Q1. All of the following procedures have proved beneficial in treating a mentally retarded child EXCEPT one. Which one is the EXCEPTION?

a) speak slowly and in very simple terms

b) listen carefully to the patient

c) schedule long appointments

d) ask the patient if there are any questions about anything you will be doing

e) Keep appointments short

Answer Key : Keep appointments short

• In addition, the following procedures are also helpful when treating children with intellectual inability :

• Give a tour to the patient before attempting to do any treatment. Introduce the patient to the office personnel.
• Give only one instruction at a time. Reward the patient with compliments after the successful completion of the procedure.
• Schedule the patient early in the day. The staff, the dentist, and the patient are less fatigued at this time.

• In treating children with intellectual inability, the following is usually found:

• They can be controlled in the same ways as normal children.
• They respond similarly to normal children of the same mental age.
• They respond inconsistently, have short attention spans, and are restless and hyperactive when undergoing dental care.

• Important : The dentist should assess the degree of mental retardation by consulting the patient’s physician before starting dental treatment.
• An important caveat is that every child responds to his or her environment with an individualized style. Practitioners must be perceptive and flexible with the use of their management techniques, and they can optimize the likelihood of a successful encounter by matching their selection of techniques to that of the patient’s style of interaction.

Q2. The management of a child who must undergo dental extractions is based on which of the following factors?

a) the age and maturity of the child

b) the past medical and dental experiences that might influence the behavior of the child

c) the physical status of the child

d) the length of time and amount of manipulation necessary to accomplish the surgery

e) All of the above

Answer Key : All of the above

• The age and maturity of the child often determine the type of anesthesia best suited for the intended procedure.
• Children below the age of reason generally are best managed under general anesthesia, since a slight amount of discomfort is always associated with the administration of a local anesthetic,
• It is very important to have total anesthesia before starting the procedure. Use both buccal and palatal infiltration on maxillary teeth and block anesthesia on mandibular teeth with infiltration, if necessary.
• The very young patient is best managed under general anesthesia, usually of the inhalation type or in combination with small doses of intravenous barbiturates.
• The most common premedication prior to general anesthesia is Versed.
• Note: Premedication with a barbiturate may cause paradoxical excitement in a young child.
• Remember: After extracting a tooth on a child patient, the biggest postoperative concern is the prevention of lip biting.

Frank behavioral rating scale:

• Class 1: child is completely uncooperative, crying, very difficult to make any progress
• Class 2: child is uncooperative, very reluctant to listen/respond to questions, some progress is possible
• Class 3: child is cooperative, but somewhat reluctant/shy
• Class 4: child is completely cooperative and even enjoys the experience

Variables that influence the child’s behavior in the dental setting:

• Age:

 (1) less than 2 years old: usually are lacking in cooperative ability.

(2) 2 years old: Tell-Show-Do technique works well and/or parent in operatory

(3) 3-7 years old: generally cooperative;

(4) 8 years old and older: usually cooperative.

• Mother’s anxiety: there is a direct correlation between the mother’s anxiety and a child’s negative behavior in the dental setting.
• Past medical history: if a patient has had positive medical experiences in the past, they are more apt to have positive dental experiences as far as behavior is concerned.

Important: The great majority of children require minimal management efforts other than providing information on what is going to happen (e.g., tell-show-do).

Q3. All of the following instances may make the use of a rubber dam impractical EXCEPT one. Which one is the EXCEPTION?

a) the presence of fixed orthodontic appliances

b) a patient with congested nasal passages or other nasal obstruction

c) a very nervous or anxious patient

d) a recently erupted tooth that will not retain a clamp

Answer Key : a very nervous or anxious patient

• One of the main advantages of using a rubber dam is that it can aid in the management of the child. It seems to quiet and calm the patient because the dam acts as a separation or barrier, both physically and psychologically.
• Other advantages include:

–  Better access and visualization

–  Control of saliva and moisture in the operating field

–  Decreased operating time

–  Provides protection from aspiration or swallowing of foreign bodies

–  The child becomes primarily a nasal breather when the rubber dam is in place. This then enhances the effects of nitrous oxide if applicable.

Nitrous oxide sedation for children: 

• for the production of conscious sedation, the inhalational route is limited to one agent, nitrous oxide.
• Desirable characteristics of nitrous oxide: it is analgesic and anxiolytic.
• It is important to remember, however, that nitrous oxide will not eliminate the need for local anesthetic pain control in most cases. 

• Note: Minimum oxygen concentration = 30%. However, concentrations of nitrous oxide in excess of 50% are usually contraindicated in dental office sedation.

• Primary advantages of nitrous oxide for conscious sedation in pediatric dentistry:

• • Rapid onset and recovery: because nitrous oxide has a very low plasma solubility, it reaches a therapeutic level in the blood rapidly, and conversely, blood levels decrease rapidly when it is discontinued.

• Ease of dose control (Titration)

• Lack of serious adverse effects: nitrous oxide is considered to be inert and nontoxic when administered with adequate oxygen. The most common side effect is nausea /vomiting.

• Notes :

1. Minimum alveolar concentration (which is the concentration required to produce immobility in 50% of patients) of nitrous oxide is 105%.
2. The total flow rate is 4 to 6 L/min for most children.
3. The maintenance dose during the dental appointment is usually around 30-35%.
4. On termination of nitrous oxide administration, inhalation of 100% oxygen for not less than 3-5 minutes is recommended. This allows diffusion of nitrogen from the venous blood into the alveolus that is then exhaled as nitrous oxide through the respiratory tract.

• Note: This process will prevent diffusion hypoxia.

Q4. The phenomenon of “strawberry tongue” is associated with:

a) herpangina

b) scarlet fever

c) diphtheria

d)  mumps

Answer Key : Scarlet fever

Scarlet fever

• It is an exotoxin-mediated disease arising from group A beta-hemolytic streptococcal infection.
• The peak incidence of scarlet fever occurs in children 4 to 8 years old
•  It is usually accompanied by symptoms of strep throat, such as sudden onset of fever, sore throat, headache, nausea, vomiting, abdominal pain, muscle pain, and fatigue.
• An enlargement of the fungiform papillae extending above the level of the white desquamating filiform papillae gives an appearance of an unripe strawberry.
• During the course of scarlet fever, the coating disappears and the enlarged red papillae extend above a smooth denuded surface, giving the appearance of a red strawberry or raspberry.
• Penicillin is the drug of choice.
• Early diagnosis and treatment are important to prevent complications, which include local abscess formation, rheumatic fever, arthritis, and glomerulonephritis.

Herpangina 

• It is a viral infection, usually of young children, characterized by mouth ulcers, but a high fever, sore throat, and headache may precede the appearance of the lesions.
• The lesions are generally ulcers with a white to whitish-gray base and a red border – usually on the roof of the mouth and in the throat.
• The ulcers may be very painful. Generally, there are only a few lesions. The disease usually runs its course in less than a week.
• Treatment is palliative. The cause is often an infection by a strain of coxsackie A virus.

Diphtheria

• It is an acute, contagious disease caused by the bacterium Corynebacterium diphtheriae, characterized by the production of a systemic toxin.
• The toxin is particularly damaging to the tissue of the heart and CNS.
• Immunization against diphtheria is available to all children in the U.S.

Other conditions to know:

• Puberty gingivitis: characterized by the enlargement of interdental areas, and spontaneous or easily stimulated bleeding. Treatment includes professional cleaning and improved oral hygiene.
• Herpes simplex infection:

– Primary herpetic gingivostomatitis: HSV-1 infection, usually occurs in children under 3 years old.

Vast majority are subclinical.

– Acute herpetic gingivostomatitis:

• If diagnosed within 3 days of onset, acyclovir suspension should be prescribed, 15 mg/kg five times daily for 7 days.
• All patients, including those presenting more than 3 days after disease onset, may receive palliative care, including plaque removal, systemic NSAIDs, and topical anesthetics.
• Recurrent herpetic simplex (Herpes labialis): vesicles located at the mucocutaneous junction of the lips, corners of the mouth, and beneath the nose. Associated with emotional stress.
• Recurrent aphthous ulcer: painful ulcers on unattached mucous membranes.

Q5. All of the following statements concerning acute necrotizing ulcerative gingivitis (ANUG) are true EXCEPT one. Which one is the EXCEPTION?

a) It is also called Vincent infection, Vincent angina, or “trench mouth“

b) It is a gingival disease characterized by painful hyperemic gingiva, punched-out erosions of the interproximal papilla, covered by a gray pseudomembrane with an accompanying fetid odor

c) Risks include poor oral hygiene, poor nutrition, smoking, and emotional stress

d) It usually affects children

e) Fusiforms and spirochetes, as well as Prevotella intermedia, have been implicated in the etiology of acute necrotizing ulcerative gingivitis (ANUG)

Answer Key : it usually affects children *** This is false; ANUG occurs in young to middle-aged

ANUG

• It is an acute fusospirochetal infection of the gingiva.
• It involves a progressive painful infection with ulceration, swelling, and sloughing of dead tissue from the mouth and throat due to the spread of infection from the gums.
• It is usually associated with poor oral hygiene and is most common in conditions where there is crowding and malnutrition.
• It is rare in preschool children.
• It can be easily diagnosed because of the involvement of the interproximal papillae and the presence of a pseudomembranous necrotic covering of the marginal tissues.
• The clinical manifestations of the disease include inflamed, painful, bleeding gingival tissue; poor appetite; fever; general malaise; and a fetid odor.
• Treatment includes debridement, hydrogen peroxide mouth rinses, and antibiotic therapy.

• Note:  Atrophic gingivitis is characterized by gingival recession without a corresponding rate of alveolar bone loss. Minor marginal and papillary gingival inflammation is found. The predominant clinical finding is the recession.

Periodontal disease in adolescents: 

• The clinical and histologic manifestations of gingival and periodontal disease in adolescents are similar to those seen in adults. 
• Bone loss from periodontitis does occur in a small percentage of teenagers, but the predominant condition noted in this age group is gingivitis.

Periodontal disease in children:

• A primary characteristic of aggressive periodontitis that differentiates it from chronic periodontitis is the rapid progression of attachment and bone loss that is evident. Aggressive periodontitis may be localized or generalized. The classic form of localized aggressive periodontitis was initially referred to as “periodontosis” and then as “localized juvenile periodontitis” (LJP). Localized aggressive periodontitis (LAP) is the new classification designated to replace LW.
• LAP is defined by several distinguishing characteristics: onset around the time of puberty, aggressive periodontal destruction localized almost exclusively to the incisors and first molars, and a familial pattern of occurrence. Actinobacillus actinomycetemcomitans is the dominant bacteria in LAP, other microorganisms that have been associated with LAP include P. gingivalis, E. corrodens, C. rectus, F. nucleatum, Bacillus capillus, Eubacterium brachy, and Capnocytophaga species and spirochetes.

• Important: 
• The one outstanding negative feature is the relative absence of local factors (plaque) to explain the severe periodontal destruction that is present.
• Generalized aggressive periodontitis (GAP) is differentiated from the localized form by the extent of involvement around most of the permanent teeth, and it is considered to include rapidly progressing periodontitis.