Iran Dental Specialty Board - Pediatric Dentistry cheat sheet

Cephalocaudal gradient: head and brain growth peaks earliest (neural growth ~80% complete by age 6), while mandibular and long-bone growth continues into late adolescence; lymphoid tissue peaks near age 10-12 (tonsils/adenoids).

Scammon growth curves: neural, general somatic, lymphoid, and genital curves differ; dental age correlates best with skeletal age, not chronologic age.

Cervical vertebral maturation staging (CVM): CS1-CS2 prepubertal, CS3-CS4 pubertal growth spurt (peak mandibular growth), CS5-CS6 deceleration/postpubertal; CS3 marks the clinically useful window for functional appliance timing.

Mandibular growth: condylar endochondral growth plus posterior border apposition and anterior resorption; the mandible grows downward and forward with rotation-anterior (counterclockwise) rotation increases chin projection, posterior (clockwise) rotation reduces it.

Maxillary growth: sutural growth (midpalatal, circummaxillary) plus surface apposition/resorption; transverse maxillary width completes early (~age 12 in girls, later in boys), so transverse discrepancies are addressed early.

Dental age assessment: Nolla stages 1-10, Demirjian stages A-H, and Moorrees stages; eruption timing varies by sex and ethnicity, so skeletal maturation is a better predictor of growth-spurt timing than dental age.

Primary tooth eruption chronology: mandibular central incisor ~6-10 months, first primary molar ~12-16 months, primary canine ~16-20 months, second primary molar ~20-30 months; +/- 6 months variation is normal.

Permanent dentition chronology: first molar and mandibular central incisor ~6 years, maxillary central incisor ~7 years, premolars ~9-12 years, second molar ~12 years, third molars ~17-21 years.

Enamel formation timing: primary teeth begin mineralization in utero (~14 weeks for incisors); enamel defects on primary incisors reflect prenatal/neonatal insults, while defects on primary second molars reflect later prenatal/early postnatal events.

Piaget stages: sensorimotor (0-2 y), preoperational (2-7 y, egocentric, magical thinking), concrete operational (7-11 y, can understand cause/effect and rules), formal operational (11+ y, abstract reasoning)-guides explanation style.

Erikson psychosocial stages relevant to dentistry: autonomy vs shame (1-3 y), initiative vs guilt (3-6 y), industry vs inferiority (6-12 y), identity vs role confusion (12-18 y).

Frankl behavior rating scale: 1 definitely negative, 2 negative, 3 positive, 4 definitely positive; a rating of 3 or 4 indicates cooperative behavior.

Tell-show-do is the foundational technique for children with normal development; it precedes and underpins most other techniques.

Positive reinforcement and descriptive praise should be specific and immediate; distraction (music, video, counting) reduces anticipatory anxiety.

Voice control: controlled alteration of voice volume, tone, or pace to influence behavior; it is a directive technique and is not permitted for children with significant communication impairment.

Parental presence/absence is decided case by case; parental anxiety correlates with child anxiety, so a calm parent may help and an anxious parent may worsen behavior.

Nitrous oxide/oxygen: 30-50% N2O typical for anxiolysis; contraindicated in upper respiratory obstruction, recent middle-ear disease, and vitamin B12 deficiency; monitor oxygenation and use scavenging.

Informed consent for behavior guidance must include the technique, alternatives, and risks; protective stabilization requires documented indication, informed consent, and continuous airway/physiologic monitoring.

Caries risk assessment tools (CAMBRA, AAPD CAT) stratify by age, fluoride exposure, diet, plaque, saliva, and disease indicators; risk category determines recall interval (low 6-12 months, moderate 3-6 months, high 1-3 months).

Fluoride varnish 5% NaF (22,600 ppm F) applied 2-4 times/year is recommended from first tooth eruption for moderate/high-risk children; it is not a substitute for home fluoride.

Fluoride toothpaste: smear/rice-grain size from first tooth to age 3, pea-size from age 3-6; supervise and discourage swallowing; 1,000-1,500 ppm F is standard.

Silver diamine fluoride 38% arrests active cavitated caries in primary teeth and root surfaces; it stains carious tissue black; contraindicated in silver allergy and when esthetics are unacceptable.

Sealants are indicated on deep pits/fissures of permanent molars in high-risk children; sealants can arrest early non-cavitated caries; resin-based sealants require dry isolation, glass ionomer tolerates moisture.

Dietary counseling: limit free sugars to <10% of energy (ideally <5%), reduce frequency of sugar exposures rather than total amount, and avoid bedtime bottles and prolonged sippy-cup use.

Early childhood caries (ECC): any caries on a child <6 years; severe ECC (S-ECC) includes any smooth-surface caries in children <3 years or 1+ cavitated/white-spot lesions on maxillary anterior teeth.

Anticipatory guidance topics by age: bottle weaning (12-18 months), first dental visit by age 1 or first tooth, fluoride toothpaste introduction, digit habit cessation by age 3-4, sports mouthguard use.

Salivary testing: flow rate, buffering capacity, and mutans streptococci/lactobacilli counts inform risk; reduced flow (medications, radiation, Sjögren) markedly raises caries risk.

Stainless steel crowns (SSC): indicated for multisurface caries, pulpotomized teeth, hypoplasia, and high-caries-risk children; hall technique (no prep, cemented) is an accepted alternative for primary molars.

SSC failure/contraindications: nickel allergy, esthetic demand, and inability to fit; zirconia crowns offer esthetics but require more reduction and have higher cost and fracture risk.

Glass ionomer cement (GIC): chemical adhesion to tooth, fluoride release, moisture tolerance; lower wear resistance, so best for Class I/III primary teeth, temporary restorations, and high-caries-risk patients.

Resin-modified GIC (RMGIC) improves strength and light-cure control over conventional GIC but still has lower wear resistance than composite.

Composite resin in primary teeth: requires rubber dam isolation; indications include Class I/II when esthetics matter; do not use in uncontrolled moisture or with poor cooperation.

Amalgam: still acceptable in selected high-risk cases but declining; avoid in children with known mercury allergy and in primary teeth where esthetics and retention are concerns.

Pulpal protection: use calcium hydroxide or MTA for indirect/direct pulp capping; place base/liner under deep restorations; avoid eugenol-containing materials directly on pulp in some protocols.

Primary molar morphology: thin enamel, large pulp chambers, bulbous crowns, and convergent roots mean conservative preparation and careful caries removal to avoid pulp exposure.

Rubber dam isolation is standard for composite, endodontics, and sealants; it protects the airway and improves moisture control in children.

Pulpotomy in primary teeth: indicated for coronal pulp inflammation with vital radicular pulp; medicaments include formocresol (traditional, effective, concerns about systemic toxicity), ferric sulfate, MTA, and calcium hydroxide; MTA and ferric sulfate show favorable outcomes.

Pulpectomy (root canal) in primary teeth: indicated when radicular pulp is irreversibly inflamed or necrotic; use resorbable paste (zinc oxide-eugenol, iodoform-based) and avoid overextension into developing permanent follicle.

Contraindications to pulp therapy: abscess, fistula, pathologic mobility, extensive root resorption, and unrestorable tooth-extraction is then indicated.

Apexogenesis: vital pulp therapy (pulpotomy, partial pulpotomy) in immature permanent teeth to allow continued root development; MTA or calcium hydroxide is used.

Apexification: induction of a calcified barrier in a nonvital immature tooth using calcium hydroxide or MTA; alternative is regenerative endodontic procedure (revascularization).

Regenerative endodontics: for necrotic immature permanent teeth with open apices; protocol includes minimal canal instrumentation, disinfection (NaOCl, triple antibiotic paste or calcium hydroxide), and induction of blood clot; outcomes include continued root thickening and apical closure.

MTA advantages: biocompatible, induces hard-tissue formation, good seal, sets in moisture; drawbacks include cost, long setting time, and potential discoloration (use white MTA or bismuth-free formulations).

Formocresol concerns: formaldehyde is a known carcinogen in animals and classified as a human carcinogen; use is restricted in some countries; alternatives include ferric sulfate and MTA.

Success criteria for pulp therapy: absence of pain, no sinus tract/swelling, no pathologic mobility or furcation radiolucency, and normal root resorption pattern in primary teeth.

Enamel infraction/fracture: no treatment needed for infraction; smooth sharp edges; composite for esthetic or functional loss.

Uncomplicated crown fracture (enamel-dentin): seal dentin with bonding agent or GIC; composite restoration; monitor pulp vitality.

Complicated crown fracture (pulp exposure): in immature teeth, partial pulpotomy (Cvek) with MTA or calcium hydroxide preserves vitality; in mature teeth, pulpotomy or root canal depending on exposure size and time.

Luxation injuries: concussion/subluxation-observe and soft diet; extrusion-reposition and splint 2 weeks; lateral luxation-reposition and splint 4 weeks; intrusion-allow spontaneous re-eruption in immature teeth, orthodontic/surgical repositioning in mature teeth.

Avulsion: handle by crown, do not scrub, store in milk/HBSS/saline; replant immediately if possible; extraoral dry time >60 minutes has poor prognosis; splint 2 weeks (flexible splint) and initiate root canal within 7-10 days for mature teeth.

Avulsion in immature teeth: revascularization may occur if replanted quickly; otherwise apexification/regenerative endodontics; do not instrument the canal aggressively.

Splinting: flexible (wire + composite, or nylon) splints preferred; duration 2 weeks for avulsion and extrusion, 4 weeks for lateral luxation and root fracture (cervical third).

Root fracture: reposition if displaced, splint 4 weeks (cervical) or 2-3 weeks (mid/apical); monitor pulp vitality and root resorption.

Follow-up schedule after trauma: 1 week, 4 weeks, 3 months, 6 months, 1 year, then yearly; monitor for pulp necrosis, inflammatory root resorption, and ankylosis.

Riga-Fede disease: traumatic ulceration on the ventral tongue from natal/neonatal teeth or sharp incisors; treatment includes smoothing the tooth or extraction if severe.

Eruption cyst/hematoma: bluish swelling over an erupting tooth; usually self-limiting; marsupialization or excision only if symptomatic or infected.

Mucocele: mucus extravasation from minor salivary gland trauma, common on lower lip; treatment is excision with gland removal; recurrence is common if gland is left.

Ranula: mucocele of the sublingual gland floor of mouth; treatment is excision of the gland or marsupialization; large ranulas may need surgical management.

Hemangioma vs vascular malformation: infantile hemangioma appears shortly after birth, grows then involutes; vascular malformations are present at birth and do not involute; propranolol is first-line for problematic infantile hemangiomas.

Aphthous ulcers: recurrent, painful, non-keratinized mucosa; treatment is topical corticosteroids and symptomatic care; distinguish from herpes (keratinized mucosa, clustered vesicles).

Herpetic gingivostomatitis: primary HSV-1 infection in children, fever and multiple vesicles/ulcers on keratinized mucosa; supportive care, hydration, and acyclovir in severe cases.

Oral candidiasis: white removable plaques on erythematous mucosa; risk factors include antibiotics, inhaled corticosteroids, immunosuppression; treat with topical nystatin or fluconazole.

Odontogenic tumors/cysts in children: dentigerous cyst (associated with impacted tooth), odontoma (most common odontogenic tumor, hamartoma), and ameloblastoma (rare in children but aggressive); biopsy is required for persistent lesions.

Amelogenesis imperfecta: hereditary enamel defect (hypoplastic, hypomaturation, hypocalcified); treatment ranges from desensitizing agents and crowns to full-coverage rehabilitation; inheritance often autosomal dominant.

Dentinogenesis imperfecta: opalescent teeth with obliterated pulp chambers, bulbous crowns, and short roots; associated with osteogenesis imperfecta (COL1A1/COL1A2 mutations); treatment includes crowns and careful endodontics.

Dentin dysplasia: type I (radicular) shows short roots and obliterated canals; type II (coronal) shows thistle-tube pulp chambers; both are autosomal dominant.

Molar-incisor hypomineralization (MIH): demarcated enamel opacities on first permanent molars and incisors; treatment ranges from desensitizing and sealants to SSC/crowns; etiology includes systemic insults in the first 3 years.

Hypodontia/oligodontia: most commonly missing teeth are third molars, maxillary lateral incisors, and mandibular second premolars; associated syndromes include ectodermal dysplasia (hypohidrotic, ED1 gene) with sparse hair, reduced sweating, and conical teeth.

Supernumerary teeth: most common in the maxillary anterior region (mesiodens); can cause delayed eruption, displacement, and diastema; extraction is often indicated.

Fluorosis (dental): diffuse opacities from excessive fluoride intake during enamel formation; Dean's index classifies severity; treatment is esthetic (microabrasion, bleaching, veneers).

Cleidocranial dysplasia: RUNX2 mutation; delayed eruption, supernumerary teeth, absent clavicles, and open fontanelles; management requires multidisciplinary care and surgical exposure of impacted teeth.

Down syndrome: trisomy 21; features include hypotonia, macroglossia, microdontia, delayed eruption, increased periodontal disease, and congenital heart defects requiring antibiotic prophylaxis in selected cases.

Local anesthetic dosing in children: maximum lidocaine 4.4 mg/kg (with epinephrine), articaine 7 mg/kg (some sources 5 mg/kg), mepivacaine 6.6 mg/kg; calculate by weight and use the smallest effective volume.

Epinephrine concentration: 1:100,000 = 0.01 mg/mL; 1:200,000 = 0.005 mg/mL; maximum epinephrine dose in children is limited (commonly 0.2 mg total or 0.04 mg/kg).

Benzodiazepines for sedation: midazolam (0.25-0.5 mg/kg oral, max 20 mg) is common; flumazenil is the reversal agent; monitor respiration and oxygenation.

Nitrous oxide/oxygen sedation: minimum 30% oxygen; contraindicated in bowel obstruction, pneumothorax, and recent middle-ear surgery; use scavenging and pulse oximetry.

Opioid sedation: fentanyl and meperidine carry respiratory depression risk; naloxone is the reversal agent; avoid in children with airway compromise.

Antibiotic prophylaxis (AHA): indicated for prosthetic heart valves, previous endocarditis, unrepaired cyanotic congenital heart disease, and repaired lesions with residual defects; amoxicillin 50 mg/kg (max 2 g) 30-60 minutes before procedure; clindamycin is no longer recommended for prophylaxis.

Anaphylaxis: epinephrine IM 0.01 mg/kg (1:1,000), max 0.3-0.5 mg, repeat every 5-15 minutes; adjuncts include oxygen, IV fluids, and antihistamines; do not delay epinephrine.

Local anesthetic toxicity: manage with airway support, oxygen, benzodiazepines for seizures, and lipid emulsion for cardiac arrest from bupivacaine.

Syncope: most common medical emergency in dental office; place supine, elevate legs, monitor vitals, and use ammonia if needed; distinguish from hypoglycemia and seizure.

Autism spectrum disorder: maintain routine, minimize sensory stimuli, use visual schedules and social stories, and consider pre-visit desensitization; avoid overstimulation from lights, sounds, and touch.

Cerebral palsy: risk of aspiration, drooling, and abnormal muscle tone; use suction, upright positioning, and short appointments; consider seizure precautions.

Down syndrome: increased risk of periodontal disease, delayed eruption, and congenital heart defects; atlantoaxial instability may require caution with neck extension.

Congenital heart disease: obtain cardiology clearance; antibiotic prophylaxis per AHA criteria; cyanotic lesions may have bleeding risk and polycythemia.

Bleeding disorders (hemophilia, von Willebrand disease): coordinate with hematology; use local hemostatic measures (pressure, tranexamic acid mouth rinse, desmopressin for mild von Willebrand); avoid aspirin and NSAIDs.

Immunocompromised children (chemotherapy, HIV): risk of infection and bleeding; consult oncology; avoid elective procedures during neutropenia; use antibiotic prophylaxis as indicated.

Seizure disorders: avoid triggers, keep suction and airway equipment ready, do not place objects in the mouth during a seizure; document seizure type and medications.

Hearing/vision impairment: use written instructions, sign language interpreters, and tactile cues; ensure communication access and informed consent.

Medically complex patients: obtain a thorough medical history, consult the primary care provider, and plan for emergency management (e.g., epinephrine, glucose, oxygen) before treatment.

Eruption guidance: serial extraction is considered in severe crowding with a predictable pattern; space maintenance is used after premature primary tooth loss to prevent space loss.

Space maintainers: band-and-loop and crown-and-loop for posterior space loss; lower lingual holding arch for bilateral loss; maintain until the permanent successor erupts.

Crossbite correction: anterior crossbite can be corrected with a removable appliance with springs or a 2x4 appliance; posterior crossbite with maxillary expansion (RPE) while sutures are open (before puberty).

Habit correction: digit sucking cessation by age 3-4; appliances (palatal crib, bluegrass appliance) for persistent habits; address tongue thrust with habit therapy.

Class II correction: functional appliances (Twin Block, Herbst, activator) are most effective during the pubertal growth spurt (CVM CS3-CS4); headgear restricts maxillary growth.

Class III: early treatment may include facemask/protraction headgear with maxillary expansion; true skeletal Class III may require orthognathic surgery after growth.

Ectopic eruption of first permanent molar: intercept with separators, distalization, or brass wire; monitor for resorption of primary second molar.

Impacted maxillary canine: early detection via radiographs; intercept with extraction of primary canine or orthodontic traction; CBCT for localization.

Interceptive orthodontics goals: eliminate habits, correct crossbites, manage space, and guide eruption; it does not replace comprehensive orthodontic treatment.