4. OpTec Lectures Flashcards
A child should reach adulthood with (4)
An intact dentition
No active caries
As few restored teeth as possible
A positive attitude to their future dental care
Operative differences between children and adults (7)
Developmental maturity/behaviour Constant change Developing dentition Operator access Tooth size and shape Preventive care Choice of restoration
Sequence of treatment planning and restorations in cooperative children (6)
Prevention Fissure sealants Preventive restorations Simple fillings (shallow cervical cavities) Fillings requiring LA but not into pulp Pulpotomies (upper arch first)
Summary of restoration longevity (5)
PMC > amalgam = composer > RMGIC > GIC
Crown prep. for conventional paediatric PMCs (2)
Occlusal reduction by 1-2mm
Buccal/lingual - peripheral reduction only
Common problems with stainless steel crowns (3)
Rocking
Canting
Loss of space
When is the Hall Technique used (2)
When no clinical/radiographic signs of plural involvement
Tooth should have sufficient sound tissue left to retain the crown
Hall technique crown review minor failures (4)
New/secondary caries
Filling/crown worn, lost or requiring other intervention
Restoration lost but tooth restorable
Reversible pulpitis treated without requiring pulpotomy or extraction
Hall technique crown review major failures (4)
Irreversible pulpitis
Abscess requiring pulpotomy or extraction
Interradicular radiolucency
Filling lost and tooth not restorable
Disadvantages of unplanned primary tooth extractions (5)
Loss of space causing increased risk of malocclusion Decreased masticatory function Impeded speech development Psychological disturbance Trauma from anaesthesia
Indications for pulp treatment (5)
Good co-operation Medical history precludes extraction Missing permanent successor Over-riding necessity to preserve tooth (space maintainer) Child under 9 years of age
Contraindications for pulp treatment (6)
Poor co-operation Poor dental attendance Cardiac defect Multiple grossly carious teeth Advanced root resorption Severe/recurrent pain or infection
Features of vital pulpotomy (2)
Carious or traumatic exposure of a bleeding pulp
Radicular pulp is preserved, and bleeding controlled
Vital pulpotomy technique (6)
Always use LA and rubber dam
Remove caries prior to access
Remove entire roof of pulp chamber using sterile diamond fissure bur
Remove coronal pulp with sterile excavator or slow-running large round steel bur
Place a cotton pledget with ferric sulphate for 20 seconds until minimal oozing
Place zinc oxide/eugenol in pulp chamber and restore using a PMC
Direct plural evaluation (2)
Normal bleeding – non-inflamed pulp (bright red colour, good haemostasis
Abnormal bleeding – inflamed pulp (deep crimson colour, continued bleeding after pressure (with ferric sulphate))
Pulpectomy indications (2)
Non-vital or hyperaemic (increased/excess blood flow) pulp
Irreversible pulpitis
Signs of a non-vital primary molar (2)
Hyperaemic pulp (increased bleeding) Pulp necrosis and furcation involvement
Symptoms of a non-vital primary molar (3)
Irreversible pulpitis
Periapical periodontitis
Chronic sinus
Aim of a primary molar pulpectomy
Prevent/control infection by extirpation of radicular pulp followed by cleaning and obturation of canals
Indication for a primary molar pulpectomy
Excellent patient cooperation
Pulpectomy procedure (8)
Non-vital/hyperaemic pulp
Open roof of pulp chamber
Remove contents of pulp chamber
Use files to remove pulpal tissue from canals to 2mm short of estimated working length (EWL)
Irrigate with chlorhexidine and dry with paper points
Obturate canals with Vitapex (CaOH and iodoform paste) or alternatively, a very thin mix of ZOE
Seal with thick mix of ZOE/GI and restore with PMC
Post-treatment radiograph in clinical setting
Potential complication of primary pulpectomy (2)
Early resorption leading to early exfoliation
Over-preparation
Follow-up of pulpotomy and pulpectomy (2)
Clinical review - 6 monthly
Radiographic review 12-18 monthly
Clinical failure of pulpotomy/pulpectomy (3)
Pathological mobility
Fistula/chronic sinus
Pain
Radiographic failure of pulpotomy/pulpectomy (3)
Increased radiolucency
External/internal resorption
Furcation bone loss
Types of fractured incisor (3)
Enamel fracture (E#) Enamel and dentine fracture (ED#) Pulpal exposure (EDP#)
Management of E# (2)
Selective grinding
Acid etched tip replacement
Management of ED# (2)
Acid etched tip replacement
Reattach crown fragment/restoration
Management of EDP# (3)
Pulp capping
Partial/total pulpotomy
Pulpectomy
Crown fractures - first aid (4)
History
Examination
Cover over exposed dentine (compomer/composite bandage - not GI)
Definitive restoration - acid-etch composite tip
Survival of pulp after exposure depends on (3)
Associated PDL injury
Extent of exposed dentine
Age of patient (open vs closed apices)
Vital immature tooth with pulp exposed (3)
Open apex
Pulp cap - <24hrs, small exposure
Pulpotomy - large exposure, delay in Tx - maintains vitality of remaining pulp and root formation can continue
Pulpectomy
Non-vital immature tooth pulp exposure (3)
Pulpectomy
Apical barrier formation
Apexification
Process of pulpectomy for on-vital immature tooth pulp exposure
Remove all necrotic pulp
Process of apical barrier formation for on-vital immature tooth pulp exposure
Mineral trioxide aggregate (MTA) used to provide apical barrier against which to condense root canal filling (gutta percha)
Process of apexification for on-vital immature tooth pulp exposure (4)
CaOH placed in root canal to induce apical barrier
Some concerns regarding long-term use of CaOH inside root canals – reduces mineral content of dentine and makes tooth more susceptible to root fracture
Recent research may also suggest that some barriers formed in this manner are full of holes
In some cases, apical barrier formation using MTA may be the treatment of choice
Process of apical barrier formation (4)
5mm of MTA should be placed at the apical end of the root
Placement can be aided by use of a microscope
Placement is carried out using obtura probes, disposable MTA carriers or experimentally using a venflon
Wait at least 24 hours for MTA to harden then obturate with a heated GP system
Vital mature tooth with pulp exposed (4)
Closed apex
Pulp cap - small exposure, <24hrs
Pulpotomy - large exposure, >24hrs, necrotic pulp
Pulpectomy - large exposure, >24hrs, necrotic pulp
Conventional RCT
Uses of CaOH (4)
Used to induce a calcific barrier following pulpotomy procedures
Induces barrier formation at apex of non-vital immature permanent incisors (apexification) - no longer treatment of choice but sometimes only practical option, takes around 9 months to complete
Useful for decreasing microbial load in non-vital mature permanent teeth
Use now being advocated for 4-6 weeks only (inter-visit dressing) due to fact that CaOH makes root dentine brittle
First aid of avulsed permanent teeth (7)
Store in fresh cold milk or saliva
Do not allow to dry out
Can wash for 10 seconds under cold water while holding only the crown if obvious debris
Do not handle to root
Re-implant quickly
Flexible splint for two weeks
Start RCT after two weeks unless the tooth has an open apex and is replanted within 30-45 minutes
Types of splinting and involvements (4)
Flexible 2 weeks - avulsion
Flexible 4 weeks - luxations and apical and middle third root fractures (up to four months for cervical)
Rigid 4 weeks - dento-alveolar fractures
Placing a trauma splint procedure (4)
Cut and bend 0.6mm stainless steel wire
Apply composite resin to traumatised tooth and those adjacent
Sink the contoured, passive wire into the composite
Shape and cure composite
Smooth rough composite and wire ends
Definition of fissure sealant
Protective plastic coating used to seal fissures and pits to prevent food and bacteria getting caught in them and causing decay
Why are fissures vulnerable to caries (2)
Fissures are less protected by fluoride than interproximal or smooth surfaces
It is not possible to clean the base of fissures with a toothbrush
Materials used for fissure sealants (2)
Bis-GMA (mostly)
Occasionally GIC
Indications for fissure sealant placement (5)
High caries risk kids (permanents molars/premolars should be sealed on eruption)
Medically compromised children
Children with learning difficulties
Physically and mentally handicapped
Recent SIGN 138 - all FPM in kids should receive FS
Fissure sealants and low cares risk kids
If a child is of low caries risk they do not need to have their first permanent teeth sealed routinely, rather these fissures should be closely monitored
Fissure sealant tooth selection (5)
Greatest benefit on occlusal surfaces of permanent molar teeth
Should also seal cingulum pits of upper incisors, buccal pits of lower molars and palatal pits of upper molars
Sealing of primary molars may be advised in high caries risk children
A child with caries in one first permanent molars should have the other three sealed immediately
Occlusal caries in first permanent molars indicates that second permanent molars must be sealed on eruption
Fissure sealant placement procedure (6)
Isolation Acid etch Wash Placement Check placement Review
Fissure sealant tooth isolation procedure (5)
Single tooth dental dam
Dry guards and cotton wool
Retraction and aspiration (dental nurse)
Work with efficient speed to decrease the chance of moisture contamination
Clean occlusal surface – preferably with pumice and water
Fissure sealant acid etch procedure (2)
Use 35% orthophosphoric acid to etch enamel surface
Avoid any etch touching the soft tissues, if it does rinse immediately as it could cause a burn
Fissure sealant wash procedure (3)
Wash etch directly into aspiratory and dry the occlusal surface (3-in-1 syringe)
Check that the etched surface has a chalky-white/frosted appearance when dry
Any etched enamel not eventually covered with the sealant will remineralised within 24 hours
Fissure sealant placement procedure (7)
Add the resin to the depths of the dry fissure pattern
Can use a brush, microbrush or small excavator
Ensure that material is in base of fissure
Avoid overfilling as this will decrease long-term retention
Excess material can be removed with a dry microbrush
Should be ‘spidery’ not ‘swimming pools’
Light cure the resin in accordance with manufacturers instructions
Fissure sealant checking placement procedure (4)
Check sealant is firmly adhered (use sharp probe to try to dislodge)
Check there are no air-blows present. If present, remove part of the sealant and re-do
Check that no material has flowed interproximally – if it has, remove with a sharp probe and dental floss
Check that there is no excess material distal to the tooth in the soft tissues
Fissure sealant review procedure (2)
Review clinically every 4-6 months
Review radiographically as per the patient’s caries risk assessment
Indications for glass ionomer fissure sealant (2)
Where good moisture control cannot be achieved
Where there is a high degree of sensitivity die to developmental or hereditary enamel defects
Types of kids where good moisture control cannot be achieved, so GIC FS should be used (3)
High risk children with partially erupted molars
Special needs children
Poorly cooperating children
Features of GIC FS (3)
Useful as release F
Poorly retained
Require regular reapplication
GIC FS placement procedure (4)
Attempt to dry tooth with air or cotton wool
Apply GI from applicator
Smooth into fissures using gloved finger or thumb
Keep finger over GI until set or place Vaseline to decrease moisture contamination until set
Definition of stained fissure (2)
Fissure that is discoloured, brown or black
Fissures where there is an area of white or opaque enamel
(Normal translucency is lost but it has no evidence of surface breakdown - cavitation)
Components of a diagnosis of stained fissure (7)
Visual (dry tooth) Probe/explorer Bitewing radiographs Electronic Fibre optic transillumination CO2 laser Air abrasion (Greater accuracy when 2 or 3 methods are used together)
Treatment of stained fissure (4)
FS and monitor if just enamel caries
If inconclusive diagnosis, clean the FS
If small lesion, preventive resin restoration/sealant restoration (PRR/SR)
If large defect, conventional restoration required
Management of virgin caries in FPMs (5)
Maximise prevention
Always prioritise FPM’s in any mixed dentition treatment plan (i.e. restore 6’s prior to dealing with lesions in primary molars)
Caries most commonly affects the pits and fissures of the FPM’s but may also develop interproximally below the contact point
When caries in the FPM’s is extensive always consider the long-term prognosis
Remember that the pulp is much more likely to be exposed on caries removal due to its size (may wish to consider stepwise caries removal in order to induce calcific barrier formation over the pulp)
Indications for appropriate time to remove FPMs (4)
Beginning of bifurcation of the lower 7 is seen to be forming on an OPT (typically around 8.5-10 years of age)
5’s and 8’s are all present and in a good position on the OPT
Mild buccal segment crowding
Class I incisor relationship
