The Japanese Journal of Pediatric Dentistry
Online ISSN : 2186-5078
Print ISSN : 0583-1199
ISSN-L : 0583-1199
Volume 46, Issue 5
Displaying 1-17 of 17 articles from this issue
  • Toshihiro Yoshihara
    2008 Volume 46 Issue 5 Pages 497-500
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    In our recent studies, the effect of maternal deprivation (MD) in the early postnatal period on the function of the hypothalamus-pituitary-adrenocortical (HPA) axis in adulthood. The following results were obtained.
    (1) MD in the postnatal period induces long-term effects on stress responsibility of the HPA axis. Furthermore, a critical age of the pup at the time of MD exists as well as a critical length of MD for inducing these effects.
    (2) It was suggested that the long-term effects of MD on the HPA axis might be mediated by decreasing negative feedback regulation in the hippocampus of the HPA axis.
    (3) Methamphetamine-induced extension of the period of the clock gene Per I expression was more enhanced in the mice subjected to MD in the early postnatal period than control.
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  • Michiyo Matsumoto
    2008 Volume 46 Issue 5 Pages 501-504
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    The quorum sensing system of Streptococcus mutans is mediated by the competence stimulating peptide CSP, whose precursor is encoded by the comC gene. A comC mutant of strain GS 5 exhibited enhanced antimicrobial sensitivity to a wide variety of different agents. However, the addition of exogenous CSP did not complement this phenotype, thus it was determined that increased tetracycline sensitivities resulted from the repression of the putative bacteriocin immunity protein gene bip, which is located immediately upstream from comC. We also found that inactivation of bip or smbG, other bacteriocin immunity protein genes present within the smb operon in S. mutans GS 5, affected antimicrobial sensitivity to a variety of antimicrobial agents. Furthermore, both the bip and smbG genes were upregulated in the presence of low concentrations of tetracycline, and also induced during biofilm formation relative to planktonic cells. These results are the first to show that the antimicrobial sensitivity of a bacterium can be modulated by some of the putative bacteriocin immunity proteins expressed by the organism.
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  • Yasunori Sasaki
    2008 Volume 46 Issue 5 Pages 505-510
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    In pediatric dentistry, it is important to investigate and utilize the infants' latent abilities for craniofacial growth and development. Cleft lip with cleft palate is one of the serious types of congenital anomaly with the highest frequencies in the craniofacial region, and need a long period of dental management during growth and development. However, how secondary palate formation is affected in cleft lip remains poorly understood. To examine the effects of presurgical nasoalveolar molding (PNAM) on palatal growth with cleft lip under some conditional differences, four patients with unilateral cleft lip and palate were selected. PNAM treatment resulted in a positive effect depending on the length of the treatment. The study suggests that an earlier start of PNAM treatment in the neonatal period could possibly provide more effective results for the growth promotion of craniofacial growth including palatal growth with cleft lip. In model mice with cleft lip and palate (CL/Fr strain), cleft palate follows reduced cell proliferation of secondary palatal mesenchyme, however, the palates successfully fused in palatal organ culture. These palatal latent abilities indicated by our research might be useful not only for clarifying the mechanism of craniofacial growth and development but also for counseling and informed consent about early treatment for infants with cleft lip and palate.
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  • Wataru Morita, Takehiko Shimizu, Takahide Maeda
    2008 Volume 46 Issue 5 Pages 511-516
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    EL/Sea mice have 100% incidence of the defect of the third molars (M3), and are used as an animal model for the study of missing teeth.
    We previously have reported that a region between 123.1 Mega base pair (Mbp) and 136.9 Mbp in chromosome 3 was involved in the defect of M3 of EL, and named this gene absence of the third molars (am3).
    The purpose of the present study is to narrow the am3 region causing the absence of M3 in EL/Sea mice, and to identify the major candidate gene.
    For this reason we generated EL/Sea congenic mice with the am3 region in which the restricted interval of chromosome 3 was replaced by a MSM/Msf-derived homologue.
    We also examined the location of chromosomal recombination in the am3 region by newly produced DNA maker.
    By comparing genotypes and phenotypes of EL congenic mice, we clearly mapped the am3 locus within an approximately 1000 kbp region between 130.7 Mbp and 131.7 Mbp.
    This region includes 5 genes, Lefl, Hadh, Cyp2u1, Sgms2 and Papss 1 as candidate genes for am3.
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  • Katsuyuki Kozai, Junji Suzuki, Yoshimori Uchikawa, Shigenari Kimoto, Y ...
    2008 Volume 46 Issue 5 Pages 517-523
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    To survey the current state of the education of Pediatric Dentistry in our country, a questionnaire investigation was done to all Dental Colleges and School of Dentistry in Universities. The questionnaire consisted of three fields, such as lecture of Pediatric Dentistry, basic laboratory practice and basic clinical practice. According to the questionnaire, the following things were confirmed. All Universities still have the syllabus concerning Pediatric Dentistry, except for one University. The average hours of lecture was 55 hours. The University with the longest course hours was 6 times higher than the shortest University. The average hours of basic laboratory practice was 35 hours. The private Universities were significantly longer than national and public Universities. While, the period of basic clinical practice was similar in all Universities, however it started 6 months earlier in private Universities compared with national and public Universities. Moreover, there were differences in intervention levels of students to the treatment of the patients and evaluation procedures of basic clinical practice in Universities.
    In the present study, it was confirmed that the education of Pediatric Dentistry varied considerably between Universities. Especially, the average hours of lecture and basic laboratory practice were longer in private Universities compared to national and public Universities. Furthermore, basic clinical practice starts significantly earlier in private Universities.
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  • Mie Sonomoto, Michiharu Daito
    2008 Volume 46 Issue 5 Pages 524-532
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    To evaluate unpleasant stress quickly and to objectively grasp whether or not there is a case which brings about hinderance to the dental treatment because of unpleasant stress and the degree to which patients are stressed in dental treatment is an important problem. In this research, we measured the saliva activation of the alpha-amylase on the chair side and did a comparative examination of the stress of the ordinary children and the handicapped children in dental treatment. Osaka Dental University attachment hospital pediatric dentistry and the disabled person dentistry has 58 ordinary children and 34handicapped children from 2 to 15 years old. We measured wether the alpha-amylase is activated before and after treatment with the colorimeter method using the portable-type amylase activated analyzer (made by Yamaha Motor Corporation). For the ordinary children, by the maladaptive behavior, there is significant difference (p<0.05) in the salivary alpha-amylase activity.
    On the other hand, an intentional change wasn't admitted by the ha ndicapped children. The handicapped children had salivary alpha-amylase activity rise significantly (p<0.05) between “before treatment”and “after treatment”. Also, because the activated change of the alpha-amylase wasn't admitted when the various treatment contents were classified, it was difficult to evaluate the stress of the handicapped children quantitatively using the saliva activation of the alpha-amylase. As a way of objectively evaluating the stress of the ordinary children, the salivary alpha-amylase activity was useful. The activated measurement of the alpha-amylase of the saliva was also useful. It is thought that the new biomarker which changes with the saliva activation of the alpha-amylase is necessary for there to be a mechanism of replying to stress and the possibility that the reactivity is different between ordinary children and handicapped children and to evaluate the stress of the handicapped children objectively.
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  • Yousuke Ga, Yoshizou Okamoto, Atuko Baba, Wataru Motokawa, Shigeki Mat ...
    2008 Volume 46 Issue 5 Pages 533-541
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    Recently, the laser application for dental clinics has become more popular in various clinical cases such as the prevention of dental caries, conservative dentistry, and ware surgical, etc. A structure with a bumpy surface was presented after laser irradiation. The effect was called “laser etching”. In the dental clinical case, the enamel was strengthened after the laser irradiation followed by the fissure sealant plugging. Thus, a higher caries preventive effect could be expected for the improvement of the acid residence of the tooth. However, it was not decided to be a current state in the evaluation of the laser etching. Then, we examined the effect of CO2 laser irradiation on the adhesive strength and observed the adhesive interface and the surface microstructure by digital microscope and SEM. We also did crystallographic analysis of the enamel after laser irradiation by X-ray diffraction and FT-IR analysis. As a result, the α-TCP formed in the enamel surface with the laser irradiation. It was found that the adhesiveness of the fissure sealant significantly decreased after the laser irradiation compared with the phosphate etching.
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  • First Visit to the Pediatric Dental Clinic of our University (2002-2006)
    Mikako Yoshida, Tomohisa Ichikawa, Kenichi Suse, Kimiko Nakagawa, Seik ...
    2008 Volume 46 Issue 5 Pages 542-547
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    The purpose of this study was to investigate the actual conditions of initial visit patients during the last 5 years (2002-2006) at the Pediatric Dental Clinic of our Meikai University and compare to the previous investigation (the first investigation: 1992-1996, the second investigation: 1997-2001).
    The following results were obtained:
    1. The mean number of patients visiting initially was 569, and it increased from the previous investigations (the first investigation; 324, the second investigation; 462).
    2. The 3-year-old children showed the highest rate (14%) among the patients making then first visit. Patient under 6-years of age amounted to about 60% of all the outpatients and this tendency was the same as the previous investigations.
    3. An investigation concerning the distance from the home to the clinic showed that most of the outpatients (30%) were within the 5 km range. About 25% of them however were from a distance of over 15 km.
    4. The chief complaint of dental caries and toothache appeared in about 50% of the patients and this was the same as the previous investigations.
    5. The mean numbers of df and DMF during the five years showed about the same score but these had a tendency to decrease to a smaller score than that of the previous investigations.
    6. The percent of patients referred from the other general practitioner (33.4%) increased in the second investigation (25%). The 3-year-old children as the generation and 5-10 km range as the distance from the house to clinic were the most abundant among the patients referred.
    7. The total number of disabled children amounted to 91, and amounted to about 3.2% of all of the outpatients.
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  • Norimasa Fujita, Masaharu Takeyasu, Michiharu Daito
    2008 Volume 46 Issue 5 Pages 548-554
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    In this study, we investigated the in vitro ability of rat pulp cells to differentiate into the chondrocyte lineage. Applying an in vitro differentiation induction system used in human bone marrow, induction of differentiation into chondrocytes was attempted. We hypothesized that, like bone marrow cells, cells in the pulp have pluripotency, and have reported their ability to differentiate into osteoblasts and nerve cells. We have also reported on the properties of stem cells in the pulp. In this study, we attempted to induce pulp cells to differentiate into chondrocytes. Between the initiation of primary culture and differentiation induction, there were no cells that expressed AGC 1 and COL 2 A 1 in the pulp. Therefore, chondrocytes were shown to be absent from pulp cells. In addition, mRNA expression assay revealed that the expression of AGC 1 was increased about 1.67-fold after differentiation induction compared with before differentiation induction, while the expression of COL 2 A 1was shown to be 1.62-fold higher than before differentiation induction in the mRNA expression assay. The increase in the number of alcian blue-positive cells as well as the increased expression of AGC 1 and COL 2 A 1 in mRNAs after differentiation induction suggests that pulp cells were in the process of differentiating into the chondrocyte lineage. These results suggest that rat pulp cells might have pluripotency. These pulp stem cells with such pluripotency will be highly useful for tissue engineering and regenerative medicine in the future.
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  • Yuri Fujiharal
    2008 Volume 46 Issue 5 Pages 555-565
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    Calicineurin(CN) is a Ca2+/calmodulin-dependent serine/threonine protein phosphatase, and consists of catalytic subunit CNA and regulatory subunit CNB. CN plays an important role in intracellular signal pathway leading to the induction of long-term depression, a form of synaptic plasticity induced by NMDA-type glutamate receptor activation. In the brain, CN is composed of CNAα, CNAβ, and CNB 1 subunits, but their cellular expression and synaptic distribution have not been explored yet.
    In the present study, I investigated expression of CNAα, CNAβ, and CNB l subunits in the layer 4 of the mouse somatosensory cortex, where whisker-related patterning, known as barrel, is formed. All three CN subunits exhibited similar cellular and subcellular distributions. Immunofluorescence visualized that the three CN subunits were distributed as tiny puncta or clusters in the cell body, dendrites, and neuropil. In double immunofluorescence for each CN subunit and MAP 2, a marker for neuronal cell bodies and dendrites, CNA α, CNAβ, and CNB 1 subunits were highly distributed on the surface of and inside MAP 2-positive dendrites. In addition, all CN subunits were positioned very close to VGLUT 1-positive excitatory terminals coming from the cortex. Low to moderate levels were found in dendrites of GAD 67-posotive inhibitory interneurons. In contrast, CNAα, CNAβ, and CNB 1 subunits showed no apparent overlap with VGLUT 2, VGAT or GLT 1, which are markers of excitatory terminals coming from the thalamus, inhibitory terminals, and astroglia, respectively. By immunoelectron microscopy using the silver-enhanced immunogold technique, metal particles representing CNAα, CNAβ, and CNB 1 subunits were detected at the highest level in spines and dendrites of excitatory neurons. Dendrites of inhibitory interneurons, which were identified by the lack of dendritic spines and the presence of asymmetrical synapse on dendritic shafts, were labeled about two times lower than those of excitatory neurons. Labeling in nerve terminal was detected but was low as compared to neuronal dendrites, and that in non-terminal portion of axons and glial elements were very low or negative.
    This study shows that calcineurin is distributed in various neural elements with particular enrichment in postsynaptic elements of excitatory neurons. Because synaptic plasticity is induced following the activation of NMDA receptors on the postsynaptic membrane, the present findings provide the molecular-anatomical evidence that CN indeed constitutes intracellular signaling pathway downstream to NMDA receptors. Considering the essential role of NMDA receptors in barrel formation, CN enriched in postsynaptic elements of excitatory neurons appears to also play a role in activity-dependent synaptic refinement in the developing somatosensory cortex.
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  • Corelationship between oral health conditions and the density of volatile sulfur compounsd (VSCs)
    Masato Saitoh, Kozue Sato, Yoshihito Kurashige, Daisuke Noro, Tae Kura ...
    2008 Volume 46 Issue 5 Pages 566-569
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    OBJECTIVE: Although the density of volatile sulfur compounds (VSCs) has been evaluated for oral malodor in adults, little information on the levels in children have been reported, thus far. The present study investigated the relationship between oral health conditions and the density of VSCs in children aged 4-6 years.
    STUDY DESIGN: The study included a total of 59 kindergartners aged 4-6 years (29 boys and 30girls) in Hokkaido. Oral malodor assessments were performed by a portable gas chromatography (Oral Chroma®, Abilit, Japan). The number of decayed and filled primary teeth (df) and plaque attached rates were determined prior to measurement on the density of VSCs. The correlation between the number of df and the density of VSCs was determined by the Person Product Moment Correlation Coefficient. Plaque attached rates, gender differences and the density of VSCs were analyzed using a one-way ANOVA and Scheffe's test. A statistically significant difference was accepted at the p<0.05levels.
    RESULTS: The density of VSCs was significantly higher in the high plaque-attached group than in the low plaque-attached group. There was no significant correlation between the density of VSCs and the number of df. There was no significant gender difference in the density of VSCs. CONCLUSIONS: These results indicate that oral malodor may be associated with the amount of plaque attached to the primary teeth in children.
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  • Juan Han, Rui Yao, Meng Li, Chieko Yokoya, Takashi Asano, Nobuo Yokoya ...
    2008 Volume 46 Issue 5 Pages 570-577
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    OBJECTIVE: This study was to investigate the maternal environmental effects in mice with spontaneous cleft lip and palate (CLP). METHODS: As parent A; A/WySn, CLP-susceptible and B 6; C 57 BL/6 CLP-resistant strain mice, F1(A×B6)andF1(B6×A) mice were obtained in which the mating mother was A strain and B 6 strain, respectively. N 2 backcross mice were obtained from A×F1(A×B6)and A×F1(B 6×A) in which the mating mother was both A strain and F1(A×B6)×A and F1(B6×A)×Ain which the mating mother was both F 1 strain. A caesarean section was done on the 17th and 18th gestational day at which time the implantation, resorption and litter size were recorded for F 1 and A as mother, respectively. Each alive N 2 backcross fetus was checked for the presence of CLP. RESULTS: 430,551,667 and 1071 N 2 backcross mice for A×F1(A×B6), A×F1(B6×A), F1(A×B6)×AandF1(B6×A)×A groups were obtained, respectively. The resorption rate in the N2[A×F1] group was significantly higher than the N2[F1×A] group. The fetus survival rate in the N 2[F 1xA] group was significantly higher than the N2[A×F1] group. The incidence rates of bilateral and unilateral CLP in the N2[A×F1] group were significantly higher than the N2[F1×A] group. There was a higher frequency of bilateral CLP for N2[AxF1] group than unilateral CLP. The pregnancy rate of the fetuses having CLP in A/WySn mothers was significantly higher than the F 1 mothers. CONCLUSION: These results suggested that the occurrence of CLP was influenced by maternal environmental effects during pregnancy. A/WySn mother showed a poor environment effect for the embryos development.
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  • Nasal Skin Temperature and Perception Levels and Psychological States
    Mikiko Kumamoto, Mototsugu Yanagida, Sadahiro Hotomi, Ayami Nishida, S ...
    2008 Volume 46 Issue 5 Pages 578-584
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    In dental treatment of children who are in development of communication ability, the dentists must precisely grasp the psychological state of patients. Although the relationship between nasal skin temperature and psychological state has been reported, their studies experimented only in stress condition. In the recovery stage, the relationships still have not been investigated. Therefore, in this study, we used ice stimulation to subjects' palms as a stressor and tried to clear the relationships between nasal skin temperature and psychological state in the recovery stage from the stress condition. The perception levels and anxiety levels during the experiment period were examined using Time series Visual Analog Scale (T-VAS) and state-trait anxiety inventory-form (STAI) respectively. The nasal skin temperature was measured with thermography every 5 minutes. As a result, when levels of pain and anxiety increased by the ice stimulation, the nasal skin surface temperature decreased. On the other hand, when the pain and anxiety were taken away after the ice stimulation was stopped, the nasal skin temperature increased and reached the same temperature as before the stimulation. These results suggest strongly that the psychological state of pain and anxiety could be predicted by the measurement of nasal skin temperature.
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  • Toyo-o Ichihashi, Tetsu Okano, Tsuguko Kondo, Hiromi Nakahara, Mitsuo ...
    2008 Volume 46 Issue 5 Pages 585-601
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    Changes in pronunciation according to the growth and development of children were examined by the frequency analysis on the continuation vowel and the VCV syllable word following a vowel. Thirty-six children from 3 to 8 years old, in which each age group consisted of three boys and three girls, participated in the examination.
    Results obtained were as follows:
    1) No significant difference on both the continuation of vowels /a/∼/o/ and the VCV syllable word following a vowel was found between genders.
    2) Though the level of fundamental frequency of F 0 and F 1 for the first formant of the vowel were significantly decreased with age, significant differences were found in the frequency of F 1 and F 2for the second formant whereas a difference was shown in F 0 among 5 vowels.
    3) Among 25 VCV syllable words following a vowel, a significant correlation between age groups and the values of F 1, F 2, and F 2-F 1 discrepancy were found dependently on the VCV syllable words.
    4) In the test of distinctness degree for articulation, [s] lines and [r] lines were indistinct in the lower age group but improved with age.
    5) No significant relation was found between the F 1, F 2, and F 2-F 1 for the continuation vowel and the primary intercanine width of the mandibular arch. In conclusion, a characteristic change of artic ulation was disclosed in children through the frequency analysis, especially in the F 0 and F 1 for the vowel which were significantly decreased with age.
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  • Toshiko Yoshida, Kyoko Moriya, Yukie Nakai, Takayuki Hirakawa, Kaori Y ...
    2008 Volume 46 Issue 5 Pages 602-608
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    Objective: The purpose of this study was to investigate the dental fear of young child patients who visited the Pediatric Dental Clinic, Okayama University Hospital for an initial examination.
    Methods: The Japanese parental version of the Dental Subscale of Children's Fear Survey Schedule (CFSS-DS) was administered to the guardians of 224 child patients aged 3-8 years with a mean age of 5.9±1.6 (118 boys and 106 girls).
    Results: The mean total CFSS-DS score was 34.0±1.6. The fear level was higher than those reported in foreign countries as well as those reported earlier in the suburbs of Okayama. There was no statistical difference in scores between boys and girls. Age was inversely correlated with dental fear score. The most feared items were “drilling”, “injections” and “choking”, which were consistent with the results of other reports. The prevalence of dental fear was 52.7%, which had scores of 33 or above, indicating high dental fear. Children with high dental fear were more likely to be younger, have no previous dental visits, have more untreated caries and to be referred due to behavior management problems. The referred patients due to behavior management problems had a statistically higher total CFSS-DS score than the rest (45.3 vs 32.5).
    Conclusions: These results suggested that among young child patients in Okayama, those with a higher level of dental fear tended to visit the Pediatric Dental Clinic, Okayama University Hospital. Extra attention should be provided in order to prevent dental fear.
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  • Tatsuhiko Kakegawa, Hideo Ohashi, Tuneo Hayashi, Reina Kuroshita, Shoj ...
    2008 Volume 46 Issue 5 Pages 609-616
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    The purpose of this study was to confirm the reliability of Quantitative light-induced fluorescence (QLF) method compared to Micro Radiograph (MR) method in determining the effect of fluoride on the remineralization of decalcified bovine and human permanent teeth.
    The items measured were ΔZ: mineral loss in the MR method, ΔF: average fluorescence loss, area: lesion size and ΔQ: fluorescence loss integrated over the lesion size in the QLF method. The demineralized bovine tooth specimens were immersed in remineralization solution for 25 days, and the degree of remineralization in the fluoride coating group (FV group) and the non coating group (control group) was compared using QLF. The effect of topical application of fluoride and fluoride mouth rinsing on the remineralization of white spots on human permanent teeth in the oral cavity was also examined
    The results obtained were as follows.
    1. There was a significant correlation between the values of ΔZ in the MR method and those of ΔF in the QLF method.
    2. The remineralization of bovine tooth in the FV group was greater than that in the control group. After 25 days, the recovery factor (ΔF) of the control group was 7.7±2.9%, while that of the FV group was 18.0±3.4%.
    3. Regarding the white spots in the oral cavity, the QLF value indicated that remineralization continued even after 2 months, and the average recovery factor was 19.9±5.9%
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  • Shiro Omichi, Hisami Nakae, Yukimi Miyamoto, Yoshinao Asahi
    2008 Volume 46 Issue 5 Pages 617-621
    Published: December 25, 2008
    Released on J-STAGE: January 18, 2013
    JOURNAL FREE ACCESS
    We treated a 12-year-old boy with Sturge-Weber syndro me for cavities. He was in the hospital for orthopaedic surgery when we discovered many cavities. The intellectually disabled boy had haemangioma on his face and mouth. We could not manage his behavior during dental treatment in two months, so we performed general anaesthesia three times to finish the treatment of all the decayed teeth during the hospitalization. Just after the first anaesthesia, he was so panicked that he scratched his brow, yet he did not get excessive bleeding. The rest of the treatment under general anaesthesia were without any troubles. This case has shown the importance of patients' parents, dentists, dental hygienists, and paediatricians in charge to cooperate with one another continuously for oral health to ensure the patients are free from bleeding during dental treatment.
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