aesthetic considerations for the child

Question 1

What are some causes for extrinsic staining to enamel?

Answer 1

• smoking
• food/beverages
• poor OH
• drugs
• chromogenic bacteria

Question 2

What are the 2 forms of intrinsic staining to enamel?

Answer 2

• local

- systemic

Question 3

What are some examples of local intrinsic staining to enamel?

Answer 3

• caries
• injury/infection to successor
• loss of vitality due to trauma

Question 4

What are some examples of systemic intrinsic staining to enamel?

Answer 4

• amelogenesis imperfecta
• MIH (molar-incisal hypoplasia)
• drugs (tetracycline)
• fluorosis
• systemic illness during tooth formation

Question 5

what is the aetiology of amelogenesis imperfecta?

What are the associated features?

Answer 5

• hereditary enamel defect (associated with single gene mutation)
• anterior open bite, absent 3rd molars, radiographically taurodontism is observed

Question 6

what is the aetiology of MIH (molar-incisor hypoplasia)?

how does it present?

Answer 6

• No known genetic or environmental cause.
• often appears on first molars and the associated developing incisors. Appears as mineralization defect. Discoloured banding. One of the most common causes for microabrasion treatment.

Question 7

What drug would be responsible for tooth discolouration?

how does it present?

Answer 7

• tetracycline
• blue/grey colour.
• Under fluorescent light they appear blue (method of diagnosis).

Question 8

what is the aetiology of fluorosis staining?

how does it present?

Answer 8

• excessive intake of fluoride either natural sources (drinking water) or toothpaste/fluoride supplements.
• Mild: enamel appears white/opaque. Severe: areas of discolouration/brown staining and pitting.

-Fluorosis is dose dependent! More fluoride ingested = more likely to have fluorosis staining.

Question 9

At what stages of a child’s development can systemic illness can cause tooth discolouration?

Answer 9

• in utero
• neo natal
• childhood

Question 10

how can in utero illness affect teeth?

Answer 10

• illness may affect hormones circulating and interefere with development of baby/ pass through placenta
• Endocrine disturbances (hypoparathyroidism)
• infections (rubella)
• drugs (thalidomide)
• nutritional deficiencies
• haematological and metabolic disorders (Rhesus compatibility

Question 11

how can neo-natal stage affect teeth?

Answer 11

• Pre-term infants
• low birth weight
• intubation during neonatal period: can affect upper incisors as pressure is put on upper gingivae and this can affect development of teeth.

Question 12

how can childhood stage affect teeth?

Answer 12

• Fevers caused by measles/other infections, chronic illness.
• Often presents in a chronological form and will affect certain teeth at different stages, can appear as developmental banding

Question 13

What are the 2 forms of intrinsic staining to dentine?

Answer 13

• local

- systemic

Question 14

What are some examples of local intrinsic staining to dentine?

Answer 14

• caries
• internal resorption
• restorative materials (amalgam can discolour teeth)
• necrotic pulp tissue (caused by trauma/infection)
• root canal filling materials.

Question 15

What are some examples of systemic intrinsic staining to dentine?

Answer 15

• dentinogenesis imperfecta
• bilirubin (haemolytic disease of new born)
• congenital porphyria
• drugs

Question 16

What is required for an accurate diagnosis of tooth discolouration?

Answer 16

• thorough history taking (mother’s obstetric history and delivery, neonatal illness/childhood illness, trauma, where they were born, fluoride habits/intake)
• clinical examination (extra and intra oral, presence/absence of primary and secondary teeth, distribution of discolouration)
• additional investigations (radiographs, sensibility test, histological sectioning of exfoliated/extracted teeth).

Question 17

what are the treatment options for tooth discolouration?

Answer 17

• micro-abrasion
• bleaching (non-vital and vital) only consultants can do this on children!
• localised composite resin restorations
• Composite resin veneers
• Porcelain veneers

Question 18

What is the definition of microabrasion?

Answer 18

controlled method of removing surface enamel to improve discolouration limited to the outer enamel. Involves both abrasion and erosion.

Question 19

what are the indications of microabrasion?

Answer 19

• fluorosis
• post-orthodontic demineralisation
• hypoplasia due to infection/trauma
• idiopathic hypoplasia
• part of treatment plan before next stage (prior to veneer placement to reduce brownness showing through

Question 20

What is considered when assessing a patient for microabrasion?

Answer 20

• the enamel is assessed.
• as too much enamel removal can be damaging to pulp and the underlying dentine (cream coloured) will become more evident.

Question 21

what warnings need to be given to the patient prior to microabrasion treatment?

Answer 21

• we tend to achieve better results with brown discolouration
• don’t offer perfection instead suggest: an attempt at improvement.
• Be aware that it can improve between visits.

Question 22

what materials are needed for microabrasion?

Answer 22

• 18% hydrochloric acid
• Pumice (grey) this is mixed with the acid
• 2X flat plastics
• Sodium bicarbonate (white). This is alkali and neutralises acid. It is mixed with water
• Rubber dam, wedgets (elasticated), floss, bib for patient-and apron for yourself it will stain clothes!
• Prisma Gloss for polishing and enhanced polishing disc/point
• Fluoride gel/toothpaste (white or clear). Can’t use Duraphat. It will stain!

Question 23

What are the steps involved in microabrasion procedure?

Answer 23

1- Clean teeth: wash and dry

2- Place rubber dam and put floss ligatures round each tooth to hold at gingival margin

3- Mix sodium bicarbonate and water to form a white paste. This is placed around entire gingival margin of each tooth. In case the hydrochloric acid runs too close to gingival margin- it will be neutralised.

4- Mix 18% HCl acid with pumice to form a grey paste.

5- Apply small amount to labial surface of tooth (microbrush)- this is the erosion part.

6- Use a rubber cup rotating slowly/flat plastic this- is the abrasion part. Rub over surface for 5 seconds.

7-Wash for 5 seconds directly using 3in1.

Repeat until stain is gone, can repeat up to 7 times in first visit.
And then a maximum of 7-8 on second visit. Total maximum: 15 EVER in a child’s life.
You must re-assess stain and condition of enamel after EACH application.

8-Remove rubber dam and floss ligatures

9-Polish with Prisma Gloss and soft flex disc/ enhanced point

10-Polish with high dose of fluoride toothpaste 2800ppm for 1 minute. Must be clear/white! NOT the topical fluoride paste (this will stain)

Question 24

What post-operative instructions are given to the patient following microabrasion treatment?

Answer 24

• No highly coloured foods (tomato based), pizza, curries, baked beans, ketchup.
• They CAN eat: potatoes, cheese sauce, pasta.
• May experience some sensitivity
• Can continue to improve after treatment that day

Question 25

When is microabrasion reviewed?

What is done at the review?

Answer 25

-Review in 1 month: Analysis of effectiveness, vitality tests, post-operative photographs.

If there is residual staining, or patient/parent requests further improvement; assess adequate enamel thickness and can do a further 7/8 applications in second visit. But no more than 15 EVER!