CDS Paediatric Dentistry Flashcards
Before commencing tx for discolouration, it is necessary to have …. (4)
An accurate diagnosis of the cause
Specialist led treatment plan
Informed consent
Pre-operative records
To ensure informed consent for tx of discolouration in children
Discuss all risks and benefits
Give written information
Discuss with pt and family that it will require maintenance in general practice, at a cost
Child or young person involved or leading, depending on age
Children receiving this tx should be at or nearing age of Gillick competence
Gillick competence
Refers to a young person under 16 with the capacity to make any relevant decision, and is used to assess whether a child is mature enough to consent to treatment
Considerations when determining Gillick competence
Child’s age, maturity and mental capacity
Their understanding of the issue and what it involves - including advantages, disadvantages and potential long-term impact
Their understanding of the risks, implications and consequences that may arise from their decicion
How well they understand any advice or information that have been given
Their understanding of any alternative options, if available
Their ability to explain a rationale around their reasoning and decision making
If a young person is being pressured or influenced by someone else
Their consent is not valid
Pre-op records for discoloured teeth
Standardisation of recording of aesthetic procedures - SHADE sheet
Clinical photos
Shade
Sensibility testing
Check for sensitivity
Diagram of defect - can be drawn on SHADE sheet
Radiographs if clinically indicated
Pt assessment - visual analogue scale etc, pt can tell how they feel discolouration is affecting their teeth
Treatment options for discolouration
Enamel microabrasion
Bleaching
Resin infiltration
Localised composite restoration
Veneers
Do nothing
Bleaching for discolouration types
Vital - provided in surgery or at home
Non-vital teeth - inside outside technique or walking bleach technique
Direct vs indirect veneers
Direct are free hand/putty guide
Indirect are lab made
When would discolouration be left untreated?
If pt doesn’t have any concerns then there is little indication to proceed with tx, even under parental pressure
Microabrasion
Removal of the surface layer of opaque enamel
Advantages of microabrasion
Easily performed
Conservative
Inexpensive
Teeth need minimal subsequent maintenance
Fast acting
Removes yellow/brown, white and multi-coloured stains
Effective
Results are permanent
Disadvantages of microabrasion
Removes enamel
Sensitivity
Teeth may become more susceptible to staining
HCl acid compounds are caustic
Required ppe for pt, dentist, nurse
Prediction of outcome difficult, could appear more yellow as normal dentine colour revealed
Must be done in surgery
Cannot be delegated to another member of dental team
Prior to starting microabrasion clinical technique
PPE - patient and team, glasses, bibs etc
Clean teeth with pumice and water
Protect soft tissue - petroleum jelly, rubber dam
Rubber dam - essential to isolate anterior teeth
Sodium bicarbonate guard for gingival protection
Maximum microabrasion
10 x 5 second bursts
Why is it important to review repeatedly during microabrasion?
Check shade
Check shape - stop if tooth starts looking flattened or if desired colour achieved
Tx following microabrasion
Follow with fluoride varnish to help with remineralisation
Important to use a white FV such as profluorid or clinpro
Polish with finest sandpaper disc
Polish with toothpaste
Why is duraphat unsuitable after microabrasion?
May introduce a yellow stain
Why do we polish with fine sandpaper disc after microabrasion?
Polishing changes the optical properties of the enamel so that areas of intrinsic discolouration become less perceptible
Makes it less obvious where the defect was
Enamel loss when using prophy with toothpaste
5-10 microns
Enamel loss using prophy with pumice
5-50 microns
Enamel loss ortho bracket bonding/debonding
5-50 microns
Enamel loss acid etch
10 microns
Enamel loss 10 x 5 second HCl pumice miroabrasion
100 microns
Opalustre by Ultradent
Purple syringes of 6.6% HCl and silicon carbide particles in water soluble paste, comes with specialised rubber cups with bristles
Prema kit
10% HCl in a preparation of fine grit silicon carbide particles in water soluble paste
Advice after microabrasion
Teeth are dehydrated
Warn pt to avoid highly coloured food and drinks for at least 24hr, recommend up to a week
“Anything that would stain a white t shirt”
Review for microabrasion
Review pt 4-6 weeks after and take post op photographs
How many cycles of microabrasion can be done?
A second can be offered but only if some improvement is seen from the first
GDC 2014 guidance on bleaching in children
Products containing or releasing between 0.1% and 6% hydrogen peroxide can not be used on under 18s except where intended wholly for the treatment or prevention of disease
This includes discolouration due to hypomineralisation, trauma, fluorosis
Vital bleaching options
Chairside - power bleaching
Night guard vital bleaching at home
Non-vital bleaching options
Inside outside technique
Walking bleach technique
Bleaching only externally on a non vital tooth
Not very effective
Important thing to tell potential bleaching pts
Results are not permanent
Chemical for chairside bleaching
Unstable, rapidly reacting hydrogen peroxide
Usually 15-38% (equivalent to 75% carbamide peroxide)
This has greater risk to soft tissues and eyes
Greater risk of sensitivity and this is more expensive
Chemical for nightguard vital bleaching
10% carbamide peroxide
Where would you cute windows in trays for nightguard vital bleaching?
Teeth you don’t wish to bleach
Which teeth would you want to avoid bleaching in nightguard vital bleaching?
Veneers
Teeth with caries
Why is important to have no gingival coverage in night guards for bleaching?
To avoid damage to gingivae and soft tissue
Instructions to pt given with night guard vital bleaching
Give written leaflet
Brush teeth thoroughly
Apply a little gel to tray
Set over teeth and press down
Remove excess
Rinse gently, do not swallow
Wear overnight (or at least 2 hours)
Remove, brush with toothpaste and rinse with cold water
Sensitive toothpaste may be required, or tooth mousse for more severe sensitivity
Advice for sensitivity
Sensitive toothpaste - can apply topically
Tooth mousse
Timescale for night guard vital bleaching
3-6 weeks
Keep going until acceptable colour
When should composite restorative work be done in relation to bleaching?
Leave for 2 weeks after bleaching to allow shade to settle before shade matching
Side effects of tooth bleaching
Tooth sensitivity is common - 15-65%
Gingival irritation - more common in higher concentrations
Tooth sensitivity and bleaching
Common in adults 15-65%
Sensitivity is related to the easy passage of hydrogen peroxide through intact enamel and dentine, reaching pulp in 5 to 15 min
Tooth sensitivity considered relatively minor in adolescents than in adults
This sensitivity is usually manageable
Why is sensitivity thought to be less of a problem for adolescent pts than in adults?
Could be due to increased enamel quality and quantity of the adolescent teeth and to larger pulp complexes allowing faster recovery from the acute inflammation experienced during a sensitivity episode
Carbamide peroxide bleach reaction
10% carbamide peroxide converts to 3% hydrogen peroxide, 7% urea, then becomes water, ammonia and CO2
Important information for pts with white lesions considering bleaching
White areas could get whiter
Advantages of non vital bleaching
Simple
Tooth conserving - compared with crown/veneer
Original tooth morphology maintained
Gingival tissues not irritated by restoration
Adolescent gingival level is not mature until around age 17, so may in future affect any restorations
No lab assistance required for walking bleach
Tooth selection for non-vital bleaching
Adequate root filling - assess with PA
- No clinical disease
- No radiological disease
Anterior teeth without large restorationes
Not amalgam or intrinsic discolouration
Not fluorosis or tetracycline discolouratione
Walking bleach method
Oxidising process allowed to proceed gradually over days
Access cavity
GP removed at least to CEJ
Clean out with ultrasonic
Bleaching agent placed on cotton pellet into the cavity
Covered with a dry cotton pellet
Seal with GIC/RMGIC
Renew bleach - ideally no more than 2 weeks between appts
If no change after 3-4 renewals, stop
6-10 changes total
Inside outside bleaching process
Access cavity
Do not necessarily need GI lining, can be helpful
Custom made mouthguard with windows cut of teeth not to be bleached
Pt applies bleaching agent to back of tooth and tray
Pt keeps access cavity clean, replacing gel, removing food debris
10% carbamide peroxide
Worn all the time except cleaning and eating
Gel changed every 2 hours except during the night
Stop when tooth shade same as those around it, usually 3-4 days, or 48 hours before next appt, contact dentist if shade not correct at this time
Restoration of the pulp chamber of discoloured tooth after bleaching
Non setting CaOH paste placed for 2 weeks, sealed in with GIC then either
1. White GP and composite resin, facility to re-bleach
2. Incrementally cured composite - no re-bleaching but stronger tooth
If regression - veneer or crown prep
Potential complications of non-vital bleaching
External cervical resorption
Spillage of bleaching agents
Failure to bleach
Over bleach
Brittleness of tooth crown
Prevention of external cervical resorption when non-vital bleaching
Layer of cement over GP - prevents bleaching agent from getting to external surface of root (not for inside outside technique), can prevent adequate bleaching of cervical area
Non-setting CaOH in tooth for 2 week before final restoration - reverses any acidity that might have occurred if above had happened
Effects of bleach on soft tissue - short term vs long term exposure
Short term
Minor ulceration/irritation
Plaque reduction
Aids wound healing
Long term
?Delayed wound healing
? Periodontal harm
?Mutagenic potential
Tooth mousse used as an adjunct to microabrasion
After microabrasion for 4 weeks home application (pea sized amount before bed) helps improve lesion but also with sensitivity
Evidence not great
Tooth mousse as adjunct to bleaching
2 weeks home application, rub on or in trays
Poorly demarcated hypomineralised lesions, mild to moderate fluorosis
Evidence not great
Medical history consideration for tooth mousse
Recaldent CPP-ACP (casein phosphopeptide - amorphous calcium phosphate) milk derived protein, careful if allergic
Resin infiltration
Infiltration of enamel lesions with low viscosity light curing resins
Surface layer is eroded, lesion desiccated and resin infiltrant applied
Resin penetrates the lesion, driven by capillary forces
Infiltrated lesions lose their discoloured appearance and look similar to sound enamel
Step by step ICON resin infiltration
1 Pretreatment - rinse and clean teeth
2 Apply etch
3 Rub in etch gel to surfaces of the teeth
4 Let it act for 2 min
5 Rinse
6 Apply icon-dry and let act 30 seconds
7 Visual inspection - is lesion accessible
If no repeat steps 2-7
If yes - apply icon-infiltrant to tooth surface and let act 3 min
Remove excess material
Light cure 40 secs
Second infiltration to compensate for polymerisation shrinkage
Polis
To reduce enamel or not for veneers - considerations
Aesthetics
Relative tooth position - in line? out of line of the arch?
Masking dark stain - may require thicker composite
Age
Psyche
Plaque removal
Enamel reduction for veneers
If tooth is overcontoured by build up of lots of composite - increases plaque retention and stagnation at the gingival margin, especially those with poor OH
Bond strength of composite resin to enamel is significantly increased after partial removal of buccal enamel
Dental anomalies can affect (4)
Number
Size and shape
Structure - hard tissue defects
Eruption and exfoliation
Hypodontia
Less than normal number of teeth
Most common missing teeth
3rd molars
9-37% of population have more than one 3rd molar missing
Mandibular premolars - 1.2-2.5%
Maxillary lateral incisors 1-2%
More common dentition for hypodontia
Permanent 3.5-6.5%
(primary 0.1-0.9%)
Teeth least likely to be missing
First permanent molars and upper central incisors
Canines not commonly missing
What does Celtic canines refer to?
More common missing canines in Ireland and West of Scotland than the rest of the world
Pattern of teeth more likely to be missing
Last in its series
eg. third molar, second premolar
EXCEPT lower centrals more than lower laterals, as they are genetically coded after
Conditions associated with hypodontia
Ectodermal dysplasia
Down syndrome
Hurler’s syndrome
Cleft palate
Incontinentia pigmentii
Tx for hypodontia
Dentures, overdentures or bridges, depending on age of the pt
Problem associated with hypodontia in the upper arch
Over eruption of lower canines
Another common dental feature associated with hypodontia
Small teeth
Premature exfoliation causes
Trauma
Following pulpotomy
Hypophosphatasia
Immunological deficiency e.g. cyclic neutropenia
Chediak-Higashi syndrome
Histiocytosis X
Delayed exfoliation causes
Infra-occlusion 1-9%, usually first primary molar, common if congenital absence of premolar, majority exfoliate by age 11-12
Double primary teeth
Hypodontia
Ectopic permanent syccessor
Following trauma
Why would natal/neonatal teeth be extracted?
Inhalation risk
Problems feeding
Chronology of dental management of hypodontia
Diagnosed - small children
Removeable prosthesis - waiting to do something more definitive, mixed dentition
Bridgework for missing laterals, orthodontics, composite build ups - teen years
Composite veneers - early 20s (gum margins reach settled level)
Crowns and conventional bridges, implants - adulthood
Enhanced prevention is necessary throughout life, if a pt does not have as many teeth as normal, it is important that they don’t lose any to caries, perio etc
Problems with occlusion associated with hypodontia
Deep overbites and reduced lower face height
Hyperdontia/supernumerary
Increased number of teeth
1.5-3.5%
Males:females 2:1
Higher frequency in Japanese
More common in maxilla
Higher frequency in cleidocranial dysplasia
Types of supernumerary
Conical
Tuberculate
Supplemental
Odontome
Conical supernumerary
Cone shaped
Most common
Tuberculate supernumerary
Barrel shaped
Has tubercles
Supplemental supernumerary
Looks like tooth of normal series, will be slightly smaller and look a bit less like the contralateral, get rid of the one in a worse orthodontic position
Odontome
Irregular mass of dental hard tissue, compound or complex
Most common cause of delayed eruption of permanent incisors
Supernumerary
Premature eruption - associated factors
High birth weight
Precocious puberty
natal/neonatal teeth (1:2000-3000 births)
Delayed eruption associated factors
Pre-term and low birth weight
Malnutrition
Associated general conditions - downs, hypothyroidism, hypopituitarism, cleidocranial dysplasia
Gingival hyperplasia/overgrowth - not so much delayed eruption as delayed appearance
Cleidocranial dysplasia
Hypoplasia of cellular component of cementum
Hypophosphatasia
Hypoplasia or aplasia of cementum, early loss of primary teeth
Anomalies of cementum
Cleidocranial dysplasia
Hypophosphatasia
Microdont
Teeth that are smaller than normal 2.5% of population F>M e.g. peg laterals
Macrodontia
Teeth larger than normal
Rare
<1% for single teeth and 0.1% in generalised form in Caucasians
Double teeth
Gemination - one tooth splits into two
Fusion - two teeth join to form one
Taurodontism
Flame shaped pulp
6.3% in UK
Dens in dente
Invagination on the palatal surface
Tooth within a tooth
Pulp system of their own
Important to seal invaginations to prevent caries
Short root anomaly
Most common in permanent maxillary incisors
2.5% incidence
15% of these children also have short roots on canines and premolars
Danger point for ortho tx
Usual causes for short root anomaly
Radiotherapy
Dentine dysplasia
Accessory roots
Anomalies of enamel
Amelogenesis imperfecta
Environmental enamel hypoplasia
Localised enamel hypoplasia
Amelogenesis imperfecta examples
Hypoplastic
Hypocalcified
Hypomaturational
Mixed forms
+ hundreds of less common forms
Environmental enamel hypoplasia types
Systemic - due to systemic disease such as liver/kidney failure
Nutritional - if poor nutrition during development of enamel
Metabolic - e.g. Rhesus incompatibility, liver disease
Infection - e.g. measles
Localised enamel hypoplasia causes
Trauma to primary teeth
Infection of primary teeth
Hypomineralised enamel
Teeth completely normal shape but with marks on them, white, brown, yellow patches
Enamel hypoplasia
Chunks of enamel missing
Generalised hard tissue defects can be either ____ or _____
Environmental
Hereditary
Treatment options for generalised fluorosis
Microabrasion/veneers/vital bleaching
MIH
Generalised environmental defect
Associated with childhood illness such as kidney or liver failure
Chronological pattern can be seen depending on the tooth development occurring during the time of illness
Prenatal causes of generalised environmental enamel defects
Rubella
Congenital syphilis
Thalidomide
Fluoride
Maternal anxiety and depression
Cardiac and kidney disease
Neonatal causes of generalised environmental enamel defects
Prematurity
Meningitis
Postnatal causes of generalised environmental enamel defects
Otitis media
Measles
Chicken pox
TB
Pneumonia
Diphtheria
Deficiency of vit A, C&D
Heart disease
Long term health problems such as organ failure
Diagnosis of amelogenesis imperfecta
Family history
Generally affects both dentitions, usually worse in permanent
Affects all teeth
Tooth size, structure and colour
Radiographs - no obvious difference in radiolucency between enamel and dentine
Hypoplastic amelogenesis imperfecta
Enamel crystals do not grow to the correct length
Hypomineralised type amelogenesis imperfecta
Crystallites fail to grow in thickness and width
Hypomaturational type amelogenesis imperfecta
Enamel crystals grow incompletely in thickness or width but to normal length with incomplete mineralisation
Problems associated with amelogenesis imperfecta
Sensitivity
Poor OH due to sensitivity
Caries/acid susceptibility
Poor aesthetics
Delayed eruption
Anterior open bite
Treatment for amelogenesis imperfecta symptoms
Preventative therapy
Composite veneers/composite wash - helps aesthetics and sensitivity
Fissure sealants
Metal onlays
Stainless steel crowns
Orthodontics
(Restorative and ortho have trouble as the tooth surface is so different that lots of bonding mechanisms will not work)
Why can orthodontics be difficult for amelogenesis imperfecta?
Tooth surface is so different that lots of bonding mechanisms will not work
Systemic disorders associated with enamel defects (not with amelogenesis imperfecta)
Epidermolysis bullosa
Incontinent pigmentii
Down’s
Prader-willi
Porphyria
Tuberous sclerosis
Pseudohypoparathyroidism
Hurler’s
Most common anomaly of dentine
Dentinogenesis imperfecta
Types of dentinogenesis imperfecta
Type I - associated with osteogenesis imperfecta
Type II - autosomal dominant, tend to have no other medical conditions
Brandywine
Anomalies of dentine
Dentinogenesis imperfecta - 3 types
Dentine dysplasia
Odontodysplasia
Dentine dysplasia
Normal crown morphology, amber radiolucency, pulp obliteration, short constricted roots
Odontoplasia
Localised arrest un tooth development, thin layers of enamel and dentine, large pulp chambers, ‘ghost teeth’ on radiographs
Diagnosis of dentinogenesis imperfecta
Appearance
Family history
Associated with osteogenesis imperfecta
Both dentitions affected
Radiography - bulbous crowns, initially very large, then obliterated pulps (I and II)
Enamel loss
Problems associated with dentinogenesis imperfecta
Aesthetics
Caries/acid susceptibility
Spontaneous abscess
Poor prognosis
Solutions for symptoms of dentinogenesis imperfecta
Prevention
Composite veneers
Overdentures
Removeable prostheses
Stainless steel crowns
What must be named on the consent form for non-vital tooth bleaching for children?
The justification for treatment - the specific dental problem
Active ingredient for vital bleaching
Hydrogen peroxide
When can under 18s have tooth bleaching?
For the purpose of treating or preventing disease
How is the fact that tooth whitening is a conservative method, explained to pts and parents?
No tooth tissue is removed
Risks of non vital tooth bleaching described in consent form
Gum sensitivity/irritation
Composite restorations can’t be whitened, may need replaced following treatment
Teeth are more vulnerable to breaking as they must be left hollow with no dressing in place, we advise to avoid high contact sports and chewy foods on the teeth being treated
This treatment may not achieve satisfactory results and further treatment may be required
Not suitable if pregnant or breastfeeding
Not suitable if pt has acatalasaemia. glucose-6-phosphate dehydrogenase deficiency
Who must sign consent form for childhood non vital bleaching?
Parent or guardian
What two places are pts advised to apply bleaching gel to, for at home bleaching?
The tray in the area of the toot being treated
Into the hollow tooth
How often should pts change the bleaching gel for inside outside technique?
Every 2 hours except during the night
When should patients doing inside outside bleaching stop?
When the shade looks the same colour as the teeth on either side
OR 48 hours before the next dental appt, if not whitened sufficiently at this time you must call the dentist
How often does inside outside technique usually take to bleach the teeth?
3-4 days
Can pts eat or drink with inside outside bleaching trays in the mouth?
No
Why is it important that inside outside bleaching is finished 48 hours before the next dental appt?
To allow the shade to settle before shade match of the definitive composite restoration
Advise for pts if bleaching gel gets onto soft tissues
Remove with a tissue
Where should bleaching gel be stored for at home whitening?
In the fridge
What should patients avoid during at home whitening treatment?
Avoid over bleaching
Avoid high colourant food and drink during and for 2 weeks following treatment - anything that would stain a white t shirt
Avoid hard food, or foods that need chewing or tearing
Avoid contact sports
What acid is normally used for microabrasion?
18% HCl
Acid used in Opalustre microabrasion proprietary kit
6.6% HCl
Acid used in Prema proprietary kit for microabrasion
10% HCl
What is mixed with HCl in opalustre and prema proprietary kits for microabrasion?
Silicon carbide instead of pumice
Congenital
Condition you are born with
Guidance for antibiotic prophylaxis
NICE
Infective Endocarditis
Infection of the heart lining endocardium, particularly affecting the valves
Life threatening
What is the concern in those with congenital heart defects when carrying out invasive procedures?
Infective endocarditis
High risk for infective endocarditis
Prosthetic valve
Previous infective endocarditis
Congenital heart disease
What are the risks of antibiotic prophylaxis?
Clostridium difficile infection CDI - can lead to colitis and eventually death
Clinical features present in a patient with infective endocarditis
Temperature over 38 degrees
Sweats or chills
Breathlessness
Weight loss
Tiredness
Muscle, joint or back pain
Why is caries prevention important in high risk for infective endocarditis patients?
IE is caused by cumulative, low grade bacteremias, therefore exacerbated by poor OH
What trauma would this be cassified as?
Intrusive luxation of URA
Trauma investigations for intrusive luxation of a primary tooth
Radiographs - review for alveolar bone fracture, primary tooth displacement extent - into adult? for foreign body
Sensibility testing
When would you extract and intruded primary tooth?
If it has been knocked into the adult
What trauma treatment could you do for intrusive luxation?
Allow tooth to spontaneously reposition itself, irrespective of the direction of displacement
Spontaneous improvement in the position of the intruded tooth usually occurs within 6mo, but up to a year
A rapid referral (within a couple of days) to a child oriented team that has experience and expertise in the management of paediatric dental injuries should be arranged
Advice to parents when child has had an intrusive luxation injury
Soft diet, care when eating
To encourage gingival healing - clean with a soft brush or cotton swab with chlorhexidine twice a day for one week
Follow up timings for intrusive luxation injury
1 week
6-8week
6 Mo
1 year
6 years - if severe
What will happen to an adult tooth if the baby tooth gets infection which touches the adult tooth?
Enamel defect - turner teeth
What is the use for transexamic acid?
Stop bleeding
How long can a tooth be out of the mouth dry and be implanted?
30 mins
How long can a tooth be out of the mouth in solution and be reimplanted?
an hour
What is the reversal drug for warfarin?
Vitamin K
Two types of odontome
Complex
Compound
Peak age of onset of diabetes
4
What is the danger of necrotic pulp in diabetic patients?
Could get infection which will cause blood sugar to spike
Which patients should you avoid prescribing anti-fungals?
Warfarin
Statins
Conc 2800 ppm F toothpaste and what is the minimum age?
0.619%
10 years old
Conc 5000ppm F toothpaste and what is the minimum age?
1.1%
16 years old
How often should bitewings be taken?
Annually, or high risk twice a year
Caries risk assessment components
Clinical evidence of previous disease
Diet
Use of fluoride
Plaque control
Saliva
Medical history
Social history/socioeconomic status
Complicated fracutre
Enamel-dentine-pulp
If an 8 year old child attends with a complicated fracture, what would you want to know about the injury before deciding between pulp cap and pulpotomy?
How long ago did it happen
Size of the exposure
Process of pulpotomy
LA
Dental dam
Remove all necrotic pulp 2-3mm radius around the exposed area
Assess pulpal bleeding - if no bleeding or hyperaemic remove more
Arrest pulpal bleeding with saline soaked cotton wool roll
Seal the pulp with GIC
Restore tooth with acid etched composite
Why could ferric sulphate not be used to arrest pulpal bleeding in a permanent anterior tooth?
Stains the tooth black
What would you expect to see at 6 month radiograph after successful pulpotomy in 11 of an 8 year old?
Continued maturation of the roots
Normal periapical tissues - no radiolucency or pathology
Continued thickening of dentine root walls
How to carry out a RCT on a 11 in an 8 year old
Give LA and place dental dam
Root access and extirpate the pulp
Seal the apex with an MTA plug
Place non setting CaOH in the canal and seal with GIC
Immediate referral to paediatric dentistry
