Pedo Competency.pdf

1 KNEE TO KNEE
LAP EXAM
2 ON WHO DO YOU
DO A LAP EXAM?
• Any age in which the child will not sit in the chair on their own
• Child 1 year of age or 6 months after the eruption of first tooth
o
It is important to see children early to check for normal development and most
importantly PARENT EDUCATION!
3 WHAT WILL YOU NEED?
• 2 chairs
o
Parent and child must be in a chair without wheels
4 Inform the Parent
• How you want them to sit (knee to knee)
• How to lay the child back into your lap
• How they will need to hold the child’s hands and hold the child’s legs under their arms
• The child may cry and that it is okay
o
When a child cries, their mouth is open
5 What You’re Looking For
• Any facial or oral abnormalities, possibly as a result of finger sucking or pacifier
• Obvious caries
• Plaque
6 Eruption
• Primary Teeth

o
o
o
20 in number (A-­‐T)
Erupt from 6 to 30 months
Begin formation in utero
as well as the 1 st permanent molar
o
Pattern:
Mandibular centrals & laterals (n,o,p,q)
Maxillary centrals & laterals (d,e,f,g)
1 st primary molars (b,i,l,s)
Canines (c,h,m,r)
2 nd primary molars (a,j,k,t)
7 Oral Hygiene Instruction
• Talk with parent about:
o
Brushing & flossing the child’s teeth
Needs to be done twice a day with a toothbrush or cloth
Only use toothpaste if child is able to spit the toothpaste out and not
swallow it.
Toothbrush should be replaced every couple of months or when the bristles
become flared
Flossing should be done everyday
Flossing cleans between teeth where a toothbrush can’t reach
Flossing isn’t needed if all contacts are visually open
o
No bottles or breast feeding at bedtime or throughout the night
This can lead to baby bottle decay and can form a bad habit for the child
primarily seen on max anterior teeth
Suggest using water instead of milk

8 Oral Hygiene Instruction
o
Avoiding sugared drinks and candy throughout the day
Do not put sugared drinks in bottles or sippy cups
Suggest that parent may limit the consumption of sugary drinks to meal times
o
Fluoride
Can apply fluoride varnish if child is cooperative
If incipient lesion found
Discuss:
Proper Fl amounts
Dietary sources of Fl for infants and children
Water fluoridation
Mechanical action of Fluoride
9 Fluoride Chart

10 After Exam
• Give parent child’s home care kit, which should include
o
o
o
Age appropriate toothbrush
Floss
Toothpaste
• Document everything that you and the parent talked about during the exam
o
o
o
OHI, response from parent, etc.
Record detailed medical and dental histories
Frankel Rating (1-­‐4)
4 being the best behavior
• Place patient on 6 month recall
• If caries found
o
provide treatment

o
give appropriate referral

1 Class II Amalgams in the Primary Dentition
• By: Yacoub Al-­‐Abwah
• Class of 2007
2 Class II amalgam restorations
• Amalgam restorations are useful in children.
• The technique is not as critical as when placing composites restorations .
• It has been shown that the success rate is 70-­‐80% when treating early to moderate
interproximal lesions.
3 Obtain adequate anesthesia and field isolation
• This can be challenging in children when cooperation is an issue.
• Rubber dam isolation helps in securing a better field of vision, as well as keeping the tongue
out the way.
• Do not start until the patient is profoundly anesthetized!
4 Proceed with preparation
• Prepare the occlusal surface using a 330, round diamond, or small pear shaped burs.
• Do not extend to include all fissures but be sure to include all susceptible fissures and pit.
• The depth should be 0.5 into dentin and make sure to include isthmus and dovetail for
retention.
• Gingival and buccolingual contacts should be just slightly open so the T-­‐band can go through
and can be placed firmly around the tooth.
• Do not make the gingival wall too deep or you will have a narrow gingival seat because of the
cervical constriction of the primary teeth.
5 Preparation
• Occlusal View
6 Preparation
7 Finishing the preparation

• Deep caries should be remove using a spoon excavator or slow speed handpiece with a
round bur.
• Be sure to bevel the axio-­‐pulpal line angle and smooth the enamel walls.
• Be sure the isthmus width is adequate as it is the most common site of amalgam failure.
• If the preparation is moderately deep use of light-­‐cured GI liner is indicated.
• If preparation is close to the pulp chamber a liner should be used.
8 Preparation consideration
• The proximal box should be broader at the cervical than at the occlusal surface.
• The axial wall of the proximal box should be 0.5mm into dentin(1mm mesiodistal width of
the gingival seat) and should follow the same contour as the outer proximal contour.
• No buccal or lingual retentive grooves are necessary in the proximal box.
9 Proceed to Amalgam placement
• The T-­‐band should be adapted around the tooth.
• Place wooden wedge beneath the gingival seat from the lingual embrasure. However,
sometimes it is fine to place it from the facial to obtain solid contact.
• Insert the amalgam incrementally, be sure to condense it well!
• Use of a small condenser may help with condensation.
10 Amalgam placement
• T-­‐Band and wedge
11 Restoration adjustment
• A slight overfill of the restoration may be helpful.
• The occlusal should be carved using a small ball burnisher and cleoid-­‐discoid carver.
• An explorer may be used to obtain good form of the marginal ridge.
• Remove the T-­‐band and remove excess amalgam at the margins.

• Pass floss through to ensure solid contact and remove debris.
12 Touch it up!
• Final restoration
13 Check Occlusion
• Remove rubber dam.
• Adjust occlusion after checking with articulating paper.
14 Post operative instructions
• Before dismissing the patient remember to give post operative instructions to the parent
and the child. The following should be emphasized:
• 1-­‐anesthesia: avoid biting on the
• anesthetized tissue.
• 2-­‐amalgam: avoid eating hard food on the
• side where the amalgam was placed for the
• rest of the day.
•
15 Thank you

1 Pulpotomy on Primary Teeth
2 Pulpotomy on Primary Teeth
• DEFINITION: It is a type of endodontic treatment, which involves the removal of the coronal part
of the pulp.
• The pulp contains connective tissue with cells, nerve fibers and blood vessels, encased by the
dentinal tissue.
• The pulp is contained in the inner root canals and pulp chamber.
3 Pulpotomy on Primary Teeth Indications
• Pulpal diagnosis: Reversible pulpitis.
4 Reversible Pulpitis
• Definition
• Reversible inflammation of the pulp
• Symptoms
• Pain: Sharp, induced by stimuli cold/sweet
• Duration: only while the stimuli present
5 Reversible Pulpitis
• Signs
• Inspection: Caries / Erosion / Fracture
• Palpation: WNL
• Percussion: WNL
• X-­‐Ray: Caries in dentin / Fracture
• Treatment
• Remove cause, maintain the vitality of
• the pulp

6 Contraindications for Pulpotomy
7 Instruments Needed

8 Technique
• Profound anesthesia for tooth and tissue.
9
10 Technique
• A rubber dam is a customized rubber sheet that fits over teeth held by a clamp and frame.
Bacteria from the saliva will not get inside the teeth. This will provide an easier time cleaning
out the bacteria and decay from inside the tooth.
The patient is protected from debris or tiny instruments being swallowed.
11 Technique
• Amputate coronal pulp.
• This is done by a round bur or
• a spoon excavator.
12 Technique

13 Technique
• Apply dry cotton pellet to get hemostasis for 3-­‐5 minutes.
14 Technique
15 Technique
• Apply dampened formocresol pellet for 5 minutes to “mummify” or fix tissue.
• Pulp stumps should appear dry after removing the cotton pellet.
16 Technique
17 Restore
• Place IRM in amputated pulp space. Make sure to condense so the IRM fills the coronal chamber
completely.
18 Restore
19 Restore
• The elective type of restoration after a pulpotomy is a Stainless Steel Crown.
20 Before & After Treatment Radiographs

21 Before & After Treatment Radiographs

22 Follow up of Pulpotomized Primary Teeth
• Clinical and radiographic periodic observation of pulpotomized tooth are required.
23 Works Cited
• Ravel, Daniel. September 1995. “Pediatric Dental Health”. Retrieved from
http://dentalresource.org/topic58pulpotomypulpectomy.html.
• Pinkham, J.R., et al, 1999. Pediatric Dentistry: Infancy Through Adolescence, 3rd edition.
1 Stainless Steel Crown
on Primary Teeth
2 Definition
• Stainless Steel Crowns-­‐ Silver colored crowns often used to restore heavily damaged primary
teeth. A very sturdy restoration, and the teeth are shed normally in most cases. Also used as

interim restorations for adult molars when a permanent crown isn't feasible at the time.
• Generally considered superior to large multisurface amalgam restorations
• Longer clinical lifespan than two or three surface amalgam restorations
• Manufactured in different sizes as a metal shell with some preformed anatomy and are
trimmed and contoured as necessary to fit individual teeth
3 Indications for SSC
• Failure of other available restorative materials is likely to occur prior to the exfoliation of the
tooth
• Interproximal decay that extends into the dentin
• Significant, observable cervical decalcification
• Significant, observable developmental defects such as hypoplasia and hypocalcification
• Following pulpotomy or pulpectomy procedure
4 Indications for SSC, cont’d:
• Restoring a primary tooth that is to be used as an abutment for a space maintainer
• Fractured tooth
• Restoration of teeth with hereditary anomalies such as dentinogenesis imperfecta or
amelogenesis imperfecta
• Restoration in disabled people or others in which oral hygiene is poor and failure of other
materials is probable
5 Contraindications for SSC
• Decay is minimal and a class II restoration is more appropriate
• Tooth is deemed unrestorable due to extensive decay
• Tooth is going to exfoliate within a year
6 Procedure
• Evaluate preoperative occlusion
o
Note the cusp-­‐fossa relationship bilaterally

7 Procedure
• Anesthesia for tooth and surrounding soft tissue
8 Procedure
• Place rubber dam
9 Procedure
• Remove decay from tooth
o
Decay removed with a large, round bur in the slow-­‐speed handpiece or with a spoon
excavator
10 Crown Preparation
• Reduce occlusion 1.5mm with diamond bur on high-­‐speed handpiece
11 Crown Preparation
• Break proximal contact with adjacent teeth
• Contact must be broken both gingivally and buccolingually
o
This is done with a tapered diamond bur in the high-­‐speed handpiece
12 Crown Preparation
• Gingival proximal margin should have a feather-­‐edge finish line
• Round all line angles
13 Procedure
• Select proper size stainless steel crown
o
o
The proper size is the smallest crown that fits the tooth
The crown margins should be 1mm subgingival
14 Occlusion
• Establish preliminary occlusal relationship
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Compare crown to adjacent marginal ridges

• When seating crown, if blanching occurs, the crown is too long or is grossly overcontoured
o
o
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Use sharp instrument to lightly mark gingival crest on crown
Remove crown and trim to 1mm below the mark on the crown with crown and
bridge scissors or a heatless wheel on the slow-­‐speed handpiece
Polish crown with rubber wheel to ensure smoothness and no rough edges
15 SSC Adjustment
(if there is blanching –lingual…. Touch up the crown dimensions with finishing burs and wheels…etc)
16 SSC Adjustment
17 Contour Crown
• Contour and crimp the crown to form a tightly fitting crown
• Firm resistance should be encountered when the crown is seated
18 Occlusion
• Remove rubber dam to do the final check of occlusion
o
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Examine occlusion bilaterally when patient is in centric occlusion
Re-­‐check for gingival blanching
19 Cement Crown
• Rinse and dry both crown and tooth
• Place 2x2 inch gauze pad posterior to crown prep to prevent crown from dropping into
oropharynx
• Fill crown 2/3 full with cement
o
Glass ionomer or polycarboxylate cement work well
20 Cement Crown
• Use crown/band pusher to ensure complete seating
• Have the patient bite down to assure that the occlusion has not been altered.

21 Cement Crown
• Remove cement from gingival sulcus
• Floss through contacts
o
Tie knot in floss and floss down through contacts and slide floss out
22 Post-­‐op Instructions
• Explain to both parent and patient that the child is still numb and that they should not bite
or pull on tissues under anesthesia
• Give modified diet instructions
o
Child must stay away from sticky foods to avoid pulling stainless steel crown off
23 References
• Pinkham, J.R., et al, 1999. Pediatric Dentistry: Infancy Through Adolescence, 3rd edition.
1 Maintenance of a Single Space With Band and Loop
2 The Purposes of Band and Loop

• To maintain space…
• When there is a missing primary molar unilaterally.
• When there are missing lower primary molars bilaterally and when the lower permanent incisors have not eru
permanent incisors are not present.
3 The Purposes of Band and Loop
• As a result:
• Space will be maintained to prevent malocclusion such as ectopic eruption
• Impaction of first or second premolars will be prevented due to the mesial drift of primary second molar or pe
4 Indications of Space Maintainer
• Some indications (in order of frequency):
• Premature loss of primary tooth
• Class I malocclusion
• No permanent tooth to replace primary tooth and space maintenance is desired
• Some class II and III
• Ectopic eruption
5 How is Space Lost Prematurely
• Some examples of premature loss of primary teeth leading to loss of space:
• Trauma
• Severe decay that requires extraction
• Missing primary teeth at birth
• Ankylosis
• Some diseases or conditions, including hypophosphatasia, diabetes and aggressive periodontitis
6 Some Types of Band and Loop Space Maintainers
• Bond the band directly on abutment tooth
• Bond the band directly on stainless steel crowned abutment tooth

7 How to Choose the Correct Band
• Choose the band that conforms to the anatomy of the tooth.
• The band should fit the tooth tightly (finger pressure seating indicates loose fitting band).
• Use band seater to seat the band (1 mm below marginal ridges).
• Lack of interproximal space between teeth will require spacers for 7-­‐10 days before fitting the band.
8 So Many Sizes!!!
9 Band and Loop Procedures (Laboratory Fabrication)
• Choose a band that fits abutment tooth tightly
• Seat the band(s) and take an impression of the quadrant or arch
• Remove the bands intra-­‐orally and place them accordingly into the impression
• Put a staple or wire above the band to prevent movement when pouring up the impression with stone mixtur
10 Band and Loop Procedures (Laboratory Fabrication)
• Pour the impression with yellow stone and remove the wire from the impression before the model completel
stone)
• Separate the impression from stone after 45 minutes
11 Yellow Stone Model with Band in Place
• Occlusal view of band around the yellow stone model
12 Band and Loop Bending Procedures
•
• Instruments Needed:
Wire (0.030)
• Wire cutters
Band remover
Band seater
3-­‐prong plier

Birdbeak plier
13 Band and
Loop Bending Procedures
• 3 Prong pliers for contour
14 Band and Loop Bending Procedures
15 Band and Loop Bending Procedures
16 Band and Loop Bending Procedures
17 Band and Loop Bending Procedures
18 Incorrect and Correct Contour and Adaptation of Band and Loop
19 Pre-­‐soldered Band and Loop with White Plaster
20 Soldering Materials
21 Soldering Method
•
• Clean the band and the metal solder pieces with alcohol.
• Place one tiny drop of flux on top of band (flux will dissolve and absorb oxides. Oxides can prevent metal piece
• Place a piece of metal solder on top of the band and then a drop of flux on top of the solder piece again (as pi
• Heat the metal solder piece. It will form a ball and spread out to cover the entire loop surface (DO NOT REMO
ELSE IT WOULD NOT SOLDER THE TWO METALS TOGETHER!)
22 Soldered Band and Loop Post-­‐heating
23 The Model After Removal of Space Maintainer
24 Polishing of Space Maintainer
25 Criteria of a Polished Space Maintainer

26 What do you do after you polished it to a high shine?
27 What do you do after you polished it to a high shine?
28 When to Remove Space Maintainer
• Remove space maintainer when permanent tooth erupts through the gingiva.
• Over-­‐retained space maintainer prevents eruption of the premolars.
29 References
• Pinkham et al. Pediatric Dentistry:Infancy Through Adolescence. Third Edition, 1999.
• Dr. Claudia Lopez lecture notes at University of Missouri-­‐Kansas City Dental School
• http://www.aapd.org/upload/articles/croll-­‐21-­‐02.pdf
• http://www.colgate.com/app/Colgate/US/OC/Information/ToothWhiteningCosDent/Orthodontics/Orthodont
• http://www.columbia.edu/itc/hs/dental/d7710/client_edit/space-­‐mgmt.pdf
• http://cudental.creighton.edu/HTM/P_bls.htm
• http://www.smilebright.org/spacemaintainer.htm
30 Other Related Links
• http://www.appliancetherapy.com/Global_Center/
• http://www.colgate.com/app/Colgate/US/OC/Information/ToothWhiteningCosDent/Orthodontics/Orthodont
• http://cudental.creighton.edu/Lectures/bls_files/frame.htm
• http://www.dentalgentlecare.com/space_maintainer.htm
• http://www.denovodental.com/PDF/Catalog/
• http://dentapreg.com/en/doctors-­‐and-­‐technicians/pediatric/

• http://www.thejcdp.com/issue026/pdfs_web/yilmaz.pdf