Contents Post-Test

Children Dentistry I

Treating children can be very challenging and a great deal of fun. This course will deal with everyday children’s dentistry with these concepts in mind.

Children respond to us. If you enter the operatory with a dreadful demeanor, you can expect the child not cooperating. If you are having a bad day, it is best to reschedule the child’s appointment.

The child is used to being entertained. He plays all day long. This does not need to change when he comes to your office. An abrupt behavior change will take place if it does change. Children 3 to 6 years old are handled differently than children 7 to 12 years old. This is not a hard and fast rule. Some children mature faster than others. A 5- or 6-year-old child may be mature enough to be treated as an older child.

The 3- to 6-Year-Old Child

Usually, the general dentist should wait until the child can function without his mother before he starts treating the child. Again, this varies with the child. Some 2-year-old children will do very well in the dental environment.

If a child 1to 3 years of age comes into your office in his mother’s arms as a dental emergency, you should refer the child and mother to a specialist. You cannot treat a child in his mother’s arms effectively. The mother has control and the child responds to her, not you.

If the child can sit in the chair by himself, and he can understand what you are saying, then he can be treated. This can be a 2-year-old child, as long as he will respond to you. You are not required to treat every patient that comes into your office. You are required to refer the patients to someone else who can treat them effectively.

Anecdote

When I first started my practice 40 years ago, I was willing to see anyone coming through the door. A woman in her early thirties was pushing a 5-year-old young lady through my door. She did not have an appointment, but her daughter was in pain. The mother said the tooth on the lower right side had a hole in it. The little girl had been up all night crying from the pain.

The look in the little girl’s eyes said she was scared and didn’t want her tooth fixed. Her mother was not taking no for an answer, and dragged the screaming child toward the door to the operatory. The child put out her three remaining appendages and braced herself against the door frame. She was not moving.

Her mother tried pushing her through the door, but the freed fourth appendage went to the door frame. Here was this irritated mother trying to force her spread-eagled child through the office door to my operatory.

This was the child’s first experience in the dental office. It was not going well. The child had been to many physicians’ offices. She knew what doctors did to her. Finally, after everyone calmed down, the child walked in, and climbed up on the chair. I think her tooth started hurting from all the clenching, or maybe it was her mother’s no-nonsense attitude.

Upon inspection of her mouth, the lower-right second deciduous molar had a large decay. Since she was in pain, I assumed the tooth was exposed. The child would have to be numbed before we could work on the tooth.

It took me a half hour to get the child to allow me to give her an injection. It took another half hour to get her numb enough to work on. Then each procedure had to be carefully explained before we could proceed. Meanwhile, my waiting room was filling up with other patients who had appointments.

They all waited patiently while I worked on this child. I managed to accomplish a pulpotomy and a temporary amalgam filling. She would need a stainless steel crown later.

The child came out of the ordeal in good spirits. She did not feel any pain from the experience. The mother came to the front office desk for her child in a bad demeanor. She was angry because she had to wait two hours while her child was being treated.

I was exhausted from the ordeal. The mother was ungrateful. The other patients with appointments had to wait, but the child was smiling. Her pain was gone, and I didn’t hurt her. I wanted to have the mother take the child somewhere else for her next appointment, but the child would not allow this. I continued to see the child for the next ten years.

This was my first experience in children’s dentistry. I learned children take time. They don’t always fit into a busy schedule. It would have been better to have taken on the emergency child prior to lunch – that way, the two hours in the operatory could have extended into my two hour lunch period and not inconvenienced my other patients.

Child’s First-Time Visit to the Dental Office

Usually, the child is given three appointments before the dental work is started. These are getting-acquainted sessions. The child’s parents should be aware of this procedure.

The First Appointment

This is usually the X-ray and diagnosis appointment. If the child is very young (in terms of maturity, that is), the first appointment may be no more than a ride in the chair and a walk around the operatories. The X-rays can be taken another day if the child is not up to sitting for the X-ray.

The doctor always sees the child. If the X-rays are not taken, the doctor should still do a preliminary exam of the child’s mouth. You can count the child’s teeth with your mirror. This gives you an opportunity to look at the child’s teeth. I never count right; I usually miss a few numbers or get them mixed up. The child will usually correct me. Then I will go on not believing I made the mistake, and do it again.

The child knows his numbers. Basically, you are having fun with the child, but you are also examining his teeth. You can show him the X-ray and count the teeth while you examine them. You are going to verify you are correct in your counting. The child is made part of the exam process.

You can blow air from the air syringe and accidentally blow air up the child’s sleeve. You act surprised, and blow the air on the child’s hand. No, it goes on the child’s teeth. The idea is to play with the child while you are examining him. You get the information you need, and the child is having a good time.

Every child is different. What works well for one child may not work well for another. You need to read the child. A quiet child may be frightened of you and the dental office. By doing something silly, the child will relax, thinking you are playing with him. You may need to go slower with this child. Another child may be outgoing and will love playing with you.

Every doctor is different in personality. What is easy for one doctor may not come easy for another. A doctor who has children of his own will know how to play with children. One who does not have children will need to learn. Before the child leaves each time, he is given a prize from the treasure chest or a sticker from the doctor. Patients come back years later and tell me how much they looked forward to the treasure chest when they were children.

The Second Appointment

This is the prophylaxis appointment. The dental assistant works the prophylaxis cup around the child’s mouth. Depending on the sensitivity of the child, the prophylaxis may only include the anterior teeth. The idea is to have the child become used to things moving around inside of his mouth. There is no pressure to complete the prophylaxis.

It is important the doctor make an appearance and play with the child a moment. This gives the doctor a chance to make a pleasant connection. This can be a look in the child’s mouth, or a light touch on the child’s nose. You need to improvise on the spot, depending on the child’s demeanor.

When I was younger, I used to swing the child up in the air when he left the chair. This usually put a big smile on his face before he went racing back to his mother. Of course, the child will not let you forget the treasure chest.

The Third Appointment

This is the appointment you want to start some of the operative work. It should be something very easy and quick. The child at this point will trust you not to hurt him. He thinks coming to the dentist is fun.

The Very Young Child

The age of the child makes a difference on how you will handle him. If he is a 2- to 3-year-old child, you may not want to numb him on this visit. In fact, you may not want to numb him at all. The aftereffect of the anesthetic may far outweigh its benefit.

Anecdote

A young child of three came into the office with decay on his posterior molars and his four maxillary anterior teeth. He was put through the three-appointment process. On the third appointment, the work was started on the lower-left side. He was anesthetized with lidocaine, and the lower-left second deciduous molar was treated with an amalgam filling. The child did not feel any pain and left with a smile on his face.

The parent was warned the child needed to be watched. This was his first experience being numb. There was the possibility he would chew his cheek. The patient came back for his next appointment with his lower left lip swelled. A huge hole went from the lower left lip to the inside of his cheek. The chewed cheek was already in the healing phase. The wound was open. There was nothing to suture.

It took two weeks for the cheek to heal. I did not give him more anesthetic. The child simply did not understand he was not to chew his cheek. We continued the remaining fillings without the benefit of anesthetic using the technique described below.

Procedure Without Anesthetic

If he has anterior decay in the maxillary anterior incisors, this may be the area to start. The location is accessible and the cooperation of the child is not critical.

Usually, you can remove the decay with a small or large spoon. The handpiece can be used to give access if it is necessary, but you cannot use the handpiece to remove any deep decay or set any undercuts. All of the handpiece work is finished before the decay is removed with the spoons. The restorations are filled with composite because the undercuts are not critical to the restoration. All of this can be done without numbing the child.

To make this work better, the child can be instructed to close his eyes and visualize a television set. He would think you are playing with him.

Go through the following sequence with him:

  1. Tell him to turn the television on. You wait a few seconds, and then ask him if the television is turned on. He will say yes.
  2. Tell him to pick his favorite cartoon and change the channel until the cartoon comes on. You wait a few seconds, and then ask him what he is watching. He will give you a description of the cartoon.
  3. Now tell him to step inside the television and play with the people in the cartoon. You wait a few seconds and ask him, “How are you doing?” He will start into an extensive dialog of what is going on.

Now you may proceed with the restoration. He will feel pain if you hurt him, but he will ignore any low-ebb pain. You can proceed with the decay removal. This is still a spoon procedure. You cannot do this with an exposed tooth. The X-rays need to be checked closely. If there is a chance of any exposure, you will need to numb the tooth.

Once the decay is removed, the composite can be placed and smoothed with the handpiece. I would not overdo this visit. The child is going to become bored with his cartoon in ten to fifteen minutes. One or two fillings should be the limit.

This procedure can be done on posterior teeth if the decay is limited to dentin. When exposing the decay, the bur needs to remain above the decay. The spoon can remove the decay.

The above procedure is a hypnosis technique. Children are hypnotized every day with the television and video games. They possess great imagination. You are only taking advantage of this to help the child overcome the discomforts of dentistry.

The Young Child, Age 3 to 6

If this is a first-time patient, you should go through the three appointment procedures. The X-ray and diagnosis are on the first appointment, and the prophylaxis is on the second. The treatment starts on the third. This can be a fun age to work with.

Developing a relationship with the child makes the dental procedures easier. Look for something on the child that is obviously pretty or cute. If a young lady’s eyelashes are long and flowing, you can make a comment about them. Example: “Those sure are pretty eyelashes. Where did you buy them?” They will make some comment that they didn’t buy them. You keep going on about them, saying you would like to buy some for yourself. Ask her how they would look on you!

If it is a young man you are dealing with, you would inquire about his shoes. You would tell him how great they look. Then you would flop your size twelves up on the chair beside his shoes and ask him if he would like to trade. This works with young ladies as well.

The point here is the conversation is absurd. This makes it funny and the child relaxes. It can be anything – a purse, or a book. Tell the child you want to buy one like it. Ask the child how you would look with one. The child knows you are playing with them. You can go on about the exchange as you work on them.

Sometimes the child is not up to the work you are into. There is no law that says you must finish the procedure at that moment. To place a temporary filling and have the child back for another session is always better. To finish the procedure and lose the patient is not good dentistry. A child between the ages of 2 and 8 years should never be left alone. This is an important concept. A child left alone becomes frightened, making him very difficult to handle. The child should remain with his parent until you are ready for him. If the office is busy, the child can be sent back to the parent after the anesthetic injections are given. This is better than leaving the child by himself in the operatory.

The anesthetic injection is an important part of dealing with children in the operatory. Giving a painless injection to a child is very easy compared to an adult. The child will follow directions without apprehension. The adult patient will react out of previous painful injections. This makes it difficult for them to relax. The child, however, does not have this memory; he can relax immediately and allow you to give the injection into loose tissue.

Do not show the child the needle or even indicate you have a needle. Again, this is a first-time patient. The child believes the dental appointments are fun. The patent is smiling and looking up at you. If you change your mood the slightest, the child will catch on immediately.

Smiling, you tell the child you are going to shake his cheek. You take his cheek and shake it. The child thinks you are playing with him. Next, place the light just below the child’s eyes. If he tries to look at the needle, the light will hit his eyes. Bring the needle around the child’s head and give the painless injection. Again, do not allow the child to see the needle. He knows needles bring pain.

Immediately upon securing the needle, rub your finger along the child’s cheek and tongue. Tell the child your finger is magical. Your finger will make his cheek and tongue fuzzy. The child thinks you are still playing with him. When the anesthetic begins to take hold, he will think it is a magic trick. The child comes in smiling and leaves smiling.

When the child is asked later about the injection, the child will say you did not give him one. You will need to eventually tell the child you are giving him an injection, but this can be years down the road.

I have had children arguing with their siblings that I had not given them an injection. This would go on for many years until I finally confess I did, indeed, give them an injection.

Rules of the Road

You should:

  1. Never leave a young child alone in the operatory.
  2. Give the child a prize after the treatment is completed.
  3. Not force a child to finish the procedure.

Older Children, 7 to 12

The older first-time children should be taken through the X-ray and prophylaxis appointments. It allows time for the child to become acquainted with your staff and office procedures before the restorations are started. If the child has never been exposed to a dental office before, this can be a good experience for them.

The child should never be pushed beyond what he can handle. There is always another day. If the child has a difficult time with the pulpotomy, the stainless steel crown can be put in place another day.

Children pick up on you very quickly. If you are relaxed, they will be relaxed. If you are pushing to move your production along, they will respond in kind and become hard to manage. They usually are good at following directions. When they find you give a painless injection, they will return to their parents with glowing reports. Many parents will send their children to you before they allow you to work on them. If the kids come back with all smiles, then you will probably be seeing the parent.

Older children should know you are going to numb them. What age you should tell them this will depend on their emotional development. You do not use terms like: “I am going to give you a shot.” Rather, “I am going to numb you along here.” Using your finger, run it along the side of the child’s face that is to be numbed. It is important the child knows what is expected of him. You do not show the needle.

The Apprehensive Child

This child is easy to recognize. The child is obviously frightened. Probably his older sibling has been telling him about the horrors of dentistry. If you try to give the injection, the child turns away or clutches your hand. This situation calls for the ‘Money Bribe.’

The ‘Money Bribe’

Children are accustomed to being bribed. You take a dollar from your pocket, and place it on the tray in front of the child. It may require a five-dollar bill for older children, or a twenty-dollar bill for adults.

You tell the apprehensive child you will give them the money if you hurt them in any way. The child will be the sole judge whether it hurts or not. Now, you would think the child would say it hurts just to take your money, but the apprehensive child will not. The child does not want it to hurt. The money is to make you give the injection painlessly. He would gladly give you the money not to hurt him. You tell him, “I have never lost any money!” When the patient’s belief is locked into this, he will allow you to give him the painless injection.

Extreme apprehensive adults will respond the same way. You cannot fool these people. They fear the injection. Dentists have lied to them in the past. They will believe you when you place the money on the tray. Fortunately, extremely apprehensive patients follow directions very well. They do not want it to hurt. This allows you to give a painless injection.

Rules of the Road for the Older Child

You should:

  1. Never show the child the needle.
  2. Remain relaxed, and the child will remain relaxed.
  3. Find something of interest to the older child – school, sports, etc.
  4. Only use the money bribe on extremely apprehensive patients. You could lose your twenty dollars.

The Painless Injection

When Is a Patient Numb?

An apprehensive patient will tell you he is numb after the first injection. The patient fears the needle more than the pain from the handpiece. So when is a patient really numb? The patient is numb when you can perform the dental procedure without inducing pain.

The patient may exhibit all the signs of being numb on the cheek, tongue, lips, etc., but still feel pain when you begin your procedure. There is nothing wrong with your technique. The patient is numb; the problem is the tooth you are working on. It is hypersensitive to cold because the patient is clenching his teeth.

When you leave the room, the patient will often clench his teeth to see if he is numb. The patient is not aware of the damage he is doing. The normal pain sequence from clenching is gone with the numbing. This allows the patient to bite very hard and make the tooth very sensitive. You cannot numb through pain caused from clenching. You may as well send the patient home.

If a patient is a known clencher, it would be wise to place a cotton roll between the patient’s teeth (on the opposite side of the mouth) after the injection. After the procedure is completed, the patient should be encouraged to continue with the cotton roll. Often after surgery, the patient will complain of pain from the extraction site. Instead of giving him drugs, you might consider asking them to place something between his teeth on the opposite side. The pain will usually go away.

The patient is not aware he is clenching. He will even deny doing it. You will need to convince him to try leaving the cotton roll in for a half hour. The pain will reduce over that period.

The painless injection technique is a series of injections. The first injection goal is to numb the injection site. Only a small amount of anesthetic is required for this. The anesthetic is given slowly while the surrounding tissue is distracted with a massaging motion.

The Inferior Alveolar Nerve Block Injection

The 27-gauge long needle is used.

“The needle is penetrated into the tissues until gently contacting bone on the internal surface of the ramus of the mandible. This should be in the area of the mandibular sulcus which funnels into the mandibular foramen.” (Monheim)

The First Injection

This is probably the easiest to accomplish because your left thumb is resting on the coronoid notch (right, if you are left-handed). The thumb points to the injection site and your left-hand fingers are touching the soft tissue around the angle of the mandible. The fingers shake the tissue gently as the tissue and mandible are lifted into the approaching needle. The tissue moves over the needle as the needle moves into the tissue. You take the needle all the way to the bone. If you miss, remove the needle and try again using the same technique. There is a tendency to push the needle hard into the tissue. This is not necessary. A gentle touch here is all you need. The patient is not feeling anything. There is no rush to inject the needle. There is no need to damage bone here.

If you find it difficult to move both hands at the same time, take the needle point up to the tissue. Then lift the mandible and tissue, and shake them into the needle. It is more dropping of the tissue than shaking it. You are only penetrating three to five millimeters into the tissue before you reach the bone.

Once the needle is in place, the shaking stops, and the tissues over the mandible are massaged. The fingers continue to work, but now they are gentle. Aspirate and inject a small amount of anesthetic very slowly. After a small amount of anesthetic (fourth of a cartridge) is injected, remove the needle and stop massaging the tissue. You are only numbing the injection site.

There is a chance to strike the lingual nerve and defeat the whole purpose of the pain-free injection if the injection site is not forward of the pterygotemporal depression. It is best to stay on the bone between the depression and the coronoid notch.

It is good to warn the child you are going to shake his cheek before you begin. An older child may become upset when you shake him around without being forewarned. Younger kids, though, will think it’s fun and think nothing of it. Of course, you cannot shake tissue that is taut. The child needs to relax his tissues by closing his mouth slightly.

Do not give a topical anesthetic before you begin. Topical anesthetics only numb the surface of the tissue. The movement of the tissue nullifies the need for a topical anesthetic. We are concerned more with the deeper layers of tissue where the topical anesthetic does not affect.

You should wait a few minutes before you give the second injection. The tissue needs a chance to numb.

The Second Injection

The second injection is easier. The site is already numbed. Look for the correct anatomical site for your injection. You will be trying to numb the inferior alveolar and lingual nerves in the pterygotemporal depression. Again, there is no hurry here.

Use the same technique as in the first injection. Bring the needle to the tissues while your fingers gently shake the tissues over the mandible into it. The patient is not numb at this point. Once you reach the bone, massage the tissue, aspirate, and inject half of the remaining anesthetic in the cartridge very slowly. This will leave you with a third of a cartridgeful of anesthetic.

The needle is removed and the massaging stops. You should wait a few minutes before you inject a third time. If you find an injection site in close proximity to the inferior alveolar nerve, you might achieve anesthesia immediately.

The Third Injection

The area where you injected the needle is numb. You do not need to shake the tissue. You may use your regular technique for finding the correct spot for your injection. This time, inject the remaining third of the anesthetic. Often, this is all you need to numb the child.

If the child is not numb after one cartridge of anesthetic, check to see if your location is correct. If the patient is not numb after one-and-a-half cartridges, you might want to consider another day. The child may not be emotionally ready to have a dental experience. Unless it is a dental emergency, there is no need to force a painful experience on the patient.

“The toxic dose of lidocaine would be obtained if more than one-and-a-half cartridges of two percent lidocaine with 1:100,000 epinephrine were injected in a patient weighing 14 kg (30 lb). Yet five-and-one-half cartridges of the same anesthetic agent would be required to reach the toxic level in an adolescent patient weighing 46 kg (100 lb).” (McDonald, Avery, Dean, Dentistry for the Child and Adolescent)

The amount of anesthetic depends on body weight. The rule of thumb: I would limit the dosage to one cartridge for children weighting 30 pounds, and limit the dosage to two cartridges for children weighing 80 to 100 pounds.

On rare occasions, the inferior alveolar block injection will cause blanching and numbness of the infraorbital area. The eye will droop, and the patient will not be able to close his eye. This blanching and numbness will go away in a few hours, but additional injections will aggravate it further. It is best the patient is sent home suggesting they stay in a darkroom until the numbness wears off.

Rules of the Road
  1. The needle is never pushed into the tissues; rather, the tissues are pushed into the needle.
  2. The tissue distraction does not allow the brain to focus on the injection site.
  3. The injections should not be rushed.
  4. This is a series of injections.
  5. The first injection is limited to a small amount of anesthetic.
  6. The patient should never see the needle.
  7. You cannot shake taut tissues.
The Infiltration Method of Injection

The 27-gauge short needle is used.

The relaxed tissue is allowed to drop over the needle point as the needle moves into the tissue. This can be an easy flip of tissue or simply a release of the cheek or lip tissue. Aspirate and inject a small amount of anesthetic into the tissue while the fingers that released the tissue gently massage it. You are only numbing the injection site.

You do not need a topical anesthetic. The injection goes deeper than the area a topical anesthetic can numb.

The First Injection

You should first select an injection site free of visible veins. It does not help the child to run the needle through a vein. It is preferable to be against bone, but this is not always possible.

The child relaxes the tissue you want to numb. Lift the tissue (lip or cheek) and move it around to ensure total relaxation.

Lift the loose tissue, making it taut. Place your needle point against the taut tissue. Then simply flip or drop the tissue over the needle. The needle point does not move. The tissue comes to the needle point. Once you are confident in the technique, the needle can move into the tissue when it drops over the point. It is not necessary for the needle to move more than a few millimeters into the tissue at this point.

You might miss the tissue with the needle. This should not discourage you. Simply allow the patient to rinse the bitter liquid from his mouth and try the technique again.

Aspirate and slowly inject a small amount of anesthetic while the fingers massage the tissue above the needle point. There is no hurry here. The child is not feeling anything.

Remove the needle while you are massaging the tissue. This is not a heavy massaging technique; you are only interested in distracting the child.

When the needle is removed, you may stop the massaging. The child will only perceive the massaging. He will not feel the needle point.

When you are numbing for more than one tooth, the procedure is the same. A small amount of anesthetic is administered in each site using the above method. You may only use a third of a cartridge in numbing the entire upper left side during the first injections.

The Second Injection

Using the same technique as the first injection, leave the needle in longer and inject a larger amount of anesthetic. The anesthetic in the cartridge should be down a fourth at this point. You cannot see under the tissue. If you keep the amount of injected anesthetic to a small amount, it will prevent loading up a vessel with the anesthetic liquid.

The needle can be taken deeper into the desired location with this injection. The injection site is numb.

The Third Injection

The patient is fairly numb. You can place the needle point straight to the bone without the massaging. It is still a good idea to give the anesthetic slowly. The total amount of anesthetic used for a single tooth should be no more than a third of a cartridge.

If you see blanching of the tissue, you are in a vessel. If the blanching is extensive, you should stop injecting additional anesthetic. You do not know where the vessel is located. If you inject more anesthetic, you run the risk of causing more blanching and discomfort to the child. Usually, the child is not numb enough to continue the appointment.

Injections Into Hard Tissue (Gingiva) After the Inferior Alveolar Nerve Block is Given

The 27-gauge short needle is used.

Gingiva – the hard tissue around the tooth – can be numbed very easily from the lingual side since this hard tissue is already numb from the inferior alveolar block. This is a good test to determine if the block took effect.

The pressurized anesthetic liquid will extrude from the site. To prevent the liquid from reaching the taste buds, a 2x2 gauze is placed beside the site. This will capture the excess liquid and keep the child from the tasting the bitter anesthetic. If a dental assistant is available, she can aspirate the excess liquid, and the 2x2 gauze will not be necessary.

Starting from the numbed lingual side of the tooth, the first injection is placed near the inter-proximal mesial area. This can be distal, but mesial is easier. Taking the needle to the bone, a small amount of anesthesia is injected into the hard tissue while a 2x2 gauze collects the excess liquid. This takes some pressure, but be careful of overdoing the pressure. It is better to find another injection site then to blow a large amount of anesthetic behind the fascia.

The tissue will blanch around the injection site. Staying in this blanched area, give another injection. Following your blanching, you can take the anesthetic any direction you choose.

The buccal side is reached by taking the blanching into the inter-proximal. You need to give enough to cause some blanching on the buccal side of the tooth. Once you are on the buccal side, you may continue the injections. You may take the blanching any direction. As long as you remain in the blanching area, the child will not feel the injections.

You should always aspirate before giving these injections. Vessels are not supposed to be in the hard gingiva, but they are. A pressured injection into a vessel will cause deep blanching, and later, discomfort to the child.

Special care needs to be taken to avoid taking the blanching into the soft tissue unless this is desired. The pressurized injection into soft tissue will immediately cause the soft tissue to swell and distort.

Injections Into Hard Tissues After the Tooth is Numbed by the Infiltration Method

The 27-gauge short needle is used.

The infiltration method usually is used for the maxillary arch and the mandibular anterior teeth. These teeth will be numb on the buccal or labial side. Start your blanching in the gingiva on the numb side just above the injection site. Each injection follows the blanching around the tooth. The excess anesthetic liquid will extrude from the site. A 2x2 gauze is needed to collect this unless the assistant is available to aspirate the liquid.

Maxillary Teeth

Starting on the labial gingiva, the injections are given above the injection site and taken to the interproximal area on each side of the tooth. You should place enough anesthetic to blanch the lingual interproximal area. Once you are on the lingual side, you may take the blanching anywhere on the hard palate and not hurt the child. A palatal injection should originate on the labial and then be taken to the lingual with the blanching technique to achieve anesthesia without pain.

Mandibular Anterior Teeth

The lower anterior injections are done in a similar manner. Once you are on the lingual, you may take the blanching either direction on the gingiva. It is important to start the blanching above the injection site.

Rules of the Road
  1. The pressure technique is not recommended for soft tissue.
  2. Only a small amount of anesthetic is necessary to numb the gingiva.
  3. Heavy pressure is not necessary to achieve gingival anesthesia
  4. If the injection cannot be made with moderate pressure, then another injection site should be located.
  5. The patient will not feel any pain if the injection remains in the blanched area.
  6. You should always aspirate before injecting the anesthetic.
  7. A 2x2 gauze placed at the injection site will prevent seepage of the extruding anesthetic to the child’s taste buds.
Mental Block Injection

The 27-gauge short needle is used.

The infiltration method is used to give the block. The patient is instructed to relax the lower lip by closing his mouth.

Taking the relaxed lip and cheek in your left hand, stretch the tissue outward. Locate an injection site free of vessels above the foramen, place the short #27-gauge needle at the site, and drop the stretched tissue over it.

Then massage the tissue over the needle point, aspirate, and slowly inject a small amount of anesthetic. Stop the massaging after you remove the needle point.

After waiting a few minutes, the second injection is given. This is done the same way except more anesthetic is injected.

The third injection does not require massaging. The injection site is numb. You may inject the site without causing pain to the patient. The needle should be taken to the bone to reduce the possibility of filling a vessel with the anesthetic liquid. Since you are near the foramen, it would be prudent to keep the amount of anesthetic injected into the site to a minimum at any one time. This prevents overloading a vein or artery. Aspirating before you inject the anesthetic does not always preclude placing the anesthetic in a vessel.

Rules of the Road
  1. The infiltration method works well in the mental block injection.
  2. The injection site should be clear of vessels.
  3. A small amount of anesthetic should be given at any one time to avoid overloading a vessel.
Injecting Exroliating Deciduous Teeth

The 27-gauge short needle is used.

The infiltration method is the preferred method followed by the blanching technique. This is not always possible because the permanent tooth may be in the injection site, blocking access to the deciduous root.

This leaves only a direct approach to the deciduous tooth. A painless injection can be achieved by lightly placing the needle into the gingival sulcus. Use slight pressure to place the anesthetic in the sulcus, and then gradually increase the pressure.

There is no hurry here. You are waiting for the blanching to occur. Once the blanching starts, you may follow the blanching around the tooth and in between the permanent teeth.

When the blanching is complete, you can ensure anesthesia by finding the space between or below the roots of the deciduous tooth. You should administer a fair amount of anesthetic under medium pressure to numb the tooth. Since the gingiva is light in this area, the injection pressure should not be extremely heavy.

Rules of the Road
  1. The gingival sulcus is the injection site for a deciduous tooth blocked by permanent teeth.
  2. The blanching technique is the method of choice for numbing blocked deciduous teeth.
  3. The best location for numbing the deciduous tooth is the space between the roots.
The Bent Needle vs. The Straight Needle
The Bent Needle

The weakest point of the #27-gauge needle is where the needle joins to the hub. If the bend in the needle is done slightly forward of this point, the needle will retain its strength. The

bend is made with the plastic covering to avoid the glove touching it. This is a 30- to 45-degree bend. A needle bent larger than 45 degrees will not return to the plastic covering. If it becomes necessary to bend the needle more, then the needle should be discarded without replacing the covering.

The main downside of bending the needle is the replacement of the cover. If you slightly unbend the needle with the plastic covering, there will be less chances of a needle punching through when the cover is replaced. If this is still a concern, simply do not cover the needle once it is bent.

The needle should be removed by twisting the hub with a pair of pliers to avoid the hands touching the needle. The needle is placed in the sharp’s container, and disposed of in the proper manner.

The advantage of the bent needle is the ease of location. The maxillary posterior is easily handled with a bent needle. It is almost impossible to reach this area with a straight needle and use the pain-free method of injecting the anesthetic. The ease of handling the injection makes the added inconvenience of dealing with a bent needle acceptable.

Straight Needle

The straight needle works very well in the administration of the inferior alveolar nerve block. However, it has serious shortcomings when you try to infiltrate posterior areas. The replacement of the plastic covering is still a concern, but the chance of the needle punching through the plastic covering is less.

The Correct Method of Replacing the Plastic Cover

The old method of replacing the plastic cover over a needle is as follows:

The goal of replacing the plastic cover is to prevent the needle from punching through the plastic covering. This can happen from a straight or a bent needle. The hub of the plastic covering is held in the forefinger and thumb of the right hand. The syringe plus needle is held in the left hand. The left thumb holds the syringe against the open left-hand fingers. Then the plastic covering is brought to the syringe. The whole process is held secure by the left-hand fingers resting on the right-hand fingers. This locks the procedure. The right thumb and index finger that hold the hub of the cover are all that move.

Once the needle point is past the right thumb and forefinger holding the hub portion of the plastic cover, the danger of the needle punching through plastic cover is gone. If manufacturers would produce metal coverings, the danger of punching through the cover would be nonexistent.

The one-handed OSHA (Occupational Safety and Health Administration) - accepted method of replacing the needle cover is as follows:

Holding the syringe with the bare needle in one hand, the needle is pushed into the free-standing plastic cover on the countertop. After the needle passes through the open end of the cover and the hub is resting against the plastic cover, it can be secured (tightened) with the other hand.

Replacing the plastic covering over a used needle is a common mistake. To ensure your own safety, it would be wise to never replace a plastic covering. The additional expense of using more needles is less costly than the risks of using a used needle stick.

Rules of the Road
  1. The bent needle allows easier accessibility in the infiltration method.
  2. The straight needle is best for the inferior alveolar nerve-block injection.
  3. You should never replace the plastic covering over a used needle.

The Emergency Child in Pain

Usually you are dealing with deciduous teeth. The parents do not see the value of taking care of the child’s teeth. Now, the child is in pain, the tooth is infected, and the parents want you to extract the offending tooth. Unless the tooth is exfoliating, you will not be extracting it.

You are probably the child’s first dentist. Your goal is to remove the pain and to have the child back for more extensive work. Usually, the child in excessive pain will cooperate, but occasionally, you will find one who will not. It is better to refer the child to a specialist than to force the child to cooperate.

The child in pain usually will open his mouth and allow you to give the anesthetic injection. If the anesthetic can be given using the painless technique, the patient will not be aware of the injection. You can run your finger along the area you are numbing, and tell the child your finger is magical. Once you are playing with the child, you may continue with your examination. Sometimes it is easier to take the X-ray after the child is numb. When the child is no longer hurting, he can be more cooperative in holding the X-ray.

Sometimes it is difficult to know when a child is numb. The child will nod, saying his tongue, cheek, lips, etc., are numb, but you must still exercise care. The child may not know what you mean by ‘numb’. A slow approach with the drill is advisable.

Sedation

It is not recommended to use sedation in children’s general dentistry. Using a little patience, the child will respond. He is in pain. He wants you to relieve him of the pain. He will allow you to do this once his fear of the procedure is reduced. Children less than two years of age should be seen by the specialist, but if the child can be handled in his mother’s arms, emergency procedures can be done. This still does not require the use of sedation medicine.

The idea of treating young children is to build their confidence and produce good patients as they grow older. Sedation does nothing but delay this learning process, and places the child in harm’s way. Yes, it allows the doctor to accomplish his goals in a busy office, but it does little to help the child overcome his fears. The slow approach described above works well, and does not require sedation.

If the doctor cannot handle the child in his office, he should refer the child to a specialist. This is better than medicating the child and accentuating the problem.

Treatment Immobilization Papoose Board

Almost all children can be treated without medication or the papoose board. In my 40 years of practice, I only found three children whom I could not handle. These were emergency patients under the age of two that required a restraint.

The papoose board has its place, but it should be the specialist who uses it. The general public does not accept its use well. It is not a practice builder.

The use of immobilization is indicated in the following situations:

  1. A patient requires diagnosis or treatment and cannot cooperate because of lack of maturity.
  2. A patient requires diagnosis or treatment and cannot cooperate because of mental or physical disabilities.
  3. A patient requires diagnosis or treatment and does not cooperate after other behavior management techniques have failed.
  4. The safety of the patient or practitioner would be at risk without the use of protective im mobilization.

(McConald, Avery, Dean
Dentistry for the Child and Adolescent)

Children’s X-rays

The pedodontic X-ray films are smaller in size. The techniques are similar to the adult X-rays. There is a point when the child will need adult X-ray films. This should be determined by the size of the child’s mouth and not the child’s age.

Usually for the younger child’s anterior teeth, one adult X-ray film is used. The child bites on an adult X-ray film placed between his anterior teeth. The point of the X-ray head is placed at a ninety-degree angle to this. This would place the point of the X-ray head over the edge of the nose for the maxillary film, and close to the edge of the chin for the mandibular film. We are mainly concerned with the placement of the permanent teeth, and whether there is infection on the apical portion of the deciduous teeth.

Whether to take three pedodontic periapical incisal X-rays or one adult X-ray is determined by the size of the child’s mouth. It is done in the same manner as the adult method using the smaller pedodontic X-rays and the Snap-a-Ray. The child does not bite on these X-ray films.

Rule of Thumb

If the adult X-ray film will fit in the child’s mouth, then the adult X-ray film should be used.

Taking the X-ray

The lead-backed X-ray film is placed in the patient’s mouth and the X-ray head of the machine is pointed at a 90-degree angle (perpendicular) to the X-ray film. No matter where the X-ray film is placed, the point of the X-ray head needs to be at a 90-degree angle to produce accurate X-rays.

When the X-ray film is not at a 90-degree angle to the X-ray machine, the roots of the teeth will come out elongated or too short, giving a false image of the teeth. This is especially important when the X-ray is being taken to establish the length of the root canal in an endodontic periapical surgical procedure.

The X-ray film needs to be held with an X-ray holder. This can be a ‘Snap-a-Ray’ plastic holder, or a position-indicator device. Both can give accurate X-rays if used correctly.

The position-indicator X-ray device uses the long cone that attaches to the X-ray head. The round plastic sleeve of the X-ray holder slips over the long cone and holds the X-ray film.

This system works very well and is excellent for first-time users of the X-ray equipment. It forces the operator to keep the point of the X-ray machine at a 90-degree angle to the X-ray film.

The Snap-a-Ray is the most common X-ray holder because it does not require a long cone X-ray machine. Most of the modern X-ray machines do not use a long cone attachment. The posterior film is inserted into the Snap-a-Ray with the bite portion of the holder on the buccal side of the film. The lead side of the X-ray film is against the small jaw of the Snap-a-Ray holder.

The top edge of the film should be level with the flat surface of the film holder, unless the muscles in the floor of the mouth prevent it. The idea is to place as much film behind the teeth as possible to ensure the roots of the teeth are on the X-ray film. The X-ray film pushes the tongue out of the way and slips in behind the molars.

Maxillary Posterior Teeth

The patient bites the occlusal portion of the Snap-a-Ray. The X-ray film remains parallel behind the teeth, and the point of the X-ray head is 90 degrees to the film. This may require moving the film toward the center of the palate. The X-ray film’s parallel alignment with the teeth may not always be possible, but the 90-degree placement of the X-ray head is possible.

Developing the X-ray

The longer the exposure, the more X-ray energy penetrates the tissues and fills the X-ray film. This translates into less developing time for sharp X-rays. The exposure time should be less than a second.

Sharp X-rays can also be obtained by developing the X-ray film for a longer period. The longer the developing time, the less exposure time is needed. This is good up to a point.

If it becomes difficult to establish the developing time, it can be done by sight. The developing time is always changing as the solutions become diluted. What was good when the developing solution was placed in the tank will be different a few days later. Developing the X-ray film by sight will overcome this problem.

Developing X-rays by Sight Method

The film is removed from the package in the darkroom with the door closed. The red light is on to give some light. The film packages are opened and the X-ray film is placed on an X-ray developing rack. The rack of X-ray film is dipped in the water tank and agitated for 5 seconds. The water is shaken off, and the rack of X-ray film is placed in the developing solution. The film is agitated.

If this is new solution, the agitation can be done for just a few seconds. Usually, the agitation should be 15 – 20 seconds. The rack of film is removed from the developing solution and looked at. If you can see the white outline of the teeth, the film is placed in the water and agitated slightly.

If you cannot see the white outline of the teeth, the film is placed back into the developing solution and agitated. The film should not be agitated for more than 30 seconds unless the solution is very weak. The film needs to be moved to the water after 30 seconds even though the outlines of the teeth are not visible. The person developing the X-ray may need to experiment. Everyone has a different rate of agitation and ability to see in the dark.

The film is agitated in the water 5 seconds to remove the excess developing solution. The film is next placed in the fixing solution and agitated for 30 seconds. If you are in a hurry to see the X-ray, it can be removed from the fixing solution and examined in the light at this point. The rack of film should be returned to the fixing solution to continue the fixing for 3 additional minutes without agitation to set the emulsion on the film.

This is a way to develop an X-ray when it is needed quickly – such as in root canal treatments and emergencies. Once the white outline of the teeth is seen on the film, the process can move along quickly. It is the agitation that allows the solutions to reach the film and speed up the process.

Bisecting Angle Technique

This technique works well for taking endodontic X-rays with the file or files in place. The X-ray film is placed tight against the lingual side of the tooth and the child holds the film in place with his finger or thumb. It does not matter where the film is placed, as long as the point of the X-ray head is 90 degrees to the film.

This runs into some problems when the film is against the maxillary molars. The zygomatic process (bony arch) may interfere with the 90-degree rule. It may be necessary to lower the point of the X-ray head below this process.

Anterior Periapical Incisal X-ray

For children with large mouths (older children), three anterior X-ray films are taken across the maxillary teeth, and three X-ray films are taken across mandibular anterior teeth. These include the two cuspid X-rays and one central incisor X-ray. For children with smaller mouths (younger children), only one X-ray is used.

The small end of the X-ray film fits into the two brackets at one end of the Snap-a-Ray. The film is placed against the lingual side of the anterior teeth. The child holds the Snap-a-Ray in place with the handle. The point of the X-ray head is set 90 degrees to the X-ray film, and the button is pushed.

The X-ray film is placed behind the anterior teeth, keeping the film as parallel as possible with the long axis of the teeth. There is a tendency to place the maxillary anterior X-ray film toward the occlusal plane. If the patient is biting on the Snap-a-Ray and the point of the head is shooting through the end of the patient’s nose, you can assume the angle is wrong.

The point of the X-ray head needs to be 90 degrees to the X-ray film. The X-ray film needs to be as parallel as possible to the long axis of the teeth. It may be necessary to move the X-ray film further posteriorly on the palate to keep the film parallel with the long axis of the teeth.

X-rays of the mandibular anterior teeth are sometimes difficult to take in small mouths. It helps when the child closes his mouth slightly after the X-ray film is put in place. This relaxes the muscles on the floor of the mouth, allowing the film to drop lower. It is important to place the point of the X-ray head 90 degrees to the film in this area. This may require the head pointing from a lower angle on the chin.

It is also helpful to move the film farther back in the mouth either by raising the tongue or by placing the film on the tongue. The child is holding the Snap-a-Ray and applying the pressure. He can relax his tongue enough to accomplish this.

Bitewing X-ray

The bitewing X-ray is used to detect decay between the contacts of the teeth. The X-ray is placed in the bitewing tab. The film side needs to be toward the bite side of the tab. The patient bites the tab and holds the film up tight to the lingual side of the teeth.

The two main difficulties with a bitewing X-ray are the overlapping of the teeth and the lack of contrast. The overlapping can be avoided if the angle of the X-ray head is exactly 90 degrees. Sometimes, this is difficult to see.

The jaw usually has an anterior and posterior angle. The bisecting point is usually at the second molar. If the point on the X-ray head uses the anterior angle, the teeth will be at 90 degrees. The cause of most overlapping in bitewing X-rays is the point of the X-ray head uses the posterior angle.

The Finger-Roll Method of Placing the Bitewing X-ray

The right and left forefinger hold the bitewing X-ray film and tab. The tongue is pushed lingually with the fingers and the film is placed against the lingual side of the mandibular teeth. The mesial edge of the film should be to the middle of the cuspid. One film will cover the contacts in most mouths, but large people may require another X-ray exposure.

The tab is pulled tight toward the buccal crossing the occlusal and the patient is instructed to bite on the tab slowly. Sometimes, the upper part of the bitewing film needs to be guided to the lingual of the maxillary teeth.

Possible Problems

The child may play with the bitewing in his mouth and displace the film. This can be corrected by the monster-face technique.

Monster Face Technique

The child is told to make a monster face by gritting his teeth together and growling. When the child has the idea, the bitewing is placed in the child’s mouth using the two finger roll. The tab is pulled across the occlusal and held. The child is instructed to bite down and make the monster face. The child clenches and growls. The button is pushed, and the film is removed.

Occlusal X-ray

This is a large, 2 x 3-inch X-ray film used to view the palate, teeth, and the alveolar bone. The occlusal X-ray film is good for locating mandibular alveolar bone fractures, impacted teeth, and supernumerary teeth.

The 2 x 3 X-ray film is placed in the patient’s mouth as far as possible and the patient is instructed to bite on it. Children with large mouths may be able to handle the 3-inch side, while children with small mouths may need the narrower 2-inch side.

The point of the X-ray head is above the tip of the nose at a 90-degree angle to the X-ray film for the maxillary exposure. The point of the X-ray head is at the chin for the mandibular exposure. It is best to use the sight method for developing this film.

Important Points:
  1. The point of the X-ray head is 90 degrees to the X-ray film.
  2. The X-ray film is parallel to the long axis of the teeth.
Possible Problems
  1. The child gags when the X-ray film is placed in the posterior region of the mouth.
    1. The child should be instructed to hold his breath while the X-ray film is in his mouth. It is important to have the point of the X-ray head in the correct location. The film is placed and the button is pushed. The patient will remove the X-ray film.
    2. Usually, the child gags because the X-ray film is not tight to the palate or the mandibular lingual tissue. This can be alleviated if the patient holds the X-ray film with his forefinger or thumb, using the bisecting angle technique.
  2. If the point of the X-ray head is not 90 degrees to the X-ray film, the roots of the teeth are elongated on the X-ray film.
  3. The developed film shows ribbing and appears to be overexposed.

The X-ray exposed the lead instead of the film. Reversing the X-ray film is the most common mistake in taking a, X-ray. The lead foil inside the X-ray film is away from the point of the X-ray head. When the film is reversed, the foil blocks out most of the X-ray exposure. The film will show fuzzy teeth with the ribbing of the foil over them.

Mounting X-rays

The mounted X-rays film should reflect the right side and the left side of the mouth when the X-ray mount is placed in front of you. The periapical X-ray film has a dimple in one corner of the film. The dimple is on the backside of the X-ray film. You should be looking into the dimple.

Keeping this in mind, the X-ray films are mounted with the maxillary right molar on the upper-right side of the mount and the left maxillary molar on the upper-left side of the mount. The maxillary molar X-ray film will show clear sinus areas. If you remember, the bicuspids are on the mesial, and the dimples are on the backside of the film, the upper-right and left-side X-ray films can be mounted.

The mandibular molar X-ray film will not show any sinus areas. Usually, the mandibular molars show two roots, as opposed to maxillary molars with three roots.

The larger maxillary anterior teeth are fairly easy to distinguish from the smaller mandibular anterior teeth because of their size.

The only really difficult X-ray films to mount are the four cuspid X-ray films. These should be the last X-ray films to be mounted because clues can be obtained from the other X-ray films. Sometimes, the maxillary sinus can be seen on the maxillary cuspids. Usually, the maxillary cuspids are larger than the mandibular cuspids.

The only real confusion is the interchange between the maxillary right and the mandibular left cuspids, and the interchange between the maxillary left and the mandibular right cuspid. If any of these four can be identified with the other clues, the remaining three X-ray films can go right in place on the mount.

Dental Emergencies

The Exfoliated Tooth

A blow to the mouth exfoliates the whole tooth. The tooth is not fractured. Usually, this involves only the anterior teeth.

Permanent Tooth
  1. The tooth should be reinserted back into the socket as soon as possible to take advantage of the organizing healing processes. If there is a delay, the tooth should be placed in milk to preserve the tissue around the tooth.
  2. Care should be taken to keep the tissue intact around the exfoliated tooth. Lightly rinse the tooth before placing it back in the socket, but avoid using soap or detergent.
  3. The treatment of choice is reinserting the tooth after giving a painless injection. The tooth needs to go all the way to the end of the socket. The tooth is held in place while the tooth is splinted with the remaining teeth using a ridge rectangular wire (.018 x .025) and composite.
  4. Make sure the tooth is out of bite. A bite splint may be necessary to accomplish this. After 6 weeks, the splint is removed. Root canal therapy and a full crown finish the treatment.
  5. If the tooth remains mobile after the full crown is placed, the bite should be checked and corrected. A two-unit bridge to splint the tooth may be required to hold it in place.
Deciduous Teeth

Whether to reinsert the deciduous teeth or not depends on the following:

  1. What is the amount of root resorption?
  2. When are the permanent teeth erupting?
  3. What is the psychological condition of the child and the parents?

The above technique of reinserting the teeth back into the bony sockets works very well. The difficulty with deciduous teeth is finding solid teeth to anchor the wire split. Sometimes, a composite cast is needed to hold the teeth. After the rectangular wire is luted on, a composite is placed over the splint and teeth. This becomes the cast for the loose teeth.

The cast composite should be a slightly different color than the teeth to aid in removing the cast after six weeks. Enough of the cast should extend posteriorly to take the anterior teeth out of bite, and cover the posterior teeth to prevent them from extruding.

The reinserted deciduous teeth will behave the same as the other deciduous teeth still in the child’s mouth. Root canal therapy is not necessary and the teeth will not need to be crowned. The body will reattach the teeth to the bony sockets, and the roots will be absorbed as the permanent teeth erupt.

Anecdote

A 4-year-old child came to my office with five of her anterior teeth in a quart of milk. She had been standing on the back of a shopping cart when her mother took her brother out of the cart. The child went down with the cart and popped her five anterior teeth out. The roots had not begun their resorption process, and there were no fractures in the teeth.

The child’s mother wanted the teeth reinserted. After giving the painless injections, the teeth were rinsed and reinserted into the socket. A wire (.018x.025) splint was put in place. Due to the difficulty of finding enough teeth to support the splint, an acrylic cast was placed over the teeth. Six weeks later, the cast and splint were removed. The teeth were solid and remained in the child’s mouth without the benefit of root canal therapy. When the perma- nent teeth erupted two years later, the roots of the deciduous teeth dissolved as normal.

Root-Canal-Exposed Vital Deciduous Anterior Tooth

Usually, a deciduous anterior tooth is not root canaled because the tooth will exfoliate when the child reaches 6 years of age. Occasionally, a root canal is called for when the child is 3 or 4 years of age. The root of the deciduous tooth is fully formed and the resorption process has not started. Rather than extract the tooth, a root canal can be performed.

Once the root canal is completed, the roots of the deciduous tooth will absorb as the permanent tooth comes in. If gutta percha is used as root canal filling material, the gutta percha will move to one side as the root is absorbed. When the tooth exfoliates, the gutta percha comes out with the tooth.

If cement is used for the filling material, it can be left in the tissue as the tooth exfoliates. A non-irritant material such as gutta percha is the treatment of choice.

Evaluate:

  1. Is the child mature enough to handle a root canal?
  2. Deciduous reabsorbing roots cannot be root canaled because the apical portion of the canal cannot be closed.
Major Fracture in the Crown Portion of the Child’s Anterior Permanent Tooth

A portion of the anterior tooth is fractured off. This may involve the pulp chamber.

  1. The treatment of choice is a full crown, though some care is needed to avoid the horns of the large pulp chamber.
  2. If the fracture results in chipping the tooth but does not expose the pulp chamber, a composite filling makes a good temporary replacement.
  3. If the fracture is through the pulp chamber, then root canal therapy is necessary before the crown can be put in place.
  4. Extraction is an option if the fracture is below the gingiva. If enough tooth structure is available to hold a crown, but not support it, the tooth beside it can be used to make a two-unit bridge.
Major Fracture in the Root Portion of an Anterior Tooth

The treatment for a root fractured in an anterior tooth depends on where the fracture occurred.

  1. X-rays will usually reveal the fracture in the root, though the fracture line may be confused with the cortical bone. Another X-ray from a different direction will take the confusion away.
  2. If the fracture is in the apical one-third, root canal therapy and apicoectomy is the treatment of choice. Often, a hairline fracture will heal itself if left alone. If the child is not in pain, this may be the treatment of choice especially if the roots are still developing. If the tooth is loose, a wire splint may be necessary.
  3. If the root fracture is in the gingival one-third of the root, extraction is the treatment of choice. The tooth will be mobile, and the gingiva will be inflamed.

The Abscessed Tooth

  1. The X-rays may show a radiolucent cyst around the apical portion of the tooth.
  2. The visual examination reveals a large hole in the tooth, with possible exposure to the pulp chamber. The buccal or labial mucosa may be red and swollen, and the tooth may be dark in color.
  3. The tooth does not respond to the cold-air syringe.
  4. The tooth is very sensitive to percussion.
  5. The tooth exhibits a two to three mobility.
  6. Blue paper shows the tooth has extruded slightly.
  7. If you press the tissue over the tooth, it causes pain. The tissue may or may not be swollen.

You will not be able to numb this tooth if swelling is present unless the abscessed tooth is located in the mandible. If you see a radiolucent cyst at the apex of the tooth, you can assume the vessels and nerves inside the tooth are necrose. The patient will not feel pain from inside the tooth.

The treatment is to relieve the patient of pain. The pain the patient is feeling comes from pressure being exerted on nerve tissue in the alveolar bone.

Treatment of Abscessed Permanent Teeth
  1. The 557 bur is used to remove any existing filling material and expose the soft decay in the tooth. Do not take the bur beyond this point.
  2. A medium-size spoon is used to remove the soft decay. This should expose any live vessels in the pulp chamber.
  3. Using a #30 needle, a small amount of anesthetic is injected into the slight exposure, or the open canals. This is mainly a precaution.
  4. A large #2 round bur at slow speed is used to remove the debris and expose the pulp chamber and canals. The slow speed will keep the bur from going through the pulp chamber floor. The patient should be warned the bur may catch and jump.
  5. Using a flame-shaped diamond, the tooth is opened more by placing a 70-degree angle on the walls. This will give the opening more light and access for viewing the canals. Using the same bur, the tooth should be taken out of bite.
  6. Using a #25 broach, the canal should be opened to allow the serous fluid (pus) to escape from the canals. A # 35 broach can be used for large canal openings.
  7. To determine when the swollen tissue over the tooth should be opened, consider:
    1. The length of time the tooth has been swelling.
    2. The amount of organized serous fluid (dead white blood cells and bacteria–pus) in the tissue. This is determined by placing a #27 needle in the tissue. Leaving a slight amount of anesthetic, a small amount of fluid is withdrawn. If it shows pus, then the tissue is ready to be drained.
    3. The tissue is drained with a #12 blade.

The location of the drain is determined by the location of the pus pocket. The blade should be taken to the bone just below the gingiva. Special care should be taken in the mental foramen area to avoid cutting the nerve.

It is good to place the aspirator next to the incision site to remove the flood of serous material (pus) upon the incision.

If the swelling is extensive and the initial drain is not sufficient, then a piece of rubber dam should be sutured into the drained incision. This will keep the drain open to allow the serous material to continue flowing out.

Treatment of Abscessed Deciduous Teeth

This is usually the child’s first dental experience. The abscessed tooth has swelling on the buccal, and protrudes slightly. The patient is usually in tears. You want to do something easy and quick to relieve the pain.

The X-rays show the outline of the periapical abscess. You know that the child is experiencing the pain from the swelling. The periapical abscess tells you that the nerves in the tooth are necrose. The tooth can be opened and drained without anesthetic.

Using a 557 bur and a contra-angle handpiece, a hole is made through the occlusal of the deciduous tooth. The hole must reach the pulp chamber to be effective. You will see the serous fluid (blood and pus) flow from the tooth, relieving the pressure and the pain. The tooth is taken out of bite with a flame-shape diamond bur.

This is the quickest way to relieve the child’s pain. The child is placed on antibiotic therapy and another appointment is made for the extraction.

The Sequence of Infection

“Clinical characteristics are, therefore initial pain during the intrabony phase, followed by a sudden relief of pain on perforation of the bone and the release of pressure. Oedema of the soft tissues follows, and then increasing pain with the spread of the infective process.” (Tyldesley)

The Sequence of Infection
  1. The exposed pulp chamber allows bacteria to enter the tooth. The tooth will respond by being sensitive to cold, and then heat. Usually, when the tooth responds to heat, it is infected with bacteria.
  2. The vessels and nerve tissue in the tooth become necrotic and the bacteria increase in number and push out the apical end of the tooth, placing pressure on the nerve in the alveolar bone. The white blood cells increase in number and attack the bacteria. The debris from the battle leaves behind a large serous fluid (pus) buildup that seeks relief. The patient experiences a great deal of pain from the building pressure.
    Treatment: If the tooth is opened at this point, a large amount of serous material (pus) will extrude from the opening and the pain will be relieved. Antibiotics are given to aid the white blood cells.
  3. The building pressure will push pus through the porous bone, leaving a lined channel behind. The bacteria, white blood cells, and the residue (pus) will enter the soft tissue. The soft tissue swells (edema) as the serous fluid spreads out into the tissue. The pain from the building pressure is relieved. The tissue will feel hot to the touch.
    Treatment: If the tooth is opened at this point, a small amount of pus will extrude from the opening. The white blood cells will continue fighting the bacteria. Antibiotic therapy will delay or stop the growth of bacteria. A cold compress is placed over the warm tissue to delay the swelling. You cannot extract the tooth at this point with local anesthetic.
  4. The swelling (edema) will subside. The body will build up a defensive wall of fibers to wall off the infection and residue, creating a pocket of serous material (dead bacteria and white blood cells.)
    Treatment: The pocket of serous material (pus) is found and drained with a #12 blade. Antibiotic therapy is continued.
  5. The body will create a lined channel and drain the serous fluid (pus) to the outside. The channel will seek warmth, point (a white pimple), and drain the fluid.
    Treatment: The serous fluid is drained at the point with a #12 blade. Antibiotic therapy is continued.
  6. Once the body has drained the serous fluid, the channel closes off, and a defensive wall of fibers builds up around the apical end of the root, creating a cyst. The tooth remains in this chronic mode until the bacteria build up enough pressure to rupture the cyst sac. This usually happens when the tooth root canal or canals become plugged. The pressure against the nerve in the bone creates pain, and starts the process all over again.
    Treatment: Using a #25 broach, the canal is reopened to relieve the pressure of the serous fluid. Antibiotic therapy is started.
  7. The body may keep the channel and point open to allow the serous fluid to continue draining into the mouth. The tooth will remain asymptomatic as long as the point remains open.
    Treatment: The tooth is extracted using local anesthetic. Antibiotic therapy is started.
Discussion
  1. The antibiotics will control the infection at any of these points in the progression of the infection. Once the infection is controlled, the hole in the tooth can be closed and root canal therapy can be started.
  2. It is not recommended to place a heat pad against the cheek to relieve pain from the edema. The tissue channel will seek the heat and point, leaving a scar on the cheek. It is better to have the point be inside the mouth where it can be controlled and not leave any visible scar. A cold compress will take the heat away from the cheek and turn the point to the inside.
  3. Some would argue the tooth should not be opened to relieve the pressure buildup. They believe antibiotic therapy should be given to bring the infection under control. When you can relieve the child of pain immediately by opening the tooth, then this should be the treatment of choice.
The Exposed Vital 6-Year-Old Molar

The tooth usually has a large decay extending to the pulp chamber. The child can be experiencing a great deal of pain from the exposure, but this can also be attributed to clenching. Often, the child will clench to relieve the pain, making the tooth more sensitive than it would normally be. You may not be able to numb the tooth until the child sits for a time with a cotton roll between his teeth.

  1. The X-ray will show a dark shadow of decay touching the pulp chamber.
  2. The visual examination will note a large decayed surface if the exposure extends to the occlusal.
  3. The tooth will be sensitive to cold air and water.
  4. The tooth may be sensitive to percussion if the child has been clenching to relieve the pain.
  5. The tooth usually has not extruded (blue paper) unless the child has been clenching to cause the periodontal ligaments to swell.
  6. The tooth usually is not mobile unless the tooth has periodontal lost of bone, or the child has been clinching.
  7. The tooth will usually not be painful to tissue probing unless the patient has been clenching.
Treatment
  1. The tooth is numbed with the painless injection technique.
  2. Using the 557 bur, remove the old filling and/or the occlusal surface to expose the decay. The 557 bur is not taken deeper at this point.
  3. Using a medium spoon, you remove the soft decay until you see the exposed pulp chamber. Usually, the exposed chamber will bleed because the vessels are inflamed.
  4. Usually, a tooth with an exposure is not numb enough with the normal inferior alveolar or filtration method of numbing. A more direct method is needed to numb the tooth. Using a #30-gauge needle, inject the anesthetic into the decay over the exposed pulp chamber. The remaining soft decay filled with anesthetic is removed with the medium- size spoon, revealing more of the exposed pulp chamber. The anesthetic touches the exposure, numbing it. Anesthetic is then injected into the larger exposure, rendering the tooth numb.
  5. The posterior 6-year-old molar after the numbing is complete:
    Using the #2 round bur, expose the remaining pulp chamber to make it ready for the root canal therapy. The bur should run slow to avoid pushing through the floor of the pulp chamber. The slow bur will jump and catch in the process. The patient should be warned of this action to avoid stress.
  6. The anterior tooth after the numbing is complete:
    Using the #557 bur, the tooth should be opened on the lingual and made ready for root canal therapy. This may be a pulpotomy if the root is not completely formed.
  7. Using the #25 broach, the nerve is removed from the canals. A larger #35 broach is used for larger canals (maxillary anterior teeth). You may not be able to remove all of the nerve from the tooth, but this is not necessary. The remaining nerve tissue can be re moved during root canal therapy. It is the exposure of the nerve to air causing the pain. The temporary filling will take care of this, however.

Note: Using the X-ray, you should determine the approximate depth of the canals before placing the broaches. It is very easy to push through the apical end of the root and punch into the sinus or the nerve in the alveolar bone. This is a greater possibility when treating young children with large, open root canals.

  1. A small cotton ball is placed in the pulp chamber and a ZOE temporary cement is placed. The cotton ball prevents the canals from plugging. You do not place temporary cement into infected teeth.
    1. a. If a large amount of red serous material (blood) is extruding from the canal, you should leave the canal open.
    2. If there is no serous material extruding (the tooth is devoid of blood), the canal should be left open. A tight cotton pellet can be placed in the pulp chamber if the child is started on antibiotic therapy immediately.
    3. If the tooth is mobile, the canal should be left open.
  2. Antibiotic therapy needs to be started if the tooth cannot be closed, or if you suspect the tooth is infected. Root canal therapy cannot be started until the tooth is asymptomatic with the pulp chamber closed.
Discussion
  1. The tooth remains painless after this treatment until the bacteria increase their numbers sufficiently to push out the apical portion of the tooth. The small amount of live nerve tissue still in the pulp chamber will delay this, but it is important to start root canal therapy as soon as possible.
  2. It is a good idea to have the patient wait 20 minutes after the temporary filling is placed. You may need to reopen the tooth if it should start throbbing.
Deciduous Molar

The treatment of an exposed deciduous molar is similar to the 6-year molar, except you will be doing a pulpotomy instead of a root canal. The tooth is numbed as described above.

The large #2 round bur is used to clean the pulp chamber of vessels, nerve tissues, and decay. This is a slow-moving bur to avoid going through the floor of the pulp chamber. The patient should be warned the bur may catch on the tooth. The double-ended spoon is used to remove any decay the bur missed.

If a contact is involved, the box form is cut with a #557 bur, and the Tofflemire (band) is placed before the pulpotomy is started. This allows the deciduous tooth to be finished with an amalgam filling upon completion of the pulpotomy.

The tooth should be cleaned with water and air and observed.

  1. If the pulp chamber is dry (no blood), the deciduous tooth is infected and should be extracted.
  2. If blood serous material is oozing at a steady pace from the tooth, the tooth is under pressure. If the flow is continuous, it can be assumed the deciduous tooth is infected. The tooth should be left open and antibiotic therapy should be started. The tooth will be extracted later.
  3. If the blood serous material flows freely and then stops, a pulpotomy can be done. This is a judgment call.

Note: Some techniques say the large, round carbide bur pulls the nerves from the canals when it is used to clean the pulp chamber. This has not been the case in the thousands of pulpotomies I have done over the years. The sharp blades of the new round carbide bur cut the nerves and vessels very effectively, leaving the nerves and vessels in the canals intact. The large metal ball on the electrosurge attachment seals the canals by matching the cavity produced by the large carbide bur.

Procedure

Materials:

  1. Electrosurge (Ellman Dento-surg) and a large metal ball attachment (the size of a #2 carbide bur)
  2. Large plugger
  3. Hollenback
  4. Carver
  5. Double-ended spoon
  6. Basic setup (explorer, mirror, etc.)
  7. Hard-setting cement with eugenol, glass slab, and spatula
  8. Contra-angle handpiece, #2 round carbide bur, #557 carbide bur

Once the pulp chamber is cleaned of debris with the #2 round bur and spoon, the vessels in the pulp chamber are sealed off with the electrosurge large ball attachment. It is important here to use the large ball to cauterize the blood vessels and nerves in the canals. A small ball or point will not cauterize the tissue unless the canals are very small.

  1. The electrosurge is set up with the ground metal paddle behind the child’s back.
  2. The large round metal ball tip is inserted in the handpiece of the electrosurge.
  3. The water and air syringe cleans the pulp chamber of blood and debris.
  4. The large metal ball is placed against the pulp stumps in the pulp chamber. The foot pedal is pressed and the large ball cauterizes the blood vessels and nerve endings. It may take a couple of tries to cauterize both stumps.
  5.  A large cotton pellet filled with 3% hydrogen peroxide is placed in the pulp chamber and pressed into place, while the permanent hard cement is mixed to a thick, dough- like consistency.
  6. The cement dough is rolled to a point. The large cotton pellet is removed, the pulp chamber is air dried, and the cement dough is placed. A large plugger pushes the cement dough into the recesses of the pulp chamber, which removes the excess cement from the tooth.
  7. The Tofflemire is removed and cement dough is carved with the Hollenback and carver. If the timing is good, the carver will work. Otherwise, the contra-angle hand piece, green stone, and plenty of water can carve the cement.
  8. If an amalgam filling is placed in the tooth, the cement is reduced enough to allow the amalgam to be placed. If the pulpotomy is being done in conjunction with a stainless steel crown, the stainless steel crown needs to be seated before the cement hardens.
Pulpotomy on a Permanent 6-Year-Old Molar

The pulpotomy on the 6-year-old molar may be preferred to attempting root canal therapy when the canal walls at the apical end of the roots are diverging. If a closure cannot be made at the apical end of the root, the endodontic treatment will fail. A molar apicoectomy procedure can correct this, but it is not a recommended treatment for a child.

The large, round #2 bur removes the blood vessel and nerves in the pulp chamber. This is similar to preparing the tooth for a root canal, except the canals are not entered. The remaining pulp stumps in the canals are sealed with the electrosurge. The large ball attachment cauterizes the vessels and nerve endings. The large cotton pellet of hydrogen peroxide is placed in the pulp chamber and held with some pressure.

If the vessels in the canals are still hemorrhaging, they are cauterized a second time with the electrosurge. The pulp chamber is air dry. The thick eugenol cement is placed with a large amalgam plugger. Enough room is left on the occlusal for the preferred restoration.

This technique works well when there is no infection in the canals. If the pulp chamber is bleeding profusely when it is opened, it can be suspected the canals will be infected. This technique only works well with healthy tissue.

Other techniques are suggested in the literature – some even suggesting doing only a partial pulpotomy. This has never worked for me. Only by taking the live tissue to the root canals and cauterizing them inside the canals can you be sure of a seal with no infection. When the tooth is opened, you introduce bacteria into the pulp chamber. Attempting to seal live tissue in a large space only invites a later problem.

Formocresol Debate

The use of formocresol was outlawed when I graduated from school 40 years ago. Why we are still subjecting children to this method of pulpotomy, I simply do not understand. The procedure has an element of danger to the child that is not necessary. Other methods are available. The one proposed above, the electrosurge, is an excellent method with no latent after effects.

The large ball needs to be used instead of the wire – proposed by a research project that claimed the patient jumped when the nerve was touched by an electosurge wire. This tells me the patient was not numbed properly.

The electrosurge method does not cause the patient to jump. His feet do not twitch. The electrosurge simply cauterized the pulp stumps of the root canals. The hydrogen peroxide cleans the pulp chamber, and the eugenol cement seals and soothes the exposed nerves. This method has been clinically tested for 40 years and works extremely well.

Conclusion

Children’s dentistry is fun and very rewarding. The process of treating children should be thought of as long-term treatment that will carry over into the child’s adult years as your practice matures. It is a building process to create better patients and friends. Time spent with children early on will later give you excellent patients who will refer others to you.