It is well recognized that the concept and methods of the behavior management, oral health and dental treatment for children with special needs has changed dramatically in the last few decades in Japan. This review summarizes those changes and trends from the clinical point of view and contains the following 5 topics discussed in the lecture at the 47^th Annual Meeting of The Japanese Society of Pediatric Dentistry, May 14, 2009.1.Trends of behavior management modalities, changing from physical ones to psychological or pharmacological, for dental patients with special needs.2.An increasing number of children with developmental disorders such as learning disability (LD),attention deficit hyperactivity disorder (AD/HD) and autism spectrum disorder (ASD) and its dental importance.3.Newly arising dental problems accompanied with increased life expectancy of vulnerable child with special needs and frail elderly.4.Remarkable bipolar phenomenon of dental condition in children with special needs, one showing severely deteriorated dental condition in a small population and the other showing to be generally healthy in a large.5.Importance of transdiciplinary approaches provided by dental and/or medical professionals to special needs patients with dental disease or oral dysfunction.

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Eruption disturbances of maxillary central incisors are frequently caused by apical lesions of the predecessors after severe dental caries or traumatic injury, and the eruptive direction is often changed labio-palatally. Since the impacted central incisors will need to be extracted if serious root dilacerations occur due to late treatment, early traction is recommended after early detection. The erupted supernumeraries in the maxillary anterior region should be extracted as soon as possible because they inevitably induce the irregular alignment or impaction of the central incisor. Small odontomas the size of rice disturb the eruption of the incisor, even if their degree of radio-opacity is low. The latedeveloped germs of the lateral incisors sometimes produce eruption disturbances of the neighboring central incisor. As the late development of the lateral incisors may be related to the fusion of the predecessors, a careful examination is needed during the early mixed dentition period when fused primary teeth are detected in the maxillary anterior region.Eruption disturbances of maxillary canines are often induced by unidentified causes (nearly 75 %),and most affected canines incline mesially. The severity of the canine impaction can be estimated by the degree of overlap between the canine tip and the root of the lateral or central incisor. Although extraction of the predecessor will be effective in mild cases, traction will be needed in severe cases. Ectopic eruption of maxillary canines is sometimes caused by peg-shaped or congenitally absent lateral incisors because the affected canines lose the normal eruptive trail formed by the lateral incisor roots. Since most eruption disturbances of the maxillary canines occur unilaterally, it is important to palpate both sides to detect potential differences in the mobility of the primary canines or the labial gingival bulge before the eruption of the canine. When a difference is clearly noticed, it is critical to take radiographs.

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Root fractures are relatively uncommon among dental trauma. Therefore, there is little evidence based on the scientific studies and a treatment method consensus has not been yet established in the case of traumatic dental injuries with root fractures. The root fractures thet have been reported comprise 0.5−7% of all dental trauma in the permanent dentition and 2−4% in the primary dentition. However, recent research suggested that more accurate X-ray diagnoses could increase frequency of detection of the root fractures. The mechanism of healing of the root fractures is little proven, but the permanent teeth with root fractures should be treated to heal with hard tissue formation. The principle of treatment for permanent teeth with root fracture is a complete repositioning for closely contact between fracture segments and firm splinting for immobilization of the segments. Splinting for 4 weeks is recommended for the permanent teeth with root fracture by IADT guidelines ; however, the periods of sprint should be extended according to case until confirmation of the phenomenon of hard tissue formation by X-ray examination. On the other hand, it seems that the healing with hard tissue formation is not seen in the primary dentition, the cause is not obvious. The primary teeth with root fractures without dislocation and mobility can be preserved without treatment, owing to the normal physiologic resorption of the apical fragment. However, extraction is the recommended treatment for the primary root fractured teeth with dislocation and mobility by IADT guidelines. Nevertheless,young children are greatly influenced by missing teeth in morphological, functional and psychological growth and development. Therefore, the trial to preserve the primary teeth with root fracture by means of long term fixation, until the permanent teeth come in, is invaluable.

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Here I review the localized aggressive periodontitis (LAP) and the periodontitis associated with Down syndrome. At first, the feature of LAP is that while the gingivitis is clinically weak, severe movement of teeth at the early stage takes place due to the drastic bone resorption of incisors and the first molar. Highly toxic Aggregatibacter actinomycetemcomitans (Aa) serotype b strains are frequently detected in periodontal pockets. Therefore, the microbacterial tests are recommended in LAP suspected cases. In addition to regular treatments, administration of systemic antibiotics, particularly tetracycline during treatment of LAP is needed.On the other hand, in the patients with Down syndrome, the severe destruction in the periodontal tissues at the early stage and the refractory tendency were shown. Therefore, plaque control is thoroughly necessary. In case that periodontopathic bacteria were detected by the microbial test, they should take an antibiotic therapy using sensitive reagents for each bacteria.However, this environment in the patients with Down syndrome is not still clear. It is necessary to analyze further the oral environment in the patients with Down syndrome in detail, and contribute the prevention and development of a new therapy for dental diseases of these patients in the future.

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The pulp has a risk of circulatory disturbance as ischemia or hemorrhage, and tissue degeneragtion might occurs after traumatic luxated injuries. Bacteria could inbade the pulp and periodontal tissue via traumatic incomplete/complete crown fractures, and cause the pulpitis, periodontitis, and pulp necrosis. Hence, these fractured tooth must be sealed or capped to prevent subsequent pulpal infection, pulpal inflammation and subsequent necrosis. For pulp exposure, pulp capping can be used as prompt treatment in 24 hours. But partial pulpotomy is recmmended for it's high success rate within 7 days after trauma.Early detection and prompt treatment of pulp necrosis is effective for preventing the pathological root resorption. Surgical endodontics can obstruct a part of progressive root resorprion and apical periodontitis with horizonral root fracture. The incidence of fractures is markedly high in endodontically treated immature teeth. The appropriated resin composite and bonding agent for the restoration of the access cavities to prevent crown-root fracture are recommended.For the early detection of pathological changes after traumatic injuries, the longitudinal perodical follow-up and objective diagnoses are proposed.

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In the root canal treatments of primary teeth, a good prognosis can be acquired by the controls of inflammation and root resorption. However, on account of the complicated root canal forms in pri mary teeth and physiological root resorption with exchange to permanent successors, there are some cases in which the ideal treatments do not become possible. In the current stage, it is important to effectively remove bacterial bio-films in root canals and smear layers with reaming and filing on root canal walls. Root canal irrigation with sodium hypochlorite with ultra sonic and/or EDTA with ultra sonic can remove bio-films and smear layers on the root canal walls. By means of irrigation, we can sufficiently utilize the effects of calcium hydroxide and other root canal medications. And the result,the prognosis of the root canal treatments seems to become good. In addition, our efforts are necessary for the development and discovery of good methods in root canal treatments including the root repair mechanism with cementum deposition of primary teeth.

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Recording and analysis of normal patterns of growth and development of the human face are among the most important clinical observations. Three-dimensional digitization technologies can now record three-dimensional coordinates of facial surfaces, allowing direct analyses of landmark coordinates that provide the basis for statistical differences in facial shape during growth and development. The aim of this study was to compare methodologies used to establish the three-dimensional coordinate system for quantifying facial morphology.The three-dimensional facial morphology of infants was recorded using a three-dimensional laser surface scanner system (VIVID 910, KONICA MINOLTA SENCING, Inc. Osaka, Japan). One hun dred and twenty normal developing children (20 boys and 20 girls each at 4, 5 and 6 years of age) had their faces scanned by VIVID.Two origins and two reference planes for the scanned data were established and compared to evaluate the effectiveness and importance of the selected coordinate system. The first origin was at Nasion on the soft tissue, and the second was defined as the mid-point of both the right and left Endocanthion points. The first reference plane was a Nasal triangle based on three reference markers : soft tissue Nasion in the midline and Alar crests on each side. The second plane was based on 8 points,Exocanthion, Endocanthion, Alar crest and Cheilion on both right and left sides. The vertical axis was defined using 6 points : G, S, Prn, Ls, Li and Pog. The lateral axis was perpendicular to the vertical axis on the established plane, and the anterior-posterior axis had the same direction as the unit vector of the plane.The Endocanthion mid-point was the better origin, resulting in slightly smaller standard deviations and coefficients of variance of all measurements, especially on the vertical axis and three-dimensional distances. When the two reference planes were compared using this origin they differed for measurements in the sagittal plane by an average of 9.7 degrees. This angle decreased with growth, and a statistically significant difference was found between 4- and 6-year-old girls. No significant differences were detected on the horizontal plane.These results suggest that the selection of the coordinate system can influence observed measurements of growth, development and even treatment effects of the face. Therefore, the coordinate system should be chosen based on the purpose of the study and the characteristics of each landmark.

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The process of facial growth is of interest in dentistry, physical anthropology, and even industry. Several Japanese national institutes, e.g., the Advanced Industrial Science and Technology and the Research Institute of Human Engineering for Quality Life have measured and reported aspects of human body size and shape, including the facial morphology of children and adults. However, the facial morphology of infants was not included in these reports.In this study, three-dimensional facial morphological measurements of infants were performed using a three-dimensional laser surface-scanner system (VIVID 910, KONICA MINOLTA SENCING, Inc. Osaka, Japan). One hundred and twenty normal developing children (20 boys and 20 girls each at 4, 5 and 6 years of age) had their faces scanned by VIVID. Four widths (inter-Exocanthion width,inter-Endocanthion width, inter-Alar crest width and inter-Cheilion width) and 6 heights (Nasal height, upper facial height, mouth height, total facial height, lower facial height and Vermilion height) were measured.Most measurements increased with age in both boys and girls. Although significant sex-related differences were detected among the three age groups, there were no consistent tendencies. The infants'growth rates for the measurements were not the same as those of adults from the literature. [I do not understand the next sentence. Perhaps you mean : “For example, widths in the upper part of the face at four years of age are already 80% that of adults. Most measurements differed significantly between 5 and 6 years of age, but only 2 measurements differed significantly between 4 and 5 years of age. These results suggest that facial growth is not constant between 4 and 6 years of age, with rates affected by both age and sex. Further investigation may be required to elucidate characteristics of facial growth during childhood.

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A new behavior-conditioning tool, that we called the Net-relaxation-training method, was applied to the handicapped children in our dental clinic. Briefly, uncooperative disabled children were wrapped in the net type restrainer and given only painless preventive treatment. They seemed to be relaxed in the net after receiving such an experience at every visit, because they may feel comfortable under the net type restrainer and may believe that the dental clinic is a safe place. After making them relax, we begin to train them by using conventional behavior modification techniques such as ‘Tell-Show-Do'.To know the effect of the net and the way to relax, we asked mothers of children who were trained by this method the children's states of cooperation before this method was received and after it had been received it. Answers from 27 mentally handicapped children (MR child) who did not have the closed tendency and 63 closed character handicapped child (AUT child) who had an intellectual disability was obtained. The result was shown below.1.The net and the way to relax remarkably improved the AUT child's cooperation.2.The change that the AUT child cooperated had a significant difference in statistics (dangerous rate 1%) and there was no significant difference in the MR child.3.The net and the way to relax seemed to be an effective action adjustment method for the closed character handicapped child who had an intellectual disability.

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Nursing mothers are busy because their duties typically include taking care of their babies and performing housekeeping, among other tasks. We are supporting nursing mothers' oral health at our ma ternity hospital. Their oral health check-ups and dental treatment provide excellent opportunities to improve the oral health of their infants and other children.Therefore, we administered a questionnaire to nursing mothers who had oral health check-ups. Herein, we report the salient results of a questionnaire survey of 110 mothers who delivered babies at our maternity hospital.1.Many of the mothers had oral health check-ups at 2 months after delivery, and the next was at 12 months after childbirth.2.The 31−35 age group (54%) and primiparous mothers (58%) ranked first among groups of respondents.3.Of the mothers, 69% had oral health check-ups during pregnancy, but most did not have a family dentist.4.The daily repetitions of tooth brushing during pregnancy and after childbirth showed no marked differences.5.Of the mothers, 29% were smokers before pregnancy ; all but one mother quit smoking after noticing their pregnancy.6.Of the mothers, 50% were concerned about their baby's oral health. Most reported worries on the questionnaire survey were related to “dental caries.”7.At our pediatric dentistry, many mothers had complained about “tooth brushing” and “baby food.”These concerns differed from those of the questionnaire results.It is necessary that nursing mothers have their oral health check-ups, just as pregnant women do. Moreover, in recent years, mothers have access to much information related to child care. Therefore,many mothers are concerned and confused. For those reasons, we seek to create a comfortable environment and system by which mothers and infants can have regular oral health check-ups. Cooperative efforts undertaken with professionals of other occupations are necessary to support mothers and their infants.

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In pediatric dental clinics, the degree of mandibular angle and anteroposterior manndibular length of a child is costumed to use the prediction of the occlusion of an adult in the case of Class 3 malocclusion. The mandible is a complex structure and the size and shape could be determined by genetic and environmental factors. The purpose of this study was to investigate the genetic factor to the degree of mandibular angle by QTL analysis using SMXA recombinant mice. We measured the degree of mandibular angle in 21 SMXA recombinant inbred (RI) strains and its parental strains, SM/J and A/J.The results were obtained as follows.1.Continuous distribution pattern of the degree of mandibular angle in SMXA RI strains suggests that the angle is not determined by a simple Mendelian inheritance but is controlled by multiple genes.2.It is conceivable that SM/J and A/J-derived alleles include both increasing and decreasing effects on growths of mandibular angle in SMXA RI strains as determined by the combination of SM/J and A/J-derived alleles.3.Based on the QTL analysis, it is suggested that the candidate genes of mandibular angle are mapped to a D 13 Mit 130 on chr. 13 with LOD score of 2.3, and NdA 29 on chr. X with LOD score of 2.2. These findings strongly suggest that mandibular angle is genetically controlled.

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In this study that targeted 317 guardians of first-year to sixth-year and 237 children of third-year to sixth-year elementary school children, we examined factors influencing regular dental check-ups by comprehending the condition of the pupils' oral cavities as well as illuminating the guardians' attitudes toward their health. The results of the study suggested that the guardians' “interest” in this regard, their “sense of value” engendering the motivation for the “interest”, and their active involvement with the pupils constitute factors that promote the undergoing of regular dental check-ups. We therefore concluded that it would be necessary to enhance dental health guidance programmes for guardians while taking into account their initiative.

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An infant's salivary fluoride concentration was measured by a flow injection analysis device that can measure ultratrace amounts of fluoride ion concentrations, to obtain basic data on the fluoride (F) ionic level in the mouth.One hundred and one 4- to 6-year-old kindergarteners (44 boys and 57 girls) in two day nurseries participated in this study. Stimulated saliva samples were collected. These collections were taken 2 hours or more after breakfast and before lunch. The saliva samples were centrifuged and then the F ionic level was measured in 0.2 ml of the supernatant using the flow injection analysis device. Moreover, a standardized solution (0.05, 0.1, 0.5 ppmF) was added to the saliva at a rate of 1 : 9, and then the temporal change of the F ionic level was measured. The reproducibility of the measurement of the infant's salivary fluoride concentration was high and this device showed an excellent stability. The mean (SD, min-max) salivary F concentration was 0.0082 (0.0026, 0.0017−0.017) ppmF. No gender difference and no age difference was observed. A significant difference was observed between the children in the two day nurseries and the F ionic level of those in the day nursery. A kindergartener who was using a fluoride mouth wash showed a high value. The F ion concentration in the saliva that contained the additional F showed a decrease of 17−45% in comparison to the F ion concentration of purified water that contained F.It was thought that the measurement of the density of F ions in the infant's saliva by means of a flow injection analysis device was effective because the F ionic levels of the infant's saliva were all below the measurement limits of the conventional F ion electrode method.

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Dystrophic epidermolysis bullosa (DEB) is a group of rare genetic skin disorders with bullae caused by mechanical stimulus. The dental health care of small children with dystrophic type of EB was described in this paper.A 3-year-old girl with DEB visited the Okayama University Pediatric Dental clinic with a letter of referral from the pediatrician. The patient had severe caries and experienced a high level of dental fear. Thus, dental examination and treatment posted a big problem. We planned (1) Improvement of management (2) Improvement of oral hygiene (3) Arrest of present caries, and scheduled for her recall once every two weeks.The Tell-Show-Do technique was performed to build up trust and confidence with the child. The toothbrush was also re-designed to provide maximum care in decreasing plaque. Fluoride application in the clinic was done. The patient was provided with a mouth wash containing fluoride for homeuse. A normal eruption of permanent teeth were observed from then on. Eventually, the patient's appetite improved.Patient with DEB should be managed by first building up mutual trust and confidence to pare the way for ease in oral health care.

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We encountered a rare case of an impacted mandibular right second primary molar with the succeeding premolar located above the impacted primary molar. The patient was a 6-year, 9-month-old girl at her first visit. No signs of redness or swelling were noted in the gingiva on the impacted tooth. Radiographic examination revealed a calcified body on the upper and distal side of the impacted primary molar. The second premolar germ showed distal inclination and was located on the upper, mesial and lingual side of the affected primary molar.The crown of the impacted primary molar was fenestrated and the calcified body was removed. Four months later, the primary molar was fenestrated again and traction was started. Because the primary molar did not erupt in spite of the traction, the primary molar was removed under general anesthesia. At that time, the tooth germ of the second premolar was preserved intact. Approximately 1 year later, the second premolar appeared in the oral cavity. At the age of 12 years and 6 months, the affected premolar was aligned within the lower dental arch and its root showed good development on the radiographic photograph.Although the etiology could not be clearly concluded, it was speculated that the process of the migration of the second premolar into the inter-radicular position of the predecessor was disturbed by unidentified causes, and that the second primary molar was impacted because of retention of the primordium of the second premolar.It was indicated that we could preserve a permanent tooth in case of an impacted primary molar with an inverse successor germ which showed good condition and position. It should also be pointed out that the early detection and treatment of impacted primary teeth are important since the influence of impaction on a successor is very serious although the frequency of impaction of primary teeth is very low.

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It is difficult to treat the molar tooth‘s occlusal guidance, so a simple and easy treatment is desired. Thus, the authors conducted the treatment of the molar tooth's occlusal guidance, by using such simple equipments like a power chain, and sectional wire.The first case was mesial inclination of the mandibular left first molar because of the submergence of the second primary molar, and treated by using, “Simple Molar Controller” which consisted of the lingual arch and the sectional wire.The second case was ectopic eruption of the mandibular both sides second molar, because of lack of eruption space, and we carried out denture guidance by using the crimpable hook and the sectional wire. The right side of the equipment was to utilize elasticity of the elastic and the wire, and the left side was to utilize elasticity of the wire. These two treatment cases showed the results as follows ;1.Because the structure of the equipment in both cases was simple, the adjustment could be completed in a short time, and the chair time of the treatment was short.2.The period of fitting equipment was 3−7 months which was comparatively short. The affected patients did not show pain or discomfort during the fitting period.The results suggest that these methods are technically easy, place little burden on the patient, and bring high treatment efficiency.

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Previously, the replantation of dislocated primary teeth had never been tried, because of adverse effect for permanent teeth germ. However, once young children lose their primary teeth, they could get dysarthria, masticatory and cosmetic disturbance, or oral habits. In the present study, we reported two cases of replantation of mandibular primary incisors, and observation until these teeth had changed to succedaneous teeth ; case 1 is a 3-year-old boy with 3 dislocated mandibular incisors, and case 2 is a 2-year-old girl with a dislocated mandibular incisor.All replanted primary incisors in the both case had a relatively good prognosis without any pain,discoloration, redness and swelling of gingiva. Eventually, they indicated normal root resorption, and changed to permanent teeth regularly. Further, none of them needed root canal treatment.Concerning the effect of replantation of dislocated primary teeth on succeedeous permanent teeth,although the white spots of labial incisal edge of the enamel surface in mandibular central incisors were seen in only case 1, other abnormalities like textured enamel surface, enamel cavity and abnormal eruption time were not observed. This result indicates that replantation of dislocated primary teeth does not have an effect on succeedeous permanent teeth, and dentists should consider this treatment procedure, especially in young patients, after sufficient informed consent.

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A 10-year-1-month-old girl presented an unerupted maxillary primary right second molar and a congenitally missing permanent 2^nd premolar case. Long term oral management and continued observation and treatment were done.1.X-ray findings and a thorough oral examination during the initial visit showed an impacted primary maxillary right second molar. At this point, the succeeding permanent 2^nd premolar was not yet visible.2.After one month from the initial visit, bone fenestration of the maxillary impacted molar was done to promote natural eruption. Observation was done for 3−6 months.3.3 months after bone fenestration, there was a tendency of eruption but no marked change. Thus, a decision to do bone fenestration again was done to move the tooth orthodontically.4.3 months after orthodontic treatment, the right permanent maxillary second premolar became visible by x-ray examination.5.The patient came back at 17 years and 5 months of age after regular recalls and presented a right permanent maxillary second premolar in the first stage of eruption. At age 18 years 10 months, she presented a premolar that almost reached the occlusal plane.

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Marshall Syndrome was first reported in 1958 by Marshall in a kindred of seven individuals over three generations. The distinctive symptoms of this rare syndrome are hearing impairment, myopia,cataracts, and retracted midface. We provided dental care to a 4-year-old patient with Marshall Syndrome. The facial characteristics of this patient included retracted midface, shallow orbit and upward naris. The maxillary dental arch had a trapezoidal form. The maxillary arch width was greater, the arch length smaller and all deciduous mesiodistal crown diameters were larger than the mean values reported by the Japanese Society of Pediatric Dentistry (1995). The eruption space for the maxillary permanent incisor teeth was estimated to be insufficient by X-ray photograph. As there are few reports of Marshall Syndrome, it is difficult to determine the constitutional growth. The patient is under periodic dental observation.

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