Non pharmacological

1. Tell show do

• Tell – Explain procedure with age appropriate language
• Show – Demonstrate procedure
• Do – Perform procedure

Communication should be gentle, addressing the child. Use euphemism (eg. call LA “sleeping juice”, rubber dam “umbrella”) and smile. Have positive reinforcement.

2. Behavior modelling – Show other children getting procedures and how they behave

3. Distraction – Music, videos, virtual reality

4. Relaxation therapy – Relaxation exercises to do at home

5. Systemic desensitization – Present the procedure in a graduated fashion to reduce anxiety

6. Hypnosis – Altered state of consciousness to produce desirable behavior

7. Aversive techniques: Must obtain parent consent, informed consent, document indication and duration. Should be legal in country of practice and be used with extreme caution.

• Hand over mouth – and explain in child’s ear. Contraindicated in children below 3 and special health care needs
• Protective stabilization – can cause physical and psychological harm. Active is by dental team, passive is by protective devices
• Voice control – Changing volume, speed or tone of voice to get child’s attention

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Pharmacological

• Nitrous oxide
• Conscious sedation
• General anesthesia

Factors when prescribing

• Safety
• Efficacy
• Affordability
• Availability
• Route of admin
• Frequency

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How to prescribe

1. Formulation of drug: PO, IV, IM, PV, PR

2. Name of drug: Paracetamol, Amoxycillin

3. Dosage: mg, g, avoid decimals

4. Frequency: OD, BD, TDS, Nocte, PRN (state minimum dose interval in PRN)

5. Duration: 5/7, 2/52, 3/12

Eg. PO Augmentin 625mg BD x 5/7

• 1-5 years: 1/4 of adult dose
• 6-12 years: 1/2 of adult dose

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Calculating Drug dosage

The Reference Manual of Pediatric Dentistry – Useful Medications For Oral Conditions

Use the app Dental Drugs (App store, Play store) to quickly refer for prescribing medications, calculating maximum anesthetic dosages or recalling common treatment/emergency protocols in practice

Bilateral bite wing (BBW)

• Patient head straight so occlusal plane is parallel to the floor
• Bite should be normal
• X-ray central beam:
  • Vertical angulation: +10°
  • Horizontal angulation:
    • Premolar BBW: 30° from mid-sagittal plane, aimed at inner canthus of the eye
    • Molar BBW: 60° from mid-sagittal plane, aimed at outer canthus of the eye

Watch video

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Intraoral periapical (IOPA)

• Identification dot on film always placed towards incisal/occlusal surface of teeth and towards midline
• Vertical angulation at occlusal plane is zero, upward is negative and downwards is positive

Maxilla

• Patient head slightly tilted down so occlusal plane is parallel to the floor

Tooth	Vertical film angulation	X-ray central beam aim
Incisors	+45°	Tip of the nose
Canine	+45°	Canine eminence – distal and inferior borders of ala of nose
Premolars	+30°	Perpendicular to pupil of the eye, film is horizontal
Molars	+20°	Perpendicular to outer canthus of the eye, film is horizontal

Mandible

• Patient head slightly tilted up so occlusal plane is parallel to the floor
• Film must touch floor of the mouth

Tooth	Vertical film angulation	X-ray central beam aim
Incisors	-15°	Tip of the chin
Canine	-20°	Perpendicular to ala of nose
Premolars	-10°	Perpendicular to pupil of the eye
Molars	-5°	Perpendicular to outer canthus of the eye

Watch video

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Orthopantomogram (OPG)

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Other radiograph techniques

Intraoral radiographs

Extraoral radiographs:

Download Medicos Dental Material App on:

• App store
• Play store

This app has instruments, their name and use and tray set ups for all dental procedures

Primary teeth

• Sequence of eruption: A-B-D-C-E

Tooth	Arch	Calcification (Weeks in utero)	Crown completion (Months)	Eruption (Months)	Root completion (Years)
A CI	Max Mand	14	1.5 2.5	10 8	1.5
B LI	Max Mand	16	2.5 3	11 13	2 1.5
C C	Max Mand	17	9	19 20	3
D M1	Max Mand	15	6 5.5	16	2
E M2	Max Mand	19 18	11 10	29 27	3

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Permanent teeth

• Sequence of eruption:
  • Maxilla: 6-1-2-4-5-3-7-8
  • Mandible: 6-1-2-3-4-5-7-8

Tooth	Arch	Tooth germ appearance (IU)	Beginning of crown calcification	Crown calcification complete	Eruption	Root completion
6 M1	Max Mand	16	At birth	2.5-3 years	6-7 years	9-10 years
1 CI	Max Mand	16	3-4 months	3-4 years	7-8 years 6-7 years	10 years 9 years
2 LI	Max Mand	16	10-12 months 3-4 months	4-5 years	8-9 years 7-8 years	11 years 10 years
3 C	Max Mand	18	4-5 months	6-7 years	11-12 years 9-10 years	13-15 years 12-14 years
4 PM1	Max Mand	20	1.5-2 years	5-6 years	10-11 years	12-13 years
5 PM2	Max Mand	22-24	2-3 years	6-7 years	10-12 years 11-12 years	12-14 year
7 M2	Max Mand	1st year	2.5-3 years	7-8 years	12-15 years 11-13 years	14-16 years
8 M3	Max Mand	3rd year	7-9 years 8-10 years	12-16 years	17-24 years 17-21 years	18-25 years

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Common teeth notation systems:

• FDI World Dental Federation notation
• Universal Numbering System
• Palmer notation

Patient positioning when extracting teeth

• Maxillary teeth: 3 inch below shoulder level of operator and 45 degree chair angulation
• Mandibular teeth: At elbow level of operator and 90 degree chair angulation
• 1st, 2nd and 3rd quadrant: Right front of patient
• 4th quadrant anterior teeth: Right front of patient
• 4th quadrant posterior teeth: Behind right side of patient/ just right side

Tooth extraction forceps and elevators

Click here

Tooth extraction techniques

Elevator techniques

Elevators works on principles of:

1. Wedge
2. Lever
3. Wheel and axle
4. Combination of the above

1. Wedge principle

2. Lever principle

3. Wheel and axle

Post extraction steps

• Ensure complete tooth and root removal and confirm by showing to patient
• Inspect socket and remove sharp bony margins – if present smoothen with a file
• Compress expanded socket with digital pressure
• Apply pressure pack
• Prescribe analgesics if needed

Post op instructions for patient

• Bite on pressure pack for 30-60 minutes
• Swallow saliva normally
• Do not rinse or spit for 24 hours
• Do not stick finger or tongue at extraction site
• Drink water and fluids normally, do not use straw
• Do not eat until the effects of anesthesia go away
• Eat soft and cold diet
• Apply cold compression/ice pack for swelling
• After 24 hours use salt water rinse
• Avoid smoking for 5 days

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Indications

1. Gross caries
2. Tooth injury and tooth cannot be salvaged
3. Tooth in jaw fracture line
4. Impacted tooth
5. Pre-prosthetic preparation
6. Orthodontics
7. Supernumerary teeth
8. Associated pathology
9. Severe periodontal disease
10. Retained deciduous teeth
11. Patient preference/economic constraints
12. Preparation for radiotherapy

Contraindications

Local:

1. History of irradiation in that area
2. Lack of cooperation or consent from patient
3. Lack of proper equipment
4. Lack of adequate skill
5. Severe infections – control infection first

Systemic:

1. Severe metabolic disease – uncontrolled DM, renal disease
2. Hepatic dysfunction – decreased coagulative factors
3. Coagulopathies – hemophilia, platelet disorder
4. History of CVD
5. Leukemia
6. Pregnancy
7. Steroid therapy

NB:

• Avoid extraction during menstruation – risk factor for alveolar osteitis

Complications

a. Complication due to injection technique and anesthetic solution:

• Needle brakage
• Failure to work
• Allergy
• Syncope
• Hematoma if in vessel

b. Complication pre-op

• Lack of cooperation, anxiety
• Poor access – trismus, decreased mouth opening, crowded/malaligned teeth

c. Complications during surgical procedure

• Difficulty in luxation – root dilaceration, curvature, hypercementosis
• Soft tissue injury
• Damage to adjacent teeth
• Fracture of mandible, alveolus or tuberosity
• Fractured instrument – eg. needle
• Tooth/root displacement into maxillary antrum – Caldwell Luc approach to remove
• Loss of extracted tooth or root – stop everything and look for it, can do chest xray
• Nerve injury:
  • Neuropraxia – temporary conduction loss
  • Axonotmesis – axon and myelin sheath damaged but epineurium, perineurium and endoneurium intact
  • Neurotmesis – nerve transection
  • Paresthesia – tingling/prickling sensation
  • Dysesthesia – abnormal sensation
  • Hyperesthesia
  • Hypoesthesia
  • Anesthesia
  • Formation of:
    • Phantom limb syndrome
    • Anesthesia dolorosa – sense of touch diminished but malfunctioning painful sensation left intact in trigeminal nerve

d. Complications after procedure

• Hemorrhage
  • Primary – laceration of artery, surgery done in infected area with granulation tissue
  • Reactionary – occurs few hours after surgery , failure of coagulation
  • Secondary – 7-10 days after surgery, due to infection + partial division of blood vessel
• Alveolar osteitis
• Infection
• Delayed healing
• Pain

Maxillary extraction forceps

Maxillary anterior forceps – Incisors and canines

Maxillary premolar forceps – Premolars

Maxillary molar forceps – Molars

Maxillary cow horn forceps – Molars with extensive loss of coronal structure

Maxillary third molar forceps – Third molars

Maxillary bayonet forceps – Roots

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Mandibular extraction forceps

Mandibular anterior forceps – Incisors and canines

Mandibular premolar forceps – Premolars

Mandibular molar forceps – Molars

Mandibular cow horn forceps – Molars with extensive loss of coronal structure

Mandibular third molars forceps – Third molars

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Elevators

Straight elevator – Luxation of maxillary and mandibular teeth

Coupland elevator – Split multi-rooted teeth and are inserted between the bone and tooth roots and rotated to elevate them out of the sockets

Apexo elevator – Extraction of root pieces

Cross bar elevator – Extraction of mandibular roots

Cryer elevator – Extraction of roots, elevation of upper third molars

Warwick James elevator – Extraction of retained roots, deciduous teeth, maxillary third molars, and teeth with less resistance

Root tip elevator – Removal of apical root tips/fragments of roots