McDonald and Avery's Dentistry for the Child and Adolescent

- 11th Edition

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 Contributors vii

Tasha Hall, DMD, MSD Carrie Klene, DDS

Director of Craniofacial Orthodontics Oral and Maxillofacial Surgeon
Department of Orthodontics Klene Center Oral & Facial Surgery
Indiana University Indiana University Health
Indianapolis, Indiana Carmel, Indiana

James Kennedy Hartsfield Jr., DMD, MS, MMSc, PhD Joan Elizabeth Kowolik, BDS, LDS, RCS Edin,
Professor and E. Preston Hicks Endowed Chair in Dip. Clin. Hyp.
Orthodontics and Oral Health Research Director, Associate Professor
Oral Health Science Pediatric Dentistry
University of Kentucky College of Dentistry Indiana University School of Dentistry
Lexington, Kentucky Indianapolis, Indiana
Adjunct Professor
Medical and Molecular Genetics George Krull, DDS
Indiana University School of Medicine Private Practice, Pediatric Dentistry (Retired)
Indianapolis, Indiana Clarkston, Michigan
Adjunct Professor
Orthodontics and Oral Facial Genetics John T. Krull, DDS
Indiana University School of Dentistry Department of Pediatric Dentistry
Indianapolis, Indiana Indiana University School of Dentistry
Adjunct Clinical Professor Indianapolis, Indiana
Orthodontics
University of Illinois at Chicago College of Dentistry John J. Manaloor, MD
Chicago, Illinois Assistant Professor of Clinical Pediatrics
Ryan White Center for Pediatric Infectious Diseases
Kerry Hege, MD, MSc Riley Hospital for Children, Indiana University School of
Assistant Professor Medicine
Pediatric Hematology/Oncology Indianapolis, Indiana
Riley Hospital at IU Health
Indiana University School of Medicine E. Angeles Martinez Mier, DDS, MSD, PHD
Indianapolis, Indiana Professor and Chair
Cariology, Operative Dentistry and Dental Public Health
Christopher V. Hughes, DMD, PhD Indiana University School of Dentistry
Professor and Chair Indianapolis, Indiana
Pediatric Dentistry
School of Dentistry, University of Mississippi Medical Hannah L. Maxey, PhD, MPH
Center Associate Professor
Jackson, Mississippi Family Medicine
Indiana University School of Medicine
Vanchit John, DDS, MSD Indianapolis, Indiana
Chairperson and Tenured Professor Director
Department of Periodontology Bowen Center for Health Workforce Research and Policy
Indiana University School of Dentistry at Indiana University School of Medicine
Indianapolis, Indiana Indianapolis, Indiana

James Earl Jones, DMD, MSD, EdD, PhD Lorri Ann Morford, PhD
Starkey Research Professor Assistant Professor
Department of Pediatric Dentistry Oral Health Science
Indiana University School of Dentistry University of Kentucky
Indianapolis, Indiana Lexington, Kentucky
Clinical Professor
Department of Pediatrics Charles Nakar, MD
Indiana University School of Medicine Pediatric Hematologist
Indianapolis, Indiana Department of Pediatric
Indiana Hemophilia and Thrombosis Center
Mathew Thomas Kattadiyil, BDS, MDS, MS Indianapolis, Indiana
Professor and Director
Advanced Specialty Education Program in
Prosthodontics
Loma Linda University School of Dentistry
Loma Linda, California

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viii Contributors

Jeffrey A. Platt, DDS, MS Kenneth J. Spolnik, DDS, MSD

Professor and Chair Chair and Program Director
Biomedical Sciences and Comprehensive Care Enododontics
Indiana University Indiana University School of Dentistry
Indianapolis, Indiana Indianapolis, Indiana

Laura Marie Romito, DDS, MS, MBA Jenny Stigers, DMD

Professor Associate Professor
Biomedical Sciences and Comprehensive Care University of Kentucky College of Dentistry
Indiana University School of Dentistry Lexington, Kentucky
Indianapolis, Indiana
Assistant Dean Dan Stoeckel, DDS, MS
IU Interprofessional Practice and Education Center Program Director
Indiana University Graduate Pediatric Dentistry
Indianapolis, Indiana Saint Louis University
Oral Pathologist
Brian Sanders, DDS, MS Department of Pathology
Sarah Jane McDonald Professor and Chair Saint Louis University
Department of Pediatric Dentistry St. Louis, Missouri
Indiana University School of Dentistry Pediatric Dentist
Riley Hospital for Children at IU Health St. Louis Children’s Hospital
Indianapolis, Indiana St. Louis, Missouri

Mark Saxen, DDS, PhD Shannon Thompson, MD

Adjunct Clinical Associate Professor Assistant Professor of Clinical Medicine
Oral Pathology, Medicine and Radiology IU Child Protection Programs
Indiana University School of Dentistry Indiana University School of Medicine
Indianapolis, Indiana Indianapolis, Indiana
Dentist Anesthesiologist
Indiana Office-Based Anesthesia Erwin G. Turner, DMD
Indianapolis, Indiana Associate Professor and Residency Director
Pediatric Dentistry
Allison Scully, DDS, MS University of Kentucky College of Dentistry
Clinical Assistant Professor Lexington, Kentucky
Department of Pediatric Dentistry
Indiana University School of Dentistry Indianapolis Jose Luis Ureña-Cirett, CD, MS
Indianapolis, Indiana Pediatric Dentistry
United States Universidad Tecnológica de México, Mexico City
CDMX
Amy D. Shapiro, MD Mexico
Medical Director
Pediatric Hematology LaQuia Walker Vinson, DDS, MPH
Indiana Hemophilia & Thrombosis Center Associate Professor, Pediatric Dentistry
Indianapolis, Indiana Graduate Program Director, Pediatric Dentistry Indiana
Adjunct Senior Investigator University School of Dentistry Indianapolis
Blood Research Institute Indianapolis, Indiana
Blood Center of Wisconsin
Milwaukee, Wisconsin John Walsh, BDentSc, MSD (Ped), IUSD, MSD(Orth)
UW, FFDRCSI
Daniel Shin, DDS, MSD Course Lead,
Clinical Assistant Professor, Director Predoctoral Faculty of Dentistry
Periodontology Royal College of Surgeons
Department of Periodontology Dublin
Indiana University School of Dentistry Ireland
Indianapolis, Indiana

Pooya Soltanzadeh, DDS, MS

Assistant Professor
Advanced Prosthodontics
Loma Linda University School of Dentistry
Loma Linda, California

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 Contributors ix

Julie Weir, BS Juan Fernando Yepes, DDS, MD, MPH, MS, DrPH
Founder Professor
Consultant Pediatric Dentistry
Julie Weir & Associates Indiana University School of Dentistry Indianapolis
Middleburg, Virginia Indianapolis, Indiana
Clinical Associate Professor
Ghaeth Yassen, BDS, MSD, PhD Pediatric and Community Dentistry
Endodontist University at Buffalo School of Dental Medicine
Department of Endodontics Buffalo, New York
Case Western Reserve University Visiting Professor
Cleveland, Ohio Pediatric Dentistry
CES University
Medellin, Antioquia
Colombia

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Reviewers

Dorothy Lynne Cataldo, DMD Cody Hughes, DMD, MSD

Private Practice, Pediatric Dentist Valley Pediatric Dental
Pediatric Dentistry Faculty Mesquite/Logandale, Nevada
NYU Langone Advanced Education Sunrise Children’s Dentistry
Tampa, Florida Las Vegas, Nevada

Brenda Bohaty, DDS, MSD, PhD Yuming Zhao, DDS, PhD

Professor and Chair, Pediatric Dentistry - UMKC School of Professor in the Department of Pediatric Dentistry
Dentistry Peking University School and Hospital of Stomatology
Director, Residency Program in Pediatric Dentistry - Beijing, China
Children’s Mercy Hospital
Kansas City, Missouri Man Qin, BDS, PhD
Professor of Department of Pediatric Dentistry
Farhad Yeroshalmi, DMD Peking University School and Hospital of Stomatology
Professor of Dentistry President of Chinese Society of Pediatric Dentistry
Albert Einstein College of Medicine Beijing, China
Chief & Residency Program Director
Department of Pediatric Dentistry
NYC Health + Hospitals/Jacobi
Bronx, New York

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 Foreword to the 11th edition of McDonald
and Avery’s Dentistry for the Child and
Adolescent: a historical review
when many American dentists had notices in their offices
that no children under the age of 12 years were accepted.
Harris opened a practice specializing in pediatric dentistry
in Detroit and decided a formal organization was needed
to spread good care. In 1927, he and others founded the
American Society for the Promotion of Children’s ­Dentistry,
which became the American Society of Dentistry for Chil-
dren (ASDC) in 1940. In 1947, he was also influential in
establishment of the American Academy of Pedodontics,
renamed the American Academy of Pediatric Dentistry
(AAPD) in 1984. In 1943, Harris was the founding editor
of the Review of Dentistry for Children, precursor of the Jour-
nal of Dentistry for Children. In the 1930s, Harris began to
formulate ideas on an international organization to bring
together children’s dentists from around the world. It was
1969 before his dream was fulfilled with establishment of
the International Association of Dentistry for Children,
which became the International Association of Paediatric
Dentistry in 1991. This all began to put children’s dentistry
Ari Kupietzky, DMD, MSc on a sounder footing, both at the general practitioner and
Private practice, Jerusalem, Israel specialist levels.
Department of Pediatric Dentistry, Rutgers School of Dental Walter E. McBride was the first president of ASDC. He
Medicine, Rutgers University, Newark, NJ and Harris devoted many hours to setting up the new orga-
Department of Pediatric Dentistry, Hebrew University‐ nization. He was also a president of the American Acad-
Hadassah School of Dental Medicine, Jerusalem, Israel emy of Pedodontics, the American Association of Dental
Editors, and the Detroit District Dental Society. McBride
was professor of pedodontics at the University of Detroit, so
Stanley Gelbier, Hon FFPH, MA, PhD,
anything he wrote or said was listened to. In 1933, he told
FDSDDPH, DHMSA a meeting of the American Dental Association that when
Honorary Professor in History of Dentistry, King’s College a general practice dentist refuses to treat children, he is
London, London, UK disregarding a major factor in practice building. He quoted
Emeritus-Professor in Dental Public Health, University of a new graduate who opened an office in a town of 2000
London, London, UK inhabitants where two dentists had practiced successfully
Past President and National Secretary, British Paedodontic for many years. They didn’t like the idea of a newcomer
Society, London, UK with the audacity of a beginner, who installed beautiful
new equipment and even employed an office assistant,
potentially taking from their income. As he especially liked
Introduction children, he suggested that they, not enjoying children’s
work, should refer them to him, and they agreed. The chil-
In 1963, when Ralph McDonald wrote Pedodontics, den- dren came, liked the new dentist, gave favorable reports
tistry for children was still in its infancy. McBride in 1952 to their parents and their mothers came for treatment: a
wrote that children were sometimes described as being practice builder.
“temperamental and hysterical, notional and incorrigible.” McBride published his Juvenile Dentistry in 1932, which
Many practitioners saw them as small adults and offered probably remained the leading text until McDonald entered
little treatment. Nevertheless, there had been for a long the field, although there were others. McBride said of his
time some enthusiastic dentists. One name to remember is own book, “It was not scientific nor theoretical, but purely
Sam Harris, who qualified from Ann Arbor Dental School a résumé of practical procedures employed over ten years
in 1924. Almost immediately, he enrolled at Boston’s in a private practice devoted entirely to children.” It is not
Forsyth Dental Infirmary for Children. He and his fellow surprising that McBride’s book was highly popular, but by
students learned much about child dental care at a time
xi

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xii Foreword to the 11th edition of McDonald and Avery’s Dentistry for the Child and Adolescent: a historical review

the end of the 1950s there was room for something new: a recently changed its policy and guidelines from behavior
text based on scientific methodology. management to behavior guidance as was proposed by
We have to remember that when McDonald began his McDonald over 50 years ago. Pedodontics was upgraded in
career in the 1940s, children suffered from massive dental 1969 as Dentistry for the Child and Adolescent, which con-
caries, the prevalence being five times more than current tained his original 11 chapters from 1963 plus an addi-
(Bernabé & Sheiham, 2014). Prevention was needed. Fol- tional 17 chapters written by 14 contributors. From the
lowing pressure from H. Trendley Dean, in 1945, Grand beginning, the editors and contributors of McDonald’s Den-
Rapids became the first city in the world to fluoridate its tistry for the Child and Adolescent have been amongst the
drinking water. Over 15 years, Dean researched decay in specialty’s pioneers and top academicians, clinicians, and
30,000 schoolchildren and found that caries in children scientists. Early contributors included Maynard Hine, Wil-
born after fluoridation was reduced by over 60 percent, liam Shafer, Ralph Phillips, Roland Dykema, James Roche,
revolutionizing dental care. For the first time, tooth decay and Paul Starkey. Many of them had their own names on
became a preventable disease! Widespread use of fluoride the cover of dental textbooks. The list of contributors was
toothpastes came way after McDonald’s first book. and remains tremendous, including esteemed colleagues
Ralph E. McDonald (1920-2015) commenced his career such as Gerald Wright, Howard Needleman, and George
in 1944 with a DDS from Indiana University School of Stookey. Amongst contemporary contributing pediatric
Dentistry. During his service as a naval dental officer, he dentist authors are Johon Aps, Ron Bell, Angus Cameron,
observed much dental disease amongst young recruits Judith Chin, Kevin Donly, Burton Edelstein, Hala Hender-
and realized the need for good dentistry already in child- son, Donald Huebener, Christopher Hughes, James Jones,
hood. McDonald read every textbook and journal about Joan Kowolik, George Krull, Jasper Lewis, Brian Sanders,
children’s dentistry that he could get his hands on. He con- Jenny Stigers, Erwin Turner, John Walsh, James Weddell,
tinued to study once he returned home. Since a degree in LaQuia Vinson, and Juan Yepes.
pediatric dentistry had not yet been established, he earned Almost until he died, McDonald remained its author.
a master’s degree in microbiology. The year 1946 saw However, in 1969, McDonald became dean of dentistry.
McDonald become an instructor in Indiana University’s This placed an added burden on his shoulders. And so,
Children’s Dental Clinic, where he pioneered the pediat- after completing the second edition in 1974, McDonald
ric dentistry program (Fig. 1). Although he didn’t realize saw the need for a co-editor. He said: “I was getting further
it, whilst writing his lecture notes, they were a textbook and further away from clinical dentistry. After producing
waiting to happen. In 1952, McDonald became chair of two editions, I realized there were areas I could no longer
the Children’s Dentistry Department. During this period of cover by myself. I brought Dave in for his clinical expertise
time, much of the dental treatment for children was given and research experience in dental materials.” For the third
by general practitioners, but some dentists trained as spe-
cialist pediatric dentists (“pedodontists” when the book was
first published). It goes without saying that both groups
needed good textbooks.
In 1963, McDonald published his book, Pedodontics, a
479-page compilation of material drawn from McDon-
ald’s lectures (Fig. 2). It contained eleven chapters and
was highly successful as a textbook for graduate students.
Interesting to note is the terminology used for Chapter 2,
“Behavior guidance in the dental office.” The AAPD only

Fig. 1 Dr. McDonald (right foreground) with patients and students in the
school’s pedodontic clinic in 1952. Fig. 2 Cover of Pedodontics published in 1963.

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 Foreword to the 11th edition of McDonald and Avery’s Dentistry for the Child and Adolescent: a historical review xiii

edition in 1978, McDonald guided David R. Avery through

the whole process and gave him full credit. The fourth edi-
tion in 1983 “was very much a shared piece of work,” said
Avery. In the sixth edition, a new author by the name of Jef-
fery A. Dean was added, but it was not until the eighth edi-
tion that he would join the editorial team of McDonald and
Avery. 2016 saw the book’s 50th anniversary 10th edition
published. As they handed over the editorship to Dr. Dean,
McDonald said: “As we entrust the continuing editions of
this textbook to others, we reflect on the many rewards we
have realized by our participation in the previous editions.
There are rewards for students, colleagues who teach and/
or practice pediatric dentistry and most importantly their
patients.” He went on: “We wish Godspeed to Dr. Dean…,
and all other future contributors as they proceed with this
work of love. We have the utmost confidence in their abili-
ties to carry on.” Fig. 3 The late Dr. Ralph E. McDonald (middle) with Dr. David R. Avery
Dentistry for the Child and Adolescent is internationally (left) and Dr. Jeffrey A. Dean (right), celebrating in 2000 the release of the
popular and has been considered a classic text for graduate 7th edition of the textbook. With that edition becoming the pediatric den-
tistry textbook with the most editions ever by surpassing Hogeboom’s total
programs worldwide. It has been translated from English of 6 editions, Drs. Avery and Dean honored Dr. McDonald with a new world
into several foreign languages, including Chinese, Farsi, record gold medal and olive wreath.
Japanese, Italian, Portuguese, Spanish, and Russian. The
textbook is now the world’s longest-running children’s den-
tistry textbook (Fig. 3). References
The specialty of pediatric dentistry has grown over the Bernabé E, Sheiham A: Period and cohort trends in caries of permanent
past century in popularity. For the 2020–21 academic year, teeth in four developed countries, Am J Public Health 104:e115–e121,
the number of positions offered and residency positions filled 2014. https://doi.org/10.2105/AJPH.2014.301869
surpasses all specialties and advanced education in general McBride, WC: Juvenile dentistry. 1952 (ed. 5), Lea & Febiger, Philadelphia.
dentistry programs. McDonald and Avery’s Dentistry for the McBride, Walter C: The business phase of Children’s Dentistry Journal of
the American Dental Association, 20(6):1003-1010, 1933.
Child and Adolescent has grown alongside, providing gradu- The health policy institute of the American Dental Association, https://
ates and specialists with knowledge, science, and technique www.ada.org/en/science-research/health-policy-institute/data-
as envisioned by McDonald so many years ago. center/dental-education

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Preface and Acknowledgements
It is a great pleasure for me to introduce the next iteration of techniques and philosophies continue to positively impact
this long standing and successful textbook on the essence, outcomes for our child and young adult patients. Increased
foundation, and innovations in the science and practice of emphasis on patient, centered care, parent and child con-
pediatric dentistry. After formally requesting and receiving sent and assent, continued public health and private prac-
fantastic feedback, compliments, and suggestions from a tice improvements, advances in minimalist approaches
broad representation of notable academics and clinicians, to restorative care, new science on dental materials, pulp
as well as adding two new associate editors with specific regeneration and revascularization, as well as a wide array
expertise in their areas covered in the text, we analyzed, of other advances, have enhanced our abilities to care
planned, and developed this edition to continue the nearly for our patients and have been incorporated into these
60-year history of the book. chapters.
As I am writing this introduction, the world is mired in Specifically, I am pleased to highlight a few additions and
the Covid-19 pandemic and slowly learning how to adapt significant updates:
to the “new abnormal.” While impacting our care and - Thirteen new authors have been added
practice, this remains an exciting time in dentistry and - Complete update of the online video contribution with
specifically pediatric dentistry, as new concepts, research, the expertise of a new video producer

Front row, left to right: Jones, Dean

Back row, left to right: Yepes, Vinson, Sanders
xiv

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 Preface and Acknowledgements xv

- Rewrite of the community dentistry chapter with three Dentistry, in particular Terry Wilson, Jr. and Caleb Clem-
critical components—dental workforce, dental delivery ents for their excellent production and editing work on all
sites and organizations, and payment source of the new videos, Amy Edmunds, Joyce Marlatt and Jas-
- Updates on preventive, interceptive, and early orth- mine Pence for their administrative support, Abby Morgan
odontic treatment, including information on pediatric and Nicole Alderson in dental illustrations for their work,
sleep apnea and Sean Stone for his guidance on the citation reference
- New emphasis on the use of silver diamine fluoride manager.
- New author update of the oral pathology chapter I’m proud of the dedication and work of our associate
- New section on vaping and oral implications editors and authors for once again helping to maintain
- Updated pain management section related to opioid use the tradition of excellence established by our mentors
and misuse and predecessors, Drs. McDonald and Avery. We hope
- New section on pediatric dental bleaching you enjoy this new edition, and as always, I look for-
- Information on coronavirus and Covid-19 in children ward to your comments and constructive criticism as we
- Updated on Periodontal Classification for children continuously strive for improvement and the highest in
- Expert Consult website with fully searchable access to quality. All the best to you, our colleagues, friends, and
the text, videos and multiple-choice questions students.
All of these enhancements take the assistance and dedi-
cation of multiple people. In particular, I’d like to thank all Jeffrey A. Dean
the great support staff at the Indiana University School of

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 1 Examination of the Mouth
and Other Relevant
Structures
JUAN F. YEPES and JEFFREY A. DEAN

CHAPTER OUTLINE Introduction Infant Dental Care

Initial Parental Contact with the Dental Detection of Substance Abuse
Office Etiologic Factors in Substance Abuse
The Diagnostic Method Specific Substances and Frequency of use
Preliminary Medical, Dental, Family, and Vaping and Electronic Cigarettes
Social History Suicidal Tendencies in Children and
Clinical Examination Adolescents
Temporomandibular Evaluation Infection Control in the Dental Office
Uniform Dental Recording Biofilm
Radiographic Examination Emergency Dental Treatment
Early Examination

Introduction procedures. Parents with even moderate income usually

find the means to have oral health care performed if the
A dentist is traditionally taught to perform a complete oral dentist explains that the child’s future oral health and
examination of the patient and to develop a treatment even general health are related to the correction of the
plan based on the examination findings. The dentist subse- oral defects.
quently makes a case presentation to the patient or parents,
outlining the recommended course of treatment. This pro-
cess should include the development and presentation of a Initial Parental Contact with the
prevention plan that outlines an ongoing comprehensive Dental Office
oral health care program for the patient and establishment
of the “dental home.” We most often think of parents’ first contact with the den-
The plan should include recommendations designed to tal office as being by telephone or electronic contact for-
correct the existing oral problems (or halt their progression) mats (Instagram, Facebook, etc). This initial conversation
and to prevent anticipated future problems. It is essential to between the parent and the office receptionist is very impor-
obtain all relevant patient and family information, to secure tant. It provides the first opportunity for the receptionist to
parental consent, and to perform a complete examination attend to the parents’ concerns by pleasantly and concisely
before embarking on this comprehensive oral health care responding to questions and by offering an office appoint-
program for pediatric patients. Anticipatory guidance is the ment. The receptionist must have a warm, friendly voice
term often used to describe the discussion and implemen- and the ability to communicate clearly. The receptionist’s
tation of such a plan with the patient and/or parents. The responses should assure the parent that the well-being of
American Academy of Pediatric Dentistry has published the child is the chief concern.
guidelines1 concerning the periodicity of examination, pre- The information recorded by the receptionist during this
ventive dental services, and oral treatment for children as conversation constitutes the initial dental record for the
summarized in Table 1.1. patient. Filling out a patient information form is a conve-
Each pediatric patient should be given an opportunity nient method of collecting the necessary initial information.
to receive complete dental care. The dentist should not Of course, most dental practices are moving toward online,
attempt to decide what the child, the parents, or a third- website-driven information and completion of patient forms
party agent will accept or can afford. If parents reject a for use even before a parent calls an office for an appoint-
portion or all of the recommendations, the dentist has ment or schedules an appointment online. Practices need to
at least fulfilled the obligation of educating the child and make accommodations to their patient information systems
the parents about the importance of the recommended to manage these very productive changes.
3

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4 PART 1 • Diagnoses

TABLE 1.1 Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/
Counseling
Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are
developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests
variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention
and the continuity of care based on the individualized needs of the child. Refer to the text of this guideline for supporting information and
references. Refer to the text in the Guidelines on Periodicity of Examinations, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment
for Infants, Children, and Adolescents (www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf) for supporting information and references.
AGE
6–12 months 12–24 months 2–6 years 6–12 years ≥12 years
Clinical oral examination1 • • • • •
Assesses oral growth and • • • • •
development2
Caries-risk assessment3 • • • • •
Radiographic assessment4 • • • • •
Prophylaxis and topical fluoride3,4 • • • • •
Fluoride supplementation5 • • • • •
Anticipatory guidance/counseling6 • • • • •
Oral hygiene counseling7 Parent Parent Patient/parent Patient/parent Patient
Dietary counseling8 • • • • •
Injury prevention counseling9 • • • • •
Counseling for nonnutritive habits10 • • • • •
Counseling for speech/language • • • • •
development
Assessment and treatment of • • •
developing malocclusion
Assessment for pit-and-fissure • • •
sealants11
Substance abuse counseling • •
Counseling for intraoral/perioral • •
piercing
Assessment and/or removal of third •
molars
Transition to adult dental care •
1First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child’s risk status/susceptibility to
disease. Includes assessment of pathology and injuries.
2By clinical examination.
3Must be repeated regularly and frequently to maximize effectiveness.
4Timing, selection, and frequency determined by child’s history, clinical findings, and susceptibility to oral disease.
5Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years of age or later in high-risk patients.
6Appropriate discussion and counseling should be an integral part of each visit for care.
7Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.
8At every appointment; initially discuss appropriate feeding practices, followed by the role of refined carbohydrates and frequency of snacking in caries

development and childhood obesity.

9Initially for play objects, pacifiers, car seats; then while learning to walk; and then with sports and routine playing, including the importance of mouthguards.
10At first, discuss the need for additional sucking: digits vs. pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For

school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.
11For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.

The Diagnostic Method

newly fractured crown needs immediate treatment, but the
Before making a diagnosis and developing a treatment plan, treatment will likely be only palliative, and further diagnostic
the dentist must collect and evaluate the facts associated with and treatment procedures will be required later.
the patient’s or parents’ chief concern and any other identi- The importance of thorough collection and evaluation of
fied problems that may be unknown to the patient or parents. the facts concerning a patient’s condition cannot be over-
Some pathognomonic signs may lead to an almost immediate emphasized. A thorough examination of the pediatric den-
diagnosis. For example, obvious gingival swelling and drain- tal patient includes an assessment of the following:
age may be associated with a single, badly carious primary
  
molar. Although these associated facts are collected and evalu- ᑏ General growth and health
ᑏ
ated rapidly, they provide a diagnosis only for a single problem ᑏ Diet
ᑏ
area. On the other hand, a comprehensive diagnosis of all of the ᑏ Chief complaint, such as pain
ᑏ
patient’s problems or potential problems may sometimes need ᑏ Extraoral soft tissue and temporomandibular joint (TMJ)
ᑏ
to be postponed until more urgent conditions are resolved. For evaluation
example, a patient with necrotizing ulcerative gingivitis or a ᑏ Intraoral soft tissue
ᑏ
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 1 • Examination of the Mouth and Other Relevant Structures 5

ᑏ ᑏ
Oral hygiene and periodontal health procedures can be planned to help the child overcome the
ᑏ Intraoral hard tissue fear and accept dental treatment.
ᑏ
ᑏ Developing occlusion Occasionally, when the parents report significant disorders,
ᑏ
ᑏ Caries risk it is best for the dentist to meet privately. They are more likely
ᑏ
ᑏ Behavior to discuss the child’s problems openly, and there is less chance
ᑏ
for misunderstandings regarding the nature of the disorders. In
  
Additional diagnostic aids are often also required, such addition, the dentist’s personal involvement at this early time
as radiographs, study models, photographs, pulp tests, and, strengthens the parents’ confidence. When an acute or chronic
infrequently, laboratory tests. In certain unusual cases, all systemic disease or anomaly is indicated, the dentist should con-
of these diagnostic aids may be necessary before a compre- sult the child’s physician to learn the status of the condition, the
hensive diagnosis can be made. Certainly, no oral diagnosis long-range prognosis, and the current drug therapy.
can be complete unless the diagnostician has evaluated the When a patient’s medical and dental history is recorded,
facts obtained by medical and dental history taking, inspec- the presence of current illnesses or history of relevant dis-
tion, palpation, exploration (if teeth are present), and often orders signals the need for special attention. In addition to
imaging (e.g., radiographs). For a more thorough review consulting the child’s physician, the dentist may decide to
of evaluation of the dental patient, refer to the chapter by record additional data concerning the child’s current physi-
Glick et al.2 in Burket’s Oral Medicine. cal condition, such as blood pressure, body temperature,
heart sounds, height and weight, pulse, and respiration.
Before any treatment is initiated, certain laboratory tests
Preliminary Medical, Dental, may be indicated and special precautions may be necessary.
Family, and Social History A decision to provide treatment in a hospital that possibly
involves general anesthesia may be appropriate.
It is important for the dentist to be familiar with the medical, The dentist and the staff must also be alert to identify poten-
dental, family, and social history of the pediatric patient. tially communicable infectious conditions that threaten the
Familial history may also be relevant to the patient’s oral health of the patient and others. Knowledge of the current
condition and may provide important diagnostic infor- recommended childhood immunization schedule is helpful.
mation in some hereditary disorders. Before the physical It is advisable to postpone nonemergency dental care for a
examination is performed, the dentist can obtain sufficient patient exhibiting signs or symptoms of acute infectious dis-
information to provide with knowledge of the child’s gen- ease until the patient recovers. Further discussions of man-
eral health from the parent or the child’s physician. Dental agement of dental patients with special medical, physical, or
assistants as well as dental hygienists can start collecting behavioral problems are presented in Parts III and V.
information/pre-screening with the parents. The dentist The pertinent facts of the medical history can be transferred
will follow this initial contact and expand or explore in more to the oral examination record (Fig. 1.2) for easy reference by
detail issues with a clear repercussion in the treatment plan. the dentist. A brief summary of important medical information
The form illustrated in Fig. 1.1 can be completed by the par- serves as a convenient reminder to the dentist and the staff,
ent. However, it is more effective for the dentist to ask the who will refer to this chart at each treatment visit.
questions marked by the parents and obtain more critical The patient’s dental history should also be summarized
details to have a better prospective of the patient. The ques- on the examination chart. This should include a record of
tions included on the form will also provide information previous care in the dentist’s office and the facts related by
about any previous dental treatment. the patient and parent(s) regarding previous care, if any, in
Information regarding the child’s social and psycho- another office. Information concerning the patient’s cur-
logical development is important. Accurate information rent oral hygiene habits and previous and current fluoride
reflecting a child’s learning, behavioral, or communication exposure helps the dentist develop an effective dental dis-
problems is sometimes difficult to obtain initially, especially ease prevention program. For example, if the family drinks
when the parents are aware of their child’s developmental well water, a sample may be sent to a water analysis labora-
disorder but are reluctant to discuss it. Behavior problems tory to determine the fluoride concentration.
in the dental office are often related to the child’s inability
to communicate with the dentist and to follow instructions.
This inability may be attributable to a learning disorder. An Clinical Examination
indication of learning disorders can usually be obtained by
the dentist when asking questions about the child’s learn- Most facts needed for a comprehensive oral diagnosis in the
ing process; for example, asking a young school-aged child young patient are obtained by thorough clinical and radio-
how he or she is doing in school is a good lead question. The graphic examination. In addition to examining the oral
questions should be age appropriate for the child. cavity structures, the dentist may wish to note the patient’s
If a young child was hospitalized previously for general size, stature, gait, or involuntary movements in some cases.
anesthetic and surgical procedures, it should be noted. Hos- The first clue to malnutrition may come from observing a
pitalization and procedures involving general anesthesia patient’s abnormal size or stature. Similarly, the severity of
can be a traumatic psychological experience for a preschool a child’s illness, even if oral in origin, may be recognized by
child and may sensitize the youngster to procedures that observing a weak, unsteady gait or lethargy and malaise as
will be encountered later in a dental office.3 If the dentist is the patient walks into the office. All relevant information
aware that a child was previously hospitalized or that the should be noted on the oral examination record (Fig. 1.2),
child fears strangers in clinic attire, the necessary time and which becomes a permanent part of the patient’s chart.

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6 PART 1 • Diagnoses

UUN
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V ER
ERRS
S TY
SIIIT
T YP
Y PEEED
D AT
DIIIA
A TR
TR CD
RIIIC
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TIIIS
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S
Riley Hospital for Children IU Health | ROC | Pediatric Dentistry DOB: EDR:
705 Riley Hospital Drive, Room #4205
Indianapolis, IN 46202-5109 NA:
317.944.3865 office | 317.944.9653 fax
www.pediatricdentistryassociates.org LC: DATE:

Birth Date: Gender: Female Male

City & State of Birth: Race: Height:_______ Weight____
Primary Care Physician:
Physician Address:
Physician Phone: Last Dental Visit:
Date of Last Medical Exam: Last Dental X-rays:

Dental History:
What is the primary reason for today’s visit?
YES NO Explain:
YES NO Explain:
Private Well City Water, City Name: Other:

With Help

Yes / No Y es / N o Yes / No
Suck Thumb/Fingers Bite/Chew Finger Nails Clench/Grind Teeth
Use Pacifier Have Speech Issues Mouth Breather

Medical History:
YES NO Explain:
YES NO Explain:
YES
Dose: Frequency of Use:

YES NO
Hospital Facility: When: Reason:

Yes / No Y es / N o Yes / No
Congenital Heart Defect/Disease Visual/Hearing Impairment Failure to Thrive
Heart Surgery Abnormal Bleeding Issues
Heart Murmur Sickle Cell Trait/Disease Born Prematurely
High Blood Pressure Hemophilia
Anemia
Asthma/Breathing Issues Kidney Problems Blood/Blood Product Transfusion
Cerebral Palsy Liver Problems HIV/AIDS
Seizures/Convulsions/Epilepsy Diabetes Varicella Vaccine / Chicken Pox
Muscle/Joint/Bone Problems TB / Tuberculosis
Thyroid/Glandular Problems MRSA
ADD/ADHD Skin Problems / Hives / Cold Sores Limited Mobility

onsibility to inform this

are providers as is necessary for

Guardian Signature:
Resident Signature: Date: Time:
Form #UPDDR217 Rev. 12/2013

Fig. 1.1 Form used in completing the preliminary medical and dental history. (Printed with permission from Indiana University–University Pediatric
Dentistry Associates.)

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2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 1 • Examination of the Mouth and Other Relevant Structures 7

Fig. 1.2 Chart used to record the oral findings and the treatment proposed for the pediatric patient. (Printed with permission from Indiana University–Uni-
versity Pediatric Dentistry Associates.)

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2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
8 PART 1 • Diagnoses

Fig. 1.2—Cont’d

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 1 • Examination of the Mouth and Other Relevant Structures 9

The clinical examination, whether the first examination

or a regular recall examination, should be all inclusive.
The dentist can gather useful information while getting
acquainted with a new patient. Attention to the patient’s
hair, head, face, neck, and hands should be among the first
observations made by the dentist after the patient is seated
in the chair.
The patient’s hands may reveal information pertinent
to a comprehensive diagnosis. The dentist may first detect
an elevated temperature by holding the patient’s hand.
Cold, clammy hands or bitten fingernails may be the first
indication of abnormal anxiety in the child. A callused or
unusually clean digit suggests a persistent sucking habit.
Clubbing of the fingers or a bluish color in the nail beds sug-
gests congenital heart disease, which may require special
precautions during dental treatment.
Fig. 1.3 Evidence of head lice infestation. Usually the insects are not
Inspection and palpation of the patient’s head and neck seen, but their eggs or nits cling to hair filaments until they hatch.
are also indicated. Unusual characteristics of the hair or (Courtesy Dr. Hala Henderson.)
skin should be noted. The dentist may observe signs of
problems such as head lice (Fig. 1.3), ringworm (Fig. 1.4),
impetigo (Fig. 1.5A,B), herpes labialis, or pink eye during
the examination. Proper referral is indicated immediately
because these conditions are contagious. After the child’s
physician has supervised treatment to control the condi-
tion, the child’s dental appointment may be rescheduled. If
a contagious condition is identified, but the child also has a
dental emergency, the dentist and the staff must take appro-
priate precautions to prevent spread of the disease to others
while the emergency is alleviated. Further treatment should
be postponed until the contagious condition is controlled.
Variations in the size, shape, symmetry, or function of the
head and neck structures should be recorded. Abnormali-
ties of these structures may indicate various syndromes or
conditions associated with oral abnormalities.

Temporomandibular Evaluation
A systematic review and meta-analysis published by da
Silva et al.4 assessed the prevalence of clinical signs of tem-
poromandibular (TMJ) disorders in children and adoles-
cents. One in six children and adolescents has clinical signs
of disorders. Okeson5 published a special report on TMJ dis-
orders in children, indicating that although several studies Fig. 1.4 Lesion on the forehead above the left eyebrow is caused by
ringworm infection. Several fungal species may cause lesions on vari-
included children aged 5–7 years, most observations have ous areas of the body. The dentist may identify lesions on the head,
been made in young adolescents. Studies have placed the face, or neck of a patient during a routine clinical examination. (Cour-
findings into the categories of symptoms or signs—those tesy Dr. Hala Henderson.)
reported by the child or parents and those identified by the
dentist during the examination. Prevalence of signs and
symptoms increases with age and may occur in 30% of that temporomandibular disorders in children can be man-
patients. aged effectively by the following conservative and revers-
One should evaluate TMJ function by palpating the head ible therapies: patient education, mild physical therapy,
of each mandibular condyle and by observing the patient behavioral therapy, medications, and occlusal splints.6 Dis-
while the mouth is closed (teeth clenched), at rest, and in cussion of the diagnosis and treatment of complex TMJ dis-
various open positions (Fig. 1.6A–D). Movements of the orders is available from many sources; we suggest Okeson’s
condyles or jaw that do not flow smoothly or that deviate Management of Temporomandibular Disorders and Occlusion
from the expected norm should be noted. Similarly, any (2020).7
crepitus that may be heard or identified by palpation as The extraoral examination continues with palpation of
well as any other abnormal sounds should be noted. Sore the patient’s neck and submandibular area (Fig. 1.6C and D).
masticatory muscles may also signal TMJ dysfunction. Again, deviations from normal, such as unusual tenderness or
Such deviations from normal TMJ function may require enlargement, should be noted and follow-up tests performed
further evaluation and treatment. There is a consensus or referrals made as indicated.

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2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.