Managing Traumatic Injuries in the Young Permanent Dentition










CHAPTER 31 Examination, Diagnosis, and Treatment Planning 451
views, at least one periapical view in each posterior quadrant, and
posterior bitewings (Fig. 31.57). e number of lms should be
dictated by the size of the tooth-bearing areas, the adequacy of
tissue coverage by the size of lms, and the needs of the child. A
12-lm survey (four posterior periapical, two anterior occlusals,
and two posterior bitewing lms) should suce for the older
In orthodontics, CBCT is useful to locate impacted teeth
with more precision than ever before. In the past, the surgeon
would expose the impacted tooth and determine the orienta-
tion of the tooth and its position in relation to adjacent
teeth. Now the dentist and surgeon can view the orientation
of the tooth, its location, and its eect on other teeth prior
to surgery. More importantly, the orthodontist can direct
the surgeon to bond the tooth in a certain position to enhance
the movement of the tooth and provide the most ecient
force vector. CBCT images are also being used to plan
orthognathic surgical procedures. e images provide a much
clearer picture of the malocclusion and the type of skeletal
movement necessary to correct the malocclusion. In addition,
new software allows surgeons to complete virtual surgery
prior to the actual surgery and have preformed bone plates
and surgical splints that t with increased accuracy. As cone
beam technology becomes more sophisticated with smaller
eld size and decreased radiation exposure, the use of tra-
ditional 2D lms will diminish.
4. Small palate size, especially early in the school-aged period,
prevents or complicates maxillary periapical radiography via a
long-cone lm-stabilizing apparatus.
5. Greater anteroposterior length in the posterior occlusion requires
more bitewing coverage.
In the early mixed-dentition period, all tooth-bearing areas
should be surveyed. Supernumerary, missing, and impacted teeth
are the most common issues revealed in the radiographic exam.
e American Academy of Pediatric Dentistry recommends posterior
bitewing lms and a panoramic radiograph or posterior bitewing
lms and selected periapical radiographs. e panoramic radiograph
oers the advantage of showing the TMJ. Denitive TMJ lms
are indicated when there are clinical signs of dysfunction or a
history of TMJ abnormalities. If a more traditional intraoral lm
survey is considered, it should include appropriate anterior occlusal
Figure 31.55 A truncated maxillary view (smaller elds of view) is a
good way to visualize the position of impacted teeth and to reduce radia-
tion to the patient. This type of information gives the clinician a very precise
idea of the tooth position.
A
B
Figure 31.56 Often images of unerupted canines and lateral incisors
are distorted on panoramic radiographs and can be better visualized on
occlusal radiographs. (A) The panoramic radiograph shows little overlap
of the maxillary left canine and lateral incisor. (B) The occlusal radiograph
shows considerable overlap of the same canine and lateral incisor.

452 Part 4 The Transitional Years: Six to Twelve Years
beam. Larger lms may be preferable because they cover more
area in each exposure.
Selection criteria also apply to this age group. Justication of
a full-mouth survey of some type is based on the need to identify
dental developmental problems and pathologic processes. e
number of lms made should reect the adequacy of composite
exposure provided by individual views, using the smallest number
possible that still reveal all necessary areas. In the age range of 6
to 12 years, several lm combinations are possible. No single set
of projections is considered best.
Treatment Planning for
Nonorthodontic Problems
e planning of care for this age group usually centers on orth-
odontic considerations, although many patients require additional
treatment. Some elements of treatment planning that may have
to be addressed but are only peripherally related to orthodontics
include the following:
1. Management of primary caries. Within this age period, many
primary teeth normally exfoliate. A decision to extract a tooth
or restore it must be made with its remaining lifespan in mind
as well as the length of time that the child will be without a
replacement. Prosthetic replacement for a short time may not
be indicated if adequate functional surfaces are available elsewhere
and space maintenance is not indicated.
2. Management of pathology. Some forms of oral pathology, such
as supernumerary teeth, odontomas, or missing teeth, are given
denitive management in this period owing to the childs
increased ability to cooperate and the impending eects of the
problem.
3. Prevention of dental disease. e choice of sealants is made during
this period to protect occlusal surfaces of the teeth. e clinician
school-aged child. It is dicult to determine whether a 12-lm
survey or a panoramic/bitewing combination yields a greater eective
radiation dose. e variables of machine type, collimation, and
lm speed make determination dicult. ere is discussion currently
in the dental imaging literature on whether to switch from the
concept of “as low as reasonably achievable” (ALARA) to “as low
as diagnostically acceptable” (ALADA).
51
Radiographic techniques used in the youngest in this age group
may include modications. e anterior area requires placement
of the lm positioner deeper in the palate to obtain proper orienta-
tion. A lm holding device can be used with a bisecting-angle
technique (Fig. 31.58). e bitewing technique used in this age
group is essentially the same as that used in the preschooler. It
may take more skill to open contacts by careful positioning of the
Figure 31.57 An appropriate radiographic examination in this age group consists of anterior occlusal
radiographs, at least one periapical lm in each posterior quadrant, and posterior bitewing radiographs.
The number of lms should be dictated by the size of the tooth-bearing areas, the adequacy of tissue
coverage by the size of the lms, and the needs of the child.
Figure 31.58 A lm holding device similar to the device shown here
can be used as an anterior lm stabilizer. The prong end is used to hold
a lm in place by the child. A bisecting-angle technique is used.

CHAPTER 31 Examination, Diagnosis, and Treatment Planning 453
14. Prot WR, Fields HW, Sarver DM. Contemporary Orthodontics. 3rd
ed. St Louis: Mosby–Year Book; 2000.
15. Polder BJ, Vant Hof MA, Van der Linden FP, et al. A meta-analysis
of the prevalence of dental agenesis of permanent teeth. Community
Dent Oral Epidemiol. 2004;32:217–226.
16. Pirinen S, Arte S, Apajalahti S. Palatal displacement of canine is
genetic and related to congenital absence of teeth. J Dent Res.
1996;75(10):1742–1746.
17. Frazier-Bowers SA, Scott MR, Cavender A, et al. Mutational analysis
of families aected with molar oligodontia. Connect Tissue Res.
2002;43(2–3):296–300.
18. Sonis AL, Tarbell N, Valachovic RW, et al. Dentofacial development
in long-term survivors of acute lymphoblastic leukemia. A comparison
of three treatment modalities. Cancer. 1990;66(12):2645–2652.
19. Küchler EC, Costa AG, Costa Mde C, et al. Supernumerary teeth
vary depending on gender. Braz Oral Res. 2011;25(1):76–79.
20. Braun A, Appel T, Frentzen M. Endodontic and surgical treat-
ment of a geminated maxillary incisor. Int Endod J. 2003;36:
380–386.
21. Velasco LF, de Araujo FB, Ferreira ES, et al. Esthetic and functional
treatment of a fused permanent tooth: a case report. Quintessence
Int. 1997;28(10):677–680.
22. Botticelli S, Verna C, Cattaneo PM, et al. Two- versus three-
dimensional imaging in subjects with unerupted maxillary canines.
Eur J Orthod. 2011;33:344–349.
23. Baccetti T. Tooth anomalies associated with failure of eruption of
rst and second permanent molars. Am J Orthod Dentofacial Orthop.
2000;118:608–610.
24. Peck S, Peck L, Kataja M. Concomitant occurrence of canine malposi-
tion and tooth agenesis: evidence of orofacial genetic elds. Am J
Orthod Dentofacial Orthop. 2002;122:657–660.
25. Garib DG, Alencar BM, Lauris JR, et al. Agenesis of maxillary lateral
incisors and associated dental anomalies. Am J Orthod Dentofacial
Orthop. 2010;137(6):732.e1.
26. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by
ectopic eruption of the canines. A clinical and radiographic analysis
of predisposing factors. Am J Orthod Dentofacial Orthop.
1988;94(6):503–513.
27. Kurol J, Bjerklin K. Ectopic eruption of maxillary rst permanent
molars: a review. ASDC J Dent Child. 1986;53(3):209–214.
28. Portela MB, Sanchez AL, Gleiser R. Bilateral distal ectopic eruption
of the permanent mandibular central incisors: a case report. Quintes-
sence Int. 2003;34(2):131–134.
29. Kimmel NA, Gellin ME, Bohannan HM, et al. Ectopic eruption of
maxillary rst permanent molars in dierent areas of the United
States. ASDC J Dent Child. 1982;49:294–299.
30. Bjerklin K, Kurol J. Ectopic eruption of the maxillary rst permanent
molar: etiologic factors. Am J Orthod. 1983;84:147–155.
31. Pulver F. e etiology and prevalence of ectopic eruption of
the maxillary rst permanent molar. J Dent Child. 1968;35:
138–146.
32. Ericson S, Kurol J. Early treatment of palatally erupting maxillary
canines by extraction of the primary canines. Eur J Orthod.
1988;10:283–295.
33. Sigler LM, Baccetti T, McNamara JA Jr. Eect of rapid maxillary
expansion and transpalatal arch treatment associated with deciduous
canine extraction on the eruption of palatally displaced canines: a
2-center prospective study. Am J Orthod Dentofacial Orthop.
2011;139(3):e235–e244.
34. Gellin ME, Haley JV. Managing cases of overretention of mandibular
primary incisors when their permanent successors erupt lingually.
ASDC J Dent Child. 1982;49:118–122.
35. Frazier-Bowers SA, Puranik CP, Mahaney MC. e etiology of
eruption disorders—further evidence of a ‘genetic paradigm.’ Semin
Orthod. 2010;16(3):180–185.
36. Prot WR, Vig KWL. Primary failure of eruption: a possible cause
of posterior open-bite. Am J Orthod Dentofacial Orthop.
1981;80:173–190.
must consider how to manage incipient smooth surface and
interproximal lesions of permanent teeth. Topical uoride
regimens should be considered if the patient is determined to
have a high caries risk. At the writing of this edition, new
treatment modalities are being introduced to treat incipient
and early caries. Silver diamine uoride has been discussed
earlier and may be used to treat sensitivity and decay in hypo-
plastic molars. A systematic review of the resin inltration
technique that uses acid pretreatment of interproximal surfaces
followed by inltration with resin into incipient or enamel-based
lesions is eective in the short and medium term.
52,53
4. Health issues. Children with disabilities or serious illnesses are
in a transitional time. e child with cancer, orofacial clefting,
cerebral palsy, or a host of other conditions may need special
consideration in regard to such issues as lifespan, realistic
functional requirements, retention of teeth for growth purposes,
and the role of the appearance of teeth in social acceptance.
Decisions regarding these issues are often complex, and input
from parents, the child, and other professionals is helpful in
decision-making. e dentist’s role is to provide information
about the need for care, the benets anticipated, the alternatives
to care (including no treatment), and the burden of maintenance
of care. ese special patients may challenge the dentists skills
in planning care, and they may require careful and frequent
observation rather than treatment.
Regardless of the specic situation, dental and periodontal
diseases are addressed rst and stabilized. Restorative care is rendered
next, and more denitive prosthodontic or orthodontic treatment
is completed last.
References
1. Hagan PP, Hagan JP, Fields HW Jr, et al. e legal status of informed
consent for behavior management technique in pediatric dentistry.
Pediatr Dent. 1984;6:204–208.
2. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of
the Hand and Wrist. Palo Alto, CA: Stanford University Press; 1959.
3. Baccetti T, Franchi L, McNamara JA Jr. An improved version of the
cervical vertebral maturation (CVM) method for the assessment of
mandibular growth. Angle Orthod. 2002;72:316–323.
4. Baccetti T, Franchi L, Toth LR, et al. Treatment timing for twin-block
therapy. Am J Orthod Dentofacial Orthop. 2000;118:159–170.
5. Ballrick JW, Fields HW, Beck FM, et al. e cervical vertebrae staging
method’s reliability in detecting pre and post mandibular growth.
Orthod Waves. 2013;72(3):105–111.
6. Marshall WA, Tanner JM. Puberty. In: Falkner F, Tanner JM, eds.
Human Growth: A Comprehensive Treatise. Vol 2. New York: Plenum
Press; 1986.
7. Moorrees CA, Fanning EA, Hunt EE Jr. Age variation of formation
stages for ten permanent teeth. J Dent Res. 1963;42:1490–1502.
8. Chertkow S. Tooth mineralisation as an indicator of the pubertal
growth spurt. Am J Orthod Dentofacial Orthop. 1980;77:79–91.
9. Fields HW, Prot WR, Nixon WL, et al. Facial pattern dierences
in long-faced children and adults. Am J Orthod Dentofacial Orthop.
1984;85:217–223.
10. Dickens S, Sarver D, Prot W. Changes in frontal soft tissue
dimensions of the lower face by age and gender. World J Orthod.
2002;3:313–320.
11. Devishree S, Guijari SK, Shubhashini PV. Frenectomy: a review with
the reports of surgical techniques. J Clin Diagn Res.
2012;6(9):1587–1592.
12. Ramord SP. e periodontal index. J Periodontol. 1967;38:602–610.
13. Loe N, Silness J. Periodontal disease in pregnancy. I. Prevalence and
severity. Acta Odontol Scand. 1963;21:533–551.

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CHAPTER 31 Examination, Diagnosis, and Treatment Planning 451 views, at least one periapical view in each posterior quadrant, and posterior bitewings (Fig. 31.57). e number of lms should be dictated by the size of the tooth-bearing areas, the adequacy of tissue coverage by the size of lms, and the needs of the child. A 12-lm survey (four posterior periapical, two anterior occlusals, and two posterior bitewing lms) should suce for the older In orthodontics, CBCT is useful to locate impacted teeth with more precision than ever before. In the past, the surgeon would expose the impacted tooth and determine the orienta-tion of the tooth and its position in relation to adjacent teeth. Now the dentist and surgeon can view the orientation of the tooth, its location, and its eect on other teeth prior to surgery. More importantly, the orthodontist can direct the surgeon to bond the tooth in a certain position to enhance the movement of the tooth and provide the most ecient force vector. CBCT images are also being used to plan orthognathic surgical procedures. e images provide a much clearer picture of the malocclusion and the type of skeletal movement necessary to correct the malocclusion. In addition, new software allows surgeons to complete virtual surgery prior to the actual surgery and have preformed bone plates and surgical splints that t with increased accuracy. As cone beam technology becomes more sophisticated with smaller eld size and decreased radiation exposure, the use of tra-ditional 2D lms will diminish.4. Small palate size, especially early in the school-aged period, prevents or complicates maxillary periapical radiography via a long-cone lm-stabilizing apparatus.5. Greater anteroposterior length in the posterior occlusion requires more bitewing coverage.In the early mixed-dentition period, all tooth-bearing areas should be surveyed. Supernumerary, missing, and impacted teeth are the most common issues revealed in the radiographic exam. e American Academy of Pediatric Dentistry recommends posterior bitewing lms and a panoramic radiograph or posterior bitewing lms and selected periapical radiographs. e panoramic radiograph oers the advantage of showing the TMJ. Denitive TMJ lms are indicated when there are clinical signs of dysfunction or a history of TMJ abnormalities. If a more traditional intraoral lm survey is considered, it should include appropriate anterior occlusal • Figure 31.55 A truncated maxillary view (smaller elds of view) is a good way to visualize the position of impacted teeth and to reduce radia-tion to the patient. This type of information gives the clinician a very precise idea of the tooth position. AB• Figure 31.56 Often images of unerupted canines and lateral incisors are distorted on panoramic radiographs and can be better visualized on occlusal radiographs. (A) The panoramic radiograph shows little overlap of the maxillary left canine and lateral incisor. (B) The occlusal radiograph shows considerable overlap of the same canine and lateral incisor. 452 Part 4 The Transitional Years: Six to Twelve Yearsbeam. Larger lms may be preferable because they cover more area in each exposure.Selection criteria also apply to this age group. Justication of a full-mouth survey of some type is based on the need to identify dental developmental problems and pathologic processes. e number of lms made should reect the adequacy of composite exposure provided by individual views, using the smallest number possible that still reveal all necessary areas. In the age range of 6 to 12 years, several lm combinations are possible. No single set of projections is considered best.Treatment Planning for Nonorthodontic Problemse planning of care for this age group usually centers on orth-odontic considerations, although many patients require additional treatment. Some elements of treatment planning that may have to be addressed but are only peripherally related to orthodontics include the following:1. Management of primary caries. Within this age period, many primary teeth normally exfoliate. A decision to extract a tooth or restore it must be made with its remaining lifespan in mind as well as the length of time that the child will be without a replacement. Prosthetic replacement for a short time may not be indicated if adequate functional surfaces are available elsewhere and space maintenance is not indicated.2. Management of pathology. Some forms of oral pathology, such as supernumerary teeth, odontomas, or missing teeth, are given denitive management in this period owing to the child’s increased ability to cooperate and the impending eects of the problem.3. Prevention of dental disease. e choice of sealants is made during this period to protect occlusal surfaces of the teeth. e clinician school-aged child. It is dicult to determine whether a 12-lm survey or a panoramic/bitewing combination yields a greater eective radiation dose. e variables of machine type, collimation, and lm speed make determination dicult. ere is discussion currently in the dental imaging literature on whether to switch from the concept of “as low as reasonably achievable” (ALARA) to “as low as diagnostically acceptable” (ALADA).51Radiographic techniques used in the youngest in this age group may include modications. e anterior area requires placement of the lm positioner deeper in the palate to obtain proper orienta-tion. A lm holding device can be used with a bisecting-angle technique (Fig. 31.58). e bitewing technique used in this age group is essentially the same as that used in the preschooler. It may take more skill to open contacts by careful positioning of the • Figure 31.57 An appropriate radiographic examination in this age group consists of anterior occlusal radiographs, at least one periapical lm in each posterior quadrant, and posterior bitewing radiographs. The number of lms should be dictated by the size of the tooth-bearing areas, the adequacy of tissue coverage by the size of the lms, and the needs of the child. • Figure 31.58 A lm holding device similar to the device shown here can be used as an anterior lm stabilizer. The prong end is used to hold a lm in place by the child. A bisecting-angle technique is used. CHAPTER 31 Examination, Diagnosis, and Treatment Planning 453 14. Prot WR, Fields HW, Sarver DM. Contemporary Orthodontics. 3rd ed. St Louis: Mosby–Year Book; 2000.15. Polder BJ, Van’t Hof MA, Van der Linden FP, et al. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol. 2004;32:217–226.16. Pirinen S, Arte S, Apajalahti S. Palatal displacement of canine is genetic and related to congenital absence of teeth. J Dent Res. 1996;75(10):1742–1746.17. Frazier-Bowers SA, Scott MR, Cavender A, et al. Mutational analysis of families aected with molar oligodontia. Connect Tissue Res. 2002;43(2–3):296–300.18. Sonis AL, Tarbell N, Valachovic RW, et al. Dentofacial development in long-term survivors of acute lymphoblastic leukemia. A comparison of three treatment modalities. Cancer. 1990;66(12):2645–2652.19. Küchler EC, Costa AG, Costa Mde C, et al. Supernumerary teeth vary depending on gender. Braz Oral Res. 2011;25(1):76–79.20. Braun A, Appel T, Frentzen M. Endodontic and surgical treat-ment of a geminated maxillary incisor. Int Endod J. 2003;36: 380–386.21. Velasco LF, de Araujo FB, Ferreira ES, et al. Esthetic and functional treatment of a fused permanent tooth: a case report. Quintessence Int. 1997;28(10):677–680.22. Botticelli S, Verna C, Cattaneo PM, et al. Two- versus three-dimensional imaging in subjects with unerupted maxillary canines. Eur J Orthod. 2011;33:344–349.23. Baccetti T. Tooth anomalies associated with failure of eruption of rst and second permanent molars. Am J Orthod Dentofacial Orthop. 2000;118:608–610.24. Peck S, Peck L, Kataja M. Concomitant occurrence of canine malposi-tion and tooth agenesis: evidence of orofacial genetic elds. Am J Orthod Dentofacial Orthop. 2002;122:657–660.25. Garib DG, Alencar BM, Lauris JR, et al. Agenesis of maxillary lateral incisors and associated dental anomalies. Am J Orthod Dentofacial Orthop. 2010;137(6):732.e1.26. Ericson S, Kurol J. Resorption of maxillary lateral incisors caused by ectopic eruption of the canines. A clinical and radiographic analysis of predisposing factors. Am J Orthod Dentofacial Orthop. 1988;94(6):503–513.27. Kurol J, Bjerklin K. Ectopic eruption of maxillary rst permanent molars: a review. ASDC J Dent Child. 1986;53(3):209–214.28. Portela MB, Sanchez AL, Gleiser R. Bilateral distal ectopic eruption of the permanent mandibular central incisors: a case report. Quintes-sence Int. 2003;34(2):131–134.29. Kimmel NA, Gellin ME, Bohannan HM, et al. Ectopic eruption of maxillary rst permanent molars in dierent areas of the United States. ASDC J Dent Child. 1982;49:294–299.30. Bjerklin K, Kurol J. Ectopic eruption of the maxillary rst permanent molar: etiologic factors. Am J Orthod. 1983;84:147–155.31. Pulver F. e etiology and prevalence of ectopic eruption of the maxillary rst permanent molar. J Dent Child. 1968;35: 138–146.32. Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod. 1988;10:283–295.33. Sigler LM, Baccetti T, McNamara JA Jr. Eect of rapid maxillary expansion and transpalatal arch treatment associated with deciduous canine extraction on the eruption of palatally displaced canines: a 2-center prospective study. Am J Orthod Dentofacial Orthop. 2011;139(3):e235–e244.34. Gellin ME, Haley JV. Managing cases of overretention of mandibular primary incisors when their permanent successors erupt lingually. ASDC J Dent Child. 1982;49:118–122.35. Frazier-Bowers SA, Puranik CP, Mahaney MC. e etiology of eruption disorders—further evidence of a ‘genetic paradigm.’ Semin Orthod. 2010;16(3):180–185.36. Prot WR, Vig KWL. Primary failure of eruption: a possible cause of posterior open-bite. Am J Orthod Dentofacial Orthop. 1981;80:173–190.must consider how to manage incipient smooth surface and interproximal lesions of permanent teeth. Topical uoride regimens should be considered if the patient is determined to have a high caries risk. At the writing of this edition, new treatment modalities are being introduced to treat incipient and early caries. Silver diamine uoride has been discussed earlier and may be used to treat sensitivity and decay in hypo-plastic molars. A systematic review of the resin inltration technique that uses acid pretreatment of interproximal surfaces followed by inltration with resin into incipient or enamel-based lesions is eective in the short and medium term.52,534. Health issues. Children with disabilities or serious illnesses are in a transitional time. e child with cancer, orofacial clefting, cerebral palsy, or a host of other conditions may need special consideration in regard to such issues as lifespan, realistic functional requirements, retention of teeth for growth purposes, and the role of the appearance of teeth in social acceptance. Decisions regarding these issues are often complex, and input from parents, the child, and other professionals is helpful in decision-making. e dentist’s role is to provide information about the need for care, the benets anticipated, the alternatives to care (including no treatment), and the burden of maintenance of care. ese special patients may challenge the dentist’s skills in planning care, and they may require careful and frequent observation rather than treatment.Regardless of the specic situation, dental and periodontal diseases are addressed rst and stabilized. Restorative care is rendered next, and more denitive prosthodontic or orthodontic treatment is completed last.References1. Hagan PP, Hagan JP, Fields HW Jr, et al. e legal status of informed consent for behavior management technique in pediatric dentistry. Pediatr Dent. 1984;6:204–208.2. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist. Palo Alto, CA: Stanford University Press; 1959.3. Baccetti T, Franchi L, McNamara JA Jr. An improved version of the cervical vertebral maturation (CVM) method for the assessment of mandibular growth. Angle Orthod. 2002;72:316–323.4. Baccetti T, Franchi L, Toth LR, et al. Treatment timing for twin-block therapy. Am J Orthod Dentofacial Orthop. 2000;118:159–170.5. Ballrick JW, Fields HW, Beck FM, et al. e cervical vertebrae staging method’s reliability in detecting pre and post mandibular growth. Orthod Waves. 2013;72(3):105–111.6. Marshall WA, Tanner JM. Puberty. In: Falkner F, Tanner JM, eds. Human Growth: A Comprehensive Treatise. Vol 2. New York: Plenum Press; 1986.7. Moorrees CA, Fanning EA, Hunt EE Jr. Age variation of formation stages for ten permanent teeth. J Dent Res. 1963;42:1490–1502.8. Chertkow S. Tooth mineralisation as an indicator of the pubertal growth spurt. Am J Orthod Dentofacial Orthop. 1980;77:79–91.9. Fields HW, Prot WR, Nixon WL, et al. Facial pattern dierences in long-faced children and adults. Am J Orthod Dentofacial Orthop. 1984;85:217–223.10. Dickens S, Sarver D, Prot W. Changes in frontal soft tissue dimensions of the lower face by age and gender. World J Orthod. 2002;3:313–320.11. Devishree S, Guijari SK, Shubhashini PV. Frenectomy: a review with the reports of surgical techniques. J Clin Diagn Res. 2012;6(9):1587–1592.12. Ramord SP. e periodontal index. J Periodontol. 1967;38:602–610.13. Loe N, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand. 1963;21:533–551. 454 Part 4 The Transitional Years: Six to Twelve Years37. Rasmussen P, Kotsaki A. Inherited primary failure of eruption in the primary dentition: report of ve cases. ASDC J Dent Child. 1997;64(1):43–47.38. Frazier-Bowers SA, Koehler KE, Ackerman JL, et al. Primary failure of eruption: further characterization of a rare eruption disorder. Am J Orthod Dentofacial Orthop. 2007;131(5):578.e1.39. Akyalcin S, Dyer DJ, English JD, et al. Comparison of 3-dimensional dental models from dierent sources: diagnostic accuracy and surface registration analysis. Am J Orthod Dentofacial Orthop. 2013;144(6):831–837.40. Bolton WA. Disharmony in tooth size and its relation to the analysis and treatment of malocclusion. Am J Orthod Dentofacial Orthop. 1958;28:113–130.41. Tanaka MM, Johnston LE. e prediction of the size of unerupted canines and premolars in a contemporary orthodontic population. J Am Dent Assoc. 1974;88:798–801.42. Fields HW, Sinclair PM. Dentofacial growth and development. ASDC J Dent Child. 1990;57:46–55.43. McNamara JA Jr. A method of cephalometric analysis. In: McNamara JA, Ribbens KA, Howe RP, eds. Clinical Alteration of the Growing Face. Monograph 12, Craniofacial Growth Series. Ann Arbor, MI: University of Michigan, Center for Human Growth and Development; 1983:81–105.44. Harvold EP. e Activator in Orthodontics. St Louis: Mosby; 1974.45. Isaacson JR, Isaacson RJ, Speidel TM, et al. Extreme variation in vertical facial growth and associated variation in skeletal and dental relations. Am J Orthod Dentofacial Orthop. 1971;41:219–229.46. Wylie WL, Johnson EL. Rapid evaluation of facial dysplasia in the vertical plane. Angle Orthod. 1952;22:165–182.47. Steiner CC. e use of cephalometrics as an aid to planning and assessing orthodontic treatment. Am J Orthod Dentofacial Orthop. 1960;46:721–735.48. Ricketts RM. Perspectives in the clinical application of cephalometrics. Angle Orthod. 1981;51:115–150.49. Jacobs SG. Localization of the unerupted maxillary canine: how to and when to. Am J Orthod Dentofacial Orthop. 1999;115(3):314–322.50. Ludlow JB, Timothy R, Walker C, et al. Eective dose of dental CBCT—a meta analysis of published data and additional data for nine CBCT units. Dentomaxillofac Radiol. 2014;44(1):20140197.51. Jaju PP, Jaju SP. Cone-beam computed tomography: time to move from ALARA to ALADA. Imaging Sci in Dent. 2015;45(4):263–265.52. Tinano N, Coll JA, Dhar V, et al. Evidence-based update of pediatric dental restorative procedures: preventive strategies. J Clin Pediatr Dent. 2015;39(3):193–197.53. Ammari MM, Soviero VM, da Silva Fidalgo TK, et al. Is non-cavitated proximal lesion sealing an eective method for caries control in primary and permanent teeth? A systematic review and meta-analysis. J Dent. 2014;42(10):1217–1227. CHAPTER 31 Examination, Diagnosis, and Treatment Planning 454.e1 Case Study: Orthodontic Considerations in Dental TraumaBeau D. MeyerThe astute clinician approaches cases of dental trauma by weighing the risks and benets of multiple treatment options, especially in cases involving more than one tooth. One must consider how the child’s condition will shape short-, intermediate-, and long-term treatment needs and outcomes. The clinical decision often leverages the benets of some factors at the expense of others while keeping the child’s overall oral health in context. It is essential to see past the immediate trauma management and understand that treatment decisions made early often dictate how the child can and will be managed in the future. One way to appreciate this approach is to reason backwardly, beginning with long-term considerations.Case DescriptionA 14-year-old female avulsed the upper right lateral incisor (#7) and the upper left central incisor (#9) after being hit by a softball bat during practice. Only one tooth was located and was placed in milk upon arrival to the emergency department (<30 minutes total dry time). The tooth was replanted, and the patient was discharged to a dentist for splinting 6 hours and 30 minutes after the trauma. Clinical exam revealed an unrepaired upper lip laceration continuous with a gingival laceration facial to #9, two avulsion sites, and tooth #9, which was recovered at the scene, had been replanted in the #7 site at the emergency room. Radiographic examination revealed a dentoalveolar fracture apical to #8 (Fig. E31.1). Tooth #7 was lost at the scene.Long-Term ConsiderationsThe overall plan for any child with a traumatic dental injury is inuenced by the status of the traumatized teeth. In managing the immediate needs of an avulsed tooth, the dentist must forecast potential replacement options in context of the overall problem list (Table E31.1). The suitability of each option ABCDEF• Figure E31.1 (A) Limited intraoral frontal view shows the central incisors in an incisal position relative to the left lateral incisor. In addition, note the left central incisor was replanted in the site of the avulsed right lateral incisor providing atypical incisal edges and embrasures. (B) Limited intraoral occlusal view showing the central incisors well palatal to the remaining arch form. (C) Intraoral periapical radiograph; note the size mismatch between the root of the left central incisor replanted into the socket of the right lateral incisor. Also note the alveolar fracture extending from the mesial wall of the right lateral incisor socket to what is left of the left central incisor socket. (D) Panoramic radiograph obtained 1 week posttrauma; note the missing maxillary right rst molar, the coronal radiolucency on the maxillary left and mandibular right rst molars, and the periapical radiolucency on the mandibular right rst molar. (E) Intraoral frontal view showing a reapproximated and functional occlusion 1 week posttrauma using orthodontic splinting/repositioning. (F) Intraoral occlusal view 1 week posttrauma showing the corrected arch form. In addition, note the extensive mesio-occlusal decay and creamy white color of the maxillary left rst molar. Continued 454.e2 Part 4 The Transitional Years: Six to Twelve Yearsdepends on the age of the patient, condition of the remaining dentition, growth, and the type of malocclusion. One condition of particular importance is ankylosis. The timing of ankylosis in relation to the child’s growth status inuences the degree of infraocclusion and is the critical factor in treatment decisions. If ankylosis occurs before age 10 or before the growth spurt, intervention is necessary to prevent unfavorable hard and soft tissue defects. The problem is determining if and when a tooth will ankylose. Because of this uncertainty, it is recommended to avoid orthodontic treatment on the traumatized dentition for 12 months.Orthodontic treatment planning in cases of trauma and this case in particular should consider tooth replacement (see Table E31.1), odds of tooth survival, and the condition of supporting bone and soft tissue to optimize esthetics. The supporting tissues, as well as root size and proximity, can make creating an ideal esthetic emergence prole difcult. The crown-to-root ratio is another consideration and may be unfavorable (see Fig. E31.1).Beyond the complications of dental trauma, this child also has molar-incisor hypomineralization (MIH). The pulp status and restorability of symptomatic hypomineralized molars is often questioned and can greatly inuence the orthodontic treatment plan. If the child were to lose teeth #7, #8, and #9 as a result of trauma, and the rst molars due to MIH, then orthodontic treatment would become exceedingly complex.Intermediate-Term ConsiderationsThe clinician should acknowledge two important factors during the intermediate stage. First, the occlusion should be free of any traumatic interferences to allow healing. Equilibration of the traumatized tooth may eliminate traumatic occlusion, but often the amount of tooth removal necessary creates pulpal and restorative problems. Orthodontic splinting/repositioning is an alternative option that can stabilize the tooth and provide a functional occlusion.Second, pulpal status and root development of traumatized and adjacent teeth must be monitored. In many cases the initial trauma management focuses on periodontal ligament (PDL) stabilization—the pulp can be addressed in the days following the trauma. Sensibility testing should be conducted at each follow-up and intervention completed as appropriate.Short-Term ConsiderationsFor immediate trauma management, the focus is to stabilize the child’s condition while keeping as many potential future options open as possible. In many cases, maintaining teeth and providing functional occlusion are the primary goals. Traditionally, this is accomplished with digital repositioning and a exible splinting material. If one cannot completely reposition the tooth, then light orthodontic forces for repositioning and splinting should be Problem List Treatment Solutions/GoalsLong TermMissing teeth 1. Orthodontic space closure (natural tooth solution)2. Articial prosthesis (removable denture, xed bridge, or implant)3. Autotransplantation (natural tooth solution)Goal: maintain as many teeth as possible and avoid prosthetic solutions that must be delayedAnkylosis1. If little to no growth is anticipated, monitor tooth or add restorative material to improve esthetics2. If growth is anticipated, decoronation or root submergence to maintain hard and soft tissue supportGoal: understand that the timing of ankylosis dictates available treatment optionsMolar-incisor hypomineralization1. Determine restorability and address pulpal symptoms2. If restorable, consider direct and/or indirect restorations3. If nonrestorable, consider extraction and orthodontic space management (maintenance for implants versus closure/substitution/autotransplantation by natural dentition)Goal: improve status of the hypomineralized teeth to allow the patient to maintain good oral hygiene and pain-free functionIntermediate TermOcclusion 1. Occlusal equilibration2. Orthodontic repositioningGoal: avoid traumatic interferences and maintain a functional occlusionPulpal treatment1. Monitor and intervene with appropriate pulpal treatment a. In immature teeth, nonvital treatment options include apexication, apexogenesis, or revascularization b. In mature teeth, nonvital treatment includes conventional root canal therapyGoal: eliminate source of odontogenic infection; promote continued root development; maintain adequate tooth structureShort TermMobile teeth 1. Digital repositioning and conventional splint2. Orthodontic repositioning using brackets and wires for splint3. ExtractionGoal: stabilize mobile dentition to allow healingSoft tissue injury1. Irrigate and remove debris2. Suture lesions that can be reapproximated3. Leave abraded tissues to healGoal: treat soft tissues to promote optimum oral hygiene and optimum esthetic outcomesDeveloping a Problem List and Treatment Solutions for Dental Trauma by Thinking About Long-, Intermediate-, and Short-Term ImplicationsTABLE 31.1 CHAPTER 31 Examination, Diagnosis, and Treatment Planning 454.e3 implemented. In cases in which there has been a time lag between the trauma and treatment, orthodontic repositioning often requires less force than digital manipulation to reposition the tooth. The lightest possible forces should be used to protect the fragile PDL cells.Treatment ProvidedIn this case, tooth displacement was managed with orthodontic brackets and a 0.012-inch nickel titanium wire (see Fig. E31.1). The misplaced #9 was left in the site of #7 due to the healing that had already started around the tooth and the anticipated difculty in removing #9 and placing it completely in place in its original socket without further damage to the PDL. The soft tissues were irrigated to remove debris and reapproximated with sutures to optimize healing potential. One week following the trauma, root canal therapy was initiated on #9 (the new right lateral incisor). Tooth #8 was monitored for vitality, and root canal therapy was initiated when a change in sensibility was detected. The splint was maintained for 6 weeks to accommodate alveolar remodeling, and a temporary esthetic appliance was made while the patient continues to heal prior to initiating comprehensive orthodontic treatment (Fig. E31.2). Although this child’s trauma may have felt overwhelming, a variety of treatment options remain to achieve an optimal, functional, and esthetic outcome because a treatment plan was developed by reasoning backward and maintaining as many teeth as possible.Questions1. Why is it important to monitor traumatized teeth for ankylosis and how do you determine if the tooth is ankylosed?Answer: The presence of ankylosis greatly inuences a future treatment plan to achieve an optimally functional and esthetic dentition. Severe ankylosis that occurs early in relation to a child’s growth and goes undetected or unmonitored has devastating effects on the hard and soft tissues that can be difcult to correct. Treatment options for ankylosed teeth must consider a child’s growth status and the degree of infraocclusion (see Table E31.1). For growing patients, decoronation or root submergence are reasonable options to maintain alveolar bone. In nongrowing patients, adding restorative materials may be a suitable option.2. Which tooth structure is of primary importance in the initial trauma management and why?Answer: Being gentle to the periodontal ligament is of utmost importance in the initial stage of trauma management. Successful trauma management could be dened as maintaining the traumatized tooth until the end of growth to keep as many treatment options available as possible. Periodontal sequelae to dental trauma (e.g., ankylosis or external root resorption) are among the most difcult problems to treat. Focusing on limited and gentle periodontal ligament ABCD• Figure E31.2 (A) Intraoral frontal view 6 weeks posttrauma demonstrating a temporary esthetic replacement. (B) Intraoral periapical image 6 weeks posttrauma showing completed root canal therapy and bony remodeling of the traumatized areas. Note the unfavorable crown-to-root ratio of the new lateral incisor. (C) Intraoral occlusal view 6 weeks posttrauma with the temporary esthetic replacement in place. Note the wire reinforcement for the pontic. (D) The patient was very pleased with the initial outcome and is aware of the long-, intermediate-, and short-term considerations still to be made as a result of her dental trauma. Continued 454.e4 Part 4 The Transitional Years: Six to Twelve Yearsmanipulation during the initial stage of trauma management should be the primary concern.3. What are the risks and benets of using an orthodontic splint in trauma management?Answer: Any time forces are used on traumatized teeth, the risk of an adverse sequelae increases. By using orthodontic force to reposition a tooth, the clinician assumes that risk. However, with highly exible, superelastic nickel-titanium wires (0.012 round wire), these forces are very light and continuous when compared with digital manipulation (heavy and intermittent). Furthermore, the orthodontic forces applied to a traumatized tooth have to move the tooth only through soft tissue (blood coagulum) rather than hard tissue (alveolar bone) compared with normal orthodontic care. There are several benets of an orthodontic splint. The rst is that very light forces are used to reposition teeth instead of the heavy force of digital manipulation. The second benet is the archwire (splint) can be changed or modied during the splinting time in reaction to any events in healing. The last advantage is the tooth can be tested for mobility by removing the ligation from the brace and testing the tooth. Other splints require removal of adhesive and rebonding if there is still mobility. 45532 Prevention of Dental DiseaseKECIA S. LEARY AND ARTHUR J. NOWAKCHAPTER OUTLINEFluoride AdministrationSystemic FluoridesTopical FluoridesHome CareDietSealantsConicts emerge between the parents’ desires and the child’s wishes. It is a time when parents still have a strong daily inuence on all types of activity, including oral care. With eruption of the permanent teeth, topical uoride needs and occlusal sealants take on added importance. Orthodontic treatment is often initiated during this time frame. is can contribute to some specic challenges to oral hygiene. Periodic assessments and input by the dentist are important so that the child receives the optimal protection available.Fluoride Administratione period from 6 to 12 years is extremely important with regard to uoride administration, for three major reasons: (1) the crowns of many permanent teeth continue to form during this period, (2) the posterior permanent teeth erupt and are at greater risk for developing caries until the process of “posteruptive maturation” has occurred, and (3) the child becomes increasingly responsible for the maintenance of their oral health. For the child at highest risk for caries, the optimal use of a selected uoride therapy should be used to provide protection during this rst phase of carious attack on those teeth that will constitute the permanent dentition.Systemic FluoridesStudies suggest that a substantial portion of the anticaries protec-tion provided by water uoridation in humans occurs during the preeruptive period.1,2 erefore pediatric dentists recommend drinking uoridated water to help reduce dental caries activities.3 Additional studies in laboratory animals have reported that daily doses of uoride administered via gastric intubation during the period of tooth formation reduced the incidence of caries in these teeth after eruption.4 Because systemically acquired uoride may be deposited and redistributed in developing teeth during the mineralization phase, as well as during the subsequent period before eruption, current recommendations call for systemic uoride supple-ments for children at high risk of developing caries and residing in areas where the water is uoride decient until they reach the age of 16 years.5 is protocol should help to ensure maximum protection for the posterior teeth, which are more vulnerable to carious attack. Supplemental uoride dosages remain constant for children between the ages of 6 and 16 years in areas where access to community water uoridation is less than 0.6 ppm uoride.3 However, all sources of uoride (systemic and topical) should be taken into consideration before prescribing systemic uoride.5The patient between 6 and 12 years of age presents an interesting professional challenge for the dentist. At the beginning of this period, the dentist is dealing with a patient who continues to depend on the parents but is now in a formalized school program for approximately 7 hours a day. By the end of this period, the dentist is dealing with a patient who has gained partial independence from his or her parents and is nearly ready for middle school or junior high school. ese preteens are approach-ing puberty and its many physiologic, emotional, and social challenges.In addition, a number of oral-facial changes are taking place throughout this period. Most of the primary teeth are replaced with permanent teeth. e alignment and occlusion of the teeth are developing, and the “adult face” is emerging. What “I” look like becomes important, as does the opinions of others, especially peers.Diet and dietary practices are severely challenged by the edu-cational environment and social pressures both during the day and after school hours. Requirements vary from year to year in this period. Prevalence of obesity increases greatly as opportunities to purchase high-calorie foods in schools, vending machines, and convenience stores may be combined with changes in physical activity. e growth pattern of the patient changes from slow progressive physical growth early in the period to substantial physical growth at the end of the period. e dietary requirements depend not only on growth and development but also on the level of physical and mental activity engaged in by the child. Snacking is a common practice during this period, and children are constantly prompted to think about food and eating.Many changes in manual dexterity take place during this period. Although continuing gross motor development prevails, this is the period when ne motor skills begin to mature. During this period the child is challenging the parents for independence, especially in areas of personal hygiene, clothes selection, and dietary choices. 456 Part 4 The Transitional Years: Six to Twelve YearsConcentrated Agents for Professional Application or Home UseApplications of more concentrated forms of uoride should be considered for persons who are at elevated risk for dental caries, including those who cannot or do not make optimal use of the high-frequency, low-concentration forms of uoride therapy. In general, this implies semiannual applications of concentrated uoride gels or uoride varnish applications (see Chapter 15).Several uoride gels and solutions, including combinations of APF and SnF, are available for home use. Practitioners should be aware that some of these products contain concentrations of uoride that are similar to those found in uoride toothpastes or over-the-counter rinses, and in most cases they have not undergone clinical testing. Some of these low-concentration products have also been advocated for professional application, but they are unlikely to be eective when used infrequently.10 erefore the advantage of these less concentrated products over commercially available uoride toothpastes and mouthrinses is questionable. More concentrated uoride gels (0.5% APF) have been shown to be eective in reducing the incidence of caries and may be useful in high-risk patients with rampant caries when used twice daily for caries prevention.6 NaF mouthrinses used twice daily along with traditional uoride toothpaste have demonstrated that it may also have an eect on the remineralization of incipient caries lesions.11 Fluoride mouth-rinses have also been found to inhibit the formation of the biolms on the tooth structure.12Home CareWith school activities now emerging as a major inuence in the daily schedule of the child, routine personal hygiene must be scheduled. e development of a routine ideally has been reinforced with the routines established during the preschool period. Unfortunately, it is not only school activities that ll the daily schedule for children in this age group. Internet surng and social media use on electronic devices, as well as activities such as music lessons, sports activities, dance lessons, homework, religious instruction, daily chores, babysitting, and television, all begin to inuence the daily schedule and the time remaining for personal hygiene.Although brushing after all meals is ideal, such a schedule may be unrealistic. A compromise should be worked out. An appropriate recommendation would be for a thorough brushing of the teeth with uoride toothpaste and massaging of the gingiva before bed, with additional brushing at the start of each day.7 Brushing after lunch at school is impractical because many children do not have the time or accommodations to brush their teeth at school. Swishing vigorously with water after lunch helps to dislodge any large particles of food remaining and neutralizes any acid that may be present. Brushing after dinner should also be encouraged.Parents should remain active in supervising oral care during this period. Periodic inspection of the mouth by the parent is appropriate. Because ne motor activity is further developing during this period, parental assistance may be required to remove all plaque, especially on the buccal surfaces of the posterior maxillary molars and the lingual surfaces of the mandibular posterior molars. Brushes of the appropriate size and contour should be selected to meet the child’s needs.13 With increasing oral dimensions and numbers of teeth, larger brushes should be considered. Soft nylon bristled brushes are recommended over other varieties.Topical FluoridesDuring the period from 6 to 12 years of age, the child should become increasingly responsible for the maintenance of his or her oral health. Many forms of topical uoride are appropriate for children in this age group, including uoride toothpastes, uoride mouthrinses, and concentrated uoride preparations for professional and home application.Accumulating evidence continues to support the eectiveness and importance of frequent applications of agents that contain relatively low concentrations of uoride. e two principal forms of these agents in the United States are uoride toothpastes and uoride mouthrinses. Daily prescription strength toothpaste and weekly prescription uoride mouthrinses are recommended for those children who have been identied as high risk with moderate levels of evidence.6Fluoride Toothpastese twice-daily use of a uoride-containing dentifrice should form the foundation of the child’s preventive dental activities. To maximize the eect of uoridated toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether.7 Although many toothpastes include uoride in their formulations, products that have the Seal of Acceptance from the American Dental Association (ADA) should be recommended. e ADA Seal of Acceptance indicates that the product has been voluntarily submitted by the manufacturer and has met the ADA Council on Scientic Aairs’ requirements for safety and efficacy. To qualify for the seal, toothpaste evaluation includes measurement of uoride content, uoride release, uoride bioavailability in demineralized enamel, relative dentin abrasivity level, and other tests in accordance to dental standards. Currently, toothpastes with the ADA Seal include sodium uoride (NaF), sodium monouorophosphate (MFP), and stannous uoride (SnF) as active ingredients. Parents should be advised that some over-the-counter toothpaste products may contain higher uoride concentrations (e.g., 1500 ppm).8 However, the majority of toothpastes sold in the United States are 1000 ppm.Fluoride Mouthrinsese use of uoride mouthrinses increased considerably during the 1980s as a result of school-based mouth rinsing programs. e most popular preparations contain neutral NaF, although SnF and acidulated phosphate uoride (APF) rinses also are available. Several uoride mouthrinses, including many 0.05% NaF products, are available on an over-the-counter (nonprescription) basis.Numerous clinical trials conducted in the 1960s and 1970s reported caries reductions in the 20%–40% range among children in nonuoridated areas who rinsed either weekly with a 0.2% NaF rinse or daily with a 0.05% NaF product.7 More recent studies, conducted since the overall decline in dental caries in children became evident, have reported that (1) the expected benets from uoride rinsing in terms of the actual number of tooth surfaces saved from becoming carious are generally less than previously reported, and (2) rinsing appears to have a greater eect in older children (10 years of age).7 Nevertheless, the observation that uoride rinsing provides greater protection to erupting teeth during the time when rinses are being applied provides a rationale for their use in some 6- to 12-year-old age groups. Rinses are particularly indicated for persons deemed to be at high risk for caries, such as those with xed appliances, limited dexterity, or reduced salivary ow. ey are not indicated for children who do not have the ability to expectorate without swallowing.9 CHAPTER 32 Prevention of Dental Disease 457 Although mechanical toothbrushes have been available for some time, there has recently been a dramatic increase in their develop-ment and promotion. All types, shapes, head size variations, rotations, and vibrations (oscillating and ultrasonic powered) are now available. Some are modied and promoted for children, others only for adults. Some studies show dramatic improvements in plaque removal and gingival health; others report results that are not so impressive.14,15 e novelty of the device may increase children’s compliance with daily brushing. It is important to consider the initial cost and the cost of brush head replacements when recommending a mechanical brush. For patients with special health care needs, especially those with limited motor activity, these power bushes can be benecial.With the increased size and independence of the child, the bathroom becomes the ideal location for cleaning. e previously recommended supine position which increases visibility and stability in the very young child is no longer appropriate. A well-lit bathroom with a wall mirror or hand mirror greatly aids the cleaning process.Use of disclosing tablets or solutions helps the child and parent to evaluate the thoroughness of the cleaning (Fig. 32.1). At least weekly, the teeth should be disclosed, and with the parent’s supervi-sion, the child’s mouth should be inspected. Areas of disclosed plaque should be noted with instructions on modication of technique so that it will be removed daily.With the exfoliation of primary teeth and the eruption of permanent teeth, the gingiva may be tender and even swollen, causing the child to hesitate to do a thorough cleaning. Careful wiping of this area with the brush should maintain the health of the tissues. As the permanent teeth erupt, the alignment may be irregular and the gingival tissue may lose its “knife edge” anatomy with the tooth. Instead, a ledge of gingival tissue may emerge that allows plaque to accumulate (Fig. 32.2). Careful manipulation of the brush is necessary until the gingival contour assumes a smooth margin with the tooth. In mouths with a developing discrepancy between arch length and tooth size, the malalignment of the teeth causes retention of food and plaque. Until orthodontic correction, additional brushing by both child and parent may be necessary.TOOTHBRUSH INNOVATIONSM. Catherine SkotowskiBillions of dollars are spent on oral health care products each year. The toothbrush is the most commonly used oral health care product for removing plaque and delivering toothpaste to the teeth. For many years, toothbrushes designed for children varied only slightly from those designed for adults, primarily by size, colors, and designs on the toothbrush. However, nowadays a consumer can stroll down any oral health care aisle of a grocery store, pharmacy, or department store and nd several types of toothbrushes in many shapes and sizes, designed specically for children. Toothbrush handles have been ergonomically designed for better grip control and the varying levels of a child’s manual dexterity development. Toothbrush bristles are usually soft but are often arranged in various heights to optimize plaque removal on all sides of the teeth. Although some manufacturers have added longer bristles at the tip of the brush head to facilitate plaque removal on the distal surfaces of the most posterior teeth, others have extended bristle lengths at the outer portions of the brush head to aid in cleansing buccal and lingual surfaces. Bristles can be multicolored merely for appearances; however, in one manufacturer’s case, a small section of colored bristles have been added to “indicate” when it is time to replace the toothbrush. Toothbrushing apps for electronic device use have also become popular, assisting children with various oral health concepts in innovative and fun ways.One of the most noticeable advances to the toothbrush market is the advent of power toothbrushes designed specically for children. Although power toothbrushes were rst introduced in the 1960s, it has only been in the past few decades or so that manufacturers have targeted the children’s power toothbrush market. Smaller brush heads, the use of brighter colors, popular cartoon characters, and built-in timers (some with musical tunes) are some of the features designed to make power brushes more appealing to children and adolescents. Some of the power toothbrushes have rechargeable stands that require electricity, whereas others on the less expensive end are battery operated. In terms of plaque removal, power toothbrushes appear to be as effective as, if not better than, manual toothbrushes.14,15The novelty toothbrushes, both manual and power, may provide some extra motivation for those who use them because they are unique, fun to use, and possibly more appealing. The ultimate desired outcome of their use is improved oral hygiene efforts on the part of children and adolescents (the wish of many dedicated oral health professionals).• Figure 32.1 Disclosing solution and tablets used to evaluate the thor-oughness of cleaning. (Pictured: Young’s cherry-avored Trace Disclosing Solution, 2-Tone Disclosing Solution, and Disclosing Tablets. Courtesy Practicon Dental, Greenville, NC.)• Figure 32.2 Mixed dentition. Note crowding of teeth and ledge of gingiva and areas of gingivitis. 458 Part 4 The Transitional Years: Six to Twelve Years(SSBs) are dened as soda, fruit drinks (including sweetened bottled waters and fruit juices and nectars with added sugars), sports and energy drinks, and sweetened coees and teas. Consumption of SSBs in 6- to 11-year-olds increased daily from an average of 17.4 ounces in 1994 to 20.5 ounces in 2004.18 Currently 64.5% of boys and 61% of girls aged 2 to 19 years of age consume at least one SSB daily.19 Milk consumption declined from 81% to 77% of children having at least one serving per day.18 Added sugar consumption increased from 275 kcal/day in 1977 to 1978 to a peak of 387 kcal/day in 2003 to 2004 and declined to 326 kcal/day in 2011 to 2012.20 is change was a 51-kcal/day increase from the 1970s, and added sugar intakes of children continue to exceed recommendations.20 Although per capita consumption of sweeteners was approximately 142 pounds annually in 2008, up 19% since 1970,21 there has been a substantial decrease in the use of ordinary rened table sugar. Forty-three percent of the sweeteners used currently are rened sugar from sugarcane and beets; 57% are from corn sweeteners. Beverages (not milk or 100% fruit juice) account for almost half (47%) of all added sugars consumed by the US population, and SSBs account for 39% of these sugars (25% soft drinks, 11% fruit drinks, and 3% sport/energy drinks).22 e high daily rates of SSB consumption and between-meal intake of sugars remain a risk factor for children susceptible to proximal caries even though caries development is now declining in the United States.23 Caries rates have dramatically reduced during the last 20 years, even as dramatic changes have taken place in our dietary practices. Data have demonstrated that those children with a higher SSB content have a higher prevalence of dental caries even when adjusting for socioeconomic and maternal oral health characteristics.24 e use of SSBs also diers according to race/ethnicity and geographic region.25 It is important that dentists stay aware of dietary practices and changes taking place and monitor Toward the end of this period the child may have developed enough ne motor activity to be able to oss. Like any other motor activity, this skill must be learned and practiced frequently. Parents can be helpful in assisting the child. Inappropriate use of the oss by “snapping” it into the interproximal surfaces can injure the gingiva. Once passed through the contact, the oss must be carefully manipulated along one surface of the tooth and then the opposite surface, making sure that it reaches the area just under the gingival crevice. One of the many commercially available oss holders may greatly assist in the process (Fig. 32.3).As the child extends his or her social activities, overnight, weekend, or extended periods away from home occur. As they “pack their bags,” toothbrushes, dentifrices, and oss will probably be thought of last, if at all. Again, parents must ensure that the appropriate tools are available; whether they will be used is another question.Children with developmental disabilities may require partial or total assistance in oral care, depending on their mental and physical capabilities. If a parent must help with or be totally responsible for mouth care, a mouth prop may be helpful (Fig. 32.4). With good head stability and mouth propping, the cleaning process is enhanced. Children with severe mobility limitations may require more than one person to assist in activities like toothbrushing. Modications to oral hygiene devices may also be needed. For instance, a three-headed toothbrush may be useful. Stabilization and proper positioning may be necessary, and if so, the bathroom may be an inappropriate location. Use of the bedroom or other living area with available oor space, beds, or couches allows the child to be placed in a supine position and stabilized. In these situations the use of a dentifrice further complicates the process because of the foaming and the need to expectorate; however, there are toothpastes that do not contain sodium lauryl sulfates (the foaming agents) and still contain uoride.DietAccording to prevalence data from 2013 to 2014, 17.4% of school-aged children were considered obese, and there are many factors responsible, including diet and physical activity.16 Diet also may play a role in the dental caries process.17 Sugar-sweetened beverages • Figure 32.3 Disposable ossers designed especially to make ossing easier for children. (Pictured: SmileGoods FlosSeas Flossers. Courtesy Practicon Dental, Greenville, NC.)• Figure 32.4 A mouth prop and a three-headed toothbrush can be used to facilitate oral health care in a child with special health care needs. (Pictured: Open Wide Mouth Rest and Surround toothbrush. Courtesy Specialized Care Co., Inc., Hampton, NH.) CHAPTER 32 Prevention of Dental Disease 459 and it is important to recognize the role these may play in the diet of school-aged children. As dentists, it is important to advocate for nutritional and healthy school choices, such as bottled water, and collaborate with other community health leaders in maintaining appropriate choices.26A favorite activity of many school-aged children is gum chewing. Although frowned on by school ocials and parents, it may have anticaries eect. Studies have reported an increase in salivary ow and mechanical pumping of saliva to interproximal sites. is results in a neutralization of interproximal acids. ese studies have used both sugarless and sugar-containing gums. All studies agree on the benecial eects of sugarless gums, but a dierence of opinion exists on the eect of sugar-containing gums.31–33 Xylitol-containing gums have been shown to decrease Streptococcus mutans levels in saliva and plaque when used routinely.34 Reduction in caries incidences is reported in all age groups, and when the xylitol-containing gum is used by mothers, it may decrease the transmission of S. mutans from mother to child.35 However, it is important to recognize that therapeutic doses of xylitol and high frequency may be dicult to achieve. Systemic reviews regarding the eectiveness show only a small eect of caries prevention in the pediatric population.36e diets of children with developmental disabilities may be modied for a number of reasons. To increase caloric requirements, supplements are frequently added to routine foods. Unfortunately, these supplements are frequently rened carbohydrates, which increase the risk of acid production. Foods may be altered, minced, pureed, or mashed to assist the child in swallowing and to meet the need for less chewing. Due to chewing and swallowing dicul-ties, fresh fruits and vegetables are often withheld from the diet and substituted with pastries, canned fruits, puddings, and gelatin desserts, which contain a high percentage of rened carbohydrates. e dentist and their sta must be aware of these modications and be realistic in providing alternative dietary recommendations to parents of children with developmental disabilities.SealantsSealants are recommended for children to reduce caries risk on the occlusal surface of permanent teeth. is age group is particularly vulnerable to dental decay due to the changes in diet, the inde-pendence in oral hygiene practices, and newly erupting teeth. Evidence continually supports that sealants reduce the risk of dental decay in pit and ssures.37 is age group would benet from sealants due to the fact that rst and second molars will be erupting. is is the age group frequently targeted for school-based sealant programs (see Chapter 33).References1. O’Mullane DM, Baez RJ, Jones S, et al. Fluoride and oral health. Community Dent Health. 2016;33:66–99.2. Groeneveld A, Van Eck AA, Backer Dirks O. Fluoride in caries preven-tion: is the eect pre- or post-eruptive? J Dent Res. 1990;69(special issue):751–755.3. American Academy of Pediatric Dentistry. Guideline on uoride therapy. Pediatr Dent. 2016;38(6):181–184.4. Hunt CE, Navia JM. Pre-eruptive eects of Mo, B, Sr, and F on dental caries in the rat. Arch Oral Biol. 1975;20:497–501.5. Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recom-mendations on the prescription of dietary uoride supplements for caries prevention: a report of the American Dental Association Council on Scientic Aairs. J Am Dent Assoc. 2010;141:1480–1489.their patients’ dietary habits, as well as their weight gains, between appointments.Although children are introduced to a variety of new foods during the preschool years, the real challenge is to develop good dietary habits during this age group. At this age, there is exposure to a full day in school with frequent treats and school lunches, either from home or purchased at school; vending machines26; and a multitude of after-school activities, usually associated with food.27 All of these factors inuence children’s dietary habits, as well as the habits that are formed at home regarding modeling healthy food choices.27 In addition, children in this age group are heavily inuenced by the commercial media, especially television. e eect of food choices and purchases has been carefully studied, and although advocacy organizations have attempted to inuence the number of commercials related to food shown during the daytime hours, it remains common for the school-aged child to be exposed to many enticements during a period of television, radio, and social media entertainment. If children accompany parents to the market, the purchases they request are frequently related to commercials they have encountered. e more that children eat food outside the home, the higher the likelihood their diet is to be unhealthy.28 School-aged children are getting foods with little nutritional value not only from fast food restaurants, but also from convenience stores and schools.27 Although some dramatic changes have occurred recently in food selection and dietary practices, we know that a large percentage of a family’s meals are eaten on the run, whether they are from fast food res-taurants or in the form of prepackaged meals.For children with severe caries, the dentist must evaluate all etiologic factors, including diet and dietary practices. A dietary history may be helpful in determining diet practices. Every exposure to a food containing a rened carbohydrate, especially one that adheres to the teeth and dissolves slowly, produces acid in and around the plaque and this may help to identify areas of concern to help a family make small changes in diet. However, the key concepts to diet recommendations are limiting meals and snacks to three to six dened meals or snacks a day, limiting SSB consump-tion, and eating according to the Choose MyPlate guidelines from the US Department of Agriculture (USDA).29 It is unrealistic to recommend to a parent of a 6- to 12-year-old child to cut out all candy and sweets. It is better to advise them of possible substitutes, such as a chocolate candy instead of a caramel, or that consumption of candy and sweets should take place only after meals have been eaten rather than before or between meals. Children can learn appropriate eating habits, but they must be realistic, and the parents must be enthusiastic about the change.30 Families that encourage a home food environment that models healthy eating, by helping to provide some limits on food (while not being too restrictive) and having healthy food at home, will fare much better in helping to maximize the likelihood of a child’s healthy weight and eating.27Regarding meals at school, parents must work with school authorities to provide wholesome and nutritious meals that also have eye appeal for the child. In addition, parents should work with specic teachers to encourage the use of appropriate snacks and party foods for special occasions. More than 100,000 schools and 31 million children are participating in free and reduced-cost meals as part of the USDA National School Lunch/Breakfast Programs. ere are a set of strict guidelines that now encourage healthy, reduced calorie and sodium meals that also provide fruits and vegetables through the schools. e most recent guidelines recommend only unavored 1% or nonfat milk and avored nonfat milk. Children may have access to vending machines at school, 460 Part 4 The Transitional Years: Six to Twelve Years22. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 dietary guidelines for Americans, 8th ed; 2015. http://health.gov/dietaryguidelines/2015/guidelines/.23. Marshall TA, Brott B, Eichenberger-Gilmore J, et al. e roles of meal, snack, and deaily total food and beverage exposures on caries experience in young children. J Public Health Dent. 2005;65:166–173.24. Wilder J, Kaste LM, Handler A, et al. e association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Pub Health Dent. 2016;76:76–84.25. Centers for Disease Control and Prevention. Get the facts: sugar-sweetened beverages and consumption; 2017. https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html. Accessed August 16, 2017.26. American Academy of Pediatric Dentistry. Policy on beverage vending machines in schools. Pediatr Dent. 2016;38(special issue):60–61.27. Couch SC, Glanz K, Zhou C, et al. Home food environment in relation to children’s diet quality and weight status. J Acad Nutr Diet. 2014;114:1569–1579.28. Vepasäläinen H, Mikkilä V, Erkkola M, et al. Association between home and school food environments and dietary patterns among 9-11-year-old children in 12 countries. Int J Obes Suppl. 2015;5(suppl 2):S66–S73.29. US Department of Agriculture. Choose my plate; 2017. https://www.choosemyplate.gov/. Accessed August 16, 2017.30. Singleton JC, Achterberg L, Shannon B. Role of food and nutrition in the health perceptions of young children. J Am Diet Assoc. 1992;92:67–70.31. Beiswanger BB, Elias A, Crawford JL, et al. e eects of sugarless chewing gum use after meals on dental caries. J Dent Res. 1996;75(special edition):1003.32. Jensen ME. Responses of interproximal plaque pH to snack foods and eect of chewing sorbitol-containing gum. J Am Dent Assoc. 1986;113:262–266.33. Jensen ME, Wefel JS. Human plaque pH responses to meals and the eects of chewing gum. Br Dent J. 1989;167:204–208.34. Deshpande A, Jadad AR. e impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trails and observational studies. J Am Dent Assoc. 2008;184:1602–1614.35. Nakai Y, Shinga-Ishihara C, Kaji M, et al. Xylitol gum and maternal transmission of mutans streptococci. J Dent Res. 2010;89:56–60.36. Marghalani A, Guinto E, Phan M, et al. Eectiveness of Xylitol in reducing dental caries in children. Ped Dent. 2017;39:103–110.37. Wright JT, Tampi MP, Graham L, et al. Sealants for preventing and arresting pit-and-ssure occlusal caries in primary and permanent molars, a systematic review of randomized controlled trials—a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc. 2016;147:631–645.6. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical uoride for caries prevention: executive summary of the updated clinical recommenda-tions and supporting systemic review. J Am Dent Assoc. 2013;144:1279–1291.7. Recommendations for using uoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2001;50(RR–14):1–42.8. Centers for Disease Control and Prevention. Community water uoridation: other uoride products; 2016. https://www.cdc.gov/uoridation/basics/uoride-products.html. Accessed August 16, 2017.9. Adair SM. Evidence-based use of uoride in contemporary pediatric dental practice. Pediatr Dent. 2006;28:133–142.10. Crall JJ, Bjerga JM. Fluoride uptake and retention following combined applications of APF and stannous uoride in vitro. Pediatr Dent. 1984;6:226–229.11. Songsiripradubboon S, Hamba H, Trairatvorakul C, et al. Sodium uoride mouthrinse used twice daily increased incipient caries lesion remineralization in an in situ model. J Dent. 2014;42:271–278.12. Hannig C, Gaeding A, Basche S, et al. Eect of conventional mouthrinses on initial bioadhesion to enamel and dentin in situ. Caries Res. 2013;47:150–161.13. Nowak AJ, Skotowski MC, Widmer R, et al. A practice based evalu-ation of a range of children’s manual toothbrushes: safety and acceptance. Compend Contin Educ Dent. 2002;23(3 suppl 2):17–24.14. Grossman E, Proskin H. A comparison of the ecacy and safety of an electric and manual children’s toothbrush. J Am Dent Assoc. 1997;128:469–474.15. Nowak AJ, Skotowski MC, Cugini M, et al. A practice based study of a children’s power toothbrush: ecacy and acceptance. Compend Contin Educ Dent. 2002;23(3 suppl 2):25–32.16. U.S. Department of Health and Human Services. Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS Data Brief. 2015;(219).17. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292–2299.18. Turner L, Chaloupka FJ. Wide availability of high-caloric beverages in US elementary schools. Arch Pediatr Adolesc Med. 2011;165(3):223–228.19. Rosinger A, Herrick K, Gahche J, et al. U.S. Department of Health and Human Services. Sugar-sweetened beverage consumption among US youth, 2011-2014. NCHS Data Brief. 2017;(271).20. Powell ES, Smith-Tallie LP, Popkin BM. Added sugars intake across the distribution of US children and adult consumers: 1977-2012. J Acad Nutr Diet. 2016;116:1543–1550.21. Wells HW, Buzby JC: Dietary assessment of major trends in U.S. food consumption, 1970-2005, Economic Information Bulletin No. (EIB-33), March 2008. 46133 Pit and Fissure Sealants: Scientic and Clinical RationaleMARTHA H. WELLSCHAPTER OUTLINEEpidemiology of Pit and Fissure CariesSealant EectivenessCurrent Sealant UtilizationHow Sealants WorkTypes of SealantsColorFiller ContentFluoride-Releasing SealantsGlass IonomerPolyacid-Modied Resin Composites (Compomers)Who Really Needs Sealants?Caries Risk AssessmentSealant Versus Fluoride Varnish: Which Is More Likely to Reduce Occlusal Caries?Age at PlacementWhich Teeth Should Be Sealed?Preparing the Tooth for a SealantCleaning the ToothMechanical PreparationEect of a Recent Professionally Applied Fluoride TreatmentFactors Aecting Sealant SuccessEtchantDrying Agents and TimeCuringIsolationTiming of Sealant PlacementUse of Intermediate Bonding AgentAuxiliary ApplicationFour-Handed DeliverySchool-Based Sealant ProgramsOther Uses for SealantInterproximal Dental SealantSealing RestorationsPreventing White Spot LesionsSealant SafetyFuture AdvancesSummaryuoride exposure, enhanced awareness of the benets of early care, increased access to dental care, and increased nancial coverage by insurance companies, group plans, and government-funded programs of preventive and restorative dental procedures for children.Despite these eorts, dental caries is still the single most common chronic disease of childhood, more common than asthma and hay fever.2 e facts from the most recent National Health and Nutrition Examination Survey (NHANES) for the years 2011 to 2012 are alarming3,4:• Approximately56%ofchildrenaged6to8haddentalcariesin their primary teeth, and 21% of children aged 6 to 11 had experienced caries in their permanent teeth.• eprevalenceofcariescontinuestorisewithage,as67%ofadolescents aged 16 to 19 had experienced tooth decay.In the past several decades, “the power of prevention” perspective has been permeating health care, as we have begun to focus on the burdens that chronic diseases leave in their wake—decreased life expectancy, reduced quality of life, and escalating health care costs. Of particular interest to the dental profession is dental caries, a chronic disease aecting more than 90% of adults aged 20 to 64.1 Although chronic diseases are among the most common and costly of all health problems, they are also among the most preventable. One of the most powerful prevention tools that the dental health profession has is the dental sealant.Epidemiology of Pit and Fissure CariesIn the past several decades, dramatic improvements in the pre-vention of caries have occurred due to a multitude of factors:

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