during school age and is present
id into a socially acceptable way.
through the entire life.
 It establishes and maintains the person’s moral conscious
Q.5. Oedipus complex.
on the basis of a complex of ideas and values internalized
by parents. Ans.
 It stems from internalization of feeling good and bad, love  Freud believed that an individual progresses through sev-
and hate, praising and forbidding, rewards and punish- eral developmental stages that affect personality.
ment.  According to Freud’s psychosexual theory, the phallic stage
 It is linked to a social consciousness derived in part from of development is characterized by Oedipus complex and
the familial cultural restrictions placed on the growing Electra complex.
child.
Oedipus Complex
Q.3. Trust versus mistrust.
 The child begins to direct their awakened sexual impulses
Ans. towards the parent of the opposite sex.
 It is the tendency of young boy child being attached more
 The trust versus mistrust is dealt in ‘stage I’ of psychologi-
to mother than the father and they consider father as their
cal theory given by Erik H. Erikson, which extends over
enemy.
1st year of life.
 The name Oedipal complex (comes from Greek mythol-
 Basic needs are met by the person whom he trusts. When ogy). Oedipus—the King of Thebes, unwillingly slew his
these are not met he develops mistrust. Child with a sense father and married his mother.
of trust may have the sense of mistrust activated at a later
stage such as parents getting divorced. Q.6. Sensorimotor period.
 Hope and danger present. Example: Child with a sense
of mistrust may come to trust a particular person like Ans.
a teacher who has taken the trouble to be trustworthy  Piaget has described four major periods of cognitive
developing hope. growth, among which the sensorimotor period is first
stage extending from birth to 18 months in which an inte-
Q.4. Enumerate basic emotions of children. What is id gration of sensory modalities is learned by the infant.
and ego?
 In this period the infant responds in a relatively undiffer-
Ans. entiated reflexive pattern. He learns to integrate the sen-
sory modalities and is able to look towards the object and
 Anxiety and fear are basic emotions of a child.
make a sound or reach and hold the object he desires.
Id (instinctual drives)  It lasts from birth to approximately 2 years of age. Object
permanence, primitive beginning of symbolic thought
 Id is that portion of mind that contains unconscious and animism are the hallmarks of this stage.
drives for pleasure and destruction.  During this stage, infants understand their environment
 It is governed by ‘the pleasure principle’. by physically manipulating the world around them.
 It is present at birth, is impulse ridden and strives for  Knowledge of the world is limited to sensory perceptions
immediate pleasure and gratification without regard to and motor activities. Behaviour is limited to simple motor
rules, realities of life or morals of any kind. responses to sensory stimuli.
Quick Review Series for BDS 4th Year: Paedodontics
28

Topic 4 PARENT COUNSELLING AND


CHILD BEHAVIOUR
LONG ESSAYS

Q.1. Discuss the importance of first appointment for to the office, and a reminder of appointment date and
the child patient. time.
Ans. ii. A medical health history form stamped with red ink
in an upper corner—‘Please complete and bring with
 It is generally recommended that a child’s first visit be you’.
made at no later than 3–4 years of age. iii. A note of welcome addressing the young patient.
 Dental care for children has been designed primarily  The physical layout of the reception area and business
to prevent oral pain and infection, the occurrence and desk must allow staff members a full view of the recep-
progress of dental caries, the premature loss of primary tion room. On arrival, the patient and parents should be
teeth, the loss of arch length, and the development of an greeted by a team member, whether or not a sign-in sheet
association between fear and dental care. is used.
 A well-trained team member should escort new patient
Importance of first appointment for a child patient is as fol-
lows: arrivals to a conference room or the operatory. At this
time, the staff person should review the child’s health his-
 A good first appointment experience provides the foun- tory with parents, recording pertinent notes for the den-
dation for an enjoyable, long-term relationship with tist.
patients and parents.  The patient and parents may be given a brief tour of the
 Unless the young child presents with an acute dental prob- office, and the tour guide can reinforce information given
lem, the first visit usually involves only an examination, in the practice brochure.
radiographic evaluation and if possible a prophylaxis and  The dentist should then be introduced by the staff member
topical fluoride treatment. It is readily accepted by most who interviewed the new patient and parents. After a short
of the children. conversation addressed mainly to the patient, the dentist
 The impression given on the very first visit is long lasting; should again review the health history with the parents,
although walk-in emergencies occur occasionally, most reading notes made by the staff member during the inter-
initial contacts with a practice are by telephone. view.
 A caller frequently judges the entire practice by a voice on  The above routine provides two opportunities to ensure
the telephone; the business staff should be trained in cor- that the health history has been correctly completed and
rect telephone etiquette and procedures. that the review with parents is documented.
 During the initial telephone conversation, certain infor-  If the initial conversation occurred in a conference room,
mation should be gathered from the parenting adult. the dentist should leave while the team member prepares
 Use of a form can help to standardize the procedure. A to take the child to the operatory. In this way, if the child is
completed form about patient details by the reception- upset, the dentist who must gain full cooperation during
ist and its use during the first visit is an invaluable aid in the dental examination is not involved.
patient registration and can be kept permanently in the  In many offices, parents accompany their child to the
patient chart. operatory. Although this often adds stress and causes the
 A packet mailed before the first examination is an excel- child’s behaviour to be worse, the presence of parents in
lent introduction to the practice. The items that a packet the operatory is a reality in many paediatric dental offices
might contain following: in today’s litigious society.
i. A brochure that provides information about the prac-  The dentist has to wisely limit the number of adults
tice, the practice web address, a list of services offered, accompanying each patient to the operatory.
general advice about how parents can best help chil-  After the examination, the dentist should present the case
dren prepare for the first dental appointment, a map to the parents who usually want answers to the following
Topic wise Solved Questions of Previous Years
29

questions: ‘What is wrong?’, ‘Can it be fixed?’, ‘How much e. Use of fear-promoting words, use of subtle, flattery,
will it cost?’ The practitioner should keep these questions praise and reward
in mind and plan case presentations accordingly. f. Presence of parents in the operatory.
 Many new-to-practice dentists are over talk during case
presentations, confusing parents and patients with exces- I. Factors Involving the Child
sive clinical terminology.
 At some point during the first appointment, an assist- a. Growth and Development
ant or hygienist should give home care instructions. The i. The genetic, familial, cultural, interpersonal and psychic
patient and parents are then escorted to a checkout area. factors influence the growth and development processes
 The next appointment is usually scheduled before the fee of a child.
is collected. After checkout, a staff member should express ii. Most children demonstrate emotional maturation along
thanks to the parents for choosing the office and remind with physical growth.
them that the practice appreciates referrals. iii. During maturation, the child’s behaviour is systemically
 The child and parents should leave the office feeling that affected by the inherent genetic makeup.
the dentist and staff are extraordinarily caring, thorough iv. With each new experience, a new behaviour develops as
skilled, and efficient. directed by the child’s internal system from his motiva-
 The first appointment should make parents eager to tion and from the consequences of his behaviour.
recommend the practice to other family members and
friends. b. IQ (Intelligent Quotient) of the Child
 Except for the emergency treatment or non-invasive
procedure it is wise not to perform any other treatment i. IQ assessment is the method of quantifying the mental
during the first visit, even in a very cooperative child. ability in relation to chronological age.
 The highest rates of uncooperative behaviour during the ii. It is assessed and measured by tasks, examining memory,
first session occur when the child is separated from his spatial relationship, reasoning, etc.
mother during the taking of the radiograph. This behav- iii. A positive relationship exists between IQ and the
iour may be due to the fear of abandonment, which is acceptance of dental treatment.
common in children younger than four.
c. Past Dental Experience
Q.2. Enumerate the factors influencing child’s behav- i. A fear might develop in the child towards dental treat-
iour. Describe the parental influences on the behaviour ment due to any of the previous painful experiences.
of children during dental treatment. ii. It is very important to alleviate this fear before one can
Ans. accept a tolerable behaviour.

The various factors influencing the behaviour of a child are as d. Social and Adaptive Skills
follows:
i. The level of child’s social and adaptive skills is an impor-
I. Factors involving the child tant aspect of the overall functioning of the child.
a. Growth and development ii. It is important to consider how effective the child is in
b. IQ of the child meeting the standards for personal independence and
c. Past dental experience social responsibility in everyday situations.
d. Social and adaptive skill
e. Position of the child in the family. e. Position of the Child in the Family
II. Factors involving the parents The child’s position in the family also influences his/her be-
a. Family influence haviour as follows:
b. Parent–child relationship i. First child: Uncertainty, mistrust, insecurity, stinginess,
c. Maternal anxiety dependence, responsibility, authoritarianism, jealousy,
d. Attitude of parents to dentistry. sensitiveness etc.
ii. Second child: Independence, aggressiveness, extrovert,
III. Factors under the control of dentist adventuresome.
a. Environment of the dental office iii. Middle child: Aggressiveness, easily distracted, infertility
b. Personality of the dentist (his attitude and attire) and prone behaviour disorders
c. Scheduling of appointment iv. Last child: Secure, confident, immature, envy, irrespon-
d. Dentist’s skill and speed sible, spontaneous good and bad behaviour.
Quick Review Series for BDS 4th Year: Paedodontics
30

II. Factors Involving the Parents i. Overprotective/overanxious parents


Factors responsible for maternal overprotection may be:
a. Family Influence
 History of previous miscarriage or a long delay in concep-
 The home environment is an important factor in the tion.
development of a child’s personality and his behaviour  Family’s financial condition.
patterns.
 Death of a sibling.
 Socioeconomic status of parents has some consideration  Serious illness or handicapped condition.
in behaviour modulation in dental office. Parents belong-
 Parental absence by divorce or death.
ing to low socioeconomic status show authorization in
 This overprotective attitude is characterized by undue con-
controlling the child than the middle- and high-income
cern for the child in terms of feeding, dressing, bathing, etc.
groups.
 Parents are constantly involved with child’s daily social
 Maternal influence on the children’s mental, physical and
activities and may not allow him to participate in risk
emotional development begins even before birth. Moth-
involving games/situations.
er’s nutritional status and the state of physical health can
 The overprotective mother retards the normal psychologic
affect the neurological as well as somatic development of
maturation of the child and tends to infanticise him.
the fetus, which directly influences the children’s mental,
 The child is not permitted to play alone.
physical and emotional development.
 The overprotective mother is associated with a submis-
sive, shy and anxious child. These children are usually shy,
b. Parent–Child Relationship timid and fearful.
Parents play an important role in the child’s psychological  Aggressive child is demanding and expects constant atten-
development, but more emphasis is given on the mother. tion and services.
 Bell has termed the parent–child relationship as ‘one  They lack the ability to make decisions for themselves.
tailed’, since parental characteristics are viewed as having  With encouragement and assurance the child usually
unilateral influences on those developing in the child. responds in a satisfactory manner. The child will be a
 According to this theory, the child’s characteristics includ- cooperative dental patient.
ing the personality, behaviour and reaction to stressful
situation are the direct product of various maternal char- ii. Overindulgence
acteristics.  It may be associated with overprotective or dominant
 It was found that loving mothers tend to have calm, happy natural trait.
children, while hostile mothers tend to have children who  Relatives such as grandparents are also overindulgent.
are excitable and unhappy.  The parents give the child whatever he might want, as far
 Most of the relevant mother–child relationship falls into as financially possible including toys, candy and clothes.
two broad categories:  They usually place very little restraint upon their child’s
i. Autonomy versus control behaviour.
ii. Hostility versus love. The behaviour of this type of child is as follows:
 Mothers who allowed autonomy and expressed affection  Child is spoilt and is accustomed to getting his own way.
had children who were friendly and cooperative.  His emotional development is impeded, and is aggressive,
 Conversely, punitive mothers and those who ignored their demanding and displays temper tantrums.
children did not exhibit these positive behavioural char-  He is usually incapable of amusing himself and keeps the
acteristics. Friendly, cooperative child will probably also adults around him busy devising diversion for him.
exhibit these traits in the dental office.  In the dental office, when they cannot control the situa-

 Characteristics of parent–child relationships that may


tion the way they control the situation at home they may
affect child’s behaviour in the dental office are as follows: show bursts of temper.
i. Overprotective/ overanxious iii. Underaffection and rejection
ii. Overindulgence
 Underaffection may vary from mild detachment to indif-
iii. Underaffection and rejection
ference to neglect.
iv. Domination  Mother becomes less emotionally supportive of her child
v. Identification due to her outside interests, employment or because the
vi. Authoritarian. child is unwanted.
Topic wise Solved Questions of Previous Years
31

 She may neglect the child, gives severe punishment, nag-  The mother feels that the child should follow her set of
ging and is resistant to spend time and money on the norms and ideas.
child. The behaviour of this type of child is as follows:
The behaviour of these type of children is as follows:  The response of the child will be submission, coupled
with resentment and evasion.
 These children are well-behaved and outwardly appear to
 This type of child will not directly disobey a command, he
be well-adjusted.
has heightened avoidance gradient.
 They however develop resentment and become com-
 Parents are non-supportive and are criticizing them.
pletely withdrawn to a shell.
Therefore, these children are often afraid of dentists and
 Since they have not experienced love and affection at
resist the dental treatment.
home, such a child usually lacks a feeling of belonging or
worthiness. c. Maternal Anxiety
 They may show anxiety, cry easily, are unable or unwilling
to cooperate and will resort to any behaviour to attract  Highly anxious parents tend to affect their child’s behav-
attention. iour negatively.
 Such children are usually demanding and, at extreme,  Although the scientific data reveals that children of all
rejection can lead to rivalry. ages can be affected by their mother’s anxieties, children
 They respond well to a dentist who gives them emotional under the age of 4 years are greatly affected.
support and affection.
d. Attitude of Parents to Dentistry
iv. Domination  Parents with positive dental attitude will develop the same
 Parents with dominant attitude demand from their chil- in the child. Whereas fearful parent may develop fear
dren excessive responsibility, which is incompatible with unknowingly in a child.
their chronological age.
 They cannot accept the child as he is, but compare him III. Factors under the Control of Dentist
with others older to him.
 They force the child and criticize him and this results in a. Environment of the Dental Office
resentment, evasion, submission and restlessness in the  The physical layout of the reception area and business
child. desk must allow staff members a full view of the recep-
The behaviour of these types of children is as follows: tion room. On arrival, the patient and parents should be
greeted by a team member whether or not a sign-in sheet
 They are fearful of resisting openly and will obey com-
is used.
mands slowly.
 The patient and parents may be given a brief tour of the
 With kindness and consideration they generally develop
into good dental patients. office, and the tour guide can reinforce information given
in the practice brochure.
v. Identification  Since the child may enter the dental office with some fear,
the paedodontist or his auxiliary must put the child at
 This type of parents try to relive their own lives in their ease, waiting room must be made comfortable by having
children. one corner set aside for their own use. The corner must
 In doing so, they try to give the child every advantage have books, toys and chairs set aside for them.
denied to them.  Operating room can be made more appealing by having
 If the child does not respond favourably, the parent shows pictures of laughing, playing and carefree children.
disappointment and the child has a feeling of guilt.  The child patient should not see others in pain or blood.
The behaviour of this type of child is as follows:
 He cries easily and lacks confidence. b. Personality of the Dentist
 These children should be handled kindly and with con- (His Attitude and Attire)
sideration.  The approach of the dentist should be casual, confident
and friendly towards the child.
vi. Authoritarian  The dentist should never lose his temper as this will create
 Some parents choose non-loving oriented techniques for feeling of success in the mind of the child and will ruin the
controlling child behaviour. child for all future dental visits.
 Discipline takes the form of physical punishment or verbal  Always call the child by his nickname or at least the first
ridicule. name, when approaching a new child patient.
Quick Review Series for BDS 4th Year: Paedodontics
32

 All conversations should be directed towards him. They result of improper conduct and responsibility of a care-
must include the subject of interest to the child and never taker or parents.
underestimate the intelligence of the child.  Emotion expressed actively or passively against the child
is often unplanned, but nonetheless can result in signifi-
c. Scheduling of Appointment (Time and Length of cant harm or death.
Appointment)  Child maltreatment is usually divided into following cat-
egories:
 Both time and length of appointment are important,
i. Physical abuse
when dealing with children.
ii. Sexual abuse
 Children cannot sit at one position for longer time and their
iii. Emotional or psychological abuse
threshold of tolerance is very low; hence, they should not
iv. Failure to thrive
be kept in the chair for periods longer than 30 minutes.
v. Intentional poisoning/drugging
 With longer appointment the children tend to become
vi. Munchausen syndrome by proxy
less cooperative. Once they lose their self-compose the
vii. Neglect in its many forms
cooperation is very difficult to regain.
viii. Healthcare neglect
 Children should not be given appointment during their
ix. Safety neglect
naptime.
ix. Educational abuse.
d. Dentist’s Skill and Speed
I. Physical Abuse
 To avoid any loss of time, the dentist should perform his
 It forms 60% of the child abuse-related fatalities.
duties with dexterity in a preplanned manner.
 It includes injuries that are inflicted upon child that result
 A child can endure discomfort if he knows it is soon going
from punishment, which are inappropriate for the child’s
to end.
age.
 These type of injuries may be inflicted by the parents,
e. Use of Fear-promoting Words
relatives or baby sitters.
 Avoid the use of fear-promoting words such as needle,  Groups living in poverty may have an increased incidence
injection, etc. of child abuse because of the increased number of crisis
 The alternative words that can be used are called as euphe- in their lives.
misms.  Over 90% of abusing parents have neither psychotic nor
Examples: Mosquito bite—needle prick, raincoat—rub- criminal personalities, tend to be lonely, unhappy, and are
ber dam, tooth paint—sealant angry adults under stress. They injure their children in
anger after being provoked by some misbehaviour.
f. Use of Subtle Flattery, Praise and Reward  The physical injuries sustained may be:
❍ Mild—few bruises, scratches, etc.
 One of the most important rewards sought by the child is
❍ Moderate—numerous bruises, minor burns or single
approval of the dentist.
 In praising a child, it is better to praise the behaviour than fractures.
❍ Severe—large burns, CNS injury, abdominal injury,
that of the individual.
 Tiny gifts such as alphabet erasers, tiny gold stars, toys or multiple fractures or other life-threatening injuries.
 Children living in violent homes are increasingly recog-
stickers make good rewards.
 The recognition makes the child more happy than the nized as victims of maltreatment.
 Identification, treatment, and intervention are the tasks of
material, flattery can be used as a reward after the treat-
ment. professionals from multidisciplinary backgrounds work-
ing together to provide care and evaluation in the best
Q.3. Describe in detail about child abuse and dental interests of the child.
 Education and prevention efforts may teach parents to
neglect.
redirect their actions and explore more appropriate dis-
Ans. cipline techniques and ways to manage anger or frustra-
 Child abuse and neglect (CAN) is defined ‘as any interac- tion.
tion or lack of interaction between a care giver and a child
resulting in non-accidental harm to the child’s physical or II. Sexual Abuse
developmental state’.  The National Centre on Child Abuse and Neglect defines
 Child abuse and neglect include various experience of a sexual abuse ‘to include contacts or interactions between
child that are threatening or harmful. These are always the a child and an adult’.
Topic wise Solved Questions of Previous Years
33

 Any kind of intentional sexual misuse on a child by a Various factitious signs and symptoms include:
person is termed as sexual abuse. i. Bleeding from various sites. If specimens are required,
the parents add his or her own blood to them.
III. Emotional Abuse and Neglect
ii. Recurrent sepsis from injecting contaminated fluids.
 Emotional abuse is defined as ‘the continual scapegoating iii. Chronic diarrhoea from laxatives.
and rejection of a child by parents, caretakers or teachers’. iv. Fever from rubbing or heating thermometers.
 Any form of abnormal behaviour or mental health prob- v. Rashes from rubbing the skin or applying caustic sub-
lems that harm a child are called emotional abuse. Exam- stances.
ple: continuous isolation action, degradation, terroriza-
tion, exploitation or denial of affection. VII. Neglect in its Many Forms
 Emotional and verbal abuse involve interactions or lack
of interactions on the part of the caretaker that inflict  Neglect consists of failure to provide the necessities of
damage on the child’s personality, emotional well-being, adequate food, shelter, clothing and also healthcare needs
or development. according to accepted or appropriate standards. Neglect is
a chronic form of child abuse.
 Harm to the child generally occurs in various ways over a
prolonged period. Physically neglected children tend to exhibit at least several of
 It is often difficult to demonstrate the direct or causal link these characteristics.
between the emotional and verbal abuse and the harm to a. Dirty clothing and skin with foul smell, lice and un-
the child. Such harm is usually seen as abnormal behav- kempt appearance.
iour or mental health problems that are multifactorial in
b. Undernourished
origin.
c. Rampant caries, abscess, periodontal lesions, etc.
IV. Failure to Thrive d. Uncared wounds
e. Constant sleepiness or hunger
 Failure to thrive due to lack of attention to dietary intake
of child by parent or caretaker; the child becomes mal- g. Pain and emergency-type situations are the only reasons
nourished and underweight and exhibits failure to thrive. for the patients appearing at the dental office.
 Such children are usually less than 2 years of age and are  The reason for neglect may be parents’s illness, poverty,

malnourished and underweighed. ignorance, unusual stress on the family.


 The mother may neglect to feed because she is busy with
VIII. Healthcare Neglect
external problems, preoccupied with inner problems or
does not like the infant.  When a parent or caretaker ignores the treatment recom-
 Most of the mothers feel deprived and unloved and are mendations of a health professional for the management
acutely or chronically depressed. of a treatable illness that a child has and that is becoming
worse.
V. Intentional Poisoning/Drugging  Dental care neglect also comes under this.

 Intentional over-drugging or poisoning consists of the The American Academy of Pediatric Dentistry defines
intake of harmful drugs not intended normally for use in dental neglect as ‘the failure by a parent or guardian to seek
a child. treatment for visually untreated caries, oral infection and/or
oral pain’.
 It is an uncommon lethal type of child abuse. Parents who
poison their children may have severe marital problems or
may be drug abusers. IX. Safety Neglect
 Includes gross lack of direct or indirect supervision of a
VI. Munchausen Syndrome by Proxy child that results in an injury.
 In Munchausen syndrome by proxy, children below 6
years of age and too young to reveal the deception exhibit X. Educational Abuse
parentally fabricated or induced illness.
 When a parent or a caretaker knowingly or intentionally
 The induced symptoms and signs lead to unnecessary med- keeps the child at home or fails to enroll the child in the
ical investigations, hospital admissions and treatment. school.
Quick Review Series for BDS 4th Year: Paedodontics
34

SHORT ESSAYS

Q.1. Child abuse. haemorrhages, etc. Hair pulling can be seen in the forms
of bald patches on the scalp.
Or  Intraoral examination may reveal trauma to dentition,
Write briefly about examination of abused child. injury to upper lip or labial frenum and other mucosal
conditions like warts, ecchymosis, erythema, venereal dis-
Or
eases, etc.
Orofacial signs of child abuse.  Such children should be managed by first treating the
emergency condition and, if required, referral to other cli-
Ans. nician should be done. Injuries to soft tissue and dentition
 Child abuse and neglect (CAN) is defined ‘as any interac- should be treated appropriately.
tion or lack of interaction between a care giver and a child  If required, tetanus toxoid should be given prior to pro-
resulting in non-accidental harm to the child’s physical or cedure.
developmental state’.  Documentation records in the form of case history, pho-
 Child abuse and neglect includes various experience of a tographs and radiographs should be maintained.
child that are threatening or harmful. These are always the
Q.2. Parent counselling.
result of improper conduct and responsibility of a care-
taker or parents. Ans.
 Emotion expressed actively or passively against the child
 Parent counselling can be defined as educating the parents
is often unplanned, but nonetheless can result in signifi-
regarding the child’s oral health status, optimal healthcare
cant harm or death.
and informing them about the prevention of potential
 Child maltreatment is usually divided into following cat-
dental diseases.
egories:  Parent education is very important to get a satisfactory
i. Physical abuse rapport between the entire family and the dentist.
ii. Sexual abuse
iii. Emotional or psychological abuse Purpose
iv. Neglect in its many forms  Discussion of emotional problems of children, particu-
v. Failure to thrive larly in relation to dental treatment.
vi. Intentional poisoning/drugging  Knowing about the attitudes of parents toward behaviour
vii. Munchausen syndrome by proxy management techniques used during dental treatment of
viii. Healthcare neglect children.
ix. Safety neglect  Obtaining the cooperation of a child patient, establish-
x. Educational abuse. ing a good rapport with the child and also using effective
techniques of behaviour management.
Examination of abused children includes:  Educating the parents about various dental problems and
 The assessment of the child and abuser’s behaviour is diseases and their sequelae and how they can be prevented
done by separate interviews. with accurate preventive measures if recognized earlier.
 The abused child usually does not make eye-to-eye con-  By counselling the parent in a few simple rules to follow
tact and looks afraid. before bringing the child to the dentist for the first time, a
 Signs of overall poor care are seen such as improper cloth- great service can be rendered to the parent and the child.
ing, multiple skin injuries, malnourishment, etc.  Counselling parents about dental treatment should begin
 The abuser either parent/guardian shows violent temper, preferably before children are old enough to be impressed
poor coping skills and always describes the child in nega- adversely by outside influences. Counselling can be done
tive terms. on a mass scale through various media or individually.
 At times, abuser’s behaviour reflects guilt; questioning
Some points to be discussed during parent counselling are:
regarding the incident can cause him/her to feel embar-
rassed.  Tell the parents not to voice their own personal fears in
front of the child.
General physical examination:  Tell the parents never to use dentistry as a threat or pun-
 On examination of body parts and skin, for fractures/ ishment. The feel of punishment in the child’s mind is
lacerations, burns, bruises, bite marks, head injuries, associated with unpleasantness and pain.
Topic wise Solved Questions of Previous Years
35

 Tell the parents to familiarize their child with dentistry by Importance of first appointment for a child patient is as
taking the child to the dentist to become accustomed to follows:
the dental office and the dentist.  A good first appointment experience provides the foun-
 Counsel the parent about the home environment and the dation for an enjoyable, long-term relationship with
importance of moderate parental attitudes in building patients and parents.
well-adjusted children. A well-adjusted child is generally  The first visit usually involves only an examination, radio-
a good dental patient. graphic evaluation and if possible a prophylaxis and topi-
 Explain to the parent that an occasional display of cour- cal fluoride treatment. It is readily accepted by most of
age on his part in dental matters will build courage in the children.
the child. There is a correlation between child and parent  The impression given on the very first visit is long last-
fears. ing.
 Stress to the parent, the value of regular dental care not  During the initial telephonic conversation certain infor-
only in preserving the teeth but also in the formation of mation should be gathered from the parenting adult.
good dental patients.  Use of a form can help to standardize the procedure. A
 Discourage parents from bribing their children to go to completed form about patient details by the receptionist
the dentist. used during the first visit is an invaluable aid in patient
 The parent should be instructed never to scold, shame or registration and can be kept permanently in the patient
ridicule to overcome the fear of dental treatment. This chart.
only builds resentment towards the dentist and makes the  A packet mailed before the first examination is an excel-
dentist’s efforts more difficult. lent introduction to the practice. The items that a packet
 The parent should be informed of the need for combating might contain are as follows:
all deleterious impressions of dentistry from outside the i. A brochure that provides total information about the
home. practice.
 The parent should not promise the child what the dentist
ii. A medical health history form stamped in red ink in an
is not going to do. Lying only leads to disappointment and
upper corner, ‘Please complete and bring with you’.
mistrust.
iii. A note of welcome addressing the young patient.
 Several days before the appointment, the parent should be
 On arrival, the patient and parents should be greeted by a
instructed to convey to the child in a casual manner that
they have been invited to visit the dentist. team member, whether or not a sign-in sheet is used.
 The parent should commit the child to the dentist’s care  A well-trained team member should escort new patient

once the office is reached and should not enter the treat- arrival to a conference room or the operatory. At this time,
ment room unless requested to do so by the dentist. Once the staff person should review the child’s health history
in the treatment room he should act as an invited specta- with parents, recording pertinent notes for the dentist.
tor only.  The patient and parents may be given a brief tour of the
 The parent who educates his child to be receptive to dental office, and the tour guide can reinforce information given
treatment will find that it pays dividends in the child’s in the practice brochure.
enjoyment of dentistry.  The dentist should then be introduced by the staff member
Parent counselling and education are very important to who interviewed the new patient and parents.
get a satisfactory rapport between the entire family and the  After the examination, the dentist should present the case
dentist. to the parents who usually want answers to the multiple
questions. Example: ‘What is wrong?’, ‘Can it be fixed?’,
Q.3. First dental visit. ‘How much will it cost?’. The practitioner should keep
these questions in mind and plan case presentations
Or accordingly.
Importance of child’s first dental visit.  The dentist has to wisely limit the number of adults
accompanying each patient to the operatory.
Ans.  At some point during the first appointment, an assist-
 The child’s first dental visit is generally recommended at ant or hygienist should give home care instructions. The
no later than 3–4 years of age. patient and parents are then escorted to a checkout area.
 Dental care for children has been designed primarily to  The next appointment is usually scheduled before the fee
prevent oral pain and infection as well the progress of is collected.
dental caries, the premature loss of primary teeth, the  After checkout, a staff member should express thanks to
loss of arch length, and the development of an association the parents for choosing the office and remind them that
between fear and dental care. the practice appreciates referrals.
Quick Review Series for BDS 4th Year: Paedodontics
36

 The child and parents should leave the office feeling that ii. Overindulgence
the dentist and staff are extraordinarily caring, skilled and
 It may be associated with overprotective or dominant
efficient.
natural trait.
 The first appointment should make parents eager to
 Relatives such as grandparents are also overindulgent.
recommend the practice to other family members and
 They usually place very little restraint upon their child’s
friends.
behaviour.
Q.4. Parental attitude and behaviour of children. The behaviour of this type of child is as follows:
 Child is spoilt and is accustomed to getting his own way.
Or  In the dental office, when they cannot control the situa-
Write briefly about parent–child relationship. tion the way they control the situation at home they may
show bursts of temper.
Ans.
Parent–Child Relationship iii. Underaffection and Rejection
 Underaffection may vary from mild detachment to indif-
Parents play an important role in the child’s psychological
development, but more emphasis is on the mother. ference to neglect.
 Mother becomes less emotionally supportive of her child
 Bell has termed the parent–child relationship as ‘one
due to her outside interests.
tailed’, since parental characteristics are viewed as having
a unilateral influence on those developing in the child. The behaviour of these types of children is as follows:
 According to this theory, the child’s characteristics includ-  These children are well-behaved and outwardly appear to
ing the personality, behaviour and reaction to stressful be well-adjusted.
situation are the direct product of various maternal char-  They may show anxiety, cry easily, unable or unwilling
acteristics. to cooperate and will resort to any behaviour to attract
 It was found that loving mothers tend to have calm, happy attention.
children, while hostile mothers tend to have children who  They respond well to a dentist who gives them emotional
are excitable and unhappy. support and affection.
 Characteristics of parent–child relationships that may
affect child’s behaviour in the dental office are as follows: iv. Domination
i. Overprotective/overanxious  Parents with dominant attitude demand from their chil-
ii. Overindulgence dren excessive responsibility, which is incompatible with
iii. Underaffection and rejection their chronological age.
iv. Domination  They force the child and criticize him and this results in
v. Identification resentment, evasion, submission and restlessness in the
vi. Authoritarian. child.
The behaviour of these types of children is as follows:
i. Overprotective/Overanxious Parents
 They are fearful of resisting openly and will obey com-
 Factors responsible for maternal overprotection may be mands slowly.
history of previous miscarriage, family’s financial condi-  With kindness and consideration they generally develop
tion, death of a sibling, etc. into good dental patients.
 This overprotective attitude is characterized by undue
concern for the child in terms of feeding, dressing, bath- v. Identification
ing, etc.
 This type of parents try to relive their own lives in their
 The overprotective mother retards the normal psychologic
maturation of the child and tends to infanticise him. children.
 If the child does not respond favourably, the parent shows
 The overprotective mother is associated with a submis-
sive, shy and anxious child. These children are usually shy, disappointment and the child has a feeling of guilt.
timid and fearful. The behaviour of this type of child is as follows:
 Aggressive child, demanding and expects constant atten-  He cries easily and lacks confidence.
tion and services.  These children should be handled kindly and with con-
 They lack the ability to make decisions for themselves. sideration.
Topic wise Solved Questions of Previous Years
37

vi. Authoritarian  Children fear white uniforms and smell of certain drugs
and chemicals in the hospital.
 Some parents choose non-loving oriented techniques for
controlling child behaviour.
 Discipline takes the form of physical punishment or verbal Subjective Fear
ridicule.  A child develops subjective fear based on somebody else’s
experience without actually undergoing dental treatment
The behaviour of this type of child is as follows:
himself.
 The response of the child will be submission, coupled  Parents may tell the child about an unpleasant or pain-
with resentment and evasion. producing situation undergone by them and this fear may
 Parents are non-supportive and are criticizing them. be retained in the child’s mind.
Therefore, these children are often afraid of dentists and
resist the dental treatment. Suggestive Fear

Q.5. Types of fears.  It may be acquired by observing fear in others and then
the child develops a fear for the same object as real and
Or genuine.
 Child’s anxiety is closely correlated with parental anxiety.
What is objective fear and subjective fear?
If the parent is sad the child feels sad and if the parent
Or display fear the child is fearful.

Fear in paedodontia. Imitative Fear


Ans.  A mother who fears going to the dentist may transmit this
unconsciously to her child who is observing her.
 Fear is the physio-psychological response to a realistic
 Imitative fears may be transmitted subtly and may be dis-
threat or danger to one’s existence.
played by the parent and acquired by the child without
 It is the primary emotion for survival against danger, either being aware of it.
which acquired soon after birth.
 They are generally recurrent fears and therefore are
Types of Fear more deep-seated and difficult to eradicate. Displayed
emotion, such as anxiety observed in the parent’s face,
a. Innate fear may create more of an impression than verbal sugges-
b. Objective fear tion. Example: A mother who fears going to the dentist
c. Subjective fear and goes only under great emotional stress transmits
d. Suggestive fear this fear unconsciously to her child who is observing
her.
e. Imitative fear
f. Imaginative fear.
Imaginative Fear
Innate Fear  As the imaginative capacities of the child develop, imagi-
nary fears become more intense. Imaginary fears, there-
 Innate fear is the fear without stimuli or previous experi-
fore, become greater with age and mental development,
ence and is thus also dependent on the vulnerability of
up to a certain age, when reason shows them to be ill-
the individual.
founded.
 Fears may be irrational in the sense that the child may not
Objective Fear
know why he is frightened. Memories of past experiences
 Objective fear is based on the child’s own experience. may fade entirely from his consciousness, but the emo-
They are produced by direct physical stimulation. They tion associated with the forgotten experience determines,
are the responses to stimuli that are felt, seen, heard, smelt to a large measure, his reaction to a similar event in the
or tasted, and are not linked or accepted. future.
Quick Review Series for BDS 4th Year: Paedodontics
38

SHORT NOTES

Q.1. Define fear and name the types of fear. Q.3. Different types of cry.
Ans. Or
 Fear is the physio-psychological response to a realistic
Types of cry.
threat or danger to one’s existence.
 Fear is the primary emotion for survival against danger,
Ans.
which acquired soon after birth.
 Cry is defined as a loud utterance of emotion especially
Types of Fear
when inarticulate.
a. Innate fear
b. Objective fear
c. Subjective fear Types of Cry
d. Suggestive fear  According to Eisbach (1963) four types of crying are usu-
e. Imaginative fear. ally seen in children:
a. Obstinate cry
Q.2. Communication.
b. Frightened cry
Ans. c. Hurt cry
 Establishing communication is the first objective in suc- d. Compensatory cry.
cessful management of the young child.
 The dentist not only learns about the patient but also may Obstinate Cry
relax the youngster by involving the child in conversa-
tion. It is a loud and high-pitched emotion. It is characterized as
a siren-like wail.
 There are two ways of establishing communication:
i. Verbal: Spoken language to gain confidence.
Frightened Cry
ii. Non-verbal: Expression without words like welcome
hand shake, patting, eye contact. Usually accompanied by a torrent of tears, convulsive breath-
 Effective vocabulary is important aspect as the dentist catching sobs can be seen.
must only use the words that are understandable by the
child. Hurt Cry
 The important aspect of communication is getting the
It may be loud and more frequently accompanied by a small
child to respond to dentist’s commands. It is imperative
whimper.
to use positive language which is pleasing like ‘Please can
you move your hand’ rather than use negative aspect like
‘Do not get your hand here’. Compensatory Cry
 The three most important facets of communication are It is not a cry at all; usually the cry is slow in sound and mon-
source, medium and receiver. In dentistry, dentist is the otone.
source, dental clinic is medium and child is the receiver.
 If the dentist is good, sympathetic, confident and honest, Q.4. Child abuse.
dental clinic is neat and attractive to children, with full of
Or
toys, then automatically the child will be communicating
and is well-managed. Types of child abuse.
 The fears and natural innate curiosity of the child demand
that explanations be given for each and every step of Ans.
dental treatment.  Child abuse and neglect include various experiences of a
 Honesty of approach is also very important; if the child child that are threatening or harmful. These are always the
knows that dentist is honest with his words it will bring result of improper conduct and responsibility of a care-
out a cooperative behaviour in him. taker or parents.
Topic wise Solved Questions of Previous Years
39

 Child abuse may be in the form of physical or mental  Parent education is very important to get a satisfactory
injury, intentional drugging, sexual abuse, neglect of rapport between the entire family and the dentist.
health, dental neglect, emotional or educational neglect
or maltreatment of child under 18 years of age by the Purpose
child’s caretaker or parents.  Discussion of emotional problems of children, particu-
Following are the types of child abuse: larly in relation to dental treatment.
i. Physical abuse  Knowing about the attitudes of parents towards behav-
ii. Sexual abuse iour management techniques used during dental treat-
iii. Emotional or psychological abuse ment of children.
iv. Neglect in its many forms  Obtaining the cooperation of a child patient, establish-
v. Failure to thrive ing a good rapport with the child and also using effective
vi. Intentional poisoning/drugging techniques of behaviour management.
vii. Munchausen syndrome by proxy  Educating the parents about various dental problems and
viii. Healthcare neglect diseases and their squeal and how they can be prevented
ix. Safety neglect with accurate preventive measures if recognized earlier.
x. Educational abuse. Some points to be discussed during parent counselling are:
 Tell the parents not to voice their own personal fears in
Q.5. Anticipatory guidance.
front of the child.
Ans.  Tell the parents never to use dentistry as a threat or pun-
ishment.
Anticipatory guidance includes the following things:
 Tell the parents to familiarize their child with dentistry by
 Clean infant’s gums after each feeding using a clean damp taking the child to the dentist to become accustomed to
cloth or an infant toothbrush with a small head using the dental office and the dentist.
plain water.  Counsel the parent about the home environment and the
 Plan an appointment for the infant’s first dental visit importance of moderate parental attitudes in building
within 6 months of eruption of the first tooth and before well-adjusted children.
12 months of age.  Stress to the parent, the value of regular dental care not
 After initial dental visit make future appointments based only in preserving the teeth but also in the formation of
on the schedule suggested by the dentist, based on the good dental patients.
infant’s individual needs.  Discourage parents from bribing their children.
 As soon as the first tooth erupts ( i.e. 6–10 months of age)  The parent should be instructed never to scold, shame or
start brushing twice a day using a soft bristled toothbrush ridicule to overcome the fear of dental treatment.
designed for infants.  The parent should not promise the child what the dentist
 In case infant has sore gums due to eruption of teeth, give is not going to do. Lying only leads to disappointment and
infant a clean teething ring, cool spoon or cold wet wash mistrust.
cloth or even rub his gums with a clean finger.  Several days before the appointment, the parent should be
 Following brushing at night, after the meal do not give instructed to convey to the child in a casual manner that
any eatables except water. they have been invited to visit the dentist.
 For infants at increased risk of tooth decay consult a den-
tist regarding use of fluoridated toothpaste. Q.7. Dental neglect.
 Give recommended doses of fluoride supplements to the Ans.
infants 6 months or older based on water fluoride level.
 Become familiar with the normal appearance of the  Denial of attention to the basic needs of a child, such as
infant’s teeth and gums so that problems can be identified food, clothing, shelter, medical care education and super-
if they occur. vision is known as neglect.
 Neglect is a chronic form of child abuse.
Q.6. Parent counselling.  The reason for neglect may be parent’s illness, poverty,
ignorance, unusual stress on the family.
Ans.  Physically neglected children tend to exhibit following
 Parent counselling can be defined as educating the parents characteristics.
regarding the child’s oral health status, optimal healthcare a. Dirty clothing and skin with foul smell, lice and un-
and informing them about the prevention of potential kempt appearance.
dental diseases. b. Undernourished.
Quick Review Series for BDS 4th Year: Paedodontics
40

 Healthcare neglect: In this, parents of the child do not  Safety neglect: This means the insufficient supervision by
seek treatment for an illness of the child. parents or caretakers.
 Dental neglect: This is the failure to seek treatment for  Emotional neglect: Inadequate mothering or affection
dental caries, pain and oral infection. due to an infant.

BEHAVIOURAL SCIENCE AND

Topic 5 PSYCHOLOGIC MANAGEMENT


OF CHILDREN’S BEHAVIOUR
LONG ESSAYS

Q.1. Define behaviour. Classify behaviour and discuss Rating No. 2—Negative
in detail about factors affecting child behaviour.
 Reluctance to accept treatment
 Immature, timid and whining
Or
 Some evidence of negative attitude but not pronounced.
Describe different types of behaviour of children.
Rating No. 3—Positive
Or
 Accepts treatment
How does dental office atmosphere affect behaviour of  Tense cooperative
the children?  Willingness to comply with dentist.
Ans.
Rating no. 4—Definitely Positive
Behaviour paedodontics is defined as a discipline that focuses
 Good rapport with the dentist
upon the psychological, social and learning problems of chil-
 Understanding and interested in the dental procedures
dren and adolescents as they relate to the dental situations.
 Laughs and enjoys the situation.
Behaviour is defined as any change in the functioning of
an organism. Frankl’s behaviour rating scale (1962)

Various classifications of behaviour are as follows: Rating Rating Rating Rating


No. 1 No. 2 No. 3 No. 4
I. Frankl’s classification (1962) (definitely (negative) (positive) (definitely
II. Lampshire’s classification negative) positive)
III. Wright’s classification Refuses Reluctant Accepts Unique
IV. Kopel’s classification treatment to accept treatment behaviour
treatment
V. Modified Wright’s classification (addition of symbolic
Immature Immature Tense Good rapport
modifications to the Frankl’s rating scale) cooperative
Defiant Timid and Timid and Understanding
I. Frankl’s Behaviour Rating Scale (1962) behaviour whining whining and interested
and crying
Rating No. 1—Definitely Negative forcefully
 Refuses treatment
 Immature, uncontrollable II. Lampshire’s Classification
 Defiant behaviour i. Cooperative
 Crying forcefully.  Physically and emotionally relaxed.
Topic wise Solved Questions of Previous Years
41

ii. Tense cooperative III. Potentially Cooperative Behaviour


 Tensed and cooperative.  Child is cooperative
iii. Outwardly apprehensive  Physically and mentally fit
 Avoids treatment initially.  Child’s behaviour can be modified
 Hides behind mother and avoids looking or talking to  Group of children require behavioural modification pro-
dentist but eventually accepts the treatment. cedures.
iv. Fearful Potentially cooperative behaviour is subclassified into the
 Requires considerable support so as to overcome the fears
following types:
of dental treatment. Uncon- Defiant Timid Tense Whining
v. Stubborn or defiant trolled behaviour behaviour coop- behav-
behav- erative iour
 Passively resists treatment by using techniques.
iour
vi. Hypermotive Age group Found in all Seen in Border Whining
 Child is acutely agitated and resorts to screaming and 3–6 years ages overprotective line be- throughout
kicking. child haviour the proce-
dure
vii. Handicapped
Also called Also re- Milder but Child is Cry is
 Physical or mental. incor- ferred to as highly anxious tensed in controlled,
viii. Emotionally immature rigible stubborn or mind constant
behaviour spoilt and not
 Emotionally handicapped. loud
Tears, loud They don’t Is shy but Seldom
III. Wright’s Classification crying, like to go to cooperative are the
Wrights classification of cooperativeness of children in den- physical dental clinic tears
lashing
tal office: out and
flailing of
Children’s behaviour the hands

Cooperative Lacking Potentially


IV Kopel’s Classification
behaviour cooperative cooperative
behaviour behaviour  Very young patient
 Emotionally disturbed patient
i. Uncontrolled  Child from a broken or poor family
behaviour  Pampered or spoiled child
ii. Defiant behaviour  Neurotic child
iii. Timid behaviour  Excessively fearful child
iv. Tense cooperative  Hyperactive child
behaviour  Physically handicapped child
v. Whining behaviour  Child with precious untouched medical or dental experi-
ence.
I. Cooperative Behaviour
VI. Wright’s Modification of Frankl’s Behaviour
 Child is cooperative
Rating
 Reasonably relaxed
 Develop good rapport with the dentist  Rating No. 1—Definitely negative (–)
 Laughs and enjoys the situation.  Rating No. 2—Negative (–)
 Rating No. 3—Positive (+)
II. Lacking Cooperative Behaviour  Rating No. 4—Definitely positive (++).
 This behaviour is in contrast to cooperative child
 Includes young children (0–3 years), disabled child, physi- Factors Influencing Child’s Behaviour
cally and mentally handicap. Factors influencing child’s behaviour are categorized under
 They can have major behavioural problems. following headings:
Quick Review Series for BDS 4th Year: Paedodontics
42

Factors involving Factors involving Factors involving iv. Social and adaptive skills
the child/out of the parents the dentist  If a child gets whatever he wants there are high chances of
control of dentists
child getting spoilt.
Growth and develop- Family influence Appearance of the
 Independence of the child also plays a major role.
ment dental office
IQ of the child Parent–child rela- Time of appointment v. Position of the child in the family and child’s
tionship
behaviour
Past dental experi- Maternal anxiety Length of appoint-
ence ment i. First child: Uncertainity, mistrustfulness, insecurity, de-
Social and adoptive Attitude of parents to Dentist’s skill pendence, responsibility, jealousy.
skills dentistry ii. Second child: Independence, aggressive, extrovert, fun-
Position of the child Use of good words loving, adventurous.
in the family and rewarding iii Middle child: Aggressive nature, feeling of inferiority.
iv. Last child: Secure, confident, immature, envy, irresponsi-
ble, good and bad behaviour.
I. Factors Involving the Child/Out of Control of
Dentists II. Factors Involving the Parents

i. Growth and development i. Family influence


 Growth is defined as an increase in size, whereas the devel-  Home is the first school and it’s the place where the child
opment is progression towards maturity. learns to behave.
 Both the processes proceed in a relatively predictable, log-  Mother’s behaviour plays a major role in the behaviour of
ical, step-like sequential order. the child compared to the other family members.
 These processes are influenced by genetic, familial, cul-  One tailed – it is the description for the mother–child
tural, interpersonal and psychic factors. relationship.
The basic developmental parameters that influence behav-  Mother’s nutritional status also places a role in develop-
iour are: ment of the child.
 Biologic—motor maturation as well as bodily develop-
ment. ii. Parent–child relationship
 Cognitive development—intellectual development such as  Two broad categories:
thinking and reasoning. i. Autonomy versus control
 Emotion. ii. Hostility versus love.
 Perceptual development—integration of senses such as Characteristics of parent–child relationship that may influ-
hearing and sight. ence child’s behaviour in dental clinic:
 Personality and social development—habitual way of a. Domination
behaving with others. b. Identification
 Growth of language skills.
c. Overindulgence
d. Overprotective nature
e. Authoritarian.
ii. IQ of the child
 Intelligent quotient (IQ) is the method of quantifying the Mother’s behaviour Child’s behaviour
mental ability in relation to chronological age formulated Overprotective Submissive, shy, anxious
by Alfred Binet. Overindulgent Aggressive, spoilt, demanding, display of
IQ = Mental age/chronological age × 100 temper
Under affectionate Well-behaved, unable to cooperate, shy,
iii. Past dental experience may cry easily
Rejection Aggressive, overreactive, disobedient
 Attachment attained by the child during the past dental
Dominant Aggressive, demanding, display of temper
visit plays a very important role than the number of
Identification Feeling of guilt, cries easily, loss of
visits.
confidence
 Any past unpleasant dental experience results in uncoop-
erative behaviour. Authoritarian Submissive, resentment, evasive
Topic wise Solved Questions of Previous Years
43

iii. Maternal anxiety Q.2. Discuss the importance of first appointment for
the child patient.
 Highly anxious parents affect child’s behaviour and it is
more at the age of 4 years. Or

iv. Attitude of parents to dentistry Discuss the management of the first-time dental pa-
tient.
 If parents behave positively, even the child will behave in
the same way. Or
Discuss the child’s first visit to the dental clinic.
III. Factors Involving the Dentist
Ans.
i. Appearance of dental office
 It is generally recommended that a child’s first visit be
 Appearance of dental office should make the child com- made at no later than 3–4 years of age.
fortable.
Goals of a child’s first dental visit are as follows:
 Lamps and shades should be small.
 To familiarize children with the dental setting and various
 Toys should be kept near the dental chair.
 Protect child from seeing adult’s pain or procedures like types of dental treatment.
 To provide children of all age groups a pleasant, fun-filled,
extractions.
enjoyable, non-threatening introduction to dentistry.
 Dental office staffs should show enthusiasm.
 To introduce your philosophy of holistic, child-centred
and preventive practice.
ii. Dentist behaviour
 To determine the relative risk and susceptibility of the
 Permitting the child to express. child to dental disease.
 Communicating with the child in a sweet manner.  Detection of the signs of early dental disease, e.g. white
 Making the child comfortable. spot lesions.
 Listening to children’s comments.  To assist and provide support to parents and help them to
 Providing them a comfortable environment. reduce caries incidence in children.
Common guidelines to be followed during child’s first dental
iii. Time and length of appointment visit are as follows:
 Child should not be kept for more than half-an-hour on  During the first visit, an easy, comfortable and real fun
a dental chair. way of easing the child into the dental setting may be done
by doing something that the child really enjoys.
iv. Dentist’s skill and speed  Children may have varied interests; but one thing that
never fails to arouse their attention is colours. Have a vari-
 The dentist should perform his duties with dexterity, ety of crayons, colour pencils, sketch pens, etc. that the
should avoid loss of time. child might find attractive.
 Generally it has been found that the degree of coopera-
v. Use of good words, subtle, flattery,
tion exhibited by preschool children at their first appoint-
praise and reward
ment is high since the first visit usually involves only an
 Fear-promoting words should be avoided. The following examination, radiographic evaluation and if possible a
words can be used: prophylaxis and topical fluoride treatment unless the
❍ Example: Mosquito bite → needle prick child presents with an acute dental problem. Most chil-
❍ Rain coat → rubber dam dren readily accept this.
❍ Coat rack → rubber dam frame  However, there are certain procedures during the first

❍ Cavity fighter → fluoride.


appointment that are frequently associated with uncoop-
erative behaviour.
 One of the most important rewards sought by the child is
 The highest rates of uncooperative behaviour during the
the approval of the dentist.
first session occur when the child is separated from his
 In praising a child, it is better to praise the behaviour than
mother.
the individual.
 Taking radiographs can cause some uncooperative behav-
 Tiny gifts make fine reward. Tiny gold stars, toys or stick- iour during the first session, since child may experience
ers make good gifts. It is the recognition more than the a fear of abandonment, which is common in children
material that makes the child happy younger than 4 years or it may be because of fear of the
 Flattery can also be used as a reward after the treatment. unknown.
Quick Review Series for BDS 4th Year: Paedodontics
44

 Subjective fear and maternal anxiety have been associated  Three-way syringe
with the reactions children exhibit at their first dental  Airotor
visit.  Micromotor on the nails.
 Several other factors have been associated with the reac- b. Identifying and eliminating or desensitizing any existing
tions children exhibit at their first dental visit. The promi- specific fears.
nent factor that has been related is the maternal anxiety.
 A negative attitude towards the physician and a previous iv. Above 12 Years Children
history of pain associated with medical appointments—
both have been identified as factors. Suggestions during first-visit treatment of these children are:
 Few studies have found that children of lower socioeco-  Information conveyed in such a way that their dental
nomic status exhibit more negative behaviour at their first health would improve their self-image and peer influ-
visit. ence.
 Except for the emergency treatment or non-invasive pro-  Personal perception of appearance needs to be evaluated
cedure it is wise not to perform any other treatment during before the need for any teeth alignment.
the first visit, even with a very cooperative patient. Every effort should be made to keep the first visit une-
 If the initial visit happens uneventfully, the child believes ventful. The time spent during first dental visit is a valuable
the dentist and starts trusting the stranger met. investment for the future dental visits.
 Once children are aware as to what would happen, most
of them are very prepared and tend to cooperate for the Q.3. How will you manage a rebellious child in dental
procedure. One may not have any difficulty in convincing clinic?
them. Every effort should be made to keep the first visit
Ans.
uneventful.
The following age-wise guidelines may prove useful for Managing a rebellious child in the dental clinic or a hospital
the paediatric dentist: is a common task. Managing can be done by following below
mentioned three steps:
i. 0–3 Years Children (Lacking Cooperative Ability) i. Parental counselling
 They should be examined either in knee-to-knee position ii. Voice control
on an infant examination table in the parent’s lap on the iii. Pharmacological methods.
dental chair selectively.
i. Parental Counselling
Suggestions during first visit are:
 Brief examination.  Instructing the parents to make sure that the child is
 Not to separate from the parents if possible. comfortable when the child comes for next appointment.
 Avoid using airotor, if necessary using micromotor to be By commanding the child and making him comfortable
considered. about the next appointment.
 Intermittent preparation of the tooth.
ii. Voice Control
ii. 4–6 Years Children  Voice control is a controlled alteration of voice, volume,
 They should be examined on the dental chair, sometimes tone or pace to influence and direct the patient’s behav-
in the parent’s lap on the dental chair. iour.
Suggestions during first-visit treatment of these children are:
Objectives
Effective TSD for the following:
a. To gain the patient’s attention and compliance.
 Chair movements and Chair light
b. To avert negative or avoidance behaviour.
 Suction apparatus
c. To establish authority.
 Three-way syringe
 Airotor Indications
 Micromotor on the nails.
 Voice control is indicated for the uncooperative, inatten-
iii. 7–12 Years Children tive and communicative child.

Suggestions during first-visit treatment of these children are: Contraindications


a. Effective TSD for the following:  In children who are unable to understand and cooperate
 Chair movements and chair light due to age disability, medication or emotional immatu-
 Suction apparatus rity.
Topic wise Solved Questions of Previous Years
45

Method Common parenteral agents for conscious sedation:


 Voice control is usually carried out on children of 3–6 Agents/narcotic Supplied as Recommended dose*
years. Fentanyl (Subli- Ampule(2 and 5 mL) SM → 0.002 mg/kg
 Sudden and firm commands can be used to get the child’s maze) (0.0005 mg/mL) IM → 0.002 mg/kg
attention or stop the child from whatever is being done. IV not recommended
 There is an abrupt and emphatic change in the dentist’s Alphaprodine Ampule (40 mg/mL, 1 mL) SM → 0.6 mg/kg
Ampule (60 mg/mL, 1 mL) IM → Not recommended
tone of voice to emphasize his displeasure with the child’s Vial (60 mg/ mL, 10 mL) IV → 0.2 mg/kg
inattention. Meperidine Ampule (50 mg/mL; 0.5, SM → 2 mg/kg
 Most often children seeing the dentist’s unhappiness become (Demerol) 1, 1.5 and 2 mL) IM → 2 mg/kg
quiet and start listening to the dentist’s instructions. Vial (50 mg/mL, 30 mL) IV → 0.3 mg/kg
 If used appropriately, this is one of the effective behav- Neuroleptics
iour management techniques to control child exhibiting Diphenhydramine Vial (10, 50 mg/mL, 10 SM → Not recommended
temper tantrums or defiant behaviour. (Benadryl) mL) IM → 1 mg/kg
 As soon as the child complies we should thank and com- Ampule (50 mg/mL, 1 mL) IV → 0.5 mg/kg
pliment him for the resultant excellent behaviour. Hydroxyzine Vial (50 mg/mL, 2 mL) SM → Not recommended
(Vistaril) Vial (25, 50 mg/mL, 10 IM → 1 mg /kg
iii. Pharmacological Methods mL) IV → Not recommended
Promethazine Ampule (25, 50 mg/mL, IM → 1 mg/kg
This method includes: (Phenergan) 1 mL) IV → 0.5 mg/kg
a. Oral sedation Reversal agents
b. Intravenous sedation. Naloxone (Opioid Ampule (0.4 mg/mL, IV/ IM/SC : 0.1 mg/kg/dose
reversal agent) 1 mL) to a maximum of 2 mg/dose
a. Oral sedation Flumazenil (Benzo- IV: 0.02 mg/kg/dose, may
diazepine reversal be repeated every 1 min to a
 Most accepted route of drug administration. agent) maximum 1 mg
 Absorption is not consistent. *Maximum dose.
 Recovery can be prolonged if drug is slowly metabolized.
Q.4. Describe the parental influences on the behaviour
b. Intravenous sedation of children during dental treatment.
 Can be used if the child refuses to take the drugs. Or
 Action cannot be reversed.
How does parental influence affect the behaviour of a child
 Site of injection is upper part of gluteal region. in paedodontic practice? Add a note on parent counselling.
Common oral agents for conscious sedation:
Ans.
Agents/narcotic Supplied as Recommended dose*
Meperidine Tablets (50 mg) 1–1.5 mg/kg with agents  In the treatment of children, a child cannot be treated as a
(Demerol) Syrup (50 mg/5 mL) from other group or 2 mg/ single separate entity since his/her behaviour will depend
kg without other agents a great deal on his/her parents, siblings or the family as a
Sedative hypnotics whole.
Chloral hydrate Capsule 250 and 50–70 mg/kg
 The paedodontic treatment triangle depicts this. All parts
(Noctec) 500 mg
Syrup (50 mg/mL)
of the triangle are interrelated and the arrows show that
Diazepam (Valium) Tablets (2,5 and 0.2–0.5 mg/kg alone
they are dynamic or ever-changing.
10 mg)
Phenobarbital (Nem- Capsules (30, 50 and 2–3 mg/kg alone
butal) 100 mg) Elixir Child
(30 mg/5 mL)
Antihistamines
Antihistamines Diphen- Capsules (25 and 50 1–1.5 mg/kg with narcotic
hydramine (Benadryl) mg)
Elixir (12.5 mg/mL)
Hydroxyzine Syrup (10 mg/5 mL) PO: 1–2 mg/kg
IM 1.1 mg/kg with narcotic
Society
Promethazine Tablets (10, 25, 50 and 0.5–1 mg/kg with narcotic
Phenergan 100 mg) Syrup (2, 5,
6.25 mg/mL) Parents Dentists
*Maximum dose.
Quick Review Series for BDS 4th Year: Paedodontics
46

 Here the child is the most significant part and depicted Mother–child behaviour interactions:
at the apex of the triangle. Mother plays the most signifi-
cant part in the family’s influence in child behaviour since Mother’s behaviour Child’s behaviour
she is the one the child will be usually most attached to, Overprotective Shy, anxious, lacking confidence,
though other members also play a significant role. submissive

 The parent’s attitudinal structure that moulds, shapes and Overindulgent Aggressive, spoilt, demanding, displays
temper
directs child behaviour in the early period of the offspring
development is affected by socioeconomic position, cul- Underaffection Usually well-behaved, shy, unable to
cooperate
tural development and ethnic background.
Rejecting Overactive, disobedient, aggressive
 From such sources emerge gradations of parenting rang-
ing from the authoritative progenitor to the shy one. The Authoritarian Delayed response, evasive
parent who is personally distraught or depressed has dif-
ficulty parenting in an effective manner.
Effects of Maternal Anxiety on Child Behaviour
 Highly anxious parents tend to affect their child’s behav-
Maternal Influence on Personality Development
iour negatively.
 There is a mother–child interdependency that initiates at  Although the scientific data has revealed that children of
infancy, and builds well into the preschool period. all ages can be affected by their mother’s anxiety.
 Should this interdependency extend beyond its intended  The effect is greatest with those under 4 years of age.
period, dual ambivalences may emerge between the  These might be anticipated because of the close child–
mother and her child with resultant maternal anxieties parent symbiosis that begins in infancy and gradually
and development of aberrant behaviour pattern on the diminishes.
part of the offspring.
 Bayley and Schaefer indicate that most of the relevant Parent Counselling
mother–child relationships fall into following two broad  Educating the patient is very important to get a satisfac-
categories: tory rapport between the entire family and the dentist.
A. Autonomy versus control  Personal fears: Tell the parents not to voice their own per-
B. Hostility versus love. sonal fears in front of the child.
 Dentistry not a threat: Tell the parents never to use den-
 Mothers who allowed enough autonomy and expressed
affection had children who were friendly and coopera- tistry as a threat or punishment.
 Familiarize dentistry: Tell the parents to familiarize their
tive and those who ignored their children did not have
children who exhibited these positive behavioural fea- child with dentistry by taking the child to the dentist to
tures. become accustomed to the dental office and the dentist.
 Courage display: Explain to the parent that an occasional
 ‘Bell’ termed the parent–child relationship as ‘one-tailed’;
since parental characteristics are viewed as having a uni- display of courage on his part in dental matters will build
lateral influence on those developing in the child. courage in the child.
 Parental attitudes: Counsel the parent about the home
 According to the ‘one-tailed’ theory, many of the child’s
environment and the importance of moderate parental
characteristics including his personality, behaviour and
attitudes in building well-adjusted children.
reaction to stressful situations are the direct product of
 Valuing dental care: Stress to parent, the value of regular
various parental, especially maternal characteristics.
dental care, not only in preserving the teeth but also in the
formation of good dental patients.
Parental Attitudes  Do not bribe the child.
 Never scold the child.
Some of the parental attitudes can adversely affect the child’s
 Encourage the child.
developing personality; these specific types of parental be-
haviours leading to characteristic maladaptive behaviour in
Q.5. Define behaviour management. Enumerate fun-
their children are as follows:
damentals of behaviour management techniques and
a. Overprotective attitude explain aversive conditioning in detail.
b. Overindulgent attitude
c. Over-authoritative attitude Or
d. Underaffection/rejecting attitude. Briefly mention about HOME care for child patient.
Topic wise Solved Questions of Previous Years
47

Ans. Technique of HOME


Behaviour management is a means by which the dental  Dentist gently but firmly places his hand over the child’s
health team effectively performs treatment for a child and at mouth.
the same time, installs a positive dental attitude.  In a loud voice child is told that if he cooperates the hand
Fundamentals of behaviour management are as follows: will be removed from the mouth.
 When the patient indicates his willingness to cooperate,
 To establish effective communication with the child and
usually by a nod of the head or the scream, the hand is
the parent. removed and the patient is revaluated.
 To gain the confidence of both the child and the parent
 If the disruptive behaviour continues, the dentist again
and make them accept dental treatment. places his hand over the child’s mouth and tells him to
 To teach the child and the parent about the positive aspects cooperate.
of preventive dental care.  Once the child cooperates he must be complimented.
 To provide a relaxation and comfortable environment for  The need to diagnose and treat, as well as the safety of the
the dental team to work in while treating the child. patient and practitioner must justify the use of HOME.
 Parent’s or guardian’s consent should be obtained prior to
Aversive Conditioning the use of HOME.
Aversive conditioning includes the following two tech-  Informed consent and indication for the use of HOME
niques: should be included in the patient record.
i. Hand over mouth exercise (HOME)
Indications
ii. Physical restraints.
 In case of a healthy child who is able to understand and
Hand-over-mouth Exercise Technique (HOME) cooperate, but who exhibits defiant, obstreperous or hys-
terical avoidance of behaviour to dental treatment.
 This technique was first described in the 1920s by Dr Evan-
 For normal children who are hysterical, belligerent.
geline Jordan who wrote ‘if a normal child will not listen
 Used for children with sufficient maturity to understand
but continue to cry and struggle hold a folded napkin over
simple verbal commands.
the child’s mouth and gently but firmly hold his mouth
shut. His screams increase his condition of hysteria; but if
Contraindications
the mouth is held closed, there is little sound and he soon
begins to reason’.  In children who due to age, disability, medication, or emo-
 Levitas described hand-over-mouth technique (HOMT) tional immaturity are unable to understand and cooperate.
as hand-over-mouth exercise (HOME). A hand is placed  When it will prevent the child from breathing.
over the child’s mouth and behavioural expectations are  Once communication is achieved with HOME, other
calmly explained. The child is told that the hand will be management techniques can be employed.
removed as soon as appropriate behaviour begins. When There are several variations to HOME. These are as follows:
the child responds the hand is removed and the child’s
 Hand over mouth – airway unrestricted
appropriate behaviour is reinforced. The method may
 Hand over both mouth and nose – airway restricted
require reapplication.
 Towel held over mouth only
 It was called emotional surprise therapy by Lampshire  Dry towel held over mouth and nose
and as aversive conditioning by Kramer.  Wet towel held over mouth and nose.
Objectives of HOME therapy are as follows: But it is always recommended that the hand be placed
i. To gain the child’s attention enabling communication only over the mouth so that the child’s airway should never
with the dentist so that appropriate behavioural expec- be restricted. It is very important to ensure that the child
tations can be explained. has no nasal blockage and can satisfactorily breathe through
ii. To eliminate inappropriate avoidance responses to den- nose when the mouth is closed.
tal treatment and to establish appropriate learned re-
sponses. Physical Restraints
iii. To enhance the child’s self-confidence in coping with the  Protective stabilization or restraining is defined as the
anxiety of dental treatment. restriction of the patient’s freedom of movement, with or
iv. To ensure the child’s safety in the delivery of quality den- without the patient’s permission, to decrease risk of injury
tal treatment. while allowing safe completion of treatment.
Quick Review Series for BDS 4th Year: Paedodontics
48

 Partial or complete immobilization of the patient is neces- b. Molt mouth prop:


sary, sometimes to protect the patient and/or dental staff  Very helpful for management of a difficult patient for a
from injury while providing dental care. prolonged period.
 Physical restraints in the dental office can range from  Made in both adult and children sizes.
gently holding a child’s hands during injection procedure  Allows accessibility to the opposite side of the mouth.
to full-body restraint with a papoose board.  Disadvantages include the possibility of lip and palatal
 Restraints can be performed by the dentist, staff or parent lacerations and luxation of teeth if not used correctly.
with or without the aid of a restraining device.  Caution must be exercised to prevent injury to the patient,
 Parental or guardian’s consent must be obtained prior to and the prop should not be allowed to rest on anterior
use of restraints, and the following must be included in teeth and patient’s mouth should not be forced beyond its
the patient record: natural limits.
i. Informed consent
ii. Type of restraint used c. A finger guard or an intraocclusal thimble:
iii. Indication for the stabilization The advantages are:
iv. The time and the duration of application of restraint.  It prevents mouth closure
 Inexpensive
Objectives of Using Restraints are  Fits dentist’s finger.
i. To reduce or eliminate untoward movement. Main disadvantage is the limited mobility of the dentist’s
ii. To protect the patient and dental staff from injury. hand once the splint is in place and functioning.
iii. To facilitate delivery of quality dental treatment. d. Rubber bite blocks
 Available in various sizes to fit on the occlusal surfaces of
Indications
the teeth and stabilizes the mouth in an open position.
i. A patient who requires immediate diagnosis or treat-
ment and cannot cooperate due to lack of maturity, II. Restraints for Body
mental or physical disability.
ii. A patient who requires diagnosis and/or treatment and a. Papoose board
does not cooperate after other behaviour management  It is a commercial wrapping for the body.
techniques.  Secures child against a rigid base with three pairs of canvas
iii. When the safety of the patient and/or practitioner would straps or single strap for very young child. Velcro® system
be at risk without the protective use of restraints. is easy to close and adjusting by pressing or peel-apart fas-
teners.
Contraindications  Restrains even the most uncooperative patients.

i. A cooperative patient. b. PediWrapTM


ii. A patient who cannot be restrained safely due to under-  Reinforced nylon mesh sheet with Velcro® closures avail-
lying medical or systemic conditions. able in small, medium and large sizes, which is placed on
The following are some commonly used physical restraints: prepositioned chair.
 Child is placed on the wrap and Velcro® fasteners are put
I. Oral: Mouth props, padded wrapped tongue blades, a
finger guard or an intraocclusal thimble and rubber/ on chest followed by arms and legs to avoid movements.
plastic bite blocks. c. Bean bag dental chair insert
II. Body: Papoose board, triangular sheet, PediWrapTM,  It was developed to help comfortably accommodate the
bean bag dental chair insert, safety belt, extra assistance. hypotonic and severely spastic patients who need more
III. Extremities: Posey strap, Velcro® straps, towel/tape, ex- support and less restraining.
tra assistant.
IV. Head: Forearm support, head positioner, plastic bowl, III. Restraints for Extremities
extra assistant.
a. Posey straps
I. Oral Restraints  To restrain the child’s arms and legs.
 Posey straps fasten to the arms of the dental chair and
Mechanical aids to maintain the mouth in an open position:
allow limited movement.
a. Padded and wrapped tongue blades:
 Easy to use b. Towel and tape
 Disposable  A towel wrapped around patient’s fore arms and fastened
 Inexpensive. with adhesive tapes without impeding circulation.
Topic wise Solved Questions of Previous Years
49

c. Velcro® straps and an extra assistant  Behaviour shaping is the procedure that very slowly devel-
 Velcro® straps are available in small, medium and large ops behaviour by reinforcing successive approximations of
sizes. the desired behaviour until the desired behaviour comes to
be. It is sometime called as ‘stimulus response theory’.
IV. Restraints for Head According to AAPD Guidelines 2002–03:
a. Forearm body support I. Basic behaviour management
 Head position can usually be maintained by the use of 1. Communicative management
forearm body pressure by the dental surgeon. a. Voice control
b. Non-verbal communication
b. Head positioner c. Tell–show–do
 The papoose board comes with a head positioned to sta- d. Positive reinforcement
bilize the head. e. Distraction.
c. Extra assistant 2. Parental presence or absence
 An extra assistant is required to stabilize the head.
3. Nitrous oxide/oxygen inhalation sedation.
 Physical restraints should never be used as punishment. II. Advanced behaviour management
An explanation of their benefits should be presented if 1. Hand-over-mouth exercise
communication is possible with the child as well as the 2. Medical immobilization
parents. 3. Sedation
4. General anaesthesia.
Q.6. Discuss various behaviour modification techniques In general, behaviour management methods are classified as
for child management in dental office. follows:
A. Non-pharmacological methods
Or
B. Pharmacological methods.
Describe modelling therapy in behaviour management A. Non-pharmacological methods
in paedodontic practice.
a. Preappointment behaviour modifications
Or b. Communication
What are different methods you would adopt to man- c. Behavioural shaping techniques:
age a difficult child in the dental clinic? i. Tell–show–do
ii. Desensitization
Or iii. Modelling
Discuss various behavioural managements of a 4-year- iv. Contingency.
old child throwing temper tantrums. d. Behavioural management techniques
i. Audioanalgesia
Or ii. Biofeedback
Classify behaviour management techniques. Explain iii Voice control
how you would manage a 5½-year-old boy exhibiting iv. Hypnodontics
temper tantrums. v. Coping
vi. Relaxation
Or vii. Aversive conditioning
Define behaviour management and behaviour shaping. viii. Implosion therapy
Enumerate various non-pharmacological and pharma- ix. Retraining.
cological techniques used for behaviour management. B. Pharmacological methods of behaviour management
Explain in detail about tell–show–do. I. Premedication
a. Sedatives and hypnotics
Or
b. Anti-anxiety drugs
Define behaviour management. Explain in detail TSD c. Antihistaminics.
technique. II. Conscious sedation
Ans. III. General anaesthesia.

 Behaviour management is defined as the means by which A. Non-pharmacological Methods


the dental health team effectively and efficiently performs
treatment for a child and at the same time installs a posi- The non-pharmacological methods of behaviour manage-
tive dental attitude. ment are explained in detail below.
Quick Review Series for BDS 4th Year: Paedodontics
50

a. Preappointment Behaviour Modification Objectives of TSD technique are:


 Preappointment behaviour modification includes every-  Teach the patient about important aspects of the dental
thing that is to be done to positively influence the child’s visit.
behaviour, before the child enters the dental clinic.  Familiarization of dental setting.
 Various methods used for this purpose are as follows:  Shape the patient’s response to procedures through desen-
i. Films or videotapes showing a model of a cooperative sitization and well-described expectations.
child patient. TSD is a series of successive approximations; the steps followed
ii. It can also be performed on live models, such as other in TSD are:
children or parents. A. Tell the child about the treatment to be carried out.
B. Show him part of it, how it will be done.
b. Communication C. Then do it.
 Effective communication, i.e. imparting or interchange of  TSD technique includes verbal explanations at the
thoughts, opinions or information is important factor in patient’s understanding level (tell) appropriately us-
dealing with children. ing second language or word substitutes wherever
 The first objective of successful management of a young necessary.
dental patient is to establish communication.  Demonstration of the visual, auditory, olfactory and
 Based on the age of the child there are many ways of ini- tactile aspects of the procedure in a non-threatening
tiating a verbal communication but in dental setups it is fashion (show).
affected primarily through dialogue, tone of voice, facial  Completion of the procedure without deviating from
expression and body language. what was explained and demonstrated (do).
 Involving the child in conversation will relax the child and  While working intraorally, the child should be shown
enable the dentist to learn about the patient. as much of the procedure as possible. One should be
 Verbal communication with young children is best initi- truthful with the child and yet should not frighten
ated with complementary comments about their dress or him/her.
interests followed by some questions that elicit an answer  Any deviation from that of originally explained or
other than Yes or No. demonstrated can affect the relation between the
 For the successful communication to take place all the four child and the dentist. So honesty is required to achieve
elements of communication, i.e sender, message, context positive attitude of children in future.
and receiver must be present and consistent.  TSD contains certain elements of systematic desen-
sitization.
c. Behavioural Shaping Techniques  Ingersoll (1982) however considers TSD to be an
 Behaviour shaping is the procedure by which the desired information-exposure method of behaviour shaping
behaviour is instilled and inculcated in the child. because it excludes the preparatory format contained
 Behaviour shaping is based on a planned introduction of in the original studies on systematic desensitization.
treatment procedures so that the child is gradually trained Indications
to accept treatment in a relaxed and cooperative manner.  All patients who can communicate regardless of the level
 Various behaviour-shaping techniques are as follows:
or the method of communication.
i. Tell–show–do
ii. Desensitization ii. Desensitization
iii. Modelling
iv. Contingency.  Desensitization technique involves three stages:
a. Training the patients to relax.
i. Tell–show–do technique b. Constructing a hierarchy of fear-producing stimuli.
c. Introducing each stimulus in hierarchy to relaxed pa-
 Almost five decades ago (1959) Addelston formalized a tient, starting with the stimulus which causes least
technique that encompasses several concepts from the fear.
social learning theory. It was called tell–show–do (TSD)
technique. Example: If the child is afraid of dental clinic, the general
 The TSD is a behaviour-shaping technique. It gives good desensitization should include gradual introduction of the
results and is recommended to be followed in routine child to following:
practice.  Reception, waiting room and receptionist
 The TSD method of introducing dental techniques is  Paedodontist, hygienist and nurse
extremely effective for shaping the child’s behaviour and  Dental surgery
conditioning him/her to accept treatment.  Dental chair
Topic wise Solved Questions of Previous Years
51

 Oral examination form of gifts like toothbrush kits, drawing kits, favourite
 Prophylaxis. cartoon stickers or toys appropriate for their age.
At each stage the child’s fears are allayed by the kind,  Negative reinforcers are withdrawn. Example: Withdrawal
friendly and reassuring manner of receptionist, nurse, hygi- of handpiece, if the child is afraid of the noise of that and
enist and paedodontist and positive approach of the child is using hand instruments so that the child will accept dental
reinforced. treatment in the next appointment.
 Presence (positive) or absence (negative) of these rein-
iii. Modelling (imitation) forcers increases the frequency of desired behaviour.
 Children are capable of acquiring almost any behaviour 2. Omission or time out
that they observe closely and that is not too complex for  It is the means of increasing the probability (frequency)
them to perform at their level of physical development. of a desired behaviour by withdrawal of or threatening to
 Modelling is learning by imitation based on observational withdraw a pleasant stimulus. Example: Warning or threat-
learning theory by Albert Bandura, 1969. ening the child that you will send the mother outside the
 Goal of modelling is to have the patient reproduce the operatory, if the child is not cooperating for the procedure.
behaviour exhibited by the models.
3. Punishment
Stages and requirements of modelling  It is the means of increasing the frequency of a desired
 Two stages of modelling are acquisition and perform- behaviour by the presentation of an aversive stimulus.
ance and the four requirements are attention, retention, Example: The use of voice control, protective stabilization
motoric reproduction, reinforcement and motivation or hand over mouth.
which were discussed under observational learning theory
and child psychology. d. Behavioural Management Techniques
The advantages of modelling procedures are the following: i. Audioanalgesia
 Stimulation of good behaviour. ii. Biofeedback
 Facilitation of behaviour in more appropriate manner. iii. Voice control
 Extinction of fears and apprehensions. iv. Coping
Modelling is effective particularly in the following conditions: v. Relaxation
vi. Aversive conditioning
 When the patient is in state of arousal.
vii. Implosion therapy
 When model’s behaviour has positive consequences.
viii. Retraining.
 When modelling is performed on models having higher
status and prestige. i. Audioanalgesia

iv. Contingency management  It is also called as ‘white noise’. This consists of providing
a sound stimulus intensity so that the patient finds it dif-
 This technique is based on the operant conditioning ficult to attend to anything else. The effect is due to dis-
theory of BF Skinner. traction, displacement of attention, and a positive feeling
 It is a method of modifying behaviour by presentation or on the part of the dentist that it can help.
withdrawal of the reinforcers. These reinforcers are the
pleasant or unpleasant stimuli mentioned in the operant ii. Biofeedback
conditioning theory in child psychology.
 In this method certain physiologic reaction of the body are
 Contingency management includes:
detected that may indicate fear. Example: Checking heart
1. Reinforcement: It can be either positive reinforcement
rate that may increase when the patient is under stress.
or negative reinforcement
2. Omission/time out iii. Voice control
3. Punishment.
 Voice control is a controlled alteration of volume, pace or
1. Reinforcement
tone of voice to control child’s disruptive behaviour.
 It is a method of increasing the probability (frequency) of  To establish authority, gain the child’s attention and com-
a desired behaviour by presentation of a pleasant stimulus pliance and avert negative behaviour, voice control is
or withdrawal of an aversive or unpleasant stimulus. Here done.
the stimulus is termed as reinforcer.  Voice control is most effective when used in conjunction
 Positive reinforcers are presented. Example: A pat on the with other communication. A sudden command ‘to stop
back or shoulder, shaking hand, verbal praise in the pres- crying and pay attention’ may be a necessary preliminary
ence of parent for which the child will be happy. In the measure for future communication.
Quick Review Series for BDS 4th Year: Paedodontics
52

 Sudden and firm commands can be used to get the child’s vi. Aversive conditioning
attention or stop the child from whatever is being done.
Aversive conditioning includes the following two tech-
 This is an abrupt and emphatic change in the dentist’s
niques:
tone of voice to emphasize his displeasure with the child’s
inattention. a. Hand-over-mouth exercise (HOME)
 As soon as the child complies we should thank him and b. Physical restraints.
compliment him for the resultant excellent behaviour. a. Hand-over-mouth exercise technique (HOME)
 If used properly in correct situations, voice control is an  This technique was first described in the 1920s by Dr.
effective management tool. Evangeline Jordan.
Objectives  Levitas described hand-over-mouth technique (HOMT)
 To gain the patient’s attention and compliance as hand-over-mouth exercise (HOME). A hand is placed
 To avert negative or avoidance behaviour over the child’s mouth and behavioural expectations are
 To establish authority. calmly explained. The child is told that the hand will be
Indications removed as soon as appropriate behaviour begins. When
the child responds, the hand is removed and the child’s
 Voice control is indicated for the uncooperative, inatten-
appropriate behaviour is reinforced. The method may
tive, communicative child. require reapplication.
Contraindications  It was called emotional surprise therapy by Lampshire
 In children who due to age disability, medication or emo- and as aversive conditioning by Kramer.
tional immaturity are unable to understand and cooper- Objectives of HOME therapy are as follows:
ate.
i. To gain the child’s attention enabling communication
with the dentist so that appropriate behavioural expec-
iv. Coping
tations can be explained.
 Patients differ not only in their perception and response ii. To ensure the child’s safety in the delivery of quality den-
to pain but also in their ways of dealing or coping with the tal treatment.
stress associated with painful experiences.
Indications of HOME
 Same can be used to modify child’s behaviour in the
dental clinic.  For normal children who are momentarily hysterical, bel-
ligerent or defiant.
Different coping mechanisms are as follows:
 Used for children with sufficient maturity to understand
 Distraction or displacement of attention away from the
simple verbal commands.
threat. Frequently, the patient spontaneously endeavours
to utilize this coping behaviour by thinking of something Contraindication of HOME
pleasant or diverting or this may be done deliberately by  Immature, frightened or the child with a serious physical,
the dentist by talking to the child and asking him interest- mental or emotional handicap.
ing questions. b. Physical restraints
 Verbalizing fears to others is another well-known way of
 Protective stabilization or restraining is defined as the
coping. Expressive communication serves to release ten-
restriction of patient’s freedom of movement, with or
sion.
without the patient’s permission, to decrease risk of injury
 Another best way is facing the threat of stress or the pain
while allowing safe completion of treatment.
enjoying affiliative behaviour. When people feel threat-
 Parental or guardian consent must be obtained prior to
ened, they prefer to be with others.
use of restraints.
v. Relaxation Objectives of using restraints are:
 Jacobson and others used specific relaxation technique. i. To reduce or eliminate untoward movement.
Relaxation usually involves a series of basic exercise that ii. To protect the patient and dental staff from injury.
may take several months to learn and which requires the iii. To facilitate delivery of quality dental treatment.
patient to practice at home for at least 15 minutes each
day. Indications
 Telling oneself to relax is another mechanism for personal  A patient who requires immediate diagnosis or treatment
coping. This technique apparently works by reducing ten- and cannot cooperate due to lack of maturity, mental or
sion, well-known potentiator of pain. physical disability.
Topic wise Solved Questions of Previous Years
53

The following are some commonly used physical restraints:  The child has no other choice but to face it until the nega-
 Oral: Mouth props, padded wrapped tongue blades, a tive behaviour disappears.
finger guard or an intraocclusal thimble and rubber/plas-  It comprises of HOME technique, voice control and phys-
tic bite blocks ical restraints together.
 Body: Papoose board, triangular sheet, PediWrapTM, bean
bag dental chair insert, safety belt, extra assistant. viii. Retraining
 Extremities: Posey strap, Velcro® straps, towel/tape, extra
assistant.  It is required in children displaying considerable appre-
 Head: Forearm support, head positioner, plastic bowl, hension or negative or uncooperative behaviour, which
extra assistant. may be due to a previous dental visit.
 Physical restraints should never be used as punishment. An  The objective of retraining is to build a new series of
explanation of their benefits should be presented if com- images and associations in child’s mind.
munication is possible with the child as well as parents.  If the child’s expectancy of getting hurt does not come
true, a new series of expectancies are learned that the
vii. Implosion therapy paedodontist and his auxiliaries can be trusted. The child
 In this technique the patient is flooded with many stimuli develops a new perception of dental clinic and a new rela-
which have affected him adversely. tionship to dentistry.

SHORT ESSAYS

Q.1. Paediatric treatment triangle.  In the treatment of children, a child cannot be treated as a
single separate entity since his/her behaviour will depend
Or a great deal on his/her parents, siblings or the family as a
Psychic triad. whole.
 The paedodontic treatment triangle depicts this. All parts
Or of the triangle are interrelated and the arrows show they
What do you understand by paediatric triangle? Give are dynamic or ever-changing.
its significance.  The child is the most significant part and is depicted at the
apex of the triangle.
Ans.
 Mother plays the most significant part in the family’s
Paedodontic triangle was given by Wright. influence in child behaviour since she is the one the child
 The child occupies the apex of the triangle. will be usually most attached to, though other members
 Focus is on the dentist and the parent. also play a significant role.
 All the three are interrelated.  The parent’s attitudinal structure, which moulds, shapes
and directs child behaviour in the early period of the off-
Recently ‘society’ has also been added.
spring development, is affected by socioeconomic posi-
tion, cultural development and ethnic background.
Child  The socioeconomic status of the family unit directly
affects its attitude towards the values of the dental health
process.
 The low income group or parents with below average edu-
cation have a tendency to attend dental needs when the
symptoms dictate. Certain of these families harbour anxi-
eties and fear of dental treatment, and their children take
Society on these fears and tend to be less cooperative.
 Cultural standards and ethnic orthodoxies have some
bearing on the degree of acceptance of dental health
Parents Dentists
measures. Their closed attitude fosters anxieties among
the children producing desparate behaviour forms.
Quick Review Series for BDS 4th Year: Paedodontics
54

Q.2. Aversive conditioning.  Parent’s or guardian’s consent should be obtained prior to


the use of HOME.
Or
HOME. Indications
 In case of a healthy child who is able to understand and
Or
cooperate, but who exhibits defiant, obstreperous or
Hand-over-mouth exercise (HOME). hysterical avoidance of behaviour to dental treatment.
 For normal children who are hysterical, belligerent.
Ans.  Used for children with sufficient maturity to understand
 Aversive conditioning includes the following two simple verbal commands.
techniques:
Contraindications
i. Hand-over-mouth exercise (HOME)
 In children who due to age, disability, medication, or emo-
ii. Physical restraints.
tional immaturity are unable to understand and cooperate.
 When it will prevent the child from breathing.
Hand-over-mouth Exercise Technique (Home)
But it is always recommended that the hand be placed
 This technique was first described in the 1920s by Dr only over the mouth and the child’s airway should never be
Evangeline Jordan. restricted. It is very important to ensure that the child has no
 Levitas described hand-over-mouth technique (HOMT) nasal blockage and can satisfactorily breathe through nose
as hand-over-mouth exercise (HOME). A hand is placed when the mouth is closed.
over the child’s mouth and behavioural expectations are
calmly explained. The child is told that the hand will be Physical Restraints
removed as soon as appropriate behaviour begins. When  Hand-over-mouth exercise technique
the child responds the hand is removed and the child’s  Physical restraints
appropriate behaviour is reinforced. The method may  Protective stabilization or restraining is defined as the
require reapplication. restriction of the patient’s freedom of movement with or
 It was called emotional surprise therapy by Lampshire without the patient’s permission to decrease risk of injury
and as aversive conditioning by Kramer. while allowing safe completion of treatment.
 Parental or guardian consent must be obtained prior to
Objectives of HOME therapy are as follows:
the use of restraints.
i. To gain the child’s attention enabling communication
Objectives of using restraints are:
with the dentist so that appropriate behavioural
i. To reduce or eliminate untoward movement
expectations can be explained.
ii. To protect the patient and dental staff from injury and
ii. To eliminate inappropriate avoidance responses to iii. To facilitate delivery of quality dental treatment.
dental treatment and to establish appropriate learned
responses. Indications
iii. To enhance the child’s self-confidence in coping with the
i. A patient who requires immediate diagnosis or treat-
anxiety of dental treatment.
ment and cannot cooperate due to lack of maturity,
iv. To ensure the child’s safety in the delivery of quality den-
mental or physical disability.
tal treatment.
ii. A patient who requires diagnosis and/or treatment and
does not cooperate after other behaviour management
Technique of HOME techniques.
 Dentist gently but firmly places his hand over the child’s iii. When the safety of the patient and/or practitioner would
mouth. be at risk without the protective use of restraints.
 In a loud voice, the child is told that if he cooperates the
Contraindications
hand will be removed from the mouth.
 When the patient indicates his willingness to cooperate, i. A cooperative patient
usually by a nod of the head or the scream, the hand is ii. A patient who cannot be restrained safely due to under-
removed and the patient is re-evaluated. lying medical or systemic conditions.
 If the disruptive behaviour continues, the dentist again The following are some commonly used physical restraints:
places his hand over the child’s mouth and tells him to I. Oral: Mouth props, padded wrapped tongue blades, a
cooperate. finger guard or an intraocclusal thimble and rubber/
 Once the child cooperates he must be complimented. plastic bite blocks
Topic wise Solved Questions of Previous Years
55

II. Body: Papoose board, triangular sheet, PediWrapTM, III. Potentially Cooperative Behaviour
bean bag dental chair insert, safety belt, extra assistant.
 Child is cooperative.
III. Extremities: Posey strap, Velcro® straps, towel/tape, ex-  Physically and mentally fit.
tra assistant.  Child’s behaviour can be modified.
IV. Head: Forearm support, head positioner, plastic bowl,  Group of children’s require behavioural modification
extra assistant. procedures.
 Physical restraints should never be used as punishment.
Potentially cooperative behaviour is subclassified into fol-
An explanation of their benefits should be presented if
lowing:
communication is possible with the child as well as par-
ents. Uncon- Defiant Timid be- Tense co- Whining
trolled behaviour haviour operative behaviour
Q.3. Wright’s classification of behaviour of children in behaviour behaviour
dental office. Age group Found in all Seen in Border line Whining
3–6 years ages overprotec- behaviour throughout
Ans.
tive child the proce-
Various classifications of behaviour are as follows: dure
I. Frankl’s classification (1962) Also called Also referred Milder Child is Cry is
incorrigible to as stub- but highly tensed in controlled,
II. Lampshire’s classification behaviour born or anxious mind constant
III. Wright’s classification spoilt and not
IV. Kopel’s classification loud
V. Modified Wright’s classification (addition of symbolic Tears, loud They don’t Is shy but Seldom are
modifications to the Frankl’s rating scale). crying, like to go to cooperative the tears
physical dental clinic
Wright’s classification of cooperativeness of children in lashing out
dental office and flailing
of the hands

Children’s behaviour
Q.4. TSD.
Ans.
Cooperative Lacking Potentially
behaviour cooperative cooperative  Behaviour shaping is the procedure by which the desired
behaviour behaviour behaviour is instilled and inculcated in the child.
 Behaviour shaping is based on a planned introduction of
treatment procedures so that the child is gradually trained
i. Uncontrolled to accept treatment in a relaxed and cooperative manner.
behaviour  Tell–show–do (TSD ) is one of the behaviour-shaping
ii. Defiant behaviour techniques.
iii. Timid behaviour
iv. Tense cooperative Tell–Show–Do Technique (TSD)
behaviour
v. Whining behaviour  Almost five decades ago (1959) Addelston formalized a
technique that encompasses several concepts from the
social learning theory. It was called tell–show–do (TSD)
I. Cooperative Behaviour technique.
 Child is cooperative.  The TSD is a behaviour-shaping technique. It gives good
 Reasonably relaxed. results and is recommended to be followed in routine
 Develops good rapport with the dentist. practice.
 The method of introducing dental techniques is extremely
 Laughs and enjoys the situation.
effective for shaping the child’s behaviour and condition-
ing him/her to accept treatment.
II. Lacking Cooperative Behaviour
 This behaviour is in contrast to cooperative child. Objectives of TSD Technique
 Includes young children (0–3 years), disabled child, physi-  Teach the patient about important aspects of the dental
cally and mentally handicap. visit.
 They can have major behavioural problems.  Familiarization of dental setting.
Quick Review Series for BDS 4th Year: Paedodontics
56

 Shape the patient’s response to procedures through desen- Objectives of modelling according to Rimm and Masters
sitization and well-described expectations.  Stimulation of acquisition of new behaviours.
TSD is a series of successive approximations, the steps followed  Facilitation of behaviours already in the patient’s reper-
in TSD are: toire in a more appropriate manner or time.
A. Tell the child about the treatment to be carried out.  Disinhibition of behaviour avoided because of fear.

B. Show him part of it, how it will be done.  Extinction of fears.

C. Then do it.
 TSD technique includes verbal explanations at the patient’s
Steps in Modelling
understanding level (tell) appropriately using second lan- i. First the patient’s attention is obtained.
guage or word substitutes wherever necessary. ii. The desired behaviour is modelled.
 Demonstration of the visual, auditory, olfactory and tac- iii. Physical guidance of the desired behaviour may be nec-
tile aspects of the procedure in a non-threatening fashion essary when the patient is initially expected to mimic the
(show). modelled behaviour.
 Completion of the procedure without deviating from iv. Reinforcement of the required behaviour.
what was explained and demonstrated (do).  In private practices, modelling technique yields signifi-
 While working intraorally, the child should be shown as
cant benefit with minimum effort. Rather than making
much of the procedure as possible. the child–patient wait in the waiting room where they
One should be truthful with the child and yet should not may be adversely influenced by maternal anxiety associ-
frighten him/her. ated with the dental situation, children may be brought
 Any deviation from that of originally explained or dem- into an operatory immediately upon arrival in the office if
onstrated can affect the relation between the child and the a suitable model is being treated.
dentist. So honesty is required to achieve positive attitude  It is observed that multiple model simultaneously under-
of children in future. going dental procedures seems to have remarkable calm-
 TSD contains certain elements of systematic desensitiza- ing effects on the anxious child.
tion.  According to Rimm and Master’s the effectiveness of mul-
 Ingersoll (1982), however, considers TSD to be an infor- tiple model is that ‘while single model might be presumed
mation exposure method of behaviour shaping because it by the child to have some special talents that allow them to
excludes the preparatory format contained in the original be fearless, this is less likely to be the case among a group
studies on systematic desensitization. of divergent models’.
 Furthermore, multiple models are likely to vary slightly
Indications in the ways in which they demonstrate fearless behaviour,
 All patients who can communicate regardless of the level thus providing greater latitudes of behaviour possibilities
or the method of communication. for the child.

Q.5. Describe modelling technique. Q.6. Operant conditioning.

Or Ans.

Modelling.  An individual learns to produce voluntary responses


which play a major role where the outcome is instrumen-
Ans.
tal in bringing about the reoccurrence of the stimulus.
 Bandura (1969) developed from social learning principles  This theory explains development or continuation of
a behavioural modification technique called modelling or behaviour as a result of reinforcement.
imitation.  The response to a stimulus which produces a satisfactory
 The basic modelling procedure involves allowing a outcome will be repeated whereas those which result in
patient to observe one or more individuals (models) disagreeable results will tend to diminish.
who demonstrate appropriate behaviours in a particular  Some of the terms identified with operant conditioning
situation. and are commonly used methods of influencing an indi-
 The patient will frequently imitate the model’s behav- vidual response are:
iour when placed in a similar situation. The model can be A. Reinforcement: It can be positive or negative.
live, e.g. siblings, other children or parents or filmed. For B. Systemic desensitization/counter conditioning: Method
example: Mickey mouse undergoing dental treatment in to eliminate learned maladaptive responses by substi-
picture or video format, with equally successful results. tuting more appropriate ones.
Topic wise Solved Questions of Previous Years
57

C. Reward: The result of adding positive outcomes or re- ii. IQ of the child
moving negative ones.
 Intelligent quotient (IQ) is the method of quantifying the
D. Punishment: The result of adding negative outcomes mental ability in relation to chronological age formulated
and/or removing positive ones, thus weakening the be- by Alfred Binet.
haviour or responses. IQ = mental age/chronological age × 100

Q.7. Factors affecting child behaviour in dental office. iii. Past dental experience
Ans.  Attachment attained by the child during the past dental
visit plays a very important role than the number of visits.
Factors influencing child’s behaviour are categorized under  Any past unpleasant dental experience results in uncoop-
following headings: erative behaviour.

Factors involv- Factors involving Factors involving iv. Social and adaptive skills
ing the child/ the parents the dentist
out of control of  If a child gets whatever he wants there are high chances of
dentists child getting spoilt.
 Independence of the child also plays a major role.
Growth and develop- Family influence Appearance of the
ment dental office
v. Position of the child in the family and child’s
IQ of the child Parent–child rela- Time of appointment
behaviour
tionship
Past dental experi- Maternal anxiety Length of appoint- i. First child: Uncertainity, mistrustfulness, insecurity,
ence ment dependence, responsibility, jealousy.
ii. Second child: Independence, aggressive, extrovert, fun-
Social and adoptive Attitude of parents to Dentist’s skill
skills dentistry
loving, adventurous.
iii. Middle child: Aggressive nature, feeling of inferiority.
Position of the child Use of good words iv. Last child: Secure, confident, immature, envy, irresponsi-
in the family and rewarding
ble, good and bad behaviour.

II. Factors Involving the Parents


I. Factors Involving the Child/Out of Control of
Dentists i. Family influence
i. Growth and development  Home is the first school and it’s the place where the child
learns to behave.
 Growth is defined as an increase in size, whereas the
 Mother’s behaviour plays a major role in the behaviour of
development is progression towards maturity.
the child compared to the other family members.
 Both the processes proceed in a relatively predictable
 One tailed – is the description for the mother–child
logical step-like sequential order.
relationship.
 These processes are influenced by genetic, familial,
 Mother’s nutritional status also places a role in develop-
cultural, interpersonal and psychic factors.
ment of the child.
The basic developmental parameters that influence behaviour
are: ii. Parent–child relationship
 Biologic—motor maturation as well as bodily
 Two broad categories:
development.
i. Autonomy versus control
 Cognitive development—intellectual development such as ii. Hostility versus love.
thinking and reasoning.
Characteristics of parent–child relationship that may influence
 Emotion.
child’s behaviour in dental clinic:
 Perceptual development—integration of senses such as a. Domination
hearing and sight. b. Identification
 Personality and social development—habitual way of c. Overindulgence
behaving with others. d. Overprotective nature
 Growth of language skills. e. Authoritarian.
Quick Review Series for BDS 4th Year: Paedodontics
58

Mother’s behaviour Child’s behaviour Example: Mosquito bite → Needle prick


Overprotective Submissive, shy, anxious
Rain coat → Rubber dam
Coat rack → Rubber dam frame
Overindulgent Aggressive, spoilt, demanding, display
of temper
Cavity fighter → Fluoride.
 One of the most important rewards sought by the child is
Underaffectionate Well-behaved, unable to cooperate, shy,
may cry easily
the approval of the dentist.
 In praising a child, it is better to praise the behaviour than
Rejection Aggressive, overreactive, disobedient
the individual.
Dominant Aggressive, demanding, display of tem-
 Tiny gifts make fine reward. Tiny gold stars, toys or stick-
per
ers make good gifts. It is the recognition more than the
Identification Feeling of guilt, cries easily, loss of con-
material that makes the child happy.
fidence
 Flattery can also be used as a reward after the treatment.
Authoritarian Submissive, resentment, evasive
Q.8. Types of cry
iii. Maternal anxiety
Ans.
 Highly anxious parents affect child’s behaviour, and it is
more at the age of 4 years. Elsbach (1963) described four types of children’s cries as fol-
lows:
iv. Attitude of parents to dentistry i. Obstinate cry
ii. Frightened cry
 If parents behave positively even the child will behave in
the same way. iii. Hurt cry
iv. Compensatory cry.
III. Factors Involving the Dentist
i. Obstinate Cry
i. Appearance of dental office  It is exhibited by a child who throws a temper tantrum
 Appearance of dental office should make the child com- and is loud, high pitched and has been characterized as a
fortable. siren-like wail.
 Lamps and shades should be small.  This form of belligerence represents the child’s external
 Toys should be kept near the dental chair. response to his anxiety in the dental situation.
 Protect child from seeing adult’s pain or procedures like
extractions. ii. Frightened cry
 Dental office staffs should show enthusiasm.
 It is usually accompanied by a torrent of tears and convul-
sive breath catching sobs.
ii. Dentist behaviour
 The child emitting this type of cry has been overwhelmed
 Permitting the child to express. by the situation.
 Communicating with the child in a sweet way.  It is the dentist’s responsibility to instill confidence in the
 Making the child comfortable. frightened child by providing a series of carefully struc-
 Listening to children’s comments. tured dental experience that will allow the child to cope.
 Providing them the comfortable environment.
iii. Hurt Cry
iii. Time and length of appointment
 It may be loud and frequently is accompanied by as small
 Child should not be kept for more than half an hour on a whimper.
dental chair.  The first indication that the child is in discomfort may be
a single tear falling from the corner of the eye and running
iv. Dentist’s skill and speed
down the child’s cheek.
 The dentist should perform his duties with dexterity,  The hurt cry is easily identified because the child will state
should avoid loss of time. either voluntarily or when asked that he is being hurt.
 Some children may be in pain but control their physical
v. Use of good words, subtle flattery, praise and activity so that the dentist is unaware of a problem.
reward  When it is recognized that the child is in pain, dental pro-
 Fear-promoting words should be avoided. The following cedure should be stopped and satisfactory pain control
can be used instead: obtained.
Topic wise Solved Questions of Previous Years
59

iv. Compensatory Cry Wright’s modification of Frankl’s behaviour rating:


 According to Elsbach it is not a cry at all. Rating No. 1—definitely negative (–)
 It is a droning monotone the child makes to drown out Rating No. 2—negative (–)
the noise of the dentist’s drill. Rating No. 3—positive (+)
 While it may be annoying to the dentist, it is the child’s Rating No. 4—definitely positive (++).
way of coping with what he considers unpleasant audi-
tory stimuli. Q.10. Voice control.
 It is a successful coping strategy the child has developed to Ans.
cope with the anxiety he is experiencing and therefore the
dentist should make no attempt to stop it.  Voice control is a controlled alteration of voice, volume,
tone or pace to influence and direct the patient’s behav-
Q.9. Frankl’s behaviour rating scale. iour.
Ans. Objectives
Frankl’s Behaviour Rating Scale (1962) a. To gain the patient’s attention and compliance.
b. To avert negative or avoidance behaviour.
Rating No. 1—Definitely Negative c. To establish authority.
 Refuses treatment
 Immature, uncontrollable Indications
 Defiant behaviour  Voice control is indicated for the uncooperative, inatten-
 Crying forcefully. tive and communicative child.
Rating No. 2—Negative Contraindications
 Reluctance to accept treatment  In children who due to age disability, medication or emo-
 Immature, timid and whining tional immaturity are unable to understand and cooper-
 Some evidence of negative attitude but not pronounced. ate.
Rating No. 3—Positive Method
 Accepts treatment  Voice control is usually carried out on children of 3–6
 Tense cooperative years.
 Willingness to comply with dentist.  Sudden and firm commands can be used to get the child’s
attention or stop the child from whatever is being done.
Rating No. 4—Definitely Positive  There is an abrupt and emphatic change in the dentist’s
 Good rapport with the dentist tone of voice to emphasize his displeasure with the child’s
 Understanding and interested in the dental procedures inattention.
 Laughs and enjoys the situation.  Most often children seeing the dentist’s unhappiness
become quiet and start listening to dentist’s instructions.
Frankl’s behaviour rating scale (1962)
 If used appropriately, this is one of the effective behav-
Rating Rating Rating Rating iour management techniques to control child exhibiting
No. 1 No. 2 No. 3 No. 4 temper tantrums or defiant behaviour.
(definitely (negative) (positive) (definitely  As soon as the child complies, we should thank him and
negative) positive) compliment him for the resultant excellent behaviour.
Refuses treat- Reluctant to Accepts treat- Unique behav-
ment accept treat- ment iour Q.11. What is behaviour management? How will you
ment manage a fearful child of 2 years using different behav-
Immature Immature Tense Good rapport iour modification techniques?
cooperative
Defiant behav- Timid and Timid and Understanding
Ans.
iour whining whining and interested Behaviour management is a means by which the dental
and crying health team effectively performs treatment for a child and at
forcefully
the same time installs a positive dental attitude.
Quick Review Series for BDS 4th Year: Paedodontics
60

Management of child of 2 years age situation with its unusual sounds, smells, bright lights and
tilting chairs can produce fear in the child.
 This is a period of tremendous physical, intellectual and
emotional growth of the child.  It is advisable to have the parent accompany him
 His mastery of toilet training in this year gives him a sense into the operatory to provide him with security and
of achievement, self-control and independence from reassurance.
others.  Various behaviour management techniques like parent
 Through his increased language capabilities he learns to counselling, voice control, etc. can be used in this age
express how he feels and to make his needs known. group.
 His vocabulary may vary greatly (12–1000 words) and  Different behaviour modification techniques used for
thus his comprehension may be more dependent on facial children of this age group are:
expression and tone of voice than words alone. i. Tell–show–do technique
 Also he will need to grasp and feel objects to totally
ii. Desensitization
understand their meaning.
 The 2-year-old fears falling, sudden unexpected iii. Modelling
movements, loud noises, and strangers. The dental iv. Contingency.

SHORT NOTES

Q.1. Psychic triad.  The parent’s attitudinal structure, which moulds, shapes
and directs child behaviour in the early period of the off-
Or spring development, is affected by socioeconomic posi-
Paedodontic triangle. tion, cultural development and ethnic background.

Or Q.2. Stoic behaviour.


Keyes triad. Ans.
Ans.  The stoic behaviour is seen in physically abused children.
Paedodontic triangle was given by Wright. The characteristics of this behaviour are as follows:
 The child occupies the apex of the triangle.  Accepts treatment
 Focus is on the dentist and the parent.  Tense cooperative
 All the three are interrelated.  Whining and timid
Recently ‘society’ has also been added.  Milder but little anxious
 May shield behind the parent
 May whimper but does not cry hysterically, seldom are the
Child tears seen.

Q.3. Classical conditioning.


Ans.
 Classical conditioning theory was given by Ivan Petrovich
Pavlov based on stimulus response reflex.
Society
 It was developed through experimentation with dogs on
stimulus response to an external stimulus.
Parents Dentists  When two stimuli occur together at the same time, result-
ing in a response, this response can be obtained by stimu-
 The child is the most significant part and is depicted at the lating any one of the original stimuli.
apex of the triangle.  In dentistry we can use this theory for stimulating the
 Mother plays the most significant part in the family’s development of good habits, breaking old habits, to
influence in child behaviour. remove fear and to develop positive attitude.
Topic wise Solved Questions of Previous Years
61

Q.4. Give Frankl behaviour rating scale for recording Ans.


children’s behaviour in dental office.
 Almost five decades ago (1959) Addelston formalized a
Or technique that encompasses several concepts from the
social learning theory. It was called tell–show–do (TSD)
Frankl rating. technique.
Or  Tell–show–do (TSD) is one of the behaviour shaping
techniques. It gives good results and is recommended to
Frankl behaviour rating scale. be followed in routine practice.
Ans.  The method of introducing dental techniques is extremely
effective for shaping the child’s behaviour and condition-
Frankl Behaviour Rating Scale (1962) ing him/her to accept treatment.
Rating No. 1 Rating No. 2 Rating No. 3 Rating No. 4 TSD is a series of successive approximations; the steps followed
(definitely (negative) (positive) (definitely in TSD are:
negative) positive)
i. Tell the child about the treatment to be carried out.
Refuses Reluctant Accepts Unique ii. Show him part of it, how it will be done.
treatment to accept treatment behaviour
iii. Then do it.
treatment
Immature Immature Tense Good rapport Q.7. Define HOME technique.
cooperation
Defiant Timid Timid Understanding Ans.
behaviour and interested
 Hand-over-mouth exercise technique (HOME) was first
Crying Whining Whining described in the 1920s by Dr Evangeline Jordan who
forcefully wrote ‘if a normal child will not listen but continue to cry
and struggle, hold a folded napkin over the child’s mouth
and gently but firmly hold his mouth shut. His screams
Q.5. Desensitization.
increase his condition of hysteria, but if the mouth is held
Ans. close, there is little sound and he soon begins to reason’.
 Levitas described hand-over-mouth technique (HOMT)
 Desensitization is also called as reciprocal inhibition.
 Desensitization technique involves three stages: as hand-over-mouth exercise (HOME). A hand is placed
a. Training the patients to relax. over the child’s mouth and behavioural expectations are
b. Constructing a hierarchy of fear-producing stimuli. calmly explained. The child is told that the hand will be
c. Introducing each stimulus in hierarchy to relaxed pa- removed as soon as appropriate behaviour begins. When
tient starting with the stimulus which causes least fear. the child responds, the hand is removed and the child’s
appropriate behaviour is reinforced. The method may
Example: If the child is afraid of dental clinic, the general require reapplication.
desensitization should include gradual introduction of the  It was called emotional surprise therapy by Lampshire
child to: and as aversive conditioning by Kramer.
 Reception, waiting room and receptionist
 Paedodontist, hygienist and nurse Q.8. Name different types of cry.
 Dental surgery
Ans.
 Dental chair
 Oral examination Elsbach (1963) described four types of children’s cries as fol-
 Prophylaxis. lows:
At each stage the child’s fears are allayed by the kind, i. Obstinate cry
friendly and reassuring manner of the receptionist, nurse,
ii. Frightened cry
hygienist and paedodontist, and positive approach of the
iii. Hurt cry
child is reinforced.
iv. Compensatory cry.
Q.6. Define TSD.
Q.9. Define behaviour management and behaviour
Or shaping.
Tell–show–do technique. Ans.
Quick Review Series for BDS 4th Year: Paedodontics
62

Behaviour management The following are some commonly used physical restraints:
It is a means by which the dental health team effectively and I. Oral: Mouth props, padded wrapped tongue blades, a
efficiently performs treatment for a child and at the same finger guard or an intraocclusal thimble and rubber/plastic
time installs a positive dental attitude. bite blocks.
II. Body: Papoose board, triangular sheet, PediWrapTM, bean
Behaviour shaping bag dental chair insert, safety belt, extra assistant.
It is that procedure which very slowly develops behaviour by III. Extremities: Posey strap, Velcro® straps, towel/tape, extra
reinforcing successive approximations of the desired behav- assistant.
iour until the desired behaviour comes to be. IV. Head: Forearm support, head positioner, plastic bowl, ex-
tra assistant.
Q.10. Reinforcement.
Ans. Q.13. Communicative management technique.
 Reinforcement is a method of increasing the probability Ans.
(frequency) of a desired behaviour by presentation of a  Basic ways of communication are—verbal and non-
pleasant stimulus or withdrawal of an aversive or unpleas- verbal.
ant stimulus. Here the stimulus is termed as reinforcer.
 Positive reinforcer is withdrawal, e.g. a pat on the back or
shoulder, shaking hand, verbal praise in the presence of Verbal Communication
parent for which the child will be happy. In the form of  Verbal communication is through conversation. By
gifts like toothbrush kits, drawing kits, favourite cartoon involving the child in a conversation the paedodontist
stickers or toys appropriate for their age. not only learns about the patient, but also may relax the
 Negative reinforcers are withdrawn, e.g. withdrawal of youngster.
handpiece if the child is afraid of the noise of that and  Generally verbal communication is best initiated for
using hand instruments so that the child will accept dental younger children with complimentary comments, fol-
treatment in the next appointment. lowed by questions that elicit an answer other than Yes
 Presence (positive) or absence (negative) of these rein- or No.
forcers increases the frequency of desired behaviour.  It is important that communication occur from a single
source. The message must be understood in the same way
Q.11. Define modelling. by both the sender and the receiver.
Ans.
Non-verbal Communication (Multisensory
 Modelling is learning by imitation based on observational
Communication)
learning theory by Albert Bandura, 1969.
 Goal of modelling is to have the patient reproduce the  Non-verbal message also can be sent to patients or
behaviour exhibited by the models. received from them. Body contact can be a form of non-
Stages and requirements of modelling: verbal communication.
E.g.: The clinician’s simple act of placing a hand on a
 Two stages of modelling are acquisition and perform-
child’s shoulder while sitting on a chair side stool conveys
ance and the four requirements are attention, retention,
a feeling of warmth and friendship.
motoric reproduction, reinforcement and motivation.
 Eye contact is also important. A child who avoids it is
The advantages of modelling procedures are the following: often not fully prepared to cooperate. Sitting and speak-
 Stimulation of good behaviour. ing at eye level allows for friendlier and less authoritative
 Facilitation of behaviour in more appropriate manner. communication.
 Extinction of fears and apprehensions.  Active listening by the paedodontist is very important,
thus encouraging the kind of genuine communication
Q.12. Name few physical restraints. in which the patient is stimulated to express feeling and
Ans. the paedodontist does the same as a necessary process in
communication.
 Protective stabilization or restraining is defined as the
restriction of the patient’s freedom of movement, with or Q.14. Euphemisms.
without the patient’s permission, to decrease risk of injury
while allowing safe completion of treatment. Ans.
Topic wise Solved Questions of Previous Years
63

 To improve the clarity of message to young patients pleasant or unpleasant stimuli mentioned in the operant
‘euphemisms’ or word substitutes are used to explain conditioning theory in child psychology.
things and procedures better.  Contingency management includes:
 Various euphemisms used in case of paediatric patients i. Reinforcement: Either positive reinforcement or nega-
are: tive reinforcement
Dental terminology Word substitutes ii. Omission/time out
i. Rubber dam Rubber rain coat iii. Punishment.
ii. Sealant Tooth paint
iii. Topical fluoride gel Cavity fighter Q.16. Rewarding.
iv. Air syringe Wind gun
v. Water syringe Water gun Ans.
vi. Suction Vacuum cleaner  Reward is one of the factors under the control of dentist
vii. Needle and anaesthesia Sleepy water that influences the child’s behaviour.
viii. Radiographic equipment Camera  One of the most important rewards sought by the child is
the approval of the paedodontist.
Q.15. Contingency management.
 Tiny gifts make fine reward. Tiny gold stars, toys or stick-
Ans. ers make good gifts.
 Small token gifts like baby toothbrushes after good behav-
 Contingency management technique is based on the oper-
iour also make fine rewards. It is the recognition more
ant conditioning theory of BF Skinner.
than the material that makes the child happy.
 It is a method of modifying behaviour by presentation or
 Flattery can also be used as a reward after the treatment.
withdrawal of the reinforcers. These reinforcers are the

Topic 6 THERAPEUTIC MANAGEMENT


LONG ESSAYS

Q.1. Classify pharmacological behaviour management. iii. General anaesthesia.


Describe premedication in detail.
Conscious Sedation
Ans.
A minimally depressed level of consciousness that retains the
 To provide the best quality dental service for the paedi- patient’s ability to maintain an airway independently and re-
atric patient, one may need to utilize pharmacological spond appropriately to physical stimulation and verbal com-
means to obtain a quiescent, cooperative patient. mand.
Indications for pharmacological behaviour management tech-
Deep Sedation
niques are as follows:
 Children who are either extremely young. A controlled state of depressed consciousness, accompanied
 Have reduced mental capacity. by a partial loss of protective reflexes including inability to
 Intensely fearful or have severe medical problems which
respond purposefully to a verbal command.
affect their ability to be cooperative.
General Anaesthesia
Different types of pharmacological behaviour management
techniques are as follows: A controlled state of unconsciousness, accompanied by par-
tial or complete loss of protective reflexes, including inability
i. Premedication to maintain an airway independently and respond purpose-
ii. Conscious sedation—parenteral/inhalation fully to physical stimulation or verbal command.
Quick Review Series for BDS 4th Year: Paedodontics
64

Premedication  Upon awakening the child may complain of hunger or


thirst if the sleep has been prolonged. It is better to start
Guidelines for the use of premedication are:
with little water and then to proceed with solid foods.
i. Detailed medical history: It helps to prevent undesired
 Recovery period should be under supervision.
drug interactions.
ii. Selecting a premedication agent: The type and dosage
Factors Influencing Dosage
used should never impair the vital reflexes of the child.
iii. Consent and preoperative instructions: Should be given a. Age
before any procedure.
iv. The method or route of administration should be clearly Young’s rule has not been found to be an effective method of
explained. determining premedication dosage.
v. Specific instructions regarding eating and drinking prior
to administration should be given. b. Weight
vi. Information should be provided about side effects like  Clarke's rule has also found to be ineffective in determin-
drowsiness, vertigo, exhilaration or agitation. ing premedication dosages.
viii. High levels of personnel training is a must.  Clinical experience has proved to be better than Clarke's
ix. Call for documentation of events during the treatment rule for premedication.
(vital signs, etc.).
x. Postoperative care includes—discharge only when vital c. Emotional state and activity
signs are stable, patient is alert, can walk with minimal
 Extremely anxious or defiant child will require more
assistance.
xi. While most of the oral premedications act best when premedication than will the mildly apprehensive child
taken on an empty stomach, they may also be adminis- require.
 The child who displays greater physical activity will usu-
tered with a liquid or with food in order to disguise the
unpleasant taste or to prevent nausea. ally require higher dosage than will a child who is more
passive.
Administration of Premedication
d. Route of administration
 It is better to administer premedication in the dental office
 Drugs given by IV will act more rapidly and are given in
as the dentist can use routes other than oral and also accu-
rate timing of the administration can be done. lower dose, whereas a drug given orally acts more slowly
 Another advantage of office administration is that treat- and dosage requirement is more.
 Intramuscular administration of drugs results in interme-
ment can begin at the time of optimum effect on the child
who responds quickly to the drug, whereas if the drug is diate onset of action and dosage requirements.
administered at home, the child may be in transit during
peak drug activity. e. Environment
 Generally lower doses are required when a drug is taken
Care During Premedication in a non-stressfull environment and higher doses are
 Child should never be left unattended. required under stressful environment of the dental office,
 The child’s environment should be kept as quiet as pos- where auditory, tactile and visual stimulation can be
sible to enhance drug efficacy. intense.
 The child who is aroused before the medication and has
reached peak activity may remain excited. f. Time of the day
 Child aroused by painful stimuli may display considerable Dosage may be reduced if given during the nap time of the
agitation and confusion. child; conversely dosages may have to be elevated when the
 Once the desired level of sedation is obtained it is still drug is administered during active play time of the child.
essential to administer local anaesthesia.
General Causes of Premedication Failure
Postoperative Instructions
 Prescription of an insufficient dose of drug or intentional
 After the completion of the treatment the child, whether reduction of dosage by the parents.
is asleep or awake, will be in a sedated condition for many  Failure of the child to swallow the drug or expectoration
hours, depending on the drug and the dosage used. or vomiting of a portion of the drug.
Topic wise Solved Questions of Previous Years
65

 Children with medical condition such as brain damage Indications


and other problems are often inadequately premedicated
 Patients who cannot cooperate or understand definitive
and may require increased doses or different drugs.
treatment.
 Patients lacking cooperation or lack of psychological or
Q.2. Define and discuss briefly about conscious seda- emotional maturity.
tion. Give indications and contraindications of N2O–O2  Patients who are fearful and anxious with dental care
analgesia. Describe the equipment, clinical features at requirements.
various concentration and complications of N2O–O2
analgesia. Contraindications
Ans.  COPD (chronic obstructive pulmonary disorder) preg-
nancy, myasthenia, epilepsy, obesity, bleeding disorders.
Conscious Sedation  Unwilling or unaccompanied patients.
 Dental difficulties, prolonged surgery, inadequate person-
A minimally depressed level of consciousness that retains the nel.
patient’s ability to maintain an airway independently and re-  First trimester of pregnancy.
spond appropriately to physical stimulation and verbal com-  Hypersensitivity to the agent.
mand.
Objectives
Sedation: Routes and Agents
Bennett (1978) stated the objectives as follows:
I. Inhalation  Patient’s mood should be altered.
 Nitrous oxide  Patients should be conscious, respond to verbal stimuli

II. Oral route (several drugs) and be cooperative.


 All protective reflexes intact, vital signs stable and
 Hydroxyzine (Vistaril) 25 mg/5 cc normal.
 Promethazine (Phenergan) 12.5 mg/5 cc, 2.5 mg/5 cc  Child’s pain threshold should be increased.
 Chloral hydrate (Noctec) 500 mg/5 cc, (not recommended  Amnesia should occur.
for children below 6 years)
There is only one inhalation agent that meets the require-
 Meperidine (Demerol) 50 mg/5 cc, C/I in children with ment of conscious sedation and that is nitrous oxide de-
COPD, hypothyroid or liver dysfunction scribed below:
 Diazepam (Valium) 5 mg/5 cc elixir, 2, 5, 10, 15 mg tabs.
(indicated in children < 6 years age) Nitrous Oxide (N2O)
 Triazolam (Halcion) 0.125, 0.25 mg tab
 It is the most frequently used sedation agent by 85% of
 Chlorpromazine (Thorazine) 10 mg/mL syrup, 10, 25, paediatric dentists.
100, 200 mg tab (useful in severe behavioural problems).
 Nitrous oxide is slightly sweet smelling, colourless, non-
III. Intramuscular inflammable, inert gas heavier than air.
 It is a weak analgesic; although this effect can be influ-
 Ketamine (Ketalar) 10, 50 mg/mL parenteral or oral use.
enced by the psychological preparation of the patient.
 Midazolam (versed) 1 and 5 mg/mL. Rapid onset of action
and used mainly for short procedures  It is compressed in cylinders as a liquid that vapourizes
on release.
IV. Intravenous  It has a blood gas coefficient of 0.47 and has rapid onset
 Midazolam is commonly used agent and is best for inva- and recovery time due to low solubility in blood.
sive procedures of short duration.  Should be offered to children with mild-to-moderate
 Mechanism in conscious sedation or relative analgesia is anxiety to enable them to accept dental treatment better
that the patient’s threshold to pain, cold, warmth and light and to facilitate coping across sequential visits.
touch is increased.  Can be used to facilitate dental extractions in children.
 Although the special senses may be partly obtunded  It is absorbed quickly from the alveoli of the lungs and is
and sensation of numbers is described, superficial and physically dissolved in the blood with no chemical combi-
deep reflexes remain active, and the sensorium remains nation anywhere in the body and excreted through lungs
clear. without any biotransformation.
Quick Review Series for BDS 4th Year: Paedodontics
66

Actions (Pharmacodynamics) of Nitrous Oxide Techniques


 Without impairing motor function, it creates an altered  Critical to the nitrous oxide procedure is the graceful
state of awareness and is a CNS depressant. acceptance of the nose piece by the child, since this treat-
 Increases the respiratory rate and decreases the tidal ment is not advised for the resistant paedodontic patient.
volume.  This requires explanation at the youngster’s level of com-
 Cardiac output is decreased and peripheral vascular resist- prehension, a slow approach and behaviour shaping with
ance is increased. positive reinforcement throughout.

Absorption, Fate and Excretion The common procedure of nitrous oxide induction in general
is as follows:
 Enters blood by crossing pulmonary epithelium.
 During early phases of administration brain, heart, liver
and kidney absorb the major portion of nitrous oxide Thorough inspection of equipment
from blood
 Exhaled through lungs.
The mask is placed over nose
Nasal inhaler
Fresh gas
mb b i n g

Bag is filled with 100% oxygen and delivered


ly
as al tu

Flow meter Exhaled gas


to patient for 2–3 mins
se
rne

Bag tee
Co

22 mL
flow
adapter Slowly introduce nitrous oxide and encourage
3 L bag Slide
the patient to breathe through nose
adjuster
Vacuum hose
‘Y’ connector
Fresh gas
‘Y’ connector Explain the sensation to be felt as floating,
Fresh gas
Vacuum tubing One-way
giddy, tingling of digits
control
block Outer valve
mask
Vacuum
hose Inner mask Adjust the concentration to 30% nitrous
oxide and 70% oxygen

W Gas
V W leakage
E V
E
Continuous monitoring is required throughout
To vacuum
Systems nasal hood the procedure

Fig. 6.1 Components of N2O–O2 delivery and scavenging system.


After completion of procedure give 100% oxygen
for 5 minutes
Requirements of the equipment used for the
induction of nitrous oxide (Fig. 6.1) Two techniques have been described:
i. The equipment should have a continuous flow design a. Slow induction technique
with flow meters capable of accurate regulation. b. Rapid induction or ‘surge’ technique.
ii. Automatic shutdown if oxygen level falls <20 %.
iii. Flush level for easy and immediate flushing of the sys- Slow Induction Technique
tem with 100% oxygen.  Described by Langa (1968).
iv. They can be either mobile units or operating from a cen-  First with 100% oxygen total litre flow rate/minutes of
tral supply. gases should be established. For adults 5–7 L/min and
v. Good and efficient scavenger system. children of 3–4 years 3 L/min.
vi. Adequate size nasal hood should be used for the adults  Tell–show–do approach should be used to introduce the
and children. child to the operatory.
Topic wise Solved Questions of Previous Years
67

 After stabilization of the nose piece, 100% oxygen is deliv- iii. Vomiting can be prevented by:
ered for 3–5 minutes.  Using minimum effective concentration
 Then the nitrous oxide level is increased to 30–35% for  Avoiding prolonged procedure
3–5 minutes (induction period).  Empty stomach inhalation
 During this induction period the dentist continuously  Slow return to upright position
communicates with the child to promote relaxation and
 Aspiration is unlikely, so just ask the patient to vomit
reinforce cooperative behaviour.
in a chairside emesis basin if there is vomiting.
 If the child is older, he can be asked for the physical
iv. Diffusion hypoxia: Since nitrous oxide has lower blood
changes like tingling sensation in the finger and toe and
solubility, it rapidly diffuses into alveoli and dilutes the
the eyes will take a distant gaze with sagging of eyelids.
alveoli air causing a fall in the partial pressure of oxygen
 Most dentists will prefer to increase the level of nitrous in alveoli. 100% oxygen for 10 minutes.
oxide to 50% for 3–5 minutes to provide the maximum
v. High concentration of nitrous oxide should be avoided
effect for the administration of LA.
as the pressure will be created in the air-filled body cavi-
 In dental practice concentration of N2O > 50% is con- ties, especially in the middle ear.
traindicated. After local anaesthesia the concentration can
be brought down to 30–35%.
 After the treatment-inhalation of 100% oxygen for not Contraindications
less than 5 minutes should be continued.  Very young children
 This allows diffusion of nitrogen from the venous blood  Children having common cold, tonsillitis and nasal block-
into the alveolus, which is then exhaled as nitrous oxide age.
through respiratory tract and also allows the patient to
 Bleomycin chemotherapy
return to pretreatment activities without any incident.
Inadequate oxygenation may produce nausea, light head-  Precooperative children
edness or dizziness.  First trimester of pregnancy.
 After the procedure, the child should be kept in supine
position or on his side to maintain airway patency. Upon Advantages
arriving home the child should be placed on his side and
observed carefully for the 1st hour. If he wishes to sleep,  It is a viable and cost-effective alternative to general anaes-
he can be allowed to do so. thesia.
 Nitrous oxide sedation has minimal effect on cardio-
Rapid Induction Technique vascular and respiratory function and the laryngeal
reflex.
 Described by Sorenson and Roth (1973) and Simon and  Using nitrous oxide inhalation sedation in conjunction
Vogelsberg (1975). with other sedatives may rapidly produce a state of deep
 Initiation phase is started by administering equal parts of sedation or general anaesthesia.
nitrous oxide and oxygen for 10–15 minutes.  Nitrous oxide should be used with caution on ASA 3 and
 This is followed by maintenance phase where the nitrous ASA 4 status patients, for whom it would be more appro-
oxide is reduced by half for 40 minutes. priate to administer sedation in hospital environment
 Withdrawal is by administering oxygen only. supported by a consultant anaesthetist.
 Oxygen is used to prevent anoxia, which is produced if
nitrous oxide is used alone. Disadvantages
 The common acute adverse effects associated with this
Potential Problems and Solutions
type of sedation are nausea; whereas chronic effects may
i. Sleep-frequent arousal or communication is advised. be impotence, liver toxicity and recreational abuse.
ii. Airway obstruction-frequent repositioning of the head is  Exposure to nitrous oxide can result in depression of
needed to hyperextend the mandible so that the tongue vitamin B12 activity, resulting in impaired synthesis of
is brought forward. RNA.
Quick Review Series for BDS 4th Year: Paedodontics
68

SHORT ESSAYS

Q.1. Enumerate differences between conscious seda-  Although the special senses may be partly obtunded and
tion and general anaesthesia. sensation of numbers is described, superficial and deep
reflexes remain active, and the sensorium remains clear.
Ans.
Conscious sedation General anaesthesia Indications
i. At several visits the treat- i. Generally single sitting,  Patients who cannot cooperate or understand definitive
ment procedures may be once in a lifetime proce- treatment.
performed dure.
 Patients lacking cooperation of lack of psychological or
ii. Patient is cooperative but ii. Patient is uncooperative
anxious and fearful iii. At least basic investigations
emotional maturity.
iii. No extensive investigations and also premedication and  Patients who are fearful and anxious with dental care
and no premedication are NPO is strictly required. requirements.
required. No NPO required iv. Ventilation is required
iv. Airway is maintained as v. 99% success rate reported Contraindications
patient is conscious vi. Time consuming procedure
v. No mortality vii. Patient cannot control the  Predisposing medical conditions that would make general
vi. Reoperation period is 1–2 situation anaesthesia inadvisable.
minutes Example: COPD (chronic obstructive pulmonary disor-
vii. Patient feels he is in control der) pregnancy, myasthenia, epilepsy, obesity, bleeding
of the situation disorders.
 Unwilling or unaccompanied patients.
Q.2. Conscious sedation in paediatric dentistry.  Dental difficulties prolonged surgery, inadequate person-
nel.
Or
 First trimester of pregnancy.
Conscious sedation.  Hypersensitivity to the agent.
Ans.  A healthy, cooperative patient with minimal dental
needs.
Conscious Sedation
A minimally depressed level of consciousness that retains the Q.3. Midazolam.
patient’s ability to maintain an airway independently and re- Ans.
spond appropriately to physical stimulation and verbal com-
mand.  Midazolam is a benzodiazepine similar to diazepam but
with twice the potency.
Sedation: Routes and Agents  The drug is highly lipophilic, providing for rapid absorp-
tion from the gastrointestinal tract as well as rapid entry
I. Inhalation into brain tissue.
 Nitrous oxide.  Elimination is also rapid, giving a shorter duration of
II. Oral route (several drugs) activity.
 Hydroxyzine (Vistaril)  The elimination half-life is 10 times less than that of
 Promethazine (Phenergan) diazepam.
 Diazepam (Valium)  After intravenous administration, sedation occurs in 3–5
 Chlorpromazine, etc. minutes. Recovery occurs in 2 hours, but is variable and
III. Intramuscular may require up to 6 hours for complete return to baseline
 Ketamine (Ketalar) values. There is no rebound phenomenon from metabo-
 Midazolam (versed). lites.
IV. Intravenous Available forms
 Midazolam is a commonly used agent and is best for inva-
sive procedures of short duration.  IV Midazolam use is widely reported in adults.
 Mechanism in conscious sedation or relative analgesia is  Midazolam can also be effectively given intramuscularly.
that the patient’s threshold to pain, cold, warmth and light  Recently the oral form has become available and holds
touch is increased. great promise for paediatric conscious sedation.
Topic wise Solved Questions of Previous Years
69

 Intranasal midazolam produces sedative effect within 5 Disadvantages


minutes of its administration.
 The common acute adverse effects associated with this
type of sedation are nausea; whereas chronic effects may
Advantages
be impotence, liver toxicity and recreational abuse.
 High water solubility.  Exposure to nitrous oxide can result in depression of vita-
 The possibility of thrombophlebitis is reduced to a mini- min B12 activity, resulting in impaired synthesis of RNA.
mum.
Q.5. Anaesthetic preparation of child.
Dosage
Ans.
 Oral: 0.25–1 mg/kg to a maximum single dose of 20 mg
The anaesthetic preparation of child includes the following
 IM: 0.1 0–0.15 mg/kg to a maximum dose of 10 mg
things:
 Midazolam may produce respiratory depression with
i. Patient selection and choice of technique
higher doses.
ii. Preparation indications
iii. Informed consent
Q.4. Advantages of nitrous oxide and oxygen conscious
iv. Instructions to parents
sedation.
v. Documentation.
Or
I. Patient Selection and Choice of Technique Used
Nitrous oxide sedation. Advantages and disadvantages.
 The practitioner should have a rationale for making the
Ans. choice as to which patients will most likely benefit from
the use of sedation as it embodies a group of techniques
 Nitrous oxide (N2O) is the most frequently used sedation
designed to alter patient behaviour.
agent by 85% of paediatric dentists.
 The indiscriminate application of these techniques to all
 Nitrous oxide is slightly sweet smelling, colourless, non-
patients must be avoided.
inflammable, inert gas heavier than air.
 Several behavioural or anxiety assessment profiles have
 It is a weak analgesic; although this effect can be influ-
been developed that can be of great help to the practi-
enced by the psychological preparation of the patient.
tioner as the various techniques are introduced into a
 It is compressed in cylinders as a liquid that vapourizes
practice.
on release.
 As one gains experience, this decision becomes one of
 It has a blood gas coefficient of 0.47 and has rapid onset
clinical judgment as to which approach produces the
and recovery time due to low solubility in blood.
most successful results for specific types of patients for
 Should be offered to children with mild-to-moderate that individual practitioner.
anxiety to enable them to accept dental treatment better  No one technique or agent, or combination of agents,
and to facilitate coping across sequential visits. should be expected to be successful every time.
 Can be used to facilitate dental extractions in children.  One should choose the agent and technique that best fits
 It is absorbed quickly from the alveoli of the lungs and is the patient type as well as the nature of what needs to be
physically dissolved in the blood with no chemical combi- accomplished.
nation anywhere in the body and excreted through lungs
without any biotransformation. ii. Preparation Indications

Advantages  A thorough medical history is required to determine


whether a patient is suitable for sedative procedures.
 It is a viable and cost-effective alternative to general anaes-  This along with a recent physical examination constitutes
thesia. a risk assessment or physiologic status evaluation.
 Nitrous oxide sedation has minimal effect on cardiovas-  This health evaluation should be used to place the patient
cular and respiratory function and the laryngeal reflex. in one of the categories set forth by the American Society
 Using nitrous oxide inhalation sedation in conjunction of Anaesthesiologists .
with other sedatives may rapidly produce a state of deep  Patients who are in ASA 1 are frequently considered appro-
sedation or general anaesthesia. priate candidates for minimal, moderate, or deep sedation.
 Nitrous oxide should be used with caution on ASA 3 and  Some children assigned to ASA class 2 or 3 may actually
ASA 4 status patients, for whom it would be more appro- benefit from this approach, but this must be determined
priate to administer sedation in hospital environment in consultation with the child’s physician.
supported by a consultant anaesthetist.  Generally, patients categorized into classes 3 and 4, chil-
Quick Review Series for BDS 4th Year: Paedodontics
70

dren with special needs, and those with anatomic airway if the child is sleeping to ensure an open airway.
abnormalities or extreme tonsillar hypertrophy are better  Activity should be restricted to quieter pursuits and be
managed in a hospital setting, according to AAPD guide- closely supervised for the remainder of the day.
lines.  Following treatment, the child should first be offered clear
The physical evaluation should include the following: liquids and may advance to solid foods as tolerated.
i. Vital signs, including heart, respiratory rates, blood pres-  Once solids are tolerated, there are no dietary restrictions
sure, and temperature. other than those imposed as a result of the dental proce-
ii. Evaluation of airway patency to include tonsillar size and dure performed.
any anatomic abnormalities like mandibular hypoplasia  Knowledge on the part of the parent of what to expect is
that may increase the risk of airway obstruction. the most reliable way to ensure a calm, comfortable, and
iii. ASA classification. uncomplicated postsedation period.
iv. Name, address and telephone number of the child’s  These instructions and recommendations should be
medical home. in written form and should be reviewed again with the
person responsible for the patient and given to this person
iii. Informed Consent at the time of discharge from the office.
 The parent or legal guardian must be agreeable to the use
of sedation for the child. v. Documentation
 These individuals are provided complete information  Meticulous and accurate documentation of the sedation
regarding the reasonably foreseeable risks and the benefits incidence is imperative.
associated with the particular technique and agents being  Procedural records should document:
used in clear, concise terms that are familiar to them. i. Proper response to food and liquid intake instructions.
 The consent form can be on or part of a sedation record
ii. The preoperative health evaluation, including the pa-
with space provided for the signatures of all parties.
tient’s history and a complete physical assessment
iv. Instructions to Parents along the patient’s current weight, age, and baseline
vital signs.
 Information in written form should be reviewed with the
iii. Name and address of the physician who usually cares
person caring for the child and given to this person along
for the child.
with the notice of the scheduled appointment.
 This information should include a 24 hour contact
iv. A note as to why the particular method of management
number for the practitioner. was chosen.
 Dietary instructions should be as follows (AAPD guide- v. The presence of informed consent.
lines): vi. The delivery of instructions to the caregiver.
i. Clear liquids: Water, fruit juices without pulp, carbon- vii. Before the sedation, a ‘time out’ should be performed
ated beverages, clear tea, black coffee up to 2 hours be- to confirm the patient’s name, the procedure to be per-
fore the procedure. formed, and the site of the procedure this should be
ii. Breast milk up to 4 hours before the procedure. documented in the record (AAPD #43).
iii. Infant formula up to 6 hours before the procedure. viii. Intraoperatively the appropriate vital signs should
iv. Non-human milk up to 6 hours before the procedure. be recorded as they are assessed. Timed notations
v. A light meal up to 6 hours before the procedure. Exam- regarding the patient’s appearance should be included.
ple: Toast and clear liquids. The type of drug, the dose given, the route, site, and
vi. It is permissible for routine necessary medications to time of administration should be clearly indicated. If a
be taken with a sip of water on the day of the proce- prescription is used, either a copy of the prescription or
dure. a note as to what was prescribed should also be a part
 The parent or guardian should also be advised that he or of the permanent record.
she will be expected to remain in the area of the office
ix. After completion of treatment, the patient should be
during the sedation appointment.
continuously observed in an appropriately equipped
 With regard to transportation, the instructions should
recovery area. The patient should remain under direct
request that a second person should accompany the
observation until respiratory and cardiovascular sta-
parent so that the person caring for the child may be free
bility have been ensured.
to attend to the child’s needs during the trip home.
 The caregiver should be advised that on arriving home the
x. The patient should not be discharged until the prese-
child may sleep for several hours and may be drowsy and dation level of consciousness or a level as close as possi-
irritable for up to 24 hours after the sedation. ble for that child has been achieved. At the time of dis-
 It is important to stress the need for frequent observation
charge, the condition of the patient should be noted.
Topic wise Solved Questions of Previous Years
71

Q.5. Indications and contraindications for general an- ii. Patients for whom local anaesthesia is ineffective because
aesthesia. of acute infection, anatomic variations, or allergy.
iii. Highly uncooperative, fearful, anxious, or uncommuni-
Ans. cative child or adolescent.
General anaesthesia produces reversible loss of all sensation iv. Patients requiring prolonged surgical procedures.
and consciousness. v. Patients requiring immediate, comprehensive oral den-
The indications and contraindications for general anaesthesia tal care.
are as follows:
Contraindications
Indications i. A cooperative and healthy patient with minimal dental
i. Patients who cannot cooperate due to lack of psycho- needs.
logical or emotional maturity and those with mental, ii. Medically compromised conditions that would make
physical, or medical disability. general anaesthesia inadvisable.

SHORT NOTES

Q.1. Nitrous oxide analgesia. Q.2. Ketamine.

Or Ans.

What do you understand by nitrous oxide–oxygen an-  Ketamine is a powerful analgesic which in small dosages
algesia? can produce a state of dissociation whilst maintaining the
protective reflexes.
Ans.  Side effects include hypertension, vivid hallucinations
 Nitrous oxide (N2O) is the common inhalation agent and physical movement; although these are less prevalent
used. It is a colourless, odourless, heavier than air, non- in children.
inflammable gas.  Known to increase secretions, including salivation.
 It is absorbed quickly from the alveoli of the lungs and is
physically dissolved in the blood with no chemical combi- Q.3. Diazepam.
nation anywhere in the body.
Ans.
 It is carried in the serum portion of the blood and excreted
through lungs without any biotransformation. Small  Diazepam is a benzodiazepine that is lipid soluble and
amount may be found in the body fluids and intestinal water insoluble, reaching peak levels at 2 hours.
gas.  It is rapidly absorbed from the gastrointestinal tract.
 Diazepam has strong anticonvulsant activity and provides
Actions of Nitrous Oxide some prophylaxis against this adverse reaction of other
drugs during the operative procedure.
 Creates an altered state of awareness without impaired
 Dosage: Oral or rectal 0.2–0.5 mg/kg to a maximum single
motor function and is a CNS depressant.
dose of 10 mg, intravenous 0.25 mg/kg. Supplied as: Tab-
 Increases the respiratory rate and decreases the tidal
lets 2, 5, and 10 mg and suspension 5 mg/mL.
volume.
 Biotransformation of the drug occurs quite slowly, with a
 Cardiac output is decreased and peripheral vascular resist-
half-life of 20–50 hours. The drug has three active metab-
ance is increased.
olites, and these are more anxiolytic than sedative.
 Ataxia and prolonged CNS effects are the only common
Absorption, Fate and Excretion
adverse reactions that can be anticipated when diazepam
 Enters blood by crossing pulmonary epithelium and is used for conscious sedation.
depends upon the concentration gradient.
 Expired through lungs. Q.4. Promethazine.
Quick Review Series for BDS 4th Year: Paedodontics
72

Ans. IV. Intravenous:


 Promethazine or Phenergan is a phenothiazine with  Midazolam is commonly used agent and is best for invasive
sedative and antihistaminic properties. procedures of short duration.
 It is well-absorbed after oral ingestion. Onset is within
Q.6. Pulse oximeter and its applications in paediatric
15–60 minutes, with a peak at 1–2 hours and duration of
dentistry.
4–6 hours.
 Metabolized by the liver. Ans.
 Should be used with caution in children with a history of  Pulse monitors are available that attach to the finger or
asthma, sleep apnoea, or a family history of sudden infant earlobe and produce both visual and audible signals.
death syndrome (SIDS).  The pulse oximeter is one of the most valuable pieces of
Phenothiazines lower the seizure threshold and should be electronic monitoring equipment.
avoided in seizure-prone patients.  This device continuously assesses arterial haemoglobin
oxygen saturation and pulse rate with values updated
 Interactions: Potentiates other CNS depressants.
with every heartbeat.
 Adverse reactions: Dry mouth, blurred vision, thickening
 An oxygen sensor is attached non-invasively to a digit on
of bronchial secretions, mild hypotension, extrapyramidal the hand or foot or to the earlobe and consists of a light-
effects. emitting diode and light-detecting diode.
 Dosage: Oral/intramuscular 0.5–1.1 mg/kg; subcutane-  The light-emitting diode emits both red and infrared
ous—not recommended; maximum recommended single wavelengths of light and the light-detecting diode detects
dose—25 mg. light transmitted through the tissue.
 Supplied: Tablets—12.5, 25, and 50 mg; Syrup—6.25 and  Red wavelengths are absorbed primarily by oxygenated
25 mg/mL, Injectable—25 and 50 mg/mL ampoules. haemoglobin whereas infrared wavelengths are absorbed
primarily by deoxygenated haemoglobin.
Q.5. Define conscious sedation and enumerate various  The device’s processor then calculates the percent of oxy-
agents used for the same. genation of haemoglobin and the results are conveyed
both audibly and visually.
Or  Sensor displacement is the most common cause for false
Conscious sedation. readings in children and can be minimized by using a
Ans. sensor with adhesive tabs rather than a clip-on sensor.
 The new generation of pulse oxymeters is less susceptible
Conscious sedation is defined as a minimally depressed level to motion artifacts and may be more useful than older
of consciousness that retains the patient’s ability to maintain oxymeters that do not contain the updated software
an airway independently and respond appropriately to (AAPD guidelines).
physical stimulation and verbal command.
Various agents used are: Q.7. Indications for conscious sedation.
Ans.
I. Inhalation:
 Nitrous oxide. Conscious sedation is defined as a controlled, pharmaco-
logically induced, minimally depressed state or level of con-
II. Oral route (several drugs):
sciousness in which the patient retains the ability to maintain
 Hydroxyzine (Vistaril) oral or IM: 0.6 mg/kg 1.1 mg/kg a patent airway independently and continuously and to re-
 Promethazine (Phenergan) oral/IM: 0.5 mg/kg and spond appropriately to physical stimulation or verbal com-
1.1 mg/kg mand.
 Diazepam (Valium) oral: 0.2–0.5 mg/kg, rectal: 0.25 mg/kg Indications
III. Intramuscular: Patients require dental treatment but cannot cooperate due to:
 Ketamine (Ketalar): IM/IV: 1–5 mg/kg  Lack of psychological or emotional maturity.
 Midazolam (versed): Oral: 0.25–1 mg/kg  Medical, physical, cognitive disability.
IM:1-0.15 mg/kg  Fearful and highly anxious behaviour.
Topic wise Solved Questions of Previous Years
73

Topic 7 MANAGEMENT OF
HANDICAPPED CHILDREN
LONG ESSAYS

Q.1. What are intelligence quotient (IQ) and mental i. Mild retardation
retardation? Describe features of a Down syndrome
 Children are categorized under this category when they
child.
are able to speak well enough for most of their commu-
Ans. nication needs.
 Their IQ score is usually in the range of 55–70.
Intelligent quotient (IQ) is the method of quantifying the
mental ability in relation to chronological age.  Most of the children in this category are educable and
trainable and function eventually as acceptable adults.
Formulated by Alfred Binet (1900s) as:
 It is reasonable to assume that most children with mild
Mental age retardation can cope with simple, preventive and short
IQ = × 100 procedures.
Chronological age
ii. Moderate retardation
It is measured by tasks, examining memory, spatial rela-
tionship, reasoning, etc.  Children in this category have vocabulary and language
skills such that the child can communicate at a basic level
Several tests used to determine the IQ are:
with others.
i. The Cattell infant intelligence scale (used in children
with developmental age less than 2 years).  Their IQ score is in the range of 40–55.
ii. The Stanford–Binet intelligence scale (used in children  The children in this group are generally trained to master
with developmental age at least 2 years). certain self-help skills like dressing, grooming, feeding
iii. WIPPSI (Wechsler preschool and primary scale of in- and cleaning.
telligence) used in children with chronological ages of
6–17 years. iii. Profound or severe retardation
iv. WISC-R (Wechsler intelligence scale for children-  Children in this category have little or no communication
revised) used in individuals aged 16 years and above. skills.
A positive relation exists between IQ and acceptance of
 Their IQ may be in the range of less than 35–39.
dental treatment.
 They invariably need pharmacological behaviour man-
Mental Retardation agement methods to provide dental care.

Mental retardation has been defined by the American Asso- Down Syndrome
ciation of Mental Deficiency (AAMD) as ‘subaverage general
 Most common chromosomal aberration.
intellectual functioning that originates during the develop-
mental period and is associated with impairment in adaptive  Incidence is 1 in every 600 newborns.
behaviour’.  It may occur due to trisomy of chromosome 21 in 95%,
 Initially, mental deficiency was assessed using intelligence translocation (3%) or due to mosaicism.
scores and were treated inferiorly. Now a diagnosis of
mental deficiency is made when there is inadequate adap- Predisposing Factors
tive functioning and intellectual deficiency.  Advanced maternal age.
 A child with mental retardation is classified as:  Uterine and placental abnormalities.
i. Mild
 Chromosomal aberrations.
ii. Moderate
iii. Severe or profound.
Quick Review Series for BDS 4th Year: Paedodontics
74

Clinical Features  Children are generally affectionate and cooperative and


present no special problems during management.
Head
 Dentist should introduce treatment in a non-threatening
 Microcephaly with prominent forehead. and friendly manner.
 Flattening of the occiput.  Increased incidence of leukaemia and acute and chronic
 Brachycephalic skull. infections of URT (upper respiratory tract) can also affect
treatment.
Face  Incidence of cardiac disease in Down syndrome is 40%
 Flat nasal bridge. and will require adequate prophylaxis.
 Epicanthal fold.  Preventive procedures along with chlorhexidine mouth-
 Upward slanting palpebral fissures. wash may be beneficial.
 N2O analgesia or TSD in mildly apprehensive patients can
Eyes be used and GA in those patients who are severely resist-
 Hypoplasia of iris. ant to dental treatment.
 Brushfield spots.  Pulp treatment of deciduous teeth is contraindicated in
 Chronic infections of conjunctiva. cardiac patient; therefore risk of bacteraemia in perma-
nent teeth can be considered if adequate apical seal can
Mouth be replaced.
 Underdeveloped maxilla.
Q.2. What special attention is to be taken in dental
 Both maxilla and mandible were positioned anteriorly
treatment and management of handicapped children?
under the cranial base.
 Protruding tongue, hypertrophy of vallate papillae. Or
❍ Narrow and flat palate.
❍ Delayed eruption of teeth. Define and classify handicapped child. Explain how you
❍ Congenitally missing, abnormal-shaped small and will manage mentally handicapped children in your
hypoplastic teeth. dental clinic.

Limbs Ans.
 Broad hands, feet and digits. ‘WHO’ defines a handicapped individual as ‘one who, over an
 Wide space between the first and second toes. appreciable time, is prevented by physical or mental condi-
tion from full participation in the normal activities of his age
CNS group including those of a social, recreational, educational
 Mental retardation is another characteristic finding. Level and vocational nature’.
of intelligentia may range from mild to severe retarda-
tion. Classification
 IQ often severely retarded with an IQ of 25–50. A. Nowak (1976) has classified handicapping condition into
 They are very docile. nine categories as follows:
 Generally movements are slow, clumsy and poorly coor- i. Physically handicapped, e.g. poliomyelitis, scoliosis
dinated.
ii. Mentally handicapped, e.g. mental retardation
Cardiac Problems iii. Congenital defects, e.g. cleft palate, congenital heart dis-
ease
 Septal defects are common ASD, VSD, etc. iv. Convulsive disorder, e.g. epilepsy
Leukaemia v. Communication disorder, e.g. deafness, blindness
vi. Systemic disorder, e.g. hypothyroidism, haemophilia
 Children with Down syndrome have a 10–20 fold greater vii. Metabolic disorders, e.g. juvenile diabetes
incidence of leukaemia compared to general population.
viii. Osseous disorders, e.g. rickets, osteopetrosis
 Acute lymphoblastic leukaemia—20 times more common
ix. Malignant disorders, e.g. leukaemia.
in these children.
B. Agerholm (1975) classified handicapping conditions into:
Dental Treatment i. Intrinsic – one from which the person cannot be sepa-
 The greatest problem in management is due to the pres- rated. Example: All medical and physical disabilities.
ence of mental retardation (10%); otherwise they are very ii. Extrinsic – one from which the person can be removed.
friendly and willing to cooperate. Example: Social deprivation.
Topic wise Solved Questions of Previous Years
75

C. Frank and Winter (1974) have classified handicapping as:  Patients with underlying medical conditions that con-
i. Blind or partially sighted traindicate the use of physical restraints.
ii. Deaf or partially deaf  Treatment immobilization should never be used as a
iii. Educationally subnormal threat or punishment for children.
iv. Epileptic Various physical restraints used on different parts of body are
v. Maladjusted as follows:
vi. Physically handicapped
 Entire body: Triangular sheet, Papoose board,
vii. Defective of speech
PediWrapTM, safety belt and an extra assistant.
viii. Senile.
 Extremities: Posey and Velcro® straps, towel and tape, or
D. Considering the variations in the types of treatment modali- an extra assistant.
ties for handicapped children, for the convenience of manage-  Head: Forearm body support, head positioner and an
ment, they can be categorized into two types: extra assistant.
i. Developmentally disabled child  Intraoral: Mouth props, McKesson bite blocks and
ii. Medically compromised patients. wrapped tongue blades.
Dental treatment of a person with mental retardation:
Management of Handicapped Child
 A short attention span, restlessness, hyperactivity, and
 Systematic treatment planning is required in providing erratic emotional behaviour may characterize patients
appropriate care to children with special needs. with mental retardation undergoing dental care.
 One of the biggest challenges is that the patients with  Providing dental treatment for a person with mental
special needs may not be able to participate in the dis- retardation requires adjusting to social, intellectual and
cussions on a particular treatment plan and are unable to emotional delays.
make their opinions known. The accompanying relatives The following procedures have proved beneficial in establish-
and caretakers have a crucial role to play in deciding the ing dentist–patient rapport and reducing the patient’s anxiety
eventual care received by a mentally challenged patient. about dental care:
 Most of the traditional behaviour management methods
 Give the family a brief tour of the office before attempt-
may not work and the paediatric dentist may be left with
pharmacological behaviour management methods to ing treatment and introduce the office staff to patient and
provide high-quality dental care. his/her family in order to reduce the patient’s fear of the
unknown.
Protective Stabilization  Allow the patient to bring a favourite item, e.g. stuffed
animal or toy to hold for the visit.
 Effective physical restraints or immobilization may be  Keep the parents inside the operatory.
needed in infants and patients with neuromuscular disor-  Be repetitive, speak slowly and in simple terms.
ders to diagnose and provide dental care.  Give only one instruction at a time.
 The main purpose of restraints is to limit or stop the  Actively and carefully listen to the patient.
movements of the patient’s head, extremities and torso.  Reward the patient with compliments after the successful
 Immobilization is also useful in controlling resistant completion of each procedure.
patients.  Invite the parent into the operatory for assistance and to
 Immobilization can be provided by extra assistants or any aid in communication with the patient.
device made for that purpose and informed consent to be  Ask the parents not to communicate when dentist is com-
taken before use of any type of physical restraints. municating.
Immobilization is indicated in the following situations:  Keep appointment short.
 Patient who cannot cooperate because of lack of emo-  Gradually progress to more difficult and lengthy proce-
tional maturity or physically or mentally challenging con- dures.
ditions.  Schedule the patient’s visit early in the day.
 When no other behaviour management techniques work.  Generally, patients with mild retardation can be treated as
 When there is a risk for the patient or the practitioner, if regular patients. If the extent of work is more, N2O seda-
physical restraints are not used. tion or general anaesthesia may be needed.
 However, sedation or general anaesthesia may be invari-
Contraindications for protective immobilization are:
ably needed to provide dental treatment for children with
 A cooperative patient. moderate and severe retardation.
Quick Review Series for BDS 4th Year: Paedodontics
76

SHORT ESSAYS

Q.1. Cerebral palsy. iv. Thorough medical and dental history should be taken
along with consultation with the child’s physician.
Ans.
v. Many patients may prefer to be treated in wheel chairs
 Cerebral palsy is one of the most severely handicapping which may be tipped back into the dentist’s lap.
conditions affecting childhood. v. Patient’s head should be stabilized throughout the pro-
 ‘Nelson’ described cerebral palsy as a group of non- cedure and back should be elevated to reduce swallow-
progressive disorders resulting from malfunction of the ing problems.
motor centres and pathways of the brain. vii. Use physical restraints judiciously for control of flailing
 It is characterized by paralysis, weakness, incoordination extremities.
or other aberrations of motor function and has its origin viii. The variety of mouth props and finger splints can be
either prenatally or before the CNS has reached maturity. used for control of involuntary jaw movements.
 Incidence: 0.6–5.9 per 1000 births. ix. Avoid abrupt movements, lights and noises to minimize
startle reflex reactions and introduce intraoral stimuli
Classification slowly to avoid gag reflex.
x. Local anaesthesia can be used with care and stabilization
There are five types of cerebral palsy:
against any sudden movement by the child.
Occurs in Lesion in xi. Rubber dam can be used to protect working area from
(a) Spasticity (>40% cases) Cerebral cortex hyperactive tongue movement.
(b) Athetosis (25%) Basal ganglion
xii. Gauze shields used during extraction to avoid tooth as-
piration.
(c) Ataxia (10%) Cerebellum
xiii. Premedication can be used to reduce hypertonicity, in-
(d) Rigidity (5%) Basal ganglion voluntary movements and anxiety.
(e) Tremors (5%) Basal ganglion xiv. General anaesthesia should be used as last resort if case
is not manageable.
Characteristics of cerebral palsy is the persistent neonatal xv. Do permanent restorations.
reflexes, i.e. asymmetric tonic neck reflex, tonic labyrinthine
reflex and startle reflex. Q.2. Trisomy 21.
 Along with these, mental retardation, seizure disorders,
sensory deficits like visual defects and deafness and speech Or
disorders like dysarthria are seen. Down syndrome.
Dental problems encountered are as follows:
Ans.
 Dental caries because of poor oral hygiene.
 Periodontal disease because of poor oral hygiene and  Down syndrome is the most common chromosomal aber-
phenytoin treatment. ration.
 Malocclusions seen in spastics class II division 2 and in  Incidence is 1 in every 600 newborns.
athetoids class II division I.  It may occur due to trisomy of chromosome 21 in 95%,
 Bruxism seen especially in athetoid cerebral palsy. translocation (3%) or due to mosaicism.
 Decreased VD and TMJ disorders—trauma especially in
maxillary anteriors. Predisposing Factors
 Advanced maternal age
Treatment
 Uterine and placental abnormalities
i. Communication forms an important aspect of manage-  Chromosomal aberrations.
ment of patients with cerebral palsy.
ii. Routine procedures can be accomplished; generally they Clinical Features
will understand and cooperate when the dentist explains
before starting a procedure, unless severely mentally re- Head
tarded.  Microcephaly with prominent forehead
iii. Maintain a calm, friendly and professional atmosphere;  Flattening of the occiput
be empathetic about the child’s problems.  Brachycephalic skull.
Topic wise Solved Questions of Previous Years
77

Face  Increased incidence of leukaemia and acute and chronic


infections of URT (upper respiratory tract) can also affect
 Flat nasal bridge
treatment.
 Epicanthal fold
 Upward slanting palpebral fissures.  Incidence of cardiac disease in Down syndrome is 40%
and will require adequate prophylaxis.
Eyes  Preventive procedures along with chlorhexidine
mouthwash may be beneficial.
 Hypoplasia of iris
 N2O analgesia or TSD in mildly apprehensive patients can
 Brushfield spots
 Chronic infections of conjunctiva. be used and GA in those patients who are severely resist-
ant to dental treatment.
Mouth  Pulp treatment of deciduous teeth is contraindicated in
cardiac patients; therefore risk of bacteraemia in perma-
 Underdeveloped maxilla nent teeth can be considered if adequate apical seal can
 Both maxilla and mandible were positioned anteriorly be replaced.
under the cranial base.
 Protruding tongue, hypertrophy of vallate papillae. Q.3. Learning disorders.
❍ Narrow and flat palate Ans.
❍ Delayed eruption of teeth
 The children affected with minimal brain dysfunction
❍ Congenitally missing, abnormal-shaped small and
were known to be affected by ‘learning disability’.
hypoplastic teeth.
 The signs of learning disability are as follows:
i. Attention for short spans
Limbs
ii. Distractibility
 Broad hands, feet and digits. iii. Hyperactivity
 Wide space between the first and second toes. iv. Akwardness
v. Mild speech impairment.
CNS  The term learning disability is applied to children who
exhibit a disorder in one or more of the basic physiologic
 Mental retardation is another characteristic finding. Level
processes involved in understanding or using spoken or
of intelligensia may range from mild to severe retarda-
written language.
tion.
 It may be manifested in disorders of listening, thinking,
 IQ often severely retarded with on IQ of 25–50.
reading, talking, writing or spelling.
 They are very docile.
 Learning disability includes dyslexia, developmental apha-
 Generally movements are slow, clumsy and poorly coor-
sia, brain injury and minimal brain dysfunction.
dinated.
 Boys are more commonly affected than girls.
 One form of learning disability that causes management
Cardiac Problems
problems is hyperactivity.
 Septal defects are common ASD, VSD, etc.  Their nervousness makes cooperation through long pro-
cedures difficult.
Leukaemia
 Children with Down syndrome have a 10–20 fold greater Paediatric Significance
incidence of leukaemia compared to general population.
 Most of the children cooperate for the dental procedures.
 Acute lymphoblastic leukaemia – 20 times more common
 If the child resists dental treatment occasionally, one has
in these children.
to use sedation or general anaesthesia.
Dental Treatment
Q.4. Autism.
 The greatest problem in management is due to the pres-
ence of mental retardation (10%); otherwise they are very Ans.
friendly and willing to cooperate.  Childhood autism is also known as Kanner syndrome,
 Children are generally affectionate and cooperative and early infantile autism and infantile psychosis or childhood
present no special problems during management. schizophrenia.
 Dentist should introduce treatment in a non-threatening  Nowadays the term autism is used to describe an
and friendly manner. incapacitating disturbance of mental and emotional
Quick Review Series for BDS 4th Year: Paedodontics
78

development that causes problem in learning, anaesthesia is necessary .


communicating and relating with others.  The use of positive reinforcement to promote desirable
 The term ‘autism’ is derived from the Greek word behaviour is the key to all behaviour modification pro-
‘autos’ meaning ‘self ’, which appropriately describes the grammes.
characteristic feature of this disorder namely a profound
withdrawal from people and from social reactions with Q.5. Discuss various measures in treatment and man-
people, even parents. agement of mentally retarded children.
Ans.
Aetiology
Dental treatment of a person with mental retardation
 Personalities, attitudes and behaviour of parents contrib-
ute to psychodynamics of autism.  A short attention span, restlessness, hyperactivity and
erratic emotional behaviour may characterize patients
Clinical Features with mental retardation undergoing dental care.
 Providing dental treatment for a person with mental
 It usually manifests in the first 3 years of life retardation requires adjusting to social, intellectual and
 Males more commonly affected than females. emotional delays.
 Kopel in 1977 has described 12 behavioural characteris-
tics of this disorder; they are as follows: The following procedures have proved beneficial in establish-
i. Extreme aloneness ing dentist–patient rapport and reducing the patient’s anxiety
about dental care:
ii. Language disturbances
 Give the family a brief tour of the office before attempt-
iii. Mutism
ing treatment and introduce the office staff to patient and
iv. Parrot-like repetitious speech their family in order to reduce the patient’s fear of the
v. Difficulty with the concept of ‘Yes’ unknown.
vi. Confusion in the use of personal pronouns  Allow the patient to bring a favourite item, e.g. stuffed
vii. Obsessive desire for the maintenance of sameness animal or toy to hold for the visit.
viii. Eating disturbances such as holding food in the mouth  Keep the parents inside the operatory.
and preference for a soft diet  Be repetitive, speak slowly and in simple terms.
 Give only one instruction at a time.
ix. Intrigue with spinning objects
 Actively and carefully listen to the patient.
x. Self-stimulatory behaviour  Reward the patient with compliments after the successful
xi. Hyperactivity, nystagmus and mental retardation completion of each procedure.
xii. Seizure disorder.  Invite the parent into the operatory for assistance and to
aid in communication with the patient.
Treatment and Paediatric Significance  Ask the parents not to communicate when the dentist is
communicating.
 Dentist should have a lot of patience and use a gentle and
 Keep appointment short.
slow approach to the oral cavity.
 Gradually progress to more difficult and lengthy proce-
 Maintain consistency in the environment.
dures.
 Behavioural management techniques like tell–show–do  Schedule the patient’s visit early in the day.
(TSD), positive reinforcement and rewards may be help-  Generally, patients with mild retardation can be treated as
ful in some children. regular patients. If the extent of work is more, N2O seda-
 Immobilization devices like Papoose board and PediWrapTM tion or general anaesthesia may be needed.
may produce calming effect in some children.  However, sedation or general anaesthesia may be invari-
 In case of very uncooperative children, when treatment is ably needed to provide dental treatment for children with
not possible at the chair side, use of sedation and general moderate and severe retardation.

SHORT NOTES

Q.1. Definition of handicapped child. Handicapped children.

Or Ans.
Topic wise Solved Questions of Previous Years
79

 WHO defines a handicapped individual as ‘one who, over development that causes problem in learning,
an appreciable time, is prevented by physical or mental communicating and relating with others.
condition from full participation in the normal activities  The term ‘autism’ is derived from the Greek word ‘autos’
of his age group including those of a social, recreational, meaning ‘self ’, which appropriately describes the charac-
educational and vocational nature’. teristic feature of this disorder namely a profound with-
 Nowak (1976) has classified handicapping condition into drawal from people and from social reactions with people,
nine categories. even parents.
 Personalities, attitudes and behaviour of parents contrib-
Q.2. Enlist signs of learning disorders.
ute to psychodynamics of autism.
Ans.
The signs of learning disability are as follows: Q.5. Down syndrome.
i. Attention for short spans
ii. Distractibility Or
iii. Hyperactivity Trisomy.
iv. Akwardness
v. Mild speech impairment. Or
Down syndrome.
Q.3. Munchausen syndrome by proxy.
Ans. Ans.

Munchausen syndrome is defined as significantly subaverage  Down syndrome is also called as trisomy 21 syndrome or
general intellectual functioning existing concurrently with mongolism.
deficits in adaptive behaviour and manifested during the de-  Cardiovascular defects include ventricular septal defect,
velopmental period. ALV communication, patent ductus arterim and mitral
valve prolapse.
Q.4. Autism.
 Haematological: Impaired immunodeficiency, risk of
Ans. neutropenia, eosinophilia, leukaemia.
 Musculoskeletal: Atlantoaxial instability, midface is under-
 Childhood autism is also known as Kanner syndrome,
early infantile autism, and infantile psychosis or childhood developed with relative prognathism and open bite.
schizophrenia.  Nervous: Delayed motor function, dementia.
 Nowadays the term autism is used to describe an  Oral: V-shaped, high vault palate, soft palate insufficiency,
incapacitating disturbance of mental and emotional open mouth, macroglossia.

MANAGEMENT OF CHILDREN

Topic 8 WITH SYSTEMIC DISEASES


AND HIV INFECTION
LONG ESSAYS

Q.1. Classify handicapping conditions and discuss anti- tions from full participation in the normal activities of their
biotic prophylaxis in management of patient with con- age groups, including those of a social, recreational, educa-
genital cardiac disease. tional and vocational nature’.

Ans. Classification of Handicapping Conditions


WHO has defined a handicapped person as ‘one who over an The following are the various classifications of handicapping
appreciable period is prevented by physical or mental condi- conditions:
Quick Review Series for BDS 4th Year: Paedodontics
80

I. Nowak (1976) has classified handicapping condition into Acyanotic heart disease
nine categories as  Here, due to a cardiac defect blood is shunted from left
i. Physically handicapped, e.g. poliomyelitis, scoliosis to right.
ii. Mentally handicapped, e.g. mental retardation  This group mainly includes ventricular and atrial septal
iii. Congenital defects, e.g. cleft palate, congenital heart dis- defects and defects that cause obstruction.
ease  Clinical manifestations include congestive heart failure,
iv. Convulsive disorders, e.g. epilepsy pulmonary congestion, heart murmur, laboured breath-
v. Communication disorders, e.g. deafness, blindness ing, etc.
vi. Systemic disorders, e.g. hypothyroidism, haemophilia
vii. Metabolic disorders, e.g. juvenile diabetes b. Acquired heart disease
viii. Osseous disorders, e.g. rickets, osteopetrosis
Types of acquired heart disease are as follows:
ix. Malignant disorders, e.g. leukaemia.
(I) Rheumatic heart fever
II. Agerholm (1975) classified handicapping conditions
 It is a very serious inflammatory disease that occurs as
i. Intrinsic – one from which the person cannot be sepa-
a delayed sequela to pharyngeal infections with group A
rated, e.g. all the medical and physical disabilities.
beta haemolytic streptococci.
ii. Extrinsic – one from which the person can be removed,
 The infection can involve the heart, joints, skin and cen-
e.g. social deprivation.
tral nervous system.
III. Frank and Winter (1974) have classified handicap as  It occurs most commonly under 40 years of age especially
i. Blind or partially sighted between 6 and 15 years of age; but it can occur at any age.
ii. Deaf or partially deaf  It is more common in poor children living in temperate
iii. Educationally subnormal climate at high altitude.
iv. Epileptic  Cardiac involvement is the most significant pathologic
v. Maladjusted sequela of rheumatic fever which can be fatal during the
vi. Physically handicapped acute phase or can lead to chronic rheumatic heart disease
as a result of scarring and deformity of heart valves.
vii. Defective speech
viii. Senile. (II) Infective bacterial endocarditis
IV. Considering the variations in the types of treatment mo-  It is characterized by microbial infection of the heart valves
dalities for handicapped children, for the convenience of man- or endocardium in proximity to congenital or acquired
agement, they can be categorized into cardiac defects.
i. Developmentally disabled child  It has been divided into acute and subacute forms.
ii. Medically compromised patients.  The acute form is a fulminating disease that usually
occurs as a result of microorganisms of high pathogenic-
Management of Patient with Cardiac Disease ity attacking a normal heart.
Cardiac disease can be divided into two general types:  In this erosive destruction of the valves takes place.
(a) Congenital Subacute bacterial endocarditis (SABE) usually develops
(b) Acquired. in persons with pre-existing congenital cardiac disease or
rheumatic valvular lesions. Embolization is usually the
a. Congenital Heart Diseases (CHD) characteristic feature of infective endocarditis. Vegetation
composed of microorganisms and fibrous exudate
The CHD can be classified into the following types: develops on damaged valves or endocardium.
 Cyanotic  They might separate and pass into systemic or pulmonary
 Acyanotic. circulation.
Cyanotic heart disease  Clinical symptoms include low, irregular fever, more in
 It is characterized by right-to-left shunting of blood afternoon and evenings with sweating, malaise, anorexia,
within heart. weight loss and arthralgia. Inflammation of endocardium
 Cyanosis is observed even on minor exertion. increases cardiac destruction and murmurs develop. Pain-
E.g. Fallot's tetralogy with clinical manifestations include ful fingers and toes and skin lesions develop.
cyanosis, hypoxic spells, poor physical development and  Laboratory findings can include leukocytosis, neutrophils
clubbing. and anaemia with rapid ESR.
Topic wise Solved Questions of Previous Years
81

Management  The following factors help in establishing the appropriate


 Careful consultation with cardiologist is essential before treatment plan:
any major dental procedure. i. The invasiveness of the dental procedure.
 Information concerning dental needs, anaesthesia, seda- ii. The amount of bleeding anticipated.
tion, drug therapy should be discussed beforehand. iii. The time involved in oral wound healing.
Antibiotic prophylaxis Use of Antifibrinolytics
 Bacterial endocarditis could occur following any dental
 Antifibrinolytic agents are an adjunctive therapy for dental
procedure capable of producing transient bacteraemia.
 Therefore all patients with cerebrovascular system (CVS)
management of patients with bleeding disorders and are
disorders should be administered antibiotic prophylaxis. important for prevention or treatment of oral bleeding.
 These agents include Epsilon-aminocaproic acid (Amicar,
Antibiotic prophylaxis is recommended in following dental pro- Xanodyne Pharmaceuticals, Florence, KY) and tranexamic
cedures: acid (Cyklokapron, Pfizer, New York).
 Dental procedures likely to induce any bleeding.  Haemophilic patients form loose, friable clots that may
 Surgical operations involving respiratory mucosa of max- be readily dislodged or quickly dissolved, especially in the
illary sinus. oral cavity where local fibrinolysis is increased.
 Incision and drainage of infected tissue.  Antifibrinolytics prevent clot lysis within the oral cavity.
 Intraligamentary operations. They are often used as an adjunct to factor concentrate
Dental procedures not requiring antibiotic coverage are as replacement. For some dental procedures in which mini-
follows: mal bleeding is anticipated, they may be used alone.
 Simple adjustments of orthodontic appliances.
Dosages
 Fillings above gingiva.
 In children, epsilon-aminocaproic acid is given immedi-
 Intraoral injection of local anaesthetics (except intraliga-
mentary). ately before dental treatment in an initial loading dose of
100–200 mg/kg by mouth up to a maximum total dose of
 Exfoliation of deciduous teeth.
10 g. Subsequently, 50–100 mg/kg per dose up to a total
 New denture or orthodontic appliance insertion.
maximum dose of 5 g is administered orally every 6 hours
for 5–7 days.
Q.2. Define handicapped children. What precautions
 Alternatively, for patients of approximately adult size or
should you take while carrying out dental treatment for
heavier than 30 kg, a regimen of 3 g by mouth four times
a patient suffering from haemophilia?
daily without a loading dose may be used. The advantage
Or of Epsilon-aminocaproic acid for children is that it is
available in both tablet and liquid form.
Define handicapped child and discuss management of a  The adult and paediatric dosage of tranexamic acid is 25
haemophilic child in the dental clinic. mg/kg given immediately before dental treatment. The
Or same dose is continued every 8 hours for 5–7 days.
 The oral preparation of tranexamic acid is not available
Define handicapped child in paedodontic patients and in the United
discuss management of haemophilic child for an ex- States but the intravenous formulation is available. The
traction of teeth. intravenous formulation may be administered orally if re-
quired.
Ans.
WHO has defined a handicapped person as ‘one who over an Side Effects
appreciable period is prevented by physical or mental condi-
 The common side effects associated with the use of antifi-
tions from full participation in the normal activities of their
brinolytics include headache, nausea, and dry mouth.
age groups including those of a social, recreational, educa-
 These side effects are usually tolerable and unless severe,
tional and vocational nature’.
do not require discontinuation of the medication. Other
The management of haemophilic child for an extraction of less common side effects have also been reported.
teeth:  To avoid thrombosis, antifibrinolytics should not be used
 The dentist should confer with the patient's physician when renal or urinary tract bleeding is present or when
and haematologist to formulate an appropriate treatment there is any evidence of disseminated intravascular coagu-
plan. lation.
Quick Review Series for BDS 4th Year: Paedodontics
82

Pain Control in Haemophilic Patients  High-speed vacuum ejectors must be used with caution
so that sublingual haematomas do not occur.
 Intramuscular injections of hypnotic, tranquillizing, or
 After tooth preparation periphery wax is used on the
analgesic agents are contraindicated due to the risk of
impression tray to prevent possible intraoral laceration
haematoma formation. Analgesics containing aspirin
during tray placement.
or anti-inflammatory agents (e.g. ibuprofen) may affect
 Undue trauma is avoided in cementing or finishing a
platelet function and should be avoided.
 Acute pain of moderate intensity can frequently be man- crown.
aged using acetaminophen propoxyphene hydrochloride
(Darvon). Pulpal Therapy
 For severe pain, narcotic analgesics may be required and  A pulpotomy or a pulpectomy is preferable to extraction.
are not contraindicated in the haemophilic patient.
 If the pulp of the vital tooth is exposed, an intrapulpal
injection may be used safely to control the pain.
Local Anaesthesia
 A minimum of a 40% factor correction is mandatory with Oral Surgery
block anaesthesia.
 For simple extractions of erupted permanent teeth and
 All patients should be observed for development of a hae-
multirooted primary teeth, a 30–40% factor correction is
matoma and immediately referred for treatment in case
administered within 1 hour before dental treatment.
haematoma forms after the administration of local anaes-
 Antifibrinolytic therapy should be started immediately
thesia.
before or after the procedure and should be continued for
 In the absence of factor replacement, periodontal liga-
5–10 days.
ment (PDL) injections may be used.
 The patient should be placed on a clear liquid diet for the
 The anaesthetic is administered along the four axial sur- first 72 hours.
faces of the tooth by placement of the needle into the gin-
For the next week, a soft cold diet is recommended. Dur-
gival sulcus and the periodontal ligament space.
ing this time, the patient should not use straws, metal
utensils, pacifiers or bottles.
Dental Management
After 10 days, the patient may begin to consume a more
 Appointments should be arranged so that maximum normal diet.
treatment is accomplished per visit to minimize the need  Specific postoperative instructions should be provided to
for unscheduled factor infusions and hence cost. the patient and parent.
 Rubber cup prophylaxis and supragingival scaling may be  All extractions should be completed in one appointment
safely performed without prior factor replacement ther- if possible.
apy.  After extractions are completed, the direct topical applica-
 Minor bleeding can be readily controlled with local tion of haemostatic agents, such as thrombin or microfi-
measures, such as direct pressure with moistened gauze brillar collagen haemostat (Avitene), may assist with local
square. haemostasis.
 If bleeding persists for several minutes, the topical appli-  The socket should be packed with an absorbable gelatin
cation of bovine thrombin, microfibrillar collagen and sponge (e.g. Gelfoam). Microfibrillar collagen or topical
local fibrin glue may be of value. thrombin or fibrin glue may then be placed in the wound.
Direct pressure with gauze should then be applied to the
Periodontal Therapy area for additional protection from the oral environ-
ment.
 Replacement therapy is required for procedures like sub-
 In general, the use of sutures should be avoided unless
gingival scaling, frenectomy and periodontal surgeries.
suturing is expected to markedly enhance healing, in
Restorative Procedures which case resorbable sutures are recommended.
 For surgical extractions of impacted, partially erupted or
 A rubber dam should be used to isolate the operat- unerupted teeth, a higher factor activity level may be tar-
ing field and to retract and protect the cheeks, lips and geted before surgery.
tongue. These soft tissues are highly vascular and acci-
dental lacerations may present a difficult management Surgical Complications
problem.
 Thin rubber dam is used to decrease the torque and  Despite all precautions, bleeding may occur 3–4 days
retainer should be placed carefully. postoperatively when the clot begins to break down.
Topic wise Solved Questions of Previous Years
83

 Sufficient replacement factor should be administered to ii. Cyanotic Congenital Heart Disease
control recurrent bleeding.
 Cyanotic gingivitis and stomatitis
 The typical clot in this situation is characterized as a ‘liver  Glossitis
clot’ and is dark red, usually protruding from the surgical  Delayed eruption of teeth
site and often covers the surfaces of several teeth.  Increased caries activity
 Following adequate replacement with factor concentrate,  Intrinsic dyschromia of dentition resulting from medica-
usually to a 30–40% activity level, the abnormal clot tions or blood by-product deposition.
should be removed and the area cleansed to help isolate
the source of bleeding. iii. Diabetes Mellitus
 The socket should then be repacked and use of antifibri-  Xerostomia
nolytic agents considered.  Increased caries rate
 Oral candidiasis
Antibiotic Prophylaxis  Oral ulcerations and increased severity of periodontitis
 The antibiotic prophylaxis is followed for haemophilic and bone loss.
patients with prior joint replacement surgeries.
 If the patient is immunocompromised because of HIV iv. Hypopituitarism
infection, intravenous antibiotic prophylaxis may be con-  Tooth eruption is incomplete and delayed.
sidered.  The formation of the root and closure of the apical
foramen are also delayed and incomplete.
Q.3. Give oral manifestations of systemic disease in  Vertical height of the mandible is reduced resulting in
children. What are the AHA guidelines for prevention open bite, immature facial patterns, reduced intermaxil-
of bacterial endocarditis? lary space and crowding of the teeth.

Ans. v. Hypothyroidism
Oral manifestations of various systemic diseases in children are  Delayed eruption
as follows:  Malocclusion
 Increased susceptibility to periodontal diseases, caries and
i. Chronic Renal Failure oral ulcerations
 Developmental retardation and formation of teeth.
Oral manifestations of CRF depend upon the time of onset,
duration, severity and nature of the underlying disease. vi. Hyperthyroidism
Manifestations in Soft Tissues  Susceptibility to periodontal disease and caries
 Periodontal/periapical destruction
 Generalized pallor of the oral mucosa  Premature loss of deciduous teeth and early eruption of
 Intraoral haematoma (a tendency to bruise) permanent teeth.
 Uraemic gingivo-stomatitis
 Bad mouth odour vii. Hypoparathyroidism
 Metastatic calcifications in maxillary sinus and sometimes
 Oral candidiasis
in other areas of oral cavity.
 Hypoplasia of enamel
 Hypodontia
Manifestations in Hard Tissues
 Root dysmorphogenesis
 Malocclusion due to growth retardation  Delayed tooth eruption
 Loss of lamina dura  Thickened lamina dura
 Loss of trabeculation  Chvostek sign positive, i.e. a sharp tap in front of the ear
 Ground glass appearance of the jaws over the facial nerve causes twitching of facial muscles
 Large bony lesions like giant cell tumours of hyperpar- around the mouth.
athyroidism
viii. Hyperparathyroidism
 Deposition of blood pigments in developing teeth results
in staining  Tooth drifting, mobility of tooth
 Hypoplasia with a classic appearance of regular incre-  Disappearance of lamina dura
mental defects.  Radiographically ‘ground glass’ appearance of the jaws.
Quick Review Series for BDS 4th Year: Paedodontics
84

ix. Iron-deficiency Anaemia Regimen for dental procedure as given by the American
Heart Association in 2007 is as follows:
 Cracking or splitting of nails
 Painful tongue Based on situation Drugs Adults Children
 Decreased healing capacity to oral and periodontal sur- Standard general oral Amoxicillin 2g 50 mg/kg
gery prophylaxis
Unable to take oral Ampicillin 2 g IM 50 mg/kg
 Mucosal pallor.
medication or or IV IM or IV
Cefazolin 2 g IM 50 mg/kg
x. Pernicious Anaemia or or IV IM or IV
Ceftriaxone
 Glossitis: Painful and burning sensations Allergic to penicillin or Cephalexin 2g 50 mg/kg
 Tongue is generally inflamed and beefy red in colour over ampicillin- or 600 mg 20 mg/kg
the dorsum and lateral borders oral Clindamycin 500 mg 15 mg/kg
or
 Hunter’s glossitis: Atrophy of the papillae of the tongue Azithromycin or
resulting in a smooth or bald tongue. Clarithromycin
Allergic to penicillin or Cefazolin or 1 g IM or 50 mg/kg
xi. Aplastic Anaemia ampicillin and unable Ceftriaxone IV 600 mg IM or IV
to take oral medication or IM or IV 20 mg/kg
 Pallor Clindamycin IM or IV.
 Purpura
 Spontaneous bleeding.
Q.4. Give oral manifestations of leukaemia. What pre-
xii. Polycythaemia Vera caution would you take to treat such a child?

 The gingiva and tongue appear deep purplish red Ans.


 Cyanosis due to reduced haemoglobin
 Leukaemias are haematopoietic malignancies where there
 The gingiva bleeds on slightest provocation
is uncontrolled neoplastic proliferation of abnormal leu-
 Pale mucosal petechiae, ecchymoses and haematomas. kocytes in the bone marrow and dissemination of these
cells into blood.
xiii. Leukaemia
 ALL (acute lymphoid leukaemia) accounting for 75% of
 Gingival hyperplasia all childhood leukaemias is the most common malignancy
 Ulceration of mucosa of all childhood malignancies.
 Petechiae.
The following are the oral manifestations of leukaemia
xiv. Leukopenia  Commonly observed oral manifestations are petechiae,
 Inability of the tissue to react to infection or trauma in ecchymoses, gingival bleeding, pallor and non-specific
usual manner. ulcerations.
 Gangrenous stomatitis.
xvi. Cyclic Neutropenia  Direct invasion of tissue by an infiltrate of leukaemic cells
can produce gingival hypertrophy.
 Gingivitis
 Infiltration of leukaemic cells along vascular channels can
 Stomatitis, sometimes with ulceration.
result in strangulation of pulpal tissue and spontaneous
xvii. Haemophilia abscess formation as a result of infection or focal areas of
liquefaction necrosis in the dental pulp of sound teeth.
 Gingival bleeding.  Skeletal lesions caused by leukaemic infiltration of bone
are common in childhood leukaemia.
xviii. Thrombocytopaenia
 The most common finding is a generalized osteoporosis
 Severe and profuse gingival bleeding caused by enlargement of the Haversian canals and Volk-
 Petechiae on oral mucosa. mann canals.
Topic wise Solved Questions of Previous Years
85

 Manifestations in the jaws include generalized loss of  Routine preventive and restorative treatment, includ-
trabeculation, destruction of the crypts of developing teeth, ing injections, may be considered when there are at least
loss of lamina dura, widening of the periodontal ligament 50,000 platelets/mm3.
space, and displacement of teeth and tooth buds.  If there are less than 20,000 platelets/mm3, no dental
Management of a leukaemic patient in dental clinic: treatment should be performed at such a time without a
 Before any dental treatment is administered to a child
preceding prophylactic platelet transfusion.
with leukaemia, the child’s haematologist or oncologist or  Prophylactic platelet transfusions are given for platelet
primary care physician should be consulted. levels below 10,000 cells/mm3.
 The following information is ascertained:  The use of a soft nylon toothbrush for the removal of
i. Primary medical diagnosis plaque is recommended.
ii. Anticipated clinical course  For patients who are thrombocytic or at risk for intermit-
iii. Present and future therapeutic modalities tent episodes of thrombocytopaenia because of chemo-
iv. Present general state of health therapy or active disease, the dentist should avoid pre-
iv. Present haematological status. scribing drugs that may alter platelet function, such as
 Pulp therapy on primary teeth is contraindicated in any salicylates like aspirin and other non-steroidal anti-in-
patient with a history of leukaemia. flammatory drugs.

SHORT ESSAYS

Q.1. Describe briefly about management of a child suf- Management


fering with mumps.
 Oral hygiene is important when the mouth is dry from
lack of saliva.
Ans.
 Orchitis can be relieved by prednisolone 40 mg orally
 Mumps is caused by paramyxovirus transmitted via res- daily for 4 days.
piratory droplets.
 It occurs worldwide with peak incidence in the winter. Prevention
 Paramyxovirus causes an acute contagious non-suppura-
 It is prevented by immunization with live attenuated virus
tive parotitis.
as part of measles–mumps–rubella (MMM) vaccine.
Incubation Period
Q.2. Oral manifestations of AIDS.
 It is about 18 days.
Ans.
Clinical Features
Oral manifestation of AIDS patients are as follows:
 The most noticeable symptom of mumps is the painful  Fungal infection like candidiasis.
swelling of the parotid glands, either unilateral or bilat-  Bacterial infections either generalized, localized or pyo-
eral. genic.
 Malaise, fever, trismus and pain near the angle of the jaw  Viral infections like herpes zoster, herpes simplex, and
is soon followed by tender swelling of one or both parotid hairy leukoplakia.
glands.  Linear gingival erythema.
 Less frequent clinical sequelae include orchitis occurring  Gingival and periodontal lesions like ANUG and necro-
in 20–35% of postpubertal males and aseptic meningitis. tizing ulcerative periodontitis.
 It is typically benign and resolves within a week.  Pulmonary lymphoid hyperplasia.
 The two complications are of significance:  Pyogenic bacterial infections like otitis media.
i. Orchitis with painful swelling of the testicles in  Salivary gland enlargement.
postpubertal males, which can result in sterility.  Developmental craniofacial features.
ii. Deafness in children.  Progressive encephalopathy.
Quick Review Series for BDS 4th Year: Paedodontics
86

Q.3. Dental management of von Willebrand disease.  Dry heat sterilization of instruments up to 170°C.
 Virus can be inactivated by heating lyophilized factor at
Ans.
68°C for 72 hours.
 von Willebrand disease is a hereditary bleeding disor-  Disinfectants for innate objects:
der resulting from impairment of von Willebrand factor ❍ Calcium hypochlorite 0.2%, sodium hypochlorite
(vWF). ❍ 6% hydrogen peroxide for more than 30 minutes
 The main function of von Willebrand factor (vWF) is pri- ❍ 2% glutaraldehyde and 6% hydrogen peroxide.
mary platelet plug formation.  Sodium dichloroisocyanate treatment for 10 minutes at
 As a general rule treatment planning should be modified room temperature with 10% household bleach, 50% eth-
whenever possible to provide non-surgical treatment. anol and 3% hydrogen peroxide.
 Patients with von Willebrand disease should undergo  Gloves may be disinfected by immersing them in boiling
subtyping to determine optimal therapy. water for 20 minutes and alternatively overnight soaking
 DDAVP (desmopressin acetate) may be used to achieve in 1% sodium hypochlorite.
haemostasis in most patients with type I von Willebrand
disease, where type I represents a quantitative vWF defi- Q. 5. Management of haemophilic child in dental of-
ciency with intact multimers. fice.
 When DDAVP is used, a test dose should be administered
Ans.
to document an adequate haemostatic response.
 DDAVP is not used in the patients:  For haemophilic child appointments should be arranged
❍ With less common subtypes of vWD so that maximum treatment is accomplished per visit to
❍ Who do not respond to DDAVP minimize the need for unscheduled factor infusions and
❍ With history of bleeding events hence cost.
❍ For whom replacement with exogenous vWF through  Rubber cup prophylaxis and supragingival scaling may be
the use of a concentrate is recommended. safely performed without prior factor replacement ther-
apy.
Q.4. AIDS in children.  Minor bleeding can be readily controlled with local
measures, such as direct pressure with a moistened gauze
Ans.
square.
 Acquired immunodeficiency syndrome (AIDS) is a clini-  If bleeding persists for several minutes, the topical applica-
cally defined condition caused by infection with HIV type tion of bovine thrombin, microfibrillar collagen (Avitene)
I or much less commonly type II. and local fibrin glue may be of value.
 The incubation period from the time of infection to the
appearance of symptoms of AIDS is approximately 11 Periodontal Therapy
years in adults.
 Replacement therapy is required for procedures like sub-
 Therefore HIV infected individuals can unknowingly
gingival scaling, frenectomy and periodontal surgeries.
spread the virus to the sexual or needle-sharing partners,
in case of infected mothers, to their children.
Oral Surgery
 Infants and children with AIDS have clinical findings sim-
ilar to those in adults.  For simple extractions of erupted permanent teeth and
 Early manifestations of HIV infection include pneumo- multirooted primary teeth, a 30–40% factor correction is
cystis, pneumonia, interstitial pneumonitis, weight loss administered within 1 hour before dental treatment.
and failure to thrive, hepatomegaly or splenomegaly, gen-  Antifibrinolytic therapy should be started immediately
eralized lymphadenopathy and chronic diarrhoea. before or after the procedure and should be continued for
 Recurrent and severe bacterial infections are common in 5–10 days.
paediatric patients with HIV infection.  The patient should be placed on a clear liquid diet for the
 Oral manifestations of AIDS patients include fungal, first 72 hours.
bacterial and viral infections, linear gingival erythema,  For the next week, a soft pureed diet is recommended.
pyogenic bacterial infection such as otitis media, hepat- During this time, the patient should not use straws, metal
osplenomegaly, chronic pneumonitis, progressive enceph- utensils, pacifiers, or bottles.
alopathy.  After 10 days, the patient may begin to consume a more
Preventive measures to be followed are: normal diet. Specific postoperative instructions should be
 Barrier techniques and proper sterilization.
provided to the patient and parent.
 HIV is sensitive to autoclaving at 121°C for 15 minutes at  All extractions should be completed in one appointment
1 atmospheric pressure. if possible.
Topic wise Solved Questions of Previous Years
87

 After extractions are completed, the direct topical  Importance of toothbrushing procedure and regular
application of haemostatic agents, such as thrombin or dental review must be stressed.
microfibrillar collagen or haemostat (Avitene), may assist  Boxed type of appliances are indicated for tooth move-
with local haemostasis. ment and tooth replacement.
 The socket should be packed with an absorbable gelatin
sponge (e.g. Gelfoam). Microfibrillar collagen or topical Office Management of Seizure Attack
thrombin or fibrin glue may then be placed in the wound. The following procedures are done if the seizure occurs in dental
Direct pressure with gauze should then be applied to the chair:
area.
 Lower the chair to supine position.
 In general, the use of sutures should be avoided unless
 Prevent the child from injuring himself. E.g. to prevent
suturing is expected to markedly enhance healing, in
tongue biting:
which case resorbable sutures are recommended.
❍ Mouth prop either of rubber/plastic is used.
 For surgical extractions of impacted, partially erupted, or
❍ Patients shifted to a place where they cannot harm
unerupted teeth, a higher factor activity level may be tar-
themselves.
geted before surgery.
 Maintain patent airway: Suction is useful to avoid aspi-
 Antifibrinolytic therapy should be started immediately
ration of secretions; if it is not available head should be
before or after the procedure and continued for 7–10
turned to a side.
days.
 If convulsions do not stop within few minutes give
 For simple extractions of single-rooted primary teeth (i.e. diazepam 1 mg/kg IV and slowly up to 10 mg and O2.
incisors and canines), one must evaluate the amount of
root development present to determine whether factor Q.7. Recent prophylactic regime against bacterial en-
replacement therapy is required. If there is complete root docarditis.
development, factor replacement therapy may be required,
whereas if there is only partial root formation, antifibri- Ans.
nolytic therapy along with local haemostatic agents may  Transient bacteraemia is an important initiating factor in
be all that is required. infective endocarditis.
 When the gingival tissue is repeatedly traumatized during  Procedures known to precipitate transient bacteraemias
exfoliation, use of factor replacement therapy may be in dentistry are all those that involve manipulation of gin-
required. gival tissue or the periapical region of teeth or perforation
of the vital mucosa.
Q.6. Describe dental management of epileptic patient.  Regimen for dental procedure as given by the American
Heart Association in 2007 is as follows:
Ans.
Dental management of epileptic patients should be aimed at Based on situ- Drugs Adults Children
both prevention and control of the epileptic attacks. ation
Standard general Amoxicillin 2g 50 mg/kg
Prevention of seizures in dental office can be best managed by: oral prophylaxis
i. Complete medical history, i.e. type and frequency of sei- Unable to take oral Ampicillin 2 g IM or IV 50 mg/kg
zure episodes and time and situation of the last attack. medication or 2 g IM or IV IM or IV
ii. Reduce stress on the patients with behavioural prepara- Cefazolin 50 mg/kg
tions, sedation, etc. or IM or IV
iii. Avoid use of dental chair light. Ceftriaxone
iv. Avoid seizure-promoting drugs e.g. phenothiazines, lo- Allergic to penicillin Cephalexin 2g 50 mg/kg
cal anaesthetics IV. or ampicillin—oral or 600 mg 20 mg/kg
v. Appropriate drug therapy for seizures – dilantin sodium Clindamycin 500 mg 15 mg/kg
or
and recent drugs like vigabatrin, lamotrigine, gabapen-
Azithromycin
tin and topiramate. or Clarithro-
vi. Typical fibrous gingival hyperplasia may occur; this re- mycin
quires surgical removal. 1 g IM or IV 50 mg/kg
Allergic to penicillin Cefazolin or
or ampicillin and Ceftriaxone 600 mg IM or IV
Dental Treatment unable to take oral or IM or IV 20 mg/kg
medication Clindamycin IM or IV.
 Appointments should be kept short.
Quick Review Series for BDS 4th Year: Paedodontics
88

SHORT NOTES

Q.1. Erythroblastosis fetalis.  If there are less than 20,000 platelets/mm3, no dental
treatment should be performed at such a time without a
Ans.
preceding prophylactic platelet transfusion.
Erythroblastosis Fetalis  Prophylactic platelet transfusions are given for platelet
levels below 10,000 cells/mm3.
 Anaemia due to Rh-positive red blood cells in the fetus  The use of a soft nylon toothbrush for the removal of
being attacked by antibodies from Rh-negative mother. plaque is recommended.
Oral Manifestations  For patients who are thrombocytic or at risk for intermit-
tent episodes of thrombocytopaenia because of chemother-
 Deposition of the blood pigment in the enamel and den-
apy or active disease, the dentist should avoid prescribing
tine of the developing teeth.
drugs that may affect platelet function, such as salicylates
 The pigment colour ranges from green, brown to blue
(aspirin) and non-steroidal anti-inflammatory drugs.
hue.
Q.5. Describe dental management of epileptic patient.
Q.2. Enumerate congenital anomalies.
Ans.
Ans.
Dental management of epileptic patients should be aimed at
The various congenital anomalies are as follows:
both prevention and control of the epileptic attacks.
 Cleft lip and palate
Prevention of seizures in dental office can be best managed by:
 Down syndrome
i. Complete medical history.
 Tetralogy of Fallot (TOF)
ii. Reduced stress on the patients.
 Septal defects
iii. Avoid use of dental chair light and seizure-promoting
 Congenital cardiac disorders.
drugs, e.g. phenothiazines, local anaesthetics IV.
Q.3. Give oral manifestations of leukaemia. The following procedures are done to control the seizure attack
on dental chair:
Ans.
 Lower the chair to supine position.
The following are the oral manifestations of leukaemia:  Prevent the child from injuring himself.
 Gangrenous stomatitis  Maintain patent airway.
 Gingival hypertrophy  If convulsions do not stop within few minutes give
 Spontaneous abscess formation as a result of infection or diazepam 1 mg/kg IV and slowly up to 10 mg and O2.
focal areas of liquefaction necrosis in the dental pulp of
sound teeth. Q.6. Clinical importance of platelet count in a leukae-
 Skeletal lesions caused by leukaemic infiltration of bone. mic patient.
 The most common finding is a generalized osteoporosis.
 Radiographic findings in the jaws include generalized
Ans.
loss of trabeculation, destruction of the crypts of devel-  A platelet level of 1,00,000/mm3 is adequate for most
oping teeth, loss of lamina dura, widening of the peri- dental procedures.
odontal ligament space, and displacement of teeth and  Clinical importance of platelet count is as follows:
tooth buds.
Platelet count Significance
Q.4. Management of a purpuric patient in dental clinic. (cells/mm3)

Ans. 150,000–400,000 Normal


50,000–1,50,000 Bleeding time is prolonged, but patient would
 The information regarding primary medical diagnosis, tolerate most routine procedures
present general state of health and present haematological
20,000–50,000 At moderate risk for bleeding, hence defer elec-
status is ascertained. tive surgical procedures
 When there are at least 50,000 platelets/mm3 routine pre-
<20,000 At significant risk for bleeding; defer elective
ventive and restorative treatment, including injections dental procedures
may be considered.
Topic wise Solved Questions of Previous Years
89

 Routine preventive and restorative treatment, including Absolute Significance


non-block injections, may be considered when the plate- neutrophil
let count is at least 50,000/mm3. count (cells/
mm3)
Q.7. Clinical importance of WBC counts in a leukaemic >1500 Normal
patient.
500–1000 Patient at some risk of infection;
Ans. defer elective procedures that could induce
significant transient bacteraemia
 The absolute neutrophil count is an indicator of the host’s
ability to suppress or eliminate infection. 200–500 Patient must be admitted to the hospital if
febrile and given broad-spectrum antibiotics;
 It is calculated as follows:
at moderate risk for sepsis; defer all elective
ANC = (% of neutrophils + % of bands ) total white cell procedures
count/100
 Clinical importance of the WBC count is as follows: <200 At significant risk for sepsis

Topic 9 MANAGEMENT OF CHILDREN


WITH CLEFT LIP AND PALATE
SHORT ESSAYS

Q.1. Define cleft lip and cleft palate. 6 months  Preventive oral care measures
 Discussion of anticipatory guidance protocol with
Or paediatric dentist
Treatment schedule of cleft palate.  Reinforcement of infant oral care measures and im-
portance of preventive dentistry
Ans. 12–18  Surgical repair of cleft palate
months  Preliminary speech assessment
Cleft lip and palate are congenital abnormalities that affect  Oral hygiene instructions
the upper lip and the hard and soft palate. This abnormality 2–3 years  Initial assessment by orthodontist, ENT surgeon,
may range from a small notch in the lip to a complete fissure speech therapist
extending up to the roof of mouth and nose.  Assessment of surgical result by plastic surgeon or
oral and maxillofacial surgeon
 Quarterly dental check-ups
Treatment Schedule for Patient with
 Parental education of effective oral hygiene measures
Cleft Lip and Palate
4–7 years  ENT assessment
A child with cleft lip and palate needs continuous care from  Beginning of speech therapy
the team members until the late teen age.  Early correction of crossbite
 Orthodontist’s assessment on early orthodontic treat-
The various treatments to be carried out at different ages are ment
summarized as follows: 9 years  Aesthetic surgery—lip and nose revision
 Growth modification treatment
Age Treatment  Early orthodontic treatment
At birth  Construction of feeding plate 12 years  Correction of malalignment begins
 Refer to a centre where a multidisciplinary cleft palate  Creation of space for replacement of missing teeth
team exists  Alveolar bone graft
 Primary care advice about weight gain for fitness to  Assess school psychological adjustment
surgery 16 years  Aesthetic surgery to improve appearance
 Infant oral care measures  Any major orthognathic surgeries
3 months  Surgical repair of the lip  Fixed and permanent replacement of missing teeth
 Monitoring speech and hearing  Regular restorative care
Quick Review Series for BDS 4th Year: Paedodontics
90

Q.2. Obturator in paediatric prosthodontics.  To restore a patient’s cosmetic appearance rapidly for
social contacts.
Ans.
 To act as a framework over which tissues may be shaped
An obturator is a disc or plate, natural or artificial that closes by the surgeon.
an opening or defect of the maxilla as a result of a cleft pal-  When the patient’s age or the local avascular condition of
ate or partial or total removal of maxilla for a tumour mass the tissues contraindicates surgery.
(Chalian 1971).  When the patient is susceptible to recurrence of the lesion
that produced the deformity.
Types of Obturator
Uses
i. Feeding obturator: Used to cover maxillary defects in
newborns to aid in feeding and suckling.  It may help to reconstruct the palatal contour and soft
ii. Surgical obturator: Given after surgery to aid in wound palate.
healing, holds dressings, maintains pressure on split-  It may be used for feeding purposes.
thickness skin grafts.  It improves speech or in some instances makes speech
iii. Functional obturator: To help in deglutition. possible.
iv. Speech obturator:  It may be used to keep the wound or defective area clean
 It is also known as speech aid prosthesis, nasopharyn- and may enhance the healing of postsurgical defects.
geal obturator, speech appliance, prosthetic speech  It can benefit the morale of patients with maxillary
aid, speech bulb. defects.
 It is a temporary or interim prosthesis used to close a  It reduces the flow of exudates into the mouth.
defect in the hard and/or soft palate to replace tissue  The obturator may be used as a stent to hold dressings or
lost due to developmental or surgical alterations nec- packs postsurgically in maxillary resections.
essary for the production of intelligible speech.  It reduces the possibility of postoperative haemorrhage,
and maintains pressure either directly or indirectly on
Indications split-thickness skin grafts, thus causing close adaptation
 To serve as a temporary prosthesis during the period of of the graft to the wound which prevents the formation of
surgical correction. a haematoma and ultimate failure of the graft.

SHORT NOTES

Q.1. Veau classification of cleft lip and cleft palate. Block 1 and 4 → Lip
Ans. Block 2 and 5 → Alveolus
Veau classification of cleft lip and cleft palate (1931): Block 3 and 6 → Hard palate anterior to incisive foramen
 Group 1: Cleft of the soft palate only Block 7 and 8 → Hard palate posterior to incisive foramen
 Group 2: Cleft of the hard and soft palate to the incisive Block 9 → Soft palate.
foramen
The boxes are shaded in areas where the cleft has occurred.
 Group 3: Complete unilateral cleft of the soft, hard palate
and lip and alveolar ridge on one side
 Group 4: Complete bilateral cleft of the soft hard palate 1 4
and lip and alveolar ridge on both sides. 2 5
3 6
Q.2. Kernahan and Stark classification of cleft palate.
7
Ans.
8
Kernahan stripped ‘Y’ classification
9
Symbolic classification uses a stripped ‘Y’ having numbered
blocks, which represents specific areas of the oral cavity
Fig. 9.1 Kernahan stripped ‘Y’.
(Fig. 9.1).
Topic wise Solved Questions of Previous Years
91

Topic 10 GROWTH AND DEVELOPMENT OF


THE FACE AND DENTAL ARCHES
LONG ESSAYS

Q.1. Discuss in detail about growth of the mandible. Between 8th and 12th weeks of IU life
Ans.

Prenatal Growth of Mandible There is marked acceleration of mandibular growth; as a


result mandibular length increases, the external auditory
1st structure to develop in primordium of lower jaw meatus appears to move posteriorly
is
Mandibular division of V nerve (induces osteogenesis by Between 10th and 14th weeks of IU life
production of neurotrophic factors) Secondary accessory cartilages appear to form the head
followed by of the condyle, part of the coronoid process and mental
protuberance. Soon the growing intramembranous os-
Mesenchymal condensation forming the first arch sification fuses the coronoid process to the ramus
(mandibular arch)

The ossification of the ramus proceeds and the condyle is


Mandible is derived from ossification of an osteogenic soon fused to the mandible at about 16 weeks.
membrane formed from ectomesenchymal condensation
at around 36–38 days
Meckel’s cartilage does persist until as long as 24th week
of IU life before it disappears
Resulting intramembranous bone lies lateral to Meckel’s
cartilage of 1st arch (mandibular arch)
Postnatal Growth of Mandible
 Among all the facial bones, the mandible undergoes the
At 6th week of IU life largest amount of growth postnatally and also exhibits the
In the region of bifurcation of inferior alveolar nerve into largest variability in morphology.
mental and incisive branches, a single ossification centre
 Mandibular growth in the postnatal life shows the inte-
for each half of the mandible arises
gration of the periosteal and capsular matrices of func-
tional matrix theory by Moss.
During 7th week of IU life  Capsular matrix involves the oropharyngeal functional
spaces and the mandible grows according to the functional
needs of the particular functional system. The process of
The bone begins to develop lateral to Meckel’s cartilage surface remodelling usually involves the activity of the
and continues until the posterior aspect is covered by the periosteal matrix, i.e. muscle fibres.
bone. Ossification stops at the point that will later become
the mandibular lingula, from where Meckel’s cartilage Mandible at Birth
continues into middle ear and develops into auditory
ossicles, i.e. malleus and incus. The remaining part of  Mandible at birth is much smaller in size and varies in
the Meckel’s cartilage continues on its own to form the shape from the adult form. The infant mandible has a
sphenomandibular ligament and the spinous process of short, more or less horizontal ramus with obtuse gonial
the sphenoid bone which are remnants of it angle.
 The condyles are low and at the position of the occlusal
plane. The symphyseal suture has not ossified.
Quick Review Series for BDS 4th Year: Paedodontics
92

Growth in the First Year  Following the V-principle, the interramal distance is effi-
ciently increased by the growth of mandible, which helps
 It involves growth at the symphyseal suture and lateral
the mandible to keep pace with the growth of the cranial
expansion in the anterior region to accommodate the
base.
erupting anterior teeth.
 The mental foramen is directed at right angle to the sur- Height
face of the corpus.
 Alveolar process height increases well with eruption of
 There is increased bone deposition in the posterior sur-
face of the ramus of the mandible. teeth.
 Bone deposition taking place in the lower border of mandi-
 The infant mandible is suited for the suckling activity
since the condyle and the glenoid fossa is flat, which helps ble also contributes to increase in height of the mandible.
in the anteroposterior movement of the mandible.
Rotation of Mandible
Mandible in the Adult/Concept of V-Principle  Bjork used implants to study the growth pattern of man-
dible and found that mandible undergoes growth rotation.
The adult mandible differs from the mandible of an infant It was found that though mandible undergoes rotation,
in that: the effects seen are minimal due to external compensa-
 The ramus is longer and the gonial angle is less obtuse. tion. It was concluded that the growth of the mandible is
 The bone is larger on the whole and the condyle is well- largely influenced by the functional matrices, and condy-
developed. lar cartilage has little influence in its overall growth.
 All these changes take place in the growth of the mandible
in the form of an expanding V. Summary of mandibular growth
 Because of its horseshoe shape, it is easier to visualize
Length increases by:
mandible as the V-shaped bone than the maxilla.
i. Surface apposition at posterior border of ramus and re-
sorption at anterior border.
V-Principle of Growth
ii. Deposition at bony chin
According to this principle growth of mandible in length, iii. Growth at condylar cartilage.
width and height is as follows: Height increases by:
Length i. Surface apposition at alveolar border
ii. Apposition at the lower border of mandible
 The growth of the mandible in length anteroposteriorly iii. Growth at the condylar cartilage.
is by the deposition of bone at the posterior border of the
ramus and resorption at the anterior surface, which helps Width increases by:
to lengthen mandible so that the anterior part of the ramus i. Sutural growth up to 1st year postnatally
is occupied by the posterior part of the body in the future ii. Later surface apposition at outer surface.
and accommodates the developing permanent molars. Growth sites in mandible are:
 As the articulation of the condyle to the glenoid fossa is i. Mandibular condyle
constant, the anterior displacement causes displacement ii. Posterior border of ramus
of the mandible anteriorly as it grows posteriorly. iii. Alveolar process
 There is corresponding surface remodelling at the ante- iv. Lower border of mandible
rior border with deposition in the posterior surface of the v. Suture.
symphysis and resorption in the superior part of the ante-
rior surface and deposition in the inferior aspect. Q.2. Discuss growth and development of dental arches
from birth to adolescence.
Width
Ans.
 There is deposition in the lateral surface of the ramus and
resorption on the lingual surface of mandible below the The growth and development of dental arches or occlusal de-
mylohyoid ridge. In contrast, the coronoid process under- velopment from birth to adolescence can be divided into the
goes apposition at the medial surface and resorption at following periods or stages:
the lateral surface. This expands the mandible like a V.
 The condyle undergoes reduction of bone on the lat- Predental Period
eral aspect of neck and deposition corresponding to the  This period extends from birth to 6 months of age after
V-principle makes the condyle longer at the neck. birth, i.e. 0–6 months.
Topic wise Solved Questions of Previous Years
93

 The neonate is without teeth for about 6 months of life. Deciduous Dentition Period
The alveolar arches of an infant at this time period are
 The deciduous dentition period extends from 6 months
known as gum pads.
to 6 years of postnatal life.
 It starts with eruption of deciduous mandibular central
Features of Gum Pads are as Follows
incisors and completes with second deciduous molars
 They are pink in colour and firm in consistency covered coming into occlusion.
by dense layer of fibrous periosteum.  The eruption of all primary teeth is completed by 2 ½–3½
 They are horseshoe shaped and develop in two parts: years of age.
(a) Labiobuccal portion The normal features of the ideal occlusion in the primary
(b) Lingual portion. dentition are as follows:
i. Spacing of anterior teeth: Spaces existing between the
Dental Groove
deciduous teeth called as physiologic or developmental
These two portions are separated by a groove called the den- spaces are important for normal development of perma-
tal groove (Fig. 10.1). nent dentition.
ii. Primate/anthropoid/simian spaces:
 These physiologic spaces are present invariably on
mesial side of maxillary canines and distal side of
Lateral sulcus mandibular canines.
 As these spaces are commonly seen in primates. They
Dental groove
are known as primate spaces, simian spaces or an-
Gingival groove thropoid spaces. These spaces help in placement of
the canine cusps of the opposing arch.
iii. Shallow overjet and over bite.
Fig. 10.1 Maxillary gum pad.
iv. Ovoid arch form.
v. Almost vertical inclination of anterior teeth.
Transverse Grooves vi. Flush terminal plane: The mesiodistal relation between
the distal surfaces of the upper and lower second decidu-
 The gum pads are divided into 10 segments by transverse ous molars (E) is called the terminal plane. A normal
grooves. Each segment consists of one developing decidu- feature of deciduous dentition is a flush terminal plane,
ous tooth sac. where the distal surfaces of the upper and lower second
deciduous molars are in the same plane.
Lateral Sulcus
vii. Deep bite: The deep bite occurs in the initial stages of
 The transverse groove between the canine and first decid- development and is accentuated by the more upright de-
uous molar segment is called the lateral sulcus. ciduous incisors compared to their successors.
 The lateral sulcus of mandibular arch is normally more This deep bite is reduced later due to:
distal to that of maxillary arch. (a) Eruption of deciduous molars
The lateral sulci are useful in judging the interarch relation- (b) Attrition of incisors
ship of maxilla and mandible at very early stage. (c) Forward movement of the mandible due to growth.
 Upper and lower gum pads are almost similar to each
other. Mixed Dentition Period
This period ranges from 6–12 years of age. This period can
Relationship of Gum Pads
be divided into three phases:
 When the upper and lower gum pads are approximated (a) First transitional period
there in a complete overjet all around, as the upper gum (b) Intertransitional period
pad is wider as well as longer than lower gum pad. (c) Second transitional period.
 Class II pattern is exhibited as maxillary gum pad being
more prominent. A. First Transitional Period
 Anterior open bite: This infantile open bite is considered
normal. Contact occurs between the upper and lower It is characterized by:
gum pads in first molar region and a space exists between i. Emergence of the first permanent molars.
them anteriorly known as infantile open bite which helps ii. Exchange of the deciduous incisors with permanent in-
in sucking. cisors.
Quick Review Series for BDS 4th Year: Paedodontics
94

i. Emergence of the first permanent molars In this type of relationship:


 Distal surface of mandibular second deciduous molar
 Mandibular first molar is the first permanent tooth to
erupt at around 6 years of age. 冢 冢
EE
is more mesial than that of maxillary second decid-
 The distal surface of the second deciduous molar, i.e. (E)
guides the first permanent molars into the dental arch. uous molar 冢 冢
EE
(Fig. 10.3).
 The location and relationship of the first permanent  The permanent molars erupt directly into the Angle’s
molars depend much on the distal surface relation- class I occlusion.
ship between upper and lower second deciduous molars
E . If forward growth of mandible
E
 The distal surface relationship between the upper and Persists Minimal
lower second deciduous molars can be of three types:
a. Flush terminal plane (76%)
b. Mesial-step terminal plane (14%) Leads to Establishes
c. Distal-step terminal plane (10%).
a. Flush terminal plane
Angle’s class III molar Angle’s class I molar
relationship relationship

6 E D
Distal-step terminal plane (Fig. 10.4)
6 E D

6 E D
Fig. 10.2 Flush terminal plane.

 The distal surface of the upper and lower second deciduous


6 E D
molars are in one vertical plane. This type of relationship is
called flush or vertical terminal plane relationship, which is
a normal feature of deciduous dentition (Fig. 10.2).
Fig. 10.4 Distal-step terminal plane.
 The erupting first permanent molars may also be in a
flush or end-on relationship which shifts to class relation
 In this type of relationship, the distal surface of E E is
by either:
a. Early shift or more distal to the of E E (Fig. 104).
b. Late shift.  Erupting permanent molars assume Angle’s class II occlu-
❍ Early shift: Occurs during early mixed dentition period, sion here.
where eruptive force of the first permanent molar is
sufficient to push the deciduous first and second molars ii. The exchange of incisors
forward to close the primate spaces and establish class I  The deciduous incisors are replaced by the permanent
molar relationship. incisors during first transition period.
❍ Late shift: Occurs in the late mixed dentition period.  The mesiodistal width of permanent incisors is larger
In children lacking primate spaces, the erupting per- than deciduous teeth they replace.
manent first molars drift mesially, utilizing the leeway  Incisal liability is the difference between the amount of
space when deciduous 2nd molars exfoliate. space needed for accommodation of the incisors and
b. Mesial-step terminal plane the amount of space available for them to occupy. It was
described by Warren Mayne in 1969.
 Incisal liability is:
6 E D a. 7 mm in maxillary arch
b. 5 mm in mandibular arch.
6 E D
 Incisal liability can be overcome by:
i. Utilization of interdental spaces seen in primary denti-
Fig. 10.3 Mesial-step terminal plane. tion
Topic wise Solved Questions of Previous Years
95

ii. Increase in intercanine width Ans.


iii. Change in incisor inclination. Growth has been described variedly by various paedodontists
as below:
B. Intertransitional Period
Definition of growth according to:
 It is relatively stable and no changes occur during this  Stewart 1982: Growth may be defined as developmen-
phase to mixed dentition. tal increase in mass. In other words, it is a process that
 The maxillary and mandibular arches consist of sets of leads to an increase in the physical size of the cells, tissues,
deciduous and permanent teeth during this period. organs or organisms as a whole.
 Proffit 1986: Growth refers to an increase in size or num-
C. Second Transitional Period bers.
 Stedman 1990: Growth is an increase in size of a living
i. The replacement of deciduous molars and canines by being or any of its parts, occurring in the process of devel-
the premolars and permanent cuspids, respectively, is opment.
characteristic of this phase.
 Pinkham 1994: Growth signifies an increase, expansion of
ii. The leeway space of Nance is the excess space available any given tissue.
after the exchange of the deciduous molars and ca-
nines with permanent teeth. It is utilized for mesial Definition of development according to:
drift of mandibular molars to establish class I molar
 Todd (1931): Development is an increase in complexity.
relation.
 Moyers (1988): Development refers to all the naturally
iii. Ugly duckling stage (7–11 years of age):
occurring unidirectional changes in the life of an individ-
 It is also known as Broadbent phenomenon; it is a ual from its existence as a single cell to its elaboration as a
transient or self-correcting malocclusion seen in multifunctional unit terminating in death.
maxillary incisor region, particularly during eruption
 Stedman (1990): Development refers to the act or process
of permanent canines.
of natural progression from previous, lower or embryonic
 During eruption of permanent canines they impinge stage to a later, more complex adult stage.
on roots of lateral incisors displacing them mesially,
 Pinkham (1994): Development addresses the progressive
which inturn results in transmission of force on to
evolution of a tissue.
the roots of central incisors which also get displaced
mesially. Importance of study of growth and development in paedodon-
 A resultant distal divergence of crowns of two central tics is as follows:
incisors causes a midline diastema.
 Knowledge of normal human growth is essential for the
This situation has been described by Broadbent as ugly duck- recognition of abnormal or pathologic growth.
ling stage as children tend to look ugly during this phase.  Estimation of growth potential is necessary to achieve a
stable; functional and an aesthetic result in cases of ortho-
Permanent Dentition Period dontic, surgical, orthognathic and orthopaedic correc-
tions of dentofacial disharmony.
This period extends from shedding of last primary tooth and  The study of growth in children is done to assess the health
eruption of all permanent teeth. and nutrition of children living in a nation.
The frequently seen eruption sequence of the permanent
 The study of growth in children is done to compare the
dentition is as follows:
growth of an individual child with the growth of a large
 Maxillary arch 6-1-2-4-3-5-7 sample of other children. This is important for health
Or 6-1-2-3-4-5-7 education professionals and parents who care for growing
 Mandibular arch 6-1-2-3-4-5-7 children.
Or 6-1-2-4-3-5-7  Growth rate may be the best indicator of the physical and
psychological well-being of children.
Q.4. Define growth and development. Discuss growth  To use the myofunctional appliances appropriately to
and their clinical implications. know the growth spurt period.
Quick Review Series for BDS 4th Year: Paedodontics
96

SHORT ESSAYS

Q.1. Growth spurts and growth trends. ANB Angle


Ans.  According to Sterner it is the angle between point A on
maxilla and point B on mandible. It is the difference
Growth Spurts and Differential Growth between SNA and SNB and indicates the magnitude of
 Growth does not continue uniformly at all times. There skeletal joint discrepancies. The normal value of ANB
seems to be periods when a sudden acceleration of growth angle is 2°.
 If it is less than 2° then it is indicative of class II and if it is
occurs. This sudden increase in growth is termed as
‘growth spurt’. more than 2° then indicative of class III malocclusion.
 Such accentuated growth is believed to be caused due to
Type A
the physiological alteration in hormonal secretion.
 The timing of growth spurt differs in boys and girls.  The maxilla and mandible grow together and thus ANB
 Growth spurts are mainly due to following causes: angle remains same. Should this be accompanied by class
i. Prebirth cell division I relationship and ANB does not exceed 4.5°, no treatment
ii. Postbirth hormonal influence. is indicated.

Timings of Growth Spurts Type A Subdivision


i. Just before birth.  Maxilla is protruding with ANB angle more than 4.5°. The
ii. One year after birth. treatment is to restrict the growth of maxilla while allow-
iii. Mixed dentition growth spurt: ing mandible to catch up. The prognosis is good, but may
 Boys: 8–11 years sometimes require extraction of premolars.
 Girls: 7–9 years.
iv. Prepubertal growth spurt/adolescent growth spurt: Type B
 Boys: 14–16 years  Mandible and maxilla grow forward and downward with
 Girls: 11–13 years. the growth of maxilla exceeding that of mandible.
v. Prepubertal growth spurt/adolescent growth spurt has  Poor prognosis and indicates that point B will not catch
been divided into three phases: up with point A.
a. Prepubertal take-off stage—moderate increment in  Growth of middle and lower face is predominantly in ver-
the height velocity. tical direction.
b. Pubescent phase—very rapid growth phase.
Type B Subdivision
c. Postpubescent phase—decelerating height velocity;
finally, linear growth comes to a stop with fusion of  The ANB angle is large and continues to grow, indicating
the epiphyses. unfavourable growth trend.

Clinical Application Type C


 Growth modification treatments by means of functional  The maxilla and mandible grow forward and downward
and orthopaedic appliances elicit better response during with mandible growing forward more rapidly.
growth spurts.  The ANB angle is seen to be decreasing with the mandible
 Surgical corrections involving maxilla and mandible catching up with maxilla. This indicates favourable trend.
should be carried out only after cessation of the growth  No treatment is required until eruption of canine.
spurts.
Type C Subdivision
Growth Trends
 The mandible is found to be growing more forward when
 By overlapping consequent cephalograms, Tweed discerned compared to maxilla. With this the mandibular incisors
a pattern of growth and termed it as growth trends. touch the lingual surface of maxillary incisors.
Topic wise Solved Questions of Previous Years
97

 Therefore lingual tipping of mandibular incisors and i. Lymphoid tissue


labial tipping of maxillary incisors are obvious. It proliferates rapidly in late childhood to almost 200% of
adult size (adaptation to protect child from infection). By 18
Q.2. Scammon growth curve. years it undergoes involution to reach adult size.
Ans. ii. Neural tissue
Grows very rapidly and almost reaches adult size by 6–7 years
 Throughout life human body does not grow at the same
of age, after that very little growth occurs in neural tissue.
rate; different organs grow at different rates to a different
amount and at different times; this is known as differen- iii. General/visceral + (muscle, bone and other organs)
tial growth. They exhibit ‘S’-shaped curve which indicates rapid growth
 The concepts of differential growth are more clearly up to 2–3 years of age followed by slow phase between 3–10
understood by two important aspects of growth: years of age and followed again by rapid phase of growth oc-
a. Cephalocaudal gradient of growth curring after 10th year terminating by 18–20 years.
b. Scammon curve of growth. iv. Genital tissues (reproductive organs)
Negligible growth until puberty. They grow rapidly at pu-
a. Cephalocaudal Gradient of Growth berty reaching adult size after which growth ceases.
 An axis of increased growth gradient extending from head
towards the feet is called ‘cephalocaudal growth’. Effect of Scammon Growth in Facial Region
 In fetal life, head constitutes 50% of total body length
 Mandible follows somatic growth pattern. Long time
while limbs are primitive (30%).
growth is seen until about 18–20 years in males.
At the time of birth, head constitutes 25–30% and there  Maxilla follows neural growth pattern and growth ceases
is increased growth of body and limbs. In an adult the head earlier; hence skeletal problems of the maxilla should be
constitutes only 12%, while limbs accounts to 50%. These treated earlier to mandible.
changes in the pattern of growth are because of cephalocau-
 Scammon growth curve indicates that growth rate of dif-
dal gradient.
ferent tissues are different at different ages.
Example:
Cephalocaudal Growth in Face
 The various tissues for which Scammon growth curve is
 At the time of birth, jaws and face are less developed com- plotted are lymphoid tissue, neural tissue, general or vis-
pared to skull. Maxilla being closer to head grows faster ceral tissue and genital tissue.
and growth is completed before mandibular growth. Man-  Lymphoid tissue proliferates rapidly in late childhood to
dible being away from the brain grows more and growth almost 200% of adult size.
completes later than maxilla. By 18 years it undergoes involution to reach adult size.
 Neural tissue grows very rapidly and almost reaches adult
b. Scammon Curve of Growth size by 6–7 years of age; after that very little growth occurs
Major tissues of the human body are divided into four in neural tissue.
types:  General/visceral tissue exhibits ‘S’-shaped curve which
i. Lymphoid tissue indicates rapid growth up to 2–3 years of age followed by
slow phase between 3 and 10 years of age and followed
ii. Neural tissue
again by rapid phase of growth occurring after 10th year
iii. General tissue terminating by 18–20 years.
iv. Genital tissue.  Genital tissues shows negligible growth until puberty.
These different tissues grow at different time and at different They grow rapidly at puberty reaching adult size, after
rates: which growth ceases.
Quick Review Series for BDS 4th Year: Paedodontics
98

SHORT NOTES

Q.1. Skeletal age versus dental age.  Clinical importance:


a. Knowledge of growth spurts is essential for successful
Ans.
treatment planning in orthodontics.
Skeletal age Dental age b. Growth modulation by means of functional and ortho-
It is based on the ossification of The formation of teeth or eruption dontic appliances elicit better response during growth
endochondral bone of teeth is the basis for calculating spurts.
dental age
Assessed based on the skeletal Assessed based on the number of Q.4. Gum pads.
maturity indicators like hand– teeth at each chronological age or Ans.
wrist radiographs, cervical ver- on stages of formation of crowns
tebrae, etc. and roots of the teeth i. The alveolar arches at the time of birth are called gum
pads and are firm and pink.
Q.2. Name few hormones influencing growth. ii. Maxillary gum pads develop in 2 parts namely labi-
Ans. obuccal and lingual; they are demarcated by the dental
groove. Labiobuccal part grows fast and is divided into
There are three types of hormones responsible for growth: 10 segments by transverse grooves which correspond to
the deciduous tooth sac.
Group I: Hormones influencing skeletal bone growth iii. The groove between the canine and deciduous first mo-
 Growth hormone lar is called lateral sulcus.
 Insulin iv. Gingival groove demarcates the palate from gum pads.
 Thyrotropic hormone. v. Lower gum pads are V-shaped and similar to maxillary
Group II: Hormones responsible for ossification of long gum pads, but the segments are less defined when com-
bones pared to maxillary gum pad.
vi. Gum pads’ relationship is arbitrary; they do not have
 Parathormone.
definite relationship.
Group III: Hormones responsible for pubertal growth
spurt Q.5. Broadbent phenomenon.
 Androgens Ans.
 Progesterone and oestrogen.
 Ugly duckling stage (7–11 years of age) is also known as
Q.3. What are growth spurts? In which age are they Broadbent phenomenon.
seen?  It is a transient or self-correcting malocclusion seen in
maxillary incisor region particularly during eruption of
Or permanent canines.
 During eruption of permanent canines they impinge on
Significance of growth spurts.
roots of lateral incisors displacing them mesially, which
Or in turn results in transmission of force on to the roots of
central incisors which also get displaced mesially.
Growth spurts.
 A resultant distal divergence of crowns of two central inci-
Ans. sors causes a midline diastema. This situation has been
 During process of growth, there seems to be periods when described by Broadbent as ugly duckling stage as children
a sudden acceleration of growth occurs. This sudden tend to look ugly during this phase.
increase in growth is termed growth spurt.
 The timing of the growth spurts differs in boys and girls Q.6. Age changes in mandible.
as follows: Ans.
a. Just before birth
b. One year after birth Infant mandible:
c. Mixed dentition growth spurt (boys 8–11 years and  The infant mandible has a short, more or less horizontal
girls 7–9 years) ramus with obtuse gonial angle.
d. Prepubertal growth spurt (Boys 14–16 years and girls  The condyles are low and at the position of the occlusal
11–13 years). plane.
Topic wise Solved Questions of Previous Years
99

The adult mandible differs from the mandible of an infant  The bone is larger on the whole and the condyle is well-
in that: developed.
 All these changes take place in the growth of the mandible
 The ramus is longer and the gonial angle is less obtuse. in the form of an expanding V.

Topic 11 DEVELOPMENT AND MORPHOLOGY


OF PRIMARY TEETH AND OCCLUSION
LONG ESSAYS

Q.1. What is importance of deciduous teeth? Describe The primary dentition is completely formed by about the
anatomic and histologic differences between primary age of 3 years and functions for a relatively short period of
and permanent dentition. time before it is lost completely about the age of 11 years.
 The loss of the deciduous teeth tends to mirror the erup-
Or tion sequence: incisors, first molars, canines and second
Discuss morphologic and histologic differences of pri- molars with the mandibular pairs preceding the maxillary
mary and permanent teeth and its significance. teeth. The increase in prevalence of dental caries among
tooth types reverses their order of eruption.
Or  The role of the primary teeth in mastication and their
What are morphologic differences between primary function in maintaining the space for eruption of the per-
and permanent teeth? manent teeth.
 A lack of space associated with premature loss of decid-
Ans. uous teeth is a significant factor in the development of
malocclusion.
 Emergence of the primary dentition takes place between
 The development of adequate spacing is an important
the 6th and 30th months of postnatal life.
factor in the development of normal occlusal relations
 It takes from 2 to 3 years for the primary dentition to be
in the permanent dentition. Therefore, it is important
completed, beginning with the initial calcification of the
to prevent and treat dental decay by providing the child
primary central incisor to the completion of the roots of
with a comfortable functional occlusion of the deciduous
the primary second molar.
teeth.
Importance of Primary Teeth Major differences between primary and permanent teeth
are as follows:
 The emergence of the primary dentition through the alve-
olar mucosa is an important time for the development of Primary teeth Permanent teeth
oral motor behaviour and the acquisition of masticatory Teeth are lighter in colour; bluish Darker in colour; greyish or yel-
skills. white lowish white
 At this time of development, the presence of ‘teething’ Number of teeth is 20; premolars Number of teeth is 32
problems suggest how the primary dentition can affect and molars are absent
the development of future neurobehavioural mechanisms, Crowns are wider mesiodistally Crowns are larger in cervico-
including jaw movements and mastication. in relation to the cervico-occlusal occlusal dimension than the
 Learning of mastication may be highly dependent on the height, which gives a cup- mesiodistal dimension.
stage and development of the dentition, e.g. type and shaped appearance to anterior Cuspids are less conical
teeth and square-shaped appear-
number of teeth present and occlusal relations, the matu-
ance to molars.
ration of the neuromuscular system and such factors as Cuspids are more conical
diet.
Cervical ridges are more pro- Cervical ridges are flatter
 Even for the individual child, considerable variation in the nounced especially on the buccal
times of emergence of the primary dentition may occur. aspect of first primary molar
Quick Review Series for BDS 4th Year: Paedodontics
100

Molars have narrow occlusal There is less convergence of Different Stages of Development of Teeth
table in a buccolingual plane. buccal and lingual surfaces of The tooth development progresses in the following stages
Occlusal plane is relatively flat molars towards the
occlusal surface
according to American Academy of Pediatric Dentistry:
Molars are more bulbous and Have more curved contours. A. Morphological developmental stages:
are sharply constricted cervically They have less constriction at  Dental lamina
(bell shaped) the neck  Bud stage
The enamel is thinner and has a Enamel is thicker and has a  Cap stage
more consistent depth of about thickness of about 2–3 mm  Bell stage
1 mm thickness throughout the  Advanced bell stage
entire crown
 Hertwig epithelial root sheath
Contact areas between molars Contact point between perma-  Formation of enamel and dentine matrices.
are broader, flatter and situated nent molars is situated occlusally
gingivally B. Histophysiological development stages:
The enamel rods at the cervix The enamel rods at the region  Initiation
slopes occlusally from the DEJ are oriented gingivally  Proliferation
Supplemental grooves are more Supplemental grooves are less  Histodifferentiation
Mamelons are absent Mamelons are present on incisal  Morphodifferentiation
edges of newly erupted molars  Apposition

First molar is smaller in dimen- First molar is larger in dimension  Calcification (mineralization) and maturation.
sion than 2nd molar than 2nd molar
Roots are larger and more Roots are shorter and more
Dental Lamina
slender bulbous  Two types of cells are involved in development of mam-
Pulpal outline follows the DEJ Pulp outline follows the DEJ less malian teeth, they are :
more closely; the pulp horns are closely i. Stomodeal ectoderm, which forms ameloblasts
closer to the outer surface ii. Cranial neural crest-derived (ecto) mesenchyme cells,
Root canals are more ribbon Root canals are well-defined with which form odontoblasts and cementoblasts.
like; the radicular pulp follows less branching  These two cell types juxtaposed in the developing oral cavity
a thin, tortuous and branching
interact to control the entire process of tooth development
path
like initiation, morphogenesis and cytodifferentiation.
Accessory canals in the floor of Floor of the pulp chamber does  Dental lamina begins at 6 weeks of intrauterine life and
pulp chamber lead directly into not have any accessory canals
interradicular furcation
tooth buds arise from the lamina. Initiation of primary
teeth is seen from 2nd month in utero, successor teeth
Enamel and dentine are less They are more mineralized
from 5 months in utero and initiation of accessory teeth
mineralized
from 4 months in utero for first permanent molars and 1
Secondary cementum is absent Secondary cementum is present
year after birth for second permanent molars.
Neonatal lines are present Neonatal line is seen only in first  The enamel of teeth is derived from the ectoderm and the
molar
mesoderm provides the anlage for the dentine, pulp and
High potential for repair Comparatively less potential for periodontal tissues. Neural crest cells are responsible for
repair tissues like bone, cartilage, dentine and dermis but not the
enamel which is derived from the stomodeal ectoderm.
Q.2. Describe stages of development of dentition.
Initiation (Bud) Stage
Or  The first sign of tooth development can be observed as
Enumerate different stages of tooth development? Dis- early as the 6th week of intrauterine life.
cuss various developmental abnormalities and distur-  The tooth bud consists of enamel organ, dental papilla
bances of teeth and other oral structure during these and dental sac.
developmental stages.  An epithelial thickening in the region of the future dental
arch is formed by proliferation of cells from the basal layer
Ans. of oral epithelium.
Tooth development is a dynamic process and goes through  This extends along the entire margin of the jaws and is
various stages of formation. It begins from the differentia- known as the primordium of the ectodermal portion of
tion of the oral ectoderm to dental lamina formation. the teeth which results in dental lamina.
Topic wise Solved Questions of Previous Years
101

 Ten round or ovoid swellings occur in each jaw during the  The enamel and the dentine matrix are deposited by these
same time in the positions to be occupied by the primary cells according to a definite pattern and rate.
dentition.  The formative cells begin their act at specific sites referred
 The entire primary dentition and permanent molars arise to as growth centres as soon as the dentinoenamel junc-
from the dental lamina. The permanent incisors, canines and tion is formed.
premolars develop from the buds of their predecessors.
Calcification and Maturation
Proliferation (Cap) Stage
 Matrix deposition is followed by calcification or minerali-
 The method of proliferation of cells continues in the cap zation which involves the precipitation of inorganic cal-
stage. cium salts within the deposited matrix.
 A cap is formed as a result of uneven growth in different  The process begins with a nidus around which further
parts of the bud. precipitation occurs. The nidus increases in size by addi-
 A shallow invagination appears on the deep surface of the tion of concentric laminations.
bud, with the peripheral cells of the cap later forming the  These individual calcospherites approximate and fuse
outer and inner enamel epithelium. with each other to form a homogeneously mineralized
layer of tissue matrix.
Histodifferentiation and Morphodifferentiation Various developmental abnormalities and disturbances of
(Bell) Stages teeth and other oral structure during these developmental
 The epithelium continues to invaginate and gets deeper stages:
until the enamel organ assumes the shape of a bell.  Due to the disturbances that occur at different stages of
 There is differentiation of the cells in the dental papilla development of dentition various anomalies of develop-
into odontoblasts and the cells of the inner enamel epi- ment appear which are as follows:
thelium into ameloblasts.
i. Initiation or bud stage:
 The histodifferentiation marks the end of proliferation
 If there is any disturbance in the initiation or bud stage,
as the cells lose the capacity to multiply. This stage is the
predecessor of apposition stage. anomalies of number occur. Example: Hyperdontia,
 In the morphodifferentiation stage the formative cells are hypodontia (oligodontia) or anodontia.
arranged to outline the shape and size of the tooth, the ii. Proliferation or cap stage:
process that occurs before matrix deposition.  Anomalies of size like microdontia and macrodontia
 The morphology of the tooth gets established when the occur due to disturbances in proliferation or cap stage.
inner enamel epithelium is arranged such that the margin Example: Twinning/conjoined teeth including gemina-
between it and the odontoblasts delineates the future den- tion, fusion, conation and concrescence.
tinoenamel junction.
 Mammalian tooth morphogenesis must be controlled by iii. Morphodifferentiation stage:
either ectodermally derived cells and/or ectomesenchy-  Anomalies of size and shape occur due to disturbances
mally derived cells, since these are the only cell types that in morphodifferentiation stage. Example: Dens in dente,
form teeth. dens evaginatus, talon cusp, taurodontism and dilacera-
 Current evidence suggests that the information for gen- tions.
eration of an incisor or a molar tooth is inherent in the
ectomesenchyme, whereas the establishment and actual Histodifferentiation or Bell Stage
mechanics of using this information are carried out by  Anomalies of structure will occur in this stage.
ectodermally derived cells of the enamel knot. Example: This includes amelogenesis imperfect, AI type
 Spatial domains of homeobox genes are established in the 1—hypoplastic and dentinogenesis imperfect—shields
ectomesenchyme and provide the positional information type I, II and III.
for the specification of tooth shape.
Apposition Stage
Apposition Stage  Anomalies of structure in enamel, dentine and cementum
 A layer-like deposition of a non-vital extracellular secre- occur due to disturbances in apposition stage.
tion in the form of a tissue matrix results in apposition.  In enamel: AI types II and IV, hypomaturation type, acquired
 This tissue matrix is deposited by the formative cells, enamel hypoplasia due to systemic and local causes.
ameloblasts and the odontoblasts that line up along the  In dentine: Dentine dysplasia—two types (shields),
future dentinoenamel and dentinocemental junctions at regional odontodysplasia—‘ghost teeth’ and other condi-
morphodifferentiation stage. tions with dentine abnormalities.
Quick Review Series for BDS 4th Year: Paedodontics
102

 In cementum: Anomalies of cementum as in hypophos- individual from its existence as a single cell to its elaboration
phatasia, epidermolysis bullosa, cleidocranial dysplasia. as a multifunctional unit terminating in death.

Calcification Stage Occlusion

Anomalies of structure also occur due to disturbances in cal- The term occlusion is derived from the Latin word ‘occluso’
cification stage of teeth. defined as the relationship between all the components of
the masticatory system in normal function, dysfunction and
In enamel: Hypocalcification occurs as in amelogenesis im-
parafunction.
perfecta type III—hypocalcified and enamel fluorosis.
The various stages of occlusal development are:
In dentine: Sclerotic dentine results.
i. Predentate jaw relationship
ii. The deciduous dentition period
Q.3. Define normal occlusion. Describe in brief about
iii. The mixed (transitional) dentition period
development of occlusion from 6 to 12 years.
iv. The permanent dentition period.
Or
Predentate Period
Describe development of occlusion from deciduous to
 This is the period soon after birth. During this the neonate
permanent stages.
has no teeth but the relation of the gum pads is of equal
Or importance. The alveolar process at the time of birth is
Discuss development of normal occlusion from gum called the gum pads.
 The gum pads are horseshoe shaped that are pink, firm
pad relationship till eruption of 2nd permanent molar.
and covered with a layer of dense periosteum. They are
Or divided into two parts labiobuccal and lingual by dental
What is transitional period? Describe changes seen in groove.
 The gum pad is further divided into 10 segments by trans-
occlusion in this stage.
verse groove; each segment has one developing tooth sac.
Or  A very important landmark in gum pads is lateral sulcus,
Discuss classification in brief of occlusal relationship in which is the transverse groove between canine and 1st
primary dentition, its variation and disharmony. molar. This is helpful in predicting interarch relation at a
very early stage.
Or  The maxillary gum pad is wider and longer than the man-
Define growth and development. Discuss development dibular; thus when they are approximated, there is a com-
of normal occlusion from gum pad relationship till the plete overjet all around.
 The only contact that occurs is around the molar region
eruption of 2nd permanent molar.
while space exists in anterior region. This is called infan-
Ans. tile open bite, which is considered normal and helpful
during suckling.
Growth  At birth the gum pads are not sufficiently wide to accom-
 According to Stewart 1982: Growth may be defined as modate teeth and there is relative crowding of developing
developmental increase in mass. In other words, it is a tooth crypts.
process that leads to an increase in the physical size of the
cells, tissue organs or organisms as a whole. Primary or Deciduous Dentition Period
or  The initiation of primary teeth occurs during first 6 weeks
 According to Proffit 1986: Growth refers to an increase in of intrauterine life and the first primary tooth erupts at
size or numbers. the age of 6 months.
 It takes around 2½– 3½ years for all the primary teeth to
establish their occlusion.
Development
 Some of the characteristic clinical features of deciduous
According to Todd (1931): Development is an increase in dentition according to Baume are as follows:
complexity. i. Both the dental arches are half round or ovoid in
or shape
ii. Almost flat or no curve of Spee is present
According to Moyers (1988): Development refers to all the iii. Shallow cuspal interdigitation
naturally occurring unidirectional changes in the life of an iv. Slight overjet
Topic wise Solved Questions of Previous Years
103

v. Deep bite Terminal planes


vi. Vertical inclination of the incisors (900) The mesiodistal relation between the distal surfaces of max-
vii. Spaced dentition illary and mandibular 2nd deciduous molars is called as ter-
viii. Different maxillo-mandibular relations like flush, me- minal plane.
sial and distal terminal planes.
This is of three types:
Spacing a. Flush terminal plane (74%)
 Delabarre in 1918 was the first to describe interdental  The distal surfaces of the upper and lower teeth are in a
spacing in primary dentition. straight plane (flush) and therefore are situated on the
 Baume in 1950 divided the primary dentition into two same vertical plane.
types:  It is usually most favourable relationship to guide the per-
I. Spaced dentition manent molars into class I.
II. Non-spaced dentition.
 He also concluded that primary spacing occurs around b. Mesial-step terminal plane (14%)
70% in maxilla and 63% in mandible.  The distal surface of the lower molar is more mesial to
that of the upper molar. Invariably, this guides the perma-
Spaced dentition nent molars into a class I relationship.
 Spaced dentition is supposed to be good, as spaces in  However a few can proceed into half cusp class III during
between the teeth can be utilized for adjustment of per- molar transition and further into full class III relationship
manent successors, which are always larger in size com- with continued mandibular growth.
pared to the deciduous teeth.
c. Distal-step terminal plane (10%)
 The spaces present are of two types:
 The distal surface of the lower molar is more distal to that
a. Primate spaces
of the upper molar.
b. Physiologic spaces.
 This relationship is unfavourable as it guides the perma-
a. Primate spaces: nent molars into distal occlusion.
 Exist between the upper lateral incisors and the canines
(present mesial to maxillary deciduous canines) and Anterior teeth relationship
lower canines and first deciduous molars (present distal a. Overbite
to mandibular deciduous canines).
 It is the distance that the incisal edge of the maxillary inci-
 These spaces are also called as anthropoid or simian sors overlap vertically past the incisal edge of the man-
spaces. dibular incisors.
b. Physiologic spaces:  The primary incisors erupt in a deep overbite which is

 They are present in between the primary teeth and play an corrected by eruption of posterior teeth around 5 years
important role in normal development of the permanent of age.
dentition.  The average overbite in the primary dentition is 2 mm.

 The total space present may vary from 0 to 8 mm with the b. Edge-to-edge bite
average 4 mm in the maxillary arch and 1–7 mm with the  When the incisal edges of the two incisors are in the same
average of 3 mm in the mandibular arch. plane. This is also called as a zero overbite.
 This is most common due to attrition, lengthening of
Non-spaced dentition
ramus and downward–forward growth of mandible.
 Lack of space between primary teeth either due to small
c. Canine relationship
jaw or larger teeth. This type of dentition usually indicates
 The relationship of the maxillary and mandibular decidu-
crowding in developing permanent dentition.
ous canines is one of the most stable in primary denti-
Deep bite tion.
Class I
 This occurs during initial stages of development and is
accentuated because the deciduous incisors are more  The mandibular canine interdigitates in embrasure
upright than their successors. between the maxillary lateral incisor and canine.
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104

Class II A. Emergence of 1st permanent molars


 The mandibular canine interdigitates distal to embrasure  The anteroposterior relation between the two opposing
between the maxillary lateral incisor and canine. first molars after eruption depends on:
Class III ❍ Their positions previously occupied within the jaws.
❍ The sagittal relation between the maxilla and mandi-
 The mandibular canine interdigitates in any other relation.
ble.
Arch dimensions  The occlusal relationship is established by the cone and
funnel mechanism with the upper palatal cusp (cone)
These were first measured by Zsigmondy in 1890. Frank and sliding into the lower occlusal fossa (funnel).
Baume later described the changes that can take place in arch  The mandibular molars are the first to erupt at around 6
dimensions by loss of primary teeth and during the develop- years of age. Their position and relation is dependent on
ment of occlusion. the relation of second deciduous molars as they are guided
Arch size into dental arch by the distal surfaces of these teeth.
 Size of the primary dental arch is the arch width between a. If the 2nd deciduous molar is in flush terminal plane
primary canine and second molars. Then the erupting permanent molar will also be in the same
Arch length relation. For this to change into class I relation the molar has
 Measured from the most labial surface of primary central to move 2–3 mm in a forward direction; this is accomplished
incisor to canine and to second primary molars. by:
 Early mesial shift: This occurs during early mixed denti-
Arch circumference tion period. The eruptive forces of 1st permanent molars
 It is determined by measuring the length of curved line are strong enough to push the deciduous molars forward
passing over the incisal edges and buccal cusps of teeth in the arch, thereby utilizing the primate spaces and thus
from the distal surfaces of primary second molar around establishing class I relationship.
the arch to the distal surface of second primary molar on  Late mesial shift: Many children lack primate spaces and
the other side. have a non-spaced dentition and thus erupting perma-
Arch width nent molars are not able to establish class I relation even
 Bicanine or bimolar width is called the arch width.
as they erupt.
In these cases, the molars establish class I relation by drift-
Mixed Dentition Period ing mesially and utilizing the leeway space after exfoliation of
deciduous molars and is called late mesial shift.
 The period during which both the primary and perma-
b. If the 2nd deciduous molar is in mesial-step terminal
nent teeth are present in the mouth together is known as
plane
mixed dentition.
 The permanent teeth erupting in place of previous decid- Then the erupting permanent molar will directly erupt in class
uous teeth are the successional teeth, whereas those erupt- I relation. But if further growth occurs or if there is more utili-
ing posteriorly to the primary teeth are called the acces- zation of spaces the relation can even change to class III.
sional teeth. This phase begins at around 6 years with the c. If the 2nd deciduous molar is in distal-step terminal
eruption of 1st permanent molars and lasts till about 12 plane
years of age.
Then the erupting permanent molar will erupt into class II
 It can be divided as:
relation. If further growth occurs or there is more utilization
i. First transitional period
of spaces then it can lead into end-on molar relation.
A. Emergence of the 1st permanent molars
B. Exchange of incisors
ii. Intertransitional period B. Exchange of incisors
iii. Second transitional period  The deciduous incisors are replaced by permanent inci-
❍ Emergence of cuspids, bicuspids and the second per- sors during this phase.
manent molars.  This period of transition is from 6½–8½ years.
❍ Establishment of occlusion.  The permanent incisors are larger as compared to their
primary counterparts and thus require more space for
i. First Transitional Period their alignment.
 This is characterized by emergence of 1st permanent  This difference between space available and space required
molars and exchange of deciduous incisors with perma- is called the incisor liability. This is 7 mm for maxillary
nent incisors. arch and 5 mm for mandibular arch.
Topic wise Solved Questions of Previous Years
105

Some of the factors that help in alignment of incisors by gaining crown in an opposite direction, leading to midline spac-
space are: ing.
 Utilization of interdental spacing of primary incisors—  The term ugly duckling stage indicates the unaesthetic
averages 4 mm in the maxillary arch and 3 mm in the appearance of child during this stage.
mandibular arch.  This condition corrects itself after the canines have
 Increase in intercanine arch width—this occurs as the erupted. The canines after eruption apply pressure on the
child grows. In males it is 6 mm for maxilla and 4 mm for crowns of incisors thereby causing them to shift back to
mandible whereas in females it is 4.5 mm in maxilla and original positions.
4 mm in mandible.  No orthodontic treatment should be attempted at this
 Increase in intercanine arch length—this is due to growth stage as there is danger of deflecting the canine from its
of jaws. normal path of eruption.
 Change in interincisal angulations—the angle between
the maxillary and mandibular incisors is about 150º in Permanent Dentition
primary dentition, whereas it is about 123º in permanent
 The entire permanent dentition is formed within the jaws
dentition, thus allowing more proclination and gaining
after birth except for the cusps of 1st molar, which are
space for incisor alignment. This is called incisor liability.
formed before birth.
 The most frequent sequence of eruption for maxillary
ii. Intertransitional Period
arch is 6–1–2–4-5–3–7–8 (1st molar–central incisor–
 In this period the maxillary and mandibular arches con- lateral incisor-1st premolar–2nd premolar–canine–2nd
sist of permanent incisors and permanent molars that molar–3rd molar) and in mandibular arch is 6–1–2–3–4–
sandwich the deciduous canines and molars. 5–7–8 (1st molar–central incisor–lateral incisor–canine–
 This phase lasts for l½ years and is relatively stable. Only 1st premolar–2nd premolar–2nd molar–3rd molar).
a few changes in the morphology of deciduous teeth are
Some changes that can be seen in permanent dentition are:
seen because they undergo attrition.
 Horizontal overbite decreases.
iii. Second Transitional Period  Dental arches become shorter.
 Vertical overbite decreases up to the age of 18 years by 0.5
 This phase is characterized by replacement of deciduous
mm
molars and canines by premolars and permanent cus-
 Overjet decreases by 0.7 mm between 12 and 20 years of
pids.
 This takes place around 9–10 years of age and is very criti- age.
cal for the alignment of the erupting permanent teeth.
 The most common sequence of eruption of permanent Q.4. Write in detail about eruption sequence in decid-
teeth in the maxilla is 4–3–5 (1st premolar–canine–2nd uous dentition which deciduous and permanent teeth
premolar) and in the mandible 3–4–5 (canine–1st premo- present in child aged 10 years.
lar–2nd premolar).
Or
 The combined mesiodistal width of permanent canine
and premolars is less than that of deciduous canine and Discuss development of dentition from 6 to 10 years.
molars. This is called leeway space of Nance or E space. It
is 1.8 mm (0.9 mm on each side) in maxillary arch and 3.4 Ans.
mm (1.7 mm on each side) in mandibular arch.
 This excess space is utilized by mandibular molars to Chronology of Human Dentition
establish class I relationship through late mesial shift.  The regular sequence of eruption suggests that it is under
genetic control, while the same is an event highly subject
Broadbent phenomenon to nutritional, hormonal and disease states.
 Another common occurrence during this transitional  At birth, jaws contain the partly calcified crowns of 20
period is the ugly duckling stage or Broadbent phenom- deciduous teeth and beginning of calcification of the 1st
enon. This self-correcting malocclusion is seen around permanent molars.
9–11 years of age or during eruption of canines and was  Eruption of deciduous dentition begins at an average of
first described by Broadbent in 1937. 7½ months of age and terminates at about 29 months.
 As the permanent canines erupt they displace the roots of Dental eruption is then quiescent for nearly 4 years.
lateral incisors mesially. This force is transmitted to the  At the age of 6 years the jaws contain more teeth than at
central incisors and their roots are also displaced mesially. any other time; 48 teeth are filling the body of mandible.
Thus the resultant force causes the distal divergence of the After this extreme activity there is a 2½ years of quite
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106

period until 10½ years of age. Then during the next 18 1st Birth 2½–3 years 6–7 years 9–10 years
months the remaining 12 deciduous teeth are lost and 16 molar
permanent teeth erupt. 2nd 2½–3 years 7–8 years 12–15 years 14–16 years
 The 6 years of period of the mixed dentition from 6 to 12 molar
years in the most complicated period of dental develop- 3rd 7–9 years 12–16 17–24 years 18–25 years
ment and the one in which malocclusion is most likely to molar years
develop.
 A long and valuable period of 3–7 years of quiescence fol- Mandible
lows before eruption of the lower 3rd molars to complete
Central 3–4 months 4–5 years 6–7 years 9 years
the dentition. The 3rd molars do not begin calcification
incisor
until 9th year of age and their eruption from the 16th year
Lateral 3–4 months 4–5 years 7–8 years 10 years
onwards heralds the completion of dentofacial growth
incisor
and development.
Canine 4–5 months 6–7 years 9–10 years 12–14 years
Chronology of primary dentition 1st premo- 1¾–2 years 5–6 years 10–11 12–13 years
Tooth Hard tissue Crown Eruption Root lar years
formation begins completed completed 2nd 2¼–2½ 6–7 years 11–12 13–14 years
premolar years years
Maxilla 1st molar Birth 2½–3 6–7 years 9–10 years
Central 4 months in utero 4 months 7½ months 1½ years years
incisor 2nd molar 2½–3 years 7–8 years 11–13 14–15 years
Lateral 4½ months in 5 months 9 months 2 years years
incisor utero 3rd molar 8–10 years 12–16 17–21 18–25 years
Canine 5 months in utero 9 months 18 months 3¼ years years years

1st molar 5 months in utero 6 months 14 months 2½ years


Q.5. What are causes, sequelae and management of
2nd molar 6 months in utero 11 months 24 months 3 years early loss of primary teeth?
Mandible Ans.
Central 4½ months 4½ months 6 months 1½ years
incisor in utero Early Loss of Teeth and Space Maintenance
Lateral 4½ months 4 months 7 months 1½ years
incisor in utero  If arch integrity is disrupted by early loss of primary teeth,
Canine 5 months in 9 months 16 months 3 years problems may arise that affect the alignment of the per-
utero manent dentition.
1st molar 5 months in 5½ months 12 months 2¼ years  Opposing teeth can supraerupt, more distal teeth can drift
utero and tip mesially and more forward, teeth can drift and tip
2nd molar 6 months in 10 months 20 months 3 years distally.
utero  Altered tooth positions may include a ‘symptomatic’
space deficiency with loss of arch length and circumfer-
Chronology of permanent dentition ence, blocked or deflected eruption of permanent teeth,
Tooth Hard tissue Crown Eruption Root unattractive appearance, food impaction areas, increased
formation completed completed caries and periodontal disease, and other negative aspects
begins of malocclusion.
 The altered occlusal relationships may evidence traumatic
Maxilla interferences and untoward jaw relationships.
Central 3–4 months 4–5 years 7–8 years 10 years
incisor Management of Early Loss of Primary Teeth
Lateral 10–12 months 4–5 years 8–9 years 11 years  When early primary tooth loss occurs, to optimize the
incisor normal process of occlusion development, corrective
Canine 4–5 months 6–7 years 11–12 years 13–15 years measures such as passive space maintenance, active tooth
1st 1½–1¾ years 5–6 years 10–11 years 12–13 years guidance with space regaining, or a combination of both
Premolar may be needed.
2nd 2–2¼ years 6–7 years 10–12 years 12–14 years  A study has shown that children who had premature loss
Premolar of one or more primary canines or molars were more
Topic wise Solved Questions of Previous Years
107

likely to receive orthodontic treatment in the permanent angle is more rounded than the corresponding angle on
dentition with the need more than three times greater in the central incisor and the lingual anatomy is usually less
children who had lost one or more primary teeth through prominent.
9 years of age than the control group.  The morphology of the root is essentially the same as that
 Premature loss of primary molars was especially associ- of the central incisor, except that it is longer in proportion
ated with major malalignment of permanent teeth. to the crown.
 No differences were observed in effects between loss of
first and second primary molars. iv. Mandibular Lateral Incisor
 Crowding of anterior teeth was directly affected by the
 The morphology of the mandibular lateral incisor is sim-
premature loss of primary canines.
ilar to that of the central incisor, except that the incisal
edge slopes downward distally forming a more obtuse dis-
Q.6. What are morphologic differences between maxil-
toincisal angle.
lary and mandibular primary teeth?
 The crown is also slightly larger incisocervically and mesi-
Ans. odistally than that of the central incisor.
 The root is conical, longer than that of the central inci-
The morphological differences between maxillary and man-
dibular primary teeth are as follows: sors, and shows a definite distal inclination at its apex.
 The distal surface of the root will often show a longitudi-
i. Maxillary Central Incisor nal depression or groove, separating the root into labial
and lingual moieties.
 The first notable difference between the maxillary central
incisor and its permanent successor is the fact that it has v. Maxillary Canine
a mesiodistal measurement greater than the incisocervical
measurement.  It is larger than maxillary incisors in all dimensions. All
 The labial surface is slightly convex and relatively smooth, surfaces of the crown are convex, creating a more pro-
with little evidence of developmental lines or grooves. nounced constriction at the cervix than is seen in the
 The incisal edge joins the mesial surface at an acute angle maxillary incisors.
and the distal surface at a more obtuse angle.  It has a prominent cusp dividing the incisal aspect into a
 The lingual surface shows a well-developed cingulum and mesioincisal and a distoincisal edge, the mesioincisal edge
marginal ridges; but developmental anatomic features being the longer of the two.
such as pits and grooves are usually missing.  The lingual surface presents a prominent lingual ridge,
 The root of the maxillary central is conical and tapered lingual fossae, and marginal ridges.
towards the apex.  The root of the maxillary canine is not only long and
tapered towards the apex, but also shows a characteristic
ii. Mandibular Central Incisor increase in diameter just apical to the cervical line.
 The mandibular central incisor is smaller in all dimen-
vi. Mandibular Canine
sions than the maxillary central incisor.
 When viewed from the labial aspect the tooth is symmet-  The mandibular canine appears more slender than the
ric with both the mesio- and distoincisal angles joining maxillary canine because of the smaller mesiodistal diam-
the incisal edge at almost right angles. eter in relation to crown height.
 The incisal edge is usually perfectly straight in the hori-  The relative lengths of the incisal edges are reversed in
zontal plane. the mandibular canine, making the distoincisal edge the
 The labial surface is not only less convex than that of the longer of the two.
maxillary central incisor, but it is also smooth without  The marginal ridges and cingulum are much less promi-
evidence of developmental anatomic landmarks. The lin- nent, making the labiolingual diameter smaller than that
gual surface is usually smooth with a poorly defined fossa of the maxillary canine.
and marginal ridges.  The root is smoothly tapered from the cervical line to the
 The root of the mandibular central incisor is long, evenly apex.
tapered toward the apex, and at times slightly compressed
on its mesial and distal surfaces. vii. Maxillary First Molar

iii. Maxillary Lateral Incisor  The geometric form of the maxillary first molar when
viewed from the occlusal aspect is triangular.
 The maxillary lateral incisor is essentially smaller in most  The proximal surfaces converge toward the lingual,
dimensions than the central incisor. The distoincisal creating a crown that is wider mesiodistally at the buccal
Quick Review Series for BDS 4th Year: Paedodontics
108

surface. The mesiolingual cusp is the largest, followed by x. Mandibular Second Molar
the mesiobuccal and the distobuccal.
 The mandibular second primary molar is a smaller replica
 The mesiobuccal cusp shows a greater mesiodistal
of the mandibular first permanent molar.
development than the distobuccal cusp, occupying two-
 There are three buccal cusps; the distobuccal is the largest,
thirds of the buccal surface. The mesiobuccal cusp is
followed by the mesiobuccal and the distal. There are two
also developed to a greater degree in an incisocervical
lingual cusps which are similar in size.
direction, creating an increased curvature in the cervical
 There are three pits on the occlusal surface, the central
line in the mesial half of the crown.
pit being the deepest and the distal and mesial pits less
 A view of the crown from the mesial aspect shows the
prominent.
prominent buccocervical ridge which is characteristic of
 The crown morphology shows the typical cervical con-
primary molars and, in particular, first primary molars.
striction and buccocervical ridge seen on the other pri-
 The maxillary first molar has three long and slender roots.
mary molars.
The lingual root is the longest, followed by the mesiobuc-
 As in the mandibular first primary molar, the two roots of
cal and the distobuccal.
the mandibular second molar are narrow mesiodistally.
 All three roots extend from extremely short root base in
a divergent manner which is characteristic of the primary
Q.7. Discuss various treatment modalities in case of a
molars.
premature loss of first permanent molar in a developing
occlusion.
viii. Mandibular First Molar
 The general outline of the crown of the mandibular first Ans.
primary molar when viewed from the occlusal aspect is
 The first permanent molar is unquestionably the most
rhomboid. There are usually two buccal and two lingual
important unit of mastication and is essential in the
cusps.
development of functionally desirable occlusion.
 When viewed from the buccal, the greater mesiodistal and
 A carious lesion may develop rapidly in the first perma-
incisocervical development of the mesiobuccal cusp is
nent molar and occasionally progresses from an incipient
immediately noticed.
lesion to a pulp exposure in a 6 month period.
 A marked apical curvature of the cervical line and a well-
 The loss of a first permanent molar in a child can lead to
developed buccocervical ridge occur in tooth as a charac-
changes in the dental arches that can be traced through-
teristic of the mandibular first primary molar.
out the life of that person.
 A distinguishing characteristic of this molar when viewed
 Unless appropriate corrective measures are instituted,
from the occlusal is the heavy transverse ridge connecting
these changes include diminished local function, drifting
the mesiobuccal and mesiolingual cusps.
of teeth, and continued eruption of opposing teeth.
 There are generally three pits found on the occlusal sur-
 The second molars, even if unerupted, start to drift
face—central, mesial, and distal, with the first the most
mesially after the loss of the first permanent molar. A
prominent of the three.
greater degree of forward bodily movement will occur
 The two roots mesial and distal show the typical flaring
with loss of the first permanent molar in children in the
characteristic of primary molars; both, however, end in a
8–12 year age group.
sharp edge which may be slightly bifid.
 In older children, if the loss occurs after eruption of the
second permanent molar, more exaggerated mesial tip-
ix. Maxillary Second Molar
ping of the second molar can be the expected outcome.
 The morphology of the maxillary second molar is simi- Although the premolars undergo the greatest amount of
lar to that of the maxillary first permanent molar, with a distal drifting, all the teeth anterior to the space, including
similar crown form, pit, groove, and cuspal arrangement. the central and lateral incisors on the side where the loss
 There are four major cusps. The largest is the mesiolin- occurred, may show evidence of movement.
gual. The distolingual is the smallest, while the mesiobuc-  Contacts open and the premolars, in particular, rotate
cal and distobuccal cusps are nearly equal in size. as they fall distally. There is a tendency for the maxillary
 The occlusal surface shows three pits—distal, central and premolars to move distally in unison, whereas those in the
mesial which mark the intersection of the developmental lower arch may move separately.
grooves.  When the maxillary first permanent molar loses its oppo-
 The root morphology is similar to that of the maxillary nent, it erupts at a faster rate than the adjacent teeth.
first permanent molar, except that the roots of the second  The alveolar process is also carried along with the molars
primary molar are thinner and diverge more from the and causes problems when prosthetic replacements are
root base. needed.
Topic wise Solved Questions of Previous Years
109

 The treatment of patients with the loss of first permanent an acceptable position. However, the axial inclination of
molars must be approached on an individual basis. A the second molars, particularly in the lower arch, may be
superimposed existing malocclusion, abnormal muscula- greater than normal.
ture, or the presence of deleterious oral habits can affect  The decision whether to allow the second molar to drift
the result, as in the case of the premature loss of primary mesially or to guide it forward in an upright position may
molars. be influenced by the presence of a third molar of normal
 Loss of a first permanent molar before the eruption of size.
the second permanent molar presents problems in both  If there is a question regarding the favourable develop-
anteroposterior space control and vertical eruption con- ment of a third molar on the affected side, repositioning
trol of opposing molars. the drifted second molar and holding space for a replace-
 Although it is possible to prevent overeruption of a max- ment prosthesis is usually the treatment of choice.
illary first permanent molar by placing a lower partial  When the first permanent molar is lost after the eruption
denture, there is no completely effective way to influence of the second permanent molar, orthodontic evaluation is
the path of eruption of the developing second permanent indicated, and the following points should be considered:
molar other than the use of an acrylic distal shoe exten- ❍ Is there any need of corrective treatment other than in
sion on a partial denture. the first permanent molar area?
 The second molar drifts mesially before eruption when
❍ Should the space be maintained for a replacement
the first permanent molar has been extracted. Reposition-
prosthesis?
ing this tooth orthodontically is possible after its erup-
tion. ❍ Should the second molar be moved forward into the

 However, the child must then be considered for prolonged area formerly occupied by the first molar?
space maintenance until the time when a more perma-  The latter choice is often the more satisfactory, even
nent tooth replacement can be inserted. The removal of though there will be a difference in the number of molars
the opposing first permanent molar, even when the tooth in the opposing arch. A third molar can often be removed
appears to be sound and caries free, is sometimes rec- to compensate for the difference. Without treatment the
ommended in preference to allowing it to extrude or to second molar will tip forward within a matter of weeks.
subjecting the child to prolonged space maintenance and  Another option to consider is autotransplantation of a
eventual fixed replacement. third molar into the first molar position. According to
 If the first permanent molars are removed several years Bauss and colleagues, autotransplantation has become
before eruption of the second permanent molars, there is a well-established treatment modality in cases of early
an excellent chance that the second molars will erupt in tooth loss or aplasia.

SHORT ESSAYS

Q.1. Explain local and systemic factors for delayed  Cysts/tumours of jaws
eruption of teeth.  Abnormal musculature.

Or Systemic Factors
Local and systemic causes of delayed eruption. Acceleration of Eruption
Ans.  Hyperthyroidism
 Hyperpituitarism
The various local and systemic factors that influence the erup-  Turner syndrome.
tion of teeth are as follows:
Delayed Eruption
Local Factors
 Hypopituitarism
 Lack of space in the arch  Hypothyroidism
 Early loss of primary tooth  Down syndrome
 Ankylosed primary teeth, retained roots  Cleidocranial dysostosis
 Supernumerary teeth  Hypovitaminosis A and D.
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110

Q.2. Predentate period.  Inflammation of tissues over erupting teeth results in pain
temporarily.
 During predentate period, i.e. the period soon after birth,
the neonate has no teeth. The alveolar processes at the
Management
time of birth are called the gum pads.
 The gum pads are horseshoe shaped and are pink, firm  Removal of tissue covering over the erupting teeth is not
and covered with a layer of dense periosteum. recommended.
 They are divided into two parts labiobuccal and lingual by  Non-toxic unbreakable teething toys or rings are advised.
dental groove.  Solid silicone-based teething rings are superior to their
 The gum pad is further divided into 10 segments by trans- liquid-filled counterparts, as the potentially irritant con-
verse groove; each segment has one developing tooth sac. tents may leak, if they are damaged and cannot be steri-
 A very important landmark in gum pads is lateral sulcus, lized.
which is the transverse groove between canine and 1st  Temporary pain relief is provided by the pressure pro-
molar. This is helpful in predicting interarch relation at a duced by chewing the teething ring, preferably chilled
very early stage. one.
 The maxillary gum pad is wider and longer than the man-  Pacifiers can also be used for this purpose. Teething rings
dibular; thus when they are approximated, there is a com- should be attached to the infant’s clothing and not tied
plete overjet all around. around the neck, as strangulation could result.
 The only contact that occurs is around the molar region  Hard, non-sweetened rusks, made from flour and wheat
while space exists in anterior region. This is called infan- germ with no sugar or sweetener can also be attached on
tile open bite, which is considered normal and helpful to the infant's clothing.
during suckling.  Alternative non-pharmacological holistic therapies (acu-
 At birth, the gum pads are not sufficiently wide to accom- pressure, aromatherapy, massage and homeopathy) have
modate teeth and there is relative crowding of developing been suggested as giving relief from the symptoms of
tooth crypts. teething.
 Non-irritating topical anaesthetics, some systemic anal-
Q.3. What is teething disorder? Explain its manage- gesics and antipyretics can be advised to give relief from
ment. pain and fever.
 The child may be referred to paediatrician or family phy-
Ans.
sician in case of any systemic disturbances and fever with
The term ‘teething’ literally means ‘eruption of primary temperature more than 101ºF.
teeth’.
The various clinical features of teething disorder are as follows: Q.4. Chronology of human primary teeth.
 Increased salivation, putting fingers in the mouth, diar- Or
rhoea, fever, convulsions, acute herpetic gingivo-stoma-
titis, photophobia, blinking eyes, vomiting, neuralgia, Sequence and time of eruption of primary teeth.
severe headache, cold, weight loss, toxaemia, tonsillitis, Ans.
paralysis, cholera, meningitis, tetanus, even death have
been attributed to eruption. Chronology of Human Dentition
 In the 19th century, infant mortality has been attributed  The regular sequence of eruption suggests that it is under
to teething. It was proved that no evidence exists of teeth- genetic control, while the same is an event highly subject
ing causing fever, convulsions, bronchitis or diarrhoea to nutritional, hormonal and disease states.
and all other conditions mentioned.  At birth jaws contain the partly calcified crowns of 20
 Teething neither increases the incidence of infection nor deciduous teeth and beginning of calcification of the 1st
the erythrocyte sedimentation rate (ESR) or white blood permanent molars.
cell (WBC) counts. It does not cause fever. Any fever that  Eruption of deciduous dentition begins at an average of
shows more than 101ºF temperature is not attributed to 7½ months of age and terminates at about 29 months.
teething. Dental eruption is then quiescent for nearly 4 years.
 It does cause day-time restlessness, increase in amount of  At the age of 6 years, the jaws contain more teeth than
finger sucking, drooling or rubbing of gums and possi- at any other time; 48 teeth are filling the body of mandi-
bly loss of appetite. One-third of children only show pro- ble. After this extreme activity there is a 2½ years of quite
nounced change in mucosa with small haemorrhage. period until 10½ years of age. Then during the next 18
 Eruption of teeth is a normal physiological process; the months the remaining 12 deciduous teeth are lost and 16
fever or other infections are considered coincidental. permanent teeth erupt.
Topic wise Solved Questions of Previous Years
111

Chronology of primary dentition Q.6. Young permanent first molar tooth.


Tooth Hard tissue Crown Eruption Root Or
formation begins completed completed
Importance of young permanent tooth.
Maxilla Or
Central 4 months in utero 4 months 7½ months 1½ years
incisor Importance of first permanent molar.
Lateral 4½ months in 5 months 9 months 2 years Ans.
incisor utero
 The first permanent molar is unquestionably the most
Canine 5 months in utero 9 months 18 months 3¼ years
important unit of mastication and is essential in the
1st molar 5 months in utero 6 months 14 months 2½ years
development of functionally desirable occlusion.
2nd molar 6 months in utero 11 months 24 months 3 years
 A carious lesion may develop rapidly in the first perma-
Mandible
nent molar and occasionally progress from an incipient
Central 4½ months in 4½ months 6 months 1½ years
lesion to a pulp exposure in a 6 month period.
incisor utero  The loss of a first permanent molar in a child can lead to
Lateral 4½ months in 4 months 7 months 1½ years changes in the dental arches that can be traced through-
incisor utero out the life of that person.
Canine 5 months in utero 9 months 16 months 3 years  Unless appropriate corrective measures are instituted,
1st molar 5 months in utero 5½ months 12 months 2¼ years these changes include diminished local function, drifting
2nd molar 6 months in utero 10 months 20 months 3 years of teeth, and continued eruption of opposing teeth.
 The second molars, even if unerupted, start to drift
Q.5. Transient malocclusion. mesially after the loss of the first permanent molar. A
greater degree of forward bodily movement will occur
Or with loss of the first permanent molar in children in the 8
to 12 year age group.
Self-correcting anomalies.
 In older children, if the loss occurs after eruption of the
Ans. second permanent molar, more exaggerated mesial tip-
ping of the second molar can be the expected outcome.
Anomalies that arise in the child’s developing dentition
 All the teeth anterior to the space, including the central
during the period of transition from predentate period to
permanent dentition period and get corrected on their own and lateral incisors on the side where the loss occurred,
without any dental treatment are known as self-correcting may show evidence of movement.
anomalies.  Contacts open and the premolars, in particular, rotate as
they fall distally.
Period of development Self-correcting anomaly
 When the maxillary first permanent molar loses its oppo-
During predentate period:
nent, it erupts at a faster rate than the adjacent teeth.
 Retrognathic mandible
 The alveolar process is also carried along with the molars
 Anterior open bite
and causes problems when prosthetic replacements are
 Infantile swallow
needed.
During deciduous dentition:
 The treatment of patients with the loss of first permanent
 Deep bite
molars must be approached on an individual basis. A
 Decrease overjet
superimposed existing malocclusion, abnormal muscula-
 Flush terminal plane ture, or the presence of deleterious oral habits can affect
 Primate and physiologic the result.
spacing
During mixed dentition period: Q.7. Explain morphological differences between pri-
 Anterior deep bite mary and permanent teeth.
 Mandibular anterior
Ans.
crowding
 End-on molar relation Major differences between primary and permanent teeth are
 Ugly duckling stage as follows:
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112

Primary teeth Permanent teeth  Learning of mastication may be highly dependent on the
Teeth are lighter in colour; bluish Darker in colour; greyish or
stage and development of the dentition, e.g. type and
white yellowish white number of teeth present and occlusal relations, the matu-
ration of the neuromuscular system, and such factors as
Number of teeth is 20 Number of teeth is 32
diet.
Crowns are wider mesiodistally Crowns are larger in cervico-
 The loss of the deciduous teeth tends to mirror the erup-
in relation to the cervico-occlusal occlusal dimension than the
height mesiodistal dimension tion sequence: incisors, first molars, canines and second
molars, with the mandibular pairs preceding the maxil-
Cervical ridges are more Cervical ridges are flatter
pronounced
lary teeth. The increase in prevalence of dental caries
among tooth types reverses their order of eruption.
Molars have narrow occlusal There is less convergence of
 The role of the primary teeth in mastication and their
table in a buccolingual plane buccal and lingual surfaces of
Occlusal plane is relatively flat molars towards the function in maintaining the space for eruption of the per-
occlusal surface manent teeth.
 A lack of space associated with premature loss of decid-
Molars are more bulbous and Have more curved contours
are sharply constricted cervically They have less constriction at uous teeth is a significant factor in the development of
(bell shaped) the neck malocclusion.
The enamel is thinner and has a Enamel is thicker and has a  The development of adequate spacing is an important
more consistent depth of about thickness of about 2–3 mm factor in the development of normal occlusal relations
1 mm thickness throughout the in the permanent dentition. Therefore, it is important
entire crown to prevent and treat dental decay by providing the child
Contact areas between molars Contact point between perma- with a comfortable functional occlusion of the deciduous
are broader, flatter and situated nent molars is situated occlusally teeth.
gingivally
The enamel rods at the cervix The enamel rods at the region Q.9. Development of occlusion from 6 to 12 years.
slope occlusally from the DEJ are oriented gingivally
Mamelons are absent Mamelons are present on incisal Or
edges of newly erupted molars What is transitional period. Describe changes seen in
Roots are larger and more Roots are shorter and more occlusion at the stage.
slender bulbous
Root canals are more ribbon Root canals are well-defined with Ans.
like; the radicular pulp follows less branching
 Development of occlusion from 6 to 12 years is known
a thin, tortuous and branching
path as mixed dentition period. It is the period during which
both the primary and permanent teeth are present in the
Enamel and dentine are less They are more mineralized
mineralized mouth together.
 Transitional period is the period during which permanent
Neonatal lines are present Neonatal line is seen only in first
molar
teeth start replacing the primary teeth.
The permanent teeth erupting in place of previous decid-
uous teeth are the successional teeth, whereas those erupt-
Q.8. Importance of deciduous dentition. ing posteriorly to the primary teeth are called the accessional
Ans. teeth. This phase begins at around 6 years with the eruption
of 1st permanent molars and lasts till about 12 years of age.
Importance of Deciduous Dentition  It can be divided as:
 The emergence of the primary dentition through the alve- i. First transitional period
olar mucosa is an important time for the development of a. Emergence of the first permanent molars
oral motor behaviour and the acquisition of masticatory b. Incisors transition
skills. ii. Intertransitional period
 At this time of development the presence of ‘teething’ iii. Second transitional period
problems suggest how the primary dentition can affect  Emergence of cuspids, bicuspids and the second perma-
the development of future neurobehavioural mechanisms, nent molars
including jaw movements and mastication.  Establishment of occlusion.
Topic wise Solved Questions of Previous Years
113

i. First Transitional Period is 1.8 mm (0.9 mm on each side) in maxillary arch and 3.4
mm (1.7 mm on each side) in mandibular arch.
 This is characterized by emergence of 1st permanent
molars and exchange of deciduous incisors with perma-  This excess space is utilized by mandibular molars to
nent incisors. establish class I relationship through late mesial shift.
 Another common occurrence during this transitional
a. Emergence of First Permanent Molars period is the ugly duckling stage or Broadbent phenom-
enon. This self-correcting malocclusion is seen around
The anteroposterior relation between the two opposing first
9–11 years of age or during eruption of canines and was
molars after eruption depends on:
first described by Broadbent in 1937.
 Their positions previously occupied within the jaws.
 As the permanent canines erupt they displace the roots of
 The sagittal relation between the maxilla and mandible. lateral incisors mesially. This force is transmitted to the
 The occlusal relationship is established by the cone and central incisors and their roots are also displaced mesially.
funnel mechanism with the upper palatal cusp (cone) Thus the resultant force causes the distal divergence of the
sliding into the lower occlusal fossa (funnel). crown in an opposite direction leading to midline spac-
ing.
b. Exchange of Incisors  The term ugly duckling stage indicates the unaesthetic
 The deciduous incisors are replaced by permanent inci- appearance of child during this stage.
sors during this phase.  This condition corrects itself after the canines have
 This period of transition is from 6½ to 8½ years. erupted. The canines after eruption apply pressure on the
 The permanent incisors are larger as compared to their crowns of incisors thereby causing them to shift back to
primary counterparts and thus require more space for original positions.
their alignment.  No orthodontic treatment should be attempted at this
 This difference between space available and space required stage as there is danger of deflecting the canine from its
is called the incisor liability. This is 7 mm for maxillary normal path of eruption.
arch and 5 mm for mandibular arch.
Q.10. Characteristics of primary dentition.
ii. Intertransitional Period
 In this period the maxillary and mandibular arches con- Ans.
sist of permanent incisors and permanent molars that
sandwich the deciduous canines and molars. The primary or deciduous dentition:
 This phase lasts for l½ years and is relatively stable. Only  The initiation of primary teeth occurs during first 6 weeks
a few changes in the morphology of deciduous teeth are of intrauterine life and the first primary tooth erupts at
seen because they undergo attrition. the age of 6 months.
 It takes around 2½–3½ years for all the primary teeth to
iii. Second Transitional Period
establish their occlusion.
 This phase is characterized by replacement of deciduous Some of the characteristic clinical features of deciduous denti-
molars and canines by premolars and permanent cus- tion according to Baume are as follows:
pids.
i. Both the dental arches are half round or ovoid in shape.
 This takes place around 9–10 years of age and is very criti-
ii. Almost flat or no curve of Spee is present.
cal for the alignment of the erupting permanent teeth.
iii. Shallow cuspal interdigitation.
 The most common sequence of eruption of permanent
teeth in the maxilla is 4–3–5 (1st premolar–canine–2nd iv. Slight overjet.
premolar) and in the mandible 3–4–5 (canine–1st v. Deep bite.
premolar–2nd premolar). vi. Vertical inclination of the incisors (900).
 The combined mesiodistal width of permanent canine vii. Spaced dentition.
and premolars is less than that of deciduous canine and viii. Different maxillo-mandibular relations like flush, mesial
molars. This is called leeway space of Nance or E space. It and distal terminal planes.
Quick Review Series for BDS 4th Year: Paedodontics
114

SHORT NOTES

Q.1. Teething.  The gum pads are horseshoe shaped and are pink, firm
and covered with a layer of dense periosteum.
Or  They are divided into two parts labiobuccal and lingual by
Teething disorder. dental groove.
 The gum pad is further divided into 10 segments by trans-
Ans. verse groove; each segment has one developing tooth sac.
 A very important landmark in gum pads is lateral sulcus,
 The term ‘teething’ literally means, ‘eruption of primary
which is the transverse groove between canine and 1st
teeth’.
molar. This is helpful in predicting interarch relation at a
 Increased salivation, putting fingers in the mouth, diar-
very early stage.
rhoea, fever, convulsions, acute herpetic gingivo-stoma-
 The maxillary gum pad is wider and longer than the man-
titis, cholera, meningitis, tetanus, even death have been
dibular; thus when they are approximated, there is a com-
attributed to eruption.
plete overjet all around.
 In 19th century, infant mortality has been attributed to
 The only contact that occurs is around the molar region
teething. It was proved that no evidence exists of teething
while space exists in anterior region. This is called infan-
causing fever, convulsions, bronchitis or diarrhoea and all
tile open bite, which is considered normal and helpful
other conditions mentioned.
during suckling.
 Teething neither increases the incidence of infection nor
the erythrocyte sedimentation rate (ESR) or white blood
Q.4. Eruption cyst.
cell (WBC) count. It does not cause fever.
 It does cause day-time restlessness, increase in amount of Ans.
finger sucking, drooling or rubbing of gums and possi-
 Eruption cyst is a bluish purple, elevated area of tissue,
bly loss of appetite. One-third of children only show pro-
commonly called eruption haematoma, and occasionally
nounced change in mucosa with small haemorrhage.
develops few weeks before the eruption of primary or per-
 Eruption of teeth is a normal physiological process; the
manent tooth.
fever or other infections are considered coincidental.
 The blood-filled cyst is most frequently seen in the pri-
mary second molar or the first permanent molar regions.
Q. 2. Primate spaces.
 This fact substantiates the belief that the condition devel-
Ans. ops as a result of trauma to the soft tissue during function
and usually within a few days the tooth breaks through
 The spaces present between the deciduous teeth are of two
the tissue, and the haematoma subsides.
types:
 Because the condition is almost always self-limited, treat-
a. Primate spaces
ment may occasionally be justified.
b. Physiologic spaces.
Q.5. Eruption sequestrum.
Primate Spaces
 Exist between the upper lateral incisors and the canines Ans.
(present mesial to maxillary deciduous canines) and  The eruption sequestrum is seen occasionally in children
lower canines and first deciduous molars (present distal at the time of the eruption of the first permanent molar.
to mandibular deciduous canines).  An eruption sequestrum is composed of cementum-like
 These spaces are also called as anthropoid or simian material formed within the dental follicle.
spaces.  Regardless of its origin, the hard tissue fragment is gen-
erally overlying the central fossa of the associated tooth
Q.3. Gum pads. embedded and contoured within the soft tissue.
 As the tooth erupts and the cusps emerge the fragment
Ans.
sequestrates.
 During predentate period, i.e. the period soon after birth,  Eruption sequestra are usually of little or no clinical signif-
the neonate has no teeth. The alveolar processes at the icance as it may spontaneously resolve without noticeable
time of birth are called the gum pads. symptoms. In cases where eruption sequestrum is caus-
Topic wise Solved Questions of Previous Years
115

ing local irritation and has surfaced through the mucosa  These lobes fuse together to form the labial and lingual
it may easily be removed. surfaces of teeth. The lines of fusion are seen as grooves on
the incisal edge of newly erupted incisor which are called
Q.6. Chronology of deciduous dentition. mamelons.
 These grooves wear-off as the age advances; hence pres-
Or ence of mamelons is an indication that they are young
Chronology of eruption of primary teeth. permanent incisors.
 The mamelons are not seen in primary incisors as the
Ans. enamel formation takes place from a single lobe.

The chronology of primary dentition is as follows: Q.9. Causes of precocious eruption.


Maxilla Eruption Ans.
Central incisor 7½ months
Aetiology of precocious eruption is unknown, but super-
Lateral incisor 9 months
ficially positioned tooth bud may be a reason and most of
Canine 18 months
these teeth are poorly formed.
1st Molar 14 months
The natal and neonatal teeth are also termed as premature
2nd Molar 24 months
teeth or predeciduous dentition. These teeth erupt prior to 3
Mandible Eruption months of age. Natal teeth are present at birth and neonatal
Central incisor 6 months teeth erupt within the first 30 days of life.
Lateral incisor 7 months Natal and neonatal teeth may be associated with Riga–
Canine 16 months Fede disease in which trauma to tongue during feeding is
1st Molar 12 months observed. These may also be observed in chondro-ectodermal
2nd Molar 20 months dysplasia.

Q.7. Mention different stages of tooth development. Q.10. Incisal liability.


Ans. Ans.
The tooth development progresses in the following stages ac- Incisal liability refers to the difference between the amount
cording to American Academy of Pediatric Dentistry. of space needed for the permanent incisors and the amount
A. Morphological developmental stages: of space available for them. This results in crowding of per-
manent incisors in the mandibular arch (sometimes in max-
 Dental lamina
illary arch too) at age 8–9.
 Bud stage
There are different mechanisms by which this incisal li-
 Cap stage
ability gets compensated. They are:
 Bell stage
 Advanced bell stage  Utilization of interdental spacing or the spaces between
 Hertwig epithelial root sheath the primary incisors and canines in spaced dentition.
 Formation of enamel and dentine matrices.  Increase in the arch width or intercanine width changes
leading to more outward positioning of canines after
B. Histophysiological development stages:
eruption. This accounts for a space of about 2 mm.
 Initiation  Arch length changes; labial inclination and positioning
 Proliferation of permanent incisors in a larger arc compared to upright
 Histodifferentiation primary incisors. This contributes to additional 1–2 mm
 Morphodifferentiation space.
 Apposition  Repositioning of the canines in the mandibular arch
 Calcification (mineralization) and maturation. slightly back into the primate spaces along with the
widening of arch accounts for another extra millimetre
Q.8. Mamelons. of space.
Ans.
Q.11. Mulberry molars.
 Mamelons are developmental grooves present on the
incisal edges of a newly erupted incisor. Ans.
 These are seen in permanent teeth because the enamel  Mulberry molars occur due to enamel hypoplasia of con-
formation in permanent teeth occurs in lobes. genital syphilis.
Quick Review Series for BDS 4th Year: Paedodontics
116

 It is one of the symptoms of Hutchinson triad for the This is of three types:
diagnosis of congenital syphilis.
 These molars show many small globular malformations a. Flush Terminal Plane (74%)
on the occlusal surface rather than the normal cusps and
 The distal surfaces of the upper and lower teeth are in a
groove patterns.
straight plane (flush) and therefore situated on the same
vertical plane.
Q.12. Leeway space.
 It is usually most favourable relationship to guide the per-
Or manent molars into class I.

Leeway space of Nance. b. Mesial-step Terminal Plane (14%)


Ans.  The distal surface of the lower molar is more mesial to
that of the upper molar. Invariably, this guides the perma-
 The combined mesiodistal width of permanent canine
nent molars into a class I relationship.
and premolars is less than that of deciduous canine and
 However, a few can proceed into half cusp class III during
molars. This is called leeway space of Nance or E space.
molar transition and further into full class III relationship
 It is 1.8 mm (0.9 mm on each side) in maxillary arch and
with continued mandibular growth.
3.4 mm (1.7 mm on each side) in mandibular arch.
 This excess space is utilized by mandibular molars to
c. Distal-step Terminal Plane (10%)
establish class I relationship through late mesial shift.
 The distal surface of the lower molar is more distal to that
Q.13. Ugly duckling stage. of the upper molar.
 This relationship is unfavourable as it guides the perma-
Ans.
nent molars into distal occlusion.
 Another common occurrence during the second transi-
tional period is the ugly duckling stage or Broadbent phe-
Q.15. Early and late mesial shift.
nomenon.
 This self-correcting malocclusion is seen around 9–11 Or
years of age or during eruption of canines and was first
described by Broadbent in 1937. Late mesial shift.
 As the permanent canines erupt they displace the roots of
lateral incisors mesially. This force is transmitted to the Ans.
central incisors and their roots are also displaced mesially.
Thus, the resultant force causes the distal divergence of Early Mesial Shift
the crown in an opposite direction, leading to midline  This occurs during early mixed dentition period.
spacing.  The eruptive forces of 1st permanent molars are strong
 The term ugly duckling stage indicates the unaesthetic enough to push the deciduous molars forward in the arch,
appearance of child during this stage. thereby utilizing the primate spaces and establishing class
 This condition corrects itself after the canines have I relationship.
erupted. No orthodontic treatment should be attempted
at this stage. Late Mesial Shift
 Many children lack primate spaces and have a non-spaced
Q.14. Primary molar relationship.
dentition and thus erupting permanent molars are not
Or able to establish class I relation even as they erupt.
 In these cases, the molars establish class I relation by drift-
Terminal plane relationship. ing mesially and utilizing the leeway space after exfoliation
Or of deciduous molars and this is called late mesial shift.

Flush terminal plane.


Q.16. Young permanent first molar.
Ans.
Or
The mesiodistal relation between the distal surfaces of max- Give importance of first permanent molar.
illary and mandibular 2nd deciduous molars is called as ter-
minal plane relationship. Ans.
Topic wise Solved Questions of Previous Years
117

 The first permanent molar is unquestionably the most Q.18. Skeletal age versus dental age.
important unit of mastication and is essential in the
Ans.
development of functionally desirable occlusion.
 The loss of a first permanent molar in a child can lead to
Skeletal Age
changes in the dental arches that can be traced through-
out the life of that person.  Skeletal age assessment is often made with the help of
 Unless appropriate corrective measures are instituted, hand–wrist radiograph which can be considered the ‘bio-
these changes include diminished local function, drifting logical clock’.
of teeth, and continued eruption of opposing teeth.  The ossification events are localized in the area of the
 In older children, if the loss occurs after eruption of the phalanges, carpal bones and radius.
second permanent molar, more exaggerated mesial tip-  Leonard S Fishman (1982) outlined four stages of bone
ping of the second molar can be the expected outcome. maturation found at six anatomical sites located on the
 All the teeth anterior to the space, including the central thumb, 3rd finger, 5th finger and radius. Eleven skeletal
and lateral incisors on the side where the loss occurred, maturity indicators are found in these six anatomic sites.
may show evidence of movement.
 Contacts open and the premolars, in particular, rotate as Dental Age
they fall distally.  Dental age has been based on two different methods of
 When the maxillary first permanent molar loses its oppo- assessment:
nent, it erupts at a faster rate than the adjacent teeth. i. Tooth eruption age
 The treatment of patients with the loss of first permanent ii. Tooth mineralization stage.
molars must be approached on an individual basis.
Q.19. Natal and neonatal teeth.
Q.17. FDI tooth numbering system.
Ans.
Ans.
 The natal and neonatal teeth are also termed as premature
 FDI tooth numbering system was proposed by Federation teeth or predeciduous dentition. These teeth erupt prior
Dentaire Internationale (FDI). to 3 months of age.
 This is a two-digit numbering system.  Natal teeth are present at birth and neonatal teeth erupt
The first digit represents the quadrant and the second digit within the first 30 days of life.
represents the individual tooth.  These teeth commonly occur in pairs, mostly in the lower
anterior region.
 The quadrants are denoted with the numbers 1, 2, 3 and
 The natal to neonatal teeth ratio is 3:1 with the incidence
4 for permanent teeth and 5, 6, 7 and 8 for primary teeth,
as 1 in 2000–3500. Ninety percent of these teeth are true
respectively. The teeth are numbered in each quadrant
primary teeth, others are supernumerary.
from 1 to 8 for permanent teeth and from 1 to 5 for pri-
mary teeth starting from the central incisor towards the
Q.20. Pulpal differences in primary and permanent teeth.
distal.
Example: Ans.
In the number 14: 1 denotes maxillary right quadrant, 4 Primary teeth Permanent teeth
denotes the fourth tooth in the arch from midline, i.e. first First molar is smaller in dimension First molar is larger in dimen-
premolar and it is pronounced as one–four. than 2nd molar sion than 2nd molar
In the expression 65 in primary teeth: 6 denotes maxillary Roots are larger and more slender Roots are shorter and more
left quadrant, 5 denotes the fifth (last) tooth in the quad- bulbous
rant from midline, i.e. second primary molar and it is pro- Pulpal outline follows the DEJ more Pulp outline follows the DEJ
nounced as six–five. closely; the pulp horns are closer to less closely
the outer surface. The pulp horns
The permanent teeth can be identified and charted as: are high, and the pulp chambers
18 17 16 15 14 13 1211 21 22 23 24 25 26 27 28 are large

48 47 46 45 44 43 4241 31 32 33 34 35 36 37 38 High potential for repair Comparatively less potential


for repair
The primary teeth can be identified and charted as: Root canals are more ribbon like; Root canals are well-defined
55 54 53 52 51 61 62 63 64 65 the radicular pulp follows a thin, with less branching
85 84 83 82 81 71 72 73 74 75 tortuous and branching path
Quick Review Series for BDS 4th Year: Paedodontics
118

Enamel and dentine are less They are more mineralized Q.23. Neonatal line.
mineralized. The dentine thickness
between the pulp chambers and Ans.
the enamel is limited, particularly in
some areas (lower second primary  In the deciduous teeth and in the first permanent molars,
molar) where dentine is formed partly before and partly after
Neonatal lines are present. Neonatal line is seen only birth, the prenatal and postnatal dentine are separated by
Secondary cementum is absent in first molar. Secondary an accentuated contour line. This is termed as the neona-
cementum is present tal line and is seen in enamel as well as dentine.
 This line reflects the abrupt change in environment that
Accessory canals in the floor of Floor of the pulp chamber
pulp chamber leads directly into does not have any accessory
occurs at birth. The dentine matrix formed prior to the
interradicular furcation canals birth is usually of better quality than that formed after birth,
and the neonatal line may be a zone of hypocalcification.

Q.21. Define eruption. Q.24. Features of primary dentition.


Ans. Ans.
 Maury Massler and Schour (1941) defined eruption as Some of the characteristic clinical features of deciduous denti-
a process whereby the forming tooth migrates from its tion are:
intraosseous location in the jaw to its functional position i. Both the dental arches are half round in shape or ovoid
within the oral cavity. ii. Almost no curve of Spee is present
Or
iii. Shallow cuspal interdigitation
 James K Avery defined eruption as the movement of the
iv. Slight overjet
teeth through the bone of the jaws and the overlying
mucosa to appear and function in the oral cavity. v. Deep bite
Or vi. Vertical inclination of the incisors
 The term eruption has been used to denote the tooth vii. Spaced dentition
emerging through the gingiva; but then it became more viii. Different maxillo-mandibular relations like flush, mesial
completely defined to mean continuous tooth movement and distal terminal planes.
from the dental bud to occlusal contact.
Q.25. Teeth present in jaws at birth.
Q.22. Explain dental age and chronological age. Ans.
 At birth, jaws contain the partly calcified crowns of 20
Ans.
deciduous teeth and beginning of calcification of the 1st
permanent molars.
Dental Age
Dental age has been based on two different methods of as- Q.26. Ectopic eruption.
sessment:
Ans.
i. Tooth eruption age
ii. Tooth mineralization stage.  Arch length inadequacy or a variety of local factors may
influence a tooth to erupt in a position other than normal;
Chronological Age it is known as ectopic eruption.
 It is the most commonly and easily determined develop-
mental age parameter simply figured out from the child's Q.27. Eruption sequence.
date of birth. Ans.
 It is neither an accurate indicator of stage of development  The sequence of eruption of teeth can vary with
nor it is a good predictor of growth potential. individuals.
 Chronological age is often not sufficient for assessing the  The favourable sequence observed for permanent teeth in
developmental stage and somatic maturity of the patient. the maxilla is as follows:
Topic wise Solved Questions of Previous Years
119

6, 1, 2, 4, 5, 3, 7, 8 (first molar, central incisor, lateral sor, canine, first premolar, second premolar, second mo-
incisor, first premolar, second premolar, canine, second lar, and third molar).
molar and third molar).  In primary teeth, the normal eruption sequence observed
 The favourable sequence observed for permanent teeth in in both maxilla and mandible is: A, B, D, C, E (central
the mandible is as follows: incisor, lateral incisor, first primary molar, canine, second
6, 1, 2, 3, 4, 5, 7, 8 (first molar, central incisor, lateral inci- primary molar).

ACQUIRED AND DEVELOPMENTAL

Topic 12 DISTURBANCES OF THE TEETH AND


ASSOCIATED ORAL STRUCTURES
LONG ESSAYS

Q. 1. Write in detail about developmental anomalies of  Roots are fused and single root canal is present within the
shape of teeth in children. root.
 The structure is usually one with two completely or
Ans.
incompletely separated crowns that have a single root and
The developmental disturbances affecting shape of teeth a root canal.
are as follows:  The condition is seen in both deciduous and permanent
i. Gemination, fusion and concrescence dentition, with a higher frequency in the anterior and
ii. Accessory cusps maxillary region.
 Cusp of Carabelli
 Talon cusp Treatment
 Dens invaginatus
 The treatment of a permanent anterior geminated tooth
 Dens evaginatus.
may involve reduction of the mesiodistal width of the
iii. Ectopic enamel
tooth to allow normal development of the occlusion.
a. Enamel pearls
 Devitalization of the tooth and root canal therapy fol-
b. Cervical enamel extensions.
lowed by the construction of a post crown may be needed
iv. Taurodontism
when the geminated tooth is large and malformed.
v. Dilaceration
vi. Supernumerary roots.
i.b. Fusion
i.a. Gemination  Fusion represents the union of two independently devel-
oping primary or permanent teeth.
 Gemination is a developmental anomaly that refers to
 The condition is almost always limited to the anterior
division of single tooth germ into incomplete or complete
teeth and like gemination, may show a familial tendency.
formation of two teeth.
 A geminated tooth represents an attempted division of a
Aetiology
single tooth germ by invagination occurring during the
proliferation stage of the growth cycle of the tooth.  Incomplete attempt of two tooth buds to fuse into one.
 Physical tear and premature union of two tooth buds or
Aetiology two developing teeth.
 Division of single tooth bud.
Clinical Features
Clinical Features  One of the most important criteria for fusion is the fused
tooth must exhibit confluent dentine.
 Bifid crown on a single root.
 Two separate roots + root canals—(complete or incom-
 Crowns may be partially or totally separated from each
plete).
other.
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 Both permanent and deciduous dentition are affected in b. Talon Cusp


case of fusion, although it is more common in deciduous
 Talon cusp is an anomalous projection resembling eagle's
teeth.
talon, projects lingually from cingulum area of perma-
 Fusion can be complete or incomplete and its extent will
nent incisors.
depend on stage of odontogenesis at which fusion takes
 A developmental groove is present at the site, where this
place.
projection meets with the lingual surface of tooth.
 The incisor teeth are more frequently affected in both the
 This groove is prone to caries, so it should be removed.
dentitions.
 A frequent finding in fusion of primary teeth is the con- If pulp exposure is present then endodontic therapy is
genital absence of one of the corresponding permanent done.
teeth.  Found in association with Rubinstein–Taybi syndrome.

Radiographic Examination c. Dens in Dente or Dens Invaginatus

 The radiograph may show that the fusion is limited to  Dens in dente is a developmental variation that arises as a
the crowns and roots. Fused teeth will have separate pulp result of enamel epithelial invagination of the crown sur-
chambers and separate pulp canals. face before calcification.
 Several causes of this condition are: It is because of focal
Treatment growth proliferation and focal growth retardation that
takes place in certain areas of tooth bud, increased local-
 Surgical division and selective shaping of crowns. ized external pressure.
 The multidisciplinary approach may be indicated in the  After calcification it appears as accentuation of lingual
clinical management of certain problems associated with pit.
fused teeth.
 Teeth most frequently involved are maxillary lateral and
 The disciplines of paediatric dentistry, endodontics, sur-
maxillary central incisors.
gery, restorative dentistry and orthodontics were repre-
sented in the initial management of the case, and a post
Radiographic Features
and core and a crown restoration were anticipated for the
future.  Appearance of tooth within tooth due to deep pear-shaped
invagination from lingual pits, approximating to pulp.
i.c. Concrescence
Treatment
 Concrescence is defined as the union of two adjacent teeth
by cementum only without confluence of the underlying  Application of sealant or a restoration in the opening of
dentine. the invagination is the recommended treatment to pre-
 It is the type of fusion limited only to the roots of the teeth vent pulpal involvement.
and occurs after the root formation of involved teeth is  If the condition is detected before complete eruption of
completed. the tooth, the removal of gingival tissue to facilitate cavity
 Concrescence may be developmental or postinflammatory preparation and restoration may be indicated.
or due to traumatic injury.  This anomaly makes teeth prone to caries, so endodontic
 Commonly seen between maxillary 2nd molar and therapy should be done.
unerupted 3rd molar.  The advisability of performing endodontic procedures on
such a tooth with pulpal degeneration depends on its pulp
ii. Accessory Cusps
morphology and the restorability of the crown.
a. Cusp of Carabelli
b. Talon cusp d. Dens Evaginatus (occlusal tuberculated premolar,
c. Dens invaginatus (dens in dente) Leong premolar, Evaginated odontome)
d. Dens evaginatus.  Dens evaginatus is a developmental condition that appears
as an accessory cusp or globule of enamel on occlusal sur-
a. Cusp of Carabelli face between buccal and lingual cusps of premolars uni-
 Present on mesiopalatal cusp of maxillary 1st molars. laterally or bilaterally.
 An analogous accessory cusp in seen occasionally on the  This is opposite of invagination. That means, there occurs
mesiobuccal cusp of a mandibular permanent or decidu- extrusion of the dental papilla outwards into the enamel
ous molar known as protostylid. organ.
Topic wise Solved Questions of Previous Years
121

Clinical findings  Roots are very short.


 Furcation is present just above root apex.
 This condition is more common in people of Chinese
race.
Treatment
 More common in maxillary 1st premolars but also occurs
rarely on molars, cuspids and incisors.  No treatment is required.
 Presents a tubercle of enamel with a core of dentine with
a narrow pulp chamber. v. Dilaceration
 When the tooth erupts, this bit of enamel is higher than
 Dilaceration refers to angulation or curve in root or crown
the cusps and covers the underlying mass of dentine.
of tooth.
 If present in deciduous teeth, it causes difficulty in feed-
 Angulation is caused due to trauma to the tooth during
ing.
formative stage of tooth.
 When the thin surface enamel of the tubercle breaks
 Curve is present at apical, middle or at cervical portion
down, infection of the tooth takes place resulting in death
of the pulp and abscess formation. depending on the portion forming at the time of trauma.
 Occlusal trauma in deciduous tooth may also cause dilac-
Treatment eration of permanent tooth.
 More common in the maxillary anterior region.
 It consists of extraction of the tooth.  Significance is that the tooth with bent root is difficult to
extract.
iii. Ectopic enamel
 Enamel pearls vi. Supernumerary Roots
 Cervical enamel extensions
 One or more extra roots may be present in tooth.
 Ectopic enamel or enamel pearls or enameloma or enamel
 Usually single-rooted teeth such as mandibular cuspids
drop usually occurs in furcation area below the crest of
and bicuspids are involved.
gingiva.
 Third molars of both jaws also present one or more extra
 Cervical enamel extension also occurs along the surface
roots.
of dental roots.
 Maxillary and mandibular molars are most commonly
affected. Q. 2. Describe various causes of enamel hypoplasia.
 Predisposes to development of buccal bifurcation cysts.
Ans.
iv. Taurodontism (Bull-like teeth)  Enamel hypoplasia is defined as an incomplete or defec-
tive formation of the organic enamel matrix of teeth.
 Taurodontism is a dental anomaly in which the body of
the tooth is enlarged at the expense of roots.  Amelogenesis occurs in two stages. In the first stage, the
enamel matrix forms and in the second stage, the matrix
Aetiology undergoes calcification.
 Local or systemic factors that interfere with normal matrix
 A specialized or retrograde character or a mutation. formation cause enamel surface defects and irregularities
 A primitive pattern and an atavistic feature. called enamel hypoplasia.
 Mendelian recessive trait.
 Enamel hypoplasia is of two types:
 Associated with Klinefelter syndrome.
 It is due to the failure of Hertwig epithelial root sheath to a. Hereditary (also called as amelogenesis imperfecta).
invaginate at proper horizontal level. b. Environmental.

Clinical findings a. Hereditary Enamel Hypoplasia (Amelogenesis


Imperfecta)
 It may affect both deciduous and permanent dentition,
but more common in permanent dentition.  It is a group of hereditary defects of enamel associated
 Molars are commonly affected. with other generalized defects, dentine is usually normal.
 Tooth morphology is normal.  It may be of three types:
a. Hypoplastic type: It is the defect of enamel organic ma-
Radiographic features trix formation.
 Enlarged and rectangular pulp chamber is present. b. Hypocalcification type: It is the defect of mineraliza-
 No constriction of pulp at cervical area. tion of enamel.
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122

c. Hypomaturation type: It is the defect of enamel crystal Enamel Hypoplasia Due to Birth Injuries
maturation.
 Premature children affected with Rh haemolytic diseases
at birth may suffer from enamel hypoplasia.
Clinical Features
i. In hypoplastic type enamel thickness is not complete. Enamel Hypoplasia Due to Ingestion of Fluoride
ii. In hypocalcification type enamel is soft and can be re-
 If drinking water contains fluoride content more than 1
moved by prophylactic instrument.
ppm at the time of amelogenesis, it can cause death of
iii. In hypomaturative type:
ameloblasts, so it leads to defective matrix formation.
 Enamel can be pierced with explorer point and
 It may also result in disturbances in calcification. Enamel
chipped-off.
affected is termed as mottled enamel.
 Teeth are brownish in colour.
 In mild cases white flecks appear in enamel. Moderate
 Vertical lines or grooves may be present on surface.
degree of fluoride toxicity may lead to white opaque areas
 Enamel is chalky and can be chipped-off with expo-
in enamel. In more severe case brown discolouration of
sure of underlying dentine.
enamel occurs.
 Contact points are abraded.
 Still more severe toxicity of fluoride causes corroded
crown surface.
Treatment
 There is no treatment except for improvement of cosmetic Treatment
appearance by veneering or capping of teeth.
 Defluoridation of drinking water is done if drinking water
contains excess fluoride content.
b. Environmental Enamel Hypoplasia
 The staining of enamel surface can be removed by bleach-
 In this type of enamel hypoplasia both enamel and den- ing with hydrogen peroxide (30% solution), grinding or
tine are affected. capping.

Causes Enamel Hypoplasia Due to Local Infection or Trauma


 Nutritional deficiencies  Turner first described this localized type of hypoplasia. He
 Exanthematous diseases noted defects in the enamel of two premolars and traced
 Congenital syphilis the defects to apical infection of the nearest primary
 Hypocalcaemia molar. Enamel hypoplasia resulting from local infection
 Birth injuries is called Turner tooth.
 Ingestion of fluoride  Only single tooth, generally maxillary incisor or premolar,
 Local infection is affected.
 Idiopathic.  The apically infected deciduous tooth may affect the
ameloblastic layer of permanent tooth.
Nutritional Deficiencies and  Ameloblastic layer may also get disturbed due to occlusal
Exanthematous Diseases trauma to deciduous tooth.
 Vitamin A, C and D, calcium, and phosphorus deficien-  The permanent tooth beneath infected or traumatized
cies and exanthematous diseases (e.g. chicken pox, mea- deciduous tooth is discoloured or pitted.
sles) and scarlet fever cause enamel hypoplasia of pitting  The teeth are called Turner teeth and this type of enamel
type if deficiency occurs during teeth formation. hypoplasia is termed as Turner hypoplasia.

Enamel Hypoplasia Due to Congenital Syphilis Enamel Hypoplasia Related to Brain Injury and
 In congenital syphilis crowns of maxillary central incisors Neurologic Defects
become screwdriver shaped.  Herman and McDonald observed enamel hypoplasia in
 Crown of first molar at occlusal surface is arranged into 36% of the group with cerebral palsy and in 6% of the
agglomerated mass of globule and termed as mulberry group without the disorder.
molars. The teeth affected are called as Hutchinson teeth.  A definite relationship between the time of occurrence of
the possible factors that could have caused brain damage
Enamel Hypoplasia Due to Hypocalcaemia and the apparent time of origination of the enamel defect
 Calcium level less than 6–8 mg/dL may cause enamel was established for 70% of the affected teeth of children
hypoplasia of pitting type. with cerebral palsy.
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 Cohen and Diner observed that enamel defects occurred  Pearl and Roland have pointed out that the fetus of a
with greatest frequency in children with low intelligence lead-poisoned mother can be affected because lead read-
quotients and a high incidence of neurologic defects. ily crosses the placenta during pregnancy.

Hypoplasia Associated with Nephrotic Hypoplasia Associated with Cleft Lip and Palate
Syndrome  Mink studied the incidence of enamel hypoplasia of the
 Oliver and Owings observed enamel hypoplasia in per- maxillary anterior teeth in 98 patients with repaired bilat-
manent teeth in a high percentage of children with neph- eral and unilateral complete cleft lip and palate.
rotic syndrome and found a correlation between the time  Among patients in the repaired unilateral and bilateral
of severe renal disease and the estimated time at which the complete cleft lip and palate group, 66% of those with
defective enamel formation occurred. maxillary anterior primary teeth had one or more pri-
 Koch and colleagues found a high incidence of enamel mary teeth affected with enamel hypoplasia and 92% of
defects in the primary teeth of children who were diag- those with erupted maxillary anterior permanent teeth
nosed with chronic renal failure early in infancy. had one or more permanent teeth affected with enamel
hypoplasia.
 Mink concluded that the permanent teeth are in earlier
Hypoplasia Associated with Allergies
stages of development at the time of the surgical proce-
 Rattner and Meyers discovered a correlation between dure and are more subject to damage.
enamel defects of the primary dentition and the presence
of severe allergic reactions. Hypoplasia Caused by X-radiation and
 Enamel defects were present in 26 of 45 children with con- Chemotherapy
genital allergies. The enamel lesions were localized in the
 Numerous dental abnormalities may result in surviving
occlusal third of the primary canines and first molars.
children who receive high-dose radiotherapy and chemo-
therapy during the time their teeth are forming.
Hypoplasia Associated with Lead Poisoning
 Children who receive high-dose X-radiation in the treat-
(Plumbism)
ment of a malignancy are at risk for developing rampant
 Lawson and Stout observed that in areas of Charleston, caries in the irradiated area.
South Carolina, where there were very old frame buildings,  Ameloblasts are somewhat resistant to X-radiation. How-
the incidence of pitting hypoplasia was approximately ever, a line of hypoplastic enamel that corresponds to the
100% greater than their control group of children. stage of development at the time of therapy may be seen.

SHORT ESSAYS

Q.1. Submerged teeth. Causes


Ans.  Trauma, infection, disturbed local metabolism, genetic
influence.
 Ankylosed teeth are submerged teeth, most commonly
deciduous mandibular second molars that have under-
Treatment
gone a variable degree of root resorption and have become
ankylosed to the bone.  This condition is usually treated by surgical removal of
 They may exist in three conditions: ankylosed teeth to prevent the development of malocclu-
sion, local periodontal disturbance or dental caries.
i. Minimal infraocclusion: Marginal ridge of submerged
 In case of moderate infraocclusion there are two treat-
tooth is occlusal to adjacent areas.
ment alternatives:
ii. Moderate infraocclusion: Marginal ridge of submerged a. Retain the submerged tooth:
tooth is just cervical to adjacent contact areas.. ❍ Maintain the adjacent tooth contacts and opposite
iii. Severe infraocclusion: Marginal ridge of submerged tooth contacts by fitting a stainless steel crown or by
tooth is at gingival level. building up the occlusal surface.
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b. Extract the submerged tooth: Enamel Hypoplasia Due to Ingestion of Fluoride


❍ If it interferes with normal eruption of premolars.
If drinking water contains fluoride content more than 1 ppm
 In case of severe infraocclusion, extract the submerged
at the time of amelogenesis, it can cause death of ameloblasts,
tooth.
so it leads to defective matrix formation.
It may also result in disturbances in calcification. Enamel
Q.2 . Enamel hypoplasia.
affected is termed as mottled enamel.
Ans.
Enamel Hypoplasia Due to Local Infection or
 Enamel hypoplasia is defined as an incomplete or defec-
Trauma
tive formation of the organic enamel matrix of teeth.
 Amelogenesis occurs in two stages. In the first stage, the  The apically infected deciduous tooth may affect the
enamel matrix forms, and in the second stage, the matrix ameloblastic layer of permanent tooth.
undergoes calcification.  Ameloblastic layer may also get disturbed due to occlusal
 Local or systemic factors that interfere with normal matrix trauma to deciduous tooth.
formation cause enamel surface defects and irregularities  The permanent tooth beneath infected or traumatized
called enamel hypoplasia. deciduous tooth is discoloured or pitted.
 Enamel hypoplasia is of two types:  The teeth are called Turner teeth and this type of enamel
a. Hereditary (also called as amelogenesis imperfecta) hypoplasia is termed as Turner hypoplasia.
b. Environmental.
Q.3. Turner (hypoplasia) tooth.
Causes
Ans.
 Nutritional deficiencies
 Exanthematous diseases  Turner first described this localized type of hypoplasia.
 Congenital syphilis  Individual permanent teeth have hypoplastic or hypoc-
 Hypocalcaemia alcified areas on the crown that result from infection or
 Birth injuries trauma.
 Ingestion of fluoride  Periapical inflammatory processes of primary teeth extend
 Local infection toward the buds of the pertinent permanent teeth and
 Idiopathic. affect them during their prefunctional stage of eruption.
 The infection fails to stimulate the development of a
Nutritional Deficiencies fibrous wall that would localize the lesion.
 Instead the infection spreads diffusely through the bone
 Vitamin A, C and D deficiencies and exanthematous dis-
around the buds of the successors and thereby affects
eases (e.g. chicken pox, measles) and scarlet fever cause
the important protective layer of the young enamel, the
enamel hypoplasia of pitting type if deficiency occurs
reduced enamel epithelium.
during teeth formation.
 The permanent tooth beneath infected or traumatized
deciduous tooth is discoloured or pitted. The teeth are
Enamel Hypoplasia Due to Congenital Syphilis
called Turner teeth and this type of enamel hypoplasia is
 In congenital syphilis crowns of maxillary central inci- termed as Turner hypoplasia.
sors become screwdriver shaped. Crown of first molar is
termed as mulberry molars. The teeth affected are called Q. 4. Gemination and fusion.
as Hutchinson teeth.
Ans.
Enamel Hypoplasia Due to Hypocalcaemia
Gemination
 Calcium level less than 6–8 mg/dL may cause enamel
 Gemination is a developmental anomaly that refers to
hypoplasia of pitting type.
division of single tooth germ into incomplete or complete
formation of two teeth.
Enamel Hypoplasia Due to Birth Injuries
 A geminated tooth represents an attempted division of a
 Premature children affected with Rh haemolytic diseases single tooth germ by invagination occurring during the
at birth may suffer from enamel hypoplasia. proliferation stage of the growth cycle of the tooth.
Topic wise Solved Questions of Previous Years
125

Aetiology Treatment
 Division of single tooth bud.  Surgical division and selective shaping of crowns.
 The multidisciplinary approach may be indicated in the
Clinical Features clinical management of certain problems associated with
 Bifid crown on a single root. fused teeth.
 Crowns may be partially or totally separated from each  The disciplines of paediatric dentistry, endodontics, surgery,
other. restorative dentistry, and orthodontics were represented in
 Roots are fused and single root canal is present within the the initial management of the case, and a post and core and
root. a crown restoration were anticipated for the future.
 The structure is usually one with two completely or
Q. 5. Amelogenesis imperfecta.
incompletely separated crowns that have a single root and
a root canal. Ans.
 The condition is seen in both deciduous and permanent
 Amelogenesis imperfecta is a developmental defect of the
dentition, with a higher frequency in the anterior and
enamel with a heterogeneous aetiology that affects the
maxillary region.
enamel of both the primary and permanent dentition.
Treatment  Amelogenesis imperfecta is alteration in both quality and
quantity of enamel.
 The treatment of a permanent anterior geminated tooth
may involve reduction of the mesiodistal width of the Aetiology
tooth to allow normal development of the occlusion.  Gene mutations in enamel matrix result in hypoplasia,
 Devitalization of the tooth and root canal therapy fol- hypocalcification and hypomaturation.
lowed by the construction of a post crown may be needed  Two clinically distinct forms of autosomal dominant
when the geminated tooth is large and malformed. amelogenesis imperfecta are smooth hypoplastic amelo-
genesis imperfecta and local hypoplastic amelogenesis
Fusion imperfecta associated with mutations in the enamelin
 Fusion represents the union of two independently devel- (ENAM) gene located at 4q21.
oping primary or permanent teeth.  In addition, autosomal dominant amelogenesis imper-
fecta can be associated with mutation in the Kallikrein-4
Aetiology (KLK4) gene, and autosomal recessive pigmented
hypomaturation amelogenesis imperfecta with an enam-
 Incomplete attempt of two tooth buds to fuse into one. elysin (MMP-20) gene mutation, illustrating the hetero-
geneity of the condition.
Clinical Features
 One of the most important criteria for fusion is the fused Clinical Features
tooth must exhibit confluent dentine.  Amelogenesis imperfecta has a wide range of clinical appear-
 Two separate roots + root canals—(complete or incom- ances with three broad categories—the hypocalcified type,
plete). the hypomaturation type, and the hypoplastic type.
 Both permanent and deciduous dentition are affected in  Hypoplastic teeth lack normal enamel thickness due to
case of fusion, although it is more common in deciduous inadequate deposition of matrix. Enamel is pitted with
teeth. horizontal and vertical ridges.
 Fusion can be complete or incomplete and its extent will  In hypomaturation type there is normal deposition of
depend on stage of odontogenesis at which fusion takes enamel and defective maturation of crystal structure.
place.  Affected teeth are mottled, opaque with white brown yel-
 The incisor teeth are more frequently affected in both the lowish discolouration.
dentitions.  Enamel is soft and chips-off from dentine.
 A frequent finding in fusion of primary teeth is the con-  Hypomaturation hypoplastic with taurodontism:
genital absence of one of the corresponding permanent Enamel is mottled yellow brown with areas of hypomatura-
teeth. tion. Molar teeth have taurodont shape and other teeth have
enlarged pulp change.
Radiographic Examination
 The radiograph may show that the fusion is limited to Treatment
the crowns and roots. Fused teeth will have separate pulp  There is no treatment except for improvement of cosmetic
chambers and separate pulp canals. appearance by veneering or capping of teeth.
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126

Poor aesthetics Primary teeth restored with glass ionomer/ Complete anodontia
composite veneer  It is the condition in which there is neither any deciduous
Dentinal sensitivity Full coverage with stainless steel crowns tooth nor any permanent tooth present in the oral cavity.
Dental caries Dietary advice, fluoride therapy  A complete anodontia is a common feature of hereditary
Glass ionomer/composite restorations and ectodermal dysplasia; however, in many cases cuspids are
stainless steel crowns present in this disease.
Gingival inflammation Improve preventive oral healthcare prac-  Complete anodontia occurs among children who have
tices
received high doses of radiation to the jaws as infants for
therapeutic reasons.
Q.6. Anomalies of the number of teeth.
Ans. Partial anodontia
Anomalies of the number of teeth are as follows:  It is a common phenomenon and characterized by con-
A. Anodontia: Total lack of tooth development genital absence of one or few teeth.
B. Hypodontia: Lack of development of one or more teeth  In partial anodontia any tooth can be congenitally miss-
C. Oligodontia: Lack of development of six or more teeth ing.
(a subdivision of hypodontia) E.g.: The third molars are most frequently observed con-
D. Hyperdontia: Development of increased number of genitally missing teeth.
teeth.
The mandibular first molars and the mandibular lateral
incisors are least likely to be missing.
A. Anodontia
 Anodontia is defined as the condition in which there is B and C. Hypodontia and Oligodontia
congenital absence of teeth in oral cavity.
 Oligodontia refers to the lack of development of six or
 Anodontia is rare and most cases occur in the presence of
more teeth.
ectodermal dysplasia.
 Damage to dental lamina before tooth formation can
Aetiology result in hypodontia.

The causes of anodontia are: Aetiology


i. Hereditary factor
 May be caused by genetic factors, trauma, endocrine dis-
ii. Environmental factor
iii. Familial factor turbances, infection, radiation and chemotherapeutic
iv. Syndrome associated medications.
 It may also occur in hereditary syndromes such as Crouzon
v. Radiation injury to the developing tooth germ.
syndrome, Down syndrome, ectodermal dysplasia, Hurler
Types syndrome and Turner syndrome.

 Anodontia can also be divided into following types: Clinical Features


a. True anodontia: It occurs due to failure of develop-
 It usually affects permanent third molars, second premo-
ment or formation of tooth in jaw bone.
b. Pseudo anodontia: It refers to the condition in which lars and lateral incisors in that order.
teeth are present within the jaw bone but are not clini-  Oligodontia and hypodontia may cause abnormal spac-
cally visible in the mouth, as they have not erupted, e.g. ing of teeth, delayed tooth formation, delayed deciduous
impacted teeth. tooth exfoliation and late permanent tooth eruption.
c. Induced or false anodontia: It is the condition in
which teeth are missing in the oral cavity because of Treatment
their previous extractions.  Orthodontic closure of space or prosthetic replacement of
True anodontia is of two types: teeth may be needed.
a. Complete anodontia: There is congenital absence of all
D. Hyperdontia
the teeth.
b. Partial anodontia: Congenital absence of one or few  Increase in number of teeth (excess teeth) is known as
teeth. hyperdontia.
Topic wise Solved Questions of Previous Years
127

Aetiology  Supernumerary teeth are a developmental disturbance in


the number of teeth.
 Multiple supernumerary teeth can occur in association
 A supernumerary tooth is an additional entity to the
with the syndromes like Gardner syndrome and clei-
normal series and is seen in all quadrants of the jaw.
docranial dysplasia.
 Morphological types of supernumerary teeth:
 Continue activity of dental lamina.
❍ Conical
 Complete division of eruptive teeth.
❍ Tuberculate
❍ Supplemental
Clinical Features
❍ Odontome.
 Rudimentary teeth.  Supplemental supernumerary teeth are teeth that resem-
 Erupted/impacted teeth. ble the typical anatomy of posterior and anterior teeth.
 Supplemental teeth like mesiodens, paramolars and dis-  Rudimentary supernumerary teeth are conical in shape.
tomolars. Usually they are found in syndromes like cleidocranial
 Displacement of adjacent teeth. dysplasia and orofacial digital syndrome.
 Multiple supernumerary teeth can occur in association
Treatment with the conditions like Gardner syndrome and cleidocra-
 Surgical removal or orthodontic alignment of teeth. nial dysplasia.

Q.7. Pink tooth. Q.9. Tooth discolouration (intrinsic).

Ans. Or
 Internal resorption is also known as chronic perforating Intrinsic discolouration of teeth.
hyperplasia of pulp, odontoclastoma or pink tooth of
Mummery. Ans.
 It is an unusual form of resorption that begins centrally Intrinsic Discolouration of Teeth (Pigmentation of
within the pulp, apparently initiated by a peculiar inflam- Teeth)
matory hyperplasia of the pulp.
 The primary teeth occasionally have unusual pigmenta-
Aetiology tion.
 Certain conditions arising from the pulp can cause the
 Idiopathic whole tooth to appear discoloured.
Clinical Features Intrinsic discolouration of teeth is seen in:
i. Erythroblastosis fetalis
 No early clinical signs and symptoms. ii. Porphyria
 Tooth may show pink spot (pink tooth) when more of iii. Cystic fibrosis
dentine is resorbed from one area of the crown, leaving a iv. Tetracycline therapy.
covering of translucent enamel.
 It appears as a pink area due to vascular pulp visible Intrinsic discolouration of teeth in various conditions is de-
through the translucent enamel. scribed below:

Radiographic Appearance Discolouration in Hyperbilirubinaemia


 If teeth are developing during periods of hyperbilirubi-
 Pink spot appears as round or ovoid area of radiolucency
in the central portion of the tooth. naemia, they may become intrinsically stained.
 Excess levels of bilirubin are released into the circulating
Treatment blood in a number of conditions. The two most common
disorders that cause this intrinsic staining are erythroblas-
 If condition is discovered before perforation of crown, tosis fetalis and biliary atresia.
root canal therapy may be carried out.  Erythroblastosis fetalis results from the transplacental
 Once perforation has occurred, extraction of tooth is the passage of maternal antibody active against red blood cell
treatment. antigens of the infant, which leads to an increased rate of
red blood cell destruction.
Q.8. Supernumerary teeth.  If an infant has had severe, persistent jaundice during the
Ans. neonatal period, the primary teeth may have a character-
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128

istic blue-green colour, although in a few instances brown  Tetracycline is the drug of choice in these patients.
teeth have been observed.  The unsightly yellowish grey to dark-brown discoloura-
tions of the teeth in these patients is due to tetracycline
Discolouration in Porphyria therapy during a period when their tooth crowns were
 The porphyrias are inherited and acquired disorders in forming.
which the activities of the enzymes of the heme biosyn-
thetic pathway are partially or almost completely deficient. Discolouration in Tetracycline Therapy
 As a result, abnormally elevated levels of porphyrins and/
or their precursors are produced, accumulate in tissues,  Dentists and physicians have observed that children who
and are excreted. have received tetracycline therapy during the period of
 The primary teeth of children with congenital erythro- calcification of the primary or permanent teeth show
poietic porphyria are purplish brown as a result of the a degree of pigmentation of the clinical crowns of the
deposition of porphyrin in the developing structures. The teeth.
permanent teeth also show evidence of intrinsic staining  The crowns of affected teeth are discoloured, ranging
but to a lesser degree. from yellow to brown and from grey to black.
 Tetracycline is deposited in the dentine and to a lesser
Discolouration in Cystic Fibrosis extent in the enamel of teeth that are calcifying during the
 Cystic fibrosis is an inherited, chronic, multisystem, life- time the drug is administered.
shortening disorder characterized primarily by obstruc-  The tetracyclines which are yellow, fluoresce under ultra-
tion and infection of the airways and poor digestion. violet light.

SHORT NOTES

Q. 1. Mesiodens.  Anodontia is defined as the condition in which there is


congenital absence of teeth in oral cavity.
Ans.
 Mesiodens is a maxillary supernumerary tooth between Aetiology
two central incisors and is the most common supernu-
 Hereditary, environmental or familial factors or syndrome
merary teeth.
associated.
 Autosomal dominant type of inheritance.
 90% occur in maxilla. Types
 Develops from third tooth bud or splitting of permanent
 Anodontia can be divided into following types:
tooth bud.
 More common in males compared to females. a. True anodontia
 Occurrence is very less in deciduous teeth.
 It occurs due to failure of development or formation of
tooth in jaw bone.
Q. 2. Twinning.  True anodontia is of two types:
Ans. i. Complete anodontia: There is congenital absence of all
the teeth.
 The division of a single tooth resulting in one normal and ii. Partial anodontia: Congenital absence of one or few
one supernumerary tooth. teeth.
 The number of teeth will be more than normal.
b. Pseudo anodontia
Q.3. Anodontia.
It refers to the condition in which teeth are present within
Ans. the jaw bone but are not clinically visible in the mouth, as
they have not erupted, e.g. impacted teeth.
Topic wise Solved Questions of Previous Years
129

c. Induced or false anodontia Q.7. Ankyloglossia.


It is the condition in which teeth are missing in the oral cav- Or
ity because of their previous extractions.
Tongue tie.
Q. 4. Dilaceration. Ans.
Ans.  In ankyloglossia a short lingual frenum extending from
the tip of the tongue to the floor of the mouth and onto
 Dilaceration refers to an angulation or a sharp bend or
the lingual gingival tissue limits movements of the tongue
curve in the root or crown of a formed tooth.
and causes speech difficulties.
 This condition is caused due to trauma to the tooth during
 In the older child a reduction of the frenum should be
its formative stage.
recommended only if local conditions or speech problems
 Curve is present at apical, middle or cervical portion
warrant the treatment.
depending on the portion forming at the time of trauma.
 Stripping of the lingual tissues may occur if the tongue-tie
 Dilacerated teeth frequently present difficult problems at
is not corrected.
the time of extraction.
 Surgical reduction of the abnormal lingual frenum by
 More common in the maxillary anterior region.
either lingual frenectomy, frenotomy or frenuloplasty is
indicated if it interferes with the