All posts by DentMistry

Behavior management

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


  • Nitrous oxide
  • Conscious sedation
  • General anesthesia

Molar incisor hypomineralization (MIH)

Clinical appearance of enamel hypomineralization of systemic origin affecting one or more permanent first molars (PFM) that are frequently associated with incisors


  • Oxygen shortage + low birth weight
  • Parental risks – infection, maternal psychological stress
  • Complications during delivery
  • Respiratory diseases and oxygen shortage of ameloblasts
  • Children born with poor general health
  • Childhood febrile disease


  • Demarcated opacities
  • Post eruption breakdown

Criteria for MIH severity:

Differential diagnosis

Challenges in treatment:

  • Sensitivity and rapid development of caries
  • Limited co-operation of a young child
  • Difficulty achieving anesthesia – enamel is porous so exposed dentine results in chronic pulp inflammation
  • Repeated marginal breakdown of restorations


  • Early – Stainless steel crowns
  • Moderate – Restoration
  • Late – Extract PFM
  • Fissure sealants
  • Topical fluoride – toothpaste, fluoride varnish, fluoride gel

Dental fluorosis

Dental fluorosis

Developmental disturbance of dental enamel, caused by successive exposure to high concentrations of fluoride – 1.5 mg/l (1.5 ppm) in drinking water – during tooth development , leading to enamel with lower mineral content of increased porosity


Direct inhibitory effect on enzymatic action of ameloblasts leading to defective matrix formation and subsequent hypomineralization

Clinical features:

Generalized discoloration and pits

Fluorosis index

Management: Depends on severity

  • Bleaching
  • Composite restorations
  • Veneers
  • Full crowns

Chronological hypoplasia (Linear enamel hypoplasia)

A well demarcated area of enamel hypoplasia corresponding with the period of crown formation of permanent teeth (between birth and 6 years) due to nutritional defects eg. rickets, childhood diseases etc. that may cause temporary ameloblast dysfunction

Chronological hypoplasia (Linear enamel hypoplasia)

Prescribing Drugs

Factors when prescribing

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

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

Calculating Drug dosage

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

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

Radiology: X-Ray positions

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

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


  • Patient head slightly tilted down so occlusal plane is parallel to the floor
ToothVertical film angulationX-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
IOPA x-ray positions for maxillary teeth


  • Patient head slightly tilted up so occlusal plane is parallel to the floor
  • Film must touch floor of the mouth
ToothVertical film angulationX-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
IOPA x-ray positions for mandibular teeth

Watch video

Orthopantomogram (OPG)

OPG landmarks

Other radiograph techniques

Intraoral radiographs

Extraoral radiographs:

Extraoral radiographs
Image from Pocket Dentistry

Chronology of tooth development and eruption

Primary teeth

  • Sequence of eruption: A-B-D-C-E
Notation of primary teeth
(Weeks in utero)
Crown completion
Root completion
Primary teeth development and eruption

Permanent teeth

  • Sequence of eruption:
    • Maxilla: 6-1-2-4-5-3-7-8
    • Mandible: 6-1-2-3-4-5-7-8
Tooth numbering in maxilla and mandible
ToothArchTooth germ appearance (IU)Beginning of crown calcificationCrown calcification completeEruptionRoot completion
16At birth2.5-3 years6-7 years9-10 years
163-4 months3-4 years7-8 years
6-7 years
10 years
9 years
1610-12 months
3-4 months
4-5 years8-9 years
7-8 years
11 years
10 years
184-5 months6-7 years11-12 years
9-10 years
13-15 years
12-14 years
201.5-2 years5-6 years10-11 years12-13 years
22-242-3 years6-7 years10-12 years
11-12 years
12-14 year
1st year2.5-3 years7-8 years12-15 years
11-13 years
14-16 years
3rd year7-9 years
8-10 years
12-16 years17-24 years
17-21 years
18-25 years
Secondary teeth development and eruption

Common teeth notation systems:

  • FDI World Dental Federation notation
  • Universal Numbering System
  • Palmer notation
Common teeth notation systems
© 2021 DentaGama

Tooth extraction

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

Wedge principle

2. Lever principle

Lever principle

3. Wheel and axle

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


  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



  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


  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



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

Extraction forceps and elevators

Maxillary extraction forceps

Maxillary anterior forceps – Incisors and canines

Maxillary anterior forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary premolar forceps – Premolars

maxillary premolar forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary molar forceps – Molars

Maxillary molar forceps
©Association of Oral and Maxillofacial Surgeons of India

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

Maxillary cow horn forceps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary third molar forceps – Third molars

maxillary 3rd molar foreps
©Association of Oral and Maxillofacial Surgeons of India

Maxillary bayonet forceps – Roots

Maxillary bayonet forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular extraction forceps

Mandibular anterior forceps – Incisors and canines

Mandibular anterior forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular premolar forceps – Premolars

Mandibular premolar forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular molar forceps – Molars

Mandibular molar forceps
©Association of Oral and Maxillofacial Surgeons of India

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

Mandibular cow horn forceps
©Association of Oral and Maxillofacial Surgeons of India

Mandibular third molars forceps – Third molars

Mandibular third molars forceps
©Association of Oral and Maxillofacial Surgeons of India


Straight elevator – Luxation of maxillary and mandibular teeth

Straight elevator
©Association of Oral and Maxillofacial Surgeons of India

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

Coupland elevator
©Association of Oral and Maxillofacial Surgeons of India

Apexo elevator – Extraction of root pieces

Apexo elevator
©Association of Oral and Maxillofacial Surgeons of India

Cross bar elevator – Extraction of mandibular roots

Cross Bar elevator
©Association of Oral and Maxillofacial Surgeons of India

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

Cryer elevator
©Association of Oral and Maxillofacial Surgeons of India

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

Warwick James elevator
©Association of Oral and Maxillofacial Surgeons of India

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

Root tip elevator
©Association of Oral and Maxillofacial Surgeons of India

Radioanalysis of impacted teeth

Canine localization

  • Parallax in horizontal plane: Two IOPA or USO + IOPA
  • Parallax in vertical plane: OPG (↑8°) + USO (↓65-70°) to horizontal plane
  • SLOB: Same Lingual Opposite Buccal
  • If in line with arch, will not move
  • Can do CBCT

Third molars

X-rays used:

  • IOPA – difficult due to gagging
  • OPG
  • Oblique lateral view
  • Lower/upper oblique occlusal view – buccolingual position
  • CBCT

1. Angulation

Angulation of impacted molar

2. Crown

  • Size
  • Shape
  • Dental caries
  • Resorption

3. Roots

  • Number of roots
  • Shape
  • Stage of development
  • Curvature – favorable/unfavorable
Impacted tooth root curvature - favorable/unfavorable

4. Relation to ID canal

5. Depth of tooth in alveolar bone

a. CBCT measurement tools

b. Winter’s lines method

  • 1st line (white): Occlusal surface of 1st and 2nd molar
  • 2nd line (amber):
    • Crest of interdental bone between 1st and 2nd molar
    • Extending distally along internal oblique ridge
    • Indicates amount of investing bone surrounding the tooth
  • 3rd line (red):
    • Perpendicular line dropped from white line to point of application
    • Measured from amber line to point of application
    • If red line > 5mm – difficult extraction
Winter's lines third molar impacted

c. Using roots of 2nd molar

Impacted third molar, use second molar relation

6. Buccal or lingual obliquity

  • Determine line of tooth in horizontal plane
  • Buccal obliquity – Crown inclined towards cheek
  • Lingual obliquity – Crown inclined towards tongue
  • Use:
    • Lower oblique occlusal
    • Lower 90° occlusal view

7. Others

a. Surrounding bone

  • Position of ascending ramus to determine access of tooth and the overlying bone
  • Density of bone
  • Evidence of pericoronal infection

b. Lower 2nd molar

  • Crown – Condition of restoration, caries, resorption
  • Root – Number, shape, periodontal status, condition of apices