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Operative Procedures for the Deciduous Teeth*
M organ— Operative Procedures for Deciduous Teeth T h e am algam is placed in the cavity in sm all portions and tamped to place to reach all parts o f the cavity and then condensed to rem ove the excess m ercury and to w edge the am algam into contact w ith the cavity w alls by sufficient pres sure. T h e am algam instrument is stepped in an orderly manner.
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T h e com pleted filling is carved to c o r rect tooth form and polished. I t is true that to carry out the technic properly w ill take a little m ore tim e and w ork , but on ly in so doing w ill w e ad here to professional standards and give to the patient that w hich he can ju stly expect.
O PE R A TIV E PROCED U RES F O R T H E D E C ID U O U S TEETH * B y GEORGE E. M O R G AN , D .D .S., F.A.C.D ., M ilwaukee, W is. U C C E S S or failure in dentistry for children is principally dependent on a w ork in g kn ow led ge o f the pre operative psychology and a thorough understanding o f the operative consid erations. T h e man w h o thinks that he can be successful w ith children, either in general practice or as a pedodontist, w ith ou t considering collectively these principles, is w ith ou t question destined to fail. O n the other hand, if he carefu lly studies them, preferably w hen a student, the problem s arising in dealing w ith children w ill be easily solved. T h e m ountainous peaks then becom e on ly m olehills as each trying situation is ap proached. It is regrettable that a curriculum survey on m odern dental education leaves pedodontia entirely ou t o f the curriculum . It makes one w on der w hether w e have really progressed in this century o f dentistry in A m erica. T r y in g to teach dentistry fo r children to dental students by giving them a crum b *Read before the Section on Children’s Den tistry, Preventive Dentistry and Mouth H y giene at the Seventy-Second Annual M idw in ter Clinic o f the Chicago Dental Society, Feb. 20, 1936. Jour. A .D .A ., Vol. 23, September, 1936
here and there certainly does n ot indicate progress, as the situation is no different from w hat it has been fo r the last hun dred years. W h ile the curriculum sur vey com m ittee is to be com m ended for its remarks on the need fo r better and m ore adequate dental service fo r the child, it should and w ill be criticized for not m aking pedodontia a distinct subject. Pedodon tia should no longer be le ft by the wayside, but should be given its righ tfu l place along w ith the other branches o f dentistry. O perative procedures must necessarily be preceded by g ivin g some thought to preoperative psychology, w hich plays such a vital part in the final results. PR EO P E R A T IV E PSYC H O L O G Y
First, to create an atmosphere that provides fo r relaxation means that the dental office must not be a ju m b le o f artistic array, but rather suggest room i ness and sim plicity. T h e child w ill, in proper surroundings, relax almost in stantly and, as a result, be m ost adapt able to the procedures to fo llo w . A lo n g w ith sim plicity o f atmosphere, cleanliness must predom inate, as it is one o f the best means o f establishing confidence. Pleas
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ant surroundings make the child feel w elcom e and as if he w ere am ong friends. I f the office is crow d ed and ov erly dec orated, the child is disconcerted w hen he steps into the room . H e becomes tense and fearfu l o f w hat m ay occu r— the at mosphere is foreign and his reaction is unfavorable. L o u d and shrill voices also tend to have an unfavorable response. Secondly, w e must consider the per sonality o f the child. Is he shy and fear fu l o r precocious, alert and frien d ly? C hildren form their likes and dislikes very quickly. E very child is flattered w hen he realizes that w e treat him w ith the respect show n fo r an adult. T h e n , too, any handicapped ch ild resents our consciousness o f his being u nlike other children. R em em ber it is “ M a r y ” or “ J oh n ” and n ot “ Sister” o r “ Sonny.” T o the shy, bashful child, let us be sympa thetic and kind in ou r attitu d e; w ith the alert and friendly child, firm yet kind. A le rt children are som etim es m ore diffi cu lt to manage because o f their unusual ability to adjust themselves to n ew sur roundings. T h e y are overly conscious of what is g oin g on. W it h the physically handicapped child, refuse to notice his disabilities and treat him as norm al. T h e im portance o f any service to the child is evaluated by the education w e or the parents give to it. A health habit is based on a ch ild ’s duty tow ard the betterment o f hum anity. I f he is re w arded for an act in the interest o f his health, especially by the dentist, the visit, in the m ind o f the child, n o lon ger re mains in the same category w ith that o f an obligation to him self, but becomes a favor to the dentist. T h e harm o f re w ards in dentistry for children is greater than most realize. It fiot on ly lessens the ch ild’s appreciation o f g ood teeth, but also undermines his confidence, w hich is necessary fo r the fu tu re o f dentistry for children as a health service. T h e child
comes prim arily to the dental office for dental services and not for a rew ard. T h e logical rew ard is kindness and good op erative care rather than som ething o f intrinsic value. A dentist m ay be know n by the am ount o f com m ercial products he hands out to his child patients as re wards. T h ird ly , there is your ow n personality. T h e principal means that the child has o f draw in g his conclusions as to w hether w e are satisfactory w hen he first meets us is ou r appearance. It is m ost essential that w e portray cleanliness in all o f its phases : cleanliness o f dress, o f hands and finger nails and o f speech, as we'll as cleanliness o f instruments and equipm ent. T h e yardstick that measures ou r success in pedodontia is ou r ability and capacity to get along w ith children. O u r attitude tow ard the child influences the child im measurably. I f the child cannot be man aged, it is usually the fau lt o f the dentist, and not the child. T o establish confidence, w hich is ab solutely necessary fo r success w ith chil dren, one must be exact in his procedures. It is im portant to k n ow definitely where w e are going before w e start. T h e child w ill sense indecision very quickly and is almost uncanny in ju d g in g ou r ability by the w ay w e proceed. Likew ise, aw k wardness in ou r m ethods is im mediately recognized by the child. T h is , w e prob ably never realized, w as w h a t the child referred to w hen he said, “ T h a t is a new instrum ent,” w hen, in reality, the instru m ent w as n ot new . T h e thought that occurred to the child w as “ H a v e you used it before or is the use o f it new to you ?” W e must also keep up ou r courage, because, the m inute w e lose it, the child knows he has the upper hand as far as management o f the case is concerned. Finally, the m anagem ent o f the child may be reduced to the use o f w hat might
Morgan— Operative Procedures for Deciduous Teeth be term ed practical psychology or g ood ju d g m en t. T h e daily routine o f a child o f 3 may include a nap from 1 to 3 in the aftern oon . W h a t chance w ou ld the best psychologist have in trying to d o dental w o rk fo r this child at 2 in the aftern oon ? T h e attem pt is sure to result in failure. T h e best hours fo r youn g children are from 9 to 11 in the m orning. Success in dentistry fo r children is de term ined by ou r g ood ju d g m en t in p ro vidin g a pleasant atmosphere, in selecting an assistant or hygienist, in m aking ap pointm ents, in ou r attitude tow ard the child and in ou r operative procedures. In other w ord s, it is vitally necessary that w e use g ood ju dgm en t in everything about us. O P E R A T IV E CONSIDERATIONS
B efore w e attem pt actual operative procedures, it is necessary that w e have k n ow led ge o f the com parative anatom y o f the deciduous and permanent teeth. It is only by constantly bearing in wind these anatom ic differences that successful cavity preparation can be assured. T h e deciduous teeth differ considerably in their anatom ic characteristics fro m the perm anent teeth. In com paring, the de ciduous m olars w ith the permanent m o lars, w e fin d : 1. T h e crow ns are m ore bell-shaped and there is greater constriction at the neck o f the tooth. Because o f this differ ence, it is not possible to use the same cavity preparation as fo r a permanent m olar. I f the cavity is extended gingiv ally the same depth in the deciduous tooth as in a permanent one, the horn o f the pulp w ill be exposed. 2. T h e enamel o f the deciduous tooth is m uch thinner and m ore brittle and chips easier than that o f the permanent tooth. T h is must all be considered in cavity preparation in the deciduous teeth so that thin enamel w alls w ill not be left
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unsupported by dentin. W h e n these thin enamel w alls chip, the fillin g is dislodged, and there is a recurrence o f decay. U n fortunately, these dislodged fillings do n ot drop out, but remain loose in the cavity, and decay progresses unchecked until the pulp is in volved, soon resulting in the loss o f the tooth. 3. T h e dentin o f the deciduous tooth is softer and m ore easily perm eable than that o f the perm anent. T h is allow s decay to progress m ore rapidly and discoloration to penetrate very quickly. In cavity prep aration, it is absolutely essential that all decay be rem oved, but m any pulps are needlessly exposed because the operator has failed to differentiate between de cayed and discolored or stained dentin. I f the pulp w ill be exposed by removal o f all the decay, then in reality the pulp is exposed. In other w ords, if caries has penetrated to the pulp, the pulp is ex posed, and leaving a portion o f decay in the base o f the cavity w ith the false hope o f preventing exposure is w ron g. 4. T h e deciduous pulp chambers are larger in proportion to the size o f the tooth than are the permanent and are nearer the outer surface, w ith perhaps the exception o f the occlusal area o f the de ciduous m olar. W h ile the pulp chamber dips considerably in the occlusal area o f the deciduous m olar, they do have pro nouncedly pointed pulpal horns. T h is makes a vulnerable point fo r exposure through proxim al decay and in cavity preparation, unless extrem e care is exer cised. 5. T h e deciduous m olar roots are more diverging. Care should be used in ex traction to avoid in ju ry to the developing permanent tooth, especially if the m olar is lost prem aturely, or if abnorm al resorp tion is present, to avoid the possibility o f leaving root fragm ents em bedded in the ja w . A mental picture o f tooth form ation at
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various ages o f childhood helps to deter mine the procedure. F o r exam ple, a de ciduous tooth that has no perm anent suc cessor may require different treatm ent, or
T h e areas in the deciduous teeth most susceptible to decay p rior to the eruption o f the permanent teeth are the distal sur faces o f the first deciduous m olars, the
a deciduous tooth w ith a successor that is inclined to subm erge, or a deciduous tooth held firm ly in place in the ja w fo r a child o f 10 that has a cavity w hich requires filling, but in reality, on roentgenographic exam ination, shows abnorm al resorption w ith extraction indicated.1 M a n y times, the roentgen rays take the guessw ork ou t o f ou r procedures in dentistry fo r the child and are m ost indispensable in ren dering health service to the child.2
mesial surfaces o f the second deciduous molars, the occlusal pits o f the upper second deciduous m olars, the occlusal fis
O P E R A T IV E PROCEDURES
I t is inconsistent to consider operative procedures fo r the deciduous teeth w ith ou t devoting some time to a discussion o f the mechanical equipm ent. F e w believe or have given any thought to the relation o f pain and the revolutions o f the engine per minute when the bur is in use. T h e greater the speed o f the engine, the greater the am ount o f friction, and there fore, the greater the pain.3 I f the belt o f the engine is placed on the sm all pulley and the speed is uniform , the pain from bu ring is greatly diminished. T h e use o f sharp burs and instruments, as w e ll as a dry field, lessens the pain and discom fort fo r the child. Less pain is caused if the decay is rem oved w ith a large roun d bur. T h e size o f the bur is determ ined by the size o f the cavity. T h e indiscrim inate use o f air to dry the cavity is very painful. A cotton pellet should always be used in stead. 1. K ronfeld, R u dolf: Histopathology of Teeth and Surrounding Structures, Philadel phia: Lea & Febiger, 1933, p. 225. 2. Main, L. R .: Roentgenogram, A Guide in Children’s Dentistry, J.A.D .A., 22:960 (June) 1935. 3. Bodecker, C. F .: Treatment o f Sensitive Teeth, correspondence, D. Cosmos, 70:1133 (N ov.) 1928.
sures o f the low er second deciduous m olars and the proxim al surfaces o f the upper central and lateral incisors. T o restore these teeth fo r a child 5 years old so that they w ill remain healthy until the norm al period fo r their ex folia tion is one o f the m ost difficult tasks in dentistry. In a survey o f 100 cases, it has been fou nd that 5 4 per cent o f cases o f m alocclusion are caused by premature loss and prolon ged retention o f the decid uous teeth, w hich cou ld be prevented by correct operative procedures.4 D u rin g cavity preparation, w e must constantly bear in m ind the anatom ic characteristics and the means o f conserva tion o f tooth structure. In preparing the cavity in the distal area o f the first de ciduous m olar, w hether in an upper or low er tooth, ( 1 ) the fo o d debris is re m oved w ith a spoon ex ca v a tor; ( 2 ) the overhanging w alls are broken d ow n w ith a chisel, and ( 3 ) the decay is then re m oved w ith a N o . 6 round bur. T h is is fo llo w e d by a N o . 558 short shank fissure bur, to square the w alls o f the cavity. N o w w e are ready fo r the occlusal step. N o proxim al cavities that involve the oc clusal area should be prepared w ith ou t the occlusal step. T h e occlusal step serves as a means o f retention fo r the fillin g and should be made by beginning in the occlusal surface w ith a small inverted cone bur until w e have cut through the enamel. T h e n a N o. 558 short shank fissure bur is em ployed, m ovin g distally. T h is w ill be less pain4. Brandhorst, O. W . : Promoting Normal Development by M aintaining Function o f D e ciduous Teeth, J.A.D .A., 19:1196 (July) 1932.
M organ— Operative Procedures for Deciduous Teeth fu l and w ill also aid in preventing pos sible exposure o f the hoi*n o f the pulp. T h e occlusal step should be broadened to give added strength to the restoration. T h e outline form should be such that there are no thin enamel w alls left un supported by dentin. If, at this time, a small cavity is fou n d on the mesial surface o f the second deciduous m olar, it m ay be filled as a simple proxim al cavity,5 w ith either silver or copper amalgam. T h e re are on ly three filling materials suitable fo r the distal occlusal cavity in the first deciduous m olar. T h e y are a cast g old inlay, a cast silver inlay or silver am algam . T h e g old inlay is indicated fo r very youn g patients and fo r those w h o are able and w illin g to pay fo r the best health service fo r the child. T h e cast silver inlay makes a good restoration. Silver am algam is most generally used and, if properly m anipulated, w ill, in the m a jority o f cases, preserve the tooth in a healthy state until the norm al pe riod o f exfoliation . A m atrix should always be used in placing silver am al gam in com pound cavities, in the decidu ous teeth. It is im portant that every precaution be exercised in fillin g a deciduous tooth w ith silver am algam . I f the fillin g is placed without a matrix or if a dovetail preparation6 is made, the tooth cannot remain healthy. Recurrence o f decay is sure to fo llo w , and the tooth is lost through careless operative procedure. In general, the preparation o f a mesioclusal cavity in the second deciduous m olar is the same as that o f the distal cavity in the first deciduous m olar. I f these tw o approxim ating surfaces are in need o f restoration 'at the same time, the 5. M organ, G. E .: Some Every-D ay Prob lems in Children’ s Dentistry; J.A .D .A . 20:626 (A pril) 1933. 6.
M cBride, W . C .: Juvenile Dentistry, Philadelphia: Lea & Febiger, 1932, p. 40.
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cavity in the m esioclusal surface should be filled first. I f these teeth are both to be restored w ith silver am algam , the fill ing is placed in the second deciduous m olar first and it is polished w e ll at the fo llo w in g sitting b efore the distoclusal area o f the first deciduous m olar is re stored. T h e occlusal pits o f the upper second deciduous m olars are prepared and filled, if possible individually, w ith ou t breaking d ow n o f the oblique ridge unless it has been underm ined by decay. A s these cavities are pits and n ot fissures, little extension fo r prevention is necessary. F au lty coalescence o f the lobes o f the lo w e r second deciduous m olar results in pits join ed by fissures, w h ich usually ex tend over the entire occlusal surface. T h ese pits and fissures are apparent at different ages in the same tooth.7 T h e early recognition o f a pit may assure checking o f the decay. T h e restoration o f this surface necessitates the cutting away o f the fissure, and extension fo r preven tion is essential. In the m a jority o f cases, the restoration w ill include the entire occlusal surface rather than a pit here and there. W h e n decay in the anterior deciduous teeth is not extensive, they should be re stored w ith copper am algam in a simply prepared cavity. T h ese teeth should not be cu t w edge shape. I f decay is extensive and the angle o f the tooth has been lost, and it becomes impossible to get retention w ith ou t exposing the pulp, the surface m ay be sm oothed w ith stones and disks and then protected by an application o f silver nitrate solution. A s the child grow s older, other areas o f susceptibility appear. O f these, prob ably the one m ost difficult to restore and w herein m ore restorations result in fail7. Hyatt, T . P .: D o Pits and Fissures A p pear at Different Ages in Same T ooth? D. Cosmos 74:463 (M ay) 1932.
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ure is the distal aspect o f the deciduous cuspids. T o restore these cavities prop erly, it is necessary to provide adequate retention by a lingual step preparation. Silver am algam serves w e ll as a filling material. A ft e r the eruption o f the first perma nent m olar, it is im portant that the distal surface o f the second deciduous m olar be w atch ed fo r caries. I f caries occurs, this surface can be restored w ith the proce du re as has been described fo r a com pound filling. PEDODON TEXESIS
Pedodontexesis may be defined as the scaling, polishing and cleaning o f the teeth o f children. It is one o f the opera tive procedures that has been m uch neg lected by the profession. T h e slogan “ See your dentist every six m onths” has caused a m isunderstanding am ong par ents. M a n y m others feel that they can neglect their children ’s m outh six months and still n ot approach the danger line. T h e frequency o f pedodontexesis and exam ination is dependent on the indi v idu al’s susceptibility. M a n y children ’s m ouths may be a com plete w reck if six
months is a llow ed between visits. O n ce each m onth is not too often fo r certain children, w h ile others may go as lon g as three months. Cleanliness o f the m outh is o f para m ou n t im portance in the prevention o f decay, and every child should be im pressed w ith the necessity and instructed regarding hom e care. CONCLUSIONS
1. P roperly applied psychology in creases on e’s ability to manage children, and instead o f pedodontia being a dis agreeable ordeal fo r both child and oper ator, it becomes a pleasure. 2 . A large percentage o f cases o f m al occlusion and dentofacial deform ities cou ld be prevented by careful operative procedures. 3. F requent inspection and pedodon texesis provide a means for early detection o f dental disorders and perm it correction before the effects have becom e harm ful. 4 . D entistry fo r children is not a lu x u r y ; neither is it an expensive necessity, if care is provided early, regularly and systematically. 2039 North Prospect Avenue.
T U B E R C U L O M A IN V O L V IN G A N U PPE R M O L A R T O O T H : R E P O R T O F CASE* B y E D W A R D C . S T A F N E , D .D .S ., R och ester, M in n .
u b e r c u l o m a s are com m on even in the absence o f any evidence o f active tuberculosis, and careful postm ortem examinations reveal that
T
*From the Section on Dental Surgery, T he M ayo Clinic. *Read at the meeting o f the International Association for Dental Research, Louisville, Ky., March 14, 1936. Jour. A .D .A ., Vol. 23, September, 1936
they are present in an unusually large percentage o f cases. R obertson 1 and others have show n that tuberculous in fections m ay remain latent or dorm ant fo r indefinite periods. T h e com m on lo cations fo r such tuberculom as are the , 1. Robertson, H. E .: Persistence o f Tuber culous Infections, Am. J. Pathol., (Suppl.), 9:711-718, 1933.
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T h e com pleted filling is carved to c o r rect tooth form and polished. I t is true that to carry out the technic properly w ill take a little m ore tim e and w ork , but on ly in so doing w ill w e ad here to professional standards and give to the patient that w hich he can ju stly expect.
O PE R A TIV E PROCED U RES F O R T H E D E C ID U O U S TEETH * B y GEORGE E. M O R G AN , D .D .S., F.A.C.D ., M ilwaukee, W is. U C C E S S or failure in dentistry for children is principally dependent on a w ork in g kn ow led ge o f the pre operative psychology and a thorough understanding o f the operative consid erations. T h e man w h o thinks that he can be successful w ith children, either in general practice or as a pedodontist, w ith ou t considering collectively these principles, is w ith ou t question destined to fail. O n the other hand, if he carefu lly studies them, preferably w hen a student, the problem s arising in dealing w ith children w ill be easily solved. T h e m ountainous peaks then becom e on ly m olehills as each trying situation is ap proached. It is regrettable that a curriculum survey on m odern dental education leaves pedodontia entirely ou t o f the curriculum . It makes one w on der w hether w e have really progressed in this century o f dentistry in A m erica. T r y in g to teach dentistry fo r children to dental students by giving them a crum b *Read before the Section on Children’s Den tistry, Preventive Dentistry and Mouth H y giene at the Seventy-Second Annual M idw in ter Clinic o f the Chicago Dental Society, Feb. 20, 1936. Jour. A .D .A ., Vol. 23, September, 1936
here and there certainly does n ot indicate progress, as the situation is no different from w hat it has been fo r the last hun dred years. W h ile the curriculum sur vey com m ittee is to be com m ended for its remarks on the need fo r better and m ore adequate dental service fo r the child, it should and w ill be criticized for not m aking pedodontia a distinct subject. Pedodon tia should no longer be le ft by the wayside, but should be given its righ tfu l place along w ith the other branches o f dentistry. O perative procedures must necessarily be preceded by g ivin g some thought to preoperative psychology, w hich plays such a vital part in the final results. PR EO P E R A T IV E PSYC H O L O G Y
First, to create an atmosphere that provides fo r relaxation means that the dental office must not be a ju m b le o f artistic array, but rather suggest room i ness and sim plicity. T h e child w ill, in proper surroundings, relax almost in stantly and, as a result, be m ost adapt able to the procedures to fo llo w . A lo n g w ith sim plicity o f atmosphere, cleanliness must predom inate, as it is one o f the best means o f establishing confidence. Pleas
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The Journal of the American Dental Association
ant surroundings make the child feel w elcom e and as if he w ere am ong friends. I f the office is crow d ed and ov erly dec orated, the child is disconcerted w hen he steps into the room . H e becomes tense and fearfu l o f w hat m ay occu r— the at mosphere is foreign and his reaction is unfavorable. L o u d and shrill voices also tend to have an unfavorable response. Secondly, w e must consider the per sonality o f the child. Is he shy and fear fu l o r precocious, alert and frien d ly? C hildren form their likes and dislikes very quickly. E very child is flattered w hen he realizes that w e treat him w ith the respect show n fo r an adult. T h e n , too, any handicapped ch ild resents our consciousness o f his being u nlike other children. R em em ber it is “ M a r y ” or “ J oh n ” and n ot “ Sister” o r “ Sonny.” T o the shy, bashful child, let us be sympa thetic and kind in ou r attitu d e; w ith the alert and friendly child, firm yet kind. A le rt children are som etim es m ore diffi cu lt to manage because o f their unusual ability to adjust themselves to n ew sur roundings. T h e y are overly conscious of what is g oin g on. W it h the physically handicapped child, refuse to notice his disabilities and treat him as norm al. T h e im portance o f any service to the child is evaluated by the education w e or the parents give to it. A health habit is based on a ch ild ’s duty tow ard the betterment o f hum anity. I f he is re w arded for an act in the interest o f his health, especially by the dentist, the visit, in the m ind o f the child, n o lon ger re mains in the same category w ith that o f an obligation to him self, but becomes a favor to the dentist. T h e harm o f re w ards in dentistry for children is greater than most realize. It fiot on ly lessens the ch ild’s appreciation o f g ood teeth, but also undermines his confidence, w hich is necessary fo r the fu tu re o f dentistry for children as a health service. T h e child
comes prim arily to the dental office for dental services and not for a rew ard. T h e logical rew ard is kindness and good op erative care rather than som ething o f intrinsic value. A dentist m ay be know n by the am ount o f com m ercial products he hands out to his child patients as re wards. T h ird ly , there is your ow n personality. T h e principal means that the child has o f draw in g his conclusions as to w hether w e are satisfactory w hen he first meets us is ou r appearance. It is m ost essential that w e portray cleanliness in all o f its phases : cleanliness o f dress, o f hands and finger nails and o f speech, as we'll as cleanliness o f instruments and equipm ent. T h e yardstick that measures ou r success in pedodontia is ou r ability and capacity to get along w ith children. O u r attitude tow ard the child influences the child im measurably. I f the child cannot be man aged, it is usually the fau lt o f the dentist, and not the child. T o establish confidence, w hich is ab solutely necessary fo r success w ith chil dren, one must be exact in his procedures. It is im portant to k n ow definitely where w e are going before w e start. T h e child w ill sense indecision very quickly and is almost uncanny in ju d g in g ou r ability by the w ay w e proceed. Likew ise, aw k wardness in ou r m ethods is im mediately recognized by the child. T h is , w e prob ably never realized, w as w h a t the child referred to w hen he said, “ T h a t is a new instrum ent,” w hen, in reality, the instru m ent w as n ot new . T h e thought that occurred to the child w as “ H a v e you used it before or is the use o f it new to you ?” W e must also keep up ou r courage, because, the m inute w e lose it, the child knows he has the upper hand as far as management o f the case is concerned. Finally, the m anagem ent o f the child may be reduced to the use o f w hat might
Morgan— Operative Procedures for Deciduous Teeth be term ed practical psychology or g ood ju d g m en t. T h e daily routine o f a child o f 3 may include a nap from 1 to 3 in the aftern oon . W h a t chance w ou ld the best psychologist have in trying to d o dental w o rk fo r this child at 2 in the aftern oon ? T h e attem pt is sure to result in failure. T h e best hours fo r youn g children are from 9 to 11 in the m orning. Success in dentistry fo r children is de term ined by ou r g ood ju d g m en t in p ro vidin g a pleasant atmosphere, in selecting an assistant or hygienist, in m aking ap pointm ents, in ou r attitude tow ard the child and in ou r operative procedures. In other w ord s, it is vitally necessary that w e use g ood ju dgm en t in everything about us. O P E R A T IV E CONSIDERATIONS
B efore w e attem pt actual operative procedures, it is necessary that w e have k n ow led ge o f the com parative anatom y o f the deciduous and permanent teeth. It is only by constantly bearing in wind these anatom ic differences that successful cavity preparation can be assured. T h e deciduous teeth differ considerably in their anatom ic characteristics fro m the perm anent teeth. In com paring, the de ciduous m olars w ith the permanent m o lars, w e fin d : 1. T h e crow ns are m ore bell-shaped and there is greater constriction at the neck o f the tooth. Because o f this differ ence, it is not possible to use the same cavity preparation as fo r a permanent m olar. I f the cavity is extended gingiv ally the same depth in the deciduous tooth as in a permanent one, the horn o f the pulp w ill be exposed. 2. T h e enamel o f the deciduous tooth is m uch thinner and m ore brittle and chips easier than that o f the permanent tooth. T h is must all be considered in cavity preparation in the deciduous teeth so that thin enamel w alls w ill not be left
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unsupported by dentin. W h e n these thin enamel w alls chip, the fillin g is dislodged, and there is a recurrence o f decay. U n fortunately, these dislodged fillings do n ot drop out, but remain loose in the cavity, and decay progresses unchecked until the pulp is in volved, soon resulting in the loss o f the tooth. 3. T h e dentin o f the deciduous tooth is softer and m ore easily perm eable than that o f the perm anent. T h is allow s decay to progress m ore rapidly and discoloration to penetrate very quickly. In cavity prep aration, it is absolutely essential that all decay be rem oved, but m any pulps are needlessly exposed because the operator has failed to differentiate between de cayed and discolored or stained dentin. I f the pulp w ill be exposed by removal o f all the decay, then in reality the pulp is exposed. In other w ords, if caries has penetrated to the pulp, the pulp is ex posed, and leaving a portion o f decay in the base o f the cavity w ith the false hope o f preventing exposure is w ron g. 4. T h e deciduous pulp chambers are larger in proportion to the size o f the tooth than are the permanent and are nearer the outer surface, w ith perhaps the exception o f the occlusal area o f the de ciduous m olar. W h ile the pulp chamber dips considerably in the occlusal area o f the deciduous m olar, they do have pro nouncedly pointed pulpal horns. T h is makes a vulnerable point fo r exposure through proxim al decay and in cavity preparation, unless extrem e care is exer cised. 5. T h e deciduous m olar roots are more diverging. Care should be used in ex traction to avoid in ju ry to the developing permanent tooth, especially if the m olar is lost prem aturely, or if abnorm al resorp tion is present, to avoid the possibility o f leaving root fragm ents em bedded in the ja w . A mental picture o f tooth form ation at
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various ages o f childhood helps to deter mine the procedure. F o r exam ple, a de ciduous tooth that has no perm anent suc cessor may require different treatm ent, or
T h e areas in the deciduous teeth most susceptible to decay p rior to the eruption o f the permanent teeth are the distal sur faces o f the first deciduous m olars, the
a deciduous tooth w ith a successor that is inclined to subm erge, or a deciduous tooth held firm ly in place in the ja w fo r a child o f 10 that has a cavity w hich requires filling, but in reality, on roentgenographic exam ination, shows abnorm al resorption w ith extraction indicated.1 M a n y times, the roentgen rays take the guessw ork ou t o f ou r procedures in dentistry fo r the child and are m ost indispensable in ren dering health service to the child.2
mesial surfaces o f the second deciduous molars, the occlusal pits o f the upper second deciduous m olars, the occlusal fis
O P E R A T IV E PROCEDURES
I t is inconsistent to consider operative procedures fo r the deciduous teeth w ith ou t devoting some time to a discussion o f the mechanical equipm ent. F e w believe or have given any thought to the relation o f pain and the revolutions o f the engine per minute when the bur is in use. T h e greater the speed o f the engine, the greater the am ount o f friction, and there fore, the greater the pain.3 I f the belt o f the engine is placed on the sm all pulley and the speed is uniform , the pain from bu ring is greatly diminished. T h e use o f sharp burs and instruments, as w e ll as a dry field, lessens the pain and discom fort fo r the child. Less pain is caused if the decay is rem oved w ith a large roun d bur. T h e size o f the bur is determ ined by the size o f the cavity. T h e indiscrim inate use o f air to dry the cavity is very painful. A cotton pellet should always be used in stead. 1. K ronfeld, R u dolf: Histopathology of Teeth and Surrounding Structures, Philadel phia: Lea & Febiger, 1933, p. 225. 2. Main, L. R .: Roentgenogram, A Guide in Children’s Dentistry, J.A.D .A., 22:960 (June) 1935. 3. Bodecker, C. F .: Treatment o f Sensitive Teeth, correspondence, D. Cosmos, 70:1133 (N ov.) 1928.
sures o f the low er second deciduous m olars and the proxim al surfaces o f the upper central and lateral incisors. T o restore these teeth fo r a child 5 years old so that they w ill remain healthy until the norm al period fo r their ex folia tion is one o f the m ost difficult tasks in dentistry. In a survey o f 100 cases, it has been fou nd that 5 4 per cent o f cases o f m alocclusion are caused by premature loss and prolon ged retention o f the decid uous teeth, w hich cou ld be prevented by correct operative procedures.4 D u rin g cavity preparation, w e must constantly bear in m ind the anatom ic characteristics and the means o f conserva tion o f tooth structure. In preparing the cavity in the distal area o f the first de ciduous m olar, w hether in an upper or low er tooth, ( 1 ) the fo o d debris is re m oved w ith a spoon ex ca v a tor; ( 2 ) the overhanging w alls are broken d ow n w ith a chisel, and ( 3 ) the decay is then re m oved w ith a N o . 6 round bur. T h is is fo llo w e d by a N o . 558 short shank fissure bur, to square the w alls o f the cavity. N o w w e are ready fo r the occlusal step. N o proxim al cavities that involve the oc clusal area should be prepared w ith ou t the occlusal step. T h e occlusal step serves as a means o f retention fo r the fillin g and should be made by beginning in the occlusal surface w ith a small inverted cone bur until w e have cut through the enamel. T h e n a N o. 558 short shank fissure bur is em ployed, m ovin g distally. T h is w ill be less pain4. Brandhorst, O. W . : Promoting Normal Development by M aintaining Function o f D e ciduous Teeth, J.A.D .A., 19:1196 (July) 1932.
M organ— Operative Procedures for Deciduous Teeth fu l and w ill also aid in preventing pos sible exposure o f the hoi*n o f the pulp. T h e occlusal step should be broadened to give added strength to the restoration. T h e outline form should be such that there are no thin enamel w alls left un supported by dentin. If, at this time, a small cavity is fou n d on the mesial surface o f the second deciduous m olar, it m ay be filled as a simple proxim al cavity,5 w ith either silver or copper amalgam. T h e re are on ly three filling materials suitable fo r the distal occlusal cavity in the first deciduous m olar. T h e y are a cast g old inlay, a cast silver inlay or silver am algam . T h e g old inlay is indicated fo r very youn g patients and fo r those w h o are able and w illin g to pay fo r the best health service fo r the child. T h e cast silver inlay makes a good restoration. Silver am algam is most generally used and, if properly m anipulated, w ill, in the m a jority o f cases, preserve the tooth in a healthy state until the norm al pe riod o f exfoliation . A m atrix should always be used in placing silver am al gam in com pound cavities, in the decidu ous teeth. It is im portant that every precaution be exercised in fillin g a deciduous tooth w ith silver am algam . I f the fillin g is placed without a matrix or if a dovetail preparation6 is made, the tooth cannot remain healthy. Recurrence o f decay is sure to fo llo w , and the tooth is lost through careless operative procedure. In general, the preparation o f a mesioclusal cavity in the second deciduous m olar is the same as that o f the distal cavity in the first deciduous m olar. I f these tw o approxim ating surfaces are in need o f restoration 'at the same time, the 5. M organ, G. E .: Some Every-D ay Prob lems in Children’ s Dentistry; J.A .D .A . 20:626 (A pril) 1933. 6.
M cBride, W . C .: Juvenile Dentistry, Philadelphia: Lea & Febiger, 1932, p. 40.
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cavity in the m esioclusal surface should be filled first. I f these teeth are both to be restored w ith silver am algam , the fill ing is placed in the second deciduous m olar first and it is polished w e ll at the fo llo w in g sitting b efore the distoclusal area o f the first deciduous m olar is re stored. T h e occlusal pits o f the upper second deciduous m olars are prepared and filled, if possible individually, w ith ou t breaking d ow n o f the oblique ridge unless it has been underm ined by decay. A s these cavities are pits and n ot fissures, little extension fo r prevention is necessary. F au lty coalescence o f the lobes o f the lo w e r second deciduous m olar results in pits join ed by fissures, w h ich usually ex tend over the entire occlusal surface. T h ese pits and fissures are apparent at different ages in the same tooth.7 T h e early recognition o f a pit may assure checking o f the decay. T h e restoration o f this surface necessitates the cutting away o f the fissure, and extension fo r preven tion is essential. In the m a jority o f cases, the restoration w ill include the entire occlusal surface rather than a pit here and there. W h e n decay in the anterior deciduous teeth is not extensive, they should be re stored w ith copper am algam in a simply prepared cavity. T h ese teeth should not be cu t w edge shape. I f decay is extensive and the angle o f the tooth has been lost, and it becomes impossible to get retention w ith ou t exposing the pulp, the surface m ay be sm oothed w ith stones and disks and then protected by an application o f silver nitrate solution. A s the child grow s older, other areas o f susceptibility appear. O f these, prob ably the one m ost difficult to restore and w herein m ore restorations result in fail7. Hyatt, T . P .: D o Pits and Fissures A p pear at Different Ages in Same T ooth? D. Cosmos 74:463 (M ay) 1932.
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ure is the distal aspect o f the deciduous cuspids. T o restore these cavities prop erly, it is necessary to provide adequate retention by a lingual step preparation. Silver am algam serves w e ll as a filling material. A ft e r the eruption o f the first perma nent m olar, it is im portant that the distal surface o f the second deciduous m olar be w atch ed fo r caries. I f caries occurs, this surface can be restored w ith the proce du re as has been described fo r a com pound filling. PEDODON TEXESIS
Pedodontexesis may be defined as the scaling, polishing and cleaning o f the teeth o f children. It is one o f the opera tive procedures that has been m uch neg lected by the profession. T h e slogan “ See your dentist every six m onths” has caused a m isunderstanding am ong par ents. M a n y m others feel that they can neglect their children ’s m outh six months and still n ot approach the danger line. T h e frequency o f pedodontexesis and exam ination is dependent on the indi v idu al’s susceptibility. M a n y children ’s m ouths may be a com plete w reck if six
months is a llow ed between visits. O n ce each m onth is not too often fo r certain children, w h ile others may go as lon g as three months. Cleanliness o f the m outh is o f para m ou n t im portance in the prevention o f decay, and every child should be im pressed w ith the necessity and instructed regarding hom e care. CONCLUSIONS
1. P roperly applied psychology in creases on e’s ability to manage children, and instead o f pedodontia being a dis agreeable ordeal fo r both child and oper ator, it becomes a pleasure. 2 . A large percentage o f cases o f m al occlusion and dentofacial deform ities cou ld be prevented by careful operative procedures. 3. F requent inspection and pedodon texesis provide a means for early detection o f dental disorders and perm it correction before the effects have becom e harm ful. 4 . D entistry fo r children is not a lu x u r y ; neither is it an expensive necessity, if care is provided early, regularly and systematically. 2039 North Prospect Avenue.
T U B E R C U L O M A IN V O L V IN G A N U PPE R M O L A R T O O T H : R E P O R T O F CASE* B y E D W A R D C . S T A F N E , D .D .S ., R och ester, M in n .
u b e r c u l o m a s are com m on even in the absence o f any evidence o f active tuberculosis, and careful postm ortem examinations reveal that
T
*From the Section on Dental Surgery, T he M ayo Clinic. *Read at the meeting o f the International Association for Dental Research, Louisville, Ky., March 14, 1936. Jour. A .D .A ., Vol. 23, September, 1936
they are present in an unusually large percentage o f cases. R obertson 1 and others have show n that tuberculous in fections m ay remain latent or dorm ant fo r indefinite periods. T h e com m on lo cations fo r such tuberculom as are the , 1. Robertson, H. E .: Persistence o f Tuber culous Infections, Am. J. Pathol., (Suppl.), 9:711-718, 1933.