Sports Dentistry and Mouth Protection

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CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 553.e3 spring. This sequence is repeated until the permanent molar has been moved into proper position. Several space maintenance methods can be considered to hold the tooth movement; however, because this patient was unable to tolerate a Nance button, the appliance will be left in place until the second premolar erupts into proper position.Questions1. What should a clinician do when ectopic eruption of the upper permanent rst molar is suspected?Answer: After a thorough clinical and radiographic examination, the clinician should make a determination if the permanent molar may self-correct or will require treatment. Self-correction occurs in 60% to 70% of reported cases so the clinician may elect to watch for spontaneous resolution of the problem for 6 months. If the ectopic eruption is still present at that time, treatment is indicated.2. What are the three basic goals of treatment in irreversible ectopic eruption?Answer: The rst goal is to alter the eruption of the ectopically erupting rst permanent molar so the tooth reaches an optimal position. The second is to regain space lost due to mesial migration of the rst permanent molar. This is important because it gives the second premolar adequate space to erupt into proper position. The third goal is to retain, if possible, the second primary molar because it provides function and holds space.3. What is the cascade of events that follows the premature loss of the second primary molar in cases of ectopic eruption?Answer: After the second primary molar is prematurely lost, the rst permanent molar will continue to erupt in a mesial direction into the space previously held by second primary molar. The permanent molar will also rotate around the palatal root, resulting in a mesial rotation of the tooth. Last, there will be insufcient space for the second premolar to erupt.References1. Young DH. Ectopic eruption of the rst permanent molar. J Dent Child. 1957;24:153–162.2. Pulver F. The etiology and prevalence of ectopic eruption of the maxillary rst permanent molar. J Dent Child. 1968;35:138–146.3. Bjerklin K, Kurol J. Prevalence of ectopic eruption of the maxillary rst permanent molar. Swed Dent J. 1981;5(1):29–34.4. Barberia-Leache E, Suarez-Clua MC, Saavedra-Ontiveros D. Ectopic eruption of the maxillary rst permanent molar: characteristics and occurrence in growing children. Angle Orthod. 2005;75(4):610–615.5. Dabbagh B, Sigal M, Tompson BD, et al. Ectopic eruption of the permanent maxillary rst molar: predictive factors for irreversible outcome. Pediatr Dent. 2017;39(4):215–218.6. Bjerklin K, Kurol J. Ectopic eruption of the maxillary rst permanent molar: etiologic factors. Am J Orthod Dentofacial Orthop. 1983;84(2):147–155. 554PART 5Adolescence37 The Dynamics of Change38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems39 Prevention of Dental Disease40 Restorative Dentistry for the Adolescent41 Sports Dentistry and Mouth ProtectionAdolescence represents an extremely important time in the dental care of the pediatric patient because it is a time of unprecedented change. It is the transitional period between puberty and maturity where accelerated physical growth and dynamic hormonal change are accompanied by heightened self-awareness and social maturity. As adolescents begin to develop more inde-pendence, the responsibility of dental home care should be managed eectively by themselves rather than by their parents, and this section will address the specic preventive needs of adolescents. e dentist is in a unique position among health care professionals to guide the adolescent’s oral health because of the frequent recall examinations. In turn, the adolescent should have more opportunities to discuss some of the physical, psychosocial, and risky behavioral issues that may impact his or her oral health. e practitioner must have the requisite knowledge of adolescent oral health concerns and be able to apply the principles of anticipatory guidance to the adolescent’s dental care. In addition, the dentist needs to be an excellent clinician as well as an exceptional educator and communicator in providing information that is clinically relevant and psychologically sensitive to meet the teenager’s needs. is section will provide guidance on managing the restorative and esthetic needs of adolescents. Also, as the risk for traumatic injuries increases in this age group, the section will conclude with a discussion of trauma prevention and sports dentistry. 55537 The Dynamics of ChangeDEBORAH STUDEN-PAVLOVICH AND ADRIANA MODESTO VIEIRACHAPTER OUTLINEPhysical ChangesBodyCraniofacial ChangesDental ChangesCognitive ChangesEmotional ChangesSocial ChangesBullyingSuicideRisky BehaviorsSummarytheir growth spurt later than females and therefore have a longer maturation period before the growth period is one of the reasons why the height of males generally exceeds the height of females. e earlier growth spurt of females also accounts for the period of time during which mean height of a group of young female adolescents may exceed that of males. It is also important to realize that in females menarche serves as a signal that growth is ending, but for males no such marker exists. e magnitude of the velocity of change during the growth spurt also diers between the sexes. In 1975, Tanner and colleagues1 concluded that the growth spurt in females peaks at a 9-cm change per year at age 12 years, and that in males it peaks at just over 10 cm at age 14 years.Craniofacial ChangesDuring and following adolescence, continued changes in the skeletal growth of the face and skull take place because the facial sutures are still open and viable2 and mandibular growth can potentially continue. ese changes not only cause variation and individuality in facial appearance3 but also aect the dental structures. e continued changes make a nal and unchanging dentition and occlusion a dicult concept to imagine, much less attain. ere is a slow increase in facial height accompanied by an increase in prognathism in males.4,5Prole changes occur as changes in specic locations take place. e brow area becomes larger as a result of pneumatization of the frontal sinuses and apposition on the glabella.6 Also, appositional changes during adolescence and early adult life in the frontal bone area and brow result in this area becoming more prominent.4 In adolescence, the nose and chin also become more prominent. e tip of the nasal bone lies well ahead of the basal bone of the premaxilla. Soft tissue changes also contribute to the growth in the length of the nose and can aect the harmony existing between the nose, lips, and chin. e mandible shows a greater prognathism than the maxilla because of the circumpubertal growth spurt, which has more eect on the mandible than on the maxilla, especially in males. e chin also becomes more prominent owing to local bone deposition. Lip prominence is reduced by these changes in adjacent structures.Underlying maxillary changes also occur. e maxillary sinuses, which have expanded laterally and vertically since birth, occupy the space left by the permanent teeth as they erupt. By puberty, the sinuses are usually fully developed, although they may continue to enlarge. Considerable individual variation in the size of the maxillary sinuses occurs, and they often lack symmetry. Lowering of the palatal vault continues because of remodeling. In 1966, Björk7 concluded that sutural growth as well as appositional growth Physical ChangesBodyAdolescence in some societies is a very short transitional period that marks the arrival of a child to full citizenship within his or her respective tribe and culture. In today’s technology-focused age, adolescence is a time of enormous transition and is certainly not of short duration. e current adolescent has never known a world without the internet and has received music only through down-loads. No longer children but not quite adults, adolescents confront a combination of physical and mental health issues that may result in long-term problems in adulthood, ranging from obesity, to hypertension, substance abuse, and depression. Certainly, adoles-cence is an in-between age in our society and must be understood as something separate from childhood or adulthood.Critical to the denition of adolescence, regardless of culture, and to the understanding of the adolescent physically is the concept of puberty. Puberty is the landmark in physical development when an individual becomes capable of sexual reproduction. In common law, this has been established historically in our society as age 14 years for boys and age 12 years for girls. e advent of puberty is paralleled by the development of genital tissue and secondary sexual characteristics, such as the development of hair in the genital area.It is also a time when there is an increase in the mass of muscles, a redistribution of body fat, and an increase in the rate of skeletal growth. A growth spurt is associated with this time of life. is growth spurt follows two dierent forms, depending on gender. It appears earlier in females than in males. e average onset in males is 2 years later than that in females. e fact that males experience 556 Part 5 Adolescencepositioning of the mandible and an increase in facial convexity (Fig. 37.2).4Mandibular growth contributes more than prole changes. is growth may be sucient to provide room for the third molars. In many cases growth is inadequate, and these molars become impacted (Fig. 37.3). e marked mesial inclination of the posterior per-manent teeth diminishes somewhat as the mandible completes its growth from under the maxilla, and the lower incisors tend to become upright. Often this is accompanied by crowding of the lower incisors.2Late mandibular growth imparts an increase in the vertical height of the mandibular ramus, which becomes more upright. e elongation of the ramus accommodates the massive vertical expansion of the nasal region and the lowering of the palate, which is accompanied by dental eruption. Usually the maxillary growth and mandibular growth are compatible and coordinated. If they are not, signicant orthodontic problems may result. Particularly in males, there may be late anterior growth that is undesirable.4Dental ChangesAll of the permanent teeth generally have erupted by age 12 years, except possibly the four second molars, which may erupt as late as age 13 years, and the third molars, which usually erupt between the ages of 17 and 21 years.Except for the third molars, the dentist should be concerned about any unerupted permanent tooth after age 13 years and should examine the area in question radiographically.e roots of all teeth are considered to have been completed by age 16 years except for those of the third molars, which can achieve completion as late as age 25 years.of the maxilla contributed signicantly to the increase in the height of the maxillary body (Fig. 37.1). is can be an example of sexual dimorphism in skeletal growth (Table 37.1). Vertical maxillary facial growth is often greater in females. Because the mandible does not continue to grow as much in females, marked vertical changes in the maxilla can result in downward and backward • Figure 37.1 This anterior cranial base superimposition of the Bolton standard 12- and 18-year-olds (solid line and broken line, respectively) demonstrates the magnitude of anteroposterior and vertical skeletal growth during this period as well as the soft tissue change. (Redrawn from Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton Standards of Developmental Growth. St Louis: Mosby; 1975.)Females MalesCircumpubertal growth spurt10–12 years 12–14 yearsMature size Growth plateaus at age 14 years with increases to 16 yearsActive growth to 18 yearsSupraorbital ridges Absent Well developedFrontal sinuses Small LargeNose Small LargeZygomatic prominencesSmall LargeMandibular symphysis Rounded ProminentMandibular angle Rounded Prominent lippingOccipital condyles Small LargeMastoid processes Small LargeOccipital protuberance Insignicant ProminentFrom Behrents RG. Growth in the Aging Craniofacial Skeleton. Ann Arbor, MI: Center for Human Growth and Development, University of Michigan; 1985.Growth of the Aging Skeleton: Sexual Dimorphism in Craniofacial GrowthTABLE 37.1 • Figure 37.2 This anterior cranial base superimposition of the Bolton standard 12- and 18-year-olds (solid line and broken line, respectively) demonstrates the magnitude of transverse and vertical skeletal growth during this period. (Redrawn from Broadbent BH Sr, Broadbent BH Jr, Golden WH. Bolton Standards of Developmental Growth. St Louis: Mosby; 1975.) CHAPTER 37 The Dynamics of Change 557 self-condence and personal identity of an adolescent may be compromised if his or her feelings about body image are negative. In 1984, Mussen and colleagues9 noted that the following issues create the possibility of misinterpretation and anxiety for this age group:• Beingattractiveorunattractive• Beinglovedorunloved• Beingstrongorweak• BeingmasculineorfeminineFor females, the onset of menstruation may also present cir-cumstances that can be anxiety provoking. is is not necessarily the rule, but the chances of anxiety rise if there is a prevailing negative reaction to the menstrual process by family and peers, if the child is showered with sympathy, or if there is considerable pain before and during menses. Reassurance that menstruation is a normal bodily function sometimes accompanied with emotional swings due to hormonal uctuations may alleviate the adolescent’s anxiety.e advent of puberty and the hormones associated with puberty lead to sexual feelings and urges. e timing of this process, its nature and magnitude, and the choice of what to do about these feelings and urges is handled dierently from one adolescent to another. Family guidance, the adolescent’s own values, the values of peers, and the value system of the person that the adolescent rst loves are just a few of the factors that ultimately predict how he or she will deal with these new feelings.One last emotion is critical to understanding adolescents. is is the emotion of love. Adolescents are capable of great commitment to one another, and some of these relationships can become long-term commitments. Unfortunately, many such relationships do not last, as one partner becomes uninterested. is can lead to genuine depression for the abandoned partner. Often parents do not take these romantic bonds seriously and refer to them in belittling terms.Social ChangesAdolescence represents the nal transition socially from childhood to adulthood. When it is over, if everything proceeded as it should, the emerging young adult will be able to establish and maintain loving and sexual relationships with a partner, be independent of the parents, be capable of working with peers, and be self-directed. Cognitive ChangesAccording to Piaget, adolescents go through the Formal Operations stage in their cognitive development, and by middle to late ado-lescence are capable of extremely sophisticated intellectual tasks. High ability at abstract thinking allows the adolescent to deal with complex and dicult vocational and educational challenges. Formal operational thinking and the ability to store information in the memory after perceiving it are hallmarks of the maturation of cognitive ability in adolescents.e new information available to the adolescent, along with more sophisticated ways of analyzing this information, often makes him or her appear to be a rebel, a complainer, or an accuser. Persons of this age often ascertain the possible and become dis-contented, even angry, with the real. Kiell8 pointed out in 1967 that Aristotle, more than 2000 years ago, concluded that adolescents “are passionate, irascible, and apt to be carried away by their impulses.” It has been noted that the thoughts of adolescents are both introspective and analytic. ey are also egocentric. is dwelling on one’s self may make an individual overly self-conscious. Clothes, cars, hairstyles, tastes in music, and identication with certain people or groups probably reect the adolescent’s involvement in self-consciousness.In summary, by mid- to late adolescence, most young people are capable of formal operational thinking, and can, both in and out of school, master subject material that is extensive, dicult, and abstract. ese measures of cognitive development correlate with age and experience. Adolescents are able to plan eectively, have increased reasoning ability, and are able to exhibit inhibitory control. ese aspects of brain maturation continue to develop even after adolescence is over. Many have matured into skillful, enthusiastic communicators and conversationalists. Many are also opinionated and perhaps argumentative. ese last two character-istics may make for some challenging times for parents, teachers, and dentists. Hopefully, parents will continue to guide their children with a light but steady hand, staying connected yet allowing increasing independence.Emotional Changese very rapid and dramatic changes that occur in adolescents may be paralleled by many emotional circumstances. The • Figure 37.3 This panoramic radiograph shows a complete permanent dentition of a 17-year-old patient. All four third molars are present. 558 Part 5 Adolescencerelated to physical strength or popularity, making it dicult for the victim to defend himself or herself.12Behavior falls into four categories: direct-physical (e.g., assault, theft), direct-verbal (e.g., threats, insults, name-calling), indirect-relational (e.g., social exclusion, spreading rumors), and cyberbul-lying. Cross-sectional ndings indicate that there is an increased risk of suicidal ideation and/or suicide attempts associated with bullying behavior and cyberbullying.13Bullying predicts future mental health problems. Studies have shown that bullying behavior in childhood or adolescence is a predictor of antisocial behavior and antisocial personality disorder (PD) in adulthood. Studies have focused on three groups: those who were victims, those who were bullies, and those who were both victims and bullies (bully/victims). Children and adolescents involved in bullying behavior had the worst outcomes when they were both bullies and victims, leading to depression, anxiety, and suicidality (suicidality only among males) as adults.14 More recently, it was found that female victims of bullying have an almost fourfold likelihood of developing a PD later in life compared to adolescents with no involvement in bullying behavior. Most of the females had borderline PD. Female adolescents diagnosed with anxiety disorder during adolescence had more than a three-fold risk of developing a PD during late adolescence or early adulthood.15Pediatric dentists can identify a range of health conditions that aect not only adolescents’ functioning and opportunities, but also the quality of their adult live. Assessment for adolescents with psychopathology, other signs of emotional distress, or unusual chronic complaints should also include screening for participation in bullying as victims or bullies.SuicideSuicide among young people continues to be a serious problem. For some teens, suicide may appear to be a solution to their problems and stress. Each year in the United States thousands of teenagers commit suicide.16Suicide has replaced murder/homicide as the second leading cause of death for adolescents 15 to 19 years old. Suicide rates may have increased due to the stresses and anger levels induced by electronic media and a reluctance to use antidepressant medica-tion. Fewer antidepressants have been prescribed since 2004 when the US Food and Drug Administration (FDA) required “black box warning” labels on antidepressants to warn health care providers of increased risks of suicidal thinking and behavior among children and adolescents being treated with such medications.17Suicide is especially high among teens because of the severe stressors of adolescence and the immaturity of the adolescent brain.18 Any attempt to categorize adolescence is destined to fall woefully short of the complexity of today’s reality. e best we can do as pediatric dentists is to keep pace with the emerging scientic evidence and assimilate that information with our own experiences and foundational knowledge. e goal of this approach goes beyond the mere exercise of intellectual curiosity; it reaches for an under-standing of the world of the next adolescent who sits in your dental chair.e American Academy of Pediatrics (AAP) updated its guidelines for screening patients for suicidal thoughts, identifying risks factors for suicide, and assisting at-risk young people.17 e AAP recom-mends that pediatricians look for risk factors linked to teen suicide, which include a history of physical or sexual abuse, mood disorders, substance abuse, and teens who may be lesbian, gay, or bisexual.ere is no other period in human development distinguished by psychosocial changes of the same magnitude as those experienced during adolescence. ese are formidable social challenges, and some adolescents cannot master them. Bullying, attempted or successful suicide, alcohol and substance abuse, running away from home, sexual promiscuity, and dropping out of school are some of the frequently cited instances of adolescent failure to socialize properly.Peers are important social agents in large technologic societies, in which children of the same age group are often kept together. It can be argued that as relationships and dependencies on parents start to decline, the importance of peers escalates. is shift in relationships contributes to the development of intimacy by increasing comfort with peers and encouraging openness and self-disclosure with others. Increasingly, the adolescent may nd that it is dicult to share secrets, thoughts, and fantasies with his or her parents. In these situations, the close friend becomes the adolescent’s condant. e supercial sharing of activities with friends that suced during childhood is replaced during adolescence by concern, loyalty, reliability, and respect between adolescent friends.Despite the obvious value of peers, there are peer relationships that are not so fortunate for the involved adolescent. For example, to avoid rejection or ridicule from peers an adolescent may experi-ment with drugs, participate in criminal acts, or defy authority.Another important social change in the adolescent is an increase in the size and range of acquaintances. Children younger than adolescents tend to limit their friends to those of their neighborhood, school, and perhaps church. Adolescents, on the other hand, may have individual friends, belong to a circle of friends, and can identify with larger groups such as an Explorer troop, soccer team, or “friends” from social media. An adolescent’s ability to sustain relationships with all three of these groups indicates good social skills and is a sign that the socialization process is going well.Popularity is an important desire in adolescents. ere are few adolescents who are not preoccupied with acceptance by peers. e following qualities in an adolescent seem to correlate with social acceptance by peers:• Friendly,likesotherpeople• Energeticandenthusiastic• Flexibleandforgiving• Laughs,goodsenseofhumor• Outgoing• Self-condentbutnotconceited• Appearsnatural• Tolerantoftheshortcomingsofothers• Showsleadershipqualities• Othersfeelgoodwhenthispersonisarounde adolescent who gets along with his or her peer group seems to relate successfully to adults. ose who do not achieve peer acceptance seem to have more diculty with adults and grow up to have a variety of social and emotional diculties.10 Some of the issues facing adolescents will be discussed as follows.BullyingBullying in youth is an intentional negative behavior that typically occurs repeatedly and where there is an imbalance of power, with a more powerful person or group attacking a less powerful one.11 Bullying is dened as having three elements: aggressive or delib-erately harmful behavior (1) between peers that is (2) repeated and over time and (3) involves an imbalance of power, for example, CHAPTER 37 The Dynamics of Change 559 oral soft tissue damage. In addition to oral malodor and stained teeth, adolescents who smoke experience impaired gingival health as well as delayed wound healing. Cigarette smoking also is a signicant contributing factor for the development and subsequent life-threatening eects caused by oral, pharyngeal, and laryngeal carcinomas.Currently, the use of electronic-cigarettes (e-cigarettes) and vaporizers appears to be replacing the traditional cigarette. A new survey sampling 40,000 US students indicated that US teenagers are more likely to use e-cigarettes than traditional cigarettes. e authors reported that its use is driven by the belief that e-cigarettes are less harmful.20 Many adolescents surveyed believed that e-cigarettes were a harmless form of entertainment and were unaware that they could contribute to nicotine addiction. e Centers for Disease Control and Prevention (CDC) found that although high school students are smoking traditional cigarettes less than ever before, they are using e-cigarettes at more than twice the rate of regular cigarettes.21 e dentist should be concerned that this type of tobacco use may serve as a new gateway to smoking cigarettes because the products are similar. Even though the e-cigarette market is beginning to face regulatory pressure, its production has little oversight for safety and could account for some of the heavy metals, such as lead and zinc, which have been detected in some e-cigarettes.Another adolescent smoking trend is the rising use of smoking cigars. Health ocials believe several factors are responsible for this upswing. Unlike cigarettes, cigars are promoted with candy, chocolate, and fruit avors. Cigars are taxed less and can be sold in single lots, unlike cigarettes that must be sold in packs of 20 and are more expensive. In addition, cigars are marketed more heavily in black neighborhoods than in other urban areas. e CDC reported that cigar use among African American adolescents has more than doubled since 2009, whereas traditional cigarette smoking has declined signicantly.21Sexual ActivityMany adolescents engage in sexual activity that may directly or indirectly aect their oral health. ese adolescent sexual behaviors include a range of activities from kissing and fondling, to oral, anal, and vaginal sex. e most recent Youth Risk Behavior Survey of US high school students reports:• 41%hadsexualintercourse.• 30%hadsexualintercourseduringtheprevious3months,and,of these• 43%didnotuseacondomthelasttimetheyhadsex.• 14%didnotuseanymethodtopreventpregnancy.• 21%haddrunkalcoholoruseddrugsbeforetheirlastsexualintercourse.21Risky sexual behaviors place adolescents at risk for unplanned pregnancies and sexually transmitted infections (STIs), including HIV.Certain behaviors place the adolescent at higher risk for develop-ing STIs. ese include (1) early age at sexual debut; (2) lack of condom use; (3) multiple partners; (4) prior STI; (5) history of STI in a partner; and (6) sex with a partner who is 3 or more years older. Other adolescent risk-taking behaviors that are associated with STIs are: (1) alcohol use; (2) depression; (3) dropping out of school; (4) illicit drug use; (5) pregnancy; and (6) smoking.21Adolescents contract STIs at a higher rate than adults because of sexual risk taking and possible barriers to health care access.22 During the teen’s dental examination, sexually active adolescents may present with herpes simplex virus (HSV)-2 lesions in the oral and perioral regions. According to a recent national survey, more Additionally, according to the American Foundation for Suicide Prevention (AFSP)—the nation’s largest suicide prevention network—since the risk of suicide is heightened by a convergence of multiple risk factors, with the most common being depression and other mental health conditions, screening for these risks is the rst critically important step in preventing suicide death.As pediatric dentists it is our professional responsibility to help identify those adolescents who may be at higher risk for suicide. Positive youth development suggests that a good interpersonal relationship between the adolescent patient and the pediatric dentist may inuence an improvement in the adolescent’s oral health and at the same time, serve as a good role model. Because dental health professionals frequently encounter adolescents in their practices over time as well as in their communities, we may have several potential opportunities to observe changes in behavior and to ask appropriate questions to identify adolescents at high risk for psychological problems. Referral should be made when the treatment needs are beyond the treating dentist’s scope of practice, and consultation with nondental professionals or a team approach may be indicated.19e rst step to appropriately identify these adolescents at risk is a thorough medical history that includes both systemic conditions as well as behavioral issues. Routine history taking should include questions about mood disorders, antidepressant medications, school problems, and stressful life events. Asking open-ended questions may elicit more than a “yes” or a “no” response. If the adolescent appears to be sad at the dental appointment, allow your responses to reect the patient’s mood. is approach may allow the adolescent to feel understood, and a dialogue may follow. Adolescents at risk for suicide can be identied through direct questioning or screening by self-report accompanied by knowledge of the risk factors. It is important for the pediatric dentist to maintain a nonjudgmental and open approach in questioning the adolescent.A second step in identication occurs while performing the comprehensive oral examination. Be alert to teens whose appearances and/or behaviors are beyond normal self-expression. Signs that may be indicative of inner turmoil include self-injury and increased risk-taking behavior. Extensive body art and/or branding are some examples of risky behaviors that may manifest during adolescence. e devastating oral eects associated with “meth mouth” are of increasing concern in this age group. Regularly weigh your patient at recall examinations. A signicant increase or decrease in weight or appetite could be a characteristic of depression or eating disorders. Ask if the patient is experiencing any energy loss, sleep problems, or lack of interest in daily activities. Adolescents in crisis may exhibit one or more of these behaviors, and the dental health professional should be aware of these indicators.Finally, familiarize yourself with local, state, and national resources for treatment of psychopathology and suicide prevention. A list of telephone numbers of mental health agencies, family and children services, crisis hotlines, and intervention agencies should be available in the dental oce for possible referral of your adolescent patients and their parents. Severe moodiness in a teenager may not be something that will be outgrown; it may be a behavior that requires our recognition and appropriate referral for proper intervention.Risky BehaviorsSmoking/Vapinge use of tobacco products by adolescents is widespread and may not only result in chronic systemic eects but also contribute to 560 Part 5 Adolescencethem. From a psychological standpoint, the disclosing of one’s sexual orientation may result in signicant stress for the adolescent and their families. e family may reject or disapprove this dis-closure, resulting in a lack of social support from families and friends. Some sexual minority youth may experience physical or emotional abuse; therefore as mandated reporters, the pediatric dentist needs to be aware of the probable root cause of the abuse and the perpetrator. As a result, LGBTQ adolescents also appear to be overrepresented among runaway and homeless youths in the United States.29By knowing an adolescent patient’s sexual orientation, the pediatric dentist can become more knowledgeable and sensitive to the teen’s medical and dental needs.SummaryAdolescence is the transitional period between puberty and maturity associated with accelerated physical growth and dynamic hormonal changes, contradictions in self-awareness, and the conicting demands of modern society. All of these factors contribute to the persona of the turbulent teenager. Adolescent dental patients have distinct oral needs that require enhanced understanding by dental professionals in order to provide high-quality dental services to this age group. However, for many adolescents, these years may be an emotional period and a time when dental and medical needs are neglected. e intent of the following chapters is to present clinically relevant information that will assist the dental team in providing optimal care to their adolescent patients.References1. Tanner JM, Whitehouse RH, Marshall WA, et al. Assessment of Skeletal Maturity and Prediction of Adult Height: TW2 Method. New York: Academic Press; 1975.2. Kokich VG. Age changes in the human frontozygomatic sutures from 20 to 95 years. Am J Orthod. 1976;60:411–430.3. Enlow DH. Handbook of Facial Growth. Philadelphia: Saunders; 1990.4. Behrents RG. Growth in the Aging Craniofacial Skeleton. Monograph 17, Craniofacial Growth Series. Ann Arbor, MI: Center for Human Growth and Development; 1985.5. Björk A. e face in prole. Sven Tandlak Tidskr. 1947;40(suppl 5B).6. Ranly DM. A Synopsis of Craniofacial Growth. New York: Appleton-Century-Crofts; 1980.7. Björk A. Sutural growth of the upper face studied by the implant method. Acta Odontol Scand. 1966;24:109–127.8. Kiell N. e Universal Experience of Adolescence. Boston: Beacon; 1967.9. Mussen PH, Conger JJ, Kagan J, et al. Child Development and Personal-ity. 6th ed. New York: Harper & Row; 1984.10. Hartup WW. e peer system. In: Mussen PH, ed. Handbook of Child Psychology. Vol. 4. 4th ed. Hetherington EM, volume ed. Socialization, Personality, and Social Development. New York: John Wiley; 1983.11. Nansel TR, Overpeck M, Pilla RS, et al. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285(16):2094–2100.12. Olweus D. Bullying at school: basic facts and eects of a school based intervention program. J Child Psychol Psychiatry. 1994;35(7):1171–1190.13. Brunstein KA, Sourander A, Gould M. e association of suicide and bullying in childhood to young adulthood: a review of cross-sectional and longitudinal research ndings. Can J Psychiatry. 2010;55(5):282–288.than two-thirds of US teenagers have engaged in oral sex—including nearly25%whohaveneverexperiencedintercourse.21 Consequently, STIs are spreading faster among teens than any other age group. In addition, females are more likely than males to contract HSV-2 from a single act of unprotected sex.21 Palliative treatment is recom-mended and may include analgesics (e.g., acetaminophen) and antiviral medications (e.g., acyclovir) to alleviate the symptoms. Recurrent herpes labialis may be treated with topical penciclovir cream for vesicular perioral lesions.23 e cream may have a small, favorable eect on the duration of symptoms if applied at the onset of the infection. us, it is important for the pediatric dentist to address the adolescent’s sexual activity and use this opportunity to discuss risk reduction as a component of the overall medical history.By building a trusting relationship with the adolescent over time, the dentist may be able to obtain an honest, detailed health history to ascertain the teen’s sexual activity. Since sexuality is an expected stage in the development of adolescents and young adults, pediatric dentists have a professional responsibility to be knowledge-able in initial screening and management/referral of common sexual health issues. e dental health professional’s ability to listen to adolescents’ concerns and to help them access necessary community resources will allow the pediatric dentist to serve his or her teenage patients eectively.Gender IdentityAlong with sexual activity, sexual identity develops and may solidify during adolescence. Gender identity and subsequent discussions with the patient are relatively recent to medical and dental providers. In 1983, the AAP issued its rst report on sexual minority teens, and then made revisions in 1993 and 2004.24 Since the last update, research on this subject has expanded rapidly with numerous publications about lesbian, gay, bisexual, transgender, and question-ing (LGBTQ) youth. In 2011, the Institute of Medicine published a report documenting the health of the LGBTQ people.25 ey stated that being a member of this group of adolescents is not, itself, a risky behavior. In addition, sexual minority youth should not be considered abnormal.25Typically, a young person’s sexual orientation emerges before or early in adolescence.26 In fact, many teens are in conict with their sexual attractions and some may refer to themselves as “questioning.”26 In the United States, the exact prevalence of adolescent homosexuality and same-sex experiences is unknown. Astudyof9thto12thgradersfromMassachusettsreported3%as gay, lesbian, or bisexual.27Another1%reportedas“questioning.”27 IntheNationalSurveyofFamilyGrowth,13.4%offemalesand4.0%ofmalesself-reportedofhavingsexwithsomeoneof thesame gender.28 So, the pediatrician and the pediatric dentist need to be cognizant that some of the concerns their patients may have are regarding their sexual orientation. Over the years, the pediatric dentist has probably developed lasting relationships with his or her patients, and these patients may be comfortable in discussing their concerns with the pediatric dentist. e dentist should be able to provide current and nonjudgmental information in a condential manner. In addition, the dental professional should assist the adolescent with the names of other health care professionals and agencies for possible referral. Pediatric health care providers are important in facilitating a healthy transition from adolescence to adulthood so the pediatric dentist needs to be knowledgeable about the issues facing sexual minority youth.Health care issues and disparities exist among LGBTQ teens, and unfortunately, many of the public health systems have ignored CHAPTER 37 The Dynamics of Change 561 23. Opstelten W, Knuistingh A, Eekhof J. Treatment and prevention of herpes labialis. Can Fam Physician. 2008;54:1683–1687.24. American Academy of Pediatrics, Committee on Adolescence. Homosexuality and adolescence. Pediatrics. 2004;113(6):1827–1832.25. Institute of Medicine, Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. e Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.26. Spigarelli MG. Adolescent sexual orientation. Adolesc Med State Art Rev. 2007;18(3):508–518.27. Garofalo R, Wolf RC, Wisslow LS, et al. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med. 1999;153:487–493.28. Chandra A, Mosher WD, Copen C, et al. Sexual behavior, sexual attraction, and sexual identity in the United States: data from the 2006-2008 National Survey of Family Growth. Natl Health Stat Report. 2011;36:1–36.29. National Youth Coalition for Housing. LGBT young people. http://www.youthhomelessnessmatters.info/lgbt-young-people. Accessed June 13, 2017.14. Copeland WE, Wolke D, Angold A, et al. Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry. 2013;70(4):419–426.15. Antila H, Arola R, Hakko H, et al. Bullying involvement in relation to personality disorders: a prospective follow-up of 508 inpatient adolescents. Eur Child Adolesc Psychiatry. 2017;26(7):779–789.16. American Academy of Child and Adolescent Psychiatry. Suicide in children and teens; 2017. http://www.aacap.org/AACAP/Families_and_youth/Facts_for_Families/FFF-Guide/Teen-Suicide-010.aspx. Accessed February 1, 2018.17. Shain BN. Suicide and suicide attempts in adolescents. Pediatrics. 2016;120(3):669–676.18. Romer D. Adolescent risk taking, impulsivity, and brain development: implications for prevention. Dev Psychobiol. 2010;52(3):263–276.19. American Academy of Pediatric Dentistry. Guideline on adolescent oral health care. Pediatr Dent. 2016;38(6):155–162.20. Arrazola RA, Singh T, Corey CG, et al. Tobacco use among middle and high school students—United States, 2011-2014. Morb Mortal Wkly Rep. 2015;64(14):381–385.21. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance—United States, 2015. MMWR Surveill Summ. 2016;65(6):1–174.22. Alexander SC, Fortenberry D, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr. 2014;168(2): 163–169. CHAPTER 37 The Dynamics of Change 561.e1 Case Study: Addressing Sexual Identity in Pediatric Dental PatientsA. Jerey Wood and Scott B. SchwartzStephanie, currently 13 years old, has been your patient for the past 4 years. As a longtime patient, Stephanie has a good rapport with your staff, who remember her and look forward to her visits. Although she presented to the ofce routinely for recall visits, her appointment compliance has become sporadic.Social History: Stephanie is from a large blended family and has three siblings and two half-siblings.Medical History: Stephanie’s medical history is remarkable for a history of depression, rst diagnosed at age 8, for which she receives regular counseling. As of her last recall, she does not take any prescription medications for her depression. At her last visit with you, 10 months ago, Stephanie’s mother told you in condence that Stephanie had recently asserted that she was transgender and wished to begin her transition to live as a male. The family and Stephanie’s physician were awaiting further evaluation at that time.Three days prior to today’s visit, Stephanie’s mother contacted you with the update that Stephanie had started hormone therapy to block the onset of puberty, as part of an initial management plan for Stephanie’s transition. In addition to her medical transition, Stephanie initiated a social transition, including changing her preferred name to “Sean” and pronouns to “he/him/his.” Mom conded that the family is struggling with Sean’s choices but is trying to be as supportive as possible at this difcult time. Given the recent stresses at home, Mom also informed you that Sean has initiated a course of daily uoxetine to manage worsening symptoms of depression.Dental History: Sean’s permanent dentition is unrestored and all of his permanent molars are sealed. Sean’s last recall visit with you was 10 months ago.At today’s visit, Sean appears to be prepubertal. He has a short haircut and is wearing jeans and a tee shirt, with tennis shoes. He is withdrawn, minimally communicative, and seems resentful that he had to come to the appointment. When you ask, “So, how are things going with you, Sean?” he replies, “I don’t want to talk about it.”On your oral examination, you note signicant plaque accumulation and extensive gingivitis. You also note a tongue piercing that was not present on last exam (Fig. E37.1). There is approximately 1-mm recession visible on the lingual of #24 and #25 (Fig. E37.2). Although you do not note any active carious lesions, you do smell cigarette smoke on Sean’s breath. He denies smoking.Questions1. What side effects of taking uoxetine for depression are most likely to have dental effects? a. Nausea b. Dr y mouth c. Headache d. AnxietyAnswer: b2. What are risks of oral piercings on the dentition? a. Infection b. Recession c. Fractured teeth d. All of the aboveAnswer: d• Figure E37.1 Tongue piercing. (Courtesy Dr. Gretchen Bruce and Dr. Blair Isom, University of the Pacic, Arthur A. Dugoni School of Dentistry.)• Figure E37.2 Gingival recession #24 and #25. (Courtesy Dr. Gretchen Bruce and Dr. Blair Isom, University of the Pacic, Arthur A. Dugoni School of Dentistry.)Continued 561.e2 Part 5 Adolescence3. Which methods make the dental clinic a more supportive space for patients who identify as transgender? a. Asking why they have changed to a different gender b. Use of birth name for continuity of care c. Use of gender-specic rewards d. Use of pronouns that reect preferred genderAnswer: d; refer to Table E37.1.BibliographyAmerican Academy of Pediatric Dentistry. Guideline on adolescent oral healthcare. Pediatr Dent. 2016;38(special issue):155–162.Issue Poor Management Strategy Best PracticeLegal name and preferred name are differentContinue to refer to patient by legal nameFollow patient lead, ask for preferred namePatient may have indeterminate gender appearanceContinue to use previously indicated pronounsAsk patient for his or her preferred pronounsPatient is minimally communicative Direct questions and information provided toward caregiverTry to engage patient and establish rapport/communicationShare all information with the patient and caregiver, where appropriateSuspicion that patient has begun smokingIgnore suspicions and focus on dental needsShare information about smoking, and offer to provide help with smoking cessation when the patient becomes interestedOral piercing is observed Ignore nding and dental implications Share information about oral piercing and possible hard and soft tissue trauma with patient and caregiverBest Practices for Management of Adolescent Patients Who Identify as TransgenderTABLE E37.1 562 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic ProblemsERICA BRECHER, THOMAS R. STARK,a JOHN R. CHRISTENSEN, AND ROSE D. SHEATSCHAPTER OUTLINEThe Patient HistoryThe ExaminationBehavioral AssessmentGeneral AppraisalDetermination of Developmental StatusHead and Neck ExaminationFacial ExaminationIntraoral ExaminationPeriodontal EvaluationRelated Hard and Soft Tissue ProblemsOcclusal EvaluationRadiographic EvaluationTreatment Planning for Nonorthodontic ProblemsTreatment Planning and Treatment for Orthodontic ProblemsSkeletal ProblemsDental ProblemsTemporomandibular Disorders in Children and AdolescentsDiagnosis of Temporomandibular DisorderImaging and Temporomandibular DisorderManagement of Temporomandibular Disorderfacial growth of up to 35% of total height of the face. More than a dozen teeth, primary and permanent, exfoliate and erupt between the ages of 10 and 13 years. Immunologic changes, hormonal shifts, and other subtle and not so subtle physical developments alter the oral cavity.2. e environmental challenges, with their obstacles and pitfalls. Few adults would choose to return to adolescence. Today’s adolescents encounter many challenges at home, school, and among their peers. ey are navigating the path of their future education and careers while learning to cope with the peer pressures of sex, drugs, alcohol, and smoking. Perhaps the most poignant statement on this aspect of the teenage years is that accidental death is the leading cause of mortality. Dental profes-sionals see trauma, oral manifestations of sexual activity, hormonal gingivitis, smokeless tobacco-induced hyperkeratosis, noncompli-ance with dental recommendations, and drug-related behaviors, to mention a few examples.3. e need to learn to cope, make decisions, and become independent. It is not surprising that primitive cultures associated emerging adulthood with rituals and great signicance. Adolescence has always been a time to make decisions, seek independence from ae views expressed in this chapter are those of the author and do not reect the ocial policy or position of the Department of the Army, Department of Defense, or the US Government.The classic portrayal of adolescence as a time of rising hormones, rebelliousness, and fads contrasts vividly with the way dentistry has viewed adolescent oral health. Dentistry for children ends abruptly with eruption of the permanent premolars and canines. Adult dentistry begins with consideration of what to do with the third molars. For many dental professionals, the rst intervention that comes to mind for the adolescent is orthodontic care, which is often initiated during the preadolescent transitional period.Entirely opposite to the prevailing beliefs about the quiescence of the teenage years is the reality of a rapidly changing patient challenging his or her environment head-on and learning to cope in the process. e implications of these changes for dentistry1 are summarized as follows:1. Rapid, unpredictable, and irregular skeletal and dental growth. e adolescent growth spurt is associated with accompanying CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 563 • Encourageparentstocompletehistorieswithadolescents,notfor them.• Allowtheadolescenttheopportunitytocontributetothehistoryalone, which can be done in the context of a nal check before treatment at chairside.• Nevertreatanadolescentwithoutaconsentingparentavailable.Dental care would be considered nonurgent care and most jurisdictions require adult consent.• Explain suspicions or concerns to both the parent andadolescent.• Establishapolicyondeferringtreatment anddealingwithidentied problems of a serious nature that is medicolegally consistent and sound.• Haveresourcesavailableifconsultationwithaspecialistisneeded.The Examinatione techniques of clinical examination remain the same for the adolescent, but closer attention is paid to the identication of problems specic to this group, such as occlusal disharmonies, periodontal conditions, and temporomandibular joint disorders (TMDs). Table 38.1 lists some of the clinical ndings peculiar to adolescent patients.Behavioral Assessmente access to dental care available to most healthy Americans has made it unlikely that a teenager will present for a rst dental appointment, although rst visits during adolescence are possible. Personality changes and other behavioral aberrations can suggest problems for the adolescent. Extremes in behavior, such as depression or overt sexual behavior, may indicate sexual abuse, especially if the child demonstrates a reluctance to allow oral examination. Depression, manifested by severe introversion, can also be a sign of suicidal tendency, family dysfunction, or even drug use. As a health care provider, it is the dentist’s responsibility to be aware of the impact of the problem on the child and comment to parents about noticeable changes in behavior. Although few behavioral problems preclude delivery of care, exceptions do occur. e following are situations that may require behavioral management:1. Sexual abuse. e young adolescent girl or boy who has been sexually abused with oral penetration may be reluctant to accept dental care from a dentist of the same sex as the perpetrator. Aids in uncovering this situation are a good history of previous compliance, behavioral cues, such as depression, and overt refusal ofcarewhenoralcontactismade.Nonetheless,conrmationis dicult because the parents may be unaware of the abuse. If sexual abuse is suspected, dentists are mandated reporters and must report suspicion of abuse to the appropriate local agency.2. Rampant caries. Clinicians have noted that rampant caries, a condition of rapid onset and progression of decay in an adolescent (more often a girl), is often associated with personal-ity problems (Fig. 38.1). e typical manifestation is a shy, reluctant, introverted person who is passive about treatment. e behavioral signs can be varied, with the girl crying silently or not saying a word during the appointment. In some cases, appointments can degenerate as the child whimpers and nally loses her composure. Time and engagement in conversation are often the most successful behavioral management keys in dealing with these adolescents. Dramatic changes in behavior can occur with the dentist’s verbal reinforcement of improved families, deal with sexuality, and choose a career. e dentist may see this turmoil reected in poor compliance with oral hygiene or refusal to accept treatment.The Patient Historye health history of the adolescent is constantly changing and must be kept current. An adult history format captures both of these elements. Perhaps more important from the standpoint of accuracy is the process of obtaining information from the teenager. e following are some of the topics that should be considered when taking a history from an adolescent patient.e health history should address the issues of smoking, rec-reational drugs and alcohol, birth control, pregnancy, and sexually transmitted diseases. e controversy over inclusion of these issues is easily quieted by the simple realities of adolescent life in the United States. Consider these facts:• Everyday,approximately3000teenagersstartsmoking.Ninetypercent of smokers begin before age 18.2• In2014,thelivebirthratein15-to19-year-oldwomenwas24.2per1000.3 Although teenage pregnancies have steadily declined over the past 20 years, pregnancy status should be considered because radiation and dental medications can be dangerous to a fetus.• emajorityofadolescentsnowtrydrugsoralcoholbeforeleaving high school. Untoward interactions between prescribed and illicit medications can be fatal.• Sexuallytransmitteddiseasesareepidemicintheadolescentagegroup.Halfofallnewinfectionsoccurin15-to24-year- olds.4Both the dentist and the patient are at risk if there is inadequate surveying of these elements in the health history. ese issues can be addressed forthrightly by including them as choices interspersed with others on a health history form. A less threatening approach is to phrase these questions in the past tense or to associate a risk with them in order to alert the patient to their importance.e history-taking process should allow privacy and encourage disclosure. Taking an accurate history may mean allowing the adolescent to assume greater participation in the process, yielding information that might not be available from or known to a parent. e dentist may be caught in a double bind by providing an environment that fosters disclosure if pregnancy or illicit drug use is uncovered and the parents are unaware of it. Unfortunately, the adolescent may see this as betrayal or breach of condence and the relationship between the dentist and patient may be jeopardized. ere is no easy way to deal with this type of problem, but the dentist who treats adolescents should be aware of the respon-sibilities of the situation. It also may mean delaying treatment untiltheproblemisresolved.Ingeneral,theHealthInsurancePortabilityandAccountabilityAct(HIPAA)permitsdisclosureofa minor’s medical information between provider and guardian.5 However,manystateshavespecicminorconsentandprivacylaws, which may grant exceptions for conditions such as pregnancy, substance abuse, or treatment of sexually transmitted diseases, among others. Dentists should consult their state-specic laws forfurtherinformationconcerningtheapplicabilityofHIPAAtothe disclosure of information concerning the treatment of minors. e dentist’s responsibility is to help direct the family to address the issue.e dentist can take some actions that both facilitate an accurate history and deal consistently with identied problems of a serious nature: 564 Part 5 Adolescence4. Eating disorders. Treatment of the child with an eating disorder can be dicult. Eating disorders are a type of psychiatric disorder and require appropriate medical intervention. Experience indicates that these patients, disproportionately girls, tend to develop dependency on a male authority gure.5. Illicit drug use. Clinicians have noted bizarre behavior on the part of adolescents and young adults who present for treatment after taking nonprescription medications. A number of untoward reactions to dentist-administered medications have been associ-ated with prior ingestion of drugs or alcohol by a young patient. Manifestations of drug ingestion may vary from a slight mental dissociation or drifting to outright verbal aberrations or extreme changes in personality.Another common drug used by adolescents is nicotine, in the form of cigarettes, smokeless tobacco, and e-cigarettes. is drug is addictive and has cardiovascular, respiratory, and oral conse-quences. It is important to educate adolescents that e-cigarettes are not approved for smoking cessation, and contain nicotine, toxins, and carcinogens.7 Although dicult, cessation programs combining motivated participants, nicotine replacement therapy, and behavioral support seem to have the best chances of extinguish-ing the habit.Management of behavioral problems in the adolescent can be complex and often involves parents and other professionals. Most practitioners treating adolescents try to treat these patients alone rather than in a setting in which other peers are present. is one-on-one relationship provides the necessary attention to the patient and prevents disruptive interactions. Any dentist who has worked with a group of seventh- or eighth-grade students will appreciate this recommendation. e teenager who is acting up but is simply expressing healthy emotions should respond to reason and provide compliance.An important part of behavior management in this age group involves the simple transfer of information. A good communicator is aware of the characteristics of adolescence, which enhances his or her ability to relate to teenagers. ese characteristics are as follows:1. Peers are important. e adolescent’s relationship to those outside the nuclear and extended family becomes important. Friends, classmates, teammates, and popular persons of similar age are all involved in the life of the teenager. A dentist can enhance his or her ability to communicate with adolescents by asking hygiene and provision of temporary esthetic anterior restorations that allow the patient to smile and experience a more positive self-image.3. Extreme anxiety. Pinkham and Schroeder6 described the behavioral management of the child who shows extreme anxiety at the prospect of dental treatment. Desensitization by psychological intervention may be the key to the develop-ment of acceptable clinical behavior in such children. Tools available to the dentist are the use of noninvasive therapies at rst, reinforcement of positive accomplishments, positive peer interaction, and involvement with a psychologist. e poorly treated or untreated adolescent phobic may become the adult dental phobic.Structure Finding CommentExtraoral EvaluationSkin Acne May be painful locallyAdolescent may take antibioticsMay appear as radiopacity on some radiographs if calcication occursCosmetic useCan complicate evaluation of the skinCan cause local allergic responseNeck Hematoma From suction; indicates sexual activityEars Healing or scarred puncturesMultiple ear piercings common in both sexesHair Coloring and preparationCan complicate examination of the scalpIntraoral ExaminationMucosa Generalized erythemaEffect of smokingSexually transmitted diseaseBuccal mucosa Erythema, hyperkeratosisUse of smokeless tobaccoTongue Coating, odor Smoking; poor hygiene; fungal overgrowth from medicationBreath Acetone; alcohol Excessive dieting, alcohol abuse, metabolic disorders (e.g., diabetes)Gingiva Inammation Hormonal changes (e.g., puberty gingivitis)Poor oral hygienePregnancy tumor Use of oral contraceptivesPregnancyTeeth Erosion BulimiaWear facets Temporomandibular joint disorders/bruxismExcessive stain Tobacco useCoffee or tea useDiscoloration Existing pulpal pathosis from traumaPossible Clinical Findings in Examination of the AdolescentTABLE 38.1 • Figure 38.1 This 14-year-old girl has rampant caries, which is a distinct clinical entity with rapidly progressing decay, multiple pulpally involved teeth, and short onset. Patients may give a history of minimal caries before the development of overt signs of decay. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 565 for those with excess growth issues like mandibular protrusion or vertical facial excess. e most reliable and sensible method, which speaks directly to this issue, is taking serial cephalometric radiographs and superimposing their tracings (see Fig. 31.53). e Cervical Vertebral Maturation method is a useful guide to assess peak adolescent growth and utilizes information obtained from a cephalometricradiograph(seeFig.31.4).esemethodsarehelpfulnot only for orthodontic treatment planning but also for determining when implant placement is feasible.Head and Neck Examinatione principles of the head and neck examination of the teenager are similar to those applied to the adult or child. Variations from normal can be caused by a variety of factors, the most notable of which are growth and developmental changes and the eects of the adolescent’s environment.e physical changes and habits in the teen require modication of the procedures used in children. On the positive side, the loss or redistribution of body fat and the elongation of the neck allow one to perform a better lymph node evaluation. ese changes facilitate a thorough head and neck and cancer examination.Facial ExaminationIn the facial examination the dentist analyzes the soft tissue prole and the frontal face. During adolescence the face is beginning to assume adult-like features, and treatment decisions can be based more on current rather than projected facial appearance. is does not mean that growth is complete—only that it has slowed consider-ably from its previous pace during the early adolescent growth spurt. e adult prole tends to be straighter than the adolescent’s because of continued mandibular skeletal growth. In addition, the soft tissue of the chin increases slightly in thickness. e nose continues to grow in horizontal and vertical directions. Most of this growth is horizontal but the nasal tip tends to drop a small amount. e lips are less protrusive in the adult because of these nasal and chin changes combined with a slight thinning of the soft tissue thickness of the lips.For patients with class I skeletal and dental characteristics, the facial prole examination should provide an adequate basis for analysis when minor orthodontic treatment is considered. For the patient with a skeletal problem, additional information (e.g., a cephalometric radiograph and analysis) is required to diagnose the problem denitively and prescribe treatment.Treatment of skeletal orthodontic problems during preadoles-cence or early adolescence, when the adolescent growth spurt is still active, can result in growth modication. e preadolescent patient is assumed to be growing and is expected to experience a pubertal growth spurt. e young adolescent, especially the male, still has enough growth remaining to allow signicant skeletal changes to occur with treatment. Once the adolescent has experienced the pubertal growth spurt, growth remains but is signicantly slower, and equal to the down side of the growth rate curve. Adults have such limited facial growth it is of little therapeutic potential.ese dierences in growth potential have a large impact on how skeletal malocclusion is managed in the adolescent. As the individual becomes more skeletally mature, less skeletal growth modication can be accomplished. erefore, as noted earlier, it is essential to establish the growth or developmental status of the patient in order to plan sensible treatment.about peer interaction and by knowing who is involved in the teen’s life.2. Fads and experimentation are part of adolescence. Successful adolescent practitioners are those who are aware of the trends, popular fads, and celebrities that are of interest to teens. e dentist who knows the trends and interests of the adolescent has an edge in establishing communication and in reaching the teen on a nonauthoritarian basis. ese are an entree into the teen’s world that can be fostered and can lead to discussion of more signicant issues with a sense of relationship. Contrast that access to the barrier that arises when both teen and dentist see themselves as worlds apart.3. Teens are trying to establish independence, searching for identity, making educational or career choices, and experimenting with sexuality. All of these involve a certain degree of stress. Within that stressful period are times of anxiety, satisfaction, anger, excitement,andahostofotheremotions.Howthepractitionerfosters the healthy development of personality in a child and counsels him or her toward independence and career may be important in terms of both the teen’s life and his or her dental health. In talking with teens, it is helpful to remember their “problem list” and to empathize about the stress of their lives, which is real to them. e oce visit should provide a respite from pressures and be a cameo of the role that the adolescent plays as an adult patient. e relationship that the dentist would like to have with the adolescent as an adult should be fostered.4. e basis of success in adolescent-adult interactions is a good relation-ship. e most signicant factor in successful compliance and communication is the quality of the relationship between the dentist and the adolescent. In earlier periods of life, the child could be successfully motivated with reason, praise, or other approaches. e changing values and their short-term intensity in adolescence belie the use of these approaches in fostering long-term motivation. A feeling of trust, good communication, and a perception by the teenager of the dentist’s sincere interest provide a strong motivation for compliance.General Appraisale general appraisal of the adolescent is confounded by the timing of physical growth changes, especially in the early teenage years. Within a group of young teenagers, girls can tower over boys and look far more like adults than male peers. Similarly, within a group of boys, variations in voice tone, skin condition, amount and distribution of fat, and skeletal proportion are often remarkable. Dierentiation of growth disorders is dicult at best.Determination of Developmental StatusPatients in the preadolescent stages are growing rapidly and many clinicians prefer to attempt orthodontic growth modication then. If that can be tied to the transition to the permanent detention, then one stage of orthodontic treatment can be sucient to complete the care. For others, growth modication must start before the eruption of all permanent teeth so there are two phases of treatment; growth modication is followed by a nal phase of comprehensive treatment. After peak growth, statural and facial growth decrease dramatically. At that point, the only logical options for care of a skeletal discrepancy are camouage or surgical orthodontic care.e most important question is whether patients have remaining facial growth. It determines when surgical care can be instituted 566 Part 5 Adolescenceteeth without complete root formation. e use of disclosing agents to reveal plaque may be helpful. If a panoramic radiograph is used for diagnosis, selected periapical lms may be needed if the clinical examination exposes any unusual periodontal ndings. Referral to a specialist is suggested if signicant periodontal disease is evident. During orthodontic treatment, gingival, plaque, and bleeding indices should be established at regular intervals to detect newly active periodontal disease. With the increase in childhood and adolescent obesity there has been an increase in the number of adolescents with diabetes mellitus type 2 (noninsulin-dependent diabetes).10 Approximately one-third of children and adolescents are now categorized as overweight or obese, so we are likely to see adolescent patients exhibit many of the comorbidities associated with diabetes, such as periodontal disease and bone loss. Studies support a strong correlation between glycemic control and severity of periodontitis.11 Dentists should include periodontal evaluation as a part of the adolescent examination.Related Hard and Soft Tissue ProblemsA number of pathologic conditions may occur in adolescence and may be rst noticed in this period. One is TMD, described in more detail later in this chapter. An eating disorder can manifest as enamel erosion of all teeth if vomiting is a regular component of this psychiatric disorder.12 Bulimia is the term given to characterize those Intraoral Examinatione larger size of the adolescent oral cavity permits good visualiza-tion.Normalintellectualstatusandreasonablebehaviorprovidecooperation in functional assessment of the occlusion and the temporomandibular joint (TMJ). ere are more teeth to evaluate and gingival and periodontal issues are present that were not critical in early childhood. e clinician should approach the adolescent as an adult, especially in the later teen years. For the rst visit, the dentist may choose to “walk” the adolescent through the examina-tion, using a hand mirror or computer images to explain procedures and normal ndings.Periodontal EvaluationIn the adolescent more emphasis is placed on the periodontal exam-ination. e prevalence of periodontal disease begins to increase in this age group.8 Although usually minor, loss of periodontal support due to periodontitis is common in the teenage population.9 erefore a thorough evaluation of the supporting structures is an absolute necessity. A periodontal probe is used to measure pocket depths, the width of keratinized gingiva, and the amount of attached gingiva and to establish a bleeding index (Fig. 38.2). Periodontal probing should be conned to fully erupted teeth. Mobility tests may reveal slightly increased mobility in erupted B CA• Figure 38.2 The prevalence of periodontal disease begins to increase in the adolescent patient; therefore a thorough evaluation of the periodontium is absolutely necessary. A periodontal probe is used to measure pocket depth (A) and the width of the keratinized gingiva (B). Probing is also done to establish a bleeding index (C). The amount of attached gingiva is determined by subtracting the pocket depth from the width of the keratinized gingiva. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 567 become popular in teenagers and young adults. It is associated with risks of systemic infection and tissue damage during placement, as well as tooth fracture, gingival recession, and localized infection while the item is being worn15 (Fig. 38.6).Evaluation of third molars is usually completed during mid- to late adolescence. Parents commonly ask about treating these teeth. e reasons for extraction of third molars include but are not limited to impaction or failure to erupt, periodontal disease, cysts or tumors, decay, posteruption malposition, nonfunction as a result of an absent opposing tooth, diculty with hygiene, and recurrent pericoronitis. If any of these conditions are present, the clinician should discuss removal with the parent and patient. e American Association of Oral and Maxillofacial Surgeons has conducted trials on third molars and oral health.16 ey have recommended advising patients and parents about the odds of a third molar remaining free of symptoms and pathology and then make a decision about removal. e discussion must also include the risks of surgery to remove the third molars.e concept of anterior crowding as the result of forward pressure from third molars is currently unproven and is not a reason to extract. Surgical access and root development are important issues in determining when to extract. Some root development is desired to stabilize teeth, but complete root development can make extrac-tion more dicult and may increase the likelihood of root fractures. Smokers, and females using oral contraceptives, may also run a high risk of postsurgical dry socket.who vomit regularly to purge themselves of food in a misdirected attempt to control their weight. Bulimia aects far more girls than boys, but boys can exhibit similar behavior. e regurgitated stomach contents, which are highly acidic, erode the enamel of teeth in a process called perimolysis (Fig. 38.3). Dentin is exposed, making teeth sensitive and encouraging decay. Enamel akes o, leaving sharp edges. Restorations may appear to have grown out of their preparations as enamel and dentin dissolve around them. In the early bulimic, these clinical signs may be absent. Pulpal pathosis, elongated clinical crowns, gingival recession, and loss of vertical dimension are a few of the treatment issues noted in bulimia. Unless the vomiting is stopped, extensive treatment may be futile. e dentist should work with a psychotherapist to deal with this problem. Dental erosion may have a variety of etiologies aside from bulimia in this age group, such as sports and carbonated beverage intake13 or gastroesophageal reux.14 e dentist should investigate the cause of erosion carefully before making treatment recommendations and referrals.Another pathologic problem is dental trauma. e clinical and radiographic examinations should address tooth crazing, chips, or discoloration with adjunctive radiographs to clarify the status of teeth.Notallteeththatappearsoundareclinicallyhealthy(Fig.38.4),andnotalltraumaistohardtissues.Itisimportanttoobtain a thorough trauma history during the patient interview process. e eects of smoking and oral sexual activity (Fig. 38.5) may also be identied during the examination. Oral piercing has ACB• Figure 38.3 Common intraoral ndings for a bulimic patient. (A) The loss of occlusal enamel with fractures of both the enamel and restorations is seen. (B) Progressive loss of enamel as witnessed here with posterior teeth progressively more eroded the longer they are present in the oral cavity. (C) Lingual exposure of dentin highlighted by outlines of remaining enamel and exposed surfaces of restorations. (From Casamassimo P, Castaldi C. Considerations in the dental management of the adolescent. Pediatr Clin North Am. 1982;29:648.) 568 Part 5 Adolescenceorthodontics prior to restorative treatment. e position of the teeth, the amount of supporting bone, the health of the teeth, and the number of missing teeth will determine the direction of treatment.Once again, the interaction between the facial prole and dental crowding should be considered. Committing the patient to treatment based solely on dental characteristics can have a disastrous eect on the facial prole. e nose and chin will continue to grow and the lips thin over time so the clinician must factor these changes into decisions on how to manage the crowding.Occlusal Evaluatione anteroposterior, transverse, and vertical components of the occlusion should be evaluated as described in Chapter 31. e major dierence is that arch length deciencies are no longer predicted from space analyses but are measured directly from the casts because all permanent teeth have erupted by this age (Fig. 38.7).Careful attention should be paid to teeth adjacent to edentulous areas because the adjacent teeth may need to be repositioned with • Figure 38.4 Severe resorption of roots secondary to trauma is evident on radiographic examination. These teeth were remarkably clinically stable despite the amount of root resorption. • Figure 38.5 This patient exhibits palatal hematomas secondary to oral sex. Negative intraoral pressures cause blood to be pulled to the surface of the palatal tissue. • Figure 38.6 An example of a tongue piercing, known as a dumbbell, which is common among teenagers and young adults. It has been shown to fracture enamel. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 569 adequately visualized until the premolars have fully erupted. e benet of exposing bitewing lms to examine two or four interproximal surfaces should be weighed against the risk of radiation exposure. In these cases, the caries risk assessment and a current clinical examination help to determine whether lms are necessary.e panoramic lm has a role in adolescent dentistry as a full-mouth radiographic survey for a new patient who does not have major treatment needs. e panoramic lm reveals bone pathosis and orients the examiner to the presence and position of third molars. The panoramic film also grossly displays sinuses and the TMJ (Fig. 38.8), which may be less well displayed on a multilm intraoral survey. Table 38.2 sum-marizes the issues that apply to radiography of the adolescent patient.Treatment Planning for Nonorthodontic ProblemsIn the adolescent patient, attention must be paid to the long-term consequences of treatment. Decisions made for the adolescent will inuence their care for the rest of their lives. e clinician should develop goals for the treatment and develop a treatment plan that will serve the patient not only as an adolescent but also as an adult. e decisions may be as simple as a choice of restorative material to as complex as the delivery and timing of prosthetic replacement of teeth.All phases of treatment planning should be addressed. e adolescentdepictedinFig. 38.9 illustratesthecomplexityofproblems requiring preventive, periodontal, restorative, surgical, and orthodontic management.Radiographic Evaluatione adolescent radiographic examination ranges from a transitional to an adult multilm survey, depending on the child’s dentition. e issues surrounding radiographic examination in the adolescent are related to the type and frequency of exposure. e types of lms used in adolescent radiography should be determined by the number of teeth present, the assessment of closed contacts not clinically visible, and the reason for radiographic examination. For the new adolescent patient with no apparent major dental needs, an individualized exam of posterior bitewings with a panoramic lm or selected periapical lms should suce. For the adolescent patient with major dental care needs, a full mouth intraoral exam is preferred. e number of lms is dictated by the size of the examination area and the information required to make a proper diagnosis.17e radiographic examination in this age group should address mainly growth and development issues: the eruption status of unerupted premolars and canines. Later in adolescence, a nal issue is third molar development. e development of these teeth can be evaluated by using periapical radiographs or a panoramic radiograph.e adolescent should be able to tolerate no. 2 size intraoral lms. For the child with a small oral cavity, techniques to aid in positioning are described in the radiographic section of Chapter 31.Multiple or serial periapical radiographs are required for diag-nosis of pathosis or for management of conditions that require signicant follow up, such as endodontic therapy for traumatized incisors.Bitewing radiography during early adolescence is affected by the developing occlusion and lack of contacts. A thorough clinical exam should determine if posterior surfaces can be BA• Figure 38.7 (A) Arch length analysis in the adolescent patient is measured directly from casts rather than by using prediction tables of mixed dentition space analysis because all permanent teeth usually have erupted by this age. The rst step is to measure the mesiodistal width of each individual permanent tooth. Depending on the software, the tooth widths are added together to get a sum of the mesiodistal widths in the arch. (B) Next, the arch circumference is determined by digital placement of the measuring tool from the mesial of the permanent rst molar to the mesial of the contralateral rst molar. The differ-ence between the arch circumference and the sum of the mesiodistal width indicate the amount of crowding or spacing within the arch. If one or two primary teeth have not exfoliated, the width of the contralateral erupted permanent tooth can be substituted for the unerupted permanent tooth. 570 Part 5 Adolescence• Figure 38.8 A large mucosal cyst in the sinus is evident in this panoramic radiograph of a 21-year-old patient. The cyst is possibly a reaction to pulpal pathosis in the permanent maxillary rst and second molars. BLAOcclusal upperIntraoral right Intraoral center Intraoral leftOcclusal lower• Figure 38.9 This adolescent patient has multiple problems that required interdisciplinary cooperation to solve. (A) Note the caries, periodontal disease, crowded teeth, midline discrepancy and malocclusion, and retained primary teeth. (B) The patient also has an impacted maxillary canine. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 571 3. Esthetic awareness by the patient may force the dentist to undertake management of congenital or acquired discoloration or may require repeated treatment of teeth if transitional procedures are used.4. Partiallyeruptedposteriorteethmaynotserveasgoodabutmentsfor prostheses.5. Decreased chewing eciency resulting from loss of a posterior tooth may force interim replacement with a removable appliance, although this may not be the treatment of choice.6. Planned or active orthodontic treatment may delay restoration of missing teeth.e use of acid-etch composite resins and porcelain veneers has greatly improved the management of adolescent restorative problems by providing esthetically acceptable, reasonably priced, conservative interim and permanent restorations. eir consideration as treatment options in restorative treatment planning is a must (seeChapter40).All adolescents should receive the benet of a preventive plan that addresses the needs of the adult dentition. Proper toothbrush positioning and ossing technique should be reviewed. In addition, the preventive plan should address environmental concerns, such as smoking, diet, trauma prevention, and the eect of medications on the periodontium and teeth.Periodontal and gingival concerns are solidly tied to restorative care. In the child, the minor inammation around a stainless steel crown on a primary tooth that is due to grossly adjusted margins is tolerated. In the adolescent with a cast crown, the tissues must be completely healthy.Restorative treatment planning for the teen is characterized by a number of issues.181. Pulp size is large, aecting the choice of coronal coverage.2. Anterior teeth continue to erupt, requiring consideration of various types of esthetic restorations for traumatized or defective teeth to prevent exposure of margins.Aspect RecommendationFrequencyFull mouth survey No suggested frequency or intervalDetermined by patient age, dental development, and caries risk assessmentPreferred when clinical evidence of generalized dental diseaseBitewing radiographs No suggested frequency or intervalDetermined by patient age, dental development, and caries risk assessmentShould be taken if clinical caries notedShould be taken if multiple interproximal restorations present and are being followedShould be taken if incipient caries are noted on previous lms and are being monitoredInterval for these situations should be individualized and re-evaluated at each periodic examinationPeriapical radiographs No suggested frequency or intervalPathosis or treatment needs should dictate frequencyTo evaluate dental traumaTo determine developmental status of third molarsPanoramic radiographs Possible component of a full mouth survey for a disease-free new patientEvaluate the mesiodistal position of maxillary canines“Third molar” panoramic radiograph to determine the developmental status of third molarsTypeFull mouth survey Number of lms included to be based on tissue coverage neededEarly adolescence (12–15 years): Maxillary and mandibular periapicals (no. 1 size) Canine periapicals (no. 1 or 2 size) Bitewings (two lms, no. 2 size) Four posterior quadrant periapicals (no. 2 size) to include premolars and erupted molarsLate adolescence (16–21 years): Complete set (21-lm) surveyBitewing radiographs Size determined by oral access, but no. 2 size used if possibleOne lm sufcient until eruption of second molarsPosition varies with the location and number of posterior contactsPeriapical radiographs Should be adult no. 1 size lms rather than no. 2 size; used as occlusal lm as in primary tooth surveyAn exception would be use of no. 2 lm as initial trauma screen sizePanoramic radiographs Can be used with bitewings for a full mouth survey and is desirable in caries-free and pathosis-free patients after a clinical examination“Third molar” panoramic radiograph can be used to determine developmental status of third molarsRadiographic Issues in the AdolescentTABLE 38.2 572 Part 5 Adolescencefunctional occlusion can be achieved without surgery. Traditionally, camouage of class II skeletal problems has been considered more acceptable in women and camouage of class III problems more acceptable in men because the respective convex and straight proles are more acceptable for these groups. Recent data indicate more acceptance among laypeople.19 e esthetic results in males with moderately class II problems were judged to be as acceptable as those in females with class II problems, whereas the results in males with moderate class III problems remained more esthetically acceptable than those in females with class III problems. Camouage of class III problems usually is addressed with lingual tipping of mandibular anterior teeth to obtain an acceptable overbite and overjet while at the same time moving the upper dentition anteriorly. Often, mandibular tipping is more easily accomplished when extractions are performed in the lower arch. At least for class II patients, most consider treatment by camouage extremely accept-able even though they realize they have somewhat smaller or more retrusive chin points.20With the maturity of the alveolar bone, temporary anchorage devices (TADs) have a place in orthodontic treatment planning for the adolescent, as do other skeletal anchorage methods, such as bone plates. TADs are germane to camouage treatment. Patients who previously could not lose any anchorage can now be treated with near absolute anchorage when TADs are placed. is opens new dimensions of treatment in many planes of space, especially for the anteroposterior and vertical. e direction of space closure can be carefully controlled as can absolute intrusion (Fig. 38.11). Usually age 12 years is a safe time to begin skeletal anchorage considerations due to bone maturation.Skeletal malocclusion in the nongrowing patient can also be managed with orthognathic surgery.21 e specialist works with an oral and maxillofacial surgeon to surgically reposition one or both jaws into proper alignment (Fig. 38.12). Typically, the orthodontic treatment plan calls for a presurgical period of orth-odontic tooth movement to align teeth in both arches and position the teeth over the bony bases so that they will t together following surgery. Orthognathic surgery is performed under general anesthesia, and the maxilla, mandible, or both jaws are repositioned and held in the new position by surgical screws or bone plates and screws. It is possible to move the entire jaw or individual segments of the jaw in almost any direction within the constraints of the soft tissue covering. ere is some restriction on the amount of change that can be achieved, and some types of change are more stable than others. Following the surgical procedure, jaw function is reduced with elastic traction. After healing is demonstrated, a short period of postsurgical orthodontic tooth movement is necessary to settle the teeth into the nal occlusion.Dental ProblemsIf the orthodontic problem in the adolescent is strictly dental, conventional orthodontic treatment can be used to manage the malocclusion. Identication and management of dental orthodontic problems have already been discussed and basically do not change withtheageofthepatient.However,thereareseveralaspectsofdental orthodontic treatment that have not been discussed and should be mentioned here. Despite the preventive eorts of the dental profession, some persons continue to lose permanent teeth to decay or trauma. Other patients lose primary teeth during adolescence and have no successors. When this occurs, a combina-tion of orthodontic tooth movement and restorative dentistry is recommended to obtain optimal esthetic and functional results.e two remaining elements of importance in adolescent treat-ment planning are interrelated. ey are consent and compliance. Treatment of adolescents under the age of majority requires parental consent. Payment for services also demands clarication of consent. e proposed treatment is best explained with both parent and adolescent present, although the actual delivery of care can occur with the adolescent alone in the operatory. Good one-on-one dialogue during active treatment helps to ensure compliance. Some general guidelines for communication to maximize success include the following:1. Show the adolescent the same respect and interest as you would an adult.2. Be sincere.3. Treat the adolescent in privacy as an adult, separate from younger children.4. Outlinetheproceduresandexplainthereasonsforthem.5. Minimize or eliminate authoritarian posturing, using your knowledge rather than age as a reason for your role as a dentist.6. Be exible enough to adapt to a changing relationship.Treatment Planning and Treatment for Orthodontic ProblemsAdolescent orthodontic problems create dicult treatment decisions for the general practitioner and the specialist. e nature of the malocclusion heavily inuences how the problem will be managed.Skeletal ProblemsIf the malocclusion is skeletal, treatment is aimed at altering the relationship or orientation of the jaws and teeth. is can be accomplished by growth modication, camouage, or orthognathic surgery. Because the physical maturity of the adolescent patient varies among persons of the same age, any one of three treatments may be appropriate. If the developmental assessment of the patient suggests that the patient is actively growing, growth modication is a viable treatment alternative. Growth modication, previously discussed in Chapter 36, attempts to change the actual size, shape, or orientation of the jaws to obtain an acceptable occlusion. Functional appliances and extraoral traction are used to secure these changes. e clinician may lean toward more noncompliant appliances in this age group because the remaining growth potential is so small there can be no wasted time not wearing appliances.In the nongrowing, physically mature adolescent, which is most likely the case, skeletal malocclusion is appropriately treated by camouage or orthognathic surgery. Camouage is the orthodontic movement of teeth without changing the underlying skeletal malocclusion. Camouage should be considered only when the soft tissue prole is acceptable and when tooth movement will not change or compromise the prole. Teeth are tipped or bodily moved on the denture base to positions considered less than ideal but acceptable for normal occlusion. For example, a mild class II mandibular deciency with a relatively prominent bony pogonion can be managed by camouage (Fig. 38.10). To camouage this type of problem, the upper teeth are moved backward and the lower teeth are tipped forward to bring the teeth together and disguise the skeletal problem. In conjunction with the tipping of teeth for camouage, often teeth in the maxillary arch are extracted to provide space in which to move the upper teeth backward. Although a small amount of soft tissue change may occur and the nal position of the mandibular incisors may be less than ideal, CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 573 because the adolescent has bone dense enough to support this type of anchorage. ese opportunities can be used for solutions toanteriorproblems(Fig.38.14)andposteriorproblems(Fig.38.15). Once the space has been established and is nearly ideal, a closed coil spring or loops bent into the archwire are used to hold or maintain the space until the restorative or prosthetic treatment is completed. Although this type of treatment sounds simple, close attention to detail is necessary. Uncontrolled tooth move-ment can result in unanticipated changes in the midline, overjet, and overbite.In certain cases, treatment can be accomplished with clear aligners. is is a relatively new approach to tooth movement, and was initially considered when there was generalized malalignment and good skeletal relations. e development of new materials and a more complete understanding of how aligners move teeth has expanded the types of cases being treated. e clinician uses a removable tray to exert force on the tooth to move it rather than using traditional orthodontic brackets and wires. An accurate In the anterior region, orthodontic treatment is often designed to move teeth to simplify restorative or prosthetic treatment. To provide precise control of tooth movement, orthodontic brackets should be placed on the anterior teeth and the permanent rst molars. Treatment must be carefully planned so that only the teeth that require movement are aected, and the other teeth remain stationary. is means that molar, canine, and midline relationships should be carefully studied and controlled during treatment.In cases of missing or small teeth, a diagnostic setup is performed so nal tooth position and dental relationships can be dened for the best result. Multiple setups might be required for a single patient to represent dierent treatment approaches. Digital study casts can be manipulated so several treatment alternatives can be examined by the patient and dentist (Fig. 38.13).Coil springs, elastomeric chains, and intraoral elastics can be used to open and close space for the best potential result. It is also an excellent opportunity to consider the use of a TAD, ABCD• Figure 38.10 (A) This preadolescent patient has a convex facial prole (B) due to maxillary protrusion. Because the facial prole is acceptable even though the skeletal relationships are not ideal, the teeth were moved to reduce the overjet and obtain a functional occlusion by retracting the maxillary teeth and pro-clining the mandibular teeth. (C) At the adolescent posttreatment stage, the facial prole (D) remains convex but acceptable with continued maxillary protrusion. 574 Part 5 AdolescenceACOcclusal upper Occlusal lowerIntraoral right Intraoral center Intraoral leftB• Figure 38.11 (A–C) This patient has a class II malocclusion, increased overjet, and missing teeth. In an attempt to reduce the malocclusion and the class II skeletal tendency, she was treated with extractions and space closure. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 575 EOcclusal upper Occlusal lowerIntraoral right Intraoral leftIntraoral center(D) An osseointegrated implant was placed in the palate and used to control the space closure and retraction. (E) The problems were successfully addressed using this implant-supported camouage treatment. Subsequently, the implant was removed. • Figure 38.11, cont’dDimpression or intraoral scan is made of the patient and is sent to a dental lab making aligners. e result is a digital representation of the malocclusion. Computer software has been designed to move the teeth individually in approximately 0.25 mm increments (Fig. 38.16). A series of aligners is constructed to move the teeth into position as determined by the doctor. e aligners are sent to the clinician for delivery and the patient wears one tray after another until the tooth movement is complete. e aligners are considered to be much more esthetic than traditional braces and more comfortable; however, there is still discomfort associated with tooth movement. e major drawback to removable aligners is that certain precise tooth movements are not as easy to make as with braces, so tooth movement can be less predictable. Obviously, to be successful, the patient must be thoroughly cooperative to wear the appliances as instructed. Clear aligner therapy continues to evolve and more and more challenging cases are being successfully treated.Adolescent orthodontic treatment is a challenging exercise in problem solving. A good database and growth assessment are necessary to allow the proper decisions about treatment alternatives. Unless the orthodontic problem is obviously the result of dental malalignment, the patient should be referred to a specialist because of the diculty in managing skeletal discrepancies in patients of this age. e unknowns of how much more a patient may grow and the direction the growth will occur make treatment decisions very dicult. It is not an overstatement to say decisions made at this time can impact how an individual will look the rest of his or her life.Temporomandibular Disorders in Children and AdolescentsTMDs collectively describe a group of painful and nonpainful musculoskeletal and neuromuscular conditions involving the muscles of mastication, the TMJ, and all associated structures.22 While some TMDs are asymptomatic and do not require any interventions beyond education and reassurance, painful TMDs may require therapeutic and symptomatic care. Since pain is the most common reason that patients seek treatment,23–25 it is vital that TMDs are understood in the broader perspective of orofacial pain conditions.26 Orofacial pain is a general term that includes TMDs and other pain syndromes of the head and neck.22 Chronic pain conditions, such as TMDs, frequently present during adolescence.27 Pain conditions that last from days to weeks are generally referred to as acute while chronic pain conditions tend to persist for months to years.28 Dentists are certainly well versed in treating acute dental pain; however, diagnosing and managing chronic pain in an adolescent population can be a challenging endeavor. Acute pain may resolve spontaneously or with minimal interventions, while chronic pain tends to be resistant to conventional treatment and may require a multidisciplinary approach to management.27,29 An 576 Part 5 Adolescencewith TMDs. is tool was developed as part of an international consortium, and studies using this methodology should be con-sidered to have met an appropriate level of scientic rigor. e DC-TMD also provides a helpful protocol for objectively classifying nonpainful and painful TMDs into subgroups. TMDs are divided into two main categories: (1) myogenous (muscle related) and (2) arthrogenous (joint related). Following this diagnostic paradigm is an important step toward reviewing the available data and understanding the various types of TMDs.Epidemiologic studies reveal that TMDs are a sizable public health concern aecting 5% to 12% of the total population with an estimate of 5% to 7% requiring treatment.22,31 Although uncom-mon in young children, signs and symptoms of TMD often initially present during adolescence.25,32,33 Fortunately, the prevalence of severe TMD is low in the adolescent population.34 e only study todateusingtheDC-TMDdemonstratedan11.9%prevalencein-depth description of pain medicine is beyond the scope of this text; however, as a general rule, the longer pain persists the more challenging it becomes to manage due to neuroplasticity and sensitization at the level of the central nervous system.28,29e American Academy of Orofacial Pain (AAOP) has established clinical guidelines that can be useful for diagnosing TMD in a clinical setting; however, critically evaluating TMD in a research setting is often bewildering. ere is considerable variation in the epidemiologic data due to dierences in study design, populations, and diagnostic criteria.30 It is important to recognize that population-based research, and particularly surveys, have the potential to either under- or overestimate TMD ndings.e Diagnostic Criteria for Temporomandibular Disorders (DC-TMD) oers a validated, objective methodology for research purposes.31 e DC-TMD protocol consists of a clinical exam with specic interview questions to aid in identifying individuals A BCD• Figure 38.12 (A) This nongrowing patient has a severe class II malocclusion and convex facial prole (B) due to mandibular retrusion. The teeth cannot be moved together to provide a stable, functional occlusion, so orthognathic surgery was performed to advance the mandible. (C) After surgery the patient demonstrated more mandibular prominence (D) and facial height. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 577 ABCD• Figure 38.13 It is now possible to produce digital casts and manipulate the images to simulate setups. This series of images demonstrates options for this patient with missing lower central incisors using this technology. (A) An alternative is to make space for one incisor implant. (B) This solution positions the anterior teeth with more overbite and overjet than a setup with space for two mandibular central incisors implants (C), which reduces the overbite and overjet when the posterior dental relationships are identical (D). (Courtesy OrthoCAD by Cadent, Inc., Carlstadt, NJ.)• Figure 38.14 This patient had missing maxillary lateral incisors, and the canines were substituted for them. The canines have already been recontoured to mimic a lateral incisor, and further reduction is anticipated. Palatal temporary anchorage devices (TADs) were placed before space closure. A transpalatal arch with hooks was constructed so elastomeric chains could be stretched from the hooks to the TADs. This allows the posterior teeth to come forward without lingual movement of the upper incisors. • Figure 38.15 The advent of temporary anchorage devices (TADs) has made closure of posterior space feasible when posterior permanent teeth are missing. In this case, the patient was missing both second premolars, and the clinician elected to close all the space without prosthetic replace-ment of teeth. The TADs anchor the anterior segment and the posterior teeth to move forward with minimal posterior movement of the lower incisors. This is an example of indirect anchorage. In some cases, the TAD is used to directly bring the posterior teeth forward, in which case it is called direct anchorage. 578 Part 5 AdolescenceSymptoms are based on subjective information gathered from interviewing the patient and caregiver. Most adolescents are capable of describing what they are feeling; therefore a structured approach to interviewing the patient is recommended. e following should be considered when evaluating for TMD symptoms:• Pain• Headaches• Dizziness• Nausea• Jawtightness• Jawinstability• Sleepbruxisme relationship between signs and symptoms remains unclear. Symptoms, such as pain and dysfunction, are not consistently associated with clinical signs. e clinician is cautioned not to predict a future diagnosis of a severe TMD based on clinical signs and symptoms. Although risk and perpetuating factors may be identied, none consistently lead a patient to a lifetime of a pain. Asymptomatic TMDs in adolescence are benign and tend to be self-limiting, only rarely progressing to a more serious condition.34ere is no unique theoretical model or single etiologic factor that can explain the onset of TMD.22 erefore it is not possible to foresee who will develop a signicant TMD and more importantly who will experience a transition from acute to persistent or recurrent pain. Since studies do not point to absolute etiologic factors for TMD, it is not possible to reliably predict those who will require of TMD in adolescents.35 A recent systematic review of studies using previous methodologies determined the prevalence of TMD signs to be 16% in the adolescent population.30 TMD symptoms tend to uctuate with time,32,36 and it is estimated that approximately 2% of symptomatic patients seek treatment.25 e incidence of TMD-related pain increases from early adolescence to young adulthood,32,33,37 and, similar to the adult population, TMDs tend to be more common in females than males.32,33,35 e reason for this disparity is unknown; however, it is likely related to hormonal dierences.38–40NumerousstudiesdemonstratetheimpactthatTMD and orofacial pain have on activities of daily living (ADL),41 quality of life,42 psychosocial distress,43 and sleep quality.44Prior to considering factors related to TMDs, it is important to recognize the signs and symptoms commonly associated with the diagnosis. Signs are clinically observable ndings. ere is a wide range of clinical signs that have been studied in patients with TMD. Often, the signs of TMD are also common in asymptomatic children who have no complaints about pain. ey may reect normal variations or transient changes consistent with normal ndings and have no clinical signicance.32 e following are examples of signs that should be documented:• TMJsounds(uponpalpation)• Occlusalwear• Occlusalinterferences• Limitationinmandibularrangeofmotion(ROM;<40mm)• Mandibulardeviationordeectiononopening• Tendernesstopalpationand/ormanipulationA BC D• Figure 38.16 Orthodontic treatment for adolescents can be accomplished with removable aligners. The clinician submits a polyvinylsiloxane impression of the original malocclusion (A) to the dental laboratory to create a digital representation of the malocclusion (B). A series of aligners is created by the software and then constructed on actual models. The series is sent to the clinician who monitors the progress of the case and compares the actual tooth movement with the predicted movement. At the end of treatment, the clinician can compare the actual tooth movement (C) with the predicted movement (D). CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 579 or tapping.45 Parafunction also includes lip biting, cheek biting, and biting of other tissues or objects. ese parafunctional activities may occur alone or in combinations.Sleep bruxism or nocturnal bruxism, a common form of parafunction, is classied by the International Classication of Sleep Disorders, 3rd Edition (ICSD-3) as a sleep-related movement disorder involving stereotyped, rhythmic masticatory muscle activity along with grinding and clenching of the teeth.47 It is regarded as an involuntary behavior and the pathophysiology is thought to involve a complex process involving the regions of the brain responsible for motor function.48 On the other hand, bruxing while awake (diurnal bruxism) is considered to be a voluntary condition.Bruxism is common in children and adolescents; however, it is dicult to interpret in literature due to the variability of age groups and diagnostic strategies.49 e majority of studies are surveys that rely on recall of the patient or parents,50,51 and most do not use polysomnography (PSG) or electromyography (EMG) to conrm the presence of sleep bruxism.49,50 Available data suggest sleep bruxismoccursin14%to38%ofchildren48,51 and approximately 13% to 22% of the adolescent population.48,52 Although the incidence of sleep bruxism decreases from adolescence to adulthood, longitudinal studies in adolescents have demonstrated that self-reports of both sleep bruxism and diurnal bruxism in childhood predict the same parafunctional activity during adulthood.53Noapparent gender dierences are present.e paradigm of sleep bruxism as a primary versus secondary condition should also be considered. Primary sleep bruxism is a normal phenomenon that occurs without a known cause, while secondary sleep bruxism is related to nocturnal parafunctional activity related to a specic condition or substance. Sleep bruxism has been associated with a variety of medical conditions such as gastroesophageal reux disease (GERD),54 cerebral palsy, and other neurologic conditions.55 Although a causal relationship has not been established, sleep bruxism frequently presents in patients with obstructive sleep apnea.56 Recent studies have demonstrated that in the adolescent population sleep bruxism may be associated with behavioral problems and psychosocial disorders.55,57 It should be noted that several medications and substances have been associ-ated with sleep bruxism. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors(SNRIs)58 and stimulants such as methylphenidate, caeine, and nicotine should be considered as potential secondary causes of sleep bruxism.59,60Bruxism is not consistently associated with pain.48However,sleep bruxism should be suspected as a contributing factor if a patient complains of jaw pain upon waking. Similarly, if a patient complains of masticatory pain toward the end of the day, habitual daytime parafunctional activity may be a perpetuating factor.invasive or advanced treatment. e focus on etiology should be determining the initiating, predisposing, and perpetuating factors.22,45 Initiating factors are related to onset; predisposing factors are related to risk; and perpetuating factors are factors that interfere with recovery. Like other domains of TMD, there is considerable individual variability. Degenerative disease, developmental abnor-malities, trauma, and other conditions usually have a clear and obvious relationship to TMD while other factors have weak or conicting associations. In fact, the cause of TMDs in some individuals may be unknown (Box 38.1).Bothersome TMJ sounds are often noticed due to the proximity of the TMJs to the ears. Clicking, popping, snapping, scraping, and grinding sounds associated with jaw function are commonly reported in both adolescent and adult populations.36 Dislocation and subsequent reduction of the articular disk upon jaw movements is a frequent source of TMJ sounds.26,45 A magnetic resonance image (MRI) study demonstrated that 35% of asymptomatic adults have a displaced disk.46 Unique TMJ anatomy, degenerative changes, and temporary sticking of the disk also account for TMJ sounds.45 In the adolescent population, the incidence of TMJ sounds has been reported to be as high as 17%, and data suggest TMJ clicking may come and go during this timeframe.45 TMJ noises are common in both adult and adolescent populations, and treatment for asymptomatic TMJ sounds do not typically require any management beyond education and reassurance.22,26Parafunctional activity refers to nonfunctional oromandibular movements, such as jaw clenching, tooth grinding, or tooth gnashing InheritedHemifacial MicrosomiaHemifacial atrophyJuvenile rheumatoid arthritisAnkylosisCleft relatedAcquiredInfectious (Septic Arthritis)Traumatic (sports injury)Iatrogenic (cortisone damage, surgical displacement, irradiation)Factitial (habits, hobbies)Neoplastic (tumors)IdiopathicSome Established Causes of Temporomandibular Joint Dysfunction in Children and Adolescents• BOX 38.1 SLEEP DISORDERED BREATHINGRose D. SheatsThe natural history of sleep disordered breathing (SDB) in the pediatric patient is not well understood, although data are beginning to accrue. One would anticipate that as the child matures, tonsillar and adenoidal tissue would regress, and airway space would enlarge with growth, leading to a decrease in the prevalence of SDB in adolescents. However, a longitudinal study of 319 children from age 8.5 years to 13.7 years revealed a 71% remission rate, suggesting persistence of SDB in nearly 30% of preadolescents diagnosed with SDB.1 In addition, a 10% incidence rate in the adolescent group was also demonstrated. Risk factors for persistent or incident SDB in this adolescent sample consisted of obesity and male gender, mimicking the risk factors in adult populations.Another study suggested that the prevalence of SDB in a cohort of children studied from middle childhood (8–11 years) to late adolescence (16–19 years) remained approximately 4.5%, despite the fact that 91% of middle childhood cases in the study remitted over time, and late adolescent cases were likely incident cases.2 Obesity in middle childhood was a risk Continued 580 Part 5 Adolescencethird molar removal have been found to be potential initiating events for TMDs.67However, acontrolledprospectivestudyofthird molar removal demonstrated no statistical dierence at 6 months between the control group and the wisdom tooth extraction group.68 Ankylosis, a rare but serious manifestation of TMJ trauma, occurs when there is fusion of the mandible to the cranial base or zygoma.69 Given the variability of traumatic injuries to the masticatory system and the diering levels of individual response to injury, it is reasonable to screen for trauma in patients with a history of TMD.It is important to rule out any secondary conditions as the true sourceofthepainand/ordysfunctioninTMD.Potentialsecondarycauses include systemic diseases, such as juvenile idiopathic arthritis, Ehlers-Danlos syndrome, or Marfan syndrome.45,70,71 Congenital conditions, such as hemifacial microsomia and Treacher Collins syndrome,72 or local structural factors such as hyper- or hypoplasia of the mandibular condyle or a bid condyle may also contribute to TMDs.73 Tumors and pseudotumors are rare but should be considered.74Pain in the masticatory structures may be due to referred pain from another structure.75 Examples include masticatory pain secondary to headaches,27 salivary gland pain,76 lymph node pain,77 ear pain,78,79 and dental pain. Resolution or symptom improvement of perceived temporomandibular problems can occur when eorts are directed toward the true source of the pain.Malocclusion and orthodontic treatments have been implicated as precursors of painful TMDs; however, neither have shown a clear and consistent relationship when closely scrutinized.61,62 In fact, some reported precursors, such as an anterior open bite, may actually be the result of TMD rather than the cause.26 Further-more, there is no reported relationship between malocclusion and nonpainful TMDs including asymptomatic disk displacements.63 Preventive orthodontic therapy to eliminate risk factors has not withstood scientic scrutiny, nor has orthodontic therapy to manage existing TMDs.Some have proposed a class II skeletal or dental relationship maycauseaTMD.However, full-time anteriorrepositioningocclusal splint therapy to change the occlusal scheme has not been validated in the literature.22 In fact, full-time wear of an anterior re-positioning appliance to “re-capture” the articular disk may result in a permanent posterior open bite.Nonworkingandworkingocclusalinterferences havelittleconsistencyinpredictingTMD.However,onestudydemonstratedthat patients with preexisting TMDs seem to be more vulnerable to articial occlusal interferences.64 A majority agree that prophylactic removal of occlusal interferences is contraindicated.26,29,65Nosingleocclusal factor has been isolated as a source for TMD; however, an unstable occlusal scheme or orthopedic position coupled with excessive parafunction may increase the risk for developing a TMD.A history of trauma has a modest relationship with TMD in the adolescent population.66 Jaw injuries and iatrogenic trauma from factor for the development of SDB in late adolescence, as was male gender, African American race, increased body mass index (BMI), and a history of adenotonsillectomy. Half of the habitual snorers in middle childhood remained habitual snorers in late adolescence.These studies highlight the need for early recognition of childhood obesity and timely intervention to manage this trend. Pediatric dentists should alert families to the risk of SDB development as one of the consequences of obesity and assist in facilitating referral for the medical or behavioral management of obesity.There is a controversy about the role of orthodontic premolar extractions as a risk factor for the development of SDB. The theory is that premolar extractions reduce the volume of the airway. Most studies examined the changes in the volume of the posterior airway space before and after orthodontic treatment (premolar extractions) using both two-dimensional and three-dimensional images.3 However, they failed to demonstrate an association between the dimensions of the posterior airway space and SDB. Another study analyzed over 5000 electronic medical records from a population of adults aged 40 to 70 years—the age range at which SDB is most prevalent. The study was strengthened with the inclusion of overnight sleep studies to conrm or exclude the presence of obstructive sleep apnea.4 The investigators compared a group of adults who had undergone extraction of four premolars with those who had intact dentitions (other than missing third molars). They found no difference in the prevalence of obstructive sleep apnea between the two groups, and concluded that orthodontic extraction of premolars does not pose an increased risk for SDB. This is the strongest evidence to date refuting orthodontic extractions as a risk factor for the development of SDB in the future.The adolescent patient diagnosed with SDB may be a candidate for one of the mandibular advancement devices commonly used to manage adult SDB.5,6 These appliances function by preventing the tongue from collapsing into the posterior airway during sleep and should be prescribed in collaboration with the physician managing the SDB. Because these appliances are similar to those used to manage class II dental and skeletal malocclusions, the dentist must be cautious in recommending such an appliance for class I or class III growing patients, as their impact may be unfavorable on the growth of the craniofacial skeleton. Furthermore, it has been clearly demonstrated these appliances cause changes in the occlusion over time, resulting in posterior open bites, reduced overjet and overbite, retroclined maxillary incisors, and proclined lower incisors.7 Patients, parents, and dentists must give careful consideration to the risks and benets of mandibular advancement appliances in the management of SDB before proceeding.Given the prevalence of SDB in the adolescent population, further elucidation of the role dentists play in screening and referring these patients for management of SDB bears investigation. Much research is still needed to identify the most appropriate strategies and optimal time for intervention.References1. Goodwin JL, Vasquez MM, Silva GE, et al. Incidence and remission of sleep-disordered breathing and related symptoms in 6- to 17-year old children—the Tucson Children’s Assessment of Sleep Apnea Study. J Pediatr. 2010;157:57–61.2. Spilsbury JC, Storfer-Isser A, Rosen CL, et al. Remission and incidence of obstructive sleep apnea from middle childhood to late adolescence. Sleep. 2015;38:23–29.3. Hu Z, Yin X, Liao J, et al. The effect of teeth extraction for orthodontic treatment on the upper airway: a systematic review. Sleep Breath. 2015;19:441–451.4. Larsen AJ, Rindal DB, Hatch JP, et al. Evidence supports no relationship between obstructive sleep apnea and premolar extraction: an electronic health records review. J Clin Sleep Med. 2015;11:1443–1448.5. Scherr S, Dort L, Almeida F, et al. Denition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring: a report of the American Academy of Dental Sleep Medicine. J Dent Sleep Med. 2014;1:39–50.6. Schütz TCB, Dominguez GC, Hallinan MP, et al. Class II correction improves nocturnal breathing in adolescents. Angle Orthod. 2011;81:222–228.7. Pliska BT, Nam H, Chen H, et al. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med. 2014;10:1285–1291.SLEEP DISORDERED BREATHING—cont’d CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 581 physiology of jaw function is beyond the scope of this textbook and the reader is referred to a book dedicated to TMJs.Dentists who treat adolescents should include a TMD screening examination to establish baseline function. e patient interview must include a thorough medical, dental, and social history. Identifying stressors and screening for psychological conditions can be useful as somatic complaints and behavioral problems have been associated with TMD in adolescent populations.83,84 A history of recent or past trauma to the masticatory and cervical structures also should be obtained. In addition to checking for potential etiologic factors, it is important to ask about other chronic pain conditions, such as low back pain, stomach aches, neck pain, or primary headache syndromes because they are frequently associated with TMD in adolescents.84,85Headachedisordersarecommonduring adolescence and often precede pain in the masticatory system.27 Primary headaches, such as migraine and tension-type headaches, frequently present as pain in the temporal region and may be misinterpreted as a TMD. If a bothersome primary headache is suspected, a referral to a primary care provider or neurologist is warranted.It is critical for the clinician to understand the patient’s symp-toms, especially if the chief complaint is suggestive of a TMD. e patient may complain about pain, tightness, or instability of the jaw, or even a stuy or ringing sensation in the ears. Since symptoms are subjective, it is helpful to use a systematic approach when interviewing the patient. e mnemonic OPQRSTU aids the practitioner when interviewing the adolescent patient with pain complaints (Table 38.3). It is important to identify the onset, provoking and palliating factors, quality or character, region, severity, timing, and impact of pain to provide a more objective means of quantifying a pain complaint. e natural history of the pain complaint as well as past treatments and results of those treatments also should be obtained.e clinical examination conrms the information gathered from the detailed history. Clinical signs of TMD include TMJ sounds, tenderness to palpation, and alterations in mandibular ROM. e clinical examination should assess posture and signs of parafunction.Diagnosis of Temporomandibular Disordere clinician interested in TMD management should recognize that overdiagnosis and subsequent overtreatment are perhaps the most consistent aspects of dealing with this disorder in adolescents. e AAOP guidelines and the DC-TMD provide criteria for categorizing TMDs into two main subgroups: (1) myogenous (muscle related) and (2) arthrogenous (joint related). Painful extracapsular (muscular) TMDs are commonly subdivided into myalgia and myofascial pain conditions. Intracapsular (joint related) conditions are categorized as inammatory (capsulitis), disk displace-ment disorders (reducing and nonreducing), degenerative disorders (osteoarthritis), and subluxation.22e interview and examination should identify the patient’s chief complaint and classify it as either a primarily muscular or a primarily joint-related pain condition. A thorough understanding of the relevant anatomy is essential to provide an accurate diagnosis and to provide meaningful treatment recommendations. e human TMJs are complex structures classied as ginglymoarthrodial joints. Capable of both rotation (hinging) and translation (gliding), these unique joints are composed of the mandibular condyles, glenoid fossae of the temporal bones, and interposing articular disks (Fig. 38.17). Unique to the TMJs, the articular disks are chiey composed of dense brous connective tissue. Although the disks do not contain nerves or vessels, their posterior attach-ments are highly innervated and vascular and are a potential source of intracapsular (joint) pain. e articular surfaces of the condyles and fossae are lined with brocartilage. is feature is likely responsible for the durability and healing capacity of the TMJs.22e paired muscles of mastication muscles (masseters, medial pterygoids, and temporalis) function to close the jaw while the lateral pterygoids function to open the mouth and protrude the mandible. e digastric muscles are also classied as jaw-depressing muscles. Accessory cervical musculature including the supra and infra hyoid muscles and sternocleidomastoid also may activate during mastication, swallowing, and other complex jaw movements.80–82 A detailed description of the anatomy and Onset When did pain rst begin?What was associated with pain initiation? (Trauma, eating, stress)Provoking and Palliating factorsWhat makes it pain worse? (Eating, poor sleep)What makes pain better? (Heat, ice, rest)Quality What does pain feel like? (Ache, throb, tight)Region Where is the pain? (Point with 1 nger)Severity How intense is the pain (0–10/10, mild, moderate, severe)Timing Is pain intermittent or constant?How long does pain last?When does pain occur? (Time of day, during school, during jaw function, at rest)U—“You” How does pain impact the patient? (Interferes with school, activities, sleep)“OPQRSTU” Mnemonic for Evaluating Pain SymptomsTABLE 38.3 TemporalboneCondyleCAB• Figure 38.17 Articular disk (A) is interposed between the mandibular condyle and the glenoid fossa of the temporal bone. The lateral pterygoid muscles (B) are located anterior to the disk while the posterior attachment (C) contains tissue that is richly innervated and highly vascular. 582 Part 5 AdolescenceProper palpation technique involves standing directly in front or behind the patient and using the pads of the index ngers to apply light, steady pressure. e lateral capsules of the TMJs should be palpated at rest and while the patient opens and closes the mouth andwhilemovingthemandiblefromsidetoside(Fig.38.19).is can help detect any irregular movement of the condyles as well as joint noises or pain. During the exam the patient is asked whether it feels the same on both sides, if one side feels dierent, or if either side feels sore. e presence or absence of pain with palpation, clicking, or crepitus should be documented.e palpation technique for masticatory muscles is similar (Fig. 38.20). A slight increase in nger pressure is acceptable when palpating muscles. e superior and inferior aspects of the masseter muscles and posterior, middle, and anterior aspects of the temporalis muscles should be palpated. e temporalis tendon may be palpated intraorally by placing the index nger in the vicinity of the insertion of the temporalis muscle on the coronoid process. e clinician may appreciate taut bands or discrete nodules within the musculature that are painful to palpation. e lateral pterygoid muscles are e most important aspect of the clinical exam is to reproduce the patient’s “familiar pain” by palpation of the masticatory and cervical structures. Functional manipulation of the TMJs and masticatory muscles is also recommended. A systematic palpation of the cervical and masticatory structures is critical for uncovering potential pain generators as well as evaluating for any soft tissue masses. Pain or tenderness upon palpation or discovery of taut, brous bands of the musculature may indicate overuse. Parafunc-tion, such as jaw clenching, grinding or bracing, may result in symptomatic masticatory muscles. A forward head posture with rounded shoulders may result in pain in the cervical muscles (Fig. 38.18).BA• Figure 38.18 (A) Patient demonstrates a forward head posture and rounding of the shoulders while using a mobile device. This posture puts strain on the cervical musculature. (B) An improved cervical posture will put less strain on the head and cervical muscles. BA• Figure 38.19 (A) Temporomandibular joint palpation during rest. Pain with palpation is a sign of a joint-related problem. (B) The joint is palpated during motion to detect any irregular movement of the condyles as well as joint noises or pain. CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 583 dicult to palpate intraorally and are best tested by having the patient protrude against chin resistance, which generally produces pain if the lateral pterygoid is symptomatic (Fig. 38.21). e medial pterygoid muscles are dicult to palpate or test.Cervical structures may refer pain to the orofacial region and are frequently problematic in myofascial pain syndromes where they may be the primary cause of facial pain and headaches. e cervical muscles may be palpated in a similar manner to the mastica-tory muscles. Muscles, such as the trapezius and sternocleidomastoid, may be palpated by gently gripping the musculature between the thumb and index or middle nger (Fig. 38.22).Mandibular function and ROM should be recorded. e vertical position of the mandible should be noted when various joint noises occur. Clicking when opening and closing is usually a sign of an anteriorly or anteriomedially displaced disk. Crepitus is usually a sign of joint degeneration. e amount of mandibular movement is measured with a millimeter gauge placed between an upper and lower anterior tooth. e amount of overbite is added because that is actually the distance the mandible opens. If there is an DCBA• Figure 38.20 A systematic approach to facial muscle palpation allows the clinician the ability to identify the areas of muscular involvement. (A) The clinician can start with palpating the anterior aspect of the temporalis muscle followed by (B) intraoral palpation of the temporalis tendon. (C) Following examination of the temporalis muscle, the superior and (D) inferior aspects of the masseter muscle are palpated. • Figure 38.21 It is best to test lateral pterygoid muscles by having patient protrude the lower jaw against resistance. 584 Part 5 AdolescenceBA• Figure 38.22 Palpate the cervical muscles to determine their contribution to the temporomandibular disorder. (A) Palpate the sternocleidomastoid and (B) trapezius muscles using a pincher grasp. CBA• Figure 38.23 (A) To assess passive range of motion (ROM) in a patient with temporomandibular joint disorder, the clinician should provide slow, steady pressure with the thumb and index nger. (B) The pain-free mandibular ROM was only 21 mm. (C) Assisted or passive mandibular ROM increases to 43 mm. open bite, the amount is subtracted from the maximal measurement. e same teeth should be measured to provide consistent readings. MandibularROMoflessthan40mmshouldbeconsideredtobe limited mobility.26,86 Passive range of motion or assisted opening can be assessed by placing gentle downward mandibular pressure with the thumb and index nger (Fig. 38.23). Muscle pain may also limit mandibular ROM and the limited opening can commonly be overcome with this passive maneuver. If opening limitation persists and rm resistance is encountered during assisted opening, it is possible that there is an intracapsular disorder, such as a nonreducing disk displacement. Mandibular opening deviation (movement away from midline that returns to midline) or deection CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 585 a diagnosis, supportive therapy and elimination of perpetuating factors often result in resolution. Conservative treatment options are appropriate for most painful TMDs. e patient is counseled about daytime clenching and conservative treatment approaches, such as soft diet, warm or cold compresses, and a brief course of clock-regulated analgesics, are suggested. Additional conservative treatment options, such as abdominal breathing entrainment, physical self-regulation, and biofeedback training, can be considered to supplement initial treatment strategies.22,26,29Acute TMDs may resolve with little to no interventions. Chronic TMDs tend to be more challenging and a biopsychosocial approach to pain management may be appropriate. is approach includes simultaneous management of biological, psychological, and social factors related to the patient’s persistent pain (see online Case Study).22It is important to eliminate or modify contributing factors causing TMJ problems. ere are many and varied factors the clinician must consider. Parafunction, gum chewing, nail biting, and substance abuse(nicotine,caeine,3,4-methylenedioxymethamphetamine[MDMA], others) should be reviewed. Other health-related factors contributing to the problem may be stress, primary headaches, systemic disease, poor diet, and poor sleep hygiene.22,26,28,29,89e adolescent stage of development introduces many new problems for treating TMDs. Untreated behavioral health comor-bidities, such as depression, anxiety, and posttraumatic stress disorder (PTSD), will also likely interfere with recovery. Catastrophic thinking, including rumination, magnication, and hopelessness, is a well-established barrier to symptom improvement.28 Adolescent adjustment problems may trigger TMD. Since psychosocial issues may not be readily discussed with parents or dentists, it is important to refer patients to a primary care or behavioral health provider trained in adolescent development.After the patient has been educated about TMD and conservative therapies have not proven successful, the clinician may move to a second level of therapy. Custom-designed, full coverage, removable appliances are generally recommended if self-care measures are ineective. ese appliances are typically used at nighttime and are designed to allow for eruption and positioning of teeth if the patient is in the mixed dentition. A recent randomized, controlled trial demonstrated that occlusal appliance therapy at night was more eective than relaxation therapy alone.89Pharmacologic management can be considered depending on the diagnosis. Acute inammatory joint pain may be managed withnonsteroidalantiinammatorydrugs(NSAIDs)orcorticoster-oids. More complex pharmacologic management may be indicated in cases of chronic myofascial pain and headaches.As with all dental problems, a dentist may determine that referral to another dental specialist is in the patient’s best interest. In some cases, a team approach is best because pharmacotherapy, counsel-ing, and physical therapy may be indicated to treat the problem. Dierent providers will bring dierent and unique skills. is approach is considered after conservative and reversible therapies are exhausted. Advanced treatment may be required, and dierent experts can prescribe topical and systemic medications, perform specialized injections, and provide targeted exercises. Patients with temporomandibular problems or facial pain, who are resistant to these treatments, may consider arthrocentesis or TMJ surgery.References1. Casamassimo PS. Dental and oral health problems: prevention and services. In: Congress of the United States, Oce of Technology Assessment: (persistent movement away from midline) may also be observed. Deection is commonly associated with an intracapsular disorder, such as disk displacement without reduction or TMJ ankylosis. Deviations can be caused by either an intracapsular interference or muscle engrams (muscle memory). Lateral movement of the mandible is measured and can determine if there is unilateral translation of the condyles. e amount of lateral movement is measured in millimeters of change in the maxillary and mandibular dental midlines. Less than 8 mm is considered to be limited mobility. e amount of protrusive movement is also recorded and less than 5 mm is considered limited.86 Alterations in movement may indicate a deviation in form or a reducing disk displacement. Severely decreased movement may indicate a permanently dislocated disk. Excessive movement may indicate focal or systemic ligamentous laxity, like that found in Ehlers-Danlos syndrome.71Systematic review of other adjunctive diagnostic and treatment therapies, such as kinesiology, thermography, and jaw tracking, are shown to have limited ecacy in management of TMD in children.26Imaging and Temporomandibular Disordere role of imaging in TMD diagnosis relies on the basic principles of selection criteria. Imaging should be considered when there is a history of, or the clinician suspects there is, a symptomatic intracapsular condition. Asymptomatic joint sounds alone do not merit imaging. A panoramic radiograph is generally regarded as an appropriate screening radiograph. e selection criteria for initial TMJ imaging include a:1. Recent trauma or history of progressive pathologic joint condition2. Signicant dysfunction and alteration in range of motion3. Signicant occlusal change (open bite, mandibular shift)e practitioner is cautioned not to rely solely on imaging, as radiographic changes may be a result of adaptive remodeling.22 For example, one study of symptomatic and asymptomatic children demonstrated that 10% of asymptomatic children had osteoarthritic changes in the mandibular condyles.87 TMJ imaging also has the limitations of poor specicity and sensitivity in addition to higher nancial costs and radiation burden. When more complex imaging is required, open and closed mouth MRI is usually chosen for good hard and soft tissue detail. Intravenous contrast may be added to improve visualization; however, a recent study demonstrated that asymptomatic pediatric patients often show incidental joint eusion.87 Computed tomography (CT) or cone beam computed tomography (CBCT) shows excellent hard tissue detail but generally requires more radiation than conventional radiographs.88Management of Temporomandibular DisorderDentists are in a favorable position to treat adolescent patients using the basic principles of TMD management. e clinician should determine whether to address a specic TMJ problem based on training and experience or to seek assistance from specialists in TMD therapy and orofacial pain management. Dentists managing TMD should have established referral sources; physical therapists, behavioral health providers, and primary care providers should all be part of the team.Patients with nonpainful TMDs, such as asymptomatic TMJ sounds, usually do not require treatment. 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Predictors of bruxism, other oral parafunctions, and tooth wear over a 20-year follow-up period. J Orofac Pain. 2003;17(1):50–57.54. SakaguchiK,YagiT,MaedaA,etal.Associationofproblembehaviorwith sleep problems and gastroesophageal reux symptoms. Pediatr Int.2014;56(1):24–30.55. Ortega AO, DosSantos MT, Mendes FM, et al. Association between anticonvulsant drugs and teeth-grinding in children and adolescents with cerebral palsy. J Oral Rehabil.2014;41(9):653–658.56. ManfrediniD,Guarda-NardiniL,Marchese-RagonaR.eoriesonpossible temporal relationships between sleep bruxism and obstructive sleep apnea events. An expert opinion. Sleep Breath. 2015;19(4):1459–1465.57. De Luca Canto G, Singh V, Conti P, et al. Association between sleep bruxism and psychosocial factors in children and adolescents: a systematic review. Clin Pediatr.2015;54(5):469–478.58. Patel SB, Kumar SKS. Myofascial pain secondary to medicationinduced bruxism. J Am Dent Assoc.2012;143(10):e67–e69.59. Bertazzo-SilveiraE,KrugerCM,PortodeToledoI,etal.Associationbetween sleep bruxism alcohol, caeine, tobacco, and drug use. J Am Dent Assoc.2016;147(11):859–866.60. MalkiGA,ZawawiKH,MelisM,etal.Prevalenceofbruxisminchildren receiving treatment for attention decit hyperactivity disorder: a pilot study. J Clin Pediatr Dent.2004;29(1):63–67.61. Mohlin B. TMD in relation to malocclusion and orthodontic treatment. Angle Orthod.2007;77(3):542–548.62. HirschC.No increased riskoftemporomandibulardisorders andbruxism in children and adolescents during orthodontic therapy. J Orofac Orthod.2009;70(1):39–50.63. ManfrediniD,PerinettiG,Guarda-NardiniL.Dentalmalocclusionis not related to temporomandibular joint clicking: a logistic regression analysis in a patient population. Angle Orthod. 2014;84(2): 310–315.64. LeBellY,NieiPM,JamsaT,etal.Subjectivereactionstointerventionwith articial interference in subjects with and without a history of temporomandibular disorders. Acta Odontol Scand. 2006;64: 59–63.65. KirveskariP,JamsaT,AlanenP.Occlusaladjustmentandtheincidenceof demand for temporomandibular disorder treatment. J Prosth Dent. 1998;79(4):433–438.66. Fischer DJ, Mueller BA, Critchlow CW, et al. e association of temporomandibular disorder pain with history of head and neck injury in adolescents. J Orofac Pain.2006;20(3):191–198.67. AkhterR,HassanNM,OhkuboR,etal.erelationshipbetweenjaw injury, third molar removal, and orthodontic treatment and CHAPTER 38 Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems 587.e1 Case Study: Chronic Jaw PainThomas R. StarkBackgroundA 16-year-old female presents with a chief complaint of “jaw popping and pain.” Her medical history is positive for generalized anxiety disorder (GAD) and migraine headaches. She has no known drug allergies and takes rizatriptan (Maxalt) as needed for poorly controlled migraines. Her mother expressed concerns about her jaw pain interfering with her ability to eat with the family and participate in social activities. She had orthodontic treatment 2 years ago, and the parents are concerned that this could have caused her symptoms. You observe that the patient is alert, oriented, and in no acute distress. She is neatly groomed, wearing several layers of bulky clothing, and has a nose ring. You notice multiple linear scars at different levels of healing on her left wrist. The mother signed the medical history and consent forms and returned to the waiting room because she is encouraging her daughter to be more independent.InterviewWhile interviewing the patient, you learn that her pain began during a stressful situation involving a change in schools. She points to the bilateral inferior masseter regions and describes her pain as a dull, tender ache ranging from moderate to severe. Her pain is daily; however, it bothers her most during the school week, particularly when she rst wakes and again toward the end of the day. The only relieving factors are time and taking a warm bath. She feels that her jaw pain triggers her headaches and worries that she might need jaw surgery.When asked about the scars on her wrist, she shares that she engages in cutting when overwhelmed but convincingly denied suicidal ideation. She misses her friends and is experiencing some difculties assimilating to her new environment. She reports that she is a perfectionist, excelling in academics and multiple extracurricular activities. Her schedule offers little exibility, and she takes several advanced placement classes. With college entrance exams approaching, she consumes energy drinks, snacks on high-sugar foods, and, although she does not have a prescription, occasionally takes dextroamphetamine (Adderall) to help focus. She denies alcohol use, thinks smoking is gross, and is not sexually active. She has trouble turning her mind off, and falling asleep is difcult. She eats alone in her room because she prefers to avoid listening to her parents argue. However, she avoids eating in public due to her embarrassing jaw clicking sounds. She also commented that she has struggled with eating disorders in the past. As you wash your hands, you notice a tear in her eye when she glances at a text message.Clinical ExaminationAs part of your complete examination you perform a temporomandibular joint (TMJ) examination. No pain in the TMJs is noted during palpation, distraction, and compression (Videos 38.1–38.3). An opening and reciprocal click was noted in the right TMJ (Video 38.4). Excursive movements were unrestricted, pain-free mandibular range of motion (ROM) is 15 mm, passive ROM is 50 mm, and no deviation or deection was noted (Videos 38.5–38.7). The occlusion appears stable; however, wear facets are evident on mandibular canines. When evaluating the masticatory muscles, it was noted that palpation of the masseter muscles reproduces her familiar pain and worsens her headache (Videos 38.8–38.10).Radiographic ExaminationNo gross abnormalities are noted on panoramic radiograph. The condyles appear well corticated, round, and symmetrical. Teeth #1 and #32 are not present, and #16 and #17 are unerupted (Fig. E38.1).Problem List1. Masticatory myofascial pain2. Disk displacement with reduction3. Sleep bruxismTreatment Plan and RecommendationsThe rst step is to encourage parent engagement and respect patient condentiality (unless you suspect abuse or neglect or there is a safety concern for the patient or someone else). Recognize there are multiple factors contributing to the patient’s jaw pain and headaches. Explain that her history of orthodontic treatment was likely not related to her pain. A multidisciplinary treatment approach should be suggested.Second, you should provide education and reassurance about her conditions. The clinical ndings suggest the likely source of her jaw pain is muscular. You recommend thermotherapy, clenching awareness, jaw function within a pain-free range, and a soft diet. It is important to explain TMJ disk displacements and TMJ sounds are common and tend to be benign and self-limiting. She should avoid clicking her jaw when possible. You should discuss sleep bruxism and consider fabricating an occlusal appliance for nighttime use. Although her jaw pain may trigger some of her headaches, she should consult her physician regarding this complaint. You ask to have her physician discuss ndings with you to develop a coordinated treatment plan.It is imperative to assess safety concerns including cutting, substance abuse, eating disorders, and possible bullying. You should determine if she • Figure E38.1 Panoramic radiograph. Teeth #1 and #32 are not present, and #16 and #17 are not erupted. Continued 587.e2 Part 5 Adolescencehas a support system or is open to speaking with a counselor, physician, or behavioral health provider. You can explain that biofeedback, mindfulness, relaxation training, and cognitive behavioral therapy have been shown to be effective in treating headaches, pain, and sleep problems.You should review the role of stress in jaw pain. Encourage her to speak with a trusted friend or adult regarding her multiple stressors. You can recommend elimination of caffeine and other stimulants because they increase muscle tension and interfere with sleep.Finally, you should recommend follow-up care after this trial of conservative treatment. If the patient is not showing improvement or reduction of symptoms, it may be prudent to consider referral to another health care provider. If the patient is showing signs of improvement, you should reinforce the original treatment recommendations.Questions1. Briey describe the members of a multidisciplinary team that could be helpful for this patient’s chronic jaw pain.Answer: Dentist: provide diagnosis and conservative therapy (orthotic, education, treatment recommendations); Physician: provide medical care and specialty referral to a pediatric neurologist or pediatric psychiatrist. Physical therapist: provide education on posture, assist with musculoskeletal pain, and improve jaw function. Behavioral health provider (psychologist) or counselor: address behavioral concerns such as stress management, poor sleep, anxiety, and maladaptive behaviors.2. What TMJ condition would you suspect if this patient reported a sudden decrease in mouth opening and the clinical examination revealed a passive ROM of 30 mm with a noticeable deection of her mandible to the right side upon opening?Answer: Right temporomandibular disk displacement without reduction.3. List examples of conservative recommendations for temporomandibular joint disorder that is primarily muscular in nature.Answer: Thermotherapy (moist heat), daytime clenching awareness, pain-free jaw functioning and stretching, nighttime occlusal orthotic use, biofeedback training, soft diet, maintaining proper hydration, avoiding hunger, and getting adequate sleep.4. What could be contributing to sleep bruxism in this patient?Answer: Multiple stressors (change in school, busy schedule); substance use (caffeine, dextroamphetamine); possible medical associations (gastroesophageal reux disease and obstructive sleep apnea). 588 39 Prevention of Dental DiseaseTAD R. MABRYCHAPTER OUTLINERisk AssessmentDietary ManagementHome CareFluoride AdministrationApproach to the Adolescent PatientCaries Activity During AdolescenceHigh-Frequency/Low-Concentration ApplicationsHighly Concentrated Fluoride AgentsRisk FactorsIntraoral and Perioral PiercingsAdolescent PregnancySmoking and Smokeless TobaccoTransitioning to Adulthoodyears of age. Caloric requirements increase dramatically, and large amounts of protein and carbohydrates are consumed. In both boys and girls, irregular meals, frequent snacking, vending machine purchases, fast food meals, and unusual eating patterns are common practices.ese changes can have profound eects on the oral environment and pose substantial challenges for the provision of professional dental care. e eruption of teeth into an environment of increased plaque secondary to reduced cleansing eorts combined with frequent snacking on foods and beverages high in carbohydrates can pose a signicant risk for caries development in the immature enamel of newly erupted teeth.Besides being a time of increased caries risk, adolescence is also a time when the desire for social acceptance can lead individuals to actions that place them at risk for additional dental complications. Such actions would include tobacco and e-cigarette use, intraoral and perioral piercings, and adolescent pregnancy. Periodic profes-sional visits that emphasize routine home care, optimal use of topical uorides, dietary management strategies, and counseling on the dental implications of risky behaviors are both the goals and challenges for dentists who treat adolescents.Risk AssessmentRisk assessment takes on some added dimensions for the adolescent patient. rough the years, these individuals have become increas-ingly responsible for their own oral hygiene practices. Typically, it is the rst time in their lives that they have a say in the decision-making process associated with their dental treatment options. Although treatment decisions are legally still in the hands of the parents or legal guardians, the wills and desires of the adolescent patient should not be discounted by the provider.e American Academy of Pediatric Dentistry (AAPD) has developed a set of guidelines used to assess the caries risk of patients in the mixed or permanent dentition (Table 39.1). In addition, the AAPD has developed caries management protocols based on these risk assessments (Table 39.2). Although these protocols are useful in determining the direction of patient care, they should be considered as guidelines only, and each adolescent should have an individualized treatment plan that addresses his or her unique preventive, restorative, and counseling needs.e caries risk assessment comprises just one part of the overall risk assessment for the adolescent patient. Other factors that must be considered when developing a comprehensive treatment plan include the need for, as well as the timing of, referrals for ortho-dontics or third molar extractions, where indicated. Risk factors such as pathologic dietary conditions, tobacco use, alcohol or drug Adolescence generally denotes the period between childhood and adulthood. It is known for being a phase of life associ-ated with change, rebellion, and friction. It encompasses a time frame when patients may progress from junior high school to senior high school and then go o to college, the workforce, or some other aspect of adult life. Adolescence can be a period of heightened involvement in peer group relationships, often at the expense of social or familial associations.e period encompasses the completion of physical growth and development in both girls and boys. Typically, all permanent teeth have erupted except for impacted third molars. e occlusion has stabilized either on its own or with orthodontic intervention. A gradual but continuous increase in the incidence of dental caries is often noted during this period.1 Periodontal disease may manifest itself because of fewer routine or parentally supervised home care sessions. e frequency of dental visits may decline. In addition, the increase in sex hormones in this age group is suspected to alter the subgingival microora, resulting in an increased incidence of periodontal disease.2Dietary habits undergo dramatic changes during this period. As adolescent girls complete their maximal growth and development, it is not unusual for them to begin dietary experimentation and modication. Some of these modications can lead to serious pathologic conditions such as anorexia nervosa and bulimia. In adolescent boys, similar modications in dietary habits occur. During this period the boy’s skeletal growth and body weight usually undergo dramatic changes, typically peaking at 16 to 18 CHAPTER 39 Prevention of Dental Disease 589 assessment will typically dictate the focus of education to minimize the odds of development of early childhood caries. For the adolescent patient, anticipatory guidance not only includes caries reduction strategies based on a caries risk assessment but also preventive measures aimed at reducing the likelihood these individuals would choose to participate in behaviors that could jeopardize their oral health. Adolescents often participate in these types of activities without knowing the negative consequences associated with them. e goal of this form of anticipatory guidance is to educate adolescents on the detrimental eects associated with these risky behaviors in hopes that they may elect not to participate in these activities when pressured by their peers.Several organizations such as the AAPD, as well as the American Academy of Pediatrics (AAP) and the American Dental Association (ADA), have educational materials in the form of pamphlets and brochures that can be used to guide the discussion that a dental professional may have with the at-risk adolescent (Fig. 39.1).Dietary ManagementAs with younger age groups, the overall recommendations on dietary management for adolescents should concentrate on balanced intake, reduction of the frequency of snacking, and selection of foods that are not retentive to the teeth and soft tissues. Unfortunately, these recommendations conict with the typical lifestyles of adolescents. With their newly gained independence, rebellious attitude toward established social systems, and acceptance of media messages and peer group pressure, it is a dicult task for the dentist and his or her sta to communicate recommendations and instill health-promoting behaviors.Fortunately, owing to the increasing social development that occurs in middle adolescence, there is a strong desire to look attractive. e mouth takes on added importance. e challenge to dental professionals is to somehow make the daily care of teeth, including sound dietary habits, desirable for this patient population.For the patient who has been at high risk for dental disease during the early years and has had caries in the primary or mixed dentition, dietary management is a major concern. Depending on the patient’s present oral status, emotional and psychological maturity, and parental inuences, counseling can be performed abuse, intraoral or perioral piercings, or teenage pregnancy must be factored in when planning treatment care for the adolescent. Counseling that addresses the dental as well as the medical complica-tions associated with these risk factors should be included as part of the comprehensive treatment plan. If a provider is not comfortable or feels that further counseling expertise is warranted, a referral should be made to a professional who could provide such counseling.Anticipatory guidance is the implementation of preventive strategies based on a risk assessment. It is in the patient’s best interest to preemptively provide education that might prevent the development of a pathologic condition rather than treat the condi-tion after it has occurred. For the infant or toddler a caries risk FactorsHigh RiskModerate Risk ProtectiveBiologicPatient is of low socioeconomic statusYesPatient has >3 between meal sugar-containing snacks or beverages per dayYesPatient has special health care needsYesPatient is a recent immigrant YesProtectivePatient receives optimally uoridated drinking waterYesPatient brushes teeth daily with uoridated toothpasteYesPatient receives topical uoride from health professionalYesAdditional home measures (e.g., xylitol, MI Paste, antimicrobial)YesPatient has dental home/regular dental careYesClinical FindingsPatient has ≥1 interproximal lesions YesPatient has active white spot lesions or enamel defectsYesPatient has low salivary ow YesPatient has defective restorations YesPatient wears an intraoral appliance YesCircling those conditions that apply to a specic patient helps the practitioner and patient/parent to understand the factors that contribute to or protect against caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (e.g., >1 interproximal lesion, low salivary ow) in determining overall risk.Overall assessment of the dental caries risk: Low □ Moderate □ High □From American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2016;38(Special issue):142–149.Caries Risk Assessment for Patients Older Than 6 Years (for Dental Providers)TABLE 39.1 • Figure 39.1 Brochures useful for guiding discussions with at-risk adolescents. 590 Part 5 Adolescenceoften fail to recognize the dierence between these two.8 Sports drinks are promoted by the beverage industry as products that optimize athletic performance by replacing uid and electrolytes lost in vigorous exercise. In contrast, energy drinks purport everything from an increase in energy and a decrease in fatigue to enhanced mental alertness and focus. Many of the ingredients have minimal therapeutic benet and are not well regulated. Energy drinks typically contain a blend of stimulants that include caeine, taurine, ginseng, guarana, L-carnitine, and creatine. Some of these energy drinks exceed 500 mg of caeine in a single serving, which is equivalent to the amount of caeine found in 14 cans of the typical caeinated soft drink.9 Caeine tends to increase blood pressure, heart rate, gastric secretions, body temperature, cardiac arrhythmias, and diuresis.10 Studies have shown that, although the consumption of caeine is poorly correlated with anxiety, it may result in increased anxiety for those individuals prone to anxiety disorders.11,12 Unfortunately, the sales of energy drinks continue to increase largely due to marketing eorts which target youth under 18 years of age.13Both parents and school systems are recognizing the harmful dental eects of carbonated sodas and similar beverages and are limiting the exposure of adolescents to them. Unfortunately, these carbonated beverages are frequently being replaced with sports drinks. e pH of most sports drinks is in the acidic range (pH 3 to 4), which is well within the range to cause enamel with the patient only or, if indicated, with both the patient and the parents. At this age the adolescent may enjoy independence from the involvement of his or her parents. erefore the dentist must decide the extent of parental inclusion in the dietary consultation.e sense of independence among adolescents often leads to snacking at will. Such poor eating habits are a major factor in the increasing rates of childhood obesity.3,4 Often these poor eating patterns carry over into adulthood. ere has been a notable change in snacking habits of adolescents since the 1970s.5 Several troubling issues have been identied:• enumberofadolescentswhosnackonagivendayincreasedfrom 74% in 1977 to 1978 to 98% in 2005 to 2006.• emaincontributorofsnackingcaloriesisdesserts.• Snacking,whichaccountedfor300caloriesadayin1977to1978, accounted for 526 calories a day in 2005 to 2006.6• Childrenaremovingtowardconstanteating.e busy lifestyles of adolescents nowadays make the sit-down family meal a rarity. is has a deleterious eect on the dietary patterns of adolescents. Research has shown that parental presence at family evening meals exerts substantial inuences in terms of increasing the adolescents’ consumption of fruits, vegetables, and dairy products while lowering the consumption of soft drinks.7A growing trend among adolescents is the consumption of sports drinks and energy drinks. Adolescents, as well as their parents, Risk Category DiagnosticsINTERVENTIONSRestorativeFluoride Diet SealantsaLow risk • Recallevery6–12months• Radiographsevery12–24months• Twicedailybrushingwithuoridated toothpastebNo Yes • SurveillancecModerate-riskPatient/parent engaged• Recallevery6months• Radiographsevery6–12months• Twicedailybrushingwithuoridated toothpasteb• Fluoridesupplementsd• Professionaltopicaltreatmentevery6months• Counseling Yes • Activesurveillancee of incipient lesions• Restorationofcavitatedor enlarging lesionsModerate-riskPatient/parent not engaged• Recallevery6months• Radiographsevery6–12months• Twicedailybrushingwithtoothpasteb• Professionaltopicaltreatmentevery6months• Counseling,withlimited expectationsYes• Activesurveillancee of incipient lesions• Restorationofcavitatedor enlarging lesionsHigh-risk patient/parent engaged• Recallevery3months• Radiographsevery6months• Brushingwith0.5%uoride• Fluoridesupplementsd• Professionaltopicaltreatment every 3 months• Counseling• XylitolYes• Activesurveillancee of incipient lesions• Restorationofcavitatedor enlarging lesionsHigh-riskPatient/parent not engaged• Recallevery3months• Radiographsevery6months• Brushingwith0.5%uoride• Professionaltopicaltreatment every 3 months• Counseling,withlimited expectations• XylitolYes• Restoreincipient,cavitated, or enlarging lesionsaIndicated for teeth with deep ssure anatomy or developmental defects.bLess concern about the quantity of toothpaste.cPeriodic monitoring for signs of caries progression.dNeed to consider uoride levels in drinking water.eCareful monitoring of caries progression and prevention program.From American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2016;38(Special issue):142–149.Example of a Caries Management Protocol for Patients Older Than 6 YearsTABLE 39.2 CHAPTER 39 Prevention of Dental Disease 591 Initially, a 24-hour dietary history is usually sucient. Based on the history and additional information from patients about their typical daily schedule and academic, athletic, and social obligations, the dentist or sta responsible for counseling can assist in devising an individualized preventive plan.Having the patient acknowledge problems and commit either orally or in writing to recommended interventions can help to improve compliance. During periodic examinations, the patient’s progress or lack of progress can be evaluated. Plans may have to be modied repeatedly depending on the patient’s changing needs. Because food preferences, social pressures, and growth changes occur frequently, any plan must allow for exibility.Although 24-hour diet histories are helpful, more insight can be obtained from a 5- or 7-day history that includes weekends. For improved accuracy, the patient should complete the rst day’s record with the dentist, paying particular attention to all liquid and solid foods consumed both at meals and between meals. Information about how much of the food was consumed and where the food was eaten is helpful.After the dietary history has been completed, a sta person assigned to counseling responsibilities should carefully review it with the patient. Foods high in rened carbohydrates or retentive to the oral tissues should be identied. Intake of fresh fruits and vegetables should be noted and commended. Unusual foods or dietary patterns should be noted, and the overall balance of the diet should be evaluated.Patients should be asked to list problem areas and categorize them according to the ease with which they can be changed. With problems identied and listed according to perceived ease of modication, the patient then develops a plan. It is important that it be the patient’s plan and not the dentist’s. It is the dentist’s role to guide the patient to develop a realistic plan that will build on successes. Periodic reviews can help to determine the status of the dietary modications and the need for new strategies. Reinforce-ments and rewards may be helpful, but in the end the patient’s own perception of success will likely prove to be the most rewarding aspect for both dentist and patient.A referral to a registered dietitian should be considered for the adolescent or parent who desires more intensive or more frequent dietary counseling. Consultation with a dietitian would also be useful for patients whose overall health is compromised by their dietary habits.Numerous phone apps and web-based diet analysis programs are available that provide the opportunity to track daily food and beverage consumption. ese programs typically analyze the overall diet quality and provide a score or grade. Several of the programs address the amounts of saturated fat, trans fat, cholesterol, and sodium consumed in an individual’s diet. e score or grade represents compliance with established food consumption guidelines. e most common set of guidelines are those established by the US Department of Agriculture (USDA). e USDA has been establishing dietary guidelines since 1916. In 2011 the USDA’s MyPyramid food guidance system was replaced with an updated set of guidelines titled MyPlate (see Fig. 20.2). ese guidelines target specic populations that include preschoolers 2 to 5 years of age, children 6 to 11 years of age, and pregnant and breastfeeding women, as well as dieters. Guidelines for adolescents are included in the section for children.Dietary challenges for patients with developmental disabilities can be substantial. Depending on the severity of the disability, dietary habits may or may not be aected. For the patient with severe neuromuscular involvement, diet and eating methods will demineralization.14 It is unfortunate that parents and school administrators are failing to recognize the deleterious eects of sports drinks on the dentition.e AAP Committee on Nutrition (CON) and the Council on Sports Medicine and Fitness (COSMF) recently published a report with the following recommendations to pediatricians15:• Improvetheeducationtobothparentsandchildrenonthedierences between, as well as the potential health risks of, sports drinks and energy drinks• Understandthepotentialhealthrisksthatenergydrinksposeas a result of their stimulant content• Counselat-riskindividualsastotherelationshipbetweenbothobesity and dental erosion to excessive sports drink consumption• Educatepatientsandparentsoneectivehydrationmanagement,stressing that water should be the initial beverage of choice for hydration purposesIn 2007 the Institute of Medicine recommended prohibiting energy drink use in children and adolescence, including athletes. According to the commission’s report, energy drinks have no place in the diet of adolescents.16Although sports drinks and energy drinks are a somewhat new trend among adolescents, the problem associated with the consump-tion of high-sugar beverages of any type is long-standing in this age group. Sugar-sweetened beverages have become the largest source of added sugars in the diet of adolescents in the United States.17 ese beverages include nondiet sodas, sweetened fruit juices, sweetened coee and tea drinks, and the sports and energy drinks. Some studies are attributing the increased caloric intake associated with the consumption of these beverages as a factor that is contributing to the increasing obesity rates among adolescents.18 In addition, the high sugar content of sugar-sweetened beverages has been shown to increase the risk of type 2 diabetes by increasing the dietary glycemic load, leading to insulin resistance and β cell dysfunction.19 Data from the 2011 to 2012 and 2013 to 2014 National Health and Nutrition Examination Survey (NHANES) revealed that 62.9% of youth 2 to 19 years of age drank at least one sugar-sweetened beverages daily, and nearly 20% drank two daily.20 e elevated consumption of these beverages not only aects the overall general health of adolescents in the form of increasing rates of obesity and diabetes but also has deleterious eects on the caries rates of adolescents.Dental professionals should discuss both the dental and physical risks associated with excessive sugar-sweetened beverage consumption as part of their prevention program targeted toward adolescents. It is critical that this topic be discussed with the parents or legal guardians of those patients with special health care needs because these individuals often possess obstacles that preclude the maintenance of adequate oral hygiene. e addi-tion of sugar-sweetened beverages in such an oral environment places the special needs patient at risk for the development of rampant caries.For the patient who has active lesions in the developing per-manent dentition, dietary management and modications are denitely indicated along with a comprehensive program of oral cleaning and daily topical uoride use. Developing a complete understanding of the importance of this approach with the patient and determining his or her willingness to cooperate are critical to achieving a successful outcome. If the patient is interested and willing to cooperate, a dietary history may be indicated. If not, it will be only a paper exercise and a waste of time for both parties involved. 592 Part 5 Adolescencethese agents include those with special health care needs, as well as those with orthodontic appliances. Studies have conrmed the improvement from the use of various antimicrobial agents in reducing plaque, gingivitis, and gingival bleeding sites.21–23 Ado-lescents frequently experience marginal gingivitis secondary to plaque deposits. Consideration should be given to prescribing antimicrobial mouthrinses to complement daily oral hygiene practices for such individuals.24 For those patients with develop-mental disabilities or medical conditions that limit their ability to rinse and spit, an alternative application method is to apply chlorhexidine as a varnish or gel. Chlorhexidine varnish, although commonly used for years in European and Scandinavian countries, did not become commercially available in the United States until 2011. Studies have shown that the eectiveness in reducing mutans streptococci levels is greater with the chlorhexidine varnishes than it is with the gels or mouthrinses.25 Although the benets of chlorhexidine on gingivitis are readily accepted, the benets of chlorhexidine as a caries control agent are inconclusive.25 Newer studies have suggested that probiotic mouthrinses may provide a natural defense against harmful oral bacteria.21Most studies on the eects of xylitol on caries rates focus on mothers and young children. Studies on the eects of xylitol on caries rates in adolescents are limited and have confounding results. Although the AAPD recognizes the benets of sugar substitutes such as xylitol and advocates their use as a preventive measure for children and adolescents, they do not address a specic application schedule of xylitol for adolescents.26 More research on the subject is encouraged.Fluoride AdministrationApproach to the Adolescent PatientAlthough most adolescents have the ability to carry out eective oral hygiene procedures, many neglect to perform these activities regularly. e key to promoting eective caries prevention during what can be a hectic and trying stage of life often depends on recognizing the predominant motivational factors operating in this age group and adopting an approach that is based on less than ideal compliance. e focus on personal appearance and hygiene in this age group can be used as a powerful motivator for developing preventive activities. Another strategy involves appealing to the adolescent’s desire to be viewed as autonomous and capable of taking care of him- or herself.already have been modied. Parents or caretakers must be made aware of the potentially devastating oral eects caused by pouching, which is the prolonged holding of food in the mouth, and rumina-tion, which is the regurgitation, rechewing, and reswallowing of food. Some patients with developmental disabilities may suer from gastrointestinal eux, which may cause enamel erosion. Many of these patients are on medications that cause xerostomia. If management of the diet is not possible, or if medications are an issue, eorts should be made to ensure more frequent and thorough cleansing of the oral cavity as well as frequent use of topical uorides and sialagogues, if indicated.Home CarePersonal hygiene, like any established societal activity, is met with varying responses during adolescence. Nagging by the parent or dentist will often lead to a negative response. When an adolescent patient understands the importance of oral hygiene and is ready to make a daily commitment to it, the dentist can assist him or her in developing a routine that will be acceptable to the patient and maintain a healthy oral environment.During this period, dental ossing should become a part of the daily oral hygiene routine. Adolescents should have well-developed hand-eye coordination and ne motor activity. ose who have diculty with the traditional method of ossing may benet from a oss holder (Fig. 39.2).e goal for the adolescent should be to perform thorough tooth brushing with a uoridated toothpaste at least twice each day, ideally at the start of the day and at bedtime. After meals, a vigorous rinse with water should be encouraged. If orthodontic appliances are present, additional time, as well as modications of the routine, will be necessary to remove not only the plaque but also the debris caught around the brackets and wires (Fig. 39.3). Additional attention to maintain healthy marginal gingiva is also important.Eective daily home care is essential for the adolescent patient with a developmental disability. Again, depending on the severity of the disability, the patient, the parent, or a caregiver must take responsibility for the care. Mouth props may be necessary for some patients who are unable to keep their mouths open for oral care routines (see Fig. 24.5).Chemical agents that alter plaque, such as chlorhexidine and xylitol, have become popular adjuncts to daily oral hygiene in select patients. Patients who may benet from the daily use of • Figure 39.2 Floss holders. (Courtesy Practicon Dental, Greenville, NC.)• Figure 39.3 Use of an interproximal brush to clean around brackets. (From Darby ML, Walsh MW. Dental Hygiene: Theory and Practice. 3rd ed. St Louis: Saunders; 2010.) CHAPTER 39 Prevention of Dental Disease 593 High-Frequency/Low-Concentration ApplicationsAs with younger children, the daily use of a uoride dentifrice should form the foundation of a sound personal preventive oral health program, regardless of whether the person lives in a uori-dated or a nonuoridated community. Additional protection can be provided by the daily use of a 0.05% sodium uoride rinse for those at elevated risk for the development of caries. Although these rinses are not as eective as brushing with an over-the-counter uo-ridated dentifrice, they are advisable for those “on-the-go” teenagers who do not take the time to practice thorough plaque removal. Frequent exposures to uoride may help to suppress the cariogenic potential of the oral ora and can help to establish an environment that may inhibit demineralization or promote remineralization.30 As noted previously, uoride mouthrinses also are indicated for persons who have diculty removing plaque because of the presence of orthodontic appliances or for those with predisposing medical conditions.Highly Concentrated Fluoride AgentsFrequent applications of highly concentrated uoride gels, denti-frices, or varnishes may be indicated for adolescents who exhibit poor oral hygiene or other risk-elevating factors, or who continue to exhibit high levels of carious activity at recall examinations. Gels can be applied at home by brushing or by means of customized plastic trays. Custom trays are easily fabricated using vacuum-forming devices that adapt plastic tray material over stone models of the patient’s maxillary and mandibular arches. e optimum time to apply the gels is just before bedtime, which prolongs the uoride contact with the teeth.30 Professional topical uoride applications in the form of varnishes, gels, or foams can be applied as frequently as every 3 months for moderate or high caries adolescents. An additional preventive regimen for the high caries risk adolescent with a history of ongoing caries activity is prescribing a highly concentrated uoride dentifrice (1.1% sodium uoride, 5000 ppm) for daily use. Individuals who use such highly con-centrated uoride products must be able to expectorate appropriately; therefore their use in some patients with special needs may be limited.Adolescence is a time of heightened caries activity for many individuals as a result of increased intake of cariogenic substances and inattention to oral hygiene procedures. Because uorides have been shown to exert a greater anticaries eect in patients with higher baseline levels of caries activity and because the concurrent use of various forms of uoride often produces greater caries reductions than when the agents are used separately, multiple exposures to a variety of uoride sources should be encouraged during this period of elevated risk in an attempt to control the caries process.Risk FactorsIntraoral and Perioral PiercingsA growing interest among adolescents is body modication through intraoral and perioral piercings. is mode of self-expression carries risks and complications not typically experienced with more tra-ditional types of body piercings. e increase in complications is related to the fact that these piercings involve violations of bacteria-rich mucosa that is more sensitive to disruption than would be Regardless of the psychological basis for the motivation, time should be taken to ensure that adolescents understand the nature of the disease processes that the preventive programs are addressing and the general mechanisms by which the prescribed measures are thought to counteract these processes. is emphasis on education is more likely to be accepted and will produce better long-term outcomes than a more authoritarian or condescending approach.Caries Activity During AdolescenceIn spite of a well-documented decline in caries levels in children in the United States and other Western countries over the past 50 years, adolescence still marks a period of signicant caries activity. A comparison was made on the data collected by the NHANES from the reporting period of 2011 to 2012 and the reporting period 1988 to 1994. In 2011 to 2012, 50% of 12- to 15-year-olds and 67% of 16- to 19-year-olds had experienced dental caries in their permanent teeth.27 ese numbers reect a decline in caries experience from the earlier 1988 to 1994 data of 57% (a 7% decline) in the 12- to 15-year-old group and 78% (an 11% decline) in the 16- to 19-year-old group.28 Despite the signicant decline, the 16- to 19-year-olds still had the highest caries rates of any child or adolescent age group evaluated. ese older adolescents also had the highest rate of untreated decay, at 19% compared with 12% of those aged 12 to 15.27 erefore uoride administration for the adolescent patient should continue to be an important concern during this stage of continuing caries susceptibility.Topical uorides along with occlusal sealants are the primary preventive agents of choice during adolescence because the entire permanent dentition except for third molars have typically erupted by 13 years of age.29 Most studies have shown that uorides reduce the incidence of smooth-surface caries to a greater extent than that of occlusal caries.29 Therefore the combination of uoride therapy and occlusal sealants (Fig. 39.4) can be used to provide optimal protection for all surfaces of both anterior and posterior teeth.• Figure 39.4 Occlusal sealant. (Courtesy Dr. Dennis J. McTigue.) 594 Part 5 AdolescenceAdolescent PregnancyIn 2015 the birth rate in the United States was 22.3 live births for every 1000 teenagers of ages 15 to 19 years.35 Although the trend in teenage birth rates has been declining, it is estimated that more than 232,000 teenagers give birth each year.35 Dentists who treat adolescent patients are likely to encounter pregnant teenagers at some time. When dealing with the pregnant teenager, the dental professional must address a unique set of issues. ese would include legal concerns, emotional considerations, and distinct physical and dental problems that would not otherwise be encoun-tered if the patient were not pregnant.e AAPD recommends that the initial evaluation of a pregnant adolescent takes place during her rst trimester.36 Adolescents who are pregnant are often reluctant to share this information with their dental professional, particularly early on in their pregnancy. is reluctance to divulge information on the pregnancy makes it challenging for the dental professional to provide the anticipatory guidance and treatment that ideally would be initiated at this time.It is possible that the individual responsible for consenting privileges of an adolescent could change due to a pregnancy. State laws vary widely as to who can consent to treatment for the pregnant adolescent. Treating dentists must be aware of the local statutes that address this situation, as well as those statutes that address the condentiality of the situation.Ideally, a dental prophylaxis should be completed during this rst trimester. If either adverse periodontal conditions develop or inadequate home hygiene is noted, additional hygiene appointments should also be scheduled during the second and third trimesters. Counseling during this rst visit should address dietary consider-ations, the consequences of hormonal changes on gingival health, and a preventive plan that includes measures to reduce the likelihood of postpartum vertical transmission of mutans streptococci to the newborn. Radiographs with adequate shielding can be taken during this rst trimester but are recommended only if they will aect immediate patient care. Nitrous oxide is discouraged at this time. If elective treatment is indicated, it should be completed during the second trimester and only if it is likely to prevent the develop-ment of dental complications. Otherwise, it would be best to delay such elective treatment until after delivery. e pregnant patient who is suering pain or infection should be taken care of imme-diately, regardless of the trimester of pregnancy. Any administered or prescribed medications should not pose a risk to either the expectant mother or her fetus. Fluoride supplementation is not recommended as a means to provide added protection to the developing teeth of the fetus.Often these patients will experience nausea and vomiting, which can lead to enamel erosion. An acid-neutralizing rinse should be recommended after episodes of emesis. Rinsing with a teaspoon of sodium bicarbonate mixed in a cup of warm water can provide this neutralizing eect.37 In addition, immediate toothbrushing should be discouraged.e dentist who is adequately prepared can be a strong advocate for the health and well-being of both pregnant adolescents and their unborn children. It is imperative that the dental professional who treats adolescents become familiar with the possible complica-tions as well as the recommendations for treating pregnant patients.Smoking and Smokeless Tobaccoe use of tobacco by minors is a complex issue. e data are clear that tobacco has both systemic and local impacts on the dermal tissue. Complications can be categorized as immediate or delayed, as well as localized or systemic. Immediate complications occurring at the time of piercing include pain, excessive bleeding, and nerve damage causing immediate paresthesia. It is also possible that infectious diseases, such as hepatitis B and C, and microorgan-isms responsible for the development of cellulitis and bacterial endocarditis could be introduced at the time of piercing through improper aseptic techniques. Delayed complications include the formation of tissue defects both at the site of the piercing and on tissue adjacent to the jewelry. Ninety-seven percent of patients reported some form of delayed complication.31 Fractured teeth, allergic reactions to metals, ingestion and aspiration of jewelry parts, dysphasia, masticatory problems, and hypersalivation are additional complications that have been attributed to intraoral and perioral piercings.32Although numerous case reports are available on the subject of complications associated with intraoral piercings, relatively few large studies have investigated the subject. What studies are available reveal a strong correlation between piercings and specic types of dental injuries and pathologic conditions. e most commonly reported dental conditions include fractured teeth and the develop-ment of mucogingival defects. Loss of tooth structure due to attrition or fracture has been reported to be as high as 80% in individuals with pierced tongues (Fig. 39.5).33 Similarly, studies have reported that 19% of individuals with pierced tongues experienced some type of gingival recession.34Because of the high incidence of complications associated with perioral and intraoral piercings, dental professionals should react proactively to those adolescents contemplating piercings. Increasing social acceptance is making it hard to identify those adolescents at risk. erefore dental professionals should include a discussion of the complications of perioral and intraoral piercings as part of their routine prevention program aimed at all adolescents. ose adolescents who present with existing piercings should be counseled as to their risks and possible complications. Because of the rapid development and progression of tissue defects related to piercings, it may be best to keep individuals with existing piercings on shorter recall schedules than what might otherwise be dictated from their caries risk assessments.• Figure 39.5 A fractured lower left rst permanent molar associated with an intraoral piercing. (Courtesy Maia Rodrigo.) CHAPTER 39 Prevention of Dental Disease 595 eects of smokeless tobacco, as well as the potential systemic side eects.Just as with smokers, cessation programs using a combined behavioral and pharmacologic approach can and should be initiated by dentists for their patients who use smokeless tobacco. ese can be self-help programs or those with more personal interactions. Data indicate some substantial success with these types of cessation interventions.56 Some methods such as NRT may be dicult without parental involvement, given the restrictions for NRT. Enhancing this diculty is the fact that most smokeless tobacco users do not associate this form of tobacco use with nicotine addiction.In addition to the long-lasting concerns with smoking and smokeless tobacco use among adolescents is the more recent concerns with the increasing usage of e-cigarettes and marijuana use among adolescents as detailed in Chapter 37.Transitioning to AdulthoodIn 2011 the AAP in conjunction with the American Academy of Family Physicians and the American College of Physicians released a report that provided guidelines on the transitioning of youth from a pediatric medical home to appropriate adult care. A detailed health care transition algorithm was developed that outlined the steps involved to facilitate a smooth transition.57 e transition of adolescent dental patients to adult dental care is equally if not more complicated than that of medical care. It is a process that is best accomplished with some advance planning.Borrowing from the medical model, the smooth transition of adolescents from a pediatric dental home to one with an adult focus should involve three key components: provider readiness, family readiness, and adolescent readiness. Provider readiness involves the establishment of an oce policy that addresses the age as well as the process for referring an adolescent to an adult dental provider. e AAPD does not require transfer by a specic age yet recom-mends that it be “at a time agreed upon by the patient, parent, and pediatric dentist.”58 e trend among pediatric dentists is that these transfers are taking place at an early age. Studies have found that, in the majority of pediatric dental practices, less than 10% of patients are between 15 and 21 years of age.59Family readiness describes the practice of informing the parent or legal guardians of the established oce policy well in advance body. Cardiovascular disease (stroke, heart attack, and hypertension), lung disease, and cancer of the oral and respiratory tract are well-known sequelae associated with smoking.38 Periodontal disease also is more prevalent in smokers.39 Although most oral cancers occurs after 30 years of age, they can occur earlier.40 erefore routine dental examinations on adolescents should include an inspection of all mucosal, tongue, palatal, and oropharyngeal surfaces to rule out the presence of oral cancers.Smoking cessation is dicult at best. e social and environ-mental cues that reinforce the smoking habit, combined with the potential nicotine addiction, make this a tough problem to conquer. is may be compounded in adolescents where both the habit and the search for help are often clandestine. Certainly, educating children and adolescents and preventing tobacco use is the preferred approach. When the habit has been acquired, the best cessation results appear to be those in which behavioral support is combined with nicotine replacement therapy (NRT).41 Clini-cians should attempt an intervention because they can potentially cause a great impact on the well-being of an adolescent.42 Patients willing to try to quit tobacco use should be provided treatments identied as eective, and patients unwilling to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.41 e latter can be an unstructured and informal discussion of the reasons to quit and the barriers that the patient might encounter. Working with parents and children in a cessation regimen incorporating NRT requires parental consent because doing so otherwise would be a violation of US Food and Drug Administration regulations, even though those under 18 years of age have ready access to tobacco products on most occasions.43Smokeless tobacco appears to be an increasingly popular alterna-tive to smoking, especially among young males, for whom it increased from 0.7% in 1970 to 7% in 2014.44 More distressing, the prevalence among male high school students is near 10%.44 Smokeless tobacco can easily be used to achieve the same eects of nicotine without impinging on family, friends, and smoke-free environments. Whether smokeless tobacco is implicated in oral cancer is important because since 1970 through 2004 the 5-year survival rate of oral cancer victims has increased, but only by 15%.45 Like smoking, the environment (e.g., certain social situations) can provide behavioral cues that stimulate the desire to use smokeless tobacco.46Aside from the unsightly necessities that accompany some smokeless spit tobaccos, there are other side eects that make it a questionable health practice. e potential for nicotine addiction is high with all types of tobacco products.47 Certainly long-term use of nicotine in any form carries the risk of hypertension. Blood pressure monitoring indicates that such changes follow tobacco users of any type.48 Furthermore, it appears that smokeless tobacco is a gateway drug to cigarettes.49,50Smokeless tobacco has several deleterious eects on oral health. ere appears to be greater risk of localized periodontal attachment loss in the form of gingival recession in smokeless tobacco users, commonly adjacent to where the tobacco is placed.51 ere also appears to be a greater risk of leukoplakia developing among smokeless tobacco users,52 including adolescent users.53 Fortunately, there is good evidence that suggests smokeless tobacco keratosis (Fig. 39.6) is largely reversible.54 A major area of dispute is whether smokeless tobacco is a likely cause of oral cancer. e evidence is not decisive but points in that direction.52,55 It is not unreasonable to counsel patients and help them with cessation programs so that they can prevent the transient and possibly more morbid potential • Figure 39.6 Clinical appearance of white lesion associated with smokeless tobacco (tobacco pouch keratosis). (From Ibsen OAC, Phelan JA. Oral Pathology for the Dental Hygienist. 5th ed. St Louis: Saunders; 2009.) 596 Part 5 Adolescenceand Stimulant Task Force of the American Academy of Sleep Medicine. Sleep. 2005;28(9):1163–1187.12. Diogo LR. Caeine, mental health, and psychiatric disorders. J Alzheimers Disease. 2010;20:S239–S248.13. Harris JL, Munsell CR. Energy drinks and adolescents: what’s the harm? Nutr Reviews. 2015;73(4):247–257.14. Shaw L, Smith AJ. Dental erosion—the problem and some practical solutions. Br Dent J. 1999;186(3):115–118.15. Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127(6):1182–1189.16. Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: National Academies Press; 2007.17. Reed J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc. 2010;110(10):1477–1484.18. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consump-tion of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357(9255):505–675.19. Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477–2483.20. Rosinger A, Herrick K, Gahche J, et al. Sugar-Sweetened Beverage Consumption Among US Youth, 2011-2014. NCHS Data Brief 271. Hyattsville, MD: National Center for Health Statistics; 2017.21. Harini PM, Anegundi RT. Ecacy of a probiotic and chlorhexidine mouth rinses: a short-term clinical study. J Indian Soc Pedod Prev Dent. 2010;28(3):179–182.22. Manikandan D, Balaji VR, Niazi TM, et al. Chlorhexidine varnish implemented treatment strategy for chronic periodontitis: a clinical and microbial study. J Pharm Bioall Sci. 2016;8(suppl 1): 133–137.23. Brightman LJ, Terezhalmy GT, Greenwald H, et al. e eects of a 0.12% chlorhexidine gluconate mouthrinse on orthodontic patients aged 11 through 17 with established gingivitis. Am J Orthofac Dentofac Orthop. 1991;100:324–329.24. Bhat M. Periodontal health of 14- to 17-year-old U.S. school children. J Public Health Dent. 1991;51:5–11.25. Autio-Gold J. e role of chorhexidine in caries prevention. Oper Dent. 2008;33(6):710–716.26. American Academy of Pediatric Dentistry Council on Clinical Aairs. Policy on the use of xylitol. Pediatr Dent (special issue). 2016;38: 47–49.27. Dye BA, ornton-Evans G, Xianfen L, et al. Dental Caries and Sealant Prevalence in Children and Adolescents in the US, 2011-2012, NCHS Data Brief, 191. Hayttsville, MD: National Center for Health Statistics; 2015.28. Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel uorosis—United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. 2005;54(3):1–43.29. 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):1–42.30. Castellano JB, Donly KJ. Potential remineralization of demineralized enamel after application of fluoride varnish. Am J Dent. 2004;17(6):462–464.31. Viera EP, Ribeiro AL, Pinheiro Jde J, et al. Oral piercings: immediate and late complications. J Oral Maxillofac Surg. 2011;69(12):3032–3037.32. Titus P, Smily T, Francis G, et al. Ornamental dentistry-An overview. J Evol Med Dent Sci. 2013;2(7):666–676.33. Leichter JW, Monteith BD. Prevalence and risk of traumatic gingival recession following elective lip piercing. Dent Traumatol. 2006;22(1):7–13.34. Campbell A, Moore A, Williams E, et al. Tongue piercing: impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontol. 2002;73:289–297.of when an actual transfer may occur. e family may need to investigate benet coverage issues and may elect to do reference checks on potential recipients of the transfer.Adolescent readiness would be the nal key component in the transfer process. It is possible that there could be emotional concerns for the adolescent who, essentially, grew up with and became comfortable with a single pediatric dental provider. Discussion of the transfer would serve the patient best if initiated well in advance of the actual transfer. Doing so could potentially help the provider recognize and address any anxiety associated with the transfer process. In addition, it could allow anxious adolescents to mentally prepare for their new dental home.It is estimated that 750,000 adolescents with special health care needs reach adulthood each year.60 ese patients pose a unique set of challenges to the transfer process. Although nearly 95% of pediatric dentists routinely see patients with special health care needs, less than 10% of general dentists see these same patients.61,62 e cooperative abilities of these patients may require some behavior guidance techniques best implemented by a pediatric dentist, but their dental needs may require expertise beyond the skill set of a pediatric dentist. e complexity of these cases is highly varied, and the need for transfer should be considered on an individual basis. Some special needs patients would transition quite well to an adult practice, whereas others may be better served if they remained in a pediatric-based practice their entire life. Often, coordination is needed between multiple dental as well as medical specialties to provide optimum care for these individuals. e key is that these patients have an established dental home through which such care can be coordinated. If a special needs patient is transferred from a pediatric to an adult-based practice, it is impera-tive that the continued coordination for optimum care be carried out by the newly established dental home.References1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 11. 2007;(248):1–92.2. Beck JD, Arbes SI Jr. Epidemiology of gingival and periodontal disease. In: Newman MG, Takei H, Klokkevold PR, et al, eds. Carranza’s Clinical Periodontology. 10th ed. St Louis: Saunders Elsevier; 2006:117–119.3. Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity in US children 1999-2014. Obesity J. 2016;24:1116–1123.4. Fungwe T, Guenther PM, Juan WJ, et al. e Quality of Children’s Diets in 2003-04 as Measured by the Healthy Eating Index 2005, Nutrition Insight 43. Washington, DC: Center for Nutrition Policy and Promotion, US Department of Agriculture; 2009 April.5. Piernas C, Popkin BM. Trends in snacking among US children. Health A. 2010;20(3):398–404.6. Food Surveys Research Group. Snacking Patterns of U.S. Adolescents; September, 2010, Dietary Data Brief No. 2.7. Fulkerson JA, Larson N, Horning M, et al. A review of associations between family or shared meal frequency and dietary and weight status outcomes across the lifespan. J Nutr Educ Behav. 2014;49(1):2–19.8. O’Dea JA. Consumption of nutritional supplements among adoles-cents: usage and perceived benets. Health Educ Res. 2003;18(1):98–107.9. Berger AJ, Alford K. Cardiac arrest in a young man following excess consumption of caeinated “energy drinks.” Med J Aust. 2003; 190(1):41–43.10. Nawrot P, Jordon S, Eastwood J, et al. Eects of caeine on human health. Food Addit Contam. 2003;20(1):1–30.11. Bonnett MH, Balkin TJ, Dinges DF, et al. e use of stimulants to modify performance during sleep losss: a review by the sleep deprivation CHAPTER 39 Prevention of Dental Disease 597 48. Bolinder G, de Faire U. Ambulatory 24-h blood pressure monitoring in healthy, middle-aged smokeless tobacco users, smokers, and nontobacco users. Am J Hypertens. 1998;11(10):1153–1163.49. Haddock CK, Weg MV, DeBon M, et al. Evidence that smokeless tobacco use is a gateway for smoking initiation in young adult males. Prev Med. 2001;32(3):262–267.50. Forrester K, Biglan A, Severson HH, et al. Predictors of smoking onset over two years. Nicotine Tob Res. 2007;9(12):1259–1267.51. Robertson PB, Walsh M, Greene J, et al. Periodontal eects associated with the use of smokeless tobacco. J Periodontol. 1990;61(7):438–443.52. Waterbor JW, Adams RM, Robinson JM, et al. Disparities between public health educational materials and the scientic evidence that smokeless tobacco use causes cancer. J Cancer Educ. 2004;19(1):17–28.53. Creath CJ, Cutter G, Bradley DH, et al. Oral leukoplakia and adolescent smokeless tobacco use. Oral Surg Oral Med Oral Pathol. 1991;72(1):35–41.54. Martin GC, Brown JP, Eier CW, et al. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc. 1999;130(7):945–954.55. Boetta P, Hecht S, Gray N, et al. Smokeless tobacco and cancer. Lancet. 2008;9(7):667–675.56. Severson HH, Akers L, Andrews JA, et al. Evaluating two self-help interventions for smokeless tobacco cessation. Addict Behav. 2000;25:465–470.57. American Academy of Pediatrics, American Academy of Family Physicians; American College of Physicians, et al. Supporting the health care transition from adolescents to adulthood in the medical home. Pediatrics. 2011;128(1):182–200.58. American Academy of Pediatric Dentistry. Guideline on adolescent oral health care. Pediatr Dent. 2016;38(special issue):155–162.59. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from pediatric to adult oral health care. J Am Dent Assoc. 2010;141:1351–1356.60. Seal P, Ireland M. Addressing transition to adult health care for adolescents with special health care needs. Pediatrics. 2005;115(6):1607–1612.61. Nowak AJ. Patients with special health care needs in pediatric dental practices. Pediatr Dent. 2002;24(3):227–228.62. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues aecting access to care for children with special health care needs. J Dent Educ. 2004;68(1):23–38.35. Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final Data for 2015. Hyattsville, MD: National Center for Health Statistics; 2017. National Vital Statistics Report, 66(1).36. American Academy of Pediatric Dentistry. Guideline on oral health care for the pregnant adolescent. Pediatr Dent. 2016;38(special issue):163–170.37. New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines; August 2006.38. US Department of Health and Human Services (USDHHS). e Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: USDHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promo-tion, Oce on Smoking and Health 62; 2004.39. Bergström J. Tobacco smoking and chronic destructive periodontal disease. J Odontol. 2004;92(1):1–8.40. Howlader N, Noone AM, Miller D, et al, eds. SEER Stat Fact Sheets: Oral Cavity and Pharynx, 1975–2014. Bethesda, MD: National Cancer Institute; 2004. http://seer.cancer.gov/statfacts/html/oral/cav.html. Accessed May 24, 2017.41. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Depart-ment of Health and Human Services, Public Health Service; 2000.42. Demers RY, Neale AV, Adams R, et al. e impact of physicians’ brief smoking cessation counseling: a MIRNET study. J Fam Pract. 1990;31(6):625–629.43. Johnson KC, Klesges LM, Somes GW, et al. Access of over-the-counter nicotine replacement therapy products to minors. Arch Pediatr Adolesc Med. 2004;158(3):212–216.44. Centers for Disease Control and Prevention. Smokeless tobacco use in the United States. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/use_us/index.htm. Accessed August 17, 2017.45. National Institute of Dental and Craniofacial Research. Oral cancer 5 year survival rates by race, gender, and stages of diagnosis. http://www.nidcr.nih.gov/datastatistics/. Accessed June 12, 2017.46. Coey SF, Lombardo TW. Eects of smokeless tobacco–related sensory and behavioral cues on urge, aect, and stress. Exp Clin Psychopharmacol. 1998;6(4):406–418.47. Benowitz NL. Pharmacology of nicotine: addiction and therapeutics. Annu Rev Pharmacol Toxicol. 1996;36:597–613. CHAPTER 39 Prevention of Dental Disease 597.e1 Case Study: Resin InltrationZafer C. CehreliDescription of Resin InltrationMasking of white spot lesions by resin inltration is a viable noninvasive treatment approach. In most cases the inltration technique may offer a standalone solution to arrest caries progression and to reestablish lost esthetics, whereas in more advanced cases, the same technique can be integrated with a restorative protocol to render demineralized enamel a suitablesubstrateforresinbonding.Thiscasedemonstratesatypicalexample of white spot lesions in a 9-year-old patient with some enamel loss duetobadoralhygiene(Fig.E39.1A).Theextentofdemineralizationwasnotsuitable for a preventive approach using remineralizing agents, while restoration of the lesions with conventional acid-etch resin composite would leadtounnecessarytissueloss.Thusacoapplicationofresininltrationandcomposite restoration was determined to be the most appropriate treatment approach.Theresininltrationwasusedtostrengthenthedemineralizedenamel structure and to mask the white spots while providing a suitable bonding interface for the topping composite resin in the cervical region. Followingisolationofaffectedincisorswithaheavy-gaugerubberdamandossties(seeFig.E39.1B),theteethwerecleanedthoroughlywithpumiceinaslow-speedpolishingcup,rinsed,anddried.Thehydrochloricacidgel(Icon-Etch)wasappliedontothelesionsfor2minutes(seeFig.E39.1C).Theacidwasrinsedoffwithair-watersprayfor30secondsandthendriedwithoil-freeairfor10seconds.Theabsoluteethanolsolution(Icon-Dry)wasapplied on the desiccated tooth surface to check whether the whitish-opaquecolorationontheetchedenameldiminished(seeFig.E39.1D).Becausethiswasnotobservedclinically,twoadditionalsetsofetching,drying, and ethanol application were performed until a complete color match was obtained. After the third round of ethanol application, the enamel surface was dried meticulously, and the Icon inltrant was applied on the enamel surface for 3 minutes in the absence of direct operating light so as topreventprematurephotopolymerizationoftheresin(Fig.E39.2A).Followingremovalofexcessmaterialwithacottongauze,theresininltrantwasphotopolymerizedfor40seconds(seeFig.E39.2B).Theinltrantapplication was repeated for 1 minute and light-cured. A fourth-generation bonding agent was applied on the inltrated surface to enhance adhesion (seeFig.E39.2C),andabody-shadecompositewasappliedonthecervicalregionoftheteethtorestorethelostenamelcontours(seeFig.E39.2C).Thecompositeresinwasnishedusingpolishingdisksandwheels.Thiscombined noninvasive treatment approach provided strengthening of demineralized enamel, reestablishment of lost esthetics, and adhesion of a topping composite layer without the need for retentive cavity preparation (seeFig.E39.2D).Questions1. WhatisthefunctionofIcon-Dry(absoluteethanol)intheinltrationprocedure?Answer: Icon-Dry provides a preview of the nal result of inltration by wetting desiccated enamel to mask whitish-opaque discoloration.2. Whymighttheresininltrationtechniquebeusefulpriortoplacingabonded restoration?Answer: It can render demineralized enamel a suitable substrate for resin bonding.3. What type of acid is used in the resin inltration technique?Answer: Hydrochloric acid in a gel formulation.ABCD• Figure E39.1 (A) Preoperative view showing the extent of demin-eralization due to bad oral hygiene. Note that the enamel layer has been lost in some regions. (B) The teeth should be isolated meticu-lously so as to prevent leakage of repeated applications of hydrochloric acid. The lesions appear whiter under isolation, owing to dehydration. (C) Application of hydrochloric acid gel (Icon-Etch). (D) Application of absolute ethanol (Icon-Dry) to evaluate color match and to remove residual water within the lesions. Continued 597.e2 Part 5 AdolescenceABCD• Figure E39.2 (A) Application of the Icon inltrant. (B) The resin is photopolymerized 40 seconds for each tooth. The inltrant application is then repeated. (C) The missing contours are restored with a body shade composite resin placed after application of a bonding agent. (D) Postoperative view, showing ultraconservative management of the demineralization lesions. 598 40 Restorative Dentistry for the AdolescentELIZABETH VELANCHAPTER OUTLINEFundamentals of Material SelectionFundamentals of Clinical TechniqueRestorations for Fractured Anterior TeethClinical Technique: Tooth FragmentClinical Technique: Class IV RestorationRestoration of DiastemasClinical TechniqueRestoration of Discolored TeethTreatment of Hypoplastic Spots and White Spot LesionsVeneersVital BleachingRestorations for Posterior TeethFundamentals of Material SelectionHypoplastic MolarRampant Cariesetch-and-rinse or self-etch systems. Etch-and-rinse adhesive systems, although more technique sensitive, have been shown in laboratory studies to have higher bond strength compared with the self-etch systems.2 e self-etch systems, in addition to being less technique sensitive, may reduce postoperative sensitivity by leaving behind residue that blocks outward uid ow from dentin tubules.3 ere continues to be controversy and limited clinical studies to identify which adhesive system improves the longevity of composite resin restorations.2 To optimize the longevity of the restoration, the provider should follow the manufacturer’s instructions and conrm the adhesive system is compatible with the composite resin.4 e selection of composite resin restorations can be confusing because a variety of products are available with slightly dierent physical properties.5,6 Essentially there are three types of composite resins that can be used: microlled, hybrid, and nanolled. Nanolled resins have physical properties superior to those of microlls but slightly inferior to hybrids.7 e mechanical and physical properties of hybrid composite resins are superior to those of microlled resins because they contain a higher proportion of ller particles. Hybrid resins have traditionally been chosen as a universal restorative material because they can be used in most clinical situations. Microlled resins are primarily indicated when esthetic restorations are required; because of their particle size, microlled resins can be polished to an enamel-like luster with more ease and in less time than hybrid resins.The polymerization of light-activated composite resins is accomplished by using an intense blue light with a peak wavelength of approximately 450 to 470 nm, which corresponds to the absorp-tion peak of camphoroquinone (CQ), the most popular photoinitia-tor.8 A typical light-curing polymerization unit uses light-emitting diodes (LEDs) to eciently produce blue light (Fig. 40.2), although the traditional gun-style units that contain a halogen bulb and cooling fan are still available (see Chapter 21 for a discussion of curing lights).8 No matter which light is used, light intensity should be periodically checked (via a radiometer) so that a minimal output of 350 mW/cm2 can be maintained (Fig. 40.3).8 Eye protection is important when using the curing lights, because direct viewing of the light is detrimental to vision.9 In the absence of protective amber lters, one should avoid looking directly at the light.Fundamentals of Clinical TechniqueShade selection is the rst step in achieving an esthetically pleasing restoration. e teeth to be matched should be cleaned with a Caring for the adolescent dental patient is a rewarding experience. e use of dental techniques and materials to help young people obtain a healthy and beautiful smile is a clinical challenge requiring knowledge, attention to detail, and skill. In return for their eorts, dentists receive the satisfaction of seeing a young person develop a healthy self-image that can have a positive eect on his or her maturation into adulthood.Fundamentals of Material Selectione choice of materials is an important consideration for optimizing adolescent dental restorations. When considering which material to choose for a restoration, it is essential to evaluate the tooth to be restored, the patient’s caries risk, the location of the restoration, and the forces to which the restoration will be subjected.Composite resin restorations are a popular choice because they are esthetically pleasing, preserve tooth structure, and contain no mercury. e clinical success of composite resin restoration relies on the adhesive system that provides a durable bond of composite resin to dentin and enamel, eectively sealing restoration margins and microleakage.1 To achieve this, a contemporary adhesive system should be used (Fig. 40.1). Contemporary adhesive systems include CHAPTER 40 Restorative Dentistry for the Adolescent 599 To overcome some of the shade-matching pitfalls, many clinicians allow the patient to choose between two similar shades. Another way to verify the shade is to place a small portion of composite resin on the tooth surface, polymerize it, observe the appropriateness of that shade, and then remove it with a hand instrument. It should be noted that one should not etch the tooth before doing this or removal will be dicult.It is important to maintain an uncontaminated eld during the insertion of composite resins. e most reliable and cost-eective way to control moisture is through the use of a well-adapted rubber dam. An alternative product is an intraoral vacuum system. An rubber prophylaxis cup and our of pumice. Tooth dehydration should be prevented because it leads to color change. Moistened shade tabs should be held near the tooth to be matched, only in ambient light or indirect sunlight. One should not use the high-intensity operatory light when selecting shades.Composite resins come in a variety of shades, which are usually keyed to the VITA shade guide. Unfortunately, a perfect color match between the composite resins and the VITA guide is uncom-mon, and shades among brands are variable.10 In recent years the range of shades has been increased to match the shades of teeth that have been whitened or bleached.• Figure 40.1 Representative selection of dentin-enamel adhesive products. ([A and B] Courtesy Kerr Corp., Orange, CA; [C and D] Courtesy Bisco, Inc., Schaumburg, IL; [E] Courtesy 3M ESPE, St. Paul, MN; [F] Courtesy DENTSPLY CAULK, Milford, DE; [G] Courtesy Pentron Clinical, Wallingford, CT; [H] Courtesy Shofu Dental Corp., San Marcos, CA.) 600 Part 5 Adolescenceexample is the Isolite system (Isolite Systems, Santa Barbara, CA), which has a exible plastic mouthpiece that provides retraction of the soft tissues, a bite block, and constant suction. In limited studies the Isolite system has similar reduction in spatter and humidity levels as a rubber dam (Fig. 40.4).11,12 Another approach to maintaining a dry eld is to use a commercially available lip and cheek retractor (Fig. 40.5). is plastic device, when used with gauze sponges, provides excellent access and good eld control.e use of a base or liner to protect pulp tissue in deep prepara-tions is generally believed to be benecial. A glass ionomer liner may be used in deep areas of a cavity preparation that is thought to be within 0.5 to 1.0 mm of pulpal tissue (Fig. 40.6). e liner provides chemical adherence to tooth structure and slow release of uoride.13After adhesive bonding, the photopolymerized composite should be inserted in layers no thicker than recommended by the manu-facturer, followed by curing the composite according to the manu-facturer’s instructions. Appropriately placed layers and adequate time for light exposure help to ensure maximum polymerization and minimize marginal gaps caused by shrinkage.14 In an eort to mimic the translucency of enamel and the opacity of dentin, manufacturers have produced materials with a variety of opacities. ese materials should be placed in increments in which the more opaque materials replace dentin and the more translucent materials replace enamel to produce restorations with similar optical properties to tooth structure.ABC• Figure 40.2 (A–C) Typical dental composite resin light-curing units. ([A] Courtesy Dentlight LLC, Plano, TX; [B] Courtesy SDI, Bayswater, Australia; [C] Courtesy Ultradent Products, Inc., South Jordan, UT.)• Figure 40.3 Light-curing unit showing power output via a radiometer. • Figure 40.4 An example of an intraoral vacuum system. AB• Figure 40.5 (A and B) Isolation of teeth may be enhanced through the use of a lip-retracting device. ([A] Courtesy Practicon Dental, Greenville, NC.) CHAPTER 40 Restorative Dentistry for the Adolescent 601 place the fragment in saline, Hank’s Balanced Solution, or milk while in transit to the dental oce. When there is minimal loss of tooth structure, the fragment can be bonded by etching the fragment and tooth and application of a dental adhesive to the fragment and tooth, followed by placement of highly lled owable composite resin to the fragment and tooth. e fragment is then repositioned and the proximal contacts ossed or a matrix is placed followed by light curing. In this situation the adhesive and owable composite resin should be light cured together. When there is moderate loss of tooth structure, resin-based composite should be used in lieu of owable resin. In this situation the adhesive should be cured separately. Following a direct pulp cap or partial pulpotomy, the internal section of the fragment will need to be modied to allow the best t. In either scenario, after the fragment is bonded, a shallow double chamber should be prepared along the fracture line and restored with composite resin. is procedure will add strength to the rebonding and minimize the risk for stain at the fracture line.15,18 Families should be cautioned that the longevity of the reattachment is unknown because few clinical studies have evaluated this type of repair.15 One long-term multicentered clinical study revealed that only 25% of 334 rebonded fragments were retained 7 years after bonding.19Some clinicians consider the class IV composite resin restoration an interim restoration for adolescents until a more permanent ceramic crown can be fabricated.20 However, with modern materials and techniques, the strength and color stability of composite resin class IV restorations are such that they can be considered nal restorations that will provide relatively long service.21 For early adolescents with severely fractured anterior teeth or caries, these restorations can provide years of service, allowing the teeth to mature so that pulpal injury during crown preparation is less likely.Clinical Technique: Class IV RestorationAdhesive dentistry has lessened the need for extensive mechanical retentive features in class IV restorations. e primary retentive feature is a beveled enamel cavosurface margin of a minimum of 1.0 to 2.0 mm in length (Fig. 40.7). Beveling allows maximal bond strength and minimizes leakage by exposing the ends of the enamel rods to etching. Because anterior restorations are sometimes subject to strong shearing forces that can be greater than the bond strength of the restoration to the tooth, features such as grooves or retentive points may be used to gain additional retentive strength.After administering anesthesia, followed by isolation, the bevel is prepared with a high-speed rotary instrument. Caries is removed if indicated, and a base or liner may be applied to the exposed dentin. Conditioning of the tooth is achieved in accordance with the adhesive system of choice, with adherence to the manufacturer’s directions. A wedged celluloid matrix strip can be used to prevent etching and bonding an adjacent tooth. In addition, anterior matrix systems are available to optimize curvature, anatomic form, and contacts when placing direct composite anterior restorations, such as the Garrison Anterior Matrix System or the BioClear Matrix system.22 After placing, nishing, and polishing the restoration, carefully check the restoration for interferences in all excursive movements (Fig. 40.8). Occlusal stresses on the restoration should be minimized.Restoration of DiastemasMany adolescents consider spaces between anterior teeth (diastemas) unattractive.23 Historically the only restorative treatment to ll Plastic or metal instruments are useful for material placement and contouring. Fine sable or camel hair brushes allow the easy contouring and blending of composite resin into the proper form. To prevent composite resin from adhering to the brushes and instruments, they should be lightly touched to the composite resin with a rapid dabbing motion.After the polymerization process, the contouring and nishing of the restoration is accomplished with carbide nishing burs, ultrane diamonds, or nishing disks. Fine-pointed burs are helpful for accessing contour areas that are dicult to reach, such as embrasures. Rounded burs may be used on concave surfaces, and disks may be used on at or convex surfaces. After contouring and nishing, the restoration should be polished with a series of polishing disks or rubber-abrasive instruments. e nal nish and polish of proximal areas are best done with abrasive strips.Restorations for Fractured Anterior TeethTrauma to the anterior dentition can often result in tooth fractures involving the enamel; enamel and dentin; and enamel, dentin, and pulp. Injuries such as these can cause pulpal as well as esthetic concerns and should be carefully evaluated by clinical and radio-graphic means. Clinical ndings may range from minimal thermal and pressure sensitivity to the acute distress of a pulp exposure. Radiographs are indicated in diagnosing the presence or absence of root fractures. When indicated, treatment must begin with pulpal therapy and whenever possible preservation of vital pulp tissue. (See Chapter 35 for a discussion of trauma to permanent incisors.)Clinical Technique: Tooth FragmentIf the tooth fragment is available, is relatively intact, and adapts well to the remaining tooth with no encroachment to the biologic width, the fragment can be bonded to the tooth.15 is technique allows immediate satisfaction by restoring tooth form and function with excellent esthetics and low cost.15–18 For the best results, the fragment should be hydrated. Families should be counseled to • Figure 40.6 A light-curable glass ionomer liner. (Courtesy 3M ESPE, St. Paul, MN.) 602 Part 5 AdolescenceWhen an adolescent patient wants a diastema closure, whether the spaces are the result of natural development or postorthodontic discrepancies, careful evaluation and planning are necessary. If the patient is nearing completion of orthodontic therapy but is still undergoing treatment, the restorative dentist may advise the orthodontist about the optimal arrangement of anterior teeth for diastema closure. e orthodontist may then complete active these spaces has been the fabrication of crowns. Improved composite resin materials and acid-etching technology now allow restoration of diastemas with a method that is nondestructive, reversible, and relatively inexpensive. However, patients should be forewarned that fracture and staining are possible drawbacks of composite resin diastema closure and that replacement is likely to be needed after 5 to 10 years.CBA• Figure 40.7 (A) The incisal edges of the maxillary incisors were fractured as the result of an accident; a beveled enamel cavosurface margin is placed as a retentive feature. (B) Enamel beveled surfaces of teeth shown in (A). (C) Composite resin restorations of fractured teeth shown in (A) and (B). AB• Figure 40.8 (A) The incisal edges of the mandibular incisors were fractured as the result of an accident. (B) Composite resin restorations (Filtek Restorative Material, 3M ESPE) of fractured teeth shown in (A). CHAPTER 40 Restorative Dentistry for the Adolescent 603 Clinical TechniqueAfter cleaning, shade selection, and isolation, treatment should begin one tooth at a time. e space to be eliminated should be carefully measured via a periodontal probe, calipers, or Boley gauge because after one tooth is restored in an eort to eliminate half the space, it is usually dicult to determine how much of the space has actually been restored. e entire labial surface of the tooth should be etched and bonding agent applied because most of the labial surface will be covered with a thin layer of composite resin to allow a subtle color transition from composite resin to tooth. In addition, covering most of the labial surface allows the use of visual illusions that cause the tooth to look narrower or longer, as described previously.Composite resin (preferably a resin that is viscous and opaque) should be applied, beginning at the gingival margin of the inter-proximal area. Using instruments and brushes, one should shape the material to allow a smooth-owing gingival embrasure without creating an overhanging ledge. e entire proximal surface, as well as the labial surface, can be built up and polymerized at once or incrementally. After this buildup, one should nish the proximal area to the proper contour and polish it. Next, the second tooth is restored similarly. A celluloid matrix and wedge are usually inserted after the gingival increment is polymerized to retain the composite resin and to prevent the restorations from bonding together. Upon completion, the matrix is removed, and contouring and polishing are completed (Fig. 40.9).Anterior teeth that are unusually small, such as peg lateral incisors, may be restored in the same manner as teeth requiring both mesial and distal diastema closure restorations. Again, careful treatment and place the patient into a retention phase before closing the diastema. e use of diagnostic study casts is recommended for evaluation and treatment planning. A diagnostic waxing of the proposed restorative treatment can aid both the patient and the clinician in envisioning the outcome.Important pretreatment considerations include the size and location of the space or spaces and the size (length and width) and shape of the teeth to be restored. Normally, composite resin is added to the teeth on both sides of the space. For patients who are undergoing orthodontic treatment, one should determine if the remaining space would best be left in one place, such as the midline between the maxillary central incisors, or distributed over proximal areas throughout the anterior segment. One must also consider the length and width of the teeth to be restored. If the width becomes greater than the length, those teeth appear more square, leading to an unattractive outcome that may be as displeasing as the original diastema. Because of occlusal patterns and chewing stresses, teeth usually cannot be lengthened with composite resin without creating a high probability of resin fracture. However, light reections can be used to create the illusion of a longer and narrower tooth when the composite resin is extended to cover most or the entire facial surface. To create the illusion of a narrower tooth, one should form mesial and distal line angles in composite resin that are positioned slightly nearer the middle of the tooth and add denite vertical anatomic highlights (developmental depressions). For some patients the best treat-ment is partial diastema closure, in which an existing space is made smaller by enlarging the teeth with composite resin but not making the teeth so large that they become esthetically displeasing.A BCD• Figure 40.9 (A) A preoperative view of a maxillary midline diastema, which the patient found unat-tractive. (B) The initial increment of composite resin being contoured with a sable brush before poly-merization. (C) Contouring and removing excess composite following buildup of the second tooth. (D) A postoperative view of the completed treatment. 604 Part 5 Adolescence40.11).27 Microabrasion is sometimes used in combination with vital bleaching.28VeneersComposite resin or porcelain veneers provide a treatment option for patients who have moderate to severe staining of one or more teeth. Patients are most concerned about the appearance of their maxillary teeth as they are more visible in speaking and smiling. In addition, mandibular teeth are often less likely to be successfully veneered because of limited space (insucient horizontal overlap) and unfavorable forces. For veneer treatment to be successful, the patient must have excellent periodontal health because the placement of veneers will result in contours and margins that require good treatment planning is advised to determine whether the restorations should be done only on the smaller tooth or on both the small and adjacent teeth for maximal cosmetic benet. Preoperative diagnosis is necessary to determine whether lengthening is feasible. One should forewarn patients that the possibility of fracturing increases as length increases. In situations where fracturing is a concern, a hybrid resin should be used as a substrate and a microlled resin placed on the surface. is technique increases the strength and esthetic outcome of the restoration.Restoration of Discolored TeethAlthough there are many causes of preeruptive tooth discoloration, the most common discolorations result from trauma, enamel hypoplasia (often caused by uorosis), and the administration of certain types of antibiotics during childhood. ese lesions vary from small white or yellowish ecking of the surface enamel, called enamel dysmineralization,24 to the deep intrinsic bluish gray color often visible in tetracycline staining.Treatment of Hypoplastic Spots and White Spot LesionsDiscrete hypoplastic white or yellow-brown spots can be improved by the etch-bleach-seal technique, resin inltration, vital bleaching (which is described later in this chapter), enamel microabrasion, and/or by making shallow saucer-shaped preparations in enamel to remove the intensely colored tooth structure and then restoring the enamel with composite resin. e etch-bleach-seal technique is the least invasive of all approaches.25 e aected teeth are cleaned with pumice, isolated with a rubber dam, etched for 60 seconds with 37% phosphoric acid, and rinsed. Sodium hypochlorite (5%) is applied and allowed to evaporate. e application process is repeated for 5 to 10 minutes. If improvement is not apparent, the application can continue for 15 to 20 minutes. Some teeth may need to be treated over several appointments. After satisfactory results are achieved, the teeth are sealed with a highly penetrating clear resin.25 Resin inltration (Icon, DMG-America, Englewood, NJ) has also been shown to signicantly improve the clinical appearance of white spot lesions (Fig. 40.10).26 Resin inltration is discussed in more detail later in this chapter. Microabrasion removes enamel but does not necessitate placement of a restoration. e technique for enamel microabrasion involves application of an acidic abrasive paste by a reduced-speed dental handpiece (Fig. AB• Figure 40.10 (A) Preoperatively the maxillary left central incisor is affected with enamel hypoplasia that presents as a large, white lesion. (B) Postoperatively the esthetics of the tooth is greatly improved after HCl acid etching and resin inltration. (Courtesy Zafer Cehreli.)AB• Figure 40.11 (A) Preoperative view of maxillary incisors with white and brown enamel dysmineralization defects. (B) After enamel microabrasion and home bleaching. (Courtesy Ultradent Products, Inc., South Jordan, UT.) CHAPTER 40 Restorative Dentistry for the Adolescent 605 must extend far enough to cover the stained enamel suciently to improve the color. For better periodontal health, the nish line should be kept supragingival whenever possible. Following the preparation, an accurate impression of the teeth should be made with an elastomeric impression material such as vinyl polysiloxane or polyether.At the second appointment, one should isolate the teeth and clean them with pumice. After evaluating (using a try-in paste to help hold the veneers in place) and adjusting the veneers, they should be cleaned with the etching gel and silanated according to the manufacturer’s recommendations. e preparations should be acid etched individually or in pairs and the veneers bonded in place, beginning with the central incisors. Celluloid matrices help to protect adjacent teeth. Photopolymerized or dual-polymerized resins of moderate viscosity are preferred for bonding. Excess resin should be removed from margins with brushes before polymerization. Adequate polymerization time (40 to 60 seconds in each area) should be used because the veneers will shield some light transmis-sion. Finishing and polishing are usually necessary only at the margins and may be done with abrasive strips and rubber cups (Fig. 40.15).Direct VeneersVeneers made of light-polymerized composite resins can be fabricated directly in the mouth. Compared with the indirect type, direct • Figure 40.13 Cross-sectional view of the steps in diamond instrument placement needed for preparing the facial surface of a maxillary anterior tooth. • Figure 40.14 Incisal view of veneer preparations. ABC• Figure 40.15 (A) Preoperative view of esthetically unpleasing maxillary anterior teeth. (B) Central incisors prepared for porcelain veneers. (C) Porcelain veneers in place. 0.3 mm0.5 mm0.75 mm1.0 mm0.5 mmAB• Figure 40.12 Cross-sectional views of a laboratory-processed veneer of ideal thickness without incisal coverage (A) and a veneer of greater thickness with incisal coverage (B). oral hygiene to maintain gingival health. In addition, patients should be warned that biting on hard objects, such as raw carrots or pencils, may dislodge or break veneers.Laboratory-Fabricated Veneerse indirect veneer technique has the advantage of requiring less total chair time because the veneers are fabricated in the laboratory. Excellent esthetically pleasing contours can be achieved with porcelain. Disadvantages include the necessity of two appointments, laboratory expense, and the possibility of creating an excess bulk of restorative material.e indirect technique usually requires the removal of some enamel (ideally 0.3 to 0.5 mm, but occasionally more in severely stained teeth) from the facial surface to provide space for the veneer (Fig. 40.12). Tooth preparation is best accomplished with a medium-grit diamond rotary instrument (Fig. 40.13), with the goal of producing a long chamfer nish line throughout the surfaces to be covered. is preparation extends to the proximal surfaces to include the contact areas (Fig. 40.14). Gingivally, the preparation 606 Part 5 AdolescenceCustom tray or over-the-counter vital bleaching is an at-home treatment. is method of vital bleaching uses a milder peroxide solution (usually 10% carbamide peroxide) that the patient applies and wears outside the dental oce, often at night during sleep, for approximately 2 to 3 weeks. At-home bleaching appears to work as well as power bleaching and causes less sensitivity. Concerns were initially raised about the potentially hazardous soft tissue eects of applying peroxide solutions in this manner, but long-term studies of the safety and ecacy of this approach are demonstrating no harmful eects.31 Vital bleaching also appears to cause limited damage to existing restorations, although these may no longer be a color match after the teeth have been whitened.32 Over-the-counter bleaching strips can achieve similar whitening eects but take longer to accomplish.29Restorations for Posterior TeethFundamentals of Material Selectionere are numerous materials to select from when restoring the young posterior permanent dentition. In the selection process the dentist should consider the size of the caries/defect, the occlusal forces expected to load on the restoration, the patient’s caries risk, the ability to isolate the tooth, and the patients’ preference.Resin inltration (Icon, DMG-America, Englewood, NJ) is a minimally invasive technique used to restore noncavitated proximal caries lesions that radiographically extend from the inner enamel to the outer third of dentin. Studies have suggested this technique is more eective at reducing proximal caries progression compared with noninvasive measures such as uoride varnish and ossing.33–35 is technique requires a dry working eld and care to protect gingival tissue, such as isolation with a rubber dam. For proximal lesions the teeth must be separated (approximately 50 µm) with a wedge, followed by etching with hydrochloric acid, rinsed for 30 seconds, and then dried to desiccation. e hydrochloric acid removes the hard remineralized outer layer of the lesion, allowing the penetration of the low viscosity resin into the porous enamel. It takes 3 minutes for the resin to penetrate the lesion, excess material is then removed, and the area is light cured from all sides for at least 40 seconds in total. e patient must be followed for caries progression with yearly radiographs; thus preference for this care should be for patients who have established a dental home. Because the lesions remain radiolucent in radiographs, patients should be counseled on the importance of notifying other dental providers of the treatment when they leave the practice.Composite resin restorations are a popular choice for most patients due to their esthetic nature. However, composite resin restorations in the posterior dentition have several disadvantages to consider. e lifespan of a posterior composite resin restoration is inferior to that of amalgam restorations.36 Patients with higher caries risk and multisurface restorations are at increased risk for restoration failure.37 For the clinician the technique for placing composite restorations is more sensitive and requires longer chair time. On the other hand, composite resin restorations preserve tooth structure and manufactures have spent a considerable amount of time improving the material properties of composite. For the most consistent outcome, posterior composite resin restorations should be limited to restorations of appropriate size and careful attention paid to follow the manufacturer’s instructions.Composite resins are sensitive to moisture, and care should be taken to provide adequate isolation. After the preparation is completed, use of a sectional matrix system will provide anatomically veneers oer the advantages of improved marginal adaptation, placement in one appointment, greater operator control, and no laboratory fee. e disadvantages are that direct veneers require more time, greater skill, and more patience on the part of the clini-cian. In addition, outcomes are more dicult to predict, and composite resin is more susceptible to staining than porcelain.e clinical direct technique may be performed with or without any enamel removal. Darkly stained teeth usually require some enamel removal because more composite resin is needed to mask the underlying enamel. e teeth are then pumiced and individually etched, and a bonding agent is applied. Again, celluloid matrices are used between adjacent teeth. Opaquing agents may then be painted on to cover more intensely stained areas or entire surfaces. For the best appearance, opaquing agents should be used minimally and with care. When dark banding is present, an alternative approach is to remove the band with a round bur and then replace the tooth structure with an opaque hybrid composite resin or resin-modied glass ionomer. Next, the composite resin should be applied in a layer 1.0 to 1.5 mm thick and contoured with brushes. e gingival third of the restoration should usually be an opaque yellow shade, and the remaining enamel should be covered with opaque gray or universal composite, overlapping and blending the shades to create a natural-looking, gentle color transition. In many situations a nonopaque shade can be used on the incisal one-fourth to allow a natural, translucent appearance (Fig. 40.16). After all composite resin has been added to a single tooth and contouring with brushes is complete, the material should be polymerized as recommended by the manufacturer. Finishing and polishing are best done with burs and disks, as described previously.Vital BleachingVital bleaching techniques involve the application of peroxide solutions to increase the value (whiteness) of teeth that are unusually dark. Peroxide bleaching methods appear to work best on teeth that are mildly discolored, predominantly yellow, and from which the discoloration originates in enamel rather than dentin. e basic methods for vital bleaching are: in oce power bleaching, custom-fabricated tray bleaching, and over-the-counter bleaching strips.29Power bleaching is an in-oce procedure in which a concentrated hydrogen peroxide solution is applied to rubber dam–isolated teeth while heating the teeth, usually with an electric lamp or laser.30 is method of bleaching may require numerous oce visits and often causes temporary tooth sensitivity. Typically, patients who have had this treatment require periodic retreatment to maintain the desired color.YellowopaqueUniversalopaqueUniversalnonopaque• Figure 40.16 The use of overlapping shades of composite resin to create a natural-looking directly placed veneer. CHAPTER 40 Restorative Dentistry for the Adolescent 607 Amalgam is not dependent on absolute isolation, but moisture needs to be controlled. Care should be taken to isolate with either a rubber dam or cotton products. Amalgam is a brittle material in thin sections; thus the cavity design requires more bulk of material to be placed. Amalgam does not bind to the tooth surface, and undercuts/mechanical retention must be added to the cavity design for amalgam to be a stable restoration.39 In addition, to prevent enamel fracture, all unsupported enamel should be removed while retaining a 90-degree cavosurface angle.Permanent tooth stainless steel crowns (SSCs) may be indicated as an interim restoration for structurally compromised molars for the following conditions: the tooth is partially erupted, orthodontic treatment is indicated to nalize tooth placement in the arch, teeth with severe developmental defects, and when nancial considerations are of concern.40 ere is limited literature reecting the longevity of permanent SSCs. A recent study suggests a success rate of 88% over a 4-year time period.41Signicantly more chair time is indicated for the placement of a permanent tooth SSC compared with a primary tooth SSC. e nal preparation is similar to that expected for a cast crown but with less tooth reduction. e occlusal reduction is 1.5 to 2 mm; the proximal walls are left in a slightly tapered position with a smooth feather-edge placed just below the level of the free gingival tissue. Unlike primary SSCs, permanent SSCs cannot be left in hyperocclusion and cannot be overextended into the gingival tissues, because they are more prone to periodontal issues. Hence SSCs for permanent teeth often require trimming. After crimping the SSC, the margins should be thinned and polished to a high shine. A bitewing radiograph is recommended to evaluate the mesial and distal marginal t prior to cementation with glass ionomer cement (Fig. 40.18B).40Hypoplastic MolarFor the adolescent the second permanent molars may erupt with hypoplastic defects. ese hypoplastic molars vary greatly in the severity of the defect, from slightly discolored to abnormal correct tight contacts at the height of contour (Fig. 40.17).38 With the arrival of multiple adhesive systems, care should be taken to conrm that the adhesive system used is appropriate for the clinical situation and the composite is compatible with the adhesive system (see Chapter 21 for a discussion of dental materials). e clinician should carefully follow the manufacturer’s recommendations for incremental placement, light-curing, and polishing the composite of their choice.Amalgam has been successfully used for restoring teeth for the past 150 years. However, with the demand for esthetically pleasing materials and concern over health-related mercury issues, it has been decreasing in popularity despite evidence that the longevity of amalgam restorations is longer than composite resins.36 A dis-advantage to amalgam restorations is the required cavity preparation, because it causes greater loss of tooth structure (depending on size of the lesion) compared with composite resin restorations. For large lesions, dicult-to-isolate areas in nonesthetic zones, and high caries risk patients, amalgam remains an excellent material choice.BA• Figure 40.18 (A) A hypoplastic 6-year molar with continued sensitivity despite composite restoration treatment. (B) Bitewing radiograph of stainless steel crowns prior to cementation to conrm mesial and distal width of tooth shown in (A). • Figure 40.17 An example of available sectional matrix systems. 608 Part 5 Adolescenceglass ionomers are well suited for interim caries control therapy. After urgent needs are met, careful treatment considerations for each sextant are planned with the concept that some teeth will require interim restorations to reestablish occlusion and function until denitive restorations can be placed.References1. Nedeljkovic I, Teughels W, De Munck J, et al. Is secondary caries with composites a material-based problem? Dent Mater. 2015;31(11):e247–e277.2. Masarwa N, Mohamed A, Abou-Rabii I, et al. Longevity of self-etch dentin bonding adhesives compared to etch-and-rinse dentin bonding adhesives: a systematic review. J Evid Based Dent Pract. 2016;16(2):96–106.3. Hashimoto M, Ito S, Tay FR, et al. Fluid movement across the resin-dentin interface during and after bonding. J Dent Res. 2004;83(11):843–848.4. Soldo M, Simeon P, Matijević J, et al. Marginal leakage of class V cavities restored with silorane-based and methacrylate-based resin systems. Dent Mater J. 2013;32(5):853–858.5. Puckett AD, Fitchie JG, Kirk PC, et al. Direct composite restorative materials. Dent Clin North Am. 2007;51(3):659–675, vii.6. Cramer NB, Stansbury JW, Bowman CN. Recent advances and developments in composite dental restorative materials. J Dent Res. 2011;90(4):402–416.7. da Silva EM, Poskus LT, Guimarães JG. Inuence of light-polymerization modes on the degree of conversion and mechanical properties of resin composites: a comparative analysis between a hybrid and a nanolled composite. Oper Dent. 2008;33(3): 287–293.8. Shortall AC, Price RB, MacKenzie L, et al. Guidelines for the selection, use, and maintenance of LED light-curing units—Part 1. Br Dent J. 2016;221(8):453–460.9. Shortall AC, Price RB, MacKenzie L, et al. Guidelines for the selection, use, and maintenance of LED light-curing units—Part II. Br Dent J. 2016;221(9):551–554.10. Barutcigil C, Harorli OT, Yildiz M, et al. e color dierences of direct esthetic restorative materials after setting and compared with a shade guide. J Am Dent Assoc. 2011;142(6):658–665.11. Dahlke WO, Cottam MR, Herring MC, et al. Evaluation of the spatter-reduction eectiveness of two dry-eld isolation techniques. J Am Dent Assoc. 2012;143(11):1199–1204.morphology and/or absence of tooth structure. ese teeth are prone to cavities, breakdown, and sensitivity. Restoration of these teeth is dependent on the severity of the defect. When possible, restoring the defect with glass ionomer cement or composite is ideal to minimize the removal of remaining tooth structure (see Fig. 40.18A). When using composite, the margins should be placed on nonaected enamel because the mechanical bond to aected enamel may fail. When unable to place a resin restoration on unaected enamel or when unable to obtain ideal restorative conditions (moist environment), a glass ionomer cement is a reason-able option because the chemical bond will still occur on hard but aected enamel. If the tooth continues to be sensitive or the defect is moderate to severe, a permanent tooth SSC can be used as an interim restoration until a cast crown can be placed (see Fig. 40.18B).42 If morphologically acceptable third molars are present radiographically and the long-term prognoses of the aected teeth are poor, extractions may be considered.Rampant CariesRampant caries has been dened as the “suddenly appearing, widespread, rapidly burrowing type of caries, resulting in early involvement of the pulp and aecting those teeth usually regarded as immune to ordinary decay” (Fig. 40.19).43 e identication of this disease process in the adolescent can be overwhelming for the child, family, and dentist. e underlying etiology of the disease must be identied. e clinician must determine if the disease process is rampant caries (as dened previously) or long-term dental neglect. For the adolescent a relationship built on trust with his or her dentist will be extremely valuable in identifying the etiology of the disease, especially if the disease is associated with drug use.While the etiology is being identied and corrected, the progres-sion of the disease should be minimized. Oral health education, diet modication, and the addition of adjunct uoride products should be initiated. e use of silver diamine uoride should be discussed to arrest the caries process (at least in nonesthetic zones). Because the nancial burden of rampant caries can be substantial, the family should be presented with multiple restorative treatment options. Teeth that are causing pain and localized areas of infections should be addressed immediately. Resin-modied and conventional • Figure 40.19 Radiographs of a 16-year-old with rampant caries. CHAPTER 40 Restorative Dentistry for the Adolescent 609 29. Auschill TM, Hellwig E, Schmidale S, et al. Ecacy, side-eects and patients’ acceptance of dierent bleaching techniques (OTC, in-oce, at-home). Oper Dent. 2005;30(2):156–163.30. Lo Giudice R, Pantaleo G, Lizio A, et al. Clinical and spectropho-tometric evaluation of LED and laser activated teeth bleaching. Open Dent J. 2016;10:242–250.31. Li Y. e safety of peroxide-containing at-home tooth whiteners. Compend Contin Educ Dent. 2003;24(4A):384–389.32. Attin T, Hannig C, Wiegand A, et al. Eect of bleaching on restorative materials and restorations—a systematic review. Dent Mater. 2004;20(9):852–861.33. Meyer-Lueckel H, Balbach A, Schikowsky C, et al. Pragmatic RCT on the ecacy of proximal caries inltration. J Dent Res. 2016; 95(5):531–536.34. Meyer-Lueckel H, Bitter K, Paris S. Randomized controlled clinical trial on proximal caries inltration: three-year follow-up. Caries Res. 2012;46(6):544–548.35. Dorri M, Dunne SM, Walsh T, et al. Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth. Cochrane Database Syst Rev. 2015;(11):CD010431.36. Alhareky M, Tavares M. Amalgam vs composite restoration, survival, and secondary caries. J Evid Based Dent Pract. 2016;16(2):107–109.37. Roumanas ED. e frequency of replacement of dental restorations may vary based on a number of variables, including type of material, size of the restoration, and caries risk of the patient. J Evid Based Dent Pract. 2010;10(1):23–24.38. Loomans BA, Opdam NJ, Roeters FJ, et al. A randomized clinical trial on proximal contacts of posterior composites. J Dent. 2006;34(4):292–297.39. Summitt JB, Howell ML, Burgess JO, et al. Eect of grooves on resistance form of conservative class 2 amalgams. Oper Dent. 1992;17(2):50–56.40. Randall RC. Preformed metal crowns for primary and permanent molar teeth: review of the literature. Pediatr Dent. 2002;24(5):489–500.41. Discepolo K, Sultan M. Investigation of adult stainless steel crown longevity as an interim restoration in pediatric patients. Int J Paediatr Dent. 2016.42. Mahoney EK. e treatment of localised hypoplastic and hypomin-eralised defects in first permanent molars. N Z Dent J. 2001;97(429):101–105.43. Massler J. Teen-age caries. J Dent Child. 1945;12:57–64.12. Kameyama A, Asami M, Noro A, et al. e eects of three dry-eld techniques on intraoral temperature and relative humidity. J Am Dent Assoc. 2011;142(3):274–280.13. Weiner R. Liners and bases in general dentistry. Aust Dent J. 2011;56(suppl 1):11–22.14. Souza-Junior EJ, de Souza-Régis MR, Alonso RC, et al. Eect of the curing method and composite volume on marginal and internal adaptation of composite restoratives. Oper Dent. 2011;36(2):231–238.15. Macedo GV, Ritter AV. Essentials of rebonding tooth fragments for the best functional and esthetic outcomes. Pediatr Dent. 2009;31(2):110–116.16. Jagannath-Torvi S, Kala M. Restore the natural—a review and case series report on reattachment. J Clin Exp Dent. 2014;6(5):e595–e598.17. Vaz VT, Presoto CD, Jordão KC, et al. Fragment reattachment after atypical crown fracture in maxillary central incisor. Case Rep Dent. 2014;2014:231603.18. Reis A, Loguercio AD, Kraul A, et al. Reattachment of fractured teeth: a review of literature regarding techniques and materials. Oper Dent. 2004;29(2):226–233.19. Andreasen FM, Norén JG, Andreasen JO, et al. Long-term survival of fragment bonding in the treatment of fractured crowns: a multi-center clinical study. Quintessence Int. 1995;26(10):669–681.20. Krastl G, Filippi A, Zitzmann NU, et al. Current aspects of restoring traumatically fractured teeth. Eur J Esthet Dent. 2011;6(2):124–141.21. Oliveira GM, Ritter AV. Composite resin restorations of permanent incisors with crown fractures. Pediatr Dent. 2009;31(2):102–109.22. Kwon SR, Oyoyo U, Li Y. Inuence of application techniques on contact formation and voids in anterior resin composite restorations. Oper Dent. 2014;39(2):213–220.23. Rosenstiel SF, Rashid RG. Public preferences for anterior tooth variations: a web-based study. J Esthet Restor Dent. 2002;14(2):97–106.24. Croll TP. Enamel microabrasion for removal of supercial dysmin-eralization and decalcification defects. J Am Dent Assoc. 1990;120(4):411–415.25. Wright JT. e etch-bleach-seal technique for managing stained enamel defects in young permanent incisors. Pediatr Dent. 2002;24(3):249–252.26. Senestraro SV, Crowe JJ, Wang M. et.al. Minimally invasive resin inltration of arrested white-spot lesions: a randomized clinical trial. J Am Dent Assoc. 2013;144:997–1005.27. Croll TP. Enamel microabrasion: the technique. Quintessence Int. 1989;20(6):395–400.28. Pini NI, Sundfeld-Neto D, Aguiar FH, et al. Enamel microabrasion: an overview of clinical and scientic considerations. World J Clin Cases. 2015;3(1):34–41. CHAPTER 40 Restorative Dentistry for the Adolescent 609.e1 Case Study 1: Management of the Uncomplicated Crown FractureZafer C. CehreliCrown fractures are the most frequent form of tooth injuries in children and adolescents. Reattachment of the original tooth fragment appears to be the most conservative treatment approach, even when a coronal fragment is not completely recovered intact. Reattachment of fractured fragments can offer several advantages, such as improved esthetics and function, and restoration of the surface anatomy with increased wear resistance. As such, the reattachment technique should especially be considered in children because it helps to preserve dental tissues during tooth development. A simple adhesive reattachment may not be able to restore even half of the fracture strength of intact teeth. Thus additional retentive preparations within or outside the fractured fragments, or their combinations, have become a widely accepted approach to increase fracture resistance. Such techniques include enamel beveling of the fragment and remaining crown, internal dentin groove, and external chamfer (postreattachment bevel). It has also been shown that reattachment of fragments with an intermediate resin composite layer signicantly increases the fracture strength recovery. This case presents the protocol for adhesive fragment reattachment in a 9-year-old boy with uncomplicated crown fractures of maxillary central incisors (Fig. E40.1A). The patient was referred to the clinic 2 hours after a fall accident, and the fractured tooth fragments were stored dry in a napkin during the transfer. The fragments had a good marginal t with the original tooth (see Fig. E40.1B), with minimal enamel loss along the fracture line (see Fig. E40.1B). A 1-mm-deep internal dentin groove was prepared in both fragments, which were then stored in water for 15 minutes to provide rehydration (see Fig. E40.1C). Thereafter the fragments were subjected to the following adhesive procedures (see Fig. E40.1D): acid etching, bonding agent application, and placement of an intermediate layer of composite resin. Acid-etching and bonding agent application were repeated on the original tooth fragment, but neither of the fragments received light curing (Fig. E40.2A). Following reattachment and photopolymerization from labial and palatal aspects, a 1-mm-deep postreattachment bevel was made by applying a round bur on the labial aspect of the fracture line, equally involving 1 mm of both sides in a feather style (see Fig. E40.2B). The postreattachment bevel was then etched using 37% phosphoric acid for 15 seconds, rinsed, and dried. A bonding agent was applied and light cured. A thin layer of body-shade composite resin was carefully adapted on the bevel, light cured, and nished (see Fig. E40.2C). After 1 week, the fractured fragment had an excellent color match with the original tooth, owing to rehydration and the feather-edge prole of the postreattachment composite band (see Fig. E40.2D).Questions1. Which preparation techniques can be used to increase fracture strength recovery between reattached tooth fragments?Answer: Enamel beveling of the fragment and remaining crown, internal dentin groove, and external chamfer (postreattachment bevel).2. How long should dry fractured fragments be rehydrated before adhesive reattachment?Answer: 15 minutes.ABCD• Figure E40.1 (A) Uncomplicated crown fractures on maxillary central incisors. (B) View of the tooth fragments (left). Trial t of fractured tooth segments, showing good t with some tissue loss along the fracture line (right). The fractured fragments appear whiter, owing to dehydration during transfer in a napkin. (C) Internal grooves prepared within the fractured fragments. (D) Adhesive procedures for the fractured fragment: acid etching (left), bonding agent application (middle), intermediate layer of composite resin (right). Continued 609.e2 Part 5 AdolescenceABCD• Figure E40.2 (A) Adhesive procedures for the original tooth: acid etching (left) and bonding agent application (right). (B) Postreattachment bevel. (C) Placement (left) and adaptation (right) of body-shade composite on the bevel. (D) One-week postoperative view. CHAPTER 40 Restorative Dentistry for the Adolescent 609.e3 Case Study 2: Management of Hypoplastic TeethCraig V. VinallHypoplastic teeth are more prone to sensitivity, fracture, and caries and present the task of restoring faulty dentition or maintaining its position until future restorative options are possible. Hypoplastic teeth occur due to a disturbance of the secretory or maturation phases of tooth development,1,2 with various causal relationships offered: delayed prenatal care, premature birth, maternal smoking, high prepregnancy weight mother, hypocalcemia, and systemic infections.3,4 Any tooth may present as hypoplastic, but most commonly noted teeth are permanent rst molars and incisors, subsequently referred to as molar-incisor hypoplasia.4–7An 8-year-old girl with severe early childhood caries presented with a hypoplastic #30 with cavitation in the central pit (Fig. E40.3A and B). The tooth was moderately affected. Shades of discoloration in hypoplastic enamel are predictors of severity. Chalky, white spot lesions are less porous with defects isolated within enamel, while yellow/brown lesions demonstrate greater porosity with defects potentially extending beyond the dentin-enamel junction.6,7 Increased porosity results in chronic stress to the pulpal tissues. This chronically inamed pulp is often difcult to anesthetize.6–9 Interim restorative therapy by removal of soft dentin and placement of glass ionomer cement to seal the lesion anecdotally has been found to minimize the pulpal response at subsequent treatment attempts.Due to difculty achieving profound anesthesia and increased treatment requirements, patients with hypoplastic dentition may become a behavior management concern.9 This patient was successfully treated with local anesthetic, an intracoronal restoration, and nitrous oxide (Fig. E40.4C and D).Although minimally affected teeth may require no treatment (except sealant10 or uoride varnish for sensitivity8,11,12), more severely affected teeth, or those with relentless sensitivity, may be treated with conventional restorations, stainless steel crowns, or extraction. Intracoronal restorations often fail due to inadequate bonding of resin to poorly mineralized tooth structure.8 When margins cannot be placed on unaffected tooth structure, glass ionomer restorations are preferred due to their ability to chemically bond. Stainless steel crowns are indicated in grossly hypoplastic teeth as long-term provisional restorations until either a high noble crown can be fabricated or when maintaining the rst molar’s position is no longer required (see Fig. E40.4A–C). These crowns should be cemented with a glass ionomer cement after minimal tooth preparation.Extraction should be considered for severely affected hypoplastic molars due to the morbidity and expense of a lifetime of restorations combined with increased potential for behavior management issues. Radiographs, occlusion, and orthodontic needs must be evaluated. In class I molar occlusion, the preferred timing for extraction is when radiographic exam reveals the second molar crown is fully encased in bone with initiation of calcication of the A BCD• Figure E40.3 (A) Preoperative bitewing. (B) Photo depicting clinically evident discoloration associated with hypoplasia and occlusal caries #30. (C) Postoperative bitewing. (D) #30 restored with occlusal resin modied glass ionomer. (Courtesy Scott Ludlow, DDS.)Continued 609.e4 Part 5 Adolescenceroot bifurcation and third molars are present.13 These conditions maximize the likelihood of the second and third molars erupting anteriorly. In patients with class II molar occlusion, maxillary extractions may be delayed until the second molar erupts into its traditional position, and the resulting space can be used for distalization.13In summation, hypoplastic teeth are at an increased risk for caries, and active surveillance with aggressive treatment planning should be used with the goal of preserving oral function and minimizing patient discomfort.Questions1. Yellow/brown lesions in hypoplastic enamel is associated with which of the following? a. Less porous dentin and less sensitivity b. Less porous dentin and more sensitivity c. More porous dentin and more sensitivity d. More porous dentin and less sensitivity e. The color of the hypoplastic enamel is not associated with the extent of porosity or sensitivityAnswer: c2. What is the recommended intracoronal restorative material for restorations with margins placed on poorly mineralized tooth structure? a. Amalgam b. Composite resin c. Glass ionomerAnswer: c; Recommended due to the ability to chemically bond to the tooth structure.3. What is the ideal timing for extraction of grossly hypoplastic class I permanent rst molars? a. Extraction of grossly hypoplastic permanent molars is never recommended b. After eruption of the permanent second molars c. As soon as possible after an extraction treatment plan is elected d. Radiographically the second molar crown is fully encased in bone with initiation of calcication of the root bifurcation and third molars tooth buds are presentAnswer: d4. Statistically, long-term hypoplastic molars: a. Are more prone to caries b. Require a greater number of restorations c. Are more likely to cause sensitivity d. Are associated with patients having increased dental anxiety e. All of the aboveAnswer: eReferences1. Via WF Jr. Enamel defects induced by trauma during tooth formation. Oral Surg Oral Med Oral Pathol. 1968;25:49–54.2. Kanchan T, Machado M, Rao A, et al. Enamel hypoplasia and its role in identication of individuals: a review of the literature. Indian J Dent. 2015;6(2):99–102.3. Needleman HL, Allred E, Bellinger D, et al. Antecedents and correlates of hypoplastic enamel defects of primary incisors. Pediatr Dent. 1992;13:158–166.A BC• Figure E40.4 (A) Preoperative bitewing. (B) Photo depicting clinically evident discoloration associated with hypoplasia and occlusal, buccal caries #30. (C) Postoperative radiograph #30 restored with stainless steel crown and cemented with glass ionomer cement. (Courtesy Scott Ludlow, DDS.) CHAPTER 40 Restorative Dentistry for the Adolescent 609.e5 4. Wuollet E, Laisi S, Salmela E, et al. Molar-incisor hypomineralization and the association with childhood illnesses and antibiotics in a group of Finnish children. Acta Odontol Scand. 2016;74:416–422.5. Garg N, Jain AK, Saha S, et al. Essentiality of early diagnosis of molar incisor hypomineralization in children and review of its clinical presentation, etiology and management. Int J Clin Pediatr Dent. 2012;5(3):190–196.6. Jalevik B, Noren JG. Enamel hypomineralization of permanent rst molars: a morphological study and survey of possible etiological factors. Int J Paediatr Dent. 2000;10:278–289.7. Jalevik B, Dietz W, Noren JG. Scanning electron micrograph analysis of hypomineralized enamel in permanent rst molars. Int J Paediatr Dent. 2005;15:233–240.8. William V, Messer LB, Burrow MF. Molar incisor hypomineralization: review and recommendations for clinical management. Pediatr Dent. 2006;28:224–232.9. Jalevik B, Klingberg GA. Dental treatment, dental fear and behavior management problems in children with severe enamel hypomineralization of their permanent rst molars. Int J Paediatr Dent. 2002;12:24–32.10. Sapir S, Shapira J. Clinical solutions for developmental defects of enamel and dentin in children. Pediatr Dent. 2007;29:330–336.11. Petersson L. The role of uoride in the preventive management of dentin hypersensitivity and root caries. Clin Oral Investig. 2013;17:63–71.12. Armenio RV, Fitarelli F, Armenio MF, et al. The effect of uoride gel use on bleaching sensitivity: a double-blind randomized controlled clinical trial. J Am Dent Assoc. 2008;139:592–607.13. Cobourne MT, Williams A, Harrison M. National clinical guidelines for the extraction of rst permanent molars in children. British Dent J. 2014;217:643–648. 610 41 Sports Dentistry and Mouth ProtectionANDREW SPADINGERCHAPTER OUTLINEBackgroundDevelopmental Evaluation of Child and Adolescent AthletesMedical AssessmentIntraoral AssessmentDietary AssessmentMouth Protection for Child and Adolescent AthletesTypes of MouthguardsTeam DentistConcussionsReturn to PlayProfessional Activities in Sports Dentistryinjuries, by young athletes was estimated to be $1.8 billion/year.1 e patient may have to undergo a lifetime of treatment involving restorative, endodontic, prosthodontic, implant, or surgical procedures.With the number of children and adolescents playing sports and suering from orofacial injuries, there arose a need to address these issues. Sports dentistry deals with the prevention and treatment of dental injuries and related oral diseases that result from sports and exercise.14Developmental Evaluation of Child and Adolescent AthletesMedical AssessmentAs part of a thorough medical history, it is advisable to ask parents about their child’s athletic activities.15 A complete medical examina-tion by a physician is necessary for all children and adolescents because a number of medical conditions may limit or preclude them from participating in athletics. e physician can best assess the child’s health and suggest appropriate modications and equip-ment to reduce the risk of injury. e American Academy of Pediatrics (AAP) lists carditis and fever as two conditions when no sports participation is recommended. e AAP strictly opposes participation in boxing for children, adolescents, and young adults.16Children with attention-decit/hyperactivity disorder (ADHD) are at higher risk for traumatic injuries.17 Other children identied at risk for dental trauma include risk-taking children, those being bullied, and obese children.7 Placing these children in athletic venues puts them at increased risk for traumatic dental injuries.Participation in sports involves many health hazards for children and adolescents. Parents who allow their children to pursue athletics believe the health benets gained by sports participation outweigh the risk of injuries. Sports and physical activity are associated with improved physical and emotional health, academic achievement, and quality of life for children. Higher levels of family satisfaction were also reported.3Data from an annual online survey by the Sports and Fitness Industry Association (SIFA) showed some disturbing trends. Although 30.2% of children aged 6 to 12 were engaged in sports in 2008, by 2015 the percentage dropped to 26.6%. Similarly, for adolescents aged 13 to 17, participation was 42.7% in 2008 and only 39.3% in 2015.18Reasons for the decline included lack of interest, specialization in one sport burn out, nancial burdens, increased use of video games, and, at the high school level, limitations in roster size.19BackgroundAs a dentist who treats children and adolescents, you will encounter trauma in your oce related to sports injuries. Actual numbers of children in the United States participating in sports are dicult to measure due to the lack of a centralized tracking system to collect data from the vast number of sports, leagues, and organiza-tions. In the United States, some 30 million children were estimated to participate in organized sports.1 If one includes “some form of sports” then the estimate increased to 46 million youths.2 A survey found 75% of boys and 69% of girls aged 8 to 17 participated in at least one organized sport.3Ten percent to 39% of all dental injuries in children are due to sports accidents.4 Injury rates vary in studies depending on sample size, location, age of participants, and sports played.5–8 Children between ages 7 and 11 are the most susceptible to sports-related dental trauma.9–12 With regulations for mandatory protective equipment in sports like football and lacrosse, basketball and baseball now have the highest incidences of sports-related dental injuries.12 Males aged 15 to 18 demonstrated the highest incidence of sports-related dental injuries.8 e greatest number of sports-related dental and orofacial injuries aect the upper lip, maxilla, and maxillary incisors, with 50% to 90% of the injuries aecting the maxillary incisors.5,6,13e consequences of orofacial trauma for child and adolescent athletes include pain, psychological eects, and nancial burdens. Dental treatment appointments result in lost time from school and work. e costs associated with all injuries, including orofacial CHAPTER 41 Sports Dentistry and Mouth Protection 611 Athletes may turn to high-carbohydrate diets to increase bulk or as an energy source for moderate to high intensity exercise. e majority of carbohydrates should come from whole food sources (e.g., grains, fruits, vegetables, milk or yogurt, and legumes). However, some athletes may choose foods less nutrient dense with higher sugar content. Along with increased frequency of ingestion, the high carbohydrate diet may put the athlete at greater risk for caries. e dentist should advise better food choices, provide oral hygiene instruction, and consider uoride varnish.25Amateur boxers and wrestlers may intentionally become dehydrated or practice aberrant eating behaviors to meet weight classication requirements. is can have a negative impact on strength and performance but also on the cardiovascular system. On exertion in such situations, hyperthermia and even death can result. Gymnasts who practice similar eating behaviors are at risk for these same systemic manifestations.Adolescent athletes attempting to control weight through dehydration and fasting are vulnerable to hypoglycemic syncope, caused by inadequate glucose reaching the brain. is pathophysi-ologic event can be brought on by the stress of a dental appointment. Symptoms of hypoglycemia include palpations, sweating, confusion, irritability, headache, and loss of consciousness. e dentist should be alert to these manifestations and have a ready source of sugar available in the oce emergency kit.In female adolescent athletes the dentist should be vigilant for signs of the severe eating disorders of anorexia nervosa and bulimia. Enamel erosion on the lingual surfaces of the teeth (Fig. 41.3), called perimolysis, results from persistent vomiting associated with the binge-purge cycle of eating. Enlargement of the parotid glands may occur.26 With intensive training, the eating disorders can progress to the female athlete triad of eating disorder, amenorrhea, and osteoporosis.27 Severe eating disorders signal psychological problems and immediate referral for counseling.Sports and energy drink consumption should be addressed with pediatric and adolescent athletes. Sports drinks are avored beverages that may contain carbohydrates, minerals, and nutrients, whereas energy drinks contain stimulants, caeine, or guarana and may also have varying amounts of carbohydrates and nutrients.28 Stimulant-containing energy drinks should not be part of the diets of children or adolescents.29 Pediatric athletes can benet from Intraoral AssessmentChild and adolescent athletes must have a thorough oral and dental examination for the diagnosis and management of dental caries, juvenile periodontal diseases, hard and soft tissue pathology, congenital anomalies, and developing occlusion. Young athletes in the early mixed dentition should be evaluated radiographically according to the AAPD guidelines for the naturally occurring processes of root resorption, exfoliation of primary teeth, and eruption of permanent successors.20 A class II, division I maloc-clusion puts the child at risk for sports-related injuries.21 Inadequate lip seal and excessive overjet place the protruding maxillary incisors at greater risk for injury especially in those playing contact sports (Fig. 41.1). e dentist may be able to reduce these risk factors by initiating orthodontic treatment.22 e relatively large pulp chambers in immature permanent teeth make them susceptible to pulpal exposures in crown fractures.An evaluation of the third molars in adolescent athletes is also important. Ideally, referral for extractions, if indicated, should be made so as to avoid in-season problems of pain and acute peri-coronitis. To reduce the risk of mandibular angle fractures, extraction of retained third molars should be considered in young athletes who participate in contact sports.23,24e labial mucosa, specically in the mandibular anterior region of adolescent athletes, should be evaluated for the presence of soft tissue changes such as leukoplakia associated with the habitual use of smokeless tobacco (Fig. 41.2). Snu dipping is a common habit among athletes, and unfortunately it is occurring at an increasing rate, even among young children. Child and adolescent athletes should be warned at every opportunity about the serious intraoral and systemic dangers of this addictive habit. e use of smokeless tobacco has traditionally been associated most often with baseball. However, male athletes who compete in sports organized according to weight classications (e.g., wrestling) sometimes dip snu to suppress appetite and control body weight.Dietary AssessmentA dietary assessment is another integral part of the evaluation of children and adolescent athletes. Based on the athlete’s diet, preven-tive oral strategies can be suggested. A number of factors inuence the specic nutritional needs of athletes, including the type of sport, frequency and intensity of training, tness levels, and the requirement to achieve physique changes.25• Figure 41.1 Excessive overjet and lack of lip protection place these maxillary permanent incisors at risk for traumatic injury during athletic activities. • Figure 41.2 Leukoplakia in the area between the cheek and gum caused by the placement of smokeless tobacco (snuff dipper’s pouch). (From Thibodeau GA, Patton KT. The Human Body in Health and Disease. 5th ed. St Louis: Mosby; 2010.) 612 Part 5 Adolescencesurrounding structures. Mouthguards are eective in preventing crown fractures, root fractures, luxations, and avulsions of teeth. To provide protection from both direct and indirect blows, the mouthguard must t, stay in position during contact to cushion the impact, yet allow the athlete to speak and breathe easily. In most cases the mouthguard is worn on the maxillary arch. However, in athletes with a class III malocclusion, the mouthguard is worn on the mandibular arch. If the mouthguard is strapped to the helmet, as in football or boys’ lacrosse, it is recommended that the strap has a feature that allows it to separate with the helmet in the event the helmet gets knocked o the athlete, leaving the mouthguard intact covering the teeth. To date, there is insucient evidence to determine whether mouthguards oer protection against concussions.32Helmets, facemasks, and mouthguards are eective in reducing the frequency and severity of dental and orofacial trauma.33 An extensive analysis conducted in 2007 demonstrated the overall risk of an oral facial injury was 1.6 to 1.9 times higher when not wearing a mouthguard compared with when a mouthguard was worn.32 Multiple epidemiologic surveys and studies have corroborated the protective and positive results of wearing mouthguards.22Types of Mouthguardse American Society for Testing and Materials (ASTM) recognizes three categories of mouthguards (Fig. 41.4).34Type I: Custom Fabricatedis mouthguard is custom fabricated using a dental cast of the athlete’s mouth. In the vacuum process a single layer of thermoplastic material, typically EVA (ethyl-vinyl acetate), is heated and adapted over a dental cast. Vacuum pressure pulls the softened materials over the cast for a retentive appliance. Sometimes the material can be stretched too thin over the incisal edges. Heat-pressure laminated mouthguards typically use two layers of material to better control the thickness of the material. e initial layer of EVA is adapted sports drinks in limited situations.30 However, water for hydration is the best option. Because most sport and energy drinks have a pH of 3 to 4, they can cause enamel demineralization and dental erosion.31 For those athletes drinking sports drinks, the dentist should recommend rinsing with water immediately afterward.After a thorough developmental evaluation of the young athlete has been completed, appropriate advice and recommendations can be given about the prevention of specic sports-related dental and orofacial injuries.Mouth Protection for Child and Adolescent AthletesAn athletic mouthguard is dened as a resilient device or appliance placed inside the mouth to reduce injuries to the teeth and • Figure 41.3 Lingual erosion in a patient with a history of bulimia. The facial surface of the permanent maxillary central incisors has been covered with veneer restorations. (From Bath-Balogh M, Fehrenbach MK. Illustrated Dental Embryology, Histology, and Anatomy. 3rd ed. St Louis: Saunders; 2011.)ABC• Figure 41.4 The three categories of athletic mouthguards include type III, stock (A); type II, mouth formed (B); and type I, custom fabricated (C). CHAPTER 41 Sports Dentistry and Mouth Protection 613 addition, wrestlers with braces must wear mouthguards that cover both upper and lower orthodontic appliances. New Hampshire mandated mouthguard use for high school soccer and basketball in 1990.37 Maine mandated use for high school boys’ and girls’ soccer in 1999.37 e National Collegiate Athletic Association (NCAA) requires athletes participating in certain sports to wear mouthguards38 (Table 41.1). Again, there is no mention as to which type of mouthguard is needed to comply with the rules.Boxing and mixed martial arts are the only professional sports requiring mouthguards. However, increasing numbers of professional athletes in other sports, hockey and basketball in particular, seem to be wearing mouthguards.Team Dentiste Team Dentist is a part of an athletic team’s sports medicine group whose role is to ensure the dental health and well-being of the athletes. e ASD developed a course to address specic situ-ations encountered in sports to become a certied Team Dentist. It reviews principles of injury prevention, mouthguard fabrication, doping issues, and the eects of illicit and performance enhancing drugs. Other duties include preseason dental evaluations and on-the-eld dental trauma evaluation and treatment.39e Team Dentist must be prepared and ready to provide treatment in a sports facility or athletic eld. Informed consent should be obtained prior to examination and treatment. e exam should begin assessing the ABC’s (airway, breathing, and circulation), other nondental injuries, and neurologic examination before focusing on the temporomandibular joint, teeth, and oral tissues. Treatment may not be denitive in nature, with the goal being to return the athlete to play when permissible. Team Dentists carry an emergency dental kit to provide on-site, game-time treatment (Box 41.1). ese items will allow the practitioner using universal precautions to carry out an examination and perform basic palliative treatment.ConcussionsA concussion is a brain injury and is dened as a complex patho-physiologic process aecting the brain, induced by biomechanical forces.40 e majority of signs and symptoms of concussions typically resolve in 7 to 10 days, although some cases can linger for weeks to a cast of the athlete’s dentition. An additional layer is adhered to the rst layer by using heat and pressure. e result is a mouth-guard with the minimum 3-mm thickness in the incisal areas.Both the vacuum-formed and heat-laminated mouthguards have the best t and most retention. ese appliances allow the athlete to breathe and speak easily. In addition, the fabricator has the ability to make the appliance allow for orthodontic movement of teeth. ese mouthguards are the most expensive.Type II: Mouth Formed/Boil and Biteis mouthguard is the traditional “boil and bite” mouth-formed mouthguard. Typically the material is placed in boiling water to soften it. e warm, softened material is placed in the mouth and, by a combination of biting force and nger pressure, adapted to the teeth. is mouthguard is available at most sporting goods stores or online websites. ere can be a tremendous variety of quality and hence protection, retention, and comfort. In addition, by biting through the material, the 3-mm thickness is not always present.Type III: StockStock mouthguards are purchased commercially as well. With these mouthguards, there is no attempt to t the mouthguard to the patient and therefore tend to be uncomfortable. e “retention” comes from biting down during contact. Other shortcomings include diculty in speaking and breathing with it in the mouth. e stock mouthguard is a cheap alternative and has limited uses in some orthodontic patients.e Academy for Sports Dentistry (ASD) strongly urges replacing mouthguard with the phrase “a properly tted mouthguard” to optimally protect the athlete.35 Furthermore, the ASD establishes the following criteria for a properly tted mouthguard:• Itshouldbemadeonadentalmodelusinganimpressionofthe athlete’s mouth.• Itshouldcoverandprotecttheteethandsurroundingtissues.• Toreduceimpact,itshouldhaveaminimumof3mmintheocclusal/labial area.• ItshouldbemadefromanFDA-approvedmaterial.• Itshouldhavearetentivetsoasnot tobedislodgedbyadirect or indirect blow.• Itshouldbettedbythedentistorunderadentist’ssupervision.is includes balancing the properly tted mouthguard for even occlusal contact.• Ifnecessary, the athlete should be able tospeakwhiletheappliance is in place.• eapplianceshouldberoutinelyinspectedfortandfunction.Loss of retention through wear and loss of adequate thickness due to chewing are indications for replacing the mouthguard.All types of mouthguards should be stored in a plastic container when not in use, to avoid damage from excessive heat and cold.34 Mouthguards should be rinsed with cold or lukewarm water because hot water may cause distortion. Mouthguards should be inspected regularly during the athletic season to detect distortions, tears, or bite-through problems (Fig. 41.5). When deciencies are detected, a new mouthguard should be made.Despite an abundance of studies demonstrating the protective and positive eects of wearing mouthguards, few sports require their use.22,32 e National Federation of State High School Associa-tions (NFSH) mandates high school athletes wear colored, not white or clear, mouthguards for football, eld hockey, ice hockey, lacrosse, and wrestling (if wearing braces).36 ere are no specica-tions as to what type of mouthguard the athlete must wear. In • Figure 41.5 Distortions, splits, and bite-through problems indicated the need to fabricate a new mouthguard for proper retention, comfort, and maximal protection of the athlete. 614 Part 5 Adolescenceparents, coaches, and health care professionals to disseminate information about concussions.47Concussions accounted for an estimated 8.9% of all high school injuries.48 As expected high-contact sports have higher risks for concussions. In high school athletics, boys’ football had the highest risk for concussions. For girls, soccer and basketball had the highest rate of concussion. Rugby, lacrosse, and ice hockey had higher rates of concussions.e NCAA data show slightly dierent rates of concussions.49 Wrestling, football, and ice hockey had the highest concussion rates among men’s sports. In women’s sports, eld hockey presented the highest rate, followed by soccer and ice hockey.Young, concussed athletes who return to play their sport before proper healing are at risk for a rare, fatal condition called second impact syndrome (SIS). First described in 1984, a second concussive blow to the already injured brain causes severe edema, brain hernia-tion, and death within minutes.50 According to the CDC in 1997, the true incidence of second impact is unknown.Return to PlayUnder no circumstances should a child or adolescent athlete return to play the same day as their suspected concussion. Determin-ing when an athlete returns to play after a concussion follows a protocol tailored to the individual athlete.41 Typically, a gradual return to school and social activities that do not trigger symptoms precedes any return to sports. Once asymptomatic at rest, the athlete is guided through a stepwise, mild progression of activi-ties. An athlete can only advance to the next step if his or her symptoms are not exacerbated by the next level of activity. Final clearance to return to play is determined by a physician or his or her trained designee.Some athletic programs administer a neurocognitive test, the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) as part of their preseason protocol. Younger athletes, aged 5 to 11, take a similar test, ImPACT Pediatric, to get baseline values.50 Results from the test taken at baseline (i.e., preseason) are compared with postconcussion test results. When the scores approximate the original scores, the trained physician has a measure of brain function to help make return to play decisions. A number of studies have shown a longer cognitive recovery period for children or months. e long-term eects of concussion are controversial and are still being investigated.Symptoms are variable and may include temporary loss of consciousness, headache, nausea, amnesia, abnormal behavior, sensitivity to light and noise, fatigue, balance, and vision prob-lems.41 ese symptoms may be immediate or have a delayed onset. Diagnosis of a concussion is dicult because there is no denitive medical test. Brain computed tomography (CT), magnetic resonance imaging (MRI), electroencephalogram (EEG), and blood tests are often normal. Athletes with attention-decit disorder, learning disabilities, mood disorders, and migraine history are more challenging to assess and diagnose because of the overlap of symptoms.e Acute Concussion Evaluation (ACE), the Sport Concussion Assessment Tool (SCAT3), and the Child SCAT3 for ages 5 to 12 are examples of standardized tools used by medical professionals and rst responders to record symptoms, balance, and cognitive abilities of suspected concussed athletes to aid concussion diagnosis.42–44With the large number of children and adolescents playing sports, there has been an alarming increase in the number of concussions. An estimated 300,000 sports-related concussions occur each year in the United States.45 Emergency room visits for recreation and sports-related concussions increased 62% from 2001 to 2009.46 e Centers for Disease Control and Prevention (CDC) created the Heads UP brain injury awareness program as a resource for Sport Position Mouthguard ColorCovers All Upper Teeth WhenField hockey Field Mandatory; strongly recommended for goalkeepersNot specied Not specied Regular season competition and NCAA championshipsFootball All Mandatory Readily visible color (not white or transparent)Yes Regular season competition, postseason, and NCAA championshipsWomen’s lacrosse All Mandatory Not specied Yes Regular season competition and NCAA championshipsMen’s lacrosse All Mandatory Yellow or any visible colorYes Regular season competition and NCAA championshipsNCAA, National Collegiate Athletic Association.From National Collegiate Athletic Association (NCAA). 2014–2015 NCAA Sports Medicine Handbook. Indianapolis: NCAA; 2014.NCAA Sports Requiring MouthguardsTABLE 41.1 2 × 2 gauzeLocal anestheticsNeedles/syringeSutures/scissorsCotton rollsEtchant/bonding agentComposite/plastic instrumentMirrors/explorersTongue depressorsEndo les/broachesCuring lightBonding agentTheracalVitrebondFlashlightSplint materialsGloves/maskWire cuttersCanned airDremel motor/burrsSample Emergency Dental Kit• BOX 41.1 CHAPTER 41 Sports Dentistry and Mouth Protection 615 7. Glendor U. Aetiology and risk factors related to traumatic dental injuries: a review of the literature. Dent Traumatol. 2009;25(1):19–31.8. Huang B, Wagner M, Croucher R, et al. Activities related to the occurrence of traumatic dental injuries in 15-18-year-olds. Dent Traumatol. 2009;25(1):64–68.9. Tesini DA, Soporowski NJ. Epidemiology of orofacial sports-related injuries. Dent Clin North Am. 2000;44(1):1–18.10. Rodd HD, Chesham DJ. Sports-related oral injury and mouthguard use among Sheeld school children. Community Dent Health. 1997;14(1):25–30.11. American Dental Association Council on Access, Prevention and Interprofessional Relations and Council on Scientic Aairs. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc. 2006;137(12):1712–1720.12. Stewart GB, Shields BJ, Fields S, et al. Consumer products and activities associated with dental injuries to children treated in United States emergency departments 1990-2003. Dent Traumatol. 2009;25(4):399–405.13. Takeda T, Ishigami K, Nakajima K, et al. Are all mouthguards the same and safe to use? Part 2. e inuence of anterior occlusion against a direct impact on maxillary incisors. Dent Traumatol. 2008;24(3):360–365.14. Academy for Sports Dentistry. Position Statement on e Denition of Sports Dentistry; 2012. www.academyforsportsdentistry.org/position-statement. Accessed September 13, 2013.15. Ranalli DN. Strategies for the prevention of sports-related oral injuries: a practical guide for the pediatric dentist. J Southeast Soc Pediatr Dent. 1997;3:18–19.16. Rice SG, Council on Sports Medicine and Fitness. Medical conditions aecting sports participation. Pediatrics. 2008;121:841–848.17. Sabuncuoglu O, Irmak MY. e attention-decit/hyperactivity disorder model for traumatic dental injuries: a critical review and update of the last 10 years. Dent Traumatol. 2017;33(2):71–76.18. Aspen Institute. State of play 2016: trends and developments. https://www.aspeninstitute.org/publications/state-play-2016-trends-developments/. Accessed September 13, 2017.19. Merkel DL. Youth sport: positive and negative impact on young athletes. Open Access J Sports Med. 2013;(4):151–160.20. American Academy of Pediatric Dentistry Guideline on Prescribing Dental Radiographs for Infants, Children, Adolescents and Persons with Special Health Care Needs. Pediatr Dent. 2016-2017;38(special issue):355–357.21. Fos P, Pinkham JR, Ranalli DN. Prediction of sports-related dental traumatic injuries. Dent Clin North Am. 2000;44(1):19–33.22. American Academy of Pediatric Dentistry. Policy on prevention of sports-related orofacial injuries. Pediatr Dent. 2016;38(special issue):76–80.23. Rahimi-Nedjat RK, Sagheb K, Jacobs C, et al. Association between eruption state of the third molar and the occurrence of mandibular angle fractures. Dent Traumatol. 2016;32(5):347–352.24. Yamuda T, Sawaki Y, Takeuchi M, et al. A study of sports-related mandibular angle fracture: a relation to the position of the third molars. Scand J Med Sci Sports. 1998;8:116–119.25. Broad EM, Rye LA. Do current sports nutrition guidelines conict with good oral health? Gen Dent. 2015;63(6):18–23.26. Hasler JF. Parotid enlargement: a presenting sign in anorexia nervosa. Oral Surg Oral Med Oral Pathol. 1982;53:567–573.27. Yeager K, Agostini R, Nattiv A, et al. e female triad: disordered eating, amenorrhea, osteoporosis. Med Sci Sports Exerc. 1993;25: 775–777.28. American Academy of Pediatrics. Clinical report—sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127(6):1182–1189.29. Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: National Academies Press; 2007.30. Rodriguez NR, DiMarco NM, Langley S, et al. Position of the American Dietetic Association, Dietitians of Canada, and American and adolescent athletes compared with college-aged or professional athletes.41Since 2009 the District of Columbia and all but two states, Arkansas and Wyoming, have passed laws requiring physicians, licensed health care professional, or certied athletic trainers to be trained in concussion management to protect young athletes.51 Athletes and their parents are required to sign informed consent outlining the dangers of concussions before participating in sports. Often there are strict educational requirements for coaches and trainers to identify concussions. An athlete must be removed from a game if suspected of having been concussed and may not return until being cleared by a licensed health care provider.e NCAA protects student-athletes by mandating institutions have processes to identify sports-related concussions and return to play. Student-athletes are educated about concussions and must sign a consent to report signs and symptoms of a concussion. Concussed student athletes cannot return to athletic activity for at least that day, and medical clearance is required to return to play.48Professional Activities in Sports Dentistrye American Dental Association (ADA), the AAPD, and the ASD recommend the use of properly tted mouthguards to prevent injuries.22,35,52 Despite all the evidence showing the eectiveness of wearing mouthguards, there is still a lot of work to be done to educate parents, coaches, and athletes. Cost, ranging from $60 to $285 nationwide, may be a barrier to their use.53 However, in a dierent study, only 23.2% of children wore a free mouthguard when needed.54Mandates to increase the number of high school sports requiring mouthguards are dicult to enact. Massachusetts made mouthguard use mandatory for boys’ and girls’ basketball and soccer in 2003 only to rescind them by 2009. Minnesota had a similar experience adding boys’ and girls’ soccer, baseball, softball, boys’ and girls’ basketball, and volleyball, with rules mandating mouthguard use in 1992. By 1994, due to strong resistance, the rules in Minnesota were rescinded.37Dentists should be at the forefront using routine dental visits to initiate educational discussions about mouthguards with parents and patients. Dentists may be called upon to help present the case for mouthguards to legislative bodies, school administrators, and sports organizations. Take the Team Dentist to enhance your knowledge and use your skills to help local ath-letic teams, Special Olympics, or members of the United States Olympic Team.References1. Adirim T, Cheng T. Overview of injuries in the young athlete. Sports Med. 2003;33(1):75–81.2. Barron M, Powell J. Fundamentals of injury prevention in youth sports. J Pediatr Dent Care. 2005;11(2):10–12.3. Sabo D, Veliz D. Go out and play-youth sports in America, Women’s Sports Foundation Research Report; 2008. les.eric.ed.gov/fulltext/ED539976.pdf. Accessed September 13, 2017.4. Newsome P, Tran D, Cooke M. e role of the mouthguard in the prevention of sports-related dental injuries. A review. Int J Paediatr Dent. 2001;11(6):396–404.5. Kumamoto D, Maeda Y. Global trends and epidemiology of sports injuries. J Pediatr Dent Care. 2005;11(2):15–25.6. Kumamoto D, Maeda Y. A literature review of sports-related orofacial trauma. Gen Dent. 2004;52(3):270–280. 616 Part 5 Adolescence42. Sport Concussion Assessment Tool (SCAT3). Br J Sports Med. 2013;47(5):259.43. Child Sport Concussion Assessment Tool (Child SCAT3). Br J Sports Med. 2013;47(5):263.44. urman DJ, Branche CM, Sniezek JE. e epidemiology of sports-related traumatic brain injuries in the United States: recent developments. J Head Trauma Rehabil. 1998;3(2):1–8.45. Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged <19 years—United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60(39):1337–1342.46. Centers for Disease Control and Prevention. Heads UP. http://www.cdc.gov/headsup/index.html. Accessed September 13, 2017.47. Gessel LM, Fields SK, Collins CL, et al. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503.48. National Collegiate Athletic Association (NCAA). Sports and Medicine Handbook. Guideline 21: Sport-Related Concussion. Indianapolis: NCAA; 2014-2015:56-64.49. Bey T, Ostick B. Second impact syndrome. West J Emerg Med. 2009;10(1):6–10.50. ImPACT Applications: e Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). https://www.impacttest.com. Accessed September 13, 2017.51. National Conference of State Legislatures (NCSL). Traumatic brain injury legislation. www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspx. Accessed September 13, 2017.52. Zenk JK. e ADA Council on Access, Prevention, and Interprofes-sional Relations. Northwest Dent. 2016;95(3):7–8.53. Walker J. Parents plus: getting mouthguards into kids’ mouths. J Pediatr Dent Care. 2005;11(2):39–40.54. Matalon V, Brin I, Moskovitz M, et al. Compliance of children and youngsters in the use of mouthguards. Dent Traumatol. 2008;24(4):462–467.College of Sports Medicine: nutrition and athletic performance. J Am Diet Assoc. 2009;109(3):509–527.31. Shaw L, Smith AJ. Dental erosion: the problem and some practical solutions. Br Dent J. 1999;186(3):15–18.32. Kapnik JJ, Marshal SW, Lee RB, et al. Mouthguards in sports activities: history, physical properties and injury prevention eective-ness. Sports Med. 2007;37(2):117–144.33. Ranalli DN. Sports dentistry in general practice. Gen Dent. 2000;48(2):158–164.34. American Society for Testing and Materials. Standard Practice for the Care and Use of Athletic Mouth Protectors. ASTM F697-00. Philadelphia: American Society for Testing and Materials; Reapproved 2006.35. Academy for Sports Dentistry. Position statement: a properly tted mouthguard; 2010. www.academyforsportsdentistry.org/position-statement. Accessed September 13, 2017.36. National Federation of State High School Associations. Position statement and recommendations for mouthguards in sports; 2014. https://www.nfhs.org/media/1014750/mouthguard-nfhs-smac-position-statement-october-2014.pdf. Accessed September 13, 2017.37. Mills SM. Mandatory mouthguard rules for high school athletes in the United States. Gen Dent. 2015;63(6):35–40.38. National Collegiate Athletic Association (NCAA). NCAA Sports Medicine Handbook: Guideline 3C Mouthguards. Indianapolis: NCAA; 2014-2015:111-112.39. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concus-sion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250–258.40. Halstead ME, Walter KD, Council on Sports Medicine and Fitness. Clinical Report—sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597–615.41. Gioia G, Collins M. Acute concussion evaluation (ACE); 2006. https://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf. Accessed September 13, 2017. CHAPTER 41 Sports Dentistry and Mouth Protection 616.e1 Case Study: Mouthguards and Management of Sports-Related Dental TraumaSahar M. AlrayyesA 10-year-old Hispanic female presents for an emergency dental appointment with the chief complaint of “I got hit on the face by the elbow of girl on my team while playing a basketball game. My two front teeth moved, and the ones next to them feel funny.” There was no loss of consciousness, no headache, no irritability, and no vomiting. Patient complains of moderate pain.The patient is medically healthy with no known drug allergy, and her immunizations are up to date. The patient is of low socioeconomic status and lives with her parents and younger brother. The patient has a dental home, good oral hygiene, and has no past dental trauma.Upon examination, the extraoral evaluation reveals an intact temporomandibular joint and no facial asymmetry or bony fractures. The intraoral evaluation revealed palatally displaced teeth #8 and #9 with class II mobility and no bony fracture (Figs. E41.1 and E41.2). Radiographic assessment demonstrated mid-root fracture of the two maxillary central incisors with complete apical root development, and coronal extrusion of #8 and #9 (Fig. E41.3). Sensibility tests were deferred due to the patient’s anxiety level.Nitrous oxide was titrated to a ratio of 2 L nitrous oxide to 4 L nitrous oxide for 30 minutes, due to the patient’s anxiety, and 100% oxygen was administered for 5 minutes at the end of treatment. Topical anesthetic was applied and 34 mg of 2% lidocaine with 1 : 100,000 epi was administered via maxillary inltration. Anesthesia was veried and the following treatments were completed:• Irrigatedthetraumatizedareawithsaline(Fig.E41.4)• Repositionedtheextrudedcoronalsegmentswithngerpressure (Fig. E41.5)• Placedexiblesplintxationfor4weeks(Fig.E41.6)• Radiographtocheckrepositioning• Prescriptionofchlorhexidinemouthrinsefor2weeks• Discussedprognosiswiththeparentbeingfavorableandendodontictreatment extending up to the fracture line if the teeth become nonvital• Figure E41.1 Intraoral image showing tooth displacement. • Figure E41.2 Intraoral photograph showing the extent of displacement. • Figure E41.3 Intraoral radiograph showing root fractures with dis-placed coronal fragments. Continued• Figure E41.4 Intraoral photograph showing irrigation of the wound. 616.e2 Part 5 AdolescenceA soft diet was recommended for 2 weeks to avoid biting and chewing with injured teeth. In addition, the patient was advised to maintain oral hygiene practices and to use acetaminophen or ibuprofen as needed for pain. The patient and parent were advised to avoid contact sports and to wear a mouthguard for sports activity to prevent future trauma. After the teeth have stabilized, an impression can be made for a custom, thermoplastic mouthguard fabricated by the dentist, as shown in Video 41.1. The parent was informed of the need to monitor the patient for any tooth discoloration and to call immediately if the splint breaks or loosens.The patient was scheduled for a follow-up appointment in 4 weeks to remove the splint and assess teeth #8 and #9 clinically and radiographically for any signs of pulpal or periodontal pathology (Fig. E41.7). Root canal therapy up to the fracture line would be indicated if the teeth become nonvital.Follow-upvisitsat6to8weeks,4months(Fig.E41.8),6months,1year, and 5 years will be needed.Questions1. Which splint is recommended following root fracture of permanent teeth with a class II mobile coronal fragment? a. Cap splint b. Splint with heavy gauge rectangular orthodontic wire c. Fish line splint d. No splint indicatedAnswer: c2. Which best describes indications for root canal therapy following root fracture of permanent teeth? a. Must be initiated immediately b. Should be initiated upon signs of necrosis and entire tooth should be treated c. Should be initiated upon signs of necrosis and coronal segment should be treated d. Is not indicated following root fracturesAnswer: c• Figure E41.5 Intraoral photograph showing repositioning of the coronal fragments. • Figure E41.6 Intraoral photograph showing splint. • Figure E41.7 Radiograph of 4 weeks’ follow-up. • Figure E41.8 Radiograph of 4 months’ follow-up. 617 Index617prophylaxis before, 285topical, 283oral habits, 386–393physical changes in, 260–263social changes in, 263–264Ages 6 to 12 yearscognitive changes in, 415craniofacial changes in, 411, 412fdental caries and dietary factors in, 416–417dietary counseling and, 417importance of, in transitional dentition, 416–417sucrose and, 416dental changes in, 412–413, 412fdental disease prevention, 455–460diet and, 458–459uoride administration in, 455–456home care for, 456–458sealants and, 459developmental characteristics of, 420tdynamics of change in, 411–418emotional changes in, 415examination of, 419–454behavioral assessment in, 420facial examination in, 423–424, 423f–424fhead and neck examination in, 423history in, 419–420intraoral examination in, 424–435occlusal evaluation in, 425–435oral hygiene evaluation in, 425periodontal evaluation in, 424–425, 425fradiographic evaluation in, 449–452, 451f–452fsupplemental orthodontic diagnostic techniques in, 435–452physical changes in, 411–413social changes in, 415–416treatment planning for, 419–454in nonorthodontic problems, 452–453Aggression, in ages 3 to 6 years, 263Aggressive periodontitis, 374Air abrasion, for caries removal, 305Airway (“A”), in management of medical emergencies, 151–152, 151fAirway anomalies, 88–90in specic conditions/diseases, 90tAirway assessment, case study, 96.e1, 96.e1f–96.e3f, 96.e1t, 96.e3t–96.e4tAirway narrowing, 88–90, 89fAirway obstruction, 88–90, 89fIndexfractured anterior teeth, 601, 602ffor hypoplastic molar, 607–608material selection, fundamentals of, 598, 599f–600ffor posterior teeth, 606–607, 607ffor rampant caries, 608, 608fAdolescent athletesdevelopmental evaluation of, 610–612dietary assessment in, 611–612, 612fintraoral assessment in, 611, 611fmedical assessment in, 610return to play of, 614–615Adolescent pregnancy, 594Adulthood, adolescents to, dental home in, 595–596Advanced cardiac life support (ACLS), 145–146AED. see Automated external debrillatorAordable Care Act (ACA), pediatric dental benet within, 161–162Ages 3 to 6 yearscognitive changes in, 263craniofacial changes in, 260–262, 261f, 261tdental changes in, 262–263, 262fdental disease prevention in, 282–292adaptive daily oral hygiene for, 286b–288b, 286f–288f, 286t–288tdietary counseling in, 289–291, 290fdietary management for, 289, 289buoride administration for, 282–286home care for, 291, 291fdental examination for, 266–277behavioral assessment for, 266–267examination of head and neck in, 268–270, 269t–270texamination of the face in, 270–273general appraisal in, 267–268, 268thistory for, 266, 267tintraoral examination in, 273–277occlusal evaluation in, 273–274, 274f–277fpatient record for, 265–266radiographic evaluation for, 277–280, 278b, 278f–280f, 280tsupplemental orthodontic diagnostic technique for, 277–280emotional changes in, 263uoride administration for, 282–286cost-benet considerations for, 284–285dietary, 282–283, 283tmethod of, 285–286professional application of, 283–284, 284fAAAPD. see American Academy of Pediatric DentistryACA. see Aordable Care ActAccess to care, dental public health issues and, 161–162Acero 3S crowns, 316Acetaminophen, 104, 104tAcid-etch composite resins, for adolescent restorative problems, 571Acid-etching technologyfor diastemas, 601–602eect on enamel surface of, 463, 463fACLS. see Advanced cardiac life supportAcrocephalosyndactyly, airway anomalies in, 90tActinomycosis, 139Acute bronchospasm. see AsthmaAcute coronary syndrome, 154management of, 154Acute inammatory lesions, 30t–34t, 35f–39fAcute lymphoid leukemia (ALL), 69Acute osteomyelitis, 40t–42t, 43f–45fAcute suppurative sialadenitis, 139Acyclovir, 136for primary herpetic gingivostomatitis, 73Adenomatoid odontogenic tumor, 46t, 47fAdhesive materials, resin-based composite, 309Adhesive systems, 598Adolescencebehavior guidance for, 366dental disease prevention, 588–597dietary management for, 589–592uoride administration for, 592–593home care for, 592, 592frisk assessment in, 588–589, 589f, 589t–590trisk factors for, 593–595transitioning to adulthood, 595–596dynamics of change in, 555–561cognitive changes, 557craniofacial changes, 555–556, 556f–557f, 556tdental changes, 556emotional changes, 557physical changes, 555–556social changes, 557–560oral health care in, 164–165orthodontic problems in, 562–587radiographic issues in, 571trestorative dentistry for, 598–609clinical technique, fundamentals of, 598–601, 600f–601fdiastemas, 601–604, 603fdiscolored teeth, 604–606Page number followed by t, f, or b indicates table, gure, or box, respectively; e indicates online-only entries.Adolescence (Continued) Ages 3 to 6 years (Continued) 618IndexALL. see Acute lymphoid leukemiaAllergic reactions, 152–153, 153bmanagement of, 153, 153fAlternative anesthesia systems, 113–114Alternative communicative techniques, behavior guidance, 361Alternative isolation systems, 308–309, 308f, 308tAlveolar bone grafting, for cleft lip and palate, 83–84, 83fAlveolar ventilation (AV), 91Amalgam, 294t, 296–297condensation of, 297nishing and polishing of, 297properties of, 296–297for restoration, of posterior teeth, 607Amalgam tattoo, 20t–21t, 22f–23fAmalgamation, 296, 296fAmateur boxers, dietary assessment in, 611Ameloblast, 189–190, 190f–191f, 198bAmeloblastic broma, 40t–42t, 43f–45fAmeloblastic bro-odontoma, 46t, 47fAmeloblastoma, 40t–42t, 43f–45fAmelogenesis, 58Amelogenesis imperfecta, 249, 250f, 255hypocalcication type of, 60–61hypomaturation type of, 60–61, 60ftaurodontism in, 57tAmerican Academy of Pediatric Dentistry (AAPD), in behavior guidance, 352American Society of Anesthesiologists (ASA), guidelines for perioperative fasting, 94, 94tAmides, for local anesthesia, 107Ammonia inhalant crushable capsules, 150Amoxicillin, 133Amoxicillin/clavulanate, 133Amphotericin B, 135Ampicillin, 133Analgesics, 102–105for children, 104tdosing schedules of, 105narcotic, 105nonnarcotic, 103opioid, 105Aneurysmal bone cyst, 40t–42t, 43f–45fAngioedema, 30t–34t, 35f–39fAngular cheilitis, 24t–25t, 26f–29fmanagement and treatment of, 73Ankyloglossia, 9t–10t, 11f–12f, 207f, 207tbreastfeeding and, 406classication of, 406, 406bcase study, 385.e1, 385.e1f–385.e2fetiology of, 406nonbreastfeeding issues and, 406–407oral surgery for, 405–407social concerns for, 407speech outcomes for, 407surgical treatment for, 407–409frenectomy technique as, 407–409, 408ffrenotomy technique as, 407, 407fAnkylosis, 240in primary dentition, 434–435, 435fin young permanent dentition, 505–506, 505fAnterior crossbite, orthodontic treatment, in orthodontic problems, 548fxed appliances, 548–549, 548fremovable appliances, 534, 534fAnterior open bite, 386, 387fAnterior restorations, glass ionomer for, 301Anterior teethextractionmandibular, 402, 402fmaxillary, 402, 402ffractured, restorations for, 601, 602fAnteroposterior dental problems, 548–550for anterior crossbite, 548–549, 548f–549fgrowth modication applied to, 514–517class II growth modication, 514–516class II mandibular deciency, 516class II maxillary protrusion, 515, 515fclass III growth modication, 516–517, 517fclass III mandibular protrusion, 516–517, 517ffor incisor protrusion, 549–550Antianxiety agents, 125, 125tAntibacterial agents, 132–133cephalosporins, 133, 134b, 134f, 134tclindamycin, 133–134uoroquinolones, 135macrolides, 134–135metronidazole, 135penicillins, 132–133, 132f, 132t, 134bAnticipation of painful stimuli, 100Anticipatory guidancefor dental disease, 589for infant oral health, 201–202, 206–208, 208b–209b, 209t–210tAntifungal agents, 135–136azole, 135–136clotrimazole, 136uconazole, 136itraconazole, 136miconazole, 136nystatin, 135for oropharyngeal candidiasis, 73polyenes, 135Antiherpetic agents, 136–137acyclovir, 136valacyclovir, 137Antihistamines, 125Antimicrobials, 128adverse eects of, 131–132allergic reactions, 131drug-drug interactions, 131–132long QT interval syndrome, 131photosensitivity, 131classication and use of, 128–130according to microbiology, 128–129bacteriostatic versus bactericidal, 129, 129bcategories of, 129–130chemotherapeutic spectrum of activity, 129clinical use of, 138–140bacterial, 138–139fungal, 139–140prophylaxis, 140viral, 139for dental caries, 174mechanisms of action, 130–131, 130balteration of cell membrane permeability, 131inhibition of cell wall synthesis, 130inhibition of protein synthesis, 130–131suppression of DNA synthesis, 131special considerations in, 137–138accurate dosing, 137barriers to compliance, 137unpalatable medications, 137–138Antiviral agents, 139Anxiety, 100Apert syndrome, 256airway anomalies in, 90thyperdontia in, 51tApexication, 489long-term, with calcium hydroxide, technique, 489–490short-term, with mineral trioxide aggregate, 490–492in young permanent dentition, 502f, 506Apexogenesis, in young permanent dentition, 489, 489fAphthous ulcer, 24t–25t, 26f–29fApples, dental caries and, 417Appliancesanteroposterior dental problems, 548–550for anterior crossbite, 548–549, 548f–549ffor incisor protrusion, 549–550bionator, 515xed, 534, 535f–536ffor anterior crossbite, 548–549, 548ffor dental alignment problems, 535f–536fetch/conditioner use in, 534, 537findirect bonding technique, 534, 537ffor midline diastema, 535, 539fheadgearchin cup, for class III mandibular protrusion, 516–517, 517ffor class II growth modication, 514–515, 514fhigh-pull, for vertical growth modication, 519, 519freverse-pull, for class III maxillary deciency, 516, 517fHerbst, 516, 516flingual arch appliance, for mild crowding of immature permanent dentition, 542for mandibular deciency, class II, 516, 516ffor mandibular protrusion, class III, 516–517, 517ffor maxillary constriction with posterior crossbite, 518, 518ffor maxillary deciency, class III, 516, 517ffor maxillary protrusion, class II, 514–515, 514fto modify growth, 513removable, for dental alignment problems, 534for space maintenance, 521–522temporary anchorage devices (TADs), 516twin block appliance, 515, 515ffor vertical deciency, 519, 519ffor vertical skeletal growth excess, 519, 519fW arch, in orthodontic problems, 518, 550Apposition, 198bin dental development, 190, 191f–192fArch length analysis, in orthodontic problems, 529–530mild crowding, 539–542, 540fmild to moderate spacing, 535–538, 539fmoderate crowding, 542–546, 543f–546fArch length problems, orthodontic treatment of, 395, 395fART. see Atraumatic restorative treatmentArticaine, 107, 107tASA. see American Society of AnesthesiologistsASA physical status classication, 95, 95t–96tAspirin, 104–105, 150Assistant trainingfor sealant placement, 474in sedation procedures, 119ASTDD Seven Step Model, 159, 160f 619 IndexAsthma (acute bronchospasm), 153–154management of, 154Atraumatic restorative treatment (ART), 322b, 465Attrition, dental, 193–194, 195f, 198bAuricular anomalies, 247, 248fAuthoritarian parenting styles, 355tAuthoritative parenting styles, 355tAutism spectrum disorder, case study, 264.e1, 264.e1f, 264.e2tAutomated external debrillator (AED), 147AutoMatrix, 313, 313fAutomobile accidents, causing dental injuries, 228Autosomal dominant inheritance, 246Autosomal recessive inheritance, 246Autotransplantation, in pediatric dentistry, 5AV. see Alveolar ventilationAvulsioncomplications following, 241–242in permanent dentition, 506–508, 507fsplinting technique, 508in primary dentition, 228, 230fsplinting for an, case study, 511.e1, 511.e1b, 511.e1fAzithromycin, 134Azole antifungals, 135–136BBacterial infections, antibiotic agents for, 138–139Bacterial inltration, in pulp, 331Bactericidal antibiotics, 129, 129bBacteriostatic antibiotics, 129, 129bBag-valve-mask apparatus, 147, 147fBarbiturates, 125Basal layer, 186–187, 188f, 198bBasement membrane, 186–187, 189, 189f–191f, 198bBases and liners, 293–295calcium hydroxide, 293, 294fglass ionomer cement, 293–295, 295fzinc oxide-eugenol, 293, 295fBasic behavior guidance, 357–361communication and communicative guidance, 357direct observation, 360distraction, 359, 360tmemory restructuring, 360–361nitrous oxide, 361nonverbal behavior guidance, 358–359parental presence/absence, 361positive previsit imagery, 360positive reinforcement, 359, 359ftell-show-do (TSD), 357–358, 358f, 358tvoice control, 359–360Basic life support (BLS) training, 145–146Beckwith-Wiedemann syndrome, airway anomalies in, 90tBehavior guidance, 352–370for adolescent, 366child development review in, 353–354, 353b–354b, 353ffor child with previous negative dental experience, 366–367for child with special health care needs, 367, 367bdocumenting behavior in, 362–363, 363tfactors inuencing child behavior, 354–356demographics, 354dental fear, 355environment, 354–355, 355tpain, 355parental anxiety, 356for infant/toddler, 365–366, 366ffor preschooler, 366role of, in society, 363–365changes in society and parenting, 363–364changing parental perspective, 364, 364tinformed consent, 364–365, 365bthird-party reimbursement, 364for school-aged child, 366stage for successful, setting, 356–357techniques, review of, 357–362advance, 361–362, 362falternative communicative techniques, 361basic, 357–361, 358f–359f, 358t, 360tmouth props, 362, 363fuse of, 362–363Behavior management, 352. see also Behavior guidancetechniques of, 105–106Behavioral assessmentin adolescent, 563–565, 564fin ages 3 to 6 years, 266–267in ages 6 to 12 years, 420Bell stage, 189, 189fadvanced, 189, 190fBenign migratory glossitis, 20t–21t, 22f–23fBenign mixed tumor, 30t–34t, 35f–39fBenzocaine, 107Benzodiazepines, 125Beverages, at school, 458–459Bid uvula, 9t–10t, 11f–12fBioactive glass, in pediatric dentistry, 5Bionator appliance, 515Biopsies, surgical, 403–404BIS-GMA, 297Bisphenol-A (BPA), 475, 476tBisphosphonate agents, use in children, 68Bisphosphonate-related osteonecrosis of jaws (BRONJ), 67Bitewing radiographs, in adolescent, 571tBlack, G.V., in class I restorations, 309–310, 310fBlood pressure, 92, 92tBlood pressure cu, 118, 118fBMD. see Bone mass densityBody, physical changes of, in adolescence, 555Body uids, 94alterations in, 94Body habitus, 95Body surface area (BSA), 95“Boil and bite” mouth-formed mouthguard, 613Bolton standards, of dentofacial developmental growth, 261ffor ages 6 to 12 years, 411, 412fBolton’s method, of tooth size analysis, 437–439, 438f–441fBonded wire retainer, 538, 539fBone, compact, chemical contents of, 192tBone grafting, for cleft lip and palate, 83–84, 83fBone mass density (BMD), measurement of, 68Bone scar, 48t, 49fBoxing, requiring mouthguards, 613Brachmann-de Lange syndrome, airway anomalies in, 90tBreast development, determination of developmental status and, 421Breastfeedingankyloglossia and, 406for infants, 223Breath, intraoral evaluation of, in adolescent, 564tBreathing (“B”), in management of medical emergencies, 152, 152fBroad-spectrum antibiotics, 129BRONJ. see Bisphosphonate-related osteonecrosis of jawsBrown-black lesions, 20t–21t, 22f–23fBruxism, 391–392, 392f, 579BSA. see Body surface areaBuccal mucosa, intraoral evaluation of, in adolescent, 564tBud stage, 187–188, 188f, 198bBulimia, 566–567Bulk-ll resins, 299–301Bupivacaine, 107Burkitt lymphoma, 40t–42t, 43f–45fCCaeine, 590Calcication stage, of dental development, 190–191, 192f–193f, 192t, 198bCalcifying odontogenic cyst, 46t, 47fCalcium hydroxide, 293, 294f, 294tapexication, and technique, 490, 491fCamouage, 572in adolescent orthodontics, 512–513Cancer, pediatric, 68–71. see also Leukemiadental and oral care considerations in, 69, 69b, 69f–70fmedical history and hematologic status in, 69–70, 70toral and dental treatment concerns in, 70–71, 71foral hygiene, diet, and caries prevention in, 70Candidiasisagents eective against, 139–140oropharyngeal, 73, 73fCaninesimpacted, dentoalveolar surgery for, 404primary, restorative dentistry of, 320–327class III adhesive restorations, 320–321, 320f–321f, 321bclass V restorations, 322full coronal coverage, 322–326, 323tprosthetic replacement of, 326–327, 326fwith resin-based composite crowns, 324, 324b, 325fwith veneered steel crowns and zirconia primary crowns, 324–326, 326fCap stage, 185, 187–188, 188f, 198bCapillary vascular malformation, 20t–21t, 22f–23fCapnography, 118, 118f, 144–145Cardiac arrest, 154management of, 154Cardiac output, 92Cardiovascular reactions, to local anesthesia, 109Cardiovascular system, 92–93, 92fanatomy of, 92drug considerations in, 91t, 92–93physiology of, 92, 92tCaries, 461–462activity, during adolescence, 593, 593fdevelopmentages 6 to 12 years and, 458–459in children with developmental disabilities, dietary prevention for, 459Behavior guidance (Continued) 620Indexin early childhood, 200–201incipient, sealing over, 466f, 468–469, 468f–469fmanagement, 452for patients older than 6 years, 590tprotocol, for infant, 203tocclusal, diagnosis of, 467–468pit and ssure, epidemiology of, 461–462reactions and operative procedures, in young permanent dentition, 482–483removal and protective liner, in young permanent dentition, 485risk assessmentin adolescents, 588–589in ages 6 to 12 years, 466in dental disease prevention, 218in patients older than 6 years, 589tCavitron Prophy-Jet, 469, 469fCavity preparation continuum, 304–305, 305fCelery, dental caries and, 417Celiac disease, 74oral manifestations of, 74Cell culture media, for avulsed teeth, 506Cellulitis, 30t–34t, 35f–39fCelluloid matrix, 603Cementoblast, 194f, 198bCementoblastoma, 48t, 49fCemento-ossifying broma, 46t, 47fCements, 294t, 301, 302tCementum, 187, 193f–195f, 198bchemical contents of, 192thereditary defects of, 61–63Central giant cell granuloma, 40t–42t, 43f–45fCentral nervous reactions, to local anesthesia, 109Centration, 263Cephalometric analysis, of primary dentition, 260, 261tCephalometric head lms, analysis of, 443–448angular and linear measurements in, 445, 446fdigitization of, 444–445, 444fmeasurement of overjet, overbite, and incisor position in, 447, 447f–448fposition of jaws in, 445, 446fprintout of data in, 445freference lines in, 445, 446fserial, to illustrate changes in, 447, 449fsoft tissue analyses in, 447, 448fvertical facial proportions in, 446, 446f–447fCephalosporins (cephams), 133, 134b, 134f, 134tCephams. see CephalosporinsCervical vertebral maturation, determination of developmental status and, 421, 423fCervicofacial cellulitis, 138–139Chemical burn, 13t–16t, 17f–19fChemically polymerized resin-based composite, 298Chemomechanical caries removal, 305Chemotherapyfor cancer, dental and oral sequelae of, 69, 69b, 69f–70f, 72missing teeth and, 426, 427fCheng Crowns, 316Cherubismairway anomalies in, 90tdental/oral anomalies in, 40t–42t, 43f–45ftooth eruption anomalies in, 63tChest wall, ventilation and, 91Child abusedental injuries and, 228neglect and, 165b–167b, 166fChild athletes, developmental evaluation of, 610–612dietary assessment in, 611–612, 612fintraoral assessment in, 611, 611fmedical assessment in, 610Child development review, in behavior guidance, 353–354, 353b–354b, 353fChildrenbehavior guidance forwith previous negative dental experience, 366–367with special health care needs, 367, 367bcontemporary practice and care of, in pediatric dentistry, 6dental public health and, 162–165barriers to care for low-income families and, 162Medicaid and, 163project Head Start and, 162–163, 163fschool based dental care and, 163–164, 164fwith special needs, orthodontics forcase study, 398.e1CHIP program, 161Chloral hydrate, 125cardiopulmonary eects of, 91tChlorhexidine, 592Chromosomal anomalies, 246Chronic inammatory gingival enlargement, 371–372, 372fChronic jaw pain, 587.e1, 587.e1fCicatrix, 13t–16t, 17f–19fCinnamon contact stomatitis, 13t–16t, 17f–19fCirculation (“C”), in management of medical emergencies, 151, 151b, 151fClarithromycin, 134–135Clark’s rule, 95Class I adhesive restorations, of primary molars, 310–311Class I amalgam restorations, of primary molars, 309–310common errors with, 311nishing, 315G.V. Black in, 309–310, 310fsteps in, 310bsummary of dierences, 311tClass II adhesive restoration, 312, 313fadjacent or back-to-back, 315common problems with, 315, 315fnishing, 315placement of restorative materials in, 314Class II amalgam restoration, of primary molars, 312adjacent or back-to-back, 314–315, 315fcommon problems with, 315, 315fnishing, 315general considerations in, 311–312, 312fmatrix application in, 312–313, 313foutline form for, 311–312steps of, 314bClass II mandibular deciency, growth modication of, 516, 516fClass II maxillary protrusion, growth modication of, 515, 515fClass III adhesive restorations, of primary incisors and canines, 320–321, 320f–321f, 321bClass III mandibular protrusion, growth modication of, 516–517, 517fClass III maxillary deciency, growth modication of, 516, 517fClass V restorations, of primary incisors and canines, 322Cleft lip and palate, 77–87causes of, 78, 78bchallenges and anomalies associated with, 80–81, 81fclassication of, 77–78, 80f–81fnumerical dental anomalies in, 51–52role of dentist in, 86team for, 77, 78ttimeline of interventions for, 79f, 82–84, 83f–86fCleidocranial dysplasia, 253, 253fhyperdontia in, 51t, 52, 52ftooth eruption anomalies in, 63tClindamycin, 133–134Clinpro, 464–465Clotrimazole, 136for oropharyngeal candidiasis, 73Coated tongue, 13t–16t, 17f–19fCodeine, 105Cognitive changesin adolescence, 557in ages 3 to 6 years, 263ages 6 to 12 years, 415infant to age 3 years, 195–197Cognitive development, 182t, 353, 353bCognitive elements, of pain perception, 100Coloration anomalies, dental, 58–60, 58t, 59fCommissural lip pits, 9t–10t, 11f–12fCommon wart, 30t–34t, 35f–39fCommunication and communicative guidance, in basic behavior guidance, 357Complete cleft, of lip, 77, 80fCompomers, 301, 314, 465Composite resin restorations, 598for diastemas, 601–603in posterior teeth, 606variety of shades in, 599veneers, 604–605Concentrated uoride agents, for home use, 456Concrete operational stage, in cognitive development, 353bConcussion, 613–614in permanent dentition, 506in primary dentition, 228Condensing osteitis, 48t, 49fCondyloma acuminatum, 30t–34t, 35f–39fCone beam computed tomography (CBCT), in determining tooth structure, 427–428, 429f, 448–450, 450f–451fCongenital epulis, 30t–34t, 35f–39fCongenital facial diplegia, airway anomalies in, 90tCongenital genetic disorders and syndromes, 244–258anomalies of the mouth and oral region, 248, 248fauricular anomalies in, 247, 248fbasic genetic concepts of, 245, 245fcase study, 258.e1fwith craniofacial anomalies, 251–257amelogenesis imperfecta, 255Apert syndrome, 256cleidocranial dysplasia, 253, 253fCrouzon syndrome, 256–257dentinogenesis imperfecta, 254–255Down syndrome, 251, 251fectodermal dysplasia, 252, 252fCaries (Continued) 621 Indexfragile X syndrome, 253–254, 254fhypophosphatasia, 256isolated hypodontia, 252–253isolated (nonsyndromic) orofacial clefts, 256osteogenesis imperfecta, 254Treacher Collins syndrome, 255, 255fVan der Woude syndrome, 255–256, 256fWilliams-Beuren syndrome, 253, 254fdental anomalies, 249–251, 249f–250f, 250bdevelopmental anomalies in, dental, 50–65. see also Dental anomaliesgenetic testing for, 257inheritance pattern, 246–247autosomal dominant, 246autosomal recessive, 246chromosomal anomalies, 246multifactorial inheritance, 246nontraditional inheritance, 246–247X-linked, 246molecular basis of, 245–246ocular anomalies, 247, 247f–248fCongenital heart disease, cyanotic, case study, 76.e1, 76.e1f–76.e2f, 76.e2bCongenital hypothyroidism, airway anomalies in, 90tConservative adhesive restorations, for primary teeth, 310–311, 311fContact allergy, 24t–25t, 26f–29fContemporary adhesive system, 598, 599fCoping, 354strategies, 100cognitive development and maturation in, 100in self-management, 101Coronal access, in root canal treatment, 493Coronal discoloration, 237–238, 238fCorticosteroid, for emergency use, 150Counselingin adolescent pregnancy, 594for thumb and nger habits, 387Cow horn mandibular forceps, use in children, 399, 400fCraniofacial anomalies, syndromes/disorders with, 251–257amelogenesis imperfecta, 255Apert syndrome, 256cleidocranial dysplasia, 253, 253fCrouzon syndrome, 256–257dentinogenesis imperfecta, 254–255Down syndrome, 251ectodermal dysplasia, 252, 252ffragile X syndrome, 253–254, 254fhypophosphatasia, 256isolated hypodontia, 252–253isolated (nonsyndromic) orofacial clefts, 256osteogenesis imperfecta, 254Treacher Collins syndrome, 255, 255fVan der Woude syndrome, 255–256, 256fWilliams-Beuren syndrome, 253, 254fCraniofacial changesin adolescence, 555–556, 556f–557f, 556tin ages 3 to 6 years, 260–262, 261f, 261tin ages 6 to 12 years, 411, 412fCraniofacial development, 181–185after birth, 184–185, 186f–187fintrauterine, 181–184, 183t, 184f–186fCretinism, airway anomalies in, 90tCri-du-chat syndrome, airway anomalies in, 90tCrohn disease, 74oral manifestations of, 74Crossbite, 275–276, 277fposterior, 433Crouzon syndrome, 256–257airway anomalies in, 90thyperdontia in, 51tCrowded teeth, treatment of, in orthodontic problems, 534–548generalized arch expansion, 546, 546fmild crowding, 539–542, 540fmoderate crowding, 542–546, 543f–546fmoderate crowding in anterior or mid arch, 542–543, 543fsevere crowding, 546–548, 547fCrownabnormalities in, 427, 429fsize and morphology of, 55Crown fracturewith pulp exposure, in young permanent dentition, 499, 499funcomplicated, management of, case study, 609.e1, 609.e1f–609.e2fCulture, in child behavior, 354–355Custom fabricated mouthguards, 612–613, 612fCustom tray vital bleaching, 606Cystic brosis, 73–74oral and dental treatment concerns in, 74DDandelion children, 354Dark discoloration, in primary dentition, 238Dark soft tissue lesions, dierential diagnosis of, 20t–21t, 22f–23fDC-TMD. see Diagnostic Criteria for Temporomandibular Disordersde Lange syndrome, airway anomalies in, 90tDeep bite, in orthodontic problems, 551Deep caries lesionscorrelation between histopathologic status of pulp and, 335–336preoperative diagnosis of, 332–334, 334f, 336fDeferred treatment, in behavior guidance, 361Denitive therapy (“D”), in management of medical emergencies, 152allergic reactions, 152–153, 153basthma, 153–154cardiac arrest, 154cardiac symptoms, 154diabetic emergencies, 154–155hyperventilation syndrome, 155seizures, 155–156syncope, 156Deletion 5p syndrome, airway anomalies in, 90tDemographics, in child behavior, 354Denovo Crowns, 316Dens evaginatus, 55, 533–534Dens in dente, 55, 55fDens invaginatus, 55, 55f, 249, 250fDental alignment problems, treatment ofxed appliances for, 534, 535f–536fetch/conditioner use in, 534, 537findirect bonding technique, 534, 537fremovable appliances, 534in orthodontic problems, 534associated with ectopic eruption, 522–525, 523f–525fassociated with tooth irregularities, 534Dental anomalies, 249–251, 249f–250f, 250bcleft lip and palate and, 81dierential diagnosis of, 9t–10t, 11f–12fDental care, access to, 161Dental caries, 169–179in ages 6 to 12 years, 416–417importance of, in transitional dentition, 416–417in children with cleft lip and palate, 81chronic disease management of, case study, 334–335, 335f, 418.e2tconsequences of, 169epidemiology of, 169–170permanent teeth, 170primary teeth, 169–170, 170f–171f, 170tfactors in, 170–172enamel, 170–172, 171f–172fmicrobiology, 172management, care pathways for, 176–177, 177f, 177t–178tother food factors of, 416–417preventing, 172–174antimicrobials for, 174diet for, 173, 173teducation and changing oral health behaviors for, 172–173uoride supplements for, 173–174, 174toptimally uoridated water for, 173professionally applied topical uoride for, 174sealants for, 174tooth brushing for, 173risk factors for, 174–176, 175t–176tdietary, 175enamel developmental defects, 176maternal, 175microbiologic, 175previous carious experience, 175socioeconomic status, 176visible plaque, 176sucrose and, 416Dental changesin adolescence, 556in ages 3 to 6 years, 262–263, 262fin ages 6 to 12 years, 412–413, 412fDental development, in age 3 yearscase study, 199.e1, 199.e1f–199.e2fchronology of, 196tpermanent dentition to age 3 years, 194primary dentition, 194–195, 195f, 197fgrowth, 186–190apposition, 190, 191f–192fbell stage, 189, 189f–190fbud stage, 187, 188fcalcication, 190–191, 192f–193f, 192tcap stage, 187–188, 188feruption, 191–193, 193f–194fhistodierentiation, 189, 189finitiation, 186–187, 187f–188fmorphodierentiation, 189–190, 190f–191fproliferation, 187–189, 188fintrauterine to age 3 years, 185–195, 187fDental disease, prevention ofin adolescence, 588–597dietary management for, 589–592uoride administration for, 592–593home care for, 592, 592frisk assessment in, 588–589, 589f, 589t–590tCongenital genetic disorders and syndromes (Continued) 622Indexrisk factors for, 593–595transitioning to adulthood, 595–596in ages 3 to 6 years, 282–292adaptive daily oral hygiene for, 286b–288b, 286f–288f, 286t–288tdietary counseling in, 289–291, 290fdietary management for, 289, 289buoride administration for, 282–286home care for, 291, 291fin ages 6 to 12 years, 452–453, 455–460diet and, 458–459uoride administration in, 455–456home care for, 456–458sealants and, 459in infants, 216–226caries risk assessment for, 218diet for, 222–223establishing a dental home, 218, 218buoride administration for, 218–222home care for, 223–224prenatal counseling for, 216–218, 217b, 217f–218fDental disease emphasis, in pediatric dentistry, 5Dental epithelium, 189, 191fDental examinationin ages 3 to 6 years, 266–277behavioral assessment for, 266–267examination of head and neck in, 268–270, 269t–270texamination of the face in, 270–273general appraisal in, 267–268, 268thistory for, 266, 267tintraoral examination in, 273–277occlusal evaluation in, 273–274, 274f–277fpatient record for, 265–266radiographic evaluation for, 277–280, 278b, 278f–280f, 280tsupplemental orthodontic diagnostic technique for, 277–280for ages 6 to 12 years, 419–454behavioral assessment in, 420facial examination in, 423–424, 423f–424fhead and neck examination in, 423history in, 419–420intraoral examination in, 424–435occlusal evaluation in, 425–435oral hygiene evaluation in, 425periodontal evaluation in, 424–425, 425fradiographic evaluation in, 449–452, 451f–452fsupplemental orthodontic diagnostic techniques in, 435–452Dental fear, in child behavior, 355Dental ossing, in adolescents, 592Dental home, 201in adolescence, to adulthood, 595establishing, 218, 218bDental lamina, 186, 187f–189f, 189–190, 198bdevelopment of, 186Dental lamina cysts, 13t–16t, 17f–19f, 205Dental materials, 293–303, 294tbases and liners, 293–295dentin-bonding agents, 295–296, 296frestorative materials, 296–301Dental neglect, case study, 168.e1, 168.e1f, 168.e2tDental oce, in successful behavior guidance, 356Dental organ, 185, 187f, 198bDental papilla, 187–188, 188f–191f, 193f, 198bDental problemsin adolescent, 572–575, 577f–578forthodontic treatment of, 394–395Dental public health issues, 159–168, 160baccess to care and, 161–162barriers to care for low-income families and, 162challenge of adolescence and, 164–165children and, 162–165denition of, 159federally qualied health centers and, 162Medicaid and, 161, 163pediatric dental benet within Aordable Care Act and, 161–162project Head Start and, 162–163, 163frole of individual practitioner in, 159school based dental care and, 163–164, 164fDental sac, 187, 198bDental team, in successful behavior guidance, 356Dental traumain adolescence, 567, 568fmanaging sequelae to, 504–506orthodontic considerations in, case study, 454.e1, 454.e1f, 454.e2t, 454.e3ftreatment of, in orthodontic problems, intrusion, 544f, 551, 551fDentigerous cyst, 40t–42t, 43f–45fDentincalcication of, 190chemical contents of, 192tdevelopment of, 189, 191fhereditary defects of, 61Dentin-bonding agents, 295–296, 296fDentin dysplasia, 61, 249, 250fDentin matrix, 482Dentinoblast, 185, 198bDentinocemental junction, 190Dentinogenesis, 329–330reparative, 330, 483response to injury, 330, 330fDentinogenesis imperfecta, 61, 61t, 62f, 254–255Dentin-pulp complex, 329, 482–483Dentistrole of, in cleft lip and palate, 86in successful behavior guidance, 356Dentistry, pediatric. see Pediatric dentistryDentition, developmental stage of, determination of developmental status and, 421Dentoalveolar surgery, for impacted canines, 404Desensitization, in behavior guidance, 361Developing dentition, anomalies of, 50–65of morphology, 54–57of size, 53–54in tissue composition and structure, 58–63, 58fin cementum, 61–63in coloration, 58–60, 58t, 59fin dentin, 61in enamel, 60–61, 60f, 60tof tooth eruption, 63, 63tof tooth number, 50–53Developmental anomalies, in congenital disorders and syndromes, dental, 50–65. see also Dental anomaliesDevelopmental characteristics, of 3- to 6-year-old child, 268tDevelopmental milestones, for children from birth to age 3 years, 205Developmental space, 274, 274fDevelopmental statusof adolescent, 565determination of, in ages 6 to 12 years, 420–423Dexterity, changes in, ages 6 to 12 years, 455Diabetes mellitus, 154periodontal problems in, 376Diabetic emergencies, 154–155management of, 155Diagnostic casts, 435–443Diagnostic Criteria for Temporomandibular Disorders (DC-TMD), 576Diastemas, restoration of, 601–604clinical technique in, 603–604, 603fDiazepam (Valium), 125cardiopulmonary eects of, 91tDietfor dental caries, 173, 173tdental disease prevention and, 222–223Dietary counseling, dental caries and, in ages 6 to 12 years, 417Dietary uoride supplementation, 219–221, 220b, 221t, 282–283, 283tprescription, 220bDietary habit, development of, in ages 6 to 12 years, 459Dietary management, for dental disease, 589–592Dierential diagnosis, 8of dark soft tissue lesions, 20t–21t, 22f–23fof developmental anomalies, 9t–10t, 11f–12fof mixed radiolucent and radiopaque lesions of bone, 46t, 47fof radiolucent lesions of bone, 40t–42t, 43f–45fof radiopaque lesions of bone, 48t, 49fof soft tissue enlargements, 30t–34t, 35f–39fof ulcerative lesions, 24t–25t, 26f–29fof white soft tissue lesions, 13t–16t, 17f–19fDigital casts, 437, 438fDiphenhydramine (Benadryl), 125cardiopulmonary eects of, 91tDiprivan. see PropofolDirect observation, in basic behavior guidance, 360Direct pulp cappingin normal pulp/reversible pulpitis, 339–340, 339fin permanent dentition, after traumatic pulp exposure, 499technique of, 487in young permanent dentition, 485–487, 487fDirect veneers, 605–606, 606fDisclosing tablets or solutions, 457, 457fDiscolored teeth, restoration of, 604–606hypoplastic spots, 604, 604fveneers, 604–606vital bleaching, 606white spot lesions, 604, 604fDisking, of primary teeth, 539–542, 540fDistraction, in basic behavior guidance, 359, 360tDiurnal bruxism, 579DNA triplet repeat expansion, 245–246Down syndrome, 251airway anomalies in, 90thyperdontia in, 51thypodontia in, 52–53periodontal problems in, 376taurodontism in, 57tDrug-induced gingival enlargement, 372–373, 373fDental disease, prevention of (Continued) 623 IndexDrying agents, 471, 472fDynamics of change, 555–561in age 3 years, 181–199body, 181, 182f, 182t–183tcognitive, 195–197craniofacial, 181–185dental, 185–195, 187femotional, 197–199physical, 181–195social, 199in ages 3 to 6 yearscognitive changes in, 263craniofacial changes in, 260–262, 261f, 261tdental changes in, 262–263, 262femotional changes in, 263physical changes in, 260–263social changes in, 263–264cognitive changes in, 557emotional changes in, 557physical changes, 555–556body, 555craniofacial changes, 555–556, 556f–557fdental changes, 556social changes in, 557–560bullying, 558gender identity, 560risky behaviors, 559–560sexual activity, 559–560smoking/vaping, 559suicide, 558–559Dyract eXtra, 309Dysmorphic syndrome, 247Dysmorphologist, 247–251EEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, 161–162Early childhood caries (ECC)break the cycle of, 200–201treatment of, 5Early Head Start, 162, 163fEars, extraoral evaluation of, in adolescent, 564tEating disorders, in adolescence, 564ECC. see Early childhood cariesEcchymosis, 20t–21t, 22f–23fEctoderm, 185, 187f–193f, 198bEctodermal dysplasia, 252, 252fhypodontia in, 52–53microdontia in, 54taurodontism in, 57tEctopic eruption, 429, 430fof rst permanent molarscase study, 553.e1, 553.e1f–553.e2f, 553.e1tand space maintenance, treatment of, 522–525, 523f–525flateral incisors, 524molar, 522, 523fElastomeric tape, for cleft lip and palate, 82, 82fEmergency dental kit, 614bEmergency telephone call, 236Emotional changesin adolescence, 557in ages 3 to 6 years, 263in ages 6 to 12 years, 415infant to age 3 years, 197–199Enamel, 170–172, 171f–172fcalcication of, 190chemical contents of, 192tformation of, 189, 189f, 191f–192ffractures, in young permanent dentition, 498hereditary defects of, 60–61, 60f, 60tneonatal line in, 193fEnamel and dentin fractures, in young permanent dentition, 498–499, 499fEnamel-bonding agents, 299, 300fEnamel hypocalcication, 60–61Enamel hypoplasia, 60–61, 249, 250fEnamel organ, 198bEnamel pulp, 188, 198bEnamel renal syndrome, tooth eruption anomalies in, 63tEndodontic treatment, 533, 533fEndogenous opioid system, 99Energy drink, 590in child and adolescent athletes, 611–612Environment, in child behavior, 354–355, 355tEpigenetic mechanisms, 247Epinephrine, 150eect of local anesthesia and, 108pediatric dosage of, in asthma, 153–154toxic eects of, 108EpiPen, 153. see also EpinephrineEruption, of permanent dentition, 191–193, 193f–194f, 198bages 6 to 12 years, 412, 412fangulation of teeth during, 412, 414fcause of, 193ectopic, 429, 430fof rst permanent molars, 553.e1, 553.e1f–553.e2f, 553.e1tproblems associated with, 522–525, 523f–525fguidance of, 547impaction in, 431, 432fmidline diastema during, 431–433, 432fprimary failure of, 431, 432fradiographic evaluation in, 449–452, 451f–452ftransposition in, 431, 431fugly duckling stage during, 413, 414f, 431–433, 433fEruption hematoma and cyst, 20t–21t, 22f–23fErythema migrans, 20t–21t, 22f–23fErythema multiforme, 24t–25t, 26f–29fErythematous candidiasis, 20t–21t, 22f–23fErythromycin, 134Escape, in behavior guidance, 361Esters, for local anesthesia, 107Esthetics, in space maintenance, 379Etch-and-rinse adhesive systems, 598Etch-bleach-seal technique, 604Ethyl-vinyl acetate (EVA), in custom fabricated mouthguards, 612–613Excretory function, 93Exfoliation, of primary dentition, 412Exostosis, 9t–10t, 11f–12fExtracellular uid (ECF), 94Extraction forceps, 399, 400fExtraoral evaluation, of adolescent, 564tExtraoral examination, in clinical pulpal diagnosis, 331–332, 332f–333fExtreme anxiety, in adolescence, 564Extrusionin primary dentition, 228, 229fin young permanent dentition, 506, 507f, 509fFFaces Pain Scale-Revised (FPS-R), 101–102, 102fFacial examinationin adolescent, 565in ages 3 to 6 years, 270–273facial symmetry, 273, 273flip position, 272–273, 273foverall facial pattern in, 270–271, 271fpositions of the maxilla and mandible, 271, 272fvertical facial relationship, 271–272, 272fin ages 6 to 12 years, 423–424, 423f–424fFacial fractures, oral surgery for, 404, 405bFacial injuries, oral surgery of, 404, 404fFacial space infections, 138–139Facial symmetry, 273, 273fFaciolingual movement, of incisors, 386, 387fFamilial brous dysplasiaairway anomalies in, 90tdental/oral anomalies in, 40t–42t, 43f–45fFamilylow-income, dental care for, 162role of, in pediatric dentistry, 2–3Fear(s), 101of separation from parents, 263Federally qualied health centers (FQHCs), 162Fermentable carbohydrates, 417Fibrous dysplasia, 48t, 49fFilled resin-based composite, 294tFine motor activity, development of, 456Fine-pointed burs, in restoration, 601Firm dentin, 337, 484selective removal to, 337Fissured tongue, 9t–10t, 11f–12fFixed bilateral appliances, for space maintenance, 381–382, 382fFixed orthodontic appliances, 537–538, 538ffor anterior crossbite, 548–549, 548fetch/conditioner use in, 534, 537findirect bonding technique in, 534, 537ffor midline diastema, 535, 539fremovable appliances, 534Fixed unilateral appliances, for space maintenance, 380–381, 381fFLACC (Face, Legs, Activity, Cry, Consolability), 101, 101t, 103tFlossing, in ages 6 to 12 years, 458, 458fFluconazole, 136Flumazenil, 125Fluoridation, water, 219, 455Fluoride administrationin adolescence, 592–593in ages 3 to 6 years, 282–286cost-benet considerations for, 284–285dietary, 282–283, 283tmethod of, 285–286professional application of, 283–284, 284f, 285tprophylaxis before, 285topical, 283in ages 6 to 12 years, 455–456for dental disease prevention, 218–222dietary, 219–221, 220bmechanisms of action of, 219rationale for, 218–219safety and toxicity of, 222systemic, 219–221topical, 221–222 624Indexsystemic, 455topical, 456Fluoride mouth rinses, 456, 593Fluoride mouth rinsing (FMR), 163Fluoride protection, optimal, for infant, 201Fluoride supplementsfor dental caries, 173–174, 174tdietary, 219–221, 220b, 221tFluoride toothpastes, 456Fluoride toxicity, case study, 292.e1, 292.e1t, 292.e2fFluoride varnish, 221–222sealant versus, for reduction of occlusal caries, 466Fluoride-releasing sealants, 465Fluoroquinolones, 135Fluorosis, 59, 59f, 220, 220fFMR. see Fluoride mouth rinsingFocal melanosis, 20t–21t, 22f–23fFocal sclerosing osteomyelitis, 48t, 49fFordyce granules, 13t–16t, 17f–19fFormal operations, in cognitive development, 353bFormocresol, potential substitutes for, 342–343FPS-R. see Faces Pain Scale-RevisedFQHCs. see Federally qualied health centersFracture treatmentpathologic sequelae of, 498in young permanent dentitioncrown fractures with pulp exposure, 499, 499fenamel and dentin fractures, 498–499enamel fracture, 498posterior crown fractures, 502, 504froot fractures, 502–504Fracturesanterior teeth, restorations for, 601, 602ffacial, oral surgery for, 404, 405bprimary tooth roots, management of, 403, 403fFragile X syndrome, 253–254, 254fFrankfort horizontal plane, 445, 446f–447fFRC. see Functional residual capacityFree tongue, 385.e1Frenal attachments, types of, 424–425, 425bFrenectomy techniquefor ankyloglossia, 407–409, 407f–408fcomplications of, 409Frenotomy techniquefor ankyloglossia, 407complications of, 409Frictional keratosis, 13t–16t, 17f–19fFried’s rule, 95Friendship, in ages 6 to 12 years, 416Full coronal coverageof incisors, 322–326, 323tof primary molars, 316–320, 316f, 319findications for, 317bplacement of adjacent crowns, 316in space loss, 316–320, 320fsteps of, 318b–319bFull mouth survey, in adolescent, 571tFunctional residual capacity (FRC), 91Fungal infections, agents eective against, 139–140Furred tongue, 13t–16t, 17f–19fFused primary teeth, 274–275, 275fFusion, dental, 54treatment of, 533GGardner syndrome, hyperdontia in, 51–52, 51tGarré osteomyelitis, 46t, 47fGastric pH, 93Gastrointestinal system, 93, 93fGelatin sponge, 401Gelfoam, 401Gemination, 54Gender identityin adolescence, 560in pediatric dental patientscase study, 561.e1, 561.e1f, 561.e2tGeneral anesthesiain behavior guidance, 362in behavior management, 119for dental care, 3–5General appraisalof adolescent, 565of ages 3 to 6 years, 267–268of ages 6 to 12 years, 420–423Generalized aggressive periodontitis, 375Genetic concepts, 245GFR. see Glomerular ltration rateGiant cell broma, 30t–34t, 35f–39fGingiva, intraoral evaluation of, in adolescent, 564tGingival cysts, of newborn, 13t–16t, 17f–19fGingival bromatosis, 30t–34t, 35f–39fGingival index (GI), 424–425Gingivitis, 371, 372fGlass ionomer cement, 293–295, 295fGlass ionomer liner, 600, 601fGlass ionomer sealants, 465bonding mechanism of, 464Glass ionomers, in resin based composites, 309Glomerular ltration rate (GFR), 93–94Glucose, for hypoglycemic shock, 150Glucuronyltransferase, 93Glutaraldehyde (GA), 342Glycogen storage disease II, airway anomalies in, 90tGoldenhar syndrome, airway anomalies in, 90tGorlin cyst, 46t, 47fGrowth chart, 421, 422f–423fGrowth modication, orthodonticin anteroposterior problems, 514class II mandibular deciency, 516class II maxillary-protrusive, 514–515, 514fclass III mandibular protrusion, 516–517, 517fclass III maxillary deciency, 516, 517fapplied to transverse problems, 518, 518fin vertical skeletal problems, 519, 519fGrowth spurt, 555Guidance of eruption, 547Gum chewing, caries prevention and, 459Gymnasts, dietary assessment in, 611HHabitsand infant oral health, 201oral, 386–393bruxism, 391–392, 392flip habits, 390, 390fmouth breathing, 391fnail biting, 391pacier habits, 389–390, 389fthumb and nger habits, 386–389, 387f–389ftongue thrust, 390–391Hair, extraoral evaluation of, in adolescent, 564tHairy tongue, 13t–16t, 17f–19fHalcion. see TriazolamHandpiece, for caries removal, 304Hand-wrist radiographs, determination of developmental status and, 421Hard dentin, 337, 484nonselective removal to, 337Hard tissue problems, in adolescence, 566–567, 567f–568fHarmful microora, disrupt the acquisition of, 201HATLFF. see Hazelbaker assessment tool for lingual frenulum functionHawley retainer, 538fHazelbaker assessment tool for lingual frenulum function (HATLFF), 406Head and facial developmentafter birth, 184, 186fintrauterine, 181, 183tHead and neck examinationin adolescent, 565in ages 3 to 6 years, 268–270, 269t–270tin ages 6 to 12 years, 423Head Start program, dental care under, 162–163, 163fHeadgearchin cup, for class III mandibular protrusion, 516–517, 517ffor class II maxillary protrusion, 514–515high-pull, for vertical growth modication, 519, 519freverse-pull, for class III maxillary deciency, 516, 517fHealth issues, treatment planning for, 453Health supervision, in infant oral health, 202–203Heat-pressure laminated mouthguards, 612–613Heck disease, 30t–34t, 35f–39fHeight, measurement of, determination of developmental status and, 421Hemangioma, 30t–34t, 35f–39fHematoma, 20t–21t, 22f–23fHematopoietic stem cell transplantation, 72dental and oral care considerations in, 72Hemifacial microsomia, airway anomalies in, 90tHemophilia A, 67Hepatic metabolism, 93Hepatic system, 93Herbst appliance, 516Herpetic gingivostomatitis, primary, 24t–25t, 26f–29f, 72–73, 139antiviral drugs for, 139management of, 73Herpetic infections, antiviral agents for, 139Herpetic ulcer, secondary, 24t–25t, 26f–29fHertwig epithelial root sheath, 191, 198bHigh-carbohydrate diets, in child and adolescent athletes, 611High-frequency uoride, administration of, in adolescence, 593High volume suction device, 147, 147fHighly concentrated uoride agents, administration of, in adolescence, 593Histiocytosis, periodontal problems in, 377Histiocytosis X, 40t–42t, 43f–45fHistodierentiation, 189, 189f, 198bHistory. see Patient historyHome carein adolescence, for dental disease, 592, 592ffor ages 6 to 12 years, 456–458for infants, for dental disease prevention, 223–224Human Genome Project, 244–245ethical, legal, and social implications of, 257Fluoride administration (Continued) 625 IndexHunter syndrome, airway anomalies in, 90tHurler syndrome, airway anomalies in, 90tHutchinson incisors, 54–55Hybrid composite resins, 598Hybrid resin-based composite, 300f, 301Hydrochloric acid, in restorations, for posterior teeth, 606Hydrocortisone (Solu-Cortef), 150Hydroxyzine (Vistaril), 125cardiopulmonary eects of, 91tHyperbilirubinemia, dental coloration in, 58–59, 59fHypercementosis, 57Hyperdontia, 51–52, 51f–52fsyndromes demonstrating, 51tHyperplastic labial frenum, 9t–10t, 11f–12fHypertrophy, of tonsils, 88–90, 89fHyperventilation syndrome, 155management of, 155Hypodontia, 52–53, 53f, 247cleft lip and palate and, 81hereditary traits associated with, 52tHypoglycemic shock, treatment of, 150Hypophosphatasia, 256cementum formation in, 61–63, 62fperiodontal problems in, 376, 376fHypoplastic molar, 607–608, 607fHypoplastic spots, restoration of, 604, 604fHypoplastic teeth, management of, case study, 609.e3, 609.e3f–609.e4fIIbuprofen, 104, 104tIdiopathic osteosclerosis, 48t, 49fIllicit drug use, in adolescence, 564Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), 614–615ImPACT. see Immediate Post-Concussion Assessment and Cognitive TestImpacted canines, dentoalveolar surgery for, 404Impacted permanent dentition, treatment of, 526, 527fImpaction, missing teeth and, 426, 426fIncipient caries, sealing over, 466f, 468–469, 468f–469fIncisorsfaciolingual movement of, 386, 387fHutchinson, 54–55lateral, missing, 528f, 529lateral permanent, ectopic eruption and space maintenance, 524permanent, lingual eruption of, 431, 431fposition ofin ages 6 to 12 years, 424cephalometric analysis of, 447, 447f–448fprimary, restorative dentistry of, 320–327class III adhesive restorations, 320–321, 320f–321f, 321bclass V restorations, 322full coronal coverage, 322–326, 323tprosthetic replacement of, 326–327, 326fwith resin-based composite crowns, 324, 324b, 325fwith veneered steel crowns and zirconia primary crowns, 324–326, 326fprotrusion, 549–550orthodontic treatment of, 396, 396fretrusion, orthodontic treatment of, 396, 396fIncomplete cleft, of lip, 77, 80fIncremental lines of Retzius, 190, 192f–193fIndirect pulp treatmentof normal pulp/reversible pulpitis, 337–339, 339fin young permanent dentition, 485, 486f–487fIndirect veneer technique, 605Individual practitioner, role of, in dental public health issues, 159Infant oral health, 200caries management protocols for, 203tconcepts of, 201–203as diagnostic process, 203–204goals of, 200–201oce readiness for, 211oral examination and assessment of clinical risk factors, 205, 208toral health visit in, 204–208anticipatory guidance in, 206–208, 208b–209b, 209t–210toral examination and assessment of clinical risk factors, 205, 205f, 206t, 208trisk assessment in, 204–205, 204brisk proling in, 205–206responsibility of nondental professionals regarding, 211–213, 212trisk assessment for, 201–202, 202f, 204–205, 204brisk proling in, 205–206visits, elements of, 204–208Infant orthopedics, 81–82, 82f–83fInfantile gigantism, airway anomalies in, 90tInfantsbehavior guidance for, 365–366, 366fdental care for, 162dental disease prevention for, 216–226caries risk assessment for, 218diet for, 222–223establishing a dental home, 218, 218buoride administration for, 218–222home care for, 223–224prenatal counseling for, 216–218, 217b, 217f–218fdynamics of change in, 181–199plaque removal innovations for, 224b, 224fInammatory papillary hyperplasia, 30t–34t, 35f–39fInammatory resorption, in young permanent dentition, 504–505, 505fInformed consent, in behavior guidance, 364–365, 365bInheritance patterns, in congenital genetic disorders, 246–247Initiation, 198bInstrumentation, in root canal treatment, 493Integument, 95Intermediary bases, 294tIntermediate bonding agent, 473Internal distractors, for cleft lip and palate, 84, 86fInterproximal brush, use of, 592fInterproximal dental sealants, 474Intestinal motility, 93Intracanal dressing, in root canal treatment, 493Intracellular uid (ICF), 94Intramuscular route, of sedative, 123, 123fabsorption of, 123advantages of, 123disadvantages of, 123eect of, 123lack of intravenous access of, 123liability costs in, 123onset of, 123technical advantages of, 123trauma at injection site in, 123Intranasal route, of sedatives, 122–123absorption of, 122advantages of, 122disadvantages of, 122–123discomfort in, 122–123eect of, 123liability costs in, 123onset of, 122technical advantages of, 122, 123fIntraoral examination, 273–277in adolescent, 564t, 566in ages 6 to 12 years, 424–435in clinical pulpal diagnosis, 331–332, 332f–333fIntraoral piercings, in adolescence, 593–594, 594fIntraoral vacuum system, 599–600, 600fIntrauterine growth and development, 181–184, 183t, 184f–186fIntravenous route, of sedatives, 124advantages of, 124disadvantages of, 124intravenous access of, 124liability costs in, 124patient monitoring in, 124potential complications in, 124technical disadvantages of, 124test dose of, 124titration in, 124Intrusion, dentalcomplications following, 240–241, 241fin orthodontic problems, 551, 551fin primary dentition, 228, 229fin young permanent dentition, 509fIntrusive luxation, in young permanent dentition, 506, 506fIrreversible pulpitis, 236Irrigation, in root canal treatment, 493Irritation broma, 30t–34t, 35f–39fIsolated hypodontia, 252–253Isolated (nonsyndromic) orofacial clefts, 256Isolation, of tooth, in sealant application, 472–473, 472b, 473f, 475fIsolite system, 599–600Isthmus, in root canal treatment, 493Itraconazole, 136JJaw pain, chronic, 587.e1, 587.e1fJuvenile aggressive bromatosis, 30t–34t, 35f–39fKKaryotype, 245fKeratocystic odontogenic tumor, 40t–42t, 43f–45fKetac Nano, 309Ketalar. see KetamineKetamine (Ketalar), 126cardiopulmonary eects of, 91tKlinefelter syndrome, taurodontism in, 57tKlippel-Feil syndrome, airway anomalies in, 90tKor bers, 189, 191fKotlow classication, 385.e1, 385.e1fIntramuscular route, of sedative (Continued) 626IndexLLaboratory-fabricated veneers, 605, 605fLangerhans cell histiocytosis, 40t–42t, 43f–45fLanguage development, 182tLaser frenectomy, 378.e1Laser techniques, for caries removal, 305Lateral luxationin primary dentition, 228, 230fin young permanent dentition, 506, 507fLatham appliance, for cleft lip and palate, 82, 82fLearning theory, 353Leathery dentin, 337, 484LEMON law, 96.e4tLesionsacute inammatory, 30t–34t, 35f–39fdierential diagnosis of, 8dark soft tissue, 20t–21t, 22f–23fmixed radiolucent and radiopaque, of bone, 46t, 47fradiolucent, of bone, 40t–42t, 43f–45fradiopaque, of bone, 48t, 49fulcerative, 24t–25t, 26f–29fwhite soft tissue, 13t–16t, 17f–19ftumor and tumorlike, 30t–34t, 35f–39fLeukemiaacute lymphoid, 69periodontal problems in, 377Leukocyte adhesion deciency, periodontal problems in, 376Leukoedema, 13t–16t, 17f–19fLeukoplakia, in adolescent athletes, 611, 611fLidocaine, 107, 107tLife cycle of tooth, 195f. see also Dental developmentLift the lip technique, 163fLight-activated composite resins, polymerization of, 598Light-curing polymerization unit, 598, 600fLight-emitting diode (LED) curing lights, 471Light-emitting diodes (LEDs), in light-curing polymerization unit, 598, 600fLinea alba, 13t–16t, 17f–19fLingual arch appliance, for mild crowding of immature permanent dentition, 542, 542fLingual eruption, of permanent incisors, 431, 431fLingual frenum, 374, 374fLingual thyroid, 9t–10t, 11f–12fLip and cheek retractor, 599–600, 600fLip bumper, 545, 545fLip habits, 390, 390fLip position, 272–273, 273fin ages 6 to 12 years, 424, 424fLocal and systemic diseases, oral and dental care of, 66–76cancer, 68–71celiac disease, 74complications of cancer chemotherapy and radiation therapy, 72, 72fCrohn disease, 74cystic brosis, 73–74hematopoietic stem cell transplantation, 72hemophilia A, 67–68oropharyngeal candidiasis, 73osteoporosis, 68primary herpetic gingivostomatitis, 72–73sickle cell disease, 66–67von Willebrand disease, 67–68Local anesthesiaagents, 107cardiovascular system reactions to, 109case study, 115.e1central nervous reactions to, 109complications of, 112–113, 113fduration of, 108excretion of, 107injection technique in, 110–112, 110fmechanism of action of, 106, 106fneedle selection in, 110onset time of, 107–108operator technique in, 109–112pain control with, 105–107potency of, 107properties, 107–108, 107tregional technique in, 108–109dose of, 108, 108bduration of, 108onset of, 108toxicity of, 109vasoconstrictors and eect of, 108–109Localized aggressive periodontitisin permanent dentition, 374–375, 375fin primary dentition, 375–376, 375fLocalized juvenile spongiotic gingival hyperplasia, 30t–34t, 35f–39fLong QT interval syndrome, 131Low-concentration uoride, administration of, in adolescence, 593Low-income families, dental care for, 162Lung infrastructure, 91Luxation (displacement) injuries, in young permanent dentition, 506–508Lymphangioma, 30t–34t, 35f–39fLymphatic malformation, 30t–34t, 35f–39fLymphoepithelial cyst, oral, 13t–16t, 17f–19fMMacrodontia, 54, 54f, 249, 249fMacrolled resin-based composite, 300f, 301Macrolides, 134–135Mallampati classication, 281.e1bMalocclusionin primary dentition, thumb and nger habits and, 386treatment of, in adolescent, 572Mandible, assessment of, 271, 272fMandibular anterior teeth, extraction of, 402Mandibular deciency, class II, orthodontic appliances, 516Mandibular fractures, signs and symptoms of, 405bMandibular growth, in adolescence, 556Mandibular labial frenum, 374Mandibular molar extractions, 402, 402fMandibular protrusion, class III, orthodontic, appliances, 516–517, 517fMandibular tooth anesthesia, 111–112, 112fMandibulofacial dysostosis, airway anomalies in, 90tMaxilla, assessment of, 271, 272fMaxillary anterior teeth, extraction of, 402, 402fMaxillary arch expansion, for cleft lip and palate, 84, 84fMaxillary changes, in adolescence, 555–556Maxillary constriction with posterior crossbite, orthodontic appliances, 518, 518fMaxillary deciency, class III, orthodontic appliances, 516, 517fMaxillary midline frenum, 373–374, 373fMaxillary molar extraction, 401–402, 402fMaxillary or midface fractures, signs and symptoms of, 404, 405bMaxillary posterior crossbite, orthodontic appliances, 518, 518fMaxillary primary and permanent incisor and canine anesthesia, 111, 111fMaxillary primary and permanent molar anesthesia, 111, 111fMaxillary protrusion, class II, orthodontic appliances, 514–515, 514fMedian rhomboid glossitis, 20t–21t, 22f–23fMedicaiddental participation in, 161dental programs of, 163Medical consultation, 143Medical emergencies, 142–158drugs in, 147–150, 147f, 148t–149t, 150faspirin, 150epinephrine, 150glucose, 150other, 150equipment for, 146–150, 146t, 147fmanagement of, 150–152, 150bairway, 151–152, 151fbreathing, 152, 152fcirculation, 151, 151b, 151fdenitive therapy, 152in pediatric dental oce, 142–143morbidity of, 142mortality of, 142Swiss cheese model and, 142–143, 143fpositioning in, 150preparation for, 145–150backup medical assistance, 146personal, 146sta, 146prevention of, 143–145history and physical examination in, 143, 144f–145fmedical consultation in, 143patient monitoring in, 144–145, 145fsugar in hypoglycemic, 150Medical history, in clinical pulpal diagnosis, 331Melanocytic nevus, 20t–21t, 22f–23fMelanotic macule, oral, 20t–21t, 22f–23fMelanotic neuroectodermal tumor of infancy, 40t–42t, 43f–45fMemory restructuring, in basic behavior guidance, 360–361Menarche, determination of developmental status and, 421Meperidine (Demerol), 125cardiopulmonary eects of, 91tMepivacaine, 107, 107tMesenchyme, 187, 187f, 198bMesoderm, 187, 187f, 198bMethohexital, 125Methylprednisolone (Solu-Medrol), 150Metronidazole, 135Miconazole, 136Microbiology, caries, 172Microdontia, 54, 54f, 249, 249fMicrolled resin-based composite, 300–301, 300fMicrolled resins, 598Midazolam (Versed), 125cardiopulmonary eects of, 91t 627 IndexMidline diastemaduring eruption of permanent dentition, 431–433, 432fin orthodontic problems, 535, 539fxed appliances, 535, 539fMidline discrepancy, 275Mild class II mandibular deciency, camouage for, 572, 573fMineral trioxide aggregate (MTA), 486–487apexication using, and technique, 492, 492fin pediatric dentistry, 5short-term apexication with, 490–492Missing permanent teeth, treatment of, 526–532, 528f–529f, 531f–532fankylosed primary molar extraction, 531avoiding prosthetic replacements, 530flateral incisors, 528f, 529premolars, 530–531, 530fMixed martial arts, requiring mouthguards, 613Mixed radiolucent and radiopaque lesions, of bone, dierential diagnosis of, 46t, 47fMoebius syndrome, airway anomalies in, 90tMolar extractionankylosed primary, 531mandibular, 402, 402fmaxillary, 401–402, 402fprimary, case study, 409.e1, 409.e1fMolar incisor root malformation, 55, 56fMolar loss, in primary dentition, and space maintenance, 522Molar-incisor hypomineralization, 59–60, 59fMolarsand canines, relationships in, permanent dentition and, 433ectopic eruption and space maintenance, 522, 523fmulberry, 54–55primary, restorative dentistry of, 309–320adhesive materials in, 309adjacent or back-to-back class restorations, 314–315, 315famalgam use in, 309class I adhesive restoration, 310–311, 311f, 311tclass I amalgam preparation design, 309–310, 310b, 310f, 311tclass II adhesive restoration, 312, 313fclass II amalgam preparation design, 312, 312ffull coronal coverage, 316–320, 316f, 317b–319b, 319f–320fliners and bases in, 311Molecular basis of disease, in congenital genetic disorders, 245–246Monolithic zirconia, 301Morphine, cardiopulmonary eects of, 91tMorphodierentiation, 189–190, 190f–191f, 198bMorsicatio mucosae oris, 13t–16t, 17f–19fMostellar formula, 95Motor skill acquisition, median age and range in, 183tMouth and oral region, anomalies of, 248, 248fMouth breathing, 391fMouth props, in behavior guidance, 362, 363fMouth protection, 610–616for child and adolescent athletes, 612–613Mouth-formed mouthguard, 612f, 613Mouthguards, 612–613, 612fin sports-related dental traumacase study, 616.e1, 616.e1f–616.e2ftype I, 612–613type II, 613type III, 613, 613f, 614tMTA. see Mineral trioxide aggregateMucocele, 30t–34t, 35f–39fMucopolysaccharidosistooth eruption anomalies in, 63ttype I, airway anomalies in, 90ttype II, airway anomalies in, 90tMucosa, intraoral evaluation of, in adolescent, 564tMucosal cyst, panoramic radiograph in, 570fMucosal neuromas, 30t–34t, 35f–39fMulberry molars, 54–55Multifactorial inheritance, 246Multifocal epithelial hyperplasia, 30t–34t, 35f–39fMutans streptococci, disrupting acquisition of, 201NNafcillin, 132Nail biting, 391Naloxone, 125–126NAM. see Nasoalveolar moldingNance arch, for treatment of crowded teeth, 542Nanolled resin-based composite, 300f, 301Nanolled resins, 598Naproxen, 104Narcotic analgesics, 105Nasoalveolar molding (NAM)for cleft lip and palate, 82, 83fpresurgical, case study, 87.e1, 87.e1f–87.e2fNaso-labial (lip) adhesion, for cleft lip, 82Natal and neonatal teeth, 207f, 207tNeck, extraoral evaluation of, in adolescent, 564tNecrotizing ulcerative gingivitis (NUG), 138, 376Necrotizing ulcerative periodontitis (NUP), 138Necrotizing ulcerative stomatitis (NUS), 138Neglecting parenting styles, 355tNeonatal line (neonatal ring), 190, 193fNeuroectodermal tumors of infancy, 205Neurobroma, 30t–34t, 35f–39fNeurobromatosis, airway anomalies in, 90tNeuromatrix, pain perception and, 99, 99fNeurosignature, 99Neutropenia, periodontal problems in, 377Nicotine replacement therapy (NRT), 595Nitrous oxide/oxygen sedationadministration of, 120advantages of, 120–121adverse eects of, 121in basic behavior guidance, 361cardiopulmonary eects of, 91tcontraindications to, 121disadvantages of, 121ease of control of, 120–121equipment for, 121inconvenience in, 121lack of patient acceptance, 121potential chronic toxicity to, 121potentiation of, in use with other sedatives, 121rapid onset and recovery time for, 120weak agent, 121Nocturnal bruxism, 579Nonnarcotic analgesics, 103Nonnutritive sucking habits, 210–211eects and mechanisms of, 211origins of, 210prevalence of, 210–211recommendations for, 211Nonorthodontic problemsdiagnosis of, 265treatment planning for, 280–281, 569–572, 570fcase study, 281.e1, 281.e1b, 281.e1f–281.e3fNonsteroidal antiinammatory drugs (NSAIDs), 104, 104tNontraditional inheritance, 246–247Nonverbal behavior guidance, 358–359Normal pulp/reversible pulpitis, pulp therapy for, 336–347direct pulp capping in, 339–340, 339findirect, 337–339, 339fprotective base in, 337pulpectomy and root lling, 343–347, 344f–346fpulpotomy in, 340, 341f–343fNRT. see Nicotine replacement therapyNSAIDs. see Nonsteroidal antiinammatory drugsNUG. see Necrotizing ulcerative gingivitisNumerical anomalies, of developing dentition, 50–53NUP. see Necrotizing ulcerative periodontitisNUS. see Necrotizing ulcerative stomatitisNuSmile Primary Crowns, 316Nystatin, 135Nystatin oral suspension, for oropharyngeal candidiasis, 73OObservational/behavioral assessment tool, 101Obturation, in root canal treatment, 493Occlusal evaluationin adolescence, 568, 569fin ages 3 to 6 years, 273–274alignment in, 274–275, 274f–275fanteroposterior dimension in, 275, 276fvertical dimension in, 276–277, 276f–277fin ages 6 to 12 years, 425–435alignment in, 425–426anteroposterior dimension in, 433, 434f–435ftooth number in, 426, 426f–427ftooth position in, 429–433, 429ftooth structure in, 426–428, 428f–429ftransverse relationship in, 433vertical dimension in, 433–435Ocular anomalies, 247, 247f–248fOculodentodigital dysplasiahyperdontia in, 51ttooth eruption anomalies in, 63tOdontoblasts, 189–190, 191f, 194f, 198b, 329Odontoclast, 198bOdontogenic infections, surgery in, 405, 405fOdontogenic keratocyst, 40t–42t, 43f–45fOdontoma, 426, 427fcompound and complex, 48t, 49fOMIM. see Online Mendelian Inheritance in ManOnline Mendelian Inheritance in Man (OMIM), 251Onset time, of local anesthetics, 107–108regional technique and, 108Opaquing agents, in direct veneers, 606Open bitein immature permanent dentition, 433–434orthodontic treatment of, 398Operative diagnosis, of pulp, 334–335, 334f–335fOpiate receptors, 100Mouthguards (Continued) Nonnutritive sucking habits (Continued) 628IndexOpioid analgesics, 105Opioid peptides, endogenous, 99Opioids, 125–126, 125t“OPQRSTU” mnemonic, for pain symptoms, 581, 581tOptimally uoridated water, for dental caries, 173Oral cavity, intrauterine development of, 183, 185fOral habits, 386–393bruxism, 391–392, 392flip habits, 390, 390fmouth breathing, 391fnail biting, 391pacier habits, 389–390, 389fthumb and nger habits, 386–389, 387f–389ftongue thrust, 390–391Oral health, infant, 200caries management protocols for, 203tconcepts of, 201–203as diagnostic process, 203–204goals of, 200–201oce readiness for, 211oral examination and assessment of clinical risk factors, 205, 208toral health visit in, 204–208anticipatory guidance in, 206–208, 208b–209b, 209t–210toral examination and assessment of clinical risk factors, 205, 205f, 206t, 208trisk assessment in, 204–205, 204brisk proling in, 205–206responsibility of nondental professionals regarding, 211–213, 212trisk assessment for, 201–202, 202f, 204–205, 204brisk proling in, 205–206visits, elements of, 204–208Oral health behaviors, education and changing, for dental caries, 172–173Oral health education, 163Oral health screenings, 164Oral hygiene, evaluation of, in ages 6 to 12 years, 425Oral lymphoepithelial cyst, 13t–16t, 17f–19fOral melanotic macule, 20t–21t, 22f–23fOral mucosal peeling, 13t–16t, 17f–19fOral sedatives, 122administration of, required permit for, 122advantages of, 122convenience in, 122disadvantages of, 122economy in, 122lack of toxicity of, 122onset time of, 122variability of eect and, 122Oral surgery, in children, 399–409for ankyloglossia, 405–407case study, 409.e1, 409.e1fdentoalveolar, for impacted canines, 404for facial injuries, 404, 404ffor odontogenic infections, 405, 405fpreoperative evaluation in, 399of soft tissue, 403–404biopsies in, 403–404tooth extractions as, 399–403armamentarium for, 399aspiration prevention during, 400, 401fmanagement of fractured primary tooth roots, 403, 403fmandibular anterior, 402mandibular molar, 402, 402fmaxillary anterior teeth, 402, 402fmaxillary molar, 401–402, 402fpostoperative instructions in, 401, 401btechnique for, 400–401, 401fOral-facial-digital syndromehyperdontia in, 51ttaurodontism in, 57tOrchid children, 354Orofacial granulomatosis, case study, 49.e1, 49.e1fOrofacial trauma, in child and adolescent athletes, 610Oropharyngeal candidiasis, 73Orthodontic diagnostic techniques, 435–452cephalometric head lms as, 443–448diagnostic casts as, 435–443photographs as, 435, 436fradiographic evaluation in, 449–452, 451f–452fspace analysis as, 440–443, 441f–443ftooth size analysis as, 437–439, 438f–441fOrthodontic problemsin adolescence, 562–587dental problems, 572–575, 577f–578fexamination of, 563–569, 564tpatient history of, 563skeletal problems, 572, 573f–576ftreatment planning and treatment for, 572–575examination ofbehavioral assessment for, 563–565, 564fdevelopmental status in, 565facial, 565general appraisal in, 565head and neck, 565intraoral, 566occlusal evaluation in, 568, 569fperiodontal evaluation in, 566, 566fradiographic evaluation in, 569, 570frelated hard and soft tissue problems in, 566–567, 567f–568ftreatment planning and management of, 512–553anteroposterior dental problems, 548–550anteroposterior growth modication, 514–517crowding problems, 534–548dental alignment, 534dental space maintenance, 522–526missing permanent teeth, 526–532, 528f–529f, 531f–532fskeletal problems, 512–519supernumerary teeth, 531–532, 532ftooth size discrepancies, 532–534, 533ftransverse dental problems, 550, 550ftransverse growth modication, 518, 518fvertical dental problems, 550–551, 551fvertical growth modication, 518–519Orthodontic treatmentfor cleft lip and palate, 84, 85fin primary dentition, 394–398arch length problems, 395, 395fdental problems, 394–395incisor protrusion and retrusion, 396, 396fopen bite, 398posterior crossbite, 396–397, 397f–398fskeletal problems, 394use of sealants in, 474–475, 474fOrthopedics, for cleft lip and palate, 81–82, 82f–83fOssifying broma, 46t, 47fOsteogenesis imperfecta, 254airway anomalies in, 90tOsteoma, 48t, 49fOsteomyelitis, with proliferative periostitis, 46t, 47fOsteopetrosis, tooth eruption anomalies in, 63tOsteoporosis, pediatric, 68oral and dental treatment concerns in, 68Otodental syndrome, macrodontia in, 54Overbite, 276, 276f–277f, 433–434measurement of, 447Overjet, 275measurement of, 447Overlay wire technique, 542–543Over-the-counter vital bleaching, 606Oxacillin, 132Oxygen delivery, in medical emergencies, 147, 147fPPacier habits, 389–390, 389fPainassessment and management of, 97–115characteristics, in clinical pulpal diagnosis, 332, 334fin child behavior, 355denition of, 97impact and management of, 98physiology of, 98Pain perceptionanticipatory responses and, 98central nervous system eects on, 99–100in children, 101–102age and, 103tfactors exacerbating in, 102, 102bcognitive elements of, 100emotional elements of, 100–101gate control theory of, 98–99, 99fneuromatrix and, 99, 99fpattern of, 98pharmacologic control ofanalgesics, 102–105local anesthesia, 105–107topical anesthesia, 109–110specicity of, 98theories of, 98–101Palatal cysts, of newborn, 13t–16t, 17f–19fPalatal tissue anesthesia, 111, 112fPalate, anatomy of, 77, 80fPalpation technique, for temporomandibular disorder, 582, 582f–583fPALS. see Pediatric advanced life supportPanoramic lm, in adolescent dentistry, 569Panoramic radiographs, in adolescent, 571tPapillary lesions, 30t–34t, 35f–39fPapillon-Lefèvre syndrome, periodontal problems in, 377Paramedian lip pits, 9t–10t, 11f–12fParental anxiety, in child behavior, 356Parental response, to child undergoing painful stimuli, 100Parenting styles, 355, 355tParents, in behavior guidance, 356–357expectations of, setting, 357presence/absence, 361Partial (Cvek) pulpotomy technique, 488, 488f, 501fParulis, 30t–34t, 35f–39fPathologic sequelae, of trauma to the teeth, 236–242complications following avulsion, 241–242coronal discoloration, 237–238, 238fOral surgery, in children (Continued) 629 Indexinfection of the periodontal ligament, 236–237irreversible pulpitis, 236pulp necrosis and infection, 236–237, 237frapidly progressing root resorption and, 238–240replacement external root resorption, 240, 241freversible pulpitis, 236Patient assessment, in successful behavior guidance, 356Patient history, 143, 144f–145fin ages 6 to 12 years, 419–420in diagnosis of nonorthodontic problems, 266, 267tand hematologic status of patient with cancer, 69–70, 70tprimary dentition and, 228–230Patient monitoringin prevention of medical emergencies, 144–145in sedation procedures, 119, 126PCO. see Pulp canal obliterationPDL. see Periodontal ligamentPediatric advanced life support (PALS), 145–146Pediatric dentistry, 2–7, 352anomalies of developing dentition in, 50–65. see also Dental anomaliesantimicrobials in, 128–141. see also Antimicrobialsbehavior guidance in, 2–5contemporary practice and care of children in, 6cross-millennium view of changing character of, 4t–5tdental disease emphasis and systemic disease in, 5dental public health issues in, 159–168. see also Dental public health issuesdierential diagnosis in, 8. see also Dierential diagnosisin local and systemic disease, 66–76medical emergencies in, 142–158. see also Medical emergenciesmilestones in, in United States, 3tprevention and diagnosis in, 2sedation of patient in, 116–127. see also Sedationtreatment options in, 5Pediatric developmentin adolescence, 555–561cognitive changes, 557craniofacial changes, 555–556, 556f–557f, 556tdental changes, 556emotional changes, 557physical changes, 555–556social changes, 557–560at ages 6 to 12 years, 411–418cognitive changes in, 415craniofacial changes in, 411, 412fdental changes in, 412–413, 412femotional changes in, 415physical changes in, 411–413social changes in, 415–416barriers to dental care in, 162intrauterine to age 3 yearscognitive changes, 182tcraniofacial changes, 181–185dental development, 185–195, 187femotional changes, 197–199motor skill acquisition, 183tphysical changes, 181–195social changes, 199Pediatric pain assessment, 101–102age and, 103tfactors exacerbating in, 102, 102bPediatric physiology, 88–96blood and body uids in, 94body habitus and integument in, 95cardiovascular, 92–93gastrointestinal, 93renal, 93–94respiratory, 88–92temperature control in, 95Pediatric prescription writing, 141.e1Pediatric zirconia crowns, case study, 328.e1, 328.e1f–328.e2fPeer group, for ages 6 to 12 years, 416Peers, in social changes, in adolescence, 558Penicillin G, 132–133Penicillin prophylaxis, in sickle cell disease, 67Penicillin V, 132–133Penicillins, 132–133, 132f, 132t, 134bPentobarbital, 125Periapical abscess, 40t–42t, 43f–45f, 138Periapical granuloma and cyst, 40t–42t, 43f–45fPeriapical radiographs, in adolescent, 571tPericoronitis, 138Perimolysis, 611, 612fPeriod of intuitive thought, 263Periodontal abscess, 138Periodontal disease, in smokers, 594–595Periodontal evaluationfor adolescent, 566, 566ffor ages 6 to 12 years, 424–425, 425fin children, 377Periodontal ligament (PDL), 187–189, 193f, 195f, 198b, 228, 228finfection of, 236–237, 237fPeriodontal membrane, 198bPeriodontal probe, 566Periodontal problems, 371–378anatomic, 373–374of attached gingiva, 373, 373fof frena, 373–374chronic inammatory gingival enlargement, 371–372, 372fdrug-induced gingival enlargement, 372–373, 373fgingivitis, 371, 372fperiodontitis, 374–376aggressive, 374generalized aggressive, 375necrotizing ulcerative gingivitis, 376in permanent dentition, localized aggressive, 374–375, 375fin primary dentition, localized aggressive, 375–376, 375fsystemic diseases and conditions with associated, 376–377diabetes, 376down syndrome, 376histiocytosis, 377hypophosphatasia, 376, 376fleukemia, 377leukocyte adhesion deciency, 376neutropenia, 377Papillon-Lefèvre syndrome, 377Periodontitis, 374–376aggressive, 374generalized aggressive, 375necrotizing ulcerative gingivitis, 376in permanent dentition, localized aggressive, 374–375, 375fin primary dentition, localized aggressive, 375–376, 375fin teenage population, 566Perioral piercings, in adolescence, 593–594, 594fPeripheral giant cell granuloma, 30t–34t, 35f–39fPeripheral ossifying broma, 30t–34t, 35f–39fPermanent dentition, 170anatomic dierences between primary and, 305, 306b, 306fanteroposterior dimension in, 433, 434f–435fautotransplantation for, 5cephalometric head lms of, analysis of, 443–448chronology of, 196tdevelopment ofages 3 to 6 years, 262–263, 262fages 6 to 12 years, 412, 413f–414feruption of, 191–193, 193f–194f, 198bages 6 to 12 years, 413fangulation of teeth during, 412, 414fcause of, 193ectopic, 429, 430fimpaction in, 431, 432fmidline diastema during, 431–433, 432fprimary failure of, 431, 432fproblems associated with, 522–525, 523f–525fradiographic evaluation in, 449–452, 451f–452ftransposition in, 431, 431fugly duckling stage during, 413, 414f, 431–433, 433finjuries to developing, 241f–242f, 242managing traumatic injuries in, etiology and epidemiology of, 498fmolar and canine relationships in, 433transverse relationship in, 430f, 433vertical dimension in, 433–435young, managing traumatic injuries in, 497–511etiology and epidemiology of, 497Permanent teeth. see Permanent dentitionPermanent tooth stainless steel crowns, 607Permissive parenting styles, 355tPeroxide bleaching methods, 606Personality disorder (PD), in adulthood, 558Petechiae, 20t–21t, 22f–23fPFE. see Primary failure of eruptionPharmacologic control, of painanalgesics, 102–105local anesthesia, 105–107topical anesthesia, 109–110Pharmacologic management, of behavior, 3–5Pharmacology, pediatricbody uid physiology and, 94body tissue composition and, 95cardiovascular physiology and, 91t, 92–93gastrointestinal physiology and, 93renal physiology and, 94respiratory physiology and, 91–92, 91tPhentolamine mesylate (PM), 113Phosphates, dental caries and, 417Photosensitivity, 131Physical changesin adolescence, 555–556body, 555craniofacial changes as, 555–556, 556f–557fdental changes as, 556Pathologic sequelae, of trauma to the teeth (Continued)Periodontitis (Continued) 630Indexin ages 3 to 6 years, 260–263in ages 6 to 12 years, 411–413Physiologic measurements, 101Physiologic (racial) pigmentation, 20t–21t, 22f–23fPiercings, intraoral and perioral, in adolescence, 593–594, 594fPierre Robin sequence, 80, 81fairway anomalies in, 90tPigmentation, physiologic (racial), 20t–21t, 22f–23fPink discoloration, in primary dentition, 238Pit and ssure cariesepidemiology of, 461–462on occlusal surface, 462in population subgroups, 462sealant development for, 462Plaque, chemical agents that alter, 592Plasma protein, and body uid alterations, 94Pleomorphic adenoma, 30t–34t, 35f–39fPNAM. see Presurgical nasoalveolar moldingPolyacid-modied resin composites, 465Polyenes, 135Polymerizationchemically, resin-based composite, 298of light-activated composite resins, 598light-emitting diode (LED) curing lights for, 471quartz tungsten halogen (QTH) curing light for, 471of sealants, 471visible light, resin-based composite, 298–299, 298fPompe disease, airway anomalies in, 90tPoor masticatory function, in space maintenance, 379Porcelain veneers, 604–605for adolescent restorative problems, 571Port-wine stain, 20t–21t, 22f–23fPositive pressure oxygen delivery system, 147, 147fPositive previsit imagery, in basic behavior guidance, 360Positive reinforcement, in basic behavior guidance, 359, 359fPosterior crossbitemaxillary, 386, 387fwith maxillary constriction, treatment of, 518, 518forthodontic treatment of, 396–397, 397f–398fPosterior crown fractures, in young permanent dentition, 502, 504fPosterior restorations, glass ionomer for, 301Posterior teeth, restorations for, 606–607, 607fPostoperative instruction list, for patients, 401bPower bleaching, 606Practitioner, individual, role of, in dental public health issues, 159Prader-Willi syndrome, airway anomalies in, 90tPrecontoured crowns, for primary molars, 316Precordial stethoscope, patient monitoring with, 118, 118f, 126–127, 126f–127f, 144–145, 145fPreformed metal crowns, for primary molars, 316Pregnancyadolescent, 594dental treatment for, 216, 217buorides for, 221Premature tooth loss, in space maintenance, 379Premolars, missing permanent, treatment of, 530–531, 530fPrenatal counseling, in dental disease prevention, 216–218, 217b, 217f–218fPreoperational stage, in cognitive development, 353bPreprocedural prescriptions, 119Preschool dental care, in low income families, 162Preschooler, behavior guidance for, 366Presurgical nasoalveolar molding (PNAM), case study, 87.e1, 87.e1f–87.e2fPretrimmed crowns, for primary molars, 316Preventive resin restoration (PRR), 310–311, 468–469Preventive/interceptive orthodontic treatment, 508b–509bPrilocaine, 107, 107tPrimary dentitionin ages 3 to 6 years, 273–277anterior, prosthetic replacement of, 326–327, 326fanteroposterior dimension, 275, 276farch alignment, 274–275, 274f–275farch transverse relationship, 275–276occlusal evaluation, 273–274, 274f–277fvertical dimension, 276–277, 276f–277fin ages 6 to 12 yearscaries in, 452exfoliation of, 412anatomic dierences between permanent and, 305, 306b, 306fcaries in, 169–170, 170f–171f, 170tcephalometric analysis of, 260, 261tchronology of, 196texfoliation of, 193gingiva and, 457, 457ffactors aecting dentin-pulp complex response to stimuli in, 330–331orthodontic treatment in, 394–398arch length problems, 395, 395fdental problems, 394–395incisor protrusion and retrusion, 396, 396fopen bite, 398posterior crossbite, 396–397, 397f–398fskeletal problems, 394pulp therapy for. see Pulp therapyrestorative choices for, 5restorative dentistry for, 304–328. see also Restorationsspace maintenance in, 379–385appliances for, 380–383fabrication and laboratory considerations in, 383–385, 383b, 384f–385fxed bilateral appliances, 381–382, 382fxed unilateral appliances, 380–381, 381fgeneral considerations in, 379–380, 380fremovable appliances, 382–383, 382ftraumatic injuries in, 227–243avulsion, 236classication of, 228, 228f–229fclinical examination for, 230–233concussion and subluxation, 234, 234fcrown-root fracture, 233, 234femergency care for, 233–236etiology and epidemiology of, 227–228extraoral examination for, 231extrusion, 235fractures with pulp exposure, 233fractures without pulp exposure, 233, 233f–234fhistory for, 228–230information and instructions for parents and, 236injuries to the chin, 234, 234fintraoral examination for, 231–232intrusion, 235, 235flingual luxation, 235–236pathologic sequelae of, 236–242radiographic examination for, 232–233root fractures, 233–234Primary failure of eruption (PFE), 63, 431, 432fPrimary herpetic gingivostomatitis, 24t–25t, 26f–29f, 72–73, 139antiviral drugs for, 139management of, 73Primary molar loss, and eect on erupting dentition, 522Primary molars, restorative dentistry of, 309–320adhesive materials in, 309adjacent or back-to-back class restorations, 314–315, 315famalgam use in, 309class I adhesive restoration, 310–311, 311f, 311tclass I amalgam preparation design, 309–310, 310b, 310f, 311tclass II adhesive restoration, 312, 313fclass II amalgam preparation design, 312, 312ffull coronal coverage, 316–320, 316f, 317b–319b, 319f–320fliners and bases in, 311Primary palate, anatomy of, 77, 80fPrimary teeth. see Primary dentitionPrimary tooth roots, fractured, management of, 403, 403fPrimate space, 274, 274fProle change, in adolescence, 555Proliferation, 198bProliferative stage, of dental development, 187–189, 188fPropofol (Diprivan), cardiopulmonary eects of, 91tProtective base, in normal pulp/reversible pulpitis, 337Protective stabilization, in behavior guidance, 361–362, 362fcase study, 370.e1, 370.e1f, 370.e1tProtein, dental caries and, 417Protrusion, incisor, orthodontic treatment of, 396, 396fPRR. see Preventive resin restorationPseudocholinesterase, 93Pseudomembranous candidiasis, 13t–16t, 17f–19f, 73, 73fPuberty, in physical development, 555Pulp, of primary dentitionclinical pulpal diagnosis, 331–336correlation between histopathologic status of pulp and deep caries, 335–336of deep caries lesions, 332–334, 334f, 336fextra- and intraoral examination in, 331–332, 332f–333fmedical history in, 331operative, 334–335, 334f–335fpain characteristics in, 332, 334fsensibility tests in, 332trauma in, 335, 335fhistology in, 329inammation, 331Physical changes (Continued) Primary dentition (Continued) 631 IndexPulp canal obliteration (PCO), 237f, 240, 241fin young permanent dentition, 504, 504fPulp condition, clinical diagnosis, in primary dentition, 483–484clinical examination of, 483direct pulp capping of, 485–487, 487fdirect pulp evaluation of, 484indirect pulp treatment of, 485, 486fpatient history of, 483radiographic examination of, 483–484Pulp-dentin complex, in primary dentition, 329–331, 330fPulp therapynonvital, for immature teeth, 489–493apexication, 489long-term apexication, with calcium hydroxide, 489–490regeneration, 492–493revascularization, 492–493root canal treatment, 493for normal pulp or reversible pulpitis without pulp exposure, 484–485for primary dentition, 329–351clinical pulpal diagnosis, 331–336correlation between histopathologic status of pulp and deep caries, 335–336deep caries lesions, 332–334, 334f, 336fdirect pulp capping in, 339–340, 339fextra- and intraoral examination, 331–332, 332f–333fhistology, 329indirect, 337–339, 339fmedical history, 331for normal pulp/reversible pulpitis, 336–347operative, 334–335, 334f–335fpain characteristics, 332, 334fprocedures, 336–347protective base, 337pulp-dentin complex, 329–331, 330fpulpectomy and root lling, 343–347, 344f–346fpulpotomy, 340, 341f–343fsensibility tests, 332trauma, 335, 335ffor young permanent dentition, 482–496apexogenesis, 489, 489fcaries removal and protective liner, 485cervical pulpotomy, 488–489clinical pulpal diagnosis, 483–484dentin-pulp complex concept, 482–483partial (Cvek) pulpotomy technique, 488pulpotomy procedure, 487–489Pulpectomyin normal pulp/reversible pulpitis, 343–347, 344f–346fand root lling, in young permanent dentition, 500–501Pulpitisirreversible, 236, 485of primary dentition, 336–347reversible, 236, 485–489Pulpotomycervical, in young permanent dentition, 488–489partial (Cvek) technique, 488in normal pulp/reversible pulpitis, pulp therapy for, 340, 341f–343fcase study, 351.e1, 351.e1fin permanent dentition, after traumatic pulp exposure, 499–500, 500f–501fPulse oximetry, 118, 118f, 126Pyogenic granuloma, 30t–34t, 35f–39fQQuad helixfor immature permanent dentition, 518in orthodontic problems, 550Quartz tungsten halogen (QTH) curing light, 471RRadiation therapyfor cancer, dental and oral sequelae of, 69, 69b, 69f–70f, 72missing teeth and, 426, 427fRadiographic evaluationin adolescence, 569, 570fin ages 6 to 12 years, 449–452considerations for, 449–451, 451f–452fRadiolucent lesions, of bone, dierential diagnosis of, 40t–42t, 43f–45fRadiopaque lesions, of bone, dierential diagnosis of, 48t, 49fRampant caries, 608, 608fin adolescence, 563–564, 564fRanula, 30t–34t, 35f–39fRapid palatal expansion, 518, 518fRapidly progressing root resorption, 238–240RDT. see Remaining dentin thickness; Residual dentin thicknessRed or purple-blue lesions, dierential diagnosis of, 20t–21t, 22f–23fRegenerative endodontics technique, 501–502, 503fRegional odontodysplasia, 55Remaining dentin thickness (RDT), 331Reminder therapy, for thumb and nger habits, 387–388, 388fRemovable appliancesfor dental alignment problems, 534for midline diastema, 535, 539ffor space maintenance, 382–383, 382fRenal system, 93–94, 94f, 94tReparative dentin, 330f, 331Reparative dentinogenesis, 483Replacement external root resorption, 240, 241fReplacement resorption, in young permanent dentition, 505–506Residual dentin thickness (RDT), 483Resin-based composite, 297–299, 297f, 309in adjacent or back-to-back class II restorations, 315chemically polymerized, 298in class II restorations, 314composite wear of, 299formulations of, 299–301. see also Hybrid resin-based composite; Macrolled resin-based composite; Microlled resin-based composite; Nanolled resin-based composite; Sealantsmarginal adaptation for, 299in primary incisors and canines, 324, 324b, 325fvisible light-polymerized, 298–299, 298fResin-based sealantbonding mechanism of, 463hydrophobic properties of, 473interface with enamel surface, 464fpolyacid-modied, 465Resin inltrationcase study, 597.e1, 597.e1f–597.e2fin hypoplastic spots and white spot lesions, 604, 604fin posterior teeth, 606Resin restoration, in adolescents, 598Resorptioninammatory, in young permanent dentition, 504–505replacement, in young permanent dentition, 504–505Respiratory stimulant, 150Respiratory system, 88–92, 89fanatomy of, 88–91, 89fdrug considerations in, 91–92, 91tphysiology of, 91Restorationsfor adolescent, 598–609clinical technique, fundamentals of, 598–601, 600f–601fdiastemas, 601–604, 603fdiscolored teeth, 604–606fractured anterior teeth, 601, 602ffor hypoplastic molar, 607–608material selection, fundamentals of, 598, 599f–600ffor posterior teeth, 606–607, 607ffor rampant caries, 608, 608fof primary dentition, 304–328, 305fanatomic considerations of, 305, 306b, 306fconservative adhesive restorations in, 310–311, 311finstrumentation and caries removal, 304–305, 305fresin-based composite in, 309rubber dam in, 306–307of primary incisors and canines, 320–327class III adhesive restorations, 320–321, 320f–321f, 321bclass V restorations, 322full coronal coverage, 322–326, 323tprosthetic replacement of, 326–327, 326fwith resin-based composite crowns, 324, 324b, 325fwith veneered steel crowns and zirconia primary crowns, 324–326, 326fof primary molars, 309–320adhesive materials in, 309adjacent or back-to-back class restorations, 314–315, 315famalgam use in, 309class I adhesive restoration, 310–311, 311f, 311tclass I amalgam preparation design, 309–310, 310b, 310f, 311tclass II adhesive restoration, 312, 313fclass II amalgam preparation design, 312, 312ffull coronal coverage, 316–320, 316f, 317b–319b, 319f–320fliners and bases in, 311sealing of, 474–475Restorative materials, 293, 294t, 296–301amalgam, 296–297bases and liners, 293–295bulk-ll resins, 299–301cements, 301compomers, 301dentin-bonding agents, 295–296, 296f

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