Webinar: Bioceramics in Pediatric Dentistry - Dr. Patrick Ruck

Recent advances in bioceramic materials have positioned them at the forefront of pediatric dental care. Unlike traditional calcium hydroxide or earlier MTA formulations, modern bioceramics provide superior sealing ability, biocompatibility, and long-term stability.

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In pulp therapy for primary and young permanent teeth, these properties are critical for reducing inflammation, encouraging dentin bridge formation, and improving success rates.

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Products such as NeoMTA2 and NeoPUTTY exemplify this new generation of bioactive materials: they offer improved handling, reduced discoloration, and consistent clinical outcomes, making them more predictable and child-friendly options.

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By supporting tissue regeneration and minimizing the need for retreatment, bioceramics are transforming pediatric dental care into a more conservative, biologically driven discipline.

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This evolution, grounded in scientific evidence, highlights a shift toward therapies that respect the natural vitality of teeth while ensuring long-term oral health in children.

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What Are Nolla’s Stages and Why Are They Important in Dentistry?

Nolla’s stages are a widely used method in dentistry to evaluate tooth development through crown and root formation.

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They are essential in pediatric dentistry, orthodontics, and oral surgery, as they allow clinicians to estimate dental age and improve treatment planning accuracy.

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✅ Introduction
Determining dental age is a key procedure in several dental specialties. One of the most applied methods is Nolla’s stages, first proposed in 1960, which classify tooth development into 11 stages, ranging from no calcification to complete apical closure (Nolla, 1960).
This system is clinically valuable for diagnostic, therapeutic, and forensic purposes, as it provides a biological maturity estimate rather than relying solely on chronological age.

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✅ Definition of Nolla’s Stages
Nolla’s classification is a radiographic method describing dental development across 11 consecutive stages, from no calcification (stage 0) to closed root apex (stage 10).

✅ Clinical Importance
Nolla’s stages are used to:

° Estimate dental age in children and adolescents.
° Plan orthodontic treatment, identifying the right timing for interceptive interventions.
° Support pediatric dentistry, especially in patients with delayed or altered tooth development.
° Assist forensic investigations, by estimating age in legal and anthropological contexts.

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✅ Comparison with Other Methods
Compared to systems such as Demirjian or Moorrees, Nolla’s method is simpler and widely accepted. However, some studies suggest it may underestimate age in certain populations (Lee et al., 2022).

💬 Discussion
The relevance of Nolla’s stages remains strong due to their practicality and broad clinical applications. Nonetheless, their accuracy may vary depending on the studied population. For this reason, many authors recommend combining Nolla’s system with other age estimation techniques.
In clinical practice, they are particularly useful in orthodontics and pediatric dentistry, where treatment timing depends heavily on dental maturity.

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✍️ Conclusion
Nolla’s stages represent a reliable diagnostic tool in dentistry, allowing clinicians to assess tooth development and estimate dental age with reasonable accuracy. Their use enhances treatment planning, improves prognostic evaluation, and supports both clinical and forensic decision-making.

📚 References

✔ Lee, J. Y., Kim, Y. K., & Park, J. H. (2022). Accuracy of Nolla’s stages in dental age estimation across populations: A systematic review and meta-analysis. Journal of Forensic Odonto-Stomatology, 40(1), 15–22.
✔ Nolla, C. M. (1960). The development of the permanent teeth. Journal of Dentistry for Children, 27(4), 254–266.
✔ Willems, G., Van Olmen, A., Spiessens, B., & Carels, C. (2001). Dental age estimation in Belgian children: Demirjian’s technique revisited. Journal of Forensic Sciences, 46(4), 893–895.
✔ AlQahtani, S. J., Hector, M. P., & Liversidge, H. M. (2010). Brief communication: The London atlas of human tooth development and eruption. American Journal of Physical Anthropology, 142(3), 481–490. https://doi.org/10.1002/ajpa.21258 br />

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Hall Technique vs Conventional Stainless Steel Crowns in Pediatric Dentistry: Effectiveness, Pros and Cons

Stainless steel crowns (SSC) are the gold standard for restoring extensively carious primary molars. The conventional technique requires caries removal, anesthesia, and tooth preparation.

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In contrast, the Hall Technique seals caries under a preformed metal crown without local anesthesia, tooth preparation, or caries removal, aligning with the principles of minimally invasive dentistry.

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✅ Advantages and Disadvantages

1. Hall Technique
➤ Advantages
° High success rates (~94–97% at medium-term follow-up).
° No anesthesia, drilling, or caries removal, reducing anxiety in pediatric patients.
° Shorter chair time (4–5 minutes vs ~28 minutes for conventional SSCs).
° Well accepted by children and parents.
° Spontaneous occlusal adjustment within weeks.
➤ Disadvantages
° Initial occlusal vertical dimension increase (resolves in 2–30 days).
° Not suitable in advanced pulpal involvement or extensive root resorption.
° Aesthetic limitations (visible metal).
° Requires orthodontic separators in tight contacts, which may cause discomfort.

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2. Conventional Stainless Steel Crowns (SSC)
➤ Advantages
° Long clinical track record, widely taught in dental curricula.
° Effective in a broad range of clinical cases.
➤ Disadvantages
° Invasive: requires anesthesia, tooth preparation, and caries removal.
° More time-consuming (~28 minutes per case).
° Patient discomfort and possible trauma.
° Comparable survival to Hall but requires more resources

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💬 Discussion
The Hall Technique demonstrates comparable or superior survival rates to conventional SSCs in primary molars, with additional benefits of reduced chair time, less invasiveness, and higher patient acceptance. Although initial occlusal changes and esthetics remain challenges, evidence shows these issues resolve or are clinically acceptable. The Hall Technique is especially valuable in anxious children, special needs patients, or resource-limited settings.

✍️Conclusion
Both Hall and conventional SSC techniques are effective for managing extensively carious primary molars. However, the Hall Technique offers a minimally invasive, patient-friendly alternative with high success rates and reduced treatment burden. Proper case selection remains essential to ensure long-term success.

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📚 References

✔ Altoukhi, D. H., & El-Housseiny, A. A. (2020). Hall technique for carious primary molars: A review of the literature. Dentistry Journal, 8(2), 35. https://doi.org/10.3390/dj8020035

✔ Innes, N. P. T., Ricketts, D., Chong, L. Y., Keightley, A. J., Lamont, T., & Santamaria, R. M. (2019). Preformed crowns for decayed primary molar teeth. Cochrane Database of Systematic Reviews, 2019(5), CD005512. https://doi.org/10.1002/14651858.CD005512.pub3

✔ Ludwig, K. H., Fontana, M., Vinson, L. A., Platt, J. A., & Dean, J. A. (2014). The success of stainless steel crowns placed with the Hall technique. Journal of the American Dental Association, 145(12), 1248–1253. https://doi.org/10.14219/jada.2014.95

✔ Elamin, F., Abdelazeem, N., & Honkala, E. (2019). Comparison of Hall technique and conventional stainless steel crown techniques for primary molars: A randomized controlled trial. European Archives of Paediatric Dentistry, 20(5), 467–474. https://doi.org/10.1007/s40368-019-00421-3

✔ Ayedun, O. S., Folayan, M. O., & Oyedele, T. A. (2021). Comparison of the treatment outcomes of the Hall technique and conventional stainless steel crown technique. Nigerian Journal of Clinical Practice, 24(4), 548–554. https://doi.org/10.4103/njcp.njcp_507_19

✔ Badar, S. B., Tabassum, S., & Khan, F. R. (2019). Effectiveness of Hall technique for carious primary molars: A meta-analysis. International Journal of Clinical Pediatric Dentistry, 12(2), 132–138. https://doi.org/10.5005/jp-journals-10005-1622

✔ Hu, S. (2022). Hall technique for managing carious primary molars: A systematic review. Journal of Stomatology, Oral and Maxillofacial Surgery, 123(6), 581–588. https://doi.org/10.1016/j.jormas.2022.01.003

Herkar, P. P., Karkera, R., & Thomas, A. (2022). A comparative study of stress distribution in primary molars restored with Hall and conventional SSC techniques using finite element analysis. Journal of Pediatric Dentistry, 40(3), 205–212. https://doi.org/10.4103/jpd.jpd_25_22

✔ MedRxiv. (2025, May 19). Comparative survival of Hall vs conventional preformed metal crowns in primary molars. MedRxiv. https://doi.org/10.1101/2025.05.18.25327863

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Maxillary Orthopedics vs. Interceptive Orthodontics: Key Differences, Similarities, and Treatments

1. Introduction
Maxillary orthopedics and interceptive orthodontics are closely related but distinct fields. While both aim to improve oral and facial harmony in growing patients, their approaches, timing, and appliances differ.

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2. Definitions
➤ Maxillary Orthopedics: A specialty focused on correcting discrepancies in the growth and development of the jaws using functional or fixed appliances. It is most effective between ages 6–12, when craniofacial plasticity is greatest (Solución Dental, 2024; TopDoctors, 2024; Clínica Dental Acosta Cubero, 2024).
➤ Interceptive Orthodontics: An early form of orthodontics aimed at intervening during mixed dentition to prevent or guide skeletal and dental development, correct harmful habits, and reduce the need for complex treatments later (González & Casado, 2024; Dental Peset, 2024; Moonz, 2024).

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3. Diagnosis
Both approaches require early evaluation.

➤ Maxillary Orthopedics: Diagnoses focus on skeletal discrepancies such as posterior crossbites, asymmetries, or sagittal imbalances (Solución Dental, 2024; Acosta Cubero, 2024).
➤ Interceptive Orthodontics: Diagnosis includes early malocclusions, dentoalveolar discrepancies, deleterious oral habits (thumb sucking, mouth breathing), or abnormal eruption patterns (González & Casado, 2024; Mallorca Dental, 2024; Moonz, 2024).

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4. Characteristics and Ideal Age

5. Most Common Appliances

➤ Maxillary Orthopedics
° Palatal expansion appliances (Hyrax, Quad Helix, McNamara)
° Face mask and headgear for sagittal discrepancies (retrognathia, prognathism)
° Functional plates to redirect mandibular growth
➤ Interceptive Orthodontics
° Palatal expanders and twin block devices
° Removable plates, Bionator, chin cup, mandibular advancement devices (MADs)
° Functional appliances to stop habits (tongue thrust, thumb sucking, mouth breathing)

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6. Discussion
Both therapies share the same preventive and corrective philosophy but differ in their scope. Maxillary orthopedics directly targets skeletal growth, leveraging craniofacial plasticity. Interceptive orthodontics combines skeletal and dental guidance, addressing early malocclusions and habits.
In clinical practice, they are often sequential or combined: orthopedic treatment first to establish a stable skeletal base, followed by corrective orthodontics to align permanent dentition.
Early diagnosis (ideally around age 6) maximizes effectiveness, reducing the likelihood of surgical interventions such as orthognathic surgery later in life.

7. Conclusion
Maxillary orthopedics and interceptive orthodontics are complementary but distinct strategies. Orthopedics corrects skeletal imbalances, while interceptive orthodontics prevents and modifies both skeletal and dental malocclusions. Both require early diagnosis and proper appliance selection. When combined, they lead to more stable, functional, and esthetic long-term outcomes.

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📚 References

✔ Clínica Solución Dental. (2024, December 22). Differences between maxillary orthopedics and orthodontics. Solución Dental. https://soluciondental.pe/ortopedia-maxilar/diferencias-ortopedia-ortodoncia/

✔ TopDoctors. (2024, August 7). Difference between maxillary orthopedics and orthodontics: A complete guide. TopDoctors. https://www.topdoctors.mx/articulos-medicos/diferencia-entre-ortopedia-maxilar-y-ortodoncia-una-guia-completa/

✔ González y Casado. (2024). Interceptive orthodontics, orthopedics, and functional appliances. https://gonzalezycasado.com/tratamientos/ortodoncia-interceptiva-ortopedia-y-aparatologia-funcional

✔ Dental Peset. (2024). Differences between interceptive and corrective orthodontics. https://dentalpeset.com/ortodoncia-interceptiva/

✔ Moonz Clinics. (2024). What is interceptive orthodontics and why is it important? https://moonz.com/tratamientos/ortodoncia-interceptiva-ortopedia/

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Pediatric Oral Surgery Preoperative Protocol: Complete Clinical Guide

A well-structured preoperative protocol is essential to ensure safety and optimal outcomes in pediatric oral surgery. This guide outlines the most up-to-date recommendations, covering medical evaluation, fasting guidelines, informed consent, emotional preparation, and family logistics.

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1. Preoperative Clinical and Anesthetic Evaluation

➤ Key steps:
a. Comprehensive medical history – chronic illnesses (heart disease, asthma, epilepsy, diabetes, immunodeficiencies).
b. Surgical and anesthetic history – prior complications, adverse reactions, malignant hyperthermia risk.
c. Medication and allergy review – drug and food allergies.
d. Focused physical exam – airway assessment (Mallampati, mouth opening, neck mobility), cardiovascular and respiratory systems, hydration status.
e. ASA physical status classification – determines anesthetic risk.
f. Lab tests – only when indicated (e.g., coagulation studies, CBC, blood glucose).
g. Weight and height – for accurate dosing.

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2. Fasting and Fluid Management
Proper fasting minimizes the risk of pulmonary aspiration during general anesthesia or deep sedation.

➤ American Society of Anesthesiologists (2023) guidelines:
° Clear liquids (water, pulp-free juice, electrolyte solutions): up to 2 hours before surgery.
° Breast milk: up to 4 hours before.
° Infant formula: up to 6 hours before.
° Light meals (toast, cereal): up to 6 hours before.
°Fatty meals: minimum 8 hours before.

➤ Additional recommendations:
° Confirm fasting time at patient check-in.
° Document last oral intake in the medical record.
° Provide caregivers with written and visual fasting instructions.

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3. Informed Consent and Emotional Preparation
Informed consent must be signed by the legal guardian and include:

a. Procedure description.
b. Expected benefits and risks.
c. Available alternatives.
d. Possible complications.
e. Anesthesia and sedation plan.
f. Postoperative care instructions.

➤ Emotional preparation for children:
° Use the Tell-Show-Do technique.
° Age-appropriate language and visuals (toys, storybooks).
° Parental presence during preparation when possible.
° Familiarization visits to the surgical area.

Additional item:
° Record the child’s anxiety level and strategies used to reduce it in the patient chart.

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4. Family Logistics and Home Care Planning
Caregiver preparation improves cooperation and recovery.

➤ Recommendations:
a. Designate a responsible adult to stay during the entire procedure.
b. Arrange safe transportation home (no public transit, no fatigued driver).
c. Ensure a 24-hour observation period post-surgery at home.
d. Minimize waiting time by coordinating arrival and surgery schedule.
e. Dress the child in comfortable clothing.
f. Remove jewelry, piercings, nail polish (for monitoring purposes).

➤ Additional recommendation:
° Provide caregivers with a pre-op checklist to ensure all requirements are met.

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5. Surgical Team Coordination

➤ Checklist before surgery:
a. Verify patient identity twice.
b. Mark the surgical site.
c. Confirm pediatric-sized instruments are ready (forceps, aspirators, surgical tools).
d. Prepare emergency medications and monitoring equipment.
e. Take preoperative photographs if needed for records.

✍️ Conclusion
An effective pediatric oral surgery pre-op protocol combines thorough medical evaluation, evidence-based fasting, informed consent, emotional readiness, and strong caregiver coordination. Following these steps reduces anesthetic risks, improves child cooperation, and enhances recovery outcomes in U.S. pediatric dental settings.

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📚 References

✔ American Academy of Pediatric Dentistry. (2023). Guideline on behavior guidance for the pediatric dental patient. Pediatric Dentistry, 45(6), 302–315.

✔ American Society of Anesthesiologists. (2023). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology, 138(2), 233–246.

✔ American Academy of Family Physicians. (2022). Preoperative evaluation in children. American Family Physician, 105(6), 640–648.

✔ Urbach Pediatric Dentistry. (n.d.). Pre-op instructions for nitrous oxide and oral sedation. Retrieved from https://urbachpediatricdentistry.com/pre-op-instructions/

✔ Timberlea Dental Clinic. (2019). Pediatric pre- and post-op instructions. Retrieved from https://timberleasc.ca/wp-content/uploads/2019/10/Pediatric-Pre-and-Post-Op-Instructions-1.pdf

✔ Bekids Dentistry. (n.d.). Surgical instructions: Before general anesthesia. Retrieved from https://www.bekidsdentistry.com/welcome/pediatric-dentistry/procedures/surgical-instructions/before-general-anesthesia/

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Amoxicillin vs Clindamycin in Pediatric Dentistry: Updated Clinical Guide 2025

Choosing between amoxicillin and clindamycin in pediatric dentistry requires a clear understanding of their mechanisms of action, clinical indications, weight-based dosing formulas, and safety profiles.

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✅ Mechanisms of Action

° Amoxicillin is a β-lactam antibiotic that inhibits bacterial cell wall synthesis, effective against gram-positive and some gram-negative bacteria.
° Clindamycin, a lincosamide, inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit, blocking peptide translocation.

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✅ Clinical Uses in Pediatric Dentistry

° Amoxicillin is the first-line antibiotic for pediatric dental infections due to its proven efficacy against the oral microbiota and favorable safety profile.
° Clindamycin is reserved for children allergic to penicillins or in cases of anaerobic infections, serving as a valuable alternative.

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✅ Dosage and Pediatric Dose Formula

1. Amoxicillin (children over 03 months and less than 88 lb/40kg):
20–40 mg/kg/day, divided every 8 hours, for up to 5 days
➤ Formula:
° Total daily dose (mg) = weight (kg) × mg/kg, divided into the number of doses per day.
° Example: A 20 kg child → 20 × 30 mg/kg = 600 mg/day → 200 mg every 8 h.

2. Clindamycin (oral, pediatric):
➤ Mild to moderate infections: 10–25 mg/kg/day, divided into 3 doses.
➤ Severe infections: 30–40 mg/kg/day, divided into 3–4 doses.
➤ Formula:
° Daily dose (mg) = weight × mg/kg, then split according to frequency.
° Example: 20 kg child, moderate infection → 20 × 20 mg/kg = 400 mg/day → ~133 mg every 8 h.

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✅ Advantages and Disadvantages

💬 Discussion
In the US pediatric dental setting, amoxicillin remains the gold standard for treating most dental infections in children due to its high effectiveness, safety, and ease of administration. Clindamycin plays a critical role when first-line therapy is contraindicated, particularly in cases of penicillin allergy or infections dominated by anaerobic bacteria. However, clindamycin requires caution due to its higher gastrointestinal risk profile.

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✍️ Conclusion
Amoxicillin is the preferred first-line treatment for pediatric dental infections, while clindamycin serves as a key alternative for allergic patients or specific anaerobic infections. Accurate weight-based dosing ensures safety and efficacy, aligning with current American Academy of Pediatric Dentistry guidelines.

📚 References

✔ American Academy of Pediatric Dentistry. (2022). Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. AAPD. https://www.aapd.org/globalassets/media/policies_guidelines/bp_antibiotictherapy.pdf

✔ Abdullah, F. M., et al. (2024). Antimicrobial management of dental infections: Updated review. Medicine, 103(28), e39. https://journals.lww.com/md-journal/fulltext/2024/07050/

✔ Goel, D. (2020). Antibiotic prescriptions in pediatric dentistry: A review. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC7114004/

✔ Johns Hopkins University. (2024). Clindamycin - ABX Guide. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540131/all/Clindamycin

✔ MedCentral. (2024). Clindamycin HCl Oral Monograph. https://www.medcentral.com/drugs/monograph/12235-382399/clindamycin-hcl-oral

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Partial Pulpotomy in Pediatric Dentistry: Technique, Benefits, and Key Differences

Modern pediatric dentistry emphasizes minimally invasive procedures that preserve pulp vitality and tooth structure.

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Partial pulpotomy offers a biologically favorable approach in cases of limited pulp inflammation, especially in traumatic pulp exposures or shallow carious lesions, promoting healing and long-term tooth survival.

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✅ Definition of Partial Pulpotomy
Also known as Cvek pulpotomy, partial pulpotomy involves the removal of 1–3 mm of inflamed coronal pulp tissue directly beneath the exposure, preserving the remaining healthy pulp and covering it with a biocompatible material that supports healing and dentin bridge formation.

✅ Differences Between Partial and Conventional Pulpotomy

✅ Biological Rationale
Partial pulpotomy is grounded in the understanding that pulp inflammation is often localized. When only the affected area is removed, the remaining pulp can regenerate and form a dentin bridge. Young permanent teeth, in particular, have a high regenerative capacity, which enhances success rates when proper isolation and materials are used.

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✅ Step-by-Step Technique

➤ Clinical and radiographic evaluation
° Indicated for recent pulp exposures (less than 24 hours for trauma)
° No signs of irreversible pulpitis or periapical pathology

➤ Anesthesia and isolation
° Use local anesthesia and rubber dam isolation to ensure an aseptic field.

➤ Partial pulp removal
° Excise 1–3 mm of inflamed pulp using a sterile diamond bur with water coolant.
° Rinse with sterile saline.

➤ Hemostasis
° Apply a moist cotton pellet for 2–5 minutes.
° Successful hemostasis confirms healthy pulp status.

➤ Placement of pulp capping material
° Apply a biocompatible material (e.g., MTA, Biodentine) directly onto the pulp.
° Cover with resin-modified glass ionomer or temporary cement.

➤ Final restoration
° Restore with composite resin or stainless steel crown depending on the tooth's condition and location.

Recommended Materials
° MTA (Mineral Trioxide Aggregate) – ProRoot® MTA (Dentsply Sirona), MTA Angelus®
° Biodentine™ (Septodont) – Bioactive dentin substitute with excellent sealing and biocompatibility
° TheraCal LC® (Bisco) – Light-cured resin-modified calcium silicate
° Vitrebond™ (3M) – Resin-modified glass ionomer for base/sealing

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💬 Discussion
Scientific literature strongly supports partial pulpotomy for managing pulp exposures in both primary and permanent teeth. It is especially effective when performed soon after trauma or in controlled carious exposures. Studies report success rates above 90% with bioceramic materials like MTA and Biodentine. Case selection, operator technique, and proper sealing are critical to achieving optimal outcomes.
Partial pulpotomy aligns with the minimally invasive dentistry philosophy, reducing the need for more extensive endodontic procedures and maintaining tooth vitality for longer periods.

💡 Conclusion
Partial pulpotomy is a reliable and conservative vital pulp therapy that supports biological healing and long-term function. When performed correctly and with appropriate materials, it offers a high success rate and preserves natural pulp defenses. It is recommended as a first-line treatment for immature permanent teeth and select primary teeth with localized inflammation.

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📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. https://www.aapd.org

✔ Aguilar, P., & Linsuwanont, P. (2019). Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. Journal of Endodontics, 45(5), 511–517. https://doi.org/10.1016/j.joen.2019.01.021

✔ Bogen, G., Kim, J. S., & Bakland, L. K. (2008). Direct pulp capping with mineral trioxide aggregate: An observational study. Journal of the American Dental Association, 139(3), 305–315. https://doi.org/10.14219/jada.archive.2008.0177

✔ Nowicka, A., Wilk, G., Lipski, M., Kołecki, J., & Buczkowska-Radlińska, J. (2015). Tomographic evaluation of reparative dentin formation after direct pulp capping with Ca(OH)₂, MTA, Biodentine, and dentin bonding system in human teeth. Journal of Endodontics, 41(8), 1234–1240. https://doi.org/10.1016/j.joen.2015.03.017

✔ Chisini, L. A., Collares, K., Cademartori, M. G., et al. (2022). Vital pulp therapy for primary teeth: A systematic review and meta-analysis. Clinical Oral Investigations, 26(1), 91–106. https://doi.org/10.1007/s00784-021-04076-9

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Calcium Hydroxide in Pediatric Dentistry: Updated Uses, Benefits, and Clinical Evidence

Preserving pulp vitality and supporting dental development are key goals in pediatric dentistry.

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Calcium hydroxide (Ca(OH)₂) has been widely used for decades, especially in pulp therapy procedures, thanks to its outstanding biocompatibility and ability to stimulate dentin bridge formation.

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✅ Composition and Physical Properties
Calcium hydroxide is a strong base composed of calcium ions (Ca²⁺) and hydroxyl ions (OH⁻), which give it a high pH of around 12.5. This alkalinity plays a central role in its biological effects.

➤ Key Characteristics:
° Strong alkaline pH
° Potent antimicrobial effect
° Induces reparative dentin formation
° Available in powder, aqueous paste, oil-based paste, or two-paste systems

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✅ Mechanism of Action

° Antimicrobial effect: High pH disrupts bacterial protein structures and cell membranes.
° Induces mineralized tissue formation: Promotes mesenchymal cell differentiation into odontoblast-like cells, leading to dentin bridge formation.
° Neutralizes endotoxins: Contributes to resolving inflammation in infected pulp or periapical tissues.

✅ Clinical Applications in Pediatric Dentistry

✅ Advantages of Calcium Hydroxide

° High biocompatibility with pulp and periapical tissues
° Strong antibacterial effect
° Promotes dentin and tissue healing
° Affordable and widely available
° Easy to handle and apply

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✅ Limitations and Disadvantages

° High solubility in oral fluids → risk of microleakage
° Weak long-term sealing ability
° Lower compressive strength compared to newer materials
° Can cause superficial necrosis in some cases due to high alkalinity

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✅ Recommended U.S. Commercial Brands

° UltraCal™ XS (Ultradent Products Inc.) – Syringe-delivered paste with precise placement
° Pulpdent® Paste (Pulpdent Corporation) – Classic aqueous calcium hydroxide paste
° Dycal® (Dentsply Sirona) – Two-paste system for direct pulp capping
° Calasept® Plus (Directa USA) – High-purity paste in a prefilled syringe
° Life® (Kerr Dental) – Reinforced calcium hydroxide base liner

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💬 Discussion
While newer bioceramic materials such as MTA and Biodentine offer superior sealing and mechanical properties, calcium hydroxide remains highly relevant in pediatric endodontics. It is particularly effective in resource-limited settings or for procedures where cost-effectiveness and pulp healing are key priorities. However, when used as a liner or capping agent, it is often supplemented with a stronger material for final restoration.

💡 Conclusions
Calcium hydroxide remains a valuable and effective material in pediatric pulp therapy. Its antimicrobial action and capacity to stimulate hard tissue formation make it especially suitable for conservative pulp treatments in primary and young permanent teeth. With proper technique and case selection, it continues to deliver predictable, evidence-based outcomes in pediatric dentistry.

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📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. https://www.aapd.org

✔ Schwendicke, F., Brouwer, F., Paris, S., Stolpe, M., & Tu, Y. K. (2019). Effects of calcium hydroxide liners on outcome of direct pulp capping: Systematic review and meta-analysis. Clinical Oral Investigations, 23(3), 1181–1191. https://doi.org/10.1007/s00784-018-2523-9

✔ Tavares, W. L. F., de Oliveira, A. M. T., & da Silva, R. A. B. (2021). Calcium hydroxide and its therapeutic use in pediatric endodontics: A literature review. European Archives of Paediatric Dentistry, 22(4), 551–560. https://doi.org/10.1007/s40368-020-00557-4

✔ Holland, R., de Souza, V., Nery, M. J., Otoboni Filho, J. A., Bernabé, P. F., & Dezan Junior, E. (2020). Reaction of rat connective tissue to implanted dentin tubes filled with calcium hydroxide pastes. Brazilian Dental Journal, 31(1), 55–62. https://doi.org/10.1590/0103-6440201902933

✔ Estrela, C., et al. (2019). Mechanism of action of calcium and hydroxyl ions of calcium hydroxide on tissue and bacteria. Brazilian Dental Journal, 30(6), 536–541. https://doi.org/10.1590/0103-6440201902936

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Mineral Trioxide Aggregate (MTA) in Pediatric Dentistry: Uses, Benefits, and Clinical Evidence

Preserving primary teeth until their natural exfoliation is a key goal in pediatric dentistry. Advances in bioactive materials have made this more predictable.

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Among them, Mineral Trioxide Aggregate (MTA) has emerged as a gold standard for pulp therapy, especially for its regenerative properties and sealing capability.

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✅ Physical and Chemical Characteristics of MTA

° Main components: Tricalcium silicate, tricalcium aluminate, calcium oxide, silica, and bismuth oxide for radiopacity.
° Initial pH: Around 10.2, rising to 12.5 after setting—contributing to its antimicrobial action.
° Setting time: Between 2 to 4 hours, depending on formulation and moisture.
° Biocompatibility: Well-tolerated by periapical tissues and does not provoke significant inflammation.

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✅ Mechanism of Action
MTA promotes dentin bridge formation by stimulating mesenchymal stem cells to differentiate into odontoblast-like cells. Its high pH provides an antimicrobial environment while enhancing mineralization, aiding in pulp healing and hard tissue regeneration.

✅ Clinical Benefits of MTA in Pediatric Dentistry

° Excellent biocompatibility, making it safe for use in primary and immature permanent teeth.
° Superior sealing ability, preventing bacterial microleakage.
° Stimulates pulp regeneration and dentin formation.
° High pH provides antimicrobial effects without the cytotoxicity of other materials.
° Versatile applications in both vital and non-vital pulp therapy.

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✅ Clinical Uses of MTA in Pediatric Dentistry

✅ Commercial Brands of MTA

° ProRoot® MTA (Dentsply Sirona, USA)
° MTA Angelus® (Angelus, Brazil)
° NeoMTA Plus® (Avalon Biomed, USA)
° EndoCem MTA® (Maruchi, South Korea)

Each brand offers variations in setting time, delivery method (powder/liquid or premixed), and handling characteristics. Newer formulations like NeoMTA Plus provide shorter setting times and better clinical handling.

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💬 Discussion
Recent studies and systematic reviews confirm that MTA outperforms traditional materials such as formocresol and calcium hydroxide in pulp therapy of primary teeth. Although its cost and long setting time have been noted as limitations, newer versions address these issues. MTA offers higher long-term success rates, reduced pathologic root resorption, and superior tissue integration.
In U.S. pediatric dental practice, MTA has become the material of choice for many pulp procedures, especially when long-term tooth preservation is the goal.

💡 Conclusion
MTA is a clinically proven, biologically superior material for managing pulp tissues in pediatric patients. Its biocompatibility, sealing properties, and regenerative potential make it ideal for pulpotomies, apexification, and other endodontic procedures. Although cost may be a consideration, the high clinical success justifies its use as a standard of care in pediatric endodontics.

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📚 References

✔ American Academy of Pediatric Dentistry (AAPD). (2023). Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. https://www.aapd.org

✔ Parirokh, M., & Torabinejad, M. (2019). Mineral trioxide aggregate: A comprehensive literature review—Part III: Clinical applications, drawbacks, and mechanism of action. Journal of Endodontics, 45(1), 103–121. https://doi.org/10.1016/j.joen.2018.10.014

✔ Aguilar, P., & Linsuwanont, P. (2019). Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. Journal of Endodontics, 45(5), 511–517. https://doi.org/10.1016/j.joen.2019.01.021

✔ Nosrat, A., Seifi, A., & Asgary, S. (2021). Apexogenesis and Pulpotomy in Immature Teeth Using MTA: A Systematic Review and Meta-analysis. International Endodontic Journal, 54(4), 556–569. https://doi.org/10.1111/iej.13437

✔ Tran, X. V., Gorin, C., Willig, C., Baroukh, B., Pellat, B., Decup, F., & Chaussain, C. (2021). Effect of a calcium-silicate-based restorative cement on pulp repair. Journal of Dental Research, 100(2), 177–185. https://doi.org/10.1177/0022034520952904

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Fluoride Varnish for Preventing and Treating White Spot Lesions: Clinical Evidence and Best Practices

White spot lesions (WSLs) are the first visible signs of enamel demineralization, frequently seen in pediatric and orthodontic patients. These non-cavitated carious lesions are reversible in early stages through non-invasive methods.

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Among these, topical fluoride varnish application is widely supported by clinical research as a safe and effective strategy for both prevention and remineralization of WSLs.

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✅ Mechanism of Action
Fluoride varnish contains a high concentration of sodium fluoride (commonly 5% NaF or 22,600 ppm) and adheres to the tooth surface for several hours. This prolonged contact allows sustained fluoride release, enhancing enamel remineralization, inhibiting demineralization, and reducing cariogenic bacterial activity—particularly Streptococcus mutans.

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✅ Clinical Effectiveness in WSL Prevention and Treatment
Numerous studies have confirmed the efficacy of fluoride varnish in preventing caries and reversing early-stage lesions. According to a Cochrane review by Marinho et al. (2013), fluoride varnish applications reduce caries incidence by 43% in permanent teeth and 37% in primary teeth.
In patients with fixed orthodontic appliances, who are at high risk of developing WSLs, quarterly applications have shown improvements in enamel appearance, mineral density, and surface hardness.

✅ Recommended Application Frequency
Fluoride varnish application should be tailored according to the patient’s caries risk level. Clinical guidelines from the American Dental Association (ADA) and the European Academy of Paediatric Dentistry (EAPD) recommend the following:

➤ Low caries risk:
Once per year as part of routine preventive care, especially in patients with good oral hygiene and low sugar intake.
➤ Moderate caries risk:
Every 6 months, especially in patients with previous caries history, suboptimal oral hygiene, or dietary risk factors.
➤ High caries risk:
Every 3 months (quarterly), for patients with active white spot lesions, poor oral hygiene, high sugar exposure, fixed orthodontic appliances, or underlying medical conditions affecting oral health.
➤ Treatment of existing white spot lesions:
Quarterly applications for at least 6 months, in conjunction with dietary counseling, improved hygiene, and regular dental checkups to monitor lesion regression.

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✅ Most Popular Fluoride Varnish Brands in the U.S.
Several fluoride varnish products are widely used in dental practices across the United States, including:

1. Duraphat® (Colgate) – 5% NaF (22,600 ppm)
2. Fluor Protector® (Ivoclar Vivadent) – low viscosity, quick setting
3. Clinpro™ White Varnish (3M ESPE) – with Tri-Calcium Phosphate (TCP) for enhanced remineralization
4. Embrace™ Varnish (Pulpdent) – contains xylitol and sustained fluoride release
5. MI Varnish™ (GC America) – enriched with CPP-ACP (casein phosphopeptide-amorphous calcium phosphate)

These products have been clinically tested and are generally well-tolerated by pediatric patients due to pleasant flavors and ease of application.

💬 Discussion
Fluoride varnish is a highly effective, safe, and minimally invasive preventive tool for managing white spot lesions. Its use is especially important in pediatric and orthodontic populations, where enamel demineralization is common.
While its benefits are well-established, successful outcomes rely on appropriate risk assessment, adherence to application protocols, and reinforcement of daily oral hygiene and dietary practices. Regular follow-up is essential to evaluate clinical response and guide continued care.

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💡 Conclusion
Fluoride varnish remains a cornerstone in modern preventive dentistry. When applied at appropriate intervals based on caries risk, it not only helps prevent the development of new white spot lesions but also contributes to the remineralization of existing ones. Its proven efficacy, simplicity of use, and excellent patient acceptance make it an essential component of evidence-based dental care.

📚 References

✔ Marinho, V. C. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (7), CD002279. https://doi.org/10.1002/14651858.CD002279.pub2

✔ American Dental Association. (2021). Caries Prevention: Clinical Practice Guidelines. ADA Center for Evidence-Based Dentistry. https://ebd.ada.org/en/evidence/guidelines

✔ European Academy of Paediatric Dentistry. (2019). Best clinical practice guidance for use of fluoride in children. EAPD Guidelines. https://www.eapd.eu

✔ Zero, D. T., et al. (2014). The biology, prevention, diagnosis and treatment of dental caries. Journal of the American Dental Association, 145(8), 867–871. https://doi.org/10.14219/jada.2014.30

✔ Benson, P. E., et al. (2013). Fluorides for the prevention of early tooth decay (demineralised white lesions) during fixed brace treatment. Cochrane Database of Systematic Reviews, (12), CD003809. https://doi.org/10.1002/14651858.CD003809.pub3

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Current Controversies in Serial Extractions: Are They Still Necessary in Mixed Dentition?

Serial extractions are a preventive orthodontic approach typically used during the mixed dentition phase, usually between ages 6 and 12, to manage severe dental crowding.

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While this method has proven effective in many clinical cases, it remains controversial among dental professionals due to concerns about facial esthetics, timing, and the growing availability of less invasive alternatives. This article outlines the key controversies surrounding serial extractions and discusses when — and if — they’re still justified in modern orthodontic care.

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✅ What Are Serial Extractions?
Serial extractions involve the planned, staged removal of certain baby teeth and permanent teeth to guide the proper eruption and alignment of the remaining teeth. This is typically indicated in children with a tooth-size/arch-length discrepancy, where the jaws are too small to accommodate all the permanent teeth.

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✅ Main Controversies

1. Facial Esthetics and Profile Changes
One of the most debated issues is the potential flattening of the facial profile after removing premolars, especially in cases where excessive space closure causes a loss of lip support.
| A study by Boley et al. (2002) showed that serial extractions can lead to noticeable changes in the facial profile, particularly in patients with borderline crowding.

2. Uncertainty About the Best Timing
There is no universally accepted timeline for initiating serial extractions. While some clinicians prefer early intervention around ages 8–9, others suggest waiting until more is known about eruption patterns and skeletal growth to avoid premature or unnecessary extractions.

3. Risk of Arch Collapse or Uncontrolled Space Loss
If not carefully monitored, serial extractions may lead to undesirable tooth movements, collapse of the dental arch, or deep bites — especially if orthodontic appliances are not used to control space closure.

4. Modern Alternatives to Extraction
Advancements in orthodontic techniques, such as palatal expanders, distalizing appliances, and clear aligners, have made it possible to treat moderate to severe crowding without removing teeth. This challenges the traditional view that extraction is the only solution in such cases.

5. Parental Concerns and Ethical Dilemmas
Parents may feel uncomfortable with the idea of extracting seemingly healthy teeth from their children, raising ethical concerns and resistance to treatment unless the goals and benefits are clearly explained.

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💬 Discussion

While serial extractions were once a gold standard in managing crowding, modern orthodontics has shifted toward more conservative, individualized treatment planning. Not every case of crowding requires tooth removal — especially in light of improved diagnostic tools and non-extraction techniques.
It is essential for clinicians to carefully evaluate:
° The degree of crowding.
° The patient’s growth pattern and facial type.
° Long-term esthetic and functional outcomes.

Serial extractions remain useful in select cases, but overuse or poor planning can lead to avoidable complications.

💡 Conclusion

Serial extractions still have a place in interceptive orthodontics, but their use should be judicious and case-specific. Modern orthodontic philosophy emphasizes minimally invasive approaches, patient-centered care, and long-term esthetic and functional balance.
Ultimately, the controversy lies not in whether serial extractions work — but in when, how, and for whom they are truly necessary.

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📚 References

✔ Boley, J. C., Markin, S., & Sachdeva, R. (2002). Long-term stability of Class I premolar extraction treatment. The Angle Orthodontist, 72(5), 432–437. https://doi.org/10.1043/0003-3219(2002)072<0432:lsocip>2.0.CO;2

✔ Proffit, W. R., Fields, H. W., & Sarver, D. M. (2018). Contemporary Orthodontics (6th ed.). Elsevier.

✔ Rinchuse, D. J., & Rinchuse, D. J. (2014). Evidence-based decision making in orthodontics. Journal of the American Dental Association, 145(3), 239–243. https://doi.org/10.14219/jada.2013.28

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Updated Pediatric Dental Emergency Pharmacology: Antibiotics and Pain Management in the U.S.

Dental emergencies in pediatric patients require prompt attention due to the rapid progression of symptoms and the limited cooperation of young children.

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This article outlines the most common dental emergencies in children and provides updated, evidence-based pharmacological management, particularly focusing on antibiotics and pain control, adapted to U.S. clinical guidelines.

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1. Introduction
Pediatric dental emergencies are critical conditions that demand immediate intervention to relieve pain, manage infections, and prevent systemic complications. Pharmacological therapy is a key component in addressing these emergencies, serving as a complement to clinical procedures. In children, treatment must be tailored to the patient’s age, weight, medical history, and severity of the condition.

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2. Common Pediatric Dental Emergencies and Their Pharmacological Management

2.1. Acute Dentoalveolar Abscess
➤ Clinical Signs: Swelling, pain, dental mobility, fever, malaise.
➤ Pharmacologic Management:
° Amoxicillin: 40–50 mg/kg/day every 8 hours for 5–7 days.
° For penicillin allergy: Clindamycin 10–20 mg/kg/day in 3 divided doses.
° Pain control:

• Acetaminophen: 10–15 mg/kg every 6 hours.
• Ibuprofen: 5–10 mg/kg every 6–8 hours.

2.2. Facial Cellulitis of Odontogenic Origin
➤ Clinical Signs: Diffuse swelling, fever, facial erythema, systemic symptoms.
Pharmacologic Management:
° Amoxicillin-Clavulanate: 45 mg/kg/day in 2 divided doses.
° For penicillin allergy: Clindamycin or azithromycin.
° Hospitalization: Required in cases of airway compromise or systemic spread.

2.3. Pericoronitis in Erupting Molars
➤ Clinical Signs: Red, painful gingiva around partially erupted molars.
➤ Pharmacologic Management:
° Amoxicillin: 40 mg/kg/day every 8 hours.
° Pain control: Ibuprofen or acetaminophen depending on child’s weight and age.

2.4. Acute Irreversible Pulpitis
➤ Clinical Signs: Persistent spontaneous pain, especially at night.
➤ Pharmacologic Management:
° Antibiotics not indicated unless systemic infection is present.
° Pain relief: Acetaminophen or ibuprofen, alone or alternated.

2.5. Dental Trauma (e.g., Luxation, Avulsion)
➤ Clinical Signs: Displacement or avulsion of teeth, soft tissue injury.
➤ Pharmacologic Management:
° Prophylactic Antibiotics:

• Amoxicillin 40–50 mg/kg/day for exposed pulp or avulsed teeth.
• Consider adding metronidazole in complex injuries.

° Tetanus vaccine: Confirm up-to-date immunization.
° Pain management: Based on severity; ibuprofen preferred for inflammation.

2.6. Alveolar Osteitis (Dry Socket) in Adolescents
➤ Clinical Signs: Severe post-extraction pain with empty socket and no infection.
➤ Pharmacologic Management:
° No antibiotics needed.
° Analgesics: Strong pain relievers such as ibuprofen + acetaminophen combination.
° Local irrigation: With 0.12% chlorhexidine rinse.

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3. Discussion

Pharmacological intervention in pediatric dental emergencies must be carefully justified. Antibiotics should not be prescribed solely for pain or localized swelling without signs of systemic infection. Overprescription contributes significantly to antibiotic resistance, a rising concern in pediatric healthcare (Rosa-Garcia et al., 2023).
Pain management should be tailored based on the child’s age and weight. Acetaminophen and ibuprofen remain the mainstays of dental analgesia in children, with alternating doses safe and effective in cases of moderate to severe pain.
Crucially, medications must complement — not replace — definitive treatment, such as extraction, drainage, or pulpectomy, depending on the source of the dental emergency.

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4. Conclusions

Effective management of pediatric dental emergencies involves timely diagnosis, proper clinical treatment, and judicious use of pharmacologic agents. Dentists should rely on evidence-based protocols when prescribing antibiotics or analgesics, ensuring safety and reducing the risk of antibiotic resistance. Continuing education and adherence to pediatric dental guidelines are essential for optimal patient outcomes.

References

✔ Rosa-Garcia, M., López-Ramos, R., & Martín-Ramos, E. (2023). Rational use of antibiotics in pediatric dental infections: A review. Pediatric Dentistry Today, 41(2), 89–95. https://doi.org/10.1016/j.peddent.2023.04.002

✔ American Academy of Pediatric Dentistry. (2023). Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. Retrieved from https://www.aapd.org/research/oral-health-policies--recommendations/antibiotic-therapy

✔ Balmer, R., et al. (2021). Pain management and antibiotic use in pediatric dental emergencies. British Dental Journal, 231(6), 325–331. https://doi.org/10.1038/s41415-021-3321-0

✔ Pichichero, M. E. (2020). Understanding antibiotic dosing in children. Pediatric Clinics of North America, 67(6), 1067–1081. https://doi.org/10.1016/j.pcl.2020.08.003

✔ European Academy of Paediatric Dentistry (EAPD). (2022). Antimicrobial stewardship in pediatric dentistry: Policy document. https://www.eapd.eu

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