4 - Clinical Practice Guidelines - Part 2

Question 1

What should be included in the decision for when to restore carious lesions?

Answer 1

Decisions for when to restore carious lesions should include at least clinical criteria of:

1. Visual detection of enamel cavitation.
2. Visual identification of shadowing of the enamel.
3. Radiographic recognition of enlargement of lesions over time.

Question 2

What are the benefits and risks of restorative therapy?

Answer 2

Benefits:

1. Removing cavitations or defects to eliminate areas that are susceptible to caries.
2. Stopping the progression of tooth demineralization.
3. Restoring the integrity of tooth structure.
4. Preventing the shifting of teeth due to loss of tooth structure.

Risks:

1. Lessening the longevity of teeth by making them more susceptible to fracture
2. Recurrent lesions.
3. Restoration failure.
4. Pulp exposures during caries excavation.
5. Future pulpal complications.
6. Iatrogenic damage to adjacent teeth.

Question 3

With regard to the treatment of deep caries, what are the three methods of caries removal that have been compared to complete excavation?

Answer 3

1. Stepwise excavation - a two-step caries removal process in which carious dentin is partially removed at the first appointment, leaving caries over the pulp, with placement of a temporary filling. At the second appointment, all remaining carious dentin is removed and a final restoration placed.
2. Partial - one-step caries excavation, removes part of the carious dentin, but leaves caries over the pulp, and subsequently places a base and final restoration.
3. No removal of caries before restoration of primary molars in children aged 3 to 10 years also has been reported.

Question 4

What is the benefit of incomplete caries excavation?

Answer 4

1. Pulp exposures in primary and permanent teeth are significantly reduced using incomplete caries excavation compared to complete excavation in teeth with a normal pulp or reversible pulpitis.
2. There is evidence of a decrease in pulpal complications and post-operative pain after incomplete caries excavation compared to complete excavation.
3. The risk for permanent restoration failure was similar for incompletely and completely excavated teeth.
4. With regard to the need to reopen a tooth with partial excavation of caries, there is no need to reopen the cavity and perform a second excavation.
5. No excavation can arrest dental caries so long as a good seal of the final restoration is maintained.

Question 5

Pit and fissure caries accounts for what percent of all caries in posterior teeth?

Answer 5

Pit and fissure caries accounts for approximately 80-90% of all caries in permanent posterior teeth and 44% in primary teeth.

Question 6

How long does protection from caries last?

Answer 6

Sealants placed on the occlusal surface of permanent molars in children and adolescents reduced caries up to 48 months when compared to no sealant.

Question 7

What percent reduction in caries occurs with sealants?

Answer 7

Placement of resin-based sealant in children and adolescent reduces caries incidence of 86% after one year and 57% at 48 to 54 months.

Question 8

What can the success rate of sealants be with recall and maintenance?

Answer 8

80-90% after 10 or more years.

Question 9

How much reduction in viable bacteria does sealants reduce?

Answer 9

Pit and fissure sealants lower the number of viable bacteria, including Streptococcus mutans and lactobacilli by at least 100-fold and reduced the number of lesions with any viable bacteria by about 50%

Question 10

Should sealants be placed even if follow-up cannot be ensured?

Answer 10

Yes. Caries risk for sealed teeth that have lost some or all sealant does not exceed the caries risk for never-sealed teeth. Therefore, it has been recommended to provide sealants to children even if follow-up cannot be ensured.

Question 11

Should you do anything to the tooth before sealant placement?

Answer 11

1. Do not mechanically prepare the tooth.
   - -There is limiting and conflicting evidence to support mechanical preparation with a bur prior to sealant placement, and it is not recommended.
   - -There is evidence that mechanical preparation may make a tooth more prone to caries in case of resin-based sealant loss.
2. Clean the tooth with tooth brush or hand piece prophylaxis.
   - -Teeth cleaned prior to sealant application with a tooth brush prophylaxis exhibited similar or higher success rate compared to those sealed after hand piece prophylaxis.

Question 12

What kind of primer should be used for sealants?

Answer 12

1. Acetone or ethanol solvent based primers, especially the single bottle system, enhanced the retention of sealants, whereas water-based primers were found to drastically reduce the retention of sealants.
2. A low-viscosity hydrophilic material bonding layer, as part of or under the actual sealant, is better for long-term retention and effectiveness.

Question 13

Compare glass ionomer sealants vs. resin sealants?

Answer 13

Glass ionomer sealants exhibited good short term retention comparable with resin sealants at one year, and may be used as an interim preventive agent when resin-based sealant cannot be placed as moisture control may compromise such placement.

Question 14

Should sealants be placed on primary teeth?

Answer 14

There is insufficient data to support use of fissure sealant in primary teeth.

Question 15

What is the goal of the resin infiltration?

Answer 15

The aim of the resin infiltration technique is to allow penetration of a low viscosity resin into the porous lesion body of enamel caries.

• -Resin infiltration is used to arrest the progression of non-cavitated interproximal caries lesions.
• -Resin infiltration has a potential consistent benefit in slowing the progression or reversing non-cavitated carious lesions.

Question 16

What is resin infiltration used for?

Answer 16

1. Treatment option for small, non-cavitated interproximal carious lesions in permanent teeth.
2. Restore white spot lesions formed during orthodontic treatment.

Question 17

What are the components in amalgam?

Answer 17

Amalgam contains a mixture of metals such as silver, copper, and tin, in addition to approximately 50% mercury.

Question 18

Describe the safety of amalgam?

Answer 18

1. There is insufficient evidence of associations between mercury release from dental amalgam and the various medical complaints.
2. There is no effect on the central and peripheral nervous systems and kidney function.
3. However, the FDA issued a “final rule” that reclassified dental amalgam to a Class II device (having some risk) and designated guidance that included warning labels regarding:
   - -Possible harm of mercury vapors
   - -Disclosure of mercury content
   - -Contraindications for persons with known mercury sensitivity
4. The FDA noted that there is limited information regarding dental amalgam and the long-term health outcomes in pregnant women, developing fetuses, and children under the age of six.

Question 19

How long should amalgam last in primary molars?

Answer 19

Amalgam should be expected to survive a minimum of 3.5 years and potentially in excess of 7 years.

Question 20

What can be attributed to the difference in success rates of Class II amalgams vs Class II composites in permanent teeth?

Answer 20

Higher replacement rates of composite in general practice settings can be attributed partly to general practitioners’ confusion of marginal staining for marginal caries and their subsequent premature replacements.
–The median success rate of composite and amalgam are statistically equivalent after ten years, at 92% and 94% respectively.

Question 21

What is the importance of the filler particle size in composites?

Answer 21

1. The smaller particle size allows greater polishability and esthetics.
2. The larger particle size provides strength.

-Flowable resins have a lower volumetric filler percentage than hybrid resins.

Question 22

What factors contribute to the longevity of resin composites?

Answer 22

1. Operator experience
2. Restoration size
3. Tooth position

Question 23

What dental materials is BPA found in?

Answer 23

Bisphenol A (BPA) and its derivatives are components of resin-based dental sealants and composites.

Question 24

How does BPA enter the body?

Answer 24

Trace amounts of BPA derivatives are released from dental resins through salivary enzymatic hydrolysis and may be detectable in saliva up to 3 hours after resin placement.

Question 25

What are the health risks with BPA?

Answer 25

Certain BPA derivatives may pose health risk attributable to their estrogenic properties.

Question 26

How do you reduce BPA exposure?

Answer 26

1. BPA exposure reduction is achieved by cleaning filling surfaces with pumice, cotton roll, and rinsing.
2. Additionally, potential exposure can be reduced by using a rubber dam.

-Considering the proven benefits of resin based dental materials and minimal exposure to BPA and its derivatives, it is recommended to continue using these products while taking precautions to minimize exposure.

Question 27

Describe the success rate in Class II composite and amalgam restorations in permanent molars?

Answer 27

1. In permanent molars, composite replacement after 3.4 years was no different than amalgam, but after 7-10 years the replacement rate was higher for composite.
2. Secondary caries rate was reported as 3.5 times greater for composite versus amalgam.

Question 28

How can you decrease marginal staining and detectable margins in composite restorations?

Answer 28

Etching and bonding of enamel and dentin significantly decreases marginal staining and detectable margins in composite restorations.

Question 29

What types of composites have better clinical performance?

Answer 29

Regarding different types of composites (packable, hybrid, nano, macro, and micro filled) there is strong evidence showing similar overall clinical performance for these materials.

Question 30

How does the new glass ionomer materials compare with the old glass ionomer materials?

Answer 30

1. Originally, glass ionomer materials were difficult to handle, exhibited poor wear resistance, and were brittle.
2. Advancements in conventional glass ionomer formulation led to better properties, including the formation of resin-modified glass ionomers. These products showed improvement in handling characteristics, decreased setting time, increased strength and improved wear resistance.

Question 31

What are the properties in glass ionomers that make them favorable for use in children?

Answer 31

1. Chemical bonding to both enamel and dentin.
2. Thermal expansion similar to that of tooth structure.
3. Biocompatibility.
4. Uptake and release of fluoride.
5. Decreased moisture sensitivity when compared to resins.

Question 32

How long can fluoride release occur in glass ionomers?

Answer 32

Fluoride release can occur for at least one year.

Question 33

How long do conventional glass ionomers last in primary teeth?

Answer 33

1. Regarding use of conventional glass ionomers in primary teeth, the overall median time from treatment to failure of glass ionomer restored teeth was 1.2 years.
2. Based on findings of a systematic review and meta-analysis, conventional glass ionomers are not recommended for Class II restorations in primary molars.
3. Conventional glass ionomer restorations have other drawbacks such as poor anatomical form and marginal integrity.

Question 34

When can you do resin modified glass ionomer cements (RMGIC)?

Answer 34

1. A systematic review supports the use of RMGIC in small to moderate sized Class II cavities.
2. Class II RMGIC restorations are able to withstand occlusal forces on primary molars for at least one year.
3. In general, there is insufficient evidence to support the use of RMGIC as long-term restorations in permanent teeth.

Question 35

What can you not do to the prep for RMGIC?

Answer 35

Cavosurface beveling leads to high marginal failure in RMGIC restorations and is not recommended.

Question 36

When do you do an ITR?

Answer 36

1. Very young pts
2. Uncooperative pts
3. Pts with special health care needs for whom traditional cavity preparation and/or placement of traditional dental restorations are not feasible or need to be postponed.
4. Caries control in children with multiple open carious lesions, prior to definitive restoration of the teeth.

Question 37

Does carious dentin affect the retention of glass ionomer cements?

Answer 37

In-vitro caries-affected dentin does not jeopardize the bonding of glass ionomer cements to the primary tooth dentition.

Question 38

When is ART used?

Answer 38

ART is a means of restoring and preventing caries in populations that have little access to traditional dental care and functions as definitive treatment.

Question 39

How successful is ART?

Answer 39

1. Single surface ART restorations show high survival rates in both primary and permanent teeth.
   - -Based on a meta-analysis, ART restorations presented similar survival rates to conventional approaches suing composite or amalgam fro Class II restorations in primary teeth.
   - -However, another meta-analysis showed that multi-surface ART restorations in primary teeth exhibited high failure rates.
2. With regard to multi-surface ART restorations, there is conflicting evidence.

Question 40

What are compomers composed of?

Answer 40

They contain 72% (by weight) strontium fluorosilicate glass and the average particle size is 2.5 micrometers.

Question 41

When can compomers be used?

Answer 41

1. Compomers can be used as an alternative to other restorative materials in Class I and Class II primary tooth restorations.
   - -Class I - the longevity of Class I compomer restorations in primary teeth was not statistically different compared to amalgam, but compomers were found to need replacement more frequently due to secondary caries.
   - -Class II - the risk of developing secondary caries and failure did not increase over a two-year period in primary molars.
2. There is not enough data comparing compomers to other restorative materials in permanent teeth of children.

Question 42

Compare compomers to composite and glass ionomers?

Answer 42

1. Composites - compomers have reported comparable clinical performance to composite with respect to color matching, cavosurface discoloration, anatomical form and marginal integrity and secondary caries.
2. Glass ionomers - compomers tends to have better physical properties compared to glass ionomer and resin modified glass ionomer cements in primary teeth, but no significant difference was found in cariostatic effects of compomer compared to these materials.

Question 43

What are the indications for preformed metal crowns (also known as stainless steel crowns)?

Answer 43

Indications:

1. Extensive caries
2. Cervical decalcification
3. Developmental defects (e.g., hypoplasia, hypocalcification)
4. When failure of other available restorative materials is likely (e.g., interproximal caries extending beyond line angles, pts with bruxism)
5. Following pulpotomy or pulpectomy
6. Restoring a primary tooth that is to be used as an abutment for a space maintainer
7. For the intermediate restoration of fractured teeth
8. For definitive restorative treatment for high caries-risk children
9. Used more frequently in pts whose treatment is performed under sedation or general anesthesia

Question 44

What are the evidence regarding preformed metal crowns and intracoronal restorations?

Answer 44

There are very few prospective randomized clinical trials comparing outcomes for preformed metal crowns to intracoronal restorations.

Question 45

What are the gingival health considerations regarding preformed metal crowns?

Answer 45

Inadequately contoured crown and residues of set cement remaining in contact with the gingival sulcus are suggested as reasons for gingivitis associated with preformed metal crowns, and a preventive regime including oral hygiene instruction is recommended to be incorporated into the treatment plan.

Question 46

What are the main reasons for preformed meal crown failure?

Answer 46

Crown loss and perforation.

Question 47

Why are estethci restorations of primary anterior teeth challenging?

Answer 47

1. The small size of the teeth
2. Close proximity of the pulp to the tooth surface
3. Relatively thin enamel
4. Lack of surface area for bonding
5. Issues related to child behavior

Question 48

How are Class III (interproximal) restorations of primary incisors done?

Answer 48

Often prepared with labial or lingual dovetails to incorporate a large surface area for bonding to enhance retention.

Question 49

How are Class V restorations (cervical) of primary incisors done?

Answer 49

1. Cavity preparations are similar to those in permanent teeth.
2. Due to the young age of children treated and associated behavior management difficulty, it is sometimes impossible to isolate teeth for the placement of composite restorations.
   - -In these cases, glass ionomer cement or resin-modified glass ionomer cement is suggested.

Question 50

When are full coronal restoration of carious primary incisors indicated?

Answer 50

May be indicated when:

1. Caries is present on multiple surfaces
2. The incisal edge is involved
3. There is extensive cervical decalcification
4. Pulpal therapy is indicated
5. Caries may be minor but oral hygiene is very poor
6. The child’s behavior makes moisture control very difficult

Question 51

What factors can indicate a clinical diagnosis of irreversible pulpitis or necrosis?

Answer 51

1. History of spontaneous unprovoked toothache
2. A sinus tract
3. Soft tissue inflammation not resulting from gingivitis or periodontitis
4. Excessive mobility not associated with trauma or exfoliation
5. Furcation/apical radiolucency
6. Radiographic evidence of internal/external resorption

Question 52

What factors can indicate a clinical diagnosis of normal pulp requiring pulp therapy or reversible pulpitis?

Answer 52

1. Provoked pain of short duration relieved with over-the-counter analgesics, by brushing, or upon the removal of the stimulus and without signs or symptoms of irreversible pulpitis.

Question 53

When do you extract a tooth after pulp therapy?

Answer 53

Extraction should be considered when:

1. The infectious process cannot be arrested by pulp therapy.
2. Bony support cannot be regained.
3. Inadequate tooth structure remains for a restoration.
4. Excessive pathologic root resorption exists.

Question 54

When do you follow up after pulp therapy?

Answer 54

1. Post-operative clinical assessment generally should be performed every six months and could occur as part of a pt’s periodic comprehensive oral examinations.
   - -Pts treated for an acute dental infection initially may require more frequent clinical reevaluation.

Question 55

When do you take a radiograph after pulp therapy?

Answer 55

1. A radiograph of a primary tooth pulpectomy should be obtained immediately following the procedure to document the quality of the fill and to help determine the tooth’s prognosis.
   - -This image also would serve as a comparative baseline for future films (the type and frequency of which are at the clinician’s discretion).
2. Radiographic evaluation of primary tooth pulpotomies should occur at least annually bc the success rate of pulpotomies diminishes over time.
   - -Bitewing radiographs obtained as part of the pt’s periodic comprehensive examinations may suffice.
   - -If a bitewing radiograph does not display the interradicular area, a periapical image is indicated.
3. Pulp therapy for immature permanent teeth should be reevaluated radiographically 6 and 12 months after treatment and then periodically at the discretion of the clinician.
4. For any tooth that has undergone pulpal therapy, clinical signs and/or symptoms may prompt a clinician to select a more frequent periodicity of reassessment.

Question 56

What endodontic procedures are not indicated for primary teeth?

Answer 56

Apexification, reimplantation of avulsions, and placement of prefabricated post and cores are not indicated for primary teeth.

Question 57

What are the objectives of using a liner in primary and permanent tooth restorations?

Answer 57

Objectives:

1. Preserve the tooth’s vitality
2. Promote pulp tissue healing
3. Promote tertiary dentin formation
4. Minimize bacterial microleakage

Question 58

Why should you place something over calcium hydroxide when doing an IPT?

Answer 58

If calcium hydroxide is used, a glass ionomer or reinforced zinc oxide/eugenol material should be placed over it to provide a seal against microleakage since calcium hydroxide has a high solubility, poor seal, and low compressive strength.

Question 59

Is it necessary to reenter the tooth to remove the residual caries in a primary tooth IPT?

Answer 59

Current literature indicates that there is no conclusive evidence that it is necessary to reenter the tooth to remove the residual caries.
–As long as the tooth remains sealed from bacterial contamination, the prognosis is good for caries to arrest and reparative dentin to form to protect the pulp.

Question 60

Which is better in primary teeth, IPT or pulpotomy?

Answer 60

1. Indirect pulp capping has been shown to have a higher success rate than pulpotomy in longer term studies.
   - -It also allows for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis.

Question 61

When do you do a direct pulp cap in a primary tooth?

Answer 61

1. This procedure is indicated in a primary tooth with a normal pulp following a small mechanical or traumatic exposure when conditions for a favorable response are optimal.
2. Direct pulp capping of a carious pulp exposure in a primary tooth is not recommended.

Question 62

What is the most effective long-term restoration after a primary tooth pulpotomy?

Answer 62

The most effective long-term restoration has been shown to be a stainless steel crown.
–However, if there is sufficient supporting enamel remaining, amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of 2 years or less.

Question 63

What should you see in a radiograph after a primary tooth pulpotomy?

Answer 63

1. There should be no postoperative radiographic evidence of pathologic external root resorption.
2. Internal root resorption may be self-limiting and stable. The clinician should monitor the internal resorption removing the affected tooth if perforation causes loss of supportive bone and/or clinical signs of infection and inflammation. There should be no harm to the succedaneous tooth.

Question 64

What kind of irrigation and disinfection is necessary in a primary tooth pulpectomy?

Answer 64

1. Since instrumentation and irrigation with an inert solution alone cannot adequately reduce the microbial population in a root canal system, disinfection with irrigants such as 1% sodium hypochlorite and/or chlorhexidine is an important step in assuring optimal bacterial decontamination of the canals.
   - -Bc it is a potent tissue irritant, sodium hypochlorite must not be extruded beyond the apex.
2. After the canals are dried, a resorbable material such as nonreinforced zinc/oxide eugenol, iodoform-based paste (KRI) or a combination paste of iodoform and calcium hydroxide (Vitapex, Endoflax) is used to fill the canals.

Question 65

When should you expect to see improvement after a primary tooth pulpectomy?

Answer 65

Following treatment, the radiographic infectious process should resolve in 6 months, evidenced by bone deposition in the pretreatment radiolucent areas, and pretreatment clinical signs and symptoms should resolve within a few weeks.

Question 66

How can you induce apexogenesis (root formation) in a young permanent tooth?

Answer 66

Formation of the apex in vital, young, permanent teeth can be accomplished by implementing the appropriate vital pulp therapy (i.e., indirect pulp treatment, direct pulp capping, partial pulpotomy for carious exposures and traumatic exposures).

Question 67

Should an IPT in a permanent tooth be completed in one step or two steps?

Answer 67

1. In recent years, rather than complete the caries removal in two appointments, the focus has been to excavate as close as possible to the pulp, place a protective liner, and restore the tooth without a subsequent reentry to remove any remaining affected dentin.
   - -The risk of this approach is either an unintentional pulp exposure or irreversible pulpitis.
2. More recently, the step-wise excavation of deep caries has been revisited and shown to be successful in managing reversible pulpits without pulpal perforation and/or endodontic therapy.
   - -This approach involves a two-step process. The first step is the removal of carious dentin along the dentin-enamel junction (DEJ) and excavation of only the outermost infected dentin, leaving a carious mass over the pulp. The objective is to change the cariogenic environment in order to decrease the number of bacteria, close the remaining caries from the biofilm of the oral cavity, and slow or arrest the caries development. The second step is the removal of the remaining caries and placement of a final restoration.
3. Critical to both steps of excavation is the placement of a well-sealed restoration. The decision to use a one-appointment caries excavation or a step-wise technique should be based on the individual patient circumstances since the research available is inconclusive on which approach is the most successful over time.

Question 68

In the two step IPT, what is the time interval between the steps?

Answer 68

The most common recommendation for the interval between steps is 3 to 6 months, allowing sufficient time for the formation of tertiary dentin and a definitive pulpal diagnosis.

Question 69

Describe the partial pulpotomy procedure for carious exposures?

Answer 69

1. The partial pulpotomy for carious exposures is a procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of 1-3 mm or deeper to reach healthy pulp tissue.
2. Pulpal bleeding must be controlled by irrigation with a bacteriocidal agent such as sodium hypoochlorite or chlorhexidine before the site is covered with calcium hydroxide or MTA.

Question 70

Which is better for a partial pulpotomy procedure (for both carious and traumatic exposures), calcium hydroxide or MTA?

Answer 70

1. While calcium hydroxide has been demonstrated to have long-term success, MTA results in more predictable dentin bridging and pulp health.
2. MTA (at least 1.5 mm thick) should cover the exposure and surrounding dentin followed by a layer of light cured resin-modified glass ionomer. A restoration that seals the tooth from microleakage is placed.

Question 71

What is the partial pulpotomy for traumatic exposures (Cvek pulpotomy)?

Answer 71

The partial pulpotomy for traumatic exposures is a procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of 1-3 mm or more to reach the deeper healthy tissue. Pulpal bleeding is controlled using bacteriocidal irrigants such as sodium hypochlorite or chlorhexidine, and the site then is covered with calcium hydroxide or MTA.

Question 72

What is better for a partial pulpotomy is anterior teeth, white or gray MTA?

Answer 72

1. White, rather than gray, MTA is recommended in anterior teeth to decrease the chance of discoloration.
   - -The two versions have been shown to have similar properties.

Question 73

What are the factors for success of a partial pulpotomy for traumatic exposures?

Answer 73

Neither time between the accident and treatment nor size of exposure is critical if the inflamed superficial pulp tissue is amputated to healthy pulp.

Question 74

For an apexification procedure, what do you do if you do root end closure does not happen?

Answer 74

In instances when complete closure cannot be accomplished by MTA, an absorbable collagen wound dressing (e.g., Colla-Cote) can be placed at the root end to allow MTA to be packed within the confines of the root canal space. Gutta percha is used to fill the remaining canal space.

Question 75

For an apexification procedure, what do you do if the canal walls are thin causing the tooth to be prone to fracture?

Answer 75

If the canal walls are thin, the canal space can be filled with MTA or composite resin instead of gutta percha to strengthen the tooth against fracture.

Question 76

What are the three major categories of evaluation for diagnostic orthodontic records?

Answer 76

1. Health of the teeth and oral structures.
2. Alignment and occlusal relationships of the teeth.
3. Facial and jaw proportions which includes both cephalometric radiographs and facial photographs.

Question 77

When are non-nutritive sucking behaviors considered normal?

Answer 77

1. Non-nutritive sucking behaviors are considered normal in infants and young children.
2. Early dental visits provide parents with anticipatory guidance to help their children stop sucking habits by age 36 months or younger.

Question 78

What is the etiology of bruxism?

Answer 78

The etiology is multifactorial and has been reported to include:

1. Central factors (e.g., emotional stress, parasomnias, traumatic brain injury, neurologic disabilities).
2. Morphologic factors (e.g., malocclusion, muscle recruitment).

Question 79

What are complications of bruxism?

Answer 79

Reported complications of bruxism include:

1. Dental attrition
2. Headaches
3. Temporomandibular dysfunction
4. Soreness of the masticatory muscles

Question 80

What do you do about juvenile bruxism?

Answer 80

1. Evidence indicates that juvenile bruxism is self-limiting and does not persist in adults.
2. The spectrum of bruxism management ranges from patient/parent education, occlusal splints, and psychological techniques to medications.

Question 81

Does tongue pressure impact tooth position?

Answer 81

1. There is no evidence that intermittent short-duration pressures, created when the tongue and lip contact the teeth during swallowing or chewing, have significant impact on tooth position.
2. If the resting tongue posture is forward of the normal position, incisor displacement is likely, but if resting tongue posture is normal, a tongue mental retardation thrust swallow has no clinical significance.

Question 82

What are the treatment modalities for self-injurious or self-mutilating behavior?

Answer 82

For developmentally disabled individuals, reported dental treatment modalities include:

1. Lip-bumper and occlusal bite appliances
2. Protective padding
3. Extractions

For some habits, such as lip-licking and lip-pulling which are relatively benign in relation to an effect on the dentition.

For the more severe lip and tongue biting habits, management options includes:

1. Monitoring the lesion
2. Odontoplasty
3. Providing a bite-opening appliance
4. Extracting the teeth

Question 83

What can mouth breathing cause?

Answer 83

Research on the relationship between malocclusion and mouth breathing suggests that impaired nasal respiration may contribute to the development of:

1. Increased facial height
2. Anterior open bite
3. Increased overjet
4. Narrow palate

However, it is not the sole or even the major cause of these conditions.

Question 84

What is obstructive sleep apnea associated with?

Answer 84

OSAS may be associated with:

1. Narrow maxilla
2. Crossbite
3. Low tongue position
4. Vertical growth
5. Open bite

Question 85

What is the history associated with obstructive sleep apnea?

Answer 85

History associated with OSAS may include:

1. Snoring
2. Observed apnea
3. Restless sleep
4. Daytime neurobehavioral abnormalities or sleepiness
5. Bedwetting

Question 86

What are the physical findings associated with obstructive sleep apnea?

Answer 86

1. Growth abnormalities
2. Signs of nasal obstruction
3. Adenoidal facies
4. Enlarged tonsils

Question 87

What type of parental behavior may play a negative role in the correction of an oral habit and may result in an increase in habit behaviors?

Answer 87

Nagging or punishment

Question 88

Who can you refer to for an oral habit correction?

Answer 88

1. Orthodontists
2. Psychologists
3. Myofunctional therapists
4. Otolaryngologists

Question 89

What are the most frequently missing permanent teeth?

Answer 89

Third molars > mand PM2 > max LI

Question 90

What are the most frequently missing primary teeth?

Answer 90

Hypodontia occurs less and almost always affects the maxillary incisors and first primary molars.

Question 91

What can you do for a missing maxillary lateral incisor?

Answer 91

1. Move the maxillary canine mesially and use the canine as a lateral incisor.
   - -Moving the canine into the lateral position produces little facial change, but the resultant tooth size discrepancy often does not allow a canine guided occlusion.
2. Create space for a future lateral prosthesis or implant.
   - -Opening space for a prosthesis or implant requires less tooth movement but the space needs to be maintained with an interim prosthesis, especially if an implant is planned.

Question 92

What can you do for a missing premolar?

Answer 92

1. Maintain the primary molar.
2. Extract the primary molar with subsequent placement of a prosthesis or orthodontically closing the space.
   - -In crowded arches or with multiple missing premolars, extraction of the primary molar(s) can be considered, especially in mild Class III cases.
   - -For a single missing premolar, if maintaining the primary molar is not possible, placement of a prosthesis or implant should be considered.

Question 93

Why can maintaining the primary molar in congenitally missing premolar cases cause problems?

Answer 93

1. Maintaining the primary second molar may cause occlusal problems due to its larger mesiodistal diameter, compared to the second premolar.
   - -Reducing the width of the second primary molar is a consideration, but root resorption and subsequent exfoliation may occur.
2. Preserving the primary tooth may be indicated in certain cases. However, maintaining a submerged ankylosed tooth may increase likelihood of alveolar defect which can compromise later implant success. Consideration for extraction and space maintenance may be indicated.

Question 94

What are the differences in incidences of supernumerary teeth in the primary and permanent dentition?

Answer 94

1. Supernumerary teeth are five times more common in the permanent dentition.
2. A supernumerary primary tooth is followed by a supernumerary permanent tooth in one third of the cases.

Question 95

Where do most supernumerary teeth occur?

Answer 95

1, 80-90% of all supernumeraries occur in the maxilla.

2. Half occur in the anterior area.
3. Almost all in the palatal position.

Question 96

What percent of mesiodens erupt spontaneously?

Answer 96

Only 25% of all mesiodens erupt spontaneously. Thus, surgical management often is necessary.

Question 97

What problems can supernumerary teeth cause?

Answer 97

1. Prevent or cause ectopic eruption of the permanent tooth.
2. Cause dilaceration or root resorption of the permanent incisor’s root.
3. Dentigerous cyst formation.
4. Eruption into the nasal cavity.
5. Crowding.
6. Resorption of adjacent teeth.
7. Pericoronal space ossification.
8. Crown resorption.

Question 98

What signs can indicate a supernumerary tooth is present?

Answer 98

1. Asymmetric eruption pattern of the maxillary incisors.
2. Delayed eruption.
3. Overretained primary incisor.
4. Ectopic eruption of an incisor.

Question 99

What is the best radiograph to locate the supernumerary?

Answer 99

Panoramic, occlusal and periapical radiographs all can reveal a supernumerary, but the best way to locate the supernumerary is two periapical or occlusal films reviewed by the parallax rule.

Question 100

What is the treatment for a supernumerary tooth?

Answer 100

Primary supernumerary teeth:

1. Primary supernumerary teeth normally are accommodated into the arch and usually erupt and exfoliate without complications.
   - -The removal of these teeth usually is not recommended, as the surgical intervention may disrupt or damage the underlying developing permanent dentition.

Permanent supernumerary teeth:

1. Extraction of an unerupted supernumerary tooth during the primary dentition usually is not done to allow it to erupt. Surgical extraction of unerupted supernumerary teeth can displace or damage the permanent incisor.
2. Extraction of an unerupted supernumerary during the early mixed dentition allows for a normal eruptive force and eruption of the adjacent normal permanent incisor.
   - -Waiting until the adjacent incisors have at least 2/3 root development will present less risk to the developing teeth but still allow spontaneous eruption of the incisors. Later removal of the mesiodens reduces the likelihood that the adjacent normal permanent incisor will erupt on its own, especially if the apex is completed.
   - -In 75% of cases, extraction of the mesiodens during the mixed dentition results in spontaneous eruption and alignment of the adjacent teeth. If the adjacent teeth do not erupt within 6-12 months, surgical exposure and orthodontic treatment may be necessary to aid their eruption.

Question 101

Extraction of a supernumerary tooth will allow eruption of the other permanent tooth in what percent of cases?

Answer 101

Removal of a mesiodens or other permanent supernumerary incisor results in eruption of the permanent adjacent normal incisor in 75% of cases.

Question 102

What kind of supernumeraries are more problematic?

Answer 102

Better chance for eruption: conical in shape and not inverted.
Worst for eruption: Tubercular in shape and inverted.

Question 103

What is the follow up after extraction of a supernumerary tooth?

Answer 103

After removal of the supernumerary, clinical and radiographic follow-up is indicated in 6 months to determine if the normal incisor is erupting. If there is no eruption after 6-12 months and sufficient space exists, surgical exposure and orthodontic extrusion is needed.

Question 104

Why does the ectopic eruption of the permanent first molar occur?

Answer 104

Ectopic eruption of permanent first molars occurs due to the molar’s abnormal mesioangular eruption path, resulting in an impaction at the distal prominence of the primary second molar’s crown.

Question 105

In what patients do ectopic eruption of permanent molars occur more frequently?

Answer 105

It is more common in children with cleft lip and palate.

Question 106

What can cause ectopic eruption of the maxillary incisors?

Answer 106

1. Impacted from supernumerary teeth.
2. Pulp necrosis (following trauma or caries).
3. Pulpal treatment of the primary incisor.

Question 107

What percent of ectopically erupted permanent molars self-correct?

Answer 107

66% of ectopically erupted permanent molars self-correct by age 7.

Question 108

When do you correct ectopically erupted permanent molars?

Answer 108

1. A permanent molar that presents with part of its occlusal surface clinically visible and part under the distal of the primary second molar usually does not self-correct and is the impacted type.
2. After the age of 7, definitive treatment is indicated to manage and/or avoid early loss of the primary second molar and space loss.

Question 109

What can indicate a maxillary canine impaction?

Answer 109

1. Canine bulge is not palpable
2. Asymmetric canine eruption is evident
3. Peg shaped lateral incisors are present.
4. Panoramic radiographs may demonstrate that the canine has an abnormal inclination and/or overlaps the lateral incisor root.

Question 110

When can you suspect ectopic eruption of permanent incisors?

Answer 110

1. After trauma to primary incisors.
2. Pulpally-treated primary incisors.
3. Asymmetric eruption.
4. Supernumerary incisor is diagnosed.

Question 111

What is the treatment for ectopic eruption of a permanent molar?

Answer 111

For mildly impacted first permanent molars, where little of the tooth is impacted under the primary second molar:
1. Elastic or metal orthodontic separators can be placed to wedge the permanent first molar distally.

For more severe impactions, distal tipping of the permanent molar is required. Tipping action can be accomplished with:

1. Brass wires
2. Removable appliances using springs
3. Fixed appliances such as sectional wires with open coil springs, sling shot-type appliances, a Halterman appliance or surgical uprighting.

Question 112

When should you extract the primary canine in an ectopically erupted permanent canine case?

Answer 112

1. When the canine bulge cannot be palpated in the alveolar process and there is radiographic overlapping of the canine with the formed root of the lateral during the mixed dentition.
2. When the impacted canine is diagnosed at a later age (11 to 16), if the canine is not horizontal, extraction of the primary canine lessens the severity of the permanent canine impaction and 75% will erupt.

Question 113

What can you do to help ectopically erupted canines that are palatally displaced?

Answer 113

The use of rapid maxillary expansion in the early mixed dentition has been shown to increase the rate of eruption of palatally displaced maxillary cuspids.

Question 114

Extraction of what tooth other than the primary canine may help in impacted canine cases?

Answer 114

Extraction of the first primary molar also has been reported to allow eruption of the first bicuspids and to assist in the eruption of the cuspids. This need can be determined from a panoramic radiograph.

Question 115

What periodontal considerations are there for impacted canines after orthodontic treatment?

Answer 115

Long-term periodontal health of impacted canines after orthodontic treatment is similar to nonimpacted canines.

Question 116

When does ankylosis most frequently occur in the permanent dentition?

Answer 116

In the permanent dentition, ankylosis occurs most frequently following luxation injuries.

Question 117

How does ankylosis occur cellularly?

Answer 117

1. Periodontal ligament cells are destroyed and the cells of the alveolar bone perform most of the healing. Over time, normal bony activity results in the replacement of root structure with osseous tissue.
2. Ankylosis can occur rapidly or gradually over time, in some cases as long as five years post trauma.
   - -It also may be transient if only a small bony bridge forms then is resorbed with subsequent osteoclastic activity.

Question 118

What is the treatment for ankylosis?

Answer 118

Primary dentition:

1. No treatment.
   - -With ankylosis of a primary molar, exfoliation usually occurs normally.
2. Extraction.
   - -Extraction is recommended if prolonged retention of the primary molar is noted.
   - -If a severe marginal ridge discrepancy develops, extraction should be considered to prevent the adjacent teeth from tipping and producing space loss.
   - -Extraction can assist in resolving crowded arches in complex orthodontic cases.
3. Restoration.
   - -Mildly to moderately ankylosed primary molars without permanent successors may be retained and restored to function in arches without crowding.

Permanent dentition:

1. Replacement resorption of permanent teeth usually results in the loss of the involved tooth.
2. Surgical luxation of ankylosed permanent teeth with forced eruption has been described as an aleternative to premature extraction.

Question 119

How is arch length in today’s children compared to their parents and grandparents of 50 years ago?

Answer 119

Studies of arch length in today’s children compared to their parents and grandparents of 50 years ago indicate:

1. Less arch length
2. More frequent incisor crowding
3. Stable tooth sizes

-This implies that the problem of incisor crowding and ultimate arch length discrepancies may be increasing in numbers of pts and in amount of arch length shortage.

Question 120

What can impact the functional contacts between mandibular incisors?

Answer 120

1. Growth of the aging skeleton causes further crowding and incisor rotations.
2. Functional contacts are diminished where rotations of incisors, canines and bicuspids exist.

-Occlusal harmony and temporomandibular joint health are impacted negatively by less functional contacts.

Question 121

What is the importance of transseptal fibers in the correction of rotations?

Answer 121

1. Derotation of teeth just after emergence in the mouth implies correction before the transseptal fiber arrangement has been established.
2. It has been shown that the transseptal fibers do not develop until the CEJ of erupting teeth pass the bony border of the alveolar process.

Question 122

When might you consider space maintenance in a child with an active digit habit?

Answer 122

Space maintenance may be a consideration in the primary dentition after early loss of a maxillary incisor when the child has an active digit habit.
–An intense habit may reduce the space for the erupting permanent incisor.

Question 123

What are the adverse effects associated with space maintainers?

Answer 123

1. Dislodged, broken and lost appliances.
2. Plaque accumulation.
3. Caries.
4. Damage or interference with successor eruption.
5. Undesirable tooth movement.
6. Inhibition of alveolar growth.
7. Soft tissue impingement.
8. Pain.

Question 124

What factors are important to consider for space maintenance when a primary tooth is lost prematurely?

Answer 124

1. Specific tooth lost
2. Time elapsed since tooth loss
3. Pre-existing occlusion
4. Favorable space analysis
5. Presence and root development of permanent successor
6. Amount of alveolar bone covering permanent successor
7. Pt’s health status
8. Pt’s cooperative ability
9. Active oral habits
10. Oral hygiene

Question 125

Why is follow-up necessary with space maintainers?

Answer 125

Follow-up of pts with space maintainers is necessary to assess integrity of cement and to evaluate and clean the abutment teeth.

Question 126

What are teh common causes of space loss within an arch?

Answer 126

1. Primary teeth with interproximal caries.
2. Ectopically erupting teeth.
3. Alteration in the sequence of eruption.
4. Ankylosis of a primary molar.
5. Dental impaction.
6. Transposition of teeth.
7. Loss of primary molars without proper space management.
8. Congenitally missing teeth.
9. Abnormal resorption of primary molar roots.
10. Premature and delayed eruption of permanent teeth.
11. Abnormal dental morphology.

Question 127

What are some examples of fixed and removable space regaining appliances?

Answer 127

Examples of fixed space regaining appliances:

1. Active holding arches
2. Pendulum appliances
3. Jones jig

Examples of removable space regaining appliances:

1. Hawley appliance with springs
2. Lip bumper
3. Headgear

Question 128

How can aberrations in bony growth give rise to crossbites?

Answer 128

Skeletal crossbites involve disharmony of the craniofacial skeleton. Aberrations in bony growth may give rise to crossbites in two ways:

1. Adverse transverse growth of the maxilla and mandible.
2. Disharmonious or adverse growth in the sagittal (AP) length of the maxilla and mandible.

-Such growth aberrations can be due to inherited growth patterns, trauma or functional disturbances that alter normal growth.

Question 129

What are the benefits of anterior crossbite correction?

Answer 129

1. Reduce dental attrition
2. Improve dental esthetics
3. Redirect skeletal growth
4. Improve the tooth-to-alveolus relationship
5. Increase arch perimeter

Question 130

When should anterior crossbites be corrected?

Answer 130

1. If enough space is available, a simple anterior crossbite can be aligned as soon as the condition is noted.
   - -Treatment options include acrylic incline planes, acrylic retainers with lingual springs, or fixed appliances with springs.
2. If space is needed, an expansion appliance also is an option.

Question 131

What are the benefits of posterior crossbite correction?

Answer 131

Early correction of unilateral posterior crossbites has been shown to:

1. Improve functional conditions significantly
2. Largely eliminate morphological and positional asymmetries of the mandible.

-Functional shifts should be eliminated as soon as possible with early correction to avoid asymmetric growth.

Question 132

How should Class II malocclusion be corrected?

Answer 132

1. Results of randomized clinical trials indicate that Class II malocclusion can be corrected effectively with either a single or two-phase regimen.
   - -Growth-modifying effects in some studies did not show an influence on the Class II skeletal pattern, while other studies dispute these findings.
2. There is substantial variation in treatment response to growth modification treatments (headgear or functional appliance) and no reliable predictors for favorable growth response have been found.
   - -Some reports state interceptive treatment does not reduce the need for either premolar extractions or orthognathic surgery, while others disagree with these findings.
   - -Two-phase treatment results in significantly longer treatment time.
3. Clinicians may decide to provide interceptive treatment based on other factors.
   - -Evidence suggests that, for some children, interceptive Class II treatment may improve self-esteem and decreases negative social experiences, although the improvement may not be different long-term.

Question 133

Incisor injury is associated with what overjet?

Answer 133

Incisor injury is associated with overjet greater than 3 mm.
–Further, when injury is more severe than simple enamel fractures, increased overjet and prognathic position of the maxilla are more strongly associated.

Question 134

Class III malocclusion may result from what?

Answer 134

This relationship may result from:

1. Dental factors (malposition of the teeth in the arches).
2. Skeletal factors (asymmetry, mandibular prognathism, and/or maxillary retrognathism).
3. Anterior functional shift of the mandible.
4. Combination of these factors.

Question 135

What is the etiology of Class III malocclusions?

Answer 135

Class III malocclusions can be hereditary, environmental, or both.

• -Hereditary factors - clefts of the alveolus and palate, and other craniofacial anomalies that are part of a genetic syndrome.
• -Environmental factors - trauma, oral/digital habits, caries, and early childhood OSAS.

Question 136

What is the treatment for Class III malocclusions?

Answer 136

1. Interceptive Class III treatment has been proposed for years and has been advocated as a necessary tool in contemporary orthodontics.
2. Although interceptive treatment can minimize the malocclusion and potentially eliminate future orthognathic surgery, this is not always possible. Typically, Class III pts tend to grow longer and more unpredictably and, therefore, surgery combined with orthodontics is the best alternative to achieve a satisfactory result for some pts.

Question 137

Disruptions during which levels of development can lead to what anomalies?

Answer 137

1. Disruptions in tooth initiation - hypodontia or supernumerary teeth.
2. Disruptions during morphodifferentiation - anomalies of size and shape (e.g., macrodontia, mcirodontia, taurodontism, dens invaginatus).
3. Disruptions during histodifferentiation, apposition and mineralization - enamel hypoplasia or hypomineralization for AI, DI and DD.

Question 138

What negative consequences can pts and their familes with dental developmental anomalies have?

Answer 138

1. Esthetic concerns that impact self-esteem
2. Masticatory difficulties
3. Tooth sensitivity
4. Financial burdens
5. Protracted, complex dental treatment

• These emotional and physical strains have been demonstrated, showing that persons with AI have fewer long-term relationships and children than nonaffected people.
• Due to extensive treatment needs, a pt may require sedation or general anesthesia for restorative care.

Question 139

What is amelogenesis imperfecta?

Answer 139

Amelogenesis imperfecta is a developmental disturbance that interferes with normal enamel formation in the absence of a systemic disorder.
–In general, it affects all or nearly all of the teeth in both the primary and permanent dentitions.

Question 140

What are the specific gene mutations proven to cause AI?

Answer 140

1. Amelogenin (AMELX)
2. Enamelin (ENAM)
3. Kallikrein4 (KLK4)
4. Enamelysis (MMP-20)
5. FAM83H

Question 141

What are the classification of AI?

Answer 141

The most widely accepted classification of AI includes four types:

1. Hypoplastic
   - -Hypoplastic, pitted - normal thickness, pitted surface, normal hardness.
   - -Hypoplastic, generalized - reduced thickness, smooth surface, normal hardness.
2. Hypomaturation - normal thickness, chipped surface, less hardness, opaque white coloration.
3. Hypocalcified - normal thickness, smooth surface, less hardness.
4. Hypomaturation-hypoplastic with taurodontism - also is associated with tricho-dento-osseous syndrome

Question 142

What are the clinical implications of AI?

Answer 142

1. Accelerated tooth eruption or late tooth eruption
2. Low caries susceptibility
3. Rapid attrition
4. Excessive calculus deposition
5. Gingival hyperplasia

Question 143

What pathologies are associated with AI?

Answer 143

1. Enlarged follicles
2. Impacted permanent teeth
3. Ectopic eruption
4. Congenitally missing teeth
5. Crown and/or root resorption
6. Pulp calcification
7. Agenesis of second molars
8. Although uncommon, enamel resorption and ankylosis have been reported.
9. Incidence of anterior open bite is 50% in hypoplastic AI, 31% in hyopmaturation AI, and 60% in hypocalcified AI.

Question 144

How is AI differentiated from other forms of enamel dysmineralization?

Answer 144

1. Other forms of enamel dysmineralization will exhibit a pattern abased upon the time of insult, thus affecting the enamel forming at the time. In contrast, AI will affect all teeth similarly and can have a familial history.
2. Fluorosis can mimic AI, but usually the teeth are not affected uniformly, often sparing the premolars and second permanent molars. A history of fluoride intake can id in the diagnosis.

Question 145

What systemic hereditary disorder is dentinogenesis imperfecta sometimes seen in conjunction with?

Answer 145

1. DI may be seen alone or in conjunction with the systemic hereditary disorder of the bone, osteogenesis imperfecta.
   - -Children with unexplained bone fracturing should be evaluated for DI as a possible indicator of an undiagnosed case of OI. This is important in helping delineate child abuse from mild or undiagnosed OI.

Question 146

What are the classification systems of DI?

Answer 146

Shields:

1. Dentinogensis Imperfecta I - Osteogensis imperfecta with opalescent teeth.
2. Dentinogensis Imperfecta II - Isolated Dentinogenesis Imperfecta
3. Dentinogensis Imperfecta III - Isolated Dentinogenesis Imperfecta

Witkop:

1. Dentinogenesis Imperfecta - Osteogensis imperfecta with opalescent teeth.
2. Hereditary Opalescent Dentin - Isolated Dentinogenesis Imperfecta
3. Brandywine Isolate - Isolated Dentinogenesis Imperfecta

Question 147

What genes are associated with DI?

Answer 147

1. DI Type I - the diverse mutations associated with COL1A1 and COL1A2 genes can cause the DI phenotype in association with osteogenesis imperfecta (DI type I).
   - -Type I collagen (product of COL1A1 and COL1A2 genes) is the most abundant dentin protein.
2. DI Type II and Type III - autosomal dominant conditions that have been linked to chromosome 4q12-21, suggesting these may be allelic mutations of the DSPP gene encoding dentin phosphoprotein and dentin sialoprotein.

Question 148

What are the clinical manifestations present in all three types of DI?

Answer 148

1. In all three DI types, the teeth have a variable blue-gray to yellow-brown discoloration that appears opalescent due to the defective, abnormally-colored dentin shining through the translucent enamel.
2. Due to the lack of support of the poorly mineralized dentin, enamel frequently fractures from the teeth leading to rapid wear and attrition of the teeth.
3. The severity of discoloration and enamel fracturing in all DI types is highly variable, even within the same family. If left untreated, it is not uncommon to see the entire DI-affected dentition worn to the gingiva.

Question 149

What are the specific clinical manifestations of the three types of DI?

Answer 149

1. Shields Type I (occurs with osteogensis imperfecta)
   - -Primary teeth are affected most severely, followed by permanent incisors and first molars, with the second and third molars being the least altered.
   - -Radiographically - the teeth have bulbous crowns, cervical constriction, thin roots, and early obliteration of the root canal and pulp chambers due to excessive dentin production.
   - -Periapical radiolucencies and root fractures are evident.
   - -Amber translucent color is common.
2. Shields Type II (aka hereditary opalescent dentin)
   - -Both primary and permanent dentitions are equally affected and the characteristics previously described for Type I are the same.
   - -Radiographically - pulp chamber obliteration can begin prior to tooth eruption.
3. Shields Type III - is rare.
   - -Predominant characteristic is bell-shaped crowns, especially in the permanent dentition.
   - -Unlike Types I and II, Type III involves teeth with shell-like appearance and multiple pulp exposures.
   - -Shell teeth demonstrate normal-thickness enamel in association with extremely thin dentin and dramatically enlarged pulps. The thin dentin may involve the entire tooth or be isolated to the root.

Question 150

What are the considerations for differential diagnosis of DI?

Answer 150

1. OI, other collagen disorders and numerous syndromes have DI-like phenotypes associated with them.
2. DD Type I clinically has normal appearing crowns, but radiographically the teeth have pulpal obliterations and short blunted roots.
3. DD Type II has the same phenotype as DI Type II in the primary dentition but normal to slight blue-gray discoloration in permanent dentition.

Question 151

What are the clinical manifestations of Dentin Dysplasia Type I?

Answer 151

1. Dentin Dysplasia Type I (radicular dentin dysplasia; rootless teeth).
   - -The crowns in DD Type I appear mostly normal in color and shape in both the primary and permanent dentitions. Occasionally, an amber translucency is apparent.
   - -The roots tend to be short and sharply constricted. DD Type I has been referred to as “rootless teeth” bc of the shortened root length due to a loss of organization of root dentin.
   - -Wide variation of root formation and pulp formation exists due to the timing of dentinal disorganization.
   - —-With early disorganization, the roots are extremely short or absent and no pulp can be detected.
   - —-With later disorganization, the roots are shortened with crescent or chevron-shaped pulp chambers.
   - —-With late disorganization, typical root lengths exist with pulp stones present in a normal shaped pulp chambers. This variability is most profound in the permanent dentition and can vary for each person and from tooth to tooth in a single individual.
   - -Radiographically, the roots of all teeth in the primary and permanent dentitions are either short or abnormally shaped.
   - —-The primary teeth have obliterated pulps that completely fill in before eruption. The extent of pulp canal and chamber obliteration in the permanent dentition is variable.
   - —-Both the primary and permanent teeth demonstrate multiple periapical radiolucencies. They represent chronic abscesses, granulomas, or cysts. The inflammatory lesions appear secondary to caries or spontaneous coronal exposure of microscopic threads of pulpal remnants present within the defective dentin.

Question 152

What are the clinical manifestations of Dentin Dysplasia Type II?

Answer 152

1. Dentin Dysplasia Type II (coronal dentin dysplasia).
   - -DD Type II demonstrates numerous features of DI.
   - -In contrast to DD Type I, root lengths are normal in both dentitions.
   - -The primary teeth are amber-colored closely resembling DI. The permanent teeth are normal in coloration.
   - -Radiographically, the primary teeth exhibit bulbous crowns, cervical constrictions, thin roots, and early pulp obliteration.
   - -Radiographically, the permanent teeth exhibit thistle-tube shaped pulp chambers with multiple pulp stones; periapical radiolucencies are not present.

Question 153

What are the considerations for differential diagnosis of DD?

Answer 153

1. The first differential diagnosis for DD Type II is DI. The differentiation between DD and DI can be challenging bc these two developmental anomalies form a continuum.
   - -Both DD and DI have amber tooth coloration and obliterated or occluded pulp chambers. However, the pulp chambers do not fill in before eruption in DD Type II.
   - -A finding of thistle-tube shaped pulp chamber in a single-rooted tooth increases the likelihood of DD diagnosis.
   - -The crowns in DD usually are normal in size, shape and proportion while the crowns in DI typically are bell-shaped with cervical constriction.
   - -The roots in DD usually are not present or appear normal while the roots in DI typically are short and narrow.
   - -Association of periapical radiolucencies with non-carious teeth and without obvious cause is an important characteristic of DD Type I.
2. An unrelated disorder with pulpal findings similar to DD Type II is pulpal dysplasia.
   - -This process occurs in teeth that appear clinically normal. Radiographically, pulpal dysplasia exhibits thistle-tube shaped pulp chambers and multiple pulp stones in both the primary and permanent dentitions.

Question 154

What are the restorative treatments for AI?

Answer 154

Esthetics:

1. When the enamel is intact but discolored, bleaching and/or microabrasion may be used to enhance the appearance.
2. If the enamel is hypocalcified, composite resin or porcelain veneers may be able to be retained with bonding. If the enamel or dentin cannot be bonded, full coverage restorations will be required.

Primary dentition:
1. During the primary dentition, it is important to restore the teeth for adequate function and to maintain adequate arch parameters. Primary teeth may require composite or veneered anterior crowns with posterior full coverage steel or veneered crowns.

Permanent dentition:

1. The permanent dentition usually involves a complex treatment plan with specialists from multiple disciplines. Periodontics, endodontics, and orthodontics may be necessary and treatment could include orthognathic surgery.
2. The prosthetic treatment may require veneers, full coverage crowns, implants and fixed or removable prostheses. The fabrication of an occlusal splint may be needed to reestablish vertical dimension when full mouth rehabilitation is necessary.
3. Therapy will need to be planned carefully in phases as teeth erupt and the need arises.

Question 155

What are the general considerations for management of AI?

Answer 155

1. Clinicians treating children and adolescents with AI must address the clinical and emotional demands of these disorders with sensitivity.
2. Timely intervention is critical to spare the patient from the psychosocial consequences of these potentially disfiguring conditions.

Question 156

What are the general considerations for management of DI?

Answer 156

Providing optimal oral health treatment for DI frequently includes:

1. Preventing severe attrition associated with enamel loss and rapid wear of the poorly mineralized dentin.
2. Rehabilitating dentitions that have undergone severe wear.
3. Optimizing esthetics
4. Preventing caries and periodontal disease.

The clinician must be cautious in treating individuals with OI if performing surgical procedures or other treatment that could transmit forces to the jaws, increasing the risk of bone fracture.
–Some types of protective stabilization may be contraindicated in the pts with OI.

Question 157

What are the restorative treatments for DI?

Answer 157

1. Routine restorative techniques often can be used effectively to treat mild to moderate DI.
   - -These treatments more commonly are applied to the permanent teeth, as the permanent dentition frequently is less severely affected than the primary dentition.
   - -In more severe cases with significant enamel fracturing and rapid dental wear, the treatment of choice is full coverage restorations in both the primary and permanent dentitions.
   - -The success of full coverage is greatest in teeth with crowns and roots that exhibit close to a normal shape and size, minimizing the risk of cervical fracture.
2. Ideally, restorative stabilization of the dentition will be completed before excessive wear and loss of vertical dimension occur.
   - -Cases with significant loss of vertical dimension will benefit from reestablishing a more normal vertical dimension during dental rehabilitation.
   - -Cases having severe loss of coronal tooth structure and vertical dimension may be considered candidates for overdenture therapy.
   - —-Overlay dentures placed on teeth that are covered with fluoride-releasing glass ionomer cement have been used with success.
3. Bleaching has been reported to lighten the color of DI teeth with some success; however, bc the discoloration is caused primarily by the underlying yellow-brown dentin, bleaching alone is unlikely to produce normal appearance in cases of significant discoloration.
   - -Different types of veneers can be used to improve the esthetics and mask the opalescent blue-gray discoloration of the anterior teeth.

Question 158

What are the endodontic considerations for DI?

Answer 158

1. Some pts with dentinogenesis imperfect will suffer from multiple periapical abscesses apparently resulting from pulpal strangulation secondary to pulpal obliteration or from pulp exposure due to extensive coronal wear.
2. The potential for periapical abscesses is an indication for periodic radiographic surveys on individuals with DI.
3. Bc of pulpal obliteration, apical surgery may be required to maintain the abscessed teeth. Attempting to negotiation and instrument obliterated canals in DI teeth can result in lateral perforation due to the poorly mineralized dentin.

Question 159

What type of occlusion is common in DI?

Answer 159

Class III malocclusion with high incidences of posterior crossbites and open bites occur in DI Type I and should be evaluated.

Question 160

What are the general considerations for management of DD?

Answer 160

1. The goal of treatment is to retain the teeth for as long as possible. However, due to shortened roots and periapical lesions, the prognosis for prolonged tooth retention is poor.
2. Prosthetic replacement including dentures, overdentures, partial dentures and/or dental implants may be required.

Question 161

What are the periodontal considerations for DD?

Answer 161

As a result of shortened roots with DD Type I, early tooth loss from periodontitis is frequent.

Question 162

What are the restorative treatments for DD?

Answer 162

1. Teeth with DD Type I have such poor crown to root ratios that prosthetic replacement including dentures, overdentures, partial dentures and/or dental implants are the only practical courses for dental rehabilitation.
2. Teeth with DD Type II that are of normal shape, size and support can be restored with full coverage restorations if necessary.
3. For esthetics, discolored anterior teeth can be improved with resin bonding, veneering or full coverage esthetic restorations.
4. Clinicians should be aware that even shallow occlusal restorations may result in pulpal necrosis due to the pulpal vascular channels that extend close to the dentin-enamel junction.
5. If a periapical inflammatory lesion develops, the treatment plan is guided by the root length.

Question 163

What are the endodontic considerations for DD?

Answer 163

1. Endodontic therapy, negotiating around pulp stones and through whorls of tubular dentin, has been successful in teeth without extremely short roots.
2. Periapical curettage and retrograde amalgam seals have demonstrated short-term success in teeth with short roots.

Question 164

What comprises the TMJ?

Answer 164

The TMJ is comprised of three major components:

1. Mandibular condyle
2. Mandibular fossa
3. Associated connective tissue (including the articular disk)

Question 165

Describe the development of the TMJ?

Answer 165

1. The first evidence of development of the TMJ in humans is seen 8 weeks after conception.
2. During the first decade of life, the mandibular condyle becomes less vascularized and most of the major morphological changes are completed.
3. During the second decade of life, there is continued but progressive slowing of growth.
4. The shape of the mandibular condyle may change significantly during growth with approximately 5% of condyles undergoing radiographic changes in shape between 12 and 16 years of age.
5. From adolescence to adulthood, the condyle changes to a form that is greater in width than length.
6. Although the TMJ experiences active growth in the first two decades, it undergoes active remodeling changes throughout life.

Question 166

What is the definition of TMD?

Answer 166

While TMD has been defined as “functional disturbances of the masticatory system.”
–Others have included under the umbrella of TMD: masticatory muscle disorders, degenerative and inflammatory TMJ disorders, and TMJ disk displacements.

Question 167

What medical conditions mimic TMD? What medical conditions can cause symptoms similar to TMD?

Answer 167

Medical conditions that mimic TMD:

1. Trigeminal neuralgia
2. Central nervous system lesions
3. Odontogenic pain
4. Sinus pain
5. Otological pain
6. developmental abnormalities
7. Neoplasias
8. Parotid diseases
9. Vascular diseases
10. Myofascial pain
11. Cervical muscle dysfunction
12. Eagle’s syndrome

Medical conditions that cause symptoms similar to TMD:

1. Otitis media
2. Allergies
3. Airway congestion
4. Rheumatoid arthritis

Question 168

What is the etiology of TMD?

Answer 168

Temporomandibular disorders have multiple etiological factors. Alterations in any one or a combination of teeth, periodontal ligament, the TMJ, or the muscles of mastication eventually can lead to TMD. Research is insufficient to predict reliably which pt will or will not develop TMD. Etiological factors suggested as contributing to the development of TMD are:

1. Trauma
   - -A common occurrence in childhood bc of falling, chin trauma is reported to be a factor in the development of TMD in pediatric pts.
   - -Unilateral and bilateral intracapsular or subcondylar fractures are the most common mandibular fractures in children.
   - -Closed reduction and prolonged immobilization can result in ankylosis.
2. Occlusal factors
   - -There is a relatively low association of occlusal factors and the development of temporomandibular disorders. However, several features characterize malocclusions associated with TMD:
   - —-Skeletal anterior open bite
   - —-Overjet greater than 6-7mm
   - —-Retrocuspal position (centric relation) to intercuspal position (centric occlusion) slides greater than 4mm.
   - —-Unilateral lingual cross bite
   - —-Five or more missing posterior teeth
   - —-Class III malocclusion
3. Parafunctional habits (e.g., bruxism, clenching, hyperextension, other repetitive habitual behavior)
   - -Bruxism is thought to contribute to the development of TMD by joint overloading that leads to cartilage breakdown, synovial fluid alterations and other changes within the joint.
   - -The literature on the association between parafunction and TMD in pediatric pts is contradictory. However, childhood parafunction was found to be a predictor of the same parafunction 20 years later.
   - -Other studies found correlations between reported bruxism and TMD with a 3.4 odds ratio.
   - -Children who grind their teeth were found to complain more often of pain and muscle tenderness when eating.
4. Posture
   - -Craniocervical posture has been associated with occlusion and with dysfunction of the TMJ, including abnormalities of the mandibular fossa, condyle, ramus and disc.
5. Changes in “free-way” dimension of the rest position
   - -Normally 2 to 4 mm, this may be impinged by occlusal changes, disease, muscle spasms, nervous tension, and/or restorative prosthetics.
6. Orthodontic treatment
   - -Current literature does not support that the development of TMD is caused by orthodontic treatment, regardless of whether premolars were extracted prior to treatment.

Question 169

Which TMJ signs or symptoms are seen most often in TMD?

Answer 169

Clicking is seen more frequently than either locking or luxation and affects girls more than boys.

Question 170

Which age population has the higher prevalence of TMD?

Answer 170

1. In general, the prevalence of signs and symptoms of TMD is lower in children compared to adults and is even less the younger the child but increases with increasing age.
2. Recent surveys have indicated a significantly higher prevalence of symptoms and greater need for treatment in girls than boys with the development of symptomatic TMD correlated with the onset of puberty in girls.

Question 171

What must you have for a diagnosis of TMD?

Answer 171

For a diagnosis of TMD, pts must have a history of facial pain combined with physical findings, supplemented by radiographic or imaging data when indicated.

Question 172

What psychosocial factors related to temporomandibular symptoms can affect a pt’s pain experience in TMD?

Answer 172

1. Mood disorders
2. Anxiety disorders
3. Musculoskeletal problems
4. Migraine headaches
5. Tension headaches
6. Emotional factors
7. Ulcers
8. Colitis
9. Occupational factors
10. Developmental/acquired craniofacial anomalies

Question 173

What is the classification for TMDs?

Answer 173

There is a need for improved classification of TMDs; however, they largely can be grouped into 3 classes:

1. Disorders of the muscles of mastication (including protective muscle splinting, muscle spasm, and muscle inflammation).
2. Disorders of the TMJ (including internal disk derangement, disk displacement with reduction accompanied by clicking, and anterior disk displacement without reduction seen as mechanical restriction or closed lock.)
3. Disorders in other related areas that may mimic TMD (e.g., chronic mandibular hypomobility, inflammatory joint disorders such as juvenile rheumatoid arthritis, degenerative joint disease, extrinsic trauma such as fracture.)

Question 174

What type of treatment should be done for TMDs?

Answer 174

1. Simple, conservative and reversible types of therapy are effective in reducing most TMD symptoms in children.
2. The focus of treatment should be to find a balance between active and passive treatment modalities.
   - -Active modalities include participation of the pt whereas passive modalities may include wearing a stabilization splint.
   - -The most common form of treatment of TMD in children was information combined with occlusal appliance therapy.
   - -It has been shown that combined approaches are more successful in treating TMD than single treatment modalities.

Question 175

What is the difference between reversible and irreversible treatment of TMD?

Answer 175

Reversible therapies may include:

1. Patient education (e.g., relaxation training, developing behavior coping strategies, modifying inadequate perceptions about TMD, patient awareness of clenching and bruxing habits if present).
2. Physical therapy (e.g., jaw exercises or transcutaneous electrical nerve stimulation (TENS), ultrasound, iontophoresis, massage, thermotherapy, coolant therapy).
3. Behavioral therapy (e.g., avoiding excessive chewing of hard foods or gum, voluntary avoidance of stressors, habit reversal, decreasing stress, anxiety, and/or depression).
4. Prescription medication (e.g., non-steroidal anti-inflammatory drugs, anxiolytic agents, muscle relaxers). While antidepressants have proved to be beneficial, they should be prescribed by a physician.
5. Occlusal splints. The goal of an occlusal appliance is to provide orthopedic stability to the TMJ. These alter the patient’s occlusion temporarily and may be used to decrease parafunctional activity.

Irreversible therapies can include:

1. Occlsual adjustment (i.e., permanently altering the occlusion or mandibular position by selective grinding or full mouth restorative dentistry).
2. Mandibular repositioning (designed to alter the growth or permanently reposition the mandible (e.g., headgear, functional appliances)).
3. Orthodontics.

Question 176

What are the considerations for TMD therapies in the pediatric population?

Answer 176

1. Therapeutic modalities to prevent TMD in the pediatric population are yet to be supported by controlled studies.
2. For children and adolescents with signs and symptoms of TMD, reversible therapies should be considered.
   - -Bc of inadequate data regarding their usefulness, irreversible therapies should be avoided.

Question 177

When should TMD be referred to a specialist?

Answer 177

Referral to a medical specialist may be indicated when otitis media, allergies, abnormal posture, airway congestion, rheumatoid arthritis or other medical conditions are suspected.

Question 178

How can palatal scarring affect growth and development after cleft repair?

Answer 178

Palatal scarring following primary palatal repair may result in maxillary constriction.

Question 179

How is tumor management different in children vs. adults?

Answer 179

1. Tumors generally grow faster in pediatric pts and are less predictable in behavior.
2. The same physiological factors that affect tumor growth, however, can play a favorable role in healing following primary reconstructive surgery. Pediatric pts are more resilient and heal more rapidly than their adult counterparts.

Question 180

What are the causes of odontogenic infections in children?

Answer 180

In children, odontogenic infections may involve more than one tooth and usually are due to:

1. Carious lesions
2. Periodontal problems
3. History of trauma

Question 181

Why is prompt treatment necessary for children with odontogenic infection?

Answer 181

Children are prone to dehydration, especially if they are not eating well due to pain and malaise.

Question 182

What are the symptoms of odontogenic infections of the upper portion of the face?

Answer 182

1. With infections of the upper portion of the face, pts usually complain of facial pain, fever, and inability to eat or drink.
   - -Occasionally in upper face infections, it may be difficult to find the true cause.
   - -Care must be taken to rule out sinusitis, as symptoms may mimic an odontogenic infection.
2. Infections of the lower face usually involve pain, swelling, and trismus.
   - -They frequently are associated with teeth, skin, local lymph nodes, and salivary glands.
   - -Swelling of the lower face more commonly has been associated with dental infection.

Question 183

How can most odontogenic infections be managed?

Answer 183

1. Most odontogenic infections can be managed with pulp therapy, extraction, or incision and drainage.
2. Infections of odontogenic origin with systemic manifestations (e.g., elevated temperature of 102 degrees Fahrenheit to 104 degrees Fahrenheit, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea) require antibiotic therapy.

Question 184

What are the severe complications of odontogenic infections?

Answer 184

Severe but rare complications of odontogenic infections include cavernous sinus thrombosis and Ludwig’s angina.
–These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon.

Question 185

What force is used to extract anterior teeth?

Answer 185

1. In most cases, extraction of anterior teeth is accomplished with a rotational movement, due to their single root anatomies.
   - -However, there have been reported cases of accessory roots observed in primary canines.
   - -Radiographic examination is helpful to identify differences in root anatomy prior to extraction.

Question 186

What root anatomy feature of primary molars can present a problem during extraction?

Answer 186

1. Primary molars have roots that are smaller in diameter and more divergent than permanent molars.
   - -Root fracture in primary molars is not uncommon due to these characteristics as well as the potential weakening of the roots caused by the eruption of their permanent successors.
2. Primary molars with roots encircling the successor’s crown may need to be sectioned to protect the permanent tooth’s location.

Question 187

What force is used to extract primary molars?

Answer 187

Molar extractions are accomplished by using slow continuous palatal/lingual and buccal force allowing for the expansion of the alveolar bone to accommodate the divergent roots and reduce the risk of root fracture.

Question 188

What precaution should you to make avoid other injuries when extracting primary molars?

Answer 188

When extracting mandibular molars, care should be taken to support the mandible to protect the temporomandibular joints from injury.

Question 189

What are the concerns regarding extracting a fractured primary tooth root?

Answer 189

1. The dilemma to consider when treating a fractured primary tooth root is that removing the root tip may cause damage to the succedaneous tooth, while leaving the root tip may increase the chance for postoperative infection and delay eruption of the permanent successor.
2. The literature suggests that if the fractured root tip can be removed easily, it should be removed.
   - -If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed.

Question 190

What routine evaluation measures can be done to identify impacted canines?

Answer 190

1. Routine evaluation of pts in mid-mixed dentition should involve identifying signs such as lack of canine bulges and asymmetry in pattern of exfoliation.
2. Eruption of canines and abnormal angulation or ectopic eruption of developing permanent cuspids can be detected with a radiograph.

Question 191

How can you tell from a radiograph if a canine will be impacted?

Answer 191

When the cusp tip of the permanent canine is just mesial to or overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine palatal impaction usually occurs.

Question 192

When should you extract primary canines?

Answer 192

Provided there are normal space conditions and no incisor resorption, extraction of the primary canines is the treatment of choice when:

1. Malformation or ankylosis is present
2. The risk of resorption of the adjacent tooth is evident
3. When trying to correct palatally impacted canines

Question 193

After extraction of the primary canine, what percent of ectopically-erupting permanent canines will normalize?

Answer 193

1. 78% of ectopically -erupting permanent canines normalized within 12 months after removal of the primary canines.
2. 64% normalized when the starting canine position overlapped the lateral incisor by more than half of the root.
3. 91% normalized when the starting canine position overlapped the lateral incisor by less than half of the root.

Question 194

After extraction of the primary canine, how long do you wait before further intervention?

Answer 194

If no improvement in canine position occurs in a year, surgical and/or orthodontic treatment is suggested.

Question 195

When should a decision to remove or retain third molars be made?

Answer 195

AAOMS recommends that a decision to remove or retain third molars should be made before the middle of the third decade.

• -Although prophylactic removal of all impacted or erupted disease-free third molars is not indicated, consideration should be given to removal by the third decade when there is a high probability of disease or pathology and/or the risks associated with early removal are less than the risks of later removal.
• -Removing the third molars prior to complete root formation may be surgically prudent.

Question 196

When should third molars be removed?

Answer 196

Evidence-based research supports the removal of third molars when:

1. Pathology (e.g., cysts or tumors, caries, infection, pericoronitis, periodontal disease, detrimental changes of adjacent teeth or bone) is associated.
2. The tooth is malpositioned or nonfunctional (i.e., an unopposed tooth).

There is no evidence to support or refute the prophylactic removal of disease-free impacted third molars.

Question 197

What percent of third molars have pathology? What kind of pathology is associated with third molars?

Answer 197

1. One study reported a 20% incidence of pathology for impacted third molars.
2. Pathology included, but was not limited to, internal root resorption, cysts, periodontal bone loss, resorption of the distal surface of second molars, and/or pericoronitis.

Question 198

How common are intraoperative complications of third molar removal?

Answer 198

All intraoperative complications (e.g., nerve injury, unexpected hemorrhage, unplanned transfusion or parenteral drugs, compromised airway, fracture, other injuries to adjacent teeth/structures) occurred at a frequency less than 1%.

Question 199

What postoperative complications are common after third molar removal?

Answer 199

Excluding alveolar osteitis, postoperative complications (e.g., paresthesia, infection, trismus, hemorrhage) were low.

Question 200

What factors increase the risk for complications for third molar removal?

Answer 200

Factors that increase the risk for complications:

1. Coexisting systemic conditions
2. Location of peripheral nerves
3. History of temporomandibular joint disease
4. Presence of cysts or tumors
5. Position and inclination of the molar in question

–The age of the patient is only a secondary consideration for complications.

Question 201

Are supernumerary teeth usually associated with syndromes or familial inheritance patterns?

Answer 201

No. Although some supernumerary teeth may be syndrome associated (e.g., cleidocranial dysplasia) or of familial inheritance pattern, most supernumerary teeth occur as isolated events.

Question 202

What percent of primary supernumerary teeth are followed in the permanent dentition?

Answer 202

In 33% of cases, a supernumerary tooth in the primary dentition is followed by the supernumerary tooth complement in the permanent dentition.

Question 203

How common are supernumerary teeth in the primary vs. permanent dentition and male vs. female?

Answer 203

1. Permanent dentition is affected 5 times more frequently than the primary dentition.
2. Males are affected twice as frequently as females.

Question 204

Where do supernumerary teeth occur?

Answer 204

1. Supernumerary teeth occur 10 times more often in the maxillary arch vs the mandibular arch. Approximately 90% of all single tooth supernumerary teeth are found in the maxillary arch, with a strong predilection to the anterior region.
2. The maxillary anterior midline is the most common site. The maxillary molar area is the second most common site, with the tooth known as a paramolar.

Question 205

How can you determine the 3-D location of the mesiodens or impacted root?

Answer 205

Three-dimensional information needed to determine the location of the mesiodens or impacted tooth can be obtained by:

1. Taking two periapical radiographs using either two projections taken at right angles to one another.
2. Tube shift technique (buccal object rule or Clark’s rule).
3. Cone beam computed tomography.

Question 206

What oral pathologies occur in newborn children?

Answer 206

1. Epstein’s pearls
2. Dental lamina cysts
3. Bohn’s nodules
4. Congenital epulis

Question 207

Where are Epstein’s pearls found?

Answer 207

Epstein’s pearls occur in the median palatal raphe area, as a result of trapped epithelial remnants along the line of fusion of the palatal halves.

Question 208

Where are dental lamina cysts found?

Answer 208

Dental lamina cysts, found on the crests of the dental ridges, most commonly are seen bilaterally in the region of the first primary molars.
–They result from remnants of the dental lamina.

Question 209

Where are Bohn’s nodules found?

Answer 209

Bohn’s nodules are remnants of salivary gland epithelium and usually are found on the buccal and lingual aspects of the ridge, away from the midline.

Question 210

Where are congenital epulis found?

Answer 210

Congenital epulis of the newborn, also known as granular cell tumor or Neumann’s tumor, is a rare benign tumor seen only in newborns.

• -This lesion is typically a protuberant mass arising from the gingival mucosa.
• -It is most often found on the anterior maxillary ridge.
• -Congenital epulis has a marked predilection for females at 8:1 to 10:1.

Epstein’s pearls are common, found in about 75-80% of newborns.

Question 211

Which oral pathologies of the newborn do not require treatment? Which do require treatment?

Answer 211

1. Epstein’s pearls, Bohn’s nodules and dental lamina cysts typically present as asymptomatic 1 to 3 mm nodules or papules. They are smooth, whitish in appearance, and filled with keartin. No treatment is required as these cysts usually disappear during the first 3 months of life.
2. Congenital epulis pts typically present with feeding and/or respiratory problems. Treatment normally consists of surgical excision. The newborn usually heals well, and no future complications or treatment should be expected.

Question 212

How does an eruption cyst form?

Answer 212

1. The eruption cyst is a soft tissue cyst that results from a separation of the dental follicle from the crown of an erupting tooth.
   - -Fluid accumulation occurs within this created follicular space.

Question 213

Where do eruptions cysts occur and what do they look like?

Answer 213

1. Eruption cysts more commonly are found in the mandibular molar region.
2. Color of these lesions can range from normal to blue-black or brown, depending on the amount of blood in the cystic fluid.
   - -The blood in the cystic fluid is secondary to trauma. If trauma is intense, these blood-filled lesions sometimes are referred to as eruption hematomas.

Question 214

What is the treatment for an eruption cyst?

Answer 214

Bc the tooth erupts through the lesion, no treatment is necessary. If the cyst does not rupture spontaneously or the lesion becomes infected, the roof of the cyst may be opened surgically.

Question 215

What causes a mucocele?

Answer 215

Mucoceles result from the rupture of a minor salivary gland excretory duct, with subsequent leakage of mucin into the surrounding connective tissues that later may be surrounded in a fibrous capsule.

Question 216

What do mucoceles look like?

Answer 216

Most mucoceles are well-circumscribed blush translucent fluctuant swellings (although deeper and long-standing lesions may range from normal in color to having a whitish keratinized surface) that are firm to palpation.

Question 217

Where do mucoceles occur?

Answer 217

1. Mucoceles most frequently are observed on the lower lip, usually lateral to the midline.
2. Mucoceles also can be found on the buccal mucosa, ventral surface of the tongue, retromolar region and floor of the mouth (ranula).

Question 218

What is the treatment for a mucocele?

Answer 218

Superficial mucoceles and some other mucoceles are short-lived lesions that burst spontaneously, leaving shallow ulcers that heal within a few days. Many lesions, however, require treatment to minimize the risk of recurrence.

Question 219

Is there a correlation between the height of the maxillary frenum and the diastema presence and width?

Answer 219

No. A comparison of attached frena with and without diastema found no correlation between the height of the frenum attachment and diastema presence and width.

Question 220

When do you treatment maxillary frenum anomalies?

Answer 220

1. Treatment is suggested when the attachment exerts a traumatic force on the gingiva causing the papilla to blanch when the upper lip is pulled or if it causes a diastema to remain after eruption of the permanent canines.
   - -Interference with oral hygiene measures, esthetics and psychological reasons are contributing factors that relate to treatment of the maxillary frenum.
2. Treatment options can include orthodontics, restorative dentistry, surgery or a combination of these.
3. It is recommended that treatment be delayed until the permanent incisors and cuspids have erupted and the diastema has had an opportunity to close naturally.
   - -If orthodontic treatment is indicated, the frenectomy [complete excision (i.e., removal of the whole frenum)] should be performed only after the diastema is closed as much as possible to achieve stable results.

Question 221

Where can a high mandibular labial frenum occur?

Answer 221

1. A high mandibular labial frenum sometimes can present on the labial aspect of the mandibular ridge.
   - -This is most often seen in the central incisor area and frequently occurs in individuals where the vestibule is shallow.
2. The mandibular anterior frenum, as it is known, occasionally inserts into the free or marginal gingival tissue.

Question 222

What problems can cause from a high mandibular labial frenum?

Answer 222

Movements of the lower lip cause the frenum to pull on the fibers inserting into the free marginal tissue, which, in turn, can lead to food and plaque accumulation.

Question 223

What is the treatment for a high mandibular labial frenum?

Answer 223

Early treatment can be considered to prevent subsequent inflammation, recession, pocket formation and possible loss of the alveolar bone and/or tooth.
–However, if factors causing gingival/periodontal inflammation are controlled, the degree of recession and need for treatment decreases.

Question 224

What problems can ankyloglossia cause?

Answer 224

Ankyloglossia has been associated with problems with:

1. Breastfeeding among neonates
   - -During breastfeeding, a short frenum can cause ineffective latch, inadequate milk transfer and intake, and persistent maternal nipple pain, all of which can affect feeding adversely.
   - —-When indicated, frenuloplasty (various methods to release the tongue tie and correct the anatomic situation) or frenectomy (simply cutting off of the frenulum) may be a successful approach to facilitate breastfeeding; however, there is a need for evidence-based research to determine indications for treatment.
2. Tongue mobility and speech
   - -There has been varied opinion among health care professionals regarding the correlation between ankyloglossia and speech disorders.
   - -Frenuloplasty or frenectomy in conjunction with speech therapy can be a treatment option to improve tongue mobility and speech.
3. Malocclusion
   - -There is limited evidence to show an association between ankyloglossia and Class III malocclusion. Speculations have been made that the abnormal tongue position may affect skeletal development.
4. Gingival recession
   - -Reports have been made regarding the association between frenal attachment and gingival recession; further clinical evidence, however, is warranted to show a clear relationship between these two factors.
   - -Elimination of plaque-induced gingival inflammation can minimize gingival recession without any surgical intervention.

Question 225

When should you treat ankyloglossia?

Answer 225

1. A short lingual frenum can inhibit tongue movement and create deglutition (swallowing) problems.
2. If there is no improvement in breastfeeding for a child with ankyloglossia after non-surgical intervention, frenectomy may be indicated.
3. Frenectomy for functional limitations due to severe ankyloglossia should be considered on an individual basis.

Question 226

What are the steps in a frenectomy procedure?

Answer 226

1. Frenectomy involves surgical incision, establishing hemostasis, and suturing the wound.
   - -Dressing placement or the use of antibiotics is not necessary.
2. Although there is minimal evidence-based research available, the use of laser technology and electrosurgery for frenectomies have demonstrated a shorter operative working time, the ability to control bleeding quickly, reduced pain and discomfort, fewer postoperative complications (e.g., pain, swelling, infection) and no need for suture removal, as well as increasing pt acceptance.

Question 227

What type of teeth are usually natal or neonatal teeth?

Answer 227

1. The teeth most often affected are the mandibular primary incisors.
2. In most cases, anterior natal and neonatal teeth are part of the normal complement of the dentition.

Question 228

What is the importance of a natal or neonatal molar?

Answer 228

Natal or neonatal molars have been identified in the posterior region and may be associated with systemic conditions or syndromes (Pfeieffer syndrome, histiocytosis X).

Question 229

Why do natal or neonatal teeth occur?

Answer 229

1. Although many theories exist as to why the teeth erupt prematurely, currently no studies confirm a causal relationship with any of the proposed theories.
2. The superficial position of the tooth germ associated with a hereditary factor seems to be the most accepted possibility.

Question 230

What is the treatment for natal or neonatal teeth?

Answer 230

If the tooth is not excessively mobile or causing feeding problems, it should be preserved and maintained in a healthy condition if at all possible. Close monitoring is indicated to ensure that the tooth remains stable.

Question 231

What is the treatment for Riga-Fede disease?

Answer 231

1. Treatment should be conservative and focus on creating round, smooth incisal edges.
   - -If conservative treatment does not correct the condition, extraction is the treatment of choice.
2. An important consideration when deciding to extract a natal or neonatal tooth is the potential for hemorrhage.
   - -Extraction is contraindicated in newborns due to risk of hemorrhage.
   - -Unless the child is at least 10 days old, consultation with the pediatrician regarding adequate hemostasis may be indicated prior to extraction of the tooth.

Question 232

For oral wound management, when should antibiotics be prescribed?

Answer 232

1. Facial lacerations may require topical antibiotic agents.
2. Intraoral lacerations that appear to have been contaminated by extrinsic bacteria, open fractures, and joint injury have an increased risk of infection and should be covered with antibiotics.

–Antibiotics should be administered as soon as possible for the best result.

Question 233

Considering the growing problem of drug resistance, how long should you prescribe antibiotics?

Answer 233

1. In light of the growing problem of drug resistance, the clinician should consider altering or discontinuing antibiotics following determination of either ineffectiveness or cure prior to completion of a full course of therapy.
   - -If the infection is not responsive to the initial drug selection, a culture and susceptibility testing of isolates from the infective site may be indicated.
2. The minimal duration of drug therapy should be 5 days beyond the point of substantial improvement or resolution of signs and symptoms; this is usually a 5-7 day course of treatment dependent upon the specific drug selected.

Question 234

How can bacteria gain access to the pulpal tissues?

Answer 234

Bacteria can gain access to the pulpal tissue through:

1. Caries
2. Exposed pulp or dentinal tubules
3. Cracks into the dentin
4. Defective restorations

Question 235

When are antibiotics given for pulpitis/apical periodontitis/draining sinus tract/localized intraoral swelling?

Answer 235

1. Antibiotic therapy usually is not indicated if the dental infection is contained within the pulpal tissue or the immediate surrounding tissue. In this case, the child will have no systemic signs of an infection (i.e., no fever and no facial swelling).
2. Consideration for use of antibiotics should be given in cases of advanced non-odontogenic bacterial infections such as staphylococcal mucositis, tuberculosis, gonococcal stomatitis, and oral syphilis. If suspected, it is best to refer pts for culture, biopsy, or other laboratory tests for documentation and definitive treatment.

Question 236

When are antibiotics given for an acute facial swelling of dental origin?

Answer 236

1. A child presenting with a facial swelling or facial cellulits secondary to an odontogenic infection should receive prompt dental attention.
   - -Signs of systemic involvement (i.e., fever, asymmetry, facial swelling) warrant emergency treatment.
   - -Intravenous antibiotic therapy and/or referral for medical management may be indicated.
2. Penicillin remains the empirical choice for odontogenic infections; however, consideration of additional adjunctive antimicrobial therapy (i.e., metronidazole) can be given where there is anaerobic bacterial involvement.

Question 237

When are antibiotics given for dental trauma?

Answer 237

1. Systemic antibiotics have been recommended as adjunctive therapy for avulsed permanent incisors with an open or closed apex.
   - -Tetracycline (doxycycline twice daily for 7 days) is the drug of choice, but consideration of the child’s age must be exercised in the systemic use of tetracycline due to the risk of discoloration in the developing permanent dentition. Penicillin V or amoxicillin can be given as an alternative.
2. The use of topical antibiotics to induce pulpal revascularization in immature non-vital traumatized teeth has shown some potential.
3. For luixation injuries in the primary dentition, antibiotics generally are not indicated.
4. Antibiotics can be warranted in cases of concomitant soft tissue injuries (see oral wound management section) and when dictated by the pt’s medical status.

Question 238

When are antibiotics given for pediatric periodontal diseases?

Answer 238

1. Dental plaque-induced gingivitis does not require antibiotic therapy.
2. Pediatric pts with aggressive periodontal diseases may require adjunctive antimicrobial therapy in conjunction with localized treatment.
   - -The use of systemic antibiotics has been recommended as adjunctive treatment to mechanical debridement in pts with aggressive periodontal disease.
   - -In severe and refractory cases, extraction is indicated.
3. In pediatric periodontal diseases associated with systemic disease (e.g., severe congenital neutropenia, Papillon-Lefevre syndrome, leukocyte adhesion deficiency), the immune system is unable to control the growth of periodontal pathogens and, in some cases, treatment may involve antibiotic therapy.

Question 239

When are antibiotics given for salivary gland infections?

Answer 239

1. Many salivary gland infections, following confirmation of bacterial etiology, will respond favorable to antibiotic therapy.
2. Acute bacterial parotitis has two forms: hospital acquired and community acquired. Both can be treated with antibiotics.
   - -Hospital acquired usually requires intravenous antibiotics.
   - -Chronic recurrent juvenile parotitis generally occurs prior to puberty.
3. For both acute bacterial submandibular sialadenitis and chronic recurrent submandibular sialadenitis, antibiotic therapy is included as part of the treatment.

Question 240

What considerations must be taken for pts taking antibiotics that are on oral contraceptives?

Answer 240

1. Whenever an antibiotic is prescribed to a female pt taking oral contraceptives to prevent pregnancy, the pt must be advised to use additional techniques of birth control during antibiotic therapy and for at least one week beyond the last dose, as the antibiotic may render the oral contraceptive ineffective.
2. Rifampicin has been documented to decreased the effectiveness of oral contraceptives.
3. Other antibiotics, particularly tetracycline and penicillin derivatives, have been shown to cause significant decrease in the plasma concentrations of ethinyl estradiol, causing ovulation in some individuals taking oral contraceptives.

Question 241

What bacterial species have been implicated in resultant postoperative infections of infective endocarditis?

Answer 241

1. Only a limited number of bacterial species have been implicated in resultant postoperative infections.
2. Viridans group streptococci, Staphylococcus aureus, enterococcus, pseudomonas, serratia, and candida are some of the microorganisms implicated with IE.

Question 242

What is the likely cause of IE?

Answer 242

IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract, or GU tract procedure. (Daily activities would include toothbrushing, flossing, chewing, using toothpicks, using water irrigation devices, and other activities.)

Question 243

What are the reasons for the revisions of the AHA guidelines for the prevention of IE?

Answer 243

1. Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.
2. Utilization of antibiotic prophylaxis for pts at risk does not provide absolute prevention of infection.
   - -Post-procedural symptoms of acute infection (e.g., fever, malaise, weakness, lethargy) may indicate antibiotic failure and need for further medical evaluation.
3. The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.
4. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

Question 244

What are the specific AHA revisions for dental procedures?

Answer 244

1. Only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective.
2. Infective endocarditis prophylaxis for dental procedures is reasonable only for pts with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis.
3. For pts with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
4. Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis.

Question 245

What cardiac conditions are antibiotic prophylaxis recommended?

Answer 245

Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is reasonable:

1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair.
2. Previous infective endocarditis.
3. Congenital heart disease:
   - -Unrepaired cyanotic CHD, including palliative shunts and conduits.
   - -Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.
   - -Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).
4. Cardiac transplantation recipients who develop cardiac valvulopathy.

Question 246

For what dental procedures is antibiotic prophylaxis recommended?

Answer 246

1. All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
2. The following procedures and events do not need prophylaxis: routine anesthetic injections through non-infected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.

Question 247

What are the regimens for antibiotic prophylaxis for a dental procedure?

Answer 247

Regimen: single dose 30-60 min before procedure

1. Oral: Amoxicillin: 2g for adults; 50 mg/kg for children.
2. Unable to take oral medication:
   - -Ampicillin: 2g IM or IV for adults; 50 mg/kg IM or IV for children.
   - -Cefazolin or ceftriaxone: 1g IM or IV for adults; 50 mg/kg IM or IV for children.
3. Allergic to penicillins or ampicillin-oral:
   - -Cephalexin: 2g for adults; 50 mg/kg for children
   - -Clindamycin: 600mg for adults; 20 mg/kg for children
   - -Azithromycin or clarithromycin: 500mg for adults; 15 mg/kg for children.
4. Allergic to penicillin or ampicillin and unable to take oral medication.
   - -Cefazolin or ceftriaxone: 1g IM or IV for adults; 50 mg/kg IM or IV for children.
   - -Clindamycin: 600mg IM or IV for adults; 20 mg/kg IM or IV for children.

Question 248

Patients with what other high risk oral activity may be considered for antibiotic prophylaxis?

Answer 248

1. In addition to those diagnoses listed in the AHA guidelines, pts with a reported history of injection drug use may be considered at risk for developing IE in the absence of cardiac anomalies.
2. Although quite rare, complications from intraoral tongue piercing can include IE among pts with a pre-existing cardiac valvular condition and/or history of injection drug use. Consultation with the pt’s physician may be necessary to determine susceptibility to bacteremia-induced infections.

Question 249

Patients with what types of compromised immune system conditions may need antibiotic prophylaxis?

Answer 249

Patients with the following medical conditions:

1. Immunosuppression secondary to:
   - -HIV
   - -SCIDS (severe combined immunodeficiency)
   - -Neutropenia
   - -Cancer chemotherapy
   - -Hematopoietic stem cell or solid organ transplantation
2. Head and neck radiotherapy.
3. Autoimmune disease (e.g., juvenile arthritis, systemic lupus erythematosus).
4. Sickle cell anemia.
5. Asplenism or status post splenectomy.
6. Chronic steroid usage.
7. Diabetes.
8. Bisphosphenate therapy.

-Consultation with the child’s physician is recommended for management of pts with a compromised immune system.

Question 250

When is antibiotic prophylaxis recommended for pts with nonvalvular devices?

Answer 250

1. The AHA recommends that antibiotic prophylaxis for nonvalvular devices, including indwelling vascular catheters (e.g., central lines) and cardiovascular implantable electronic devices (CIED), is indicated only at the time of placement of these devices in order to prevent surgical site infection.
2. The AHA found no convincing evidence that microorganisms associated with dental procedures cause infection of CIED and nonvalvular devices at any time after implantation.
3. The infections occurring after device implantation most often are caused by Staphylococcus aureus and coagulase negative staphylococci or other microorganisms that are non-oral in origin but are associated with surgical implantation or other active infections.
4. The AHA further states that immunosuppression is not an independent risk factor for nonvalvular device infections; immunocompromised hosts who have those devices should receive antibiotic prophylaxis as advocated for immunocompetent hosts.

Question 251

Antibiotic prophylaxis is recommended for what types of shunts in hydrocephalus?

Answer 251

Ventriculoatrial (VA), ventriculocardiac (VC), or ventriculovenus (VV) shunts for hydrocephalus are at risk of bacteremia-induced infections due to their vascular access.
–In contrast, ventriculoperitoneal (VP) shunts do not involve any vascular structures and, consequently, do not require antibiotic prophylaxis.

Question 252

What type of pts with joint replacement are antibiotic prophylaxis recommended?

Answer 252

• -A 2012 information statement published by the AAOS recommends that dentists consider antibiotic prophylaxis for at-risk joint replacement pts who are undergoing an invasive procedure.
• -Pts with an increased risk of hematogenous total joint infection are all pts with:
  1. Prosthetic joint replacement
  2. Previous prosthetic joint infection
  3. Inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus)
  4. Megaprosthesis
  5. Hemophilia
  6. Malnourishment
  7. Compromised immunity

–Antibiotic prophylaxis has not shown a significant reduction in the risk of developing joint infections subsequent to dental procedures. Therefore, antibiotic prophylaxis is not indicated for dental pts with pins, plates, screws, or other hardware that is not within a synovial joint nor is it indicated routinely for most dental pts with total joint replacements.

Question 253

What are the general types of pts that antibiotic prophylaxis is recommended for?

Answer 253

1. Cardiac conditions
2. Compromised immunity
3. Shunts, indwelling vascular catheters or medical devices
4. Prosthetic joints

Question 254

What is the most frequently documented source of sepsis in the immunosuppressed cancer pt?

Answer 254

The oral cavity is highly susceptible to the effects of chemotherapy and radiation and is the most frequently documented source of sepsis in the immunosuppressed cancer pt.

Question 255

What oral and associated systemic complications can occur in the cancer and HCT pt?

Answer 255

Oral and associated systemic complications may include:

1. Pain
2. Mucositis
3. Oral ulcerations
4. Bleeding
5. Taste dysfunction
6. Secondary infections (e.g., candidiasis, herpes simplex virus)
7. Dental caries
8. Salivary gland dysfunction (e.g., xerostomia)
9. Neurotoxicity
10. Mucosal fibrosis
11. Post-radiation osteonecrosis
12. Soft tissue necrosis
13. Temporomandibular dysfunction (e.g., trismus)
14. Craniofacial and dental developmental anomalies
15. Oral graft versus host disease (GVHD)

Question 256

When should an oral evaluation occur in a cancer pt?

Answer 256

All pts with cancer should have an oral examination prior to initiation of the oncology therapy.

Question 257

What is the key to success in maintaining a healthy oral cavity during cancer therapy?

Answer 257

The key to success in maintaining a healthy oral cavity during cancer therapy is pt compliance. The child and the parents should be educated regarding the possible acute side effects and the long-term sequelae of cancer therapies in the oral cavity.

Question 258

What are the objectives of a dental/oral examination before cancer therapy starts?

Answer 258

1. To identify and stabilize or eliminate existing and potential sources of infection and local irritants in the oral cavity-without needlessly delaying the cancer treatment or inducing complications.
2. To communicate with the oncology team regarding the pt’s oral health status, plan, and timing of treatment.
3. To educate the pt and parents about the importance of optimal oral care in order to minimize oral problems/discomfort before, during, and after treatment and about the possible acute and long-term effects of the therapy in the oral cavity and the craniofacial complex.

Question 259

For a cancer pt with an indwelling venous access line, is antibiotic prophylaxis recommended?

Answer 259

1. The AHA recommends that antibiotic prophylaxis for nonvalvular devices, including indwelling vascular catheters (i.e., central lines) is indicated only at the time of placement of these devices in order to prevent surgical site infections.
   - -The AHA found no convincing evidence that microorganisms associated with dental procedures cause infection of nonvalvular devices at any time after implantation.
   - -The infections occurring after device implantation most often are caused by staphyloccal Gram-negative bacteria or other microorganisms associated with surgical implantation or other active infections.
2. Due to the risk of antibiotic adverse events, development of drug resistance among oral flora, spectrum of non-oral bacteria causing catheter-related infections, and lack of evidence from clinical trials, antibiotic prophylaxis is not necessary for pts with an indwelling central venous catheter who are undergoing dental procedures.
3. Immunosuppression is not an independent risk factor for nonvalvular device infections; immunocompromised hosts who have those devices should receive antibiotic prophylaxis as advocated for immunocompetent hosts.

Question 260

What is evaluated at the initial evaluation of a cancer pt before the initiation of cancer therapy?

Answer 260

1. Medical history review
   - -Disease/condition (type, stage, prognosis)
   - -Treatment protocol (conditioning regimen, surgery, chemotherapy, radiation, transplant)
   - -Medications (including bisphosphonates)
   - -Allergies
   - -Surgeries
   - -Secondary medical diagnoses
   - -Hematological status [complete blood count (CBC)]
   - -Coagulation status
   - -Immunosuppression status
   - -Presence of indwelling venous access line
   - -Contact of oncology team/primary care physicians
2. Dental history review
   - -Fluoride exposure
   - -Habits
   - -Trauma
   - -Symptomatic teeth
   - -Previous care
   - -Preventive practices
   - -Oral hygiene
   - -Diet assessment
3. Oral/dental assessment
   - -Thorough head, neck, and intraoral examinations
   - -Oral hygiene assessment and training
   - -Radiographic evaluation based on history and clinical findings

For HCT pts, the medical history review includes:

• -Type of transplant
• -HCT source (i.e., bone marrow, peripheral stem cells, cord blood stem cells)
• -Matching status
• -Donor
• -Conditioning protocol
• -Date of transplant
• -Presence of GVHD or signs of transplant rejection

Question 261

What are the preventive strategies before the initiation of cancer therapy?

Answer 261

1. Oral hygiene
   - -Brushing of the teeth and tongue 2-3 times daily with regular soft nylon brush or electric toothbrush, regardless of the hematological status.
   - -Ultrasonic brushes and dental floss should be allowed only if the pt is properly trained.
   - -Pts with poor oral hygiene and/or periodontal disease may use chlorhexidine rinses daily until the tissue health improves or mucositis develops.
   - -The high alcohol content of commercially-available chlorhexidine mouthwash may cause discomfort and dehydrate the tissues in pts with mucositis; thus, an alcohol-free chlorhexidine solution is indicated in this situation.
2. Diet
   - -Non-cariogenic diet.
   - -Advise pts/parents about high cariogenic potential of dietary supplements rich in carbohydrates and oral pediatric medications rich in sucrose.
3. Fluoride
   - -Use of fluoridated toothpaste or gel, fluoride supplements if indicated, neutral fluoride gels/rinses, or applications of fluoride varnish for pts at risk for caries and/or xerostomia.
   - -A brush-on technique is convenient and may increase the likelihood of pt compliance with topical fluoride therapy.
4. Trismus prevention/treatment
   - -Pts who receive radiation therapy to the masticatory muscles may develop trismus. Thus, daily oral stretching exercises/physical therapy should start before radiation is initiated and continue throughout treatment.
   - -Therapy for trismus may include prosthetic aids to reduce the severity of fibrosis, trigger-point injections, analgesics, muscle-relaxants, and other pain management strategies.
5. Reduction of radiation to healthy oral tissues
   - -In cases of radiation to the head and neck, the use of lead-lined stents, prostheses, and shields, as well as salivary gland sparing techniques (e.g., three-dimensional conformal or intensity modulated radiotherapy, concomitant cytoprotectants, surgical transfer of salivary glands), should be discussed with the radiation oncologist.
6. Education
   - -Pt/parent education includes the importance of optimal oral care in order to minimize oral problems/discomfort before, during and after treatment and the possible acute and long-term effects of the therapy in the craniofacial complex.

Question 262

What are the hematological considerations for dental care before the initiation of cancer therapy?

Answer 262

Absolute neutrophil count (ANC):

1. If >2,000/mm3: no need for antibiotic prophylaxis
2. If 1,000 to 2,000/mm3: use clinical judgment based on the pt’s health status and planned procedures.
   - -Some authors suggest that antibiotic coverage (dosed per AHA recommendations) may be prescribed may be prescribed when the ANC is between 1,000 and 2,000/mm3.
   - -If infection is present or unclear, more aggressive antibiotic therapy may be indicated and should be discussed with the medical team.
3. If

Question 263

During a phase/cycle of chemotherapy, when does the blood count normally start falling?

Answer 263

The pt’s blood count normally start falling 5 to 7 days after the beginning of each cycle, staying low for approximately 14 to 21 days, before rising again to normal levels for a few days until the next cycle begins.

Question 264

When should dental care be completed for a cancer pt?

Answer 264

1. Ideally, all dental care should be completed before cancer therapy is initiated.
   - -When that is not feasible, temporary restorations may be placed and non-acute dental treatment may be delayed until the pt’s hematological status is stable.

Question 265

What dental procedures should be completed first for a cancer pt?

Answer 265

1. Prioritizing procedures: when all dental needs cannot be treated before cancer therapy is initiated, priorities should be infections, extractions, periodontal care (e.g., scaling, prophylaxis) and sources of tissue irritation before the treatment of carious teeth, root canal therapy for permanent teeth, and replacement of faulty restorations.
   - -The risk for pulpal infection and pain determine which carious lesions should be treated first.
   - -It is important to be aware that the signs and symptoms of periodontal disease may be decreased in immuno-suppressed teeth.

Question 266

For a cancer pt, how are treatment decisions different?

Answer 266

1. Incipient to small carious lesions may be treated with fluoride and/or sealants until definitive care can be accomplished.
2. Pulp therapy in primary teeth: although there have no studies to date that address the safety of performing pulp therapy in primary teeth prior to the initiation of chemotherapy and/or radiotherapy, many clinicians choose to provide a more definitive treatment in the form of extraction bc pulpal/periapical/furcal infections during immunosuppression periods can become life-threatening.
   - -Teeth that already have been treated pulpally and are clinically and radiographically sound should be monitored periodically for signs of internal resorption or failure due to pulpal/periapical/furcal infections.
3. Endodontic treatment in permanent teeth: symptomatic non-vital permanent teeth should receive root canal treatment at least one week before initiation of cancer therapy to allow sufficient time to assess treatment success before the chemotherapy. If that is not possible, extraction is indicated.
   - -Extraction is also the treatment of choice for teeth that cannot be treated by definitive endodontic treatment in a single visit. In that case, the extraction should be followed by antibiotic therapy (penicillin or, for penicillin-allergic pts, clindamycin) for about one week.
   - -Endodontic treatment of asymptomatic non-vital permanent teeth may be delayed until the hematological status of the pt is stable.
   - -It is important that the etiology of periapical lesions associated with previously endodontically treated teeth be determined bc they can be due to a number of factors including pulpal infections, inflammatory reactions, apical scars, cysts, and malignancy.
   - -If a periapical lesion is associated with an endodontically treated tooth and no signs or symptoms of infection are present, there is no need for retreatment or extraction since the radiolucency likely is due to an apical scar.

Question 267

For a cancer pt, what should be done about orthodontic appliances and space maintainers?

Answer 267

1. Poorly fitting appliances can abrade oral mucosa and increase the risk of microbial invasion into deeper tissues.
2. Appliances should be removed if the pt has poor oral hygiene and/or the treatment protocol or HCT conditioning regimen carries a risk for the development of moderate to severe mucositis.
3. Simple appliances (e.g., band and loops, fixed lower lingual arches) that are not irritating to the soft tissues may be left in place in pts who present good oral hygiene.
4. Removable appliances and retainers that fit well may be worn as long as tolerated by the pt who maintains good oral care.
5. Pts should be instructed to clean their appliance daily and routinely clean appliance cases with an antimicrobial solution to prevent contamination and reduce the risk of appliance-associated oral infections.
6. If band removal is not possible, vinyl mouth guards or orthodontic wax should be used to decrease tissue trauma.

Question 268

What periodontal considerations should be given for cancer pts?

Answer 268

1. Partially erupted molars can become a source of infection bc of pericoronitis.
   - -The overlying gingival tissue should be excised if the dentist believes it is a potential risk and if the hematological status permits.
2. Pts should have a periodontal assessment and appropriate therapy prior to receiving bisphosphonates as part of cancer treatment.
3. If the pt has had bisphosphonates and an invasive periodontal procedure is indicated, risks must be discussed with the pt, parents and physicians prior to the procedure.
4. Extraction is the treatment of choice for teeth with a poor prognosis that cannot be treated by definitive periodontal therapy.

Question 269

Should prophylactic antibiotics be given for a cancer pt undergoing extractions?

Answer 269

1. There are no clear recommendations for the use of prophylactic antibiotics for extractions. Recommendations generally have been empiric or based on anecdotal experience.
2. If there is documented infection associated with the tooth, antibiotics (ideally chosen with the benefit of sensitivity testing) should be administered for about one week.

Question 270

How should extractions be completed for a cancer pt?

Answer 270

Surgical procedures must be as atraumatic as possible, with no sharp bony edges remaining and satisfactory closure of the wounds.

Question 271

For a cancer pt, how can you reduce the risk of development of osteonecrosis, osteoradionecrosis, or bisphosphonate-related osteonecrosis of the jaw (BRONJ)?

Answer 271

1. To minimize the risk of development of osteonecrosis, osteoradionecrosis, or bisphosphonate-related osteonecrosis of the jaw (BRONJ), pts who will receive radiation to the jaws or bisphosphonate treatment as part of the cancer therapy must have all oral surgical procedures completed before those measures are instituted.
2. If the pt has received bisphosphonates or radiation to the jaws and an oral surgical procedure is necessary, risks must be discussed with the pt, parents and physician prior to the procedure.
3. In pts undergoing long-term potent, high-dose intravenous bisphosphonates, there is an increased risk of BRONJ after a tooth extraction ro with periodontal diseaes, although most of the evidence has been described in the adult population.
4. Pts with a high risk of BROJ are best managed by a dental specialist in coordination with the oncology team in the hospital setting.

Question 272

When should be teeth be extracted prior to initiation of cancer therapy?

Answer 272

1. Loose primary teeth should be allowed to exfoliate naturally.
2. Nonrestorable teeth, root tips, teeth with periodontal pockets greater than 6mm, symptomatic impacted teeth, and teeth exhibiting acute infections, significant bone loss, involvements of the furcation, or mobility should be removed ideally two weeks (r at least 7-10 days) before cancer therapy is initiated to allow adequate healing.
3. Some practitioners prefer to extract all third molars that are not fully erupted, particularly prior to HCT, while others favor a more conservative approach, recommending extraction of a third molar at risk for pulpal infection or those associated with with significant pathology, infection, periodontal disease or pericoronitis or if the tooth is malpositioned or non-functional.

Question 273

What are the objectives of dental/oral care during cancer therapy?

Answer 273

1. To maintain optimal oral health during cancer therapy.
2. To manage any oral side effects that may develop as a consequence of the cancer therapy.
3. To reinforce the pts and parents’ education regarding the importance of optimal oral care in order to minimize oral problems/discomfort during treatment.

Question 274

What are the preventive strategies for a cancer pt during immunosuppression periods?

Answer 274

1. Thrombocytopenia should not be the sole determinant of oral hygiene as pts are able to brush without bleeding at widely different levels of platelet count.
2. Pts should use a soft nylon brush 2 to 3 times daily and replace it on a regular (every two to three months) basis.
3. Fluoridated toothpaste may be used but, if the pt does not tolerate it during periods of mucositis due to oral burning or stinging sensations, it may be discontinued and the pt should switch to mild-flavored non-fluoridated toothpaste
4. If moderate to severe mucositis develops and the pt cannot tolerate a regular soft nylon toothbrush or an end-tufted brush, foam brushes or super soft brushes soaked in chlorhexidine may be used.
   - -Otherwise, foam or super soft brushes should be discouraged bc they do not follow allow for effective cleaning.
   - -The use of a regular brush should be resumed as soon as the mucositis improves.
5. Brushes should be air-dried between uses. Electric or ultrasonic brushes are acceptable if the pt is capable of using them without causing trauma and irritation.
6. If the pts are skilled at flossing without traumatizing the tissues, it is reasonable to continue flossing throughout the treatment.
7. Toothpicks and water irrigation devices should not be used when the pt is pancytopenic to avoid tissue.

Question 275

What kind of lip care is done for a cancer pt during immunosuppression periods?

Answer 275

Lip care: Lanolin-based creams and ointments are more effective in moisturizing and protecting against damage than petrolatum-based products.

Question 276

What kind of dental care is done for a cancer pt during immunosuppression periods?

Answer 276

1. During immunosuppression, elective dental care should not be provided.
   - -If a dental emergency arises, the treatment plan should be discussed with the pt’s physician who will make recommendations for supportive medical therapies (e.g., antibiotics, platelet transfusions, analgesia).
2. The pt should be seen every six months (or in shorter intervals if there is a risk of xerostomia, caries, trismus, and/or chronic oral GVHD) for an oral health evaluation during treatment , in times of stable hematological status and always after reviewing the medical history.

Question 277

What are the oral conditions related to cancer therapies?

Answer 277

1. Mucositis
2. Oral mucosal infections
3. Oral bleeding
4. Dental sensitivity/pain
5. Xerostomia
6. Trismus

Question 278

What is the treatment for mucositis?

Answer 278

1. Mucositis care remains focused on palliation of symptoms and efforts tor educe the influence of secondary factors on mucositis.
2. The most common prescriptions for management of mucositis include:
   - -Good oral hygiene
   - -Analgesics
   - -Non-medicated oral rinses (e.g., 0.9% saline or sodium bicarbonate mouth rinses 4-6 times/day)
   - -Parenteral nutrition as needed
3. Mucosal coating agents (e.g., Amphojel, Kaopectate, hydroxypropylmethylcellulose) and film-forming agents (e.g., Zilactin and Gelclair) also have been suggested.
4. The use of palifermin, also known as keratinocyte growth factor-1, for prevention of oral mucositis associated with HCT and oral cryotherapy as prophylaxis and treatment to decrease mucositis recently have been recommended.
   - -Palifermin has been observed to decrease the incidence and duration of severe oral mucositis in pts undergoing conditioning with high-dose chemotherapy, with or without radiotherapy, followed by HCT.
   - -The guidelines, however, did not recommend the use of sucralfate, antimicrobial lozenges, pentoxifylline, and granulocyte-macrophage-colony stimulating factor mouthwash for mucositis.
5. There is limited, but encouraging, evidence to support the use of low-level laser therapy to decrease the duration of chemotherapy-induced oral mucositis.
6. Studies on the use of chlorhexidine for mucositis have given conflicting results.
   - -Most studies have not demonstrated a prophylactic impact, although reduced colonization of candidial species has been shown.
   - -Chlorhexidine is no longer recommended for preventing oral mucositis in pts undergoing radiotherapy.
7. Pt controlled analgesia has been helpful in relieving pain associated with mucositis, reducing the requirement for oral analgesics.
8. There is no significant evidence of the effectiveness or tolerability of mixtures containing topical anesthetics (e.g., Philadelphia mouthwash, magic mouthwash).
   - -Topical anesthetics only provide short term pain relief.
   - -Lidocaine use may obtund or diminish taste and the gag reflex and/or result in a burning sensation, in addition to possible cardiovascular and central nervous system effects.

Question 279

What is important to consider in oral mucosal infections for a cancer pt during immunosuppression periods?

Answer 279

1. The signs of inflammation and infection may be greatly diminished during neutropenic periods. Thus, the clinical appearance of infections may differ significantly from the normal.
2. Oral cultures and/or biopsies of all suspicious lesions should be performed and prophylactic medications should be initiated until more specific therapy can be prescribed.

Question 280

Does prophylactic nystatin prevent or treat fungal infections in a cancer pt during immunosuppression?

Answer 280

1. No. Prophylactic nystatin is not effective for the prevention and/or treatment of fungal infections.

Question 281

What is the cause of oral bleeding for a cancer pt during immunosuppression?

Answer 281

1. Oral bleeding occurs due to thrombocytopenia, disturbance of coagulation factors, and/or damaged vascular integrity.

Question 282

How do you manage oral bleeding for a cancer pt during immunosuppression?

Answer 282

1. Management should consist of local approaches (e.g., pressure packs, antifibrinolytic rinses or topical agents, gelatin sponges) and systemic measures (e.g., platelet transfusions, aminocaproic acid).

Question 283

What is the cause of dental sensitivity/pain for a cancer pt during immunosuppression?

Answer 283

1. Tooth sensitivity could be related to decreased secretion of saliva during radiation therapy and the lowered salivary pH.
2. Pts who are using plant alkaloid chemotherapeutic agents (e.g., vincristine, vinblastine) may present with deep, constant pain affecting the mandibular molars with greater frequency, in the absence of odontogenic pathology.
   - -The pain usually is transient and generally subsides shortly after dose reduction and/or cessation of chemotherapy.

Question 284

How do you manage xerostomia for a cancer pt during immunosuppression?

Answer 284

1. Sugar-free chewing gum or candy, sucking tablets, special dentifrices for oral dryness, saliva substitutes, frequent sipping of water, alcohol-free oral rinses, and/or oral moisturizers are recommended.
2. Placing a humidifier by bedside at night may be useful.
3. Fluoride rinses and gels are recommended highly for caries prevention in these pts.
4. Saliva stimulating drugs are not approved for use in children.

Question 285

How do you manage trismus for a cancer pt during immunosuppression?

Answer 285

1. Daily oral stretching exercises/physical therapy must continue during radiation treatment.
2. Management of trismus may include prosthetic aids to reduce the severity of fibrosis, trigger-point injections, analgesics, muscle relaxants, and other pain management strategies.

Question 286

What are the objectives of a dental exam after cancer therapy is completed?

Answer 286

1. To maintain optimal oral health.
2. To reinforce to the pt/parents the importance of optimal oral and dental care for life.
3. To address and/or treat any dental issues that may arise as a result of the long-term effects of cancer therapy.

Question 287

What are the toothbrushing recommendations for a cancer pt before, during, and after cancer therapy?

Answer 287

1. Brush two to three times daily with a soft nylon toothbrush, regardless of the hematological status.
   - -Thrombocytopenia should not be the sole determinant of oral hygiene as pts are able to brush without bleeding at widely different levels of platelet count.
   - -Brushes should be air-dried between uses.
   - -Electric or ultrasonic brushes are acceptable if the pt is capable of using them without causing trauma and irritation. It pts are skilled at flossing without traumatizing the tissues, it is reasonable to continue flossing throughout treatment.
2. During immunosuppression, if moderate to severe mucositis develops and the pt cannot tolerate a regular soft nylon toothbrush or an end-tufted brush, foam brushes or super soft brushes soaked in chlorhexidine may be used. Otherwise, foam or super soft brushes should be discouraged bc they do not allow for effective cleaning. The use of a regular brush should be resumed as soon as mucositis improves.
3. The high alcohol content of commercially-available chlorhexidine mouthwash may cause discomfort and dehydrate the tissues in pts with mucositis; thus, an alcohol-free chlorhexidine solution is indicated in this situation.

Question 288

After cancer therapy is completed, how often does the pt need to be seen for periodic evaluations?

Answer 288

1. The pt should be seen at least every 6 months (or in shorter intervals if issues such as chronic oral GVHD, xerostomia, or trismus are present).
   - -Pts who have experienced moderate or severe mucositis and/or chronic oral GVHD should be followed closely for malignant transformation of their oral mucosa (e.g., oral squamous cell carcinoma).

Question 289

After cancer therapy is completed, when can orthodontic treatment begin?

Answer 289

1. Orthodontic care may start or resume after completion of all therapy and after at least a two year disease-free survival when the risk of relapse is decreased and the pt is no longer using immunosuppressive drugs.
   - -A thorough assessment of any dental developmental disturbances caused by the cancer therapy must be performed before initiating orthodontic treatment.

Question 290

If you do orthodontic treatment after cancer therapy is completed, what considerations do you need to have?

Answer 290

1. The following strategies should be considered when providing orthodontic care for pts with dental sequelae:
   (1) Use appliances that minimize the risk of root resorption.
   (2) Use lighter forces.
   (3) Terminate treatment earlier than normal.
   (4) Choose the simplest method for the treatment needs.
   (5) Do not treat the lower jaw.
2. Patients who have used or will be given bisphosphonates in the future present a challenge for orthodontic care.
   - -Although bisphosphonate inhibition of tooth movement has been reported in animals, it has not been quantified for any dose or duration of therapy in humans.

Question 291

What considerations do you give for oral surgery procedures for a pt after cancer therapy is completed?

Answer 291

1. Elective invasive procedures should be avoided in these pts.
2. Non-elective oral surgical and invasive periodontal procedures in pts who have used or are using bisphosphonates or those who received radiation therapy to the jaw have a risk of osteonecrosis and osteoradionecrosis, respectively. Consultation with oral surgeon and/or periodontist and the pt’s physician is recommended.
3. Pts with a high risk of BRONJ are best managed by in coordination with the oncology team in the hospital setting.

Question 292

What are the oral complications associated with hematopoietic cell transplantation?

Answer 292

Specific oral complications can be correlated with phases of HCT.

1. Phase I: Preconditioning
   - -The oral complications are related to the current systemic and oral health, oral manifestations of the underlying condition, and oral complications of recent medical therapy.
   - -Oral complications observed include oral infections, gingival leukemic infiltrates, bleeding, ulceration, temporomandibular dysfunction.
2. Phase II: Conditioning neutropenic phase
   - -In this phase, which encompasses the day the pt is admitted to the hospital to begin the transplant conditioning to 30 days post-HCT, the oral complications are related to the conditioning regimen and supportive medical therapies.
   - -Oral complications observed include mucositis, xerostomia, oral pain, hemorrhage, opportunistic infections, taste dysfunction, neurotoxicity (including dental pain, muscle tremors) and temporomandibular dysfunction (including jaw pain, headache, joint pain), typically with a high prevalence and severity of oral complications.
   - —-Oral mucositis usually begins 7 to 10 days after initiation of conditioning, and symptoms continue approximately two weeks after the end of conditioning.
   - —-Among allogeneic transplant pts, hyperacute GVHD can occur, causing more severe inflammation and severe mucositis symptoms, although its clinical presentation is difficult to diagnose.
3. Phase III: Engraftment to hematopoietic recovery
   - -The intensity and severity of complications begin to decrease normally 3 to 4 weeks after transplantation.
   - -Oral fungal infections and herpes simplex virus infection are most notable.
   - -Acute GVHD can become a concern for allogeneic graft recipients.
   - -Xerostomia, hemorrhage, neurotoxicity, temporomandibular dysfunction, and granulomas/papillomas sometimes are observed.
   - -HCT pts are particularly sensitive to intraoral thermal stimuli between 2 and 4 months post-transplant. The mechanism is not well understood, but the symptoms usually resolve spontaneously within a few months. Topical application of neutral fluoride or desensitizing toothpastes helps reduce the symptoms.
4. Phase IV: Immune reconstitution/recovery from systemic toxicity
   - -After day 100 post-HCT, the oral complications predominantly are related to the chronic toxicity associated with the conditioning regimen, including salivary dysfunction, craniofacial growth abnormalities, late viral infections, oral chronic GVHD, and oral squamous cell carcinoma.
   - -Xerostomia and relapse-related oral lesions may also be observed.
   - -Unless the pt is neutropenic or with severe chronic GVHD, mucosal bacterial infections are less frequently seen.
5. Phase V: Long-term survival
   - -Craniofacial, skeletal, and dental developmental issues are some of the complications face by cancer survivors and usually develop among children who were less than 6 years of age at the time of their cancer therapy.
   - -Long term effects of cancer therapy may include tooth agenesis, microdontia, crown disturbances (size, shape, enamel hypoplasia, pulp chamber anomalies), root disturbances (earl y apical closure, blunting, changes in shape or length), reduced mandibular length, and reduced alveolar process height.
   - -The severity of the dental developmental anomaly will depend on the age and stage of development during exposure to cytotoxic agents or ionizing radiation.
   - -Pts may experience permanent salivary gland hypofunction/dysfunction or xerostomia.
   - -Relapse or secondary malignancies can develop at this stage.

Question 293

What are the differences in the principles of dental and oral care before cancer therapy and before hematopoietic cell transplantation?

Answer 293

The two major differences are:

1. In HCT, the pt receives all the chemotherapy and/or total body irradiation in just a few days before the transplant.
2. There will be prolonged immunosuppression following the transplant. Elective dentistry will need to be postponed until immunological recovery has occurred, at least 100 days following HCT, or longer if chronic GVHD or other complications are present. Therefore, all dental treatment should be completed before the pt becomes immunosuppressed.

Question 294

What dental treatment can be completed during hematopoietic cell transplantation?

Answer 294

1. Phase I: Preconditioning
   - -There will be prolonged immunosuppression following the transplant. Elective dentistry will need to be postponed until immunological recovery has occurred, at least 100 days following HCT, or longer if chronic GVHD or other complications are present. Therefore, all dental treatment should be completed before the pt becomes immunosuppressed.
2. Phase II: Conditioning neutropenic phase
   - -Dental procedures usually are not allowed in this phase due to the pt’s severe immunosuppression. If emergency treatment is necessary, the dentist should consult and coordinate with the attending hematology/oncology team.
3. Phase III: Engraftment to hematopoietic recovery
   - -A dental/oral examination should be performed and invasive dental procedures, including dental cleanings and soft tissue curettage, should be done only if authorized by the HCT team bc of the pt’s continued immunosuppression.
4. Phase IV: Immune reconstitution/recovery from systemic toxicity
   - -Periodic dental examinations with radiographs can be performed, but invasive dental treatment should be avoided in pts with profound impairment of immune function.
   - -Consultation with the pt’s physician and parents regarding the risks and benefits of orthodontic care is recommended.
5. Phase V: Long-term survival
   - -Routine periodic examinations are necessary to provide comprehensive oral healthcare.
   - —-Careful examination of extraoral and intraoral tissues (including clinical, radiographic, and/or additional diagnostic examinations) are integral to diagnosing any secondary malignancies in the head and neck region.
   - -Dental treatment may require a multidisciplinary approach, involving a variety of dental specialists to address the treatment needs of each individual.
   - -Consultation with the pt’s physician is recommended when relapse or the pt’s immunologic status declines.

Question 295

What is consistently reported as a major contributing factor in unfavorable legal judgments against dentists?

Answer 295

Poor or inadequate documentation of pt care consistently is reported as a major contributing factor in unfavorable legal judgments against dentists.

Question 296

Risks management experts recommend what kind of pt record?

Answer 296

Risk management experts recommend a problem-oriented record. After data collection, a list is compiled that includes medical considerations, psychological/behavior constraints, and the oral health needs to be addressed. Problems are listed in order of importance in a standardized fashion making it less likely that an area might be overlooked. The plan identifies a general course of treatment for each problem.

Question 297

What constitutes the initial patient record?

Answer 297

The parent’s/patient’s initial contact with the dental practice, usually via telephone, during this conversation, the receptionist may record basic patient information such as:

1. Patient’s name, nickname, and date of birth.
2. Name, address, and telephone number of parent.
3. Name of referring party.
4. Significant medical history.
5. Chief complaint.

–Such information constitutes the initial dental record. At the first visit to the dental office, additional information would be obtained and a permanent dental record developed.

Question 298

What must be in the patient record?

Answer 298

The dental record must include each of the following specific components:

1. Medical history.
2. Dental history.
3. Clinical assessment.
4. Diagnosis.
5. Treatment recommendations.
6. Progress notes.
7. Acknowledgment of receipt of Notice of Privacy Practices/Health Insurance Portability and Accountability Act (HIPAA) consent.

Question 299

What do you do if the parent cannot provide adequate details regarding a pt’s medical history?

Answer 299

When the parent cannot provide adequate details regarding a pt’s medical history, or if the dentist providing care is unfamiliar with the pt’s medical diagnosis, consultation with the medical health care provider may be indicated.

Question 300

What should you do in the record for pt’s with significant medical conditions?

Answer 300

Records of pts with significant medical conditions should be marked “Medical Alert” in a conspicuous yet confidential manner.

Question 301

What additional information in the medical history is necessary to be obtained for adolescents?

Answer 301

The practitioner should obtain additional information confidentially from teenagers. Topics to be discussed may include:

1. Nutritional and dietary considerations
2. Eating disorders
3. Alcohol and substance abuse
4. Tobacco usage
5. Over-the-counter medications and supplements
6. Body art (e.g., intra- and extraoral piercings, tattoos)
7. Pregnancy

Question 302

When should the medical history be updated?

Answer 302

At each pt visit, the history should be consulted and updated. A written update should be obtained at each recall visit.

Question 303

What are the components of a comprehensive oral examination?

Answer 303

1. General health/growth assessment
2. Pain assessment
3. Extraoral soft tissue examination
4. TMJ assessment
5. Intraoral soft tissue examination
6. Oral hygiene and periodontal health assessment
7. Assessment of the developing occlusion
8. Intraoral hard tissue examination
9. Radiograph assessment, if indicated
10. Caries risk assessment
11. Assessed behavior of child

Question 304

What should the dentist obligated to do when discussing the treatment plan?

Answer 304

1. The dentist is obligated to educate the parent on the need for and benefits of the recommended care, as well as risks, alternatives, and expectations if no intervention is provided.
   - -When deemed appropriate, the pt should be included in these discussions.
   - -The dentist should not attempt to decide what the parent will accept or can afford.
2. After the treatment plan is presented, the parent should have the opportunity to ask questions regarding the proposed care and have concerns satisfied prior to giving informed consent.
3. Documentation should include that the parent appeared to understand and accepted the proposed procedures. Any special restrictions of the parent should be documented.

Question 305

What is the minimal information that the progress note contain?

Answer 305

An entry must be made in the pt’s record that accurately and objectively summarizes each visit. The entry must minimally contain the following information:

1. Date of visit
2. Reason for visit/chief complaint
3. Radiographic exposures and interpretation, if any
4. Treatment rendered including, but not limited to, the type and dosage of anesthetic agents, medications, and/or nitrous oxide/oxygen and type/duration of protective stabilization.
5. Post-operative instructions and prescriptions as needed.

In addition, the entry generally should document:

1. Changes in the medical history, if any
2. Adult accompanying child
3. Verification of compliance with preoperative instructions
4. Reference to supplemental documents
5. Pt behavior guidance
6. Anticipated follow-up visit

Question 306

What is the SOAP standardized note?

Answer 306

SOAP is an acronym for:
“Subjective” or the pt’s response and feeling to treatment.
“Objective” or the observations of the clinician.
“Assessment” or diagnosis of the problem.
“Procedures accomplished and plans” for subsequent problem resolving activities.

Question 307

During orthodontic treatment, what additional information should be contained in the progress note?

Answer 307

During orthodontic treatment, progress notes should include deficiencies in oral hygiene, loose bands and brackets, pt complaints, caries, root resorption, and cancellations and failures.

Question 308

What is informed consent?

Answer 308

1. Informed consent is the process of providing the patient or, in the case of a minor incompetent adult, the parent with relevant information regarding diagnosis and treatment needs so that an educated decision regarding treatment can be made by the patient or parent.
2. The ADA states that dentists are “required to provide information to patients/parents about the dental health problems the dentist observes, the nature of any proposed treatment, the potential benefit and risks associated with that treatment, any alternatives to the treatment proposed, and the potential risks and benefits of alternative treatments, including no treatment.”

Question 309

Who determines the criteria for informed consent?

Answer 309

State laws and court decisions determine the criteria for informed consent.

Question 310

What are the standards for informed consent?

Answer 310

1. Some states follow a patient-oriented standard - that information which a reasonably prudent patient/parent in same or similar circumstances would wish to know.
2. Other states follow a practitioner-oriented standard - that information which a health care provider, practicing within the standard of care, would reasonably provide to a patient/parent in the same circumstances.
3. A hybrid approach, combining the patient-oriented and practitioner-oriented standards, is followed by some states.

• -Regardless of the standard a state has chosen to follow, the treating practitioner must disclose information that he/she considers material to the patient’s/parent’s decision-making process and provide a warning of death or serious bodily injury where that is a known risk of the procedure.
• -The informed consent process generally excludes adverse consequences associated with a simple procedure if the risk of occurrence is considered remote and when such circumstances commonly are understood by the profession to be so.

Question 311

What are some examples of adults that may accompany the pediatric patient and may not be a legal guardian allowed by law to consent to medical procedures?

Answer 311

Examples of such an adult include a grandparent, step-parent, noncustodial parent in instances of divorce, babysitter, or friend of the family.
–A child in foster care or a ward of the state may be accompanied by a caretaker who may or may not be allowed to consent to medical procedures, according to individual state law.

Question 312

What are ways in which you can verify who is authorized to consent for medical treatment for the patient?

Answer 312

1. It is advisable that the oral health care provider obtain a copy of court orders appointing a guardian to verify who is authorized to consent for medical treatment for the patient.
2. One option to consider is obtaining a parent’s authorization via a consent by proxy or power of attorney agreement for any other individual to make dental treatment decisions for a child.
   - -In situations where individuals other than the parent regularly bring the child to the dental office, this can help eliminate doubt as to whether such individual has the legal authority to provide informed consent.
   - —-Practitioners, however, should consult their own attorney in deciding whether to utilize such a form in their own practice.
3. Another option for obtaining authorization for treatment is a telephone conversation with the parent.
   - -The parent should be told there are two people on the telephone and asked to verify the patient’s name, date of birth, and address and to confirm he/she has responsibility for the patient.
   - -The parent is presented with all elements of a valid informed consent followed by documentation in the patient’s chart with signatures.

Question 313

When are practitioners mandated to provide access to translation services?

Answer 313

1. Practitioners may need to provide access to translation services (e.g., in person, by telephone, by subscription to a language line).
2. Practitioners who receive federal funding, as well as those in a significant number of states are mandated to provide these services at no cost to the patient.

Question 314

What is an informed refusal?

Answer 314

1. Informed refusal occurs when the patient/parent refuses the proposed and alternative treatments. The dentist must inform the patient/parent about the consequences of not accepting the proposed treatment and obtain a signed informed refusal.
2. It is recommended by the ADA that informed refusal be documented in the chart and that the practitioner should attempt to obtain an informed refusal signed by the parent for retention in the patient record.
3. An informed refusal, however, does not release the dentist from the responsibility of providing a standard of care.

Question 315

What do you do if the patient refuses treatment?

Answer 315

1. Attempt to obtain an informed refusal signed by the parent for retention in the patient record.
2. If the dentist believes the informed refusal violates proper standards of care, he/she should recommend the pt seek another opinion and/or dismiss the pt from the practice.

Question 316

What should be the layout of a consent form?

Answer 316

1. It is best to use simple words and phrases, avoiding technical terms, so that it may be easily understood.
2. A modified or customized consent form is preferred over a standard form and should be in a format that is readily understandable to a lay person.
3. Overly broad statements such as “any and all treatment deemed necessary…” or “all treatment which the doctor in his/her best medical judgment deems necessary, including but not limited to…” should be avoided.
   - -Courts have determined it to be so broad and unspecific that it does not satisfy the duty of informed consent.
4. Informed consent and informed refusal forms should be procedure specific, with multiple forms likely to be used.
   - -For example, risks associated with restorative procedure will differ from those associated with an extraction.
   - -Separate forms, or separate areas outlining each procedure on the same form, would be necessary to accurately advise the pt regarding each procedure.