Guidelines (created by another user) Flashcards
Fluoride Use contributes to?
Prevention, inhibition and reversal of caries
What topics are included in anticipatory guidance/counseling?
diet, oral hygiene, nonnutritive habits, injury prevention, speech/language milestones, piercings, substance abuse
Injury prevention topics for the infant to young child should focus on what topics?
car seat, electrical cord safety, play objects, pacifiers.
Children with white spot lesions are considered what level of caries risk?
high
Xylitol use and its effects?
decrease MS levels in plaque and saliva and reduce dental caries
CRA is split into 3 categories which are?
biological, protective, and clinical findings
CRA biological factors for 0-5 yo indicating HIGH risk include?
primary caregiver has active caries, low SES, >3 sugary snacks or beverages, put to bed with bottle containing sugar
CRA biological factors for 0-5 yo indicating MOD risk include?
child with SN, recent immigrant
CRA clinical findings for 0-5yo indicating HIGH risk include?
dmfs>1, white spot or enamel defects present, elevated MS levels
CRA clinical findings for 0-5yo indicating MOD risk include?
plaque on teeth
CRA biological and clinical findings for >=6yo indicating HIGH risk include?
low SES >3 snacks >=1 interproximal lesion low salivary flow active WSL or enamel defect
CRA biological and clinical findings for >=6yo indicating MOD risk include?
recent immigrant
SHCN
defective restoration
intraoral appliance
Whats the difference in caries management protocol in >3yo for a high risk patient with an engaged parent and one without?
With an engaged parent, you can actively surveil incipient lesions, with a non-engaged parent you may want to restore incipient lesions.
Periodontal dx in pregnant patients is linked to what findings?
preterm deliveries, low birth weight babies, preeclampsia
primary goal of perinatal oral health care with regards to caries transmission?
lower cariogenic bacteria in mother to delay colonization of infant.
For pregnant women frequently vomiting, what remedy may help against erosion?
rinsing with a cup of water containing a teaspoon of baking soda and waiting an hour before brushing
In pregnant patients, what can help reduce plaque levels?
Fl toothpaste and rinsing with a sodium fluoride rinse or chlorhexidene rinse
Safest time to perform dental treatment on a pregnant pt?
second trimester
How many times should a pregnant pt chew xylitol gum ?
2-3 times a day to help reduce MS levels and colonization
what are some behaviors that parents can avoid which will help prevent early colonization of MS in infants?
avoid saliva sharing behaviors such as sharing utensils, cleaning a pacifier or toy, sharing cups
is human breast milk associated with increased risk of caries?
No, but frequent night time bottle feeding is.
What is associated with increased risk of caries in infants?
breastfeeding>7 times a day after 12 months, nighttime bottle feeding with juice, repeated use of no spill cup, and frequent snacking
When should third molars be removed?
when impaction or malposition can lead to caries, cysts, pericoronitis, periodontal problems, pain and generally when risks of early removal are less than risks of late removal.
What is positive youth development?
aspect of adolescent oral health care in which you build a strong interpersonal relationship with the patient addressing psychological and social needs.
what is perimyolysis?
enamel erosion seen in bulimics
nutrients of particular importance during pregnancy are?
b6 b12 folate calcium zinc
category A drugs in pregnancy?
studied in humans and safe to use
category B drugs in pregnancy?
show no evidence of risk to humans(Pen, Amox, Lido, Tylenol)
category C drugs in pregnancy?
use with caution, such as aspirin containing drugs and NSAIDs
category D drugs in pregnancy?
do not use, such as tetracycline
pregnant women who smoke increase risks of?
ectopic pregnancy, spontaneous abortion, preterm delivery, low birth weight infants, intellectual disability, clefts, SIDS
infants exposed to secondhand smoke have higher rates of?
lower respiratory illness, middle ear infections, asthma, and caries
What is the consensus on using bleaching products in pregnant females?
Avoid using them in females who have existing amalgam restorations as hydrogen peroxide can release inoraganic mercury into the bloodstream
what oral changes may occur secondary to pregnancy?
xerostomia, shift in microbial flora(to more anaerobic) causing periodontitis.
consensus on antacids used during pregnancy?
they have high sugar content and increase risk of caries
what drugs are not recommended during pregnancy?
aspirin containing products, nsaids(if necessary, avoid during 1st and 3rd trimester), erythromycin, tetracycline
aapd defines special health care needs as?
any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment that impose limitations in self-maintenance. Can be congenital, acquired, or developmental.
which shcn patients are most susceptible to effects of oral diseases?
pts with compromised immunity(leukemia, HIV), cardiac conditions associated with endocarditis
SCHN also include patients with disorders or conditions which manifest only in oro-facial complex, such as?
AI, DI, cleft lip/palate, oral cancer
What is the most common site of inflicted oral injuries?
lips, then oral mucosa, teeth, gingiva, and tongue
Unintentional or accidental injuries must be distinguished from abuse by?
judging whether the history, including timing and mechanism of injury is consistent with the characteristics of the injury
what finding in prepubertal children is pathognomonic of sexual abuse?
oral and perioral gonorrhea in prepubertal children
why is HPV resulting in oral or perioral warts not necessarily sexual abuse?
can be transmitted by oral-genital contact, vertically from mother to infant during birth, horizontally transmitted through nonsexual contact from a child or caregivers hand to mouth
ecchymoses, lacerations, or abrasions found in what pattern may indicate bite mark abuse?
ellipitcal or ovoid
Bite marks have a central area of ecchymoses caused two ways, which are?
positive pressure through biting or negative pressure through suctioning.
dog bite vs human bite?
dog bite tears flesh, human bite compresses flesh causing abrasions, lacerations, contusions
an intercanine distance measuring more than ? is suspicious of an adult bite
3.0 cm
what technique is employed to swab for DNA in potential abuse situations?
double swab technique. First use a sterile swab moistened with distilled water, then use a second dry swab on the same area. A third control swab is taken from an uninvolved area.
define dental neglect
willful failure of parent to seek and follow through with treatment
Fluoride mechanisms of action?
inhibit demineralization, promote remineralization, inhibit dental caries my affecting metabolic activity
fluoride toothpaste recommendations for less than 3 and greater than 3 yo?
rice size for less than 3, pea size for greater than 3
when are fluoride supplements considered?
in high risk children drinking fluoride deficient water(
what is xylitol?
5 carbon, naturally occurring sugar, found in trees, fruits, vegetables, and is intermediate product of glucose metabolic pathway.
Xylitol amount needed and its effects?
3-8g/day, reduces levels of MS in the plaque and saliva, works most effectively on erupting teeth, gum not recommended in less than 4yo(use syrup)
xylitol side effects?
gas and diarrhea. Can be reduced if xylitol introduced slowly
which pain intensity scales are used in pediatric dentistry?
FACES pain scale for ages 4-12, wong baker for children over 3.
communication in behavior management of a child is affected through what 4 characteristics?
dialogue, tone of voice, facial expression and body language.
the four essential ingredients of communication in behavior management are?
the sender
the message, including facial expression and body language
the context
the receiver
what characteristics influence a childs reaction to the dental setting?
age/cognitive level temperament/personality anxiety and fear reaction to strangers previous dental experience maternal dental anxiety
what are the goals of behavior guidance?
establish communication alleviate fear and anxiety deliver quality dental care build a trusting relationship promote positive dental attitude
Basic behavior guidance techniques include these communicative techniques
TSD voice control nonverbal communication positive reinforcement distraction
stabilization devices must be used with caution in patients with what medical history?
patients with respiratory compromise(asthma)
patients who will receive medications(local anesthetics, sedatives) that can depress respiration
what are contraindications to protective stabilization?
cooperative, non sedated patients
previous physical or psychological trauma from protective stabilization
patients who cannot be stabilized safely due to medical(asthma) or physical conditions(OI)
patients requiring non emergent treatment
When is sedation indicated?
fearful, anxious patient whom basic behavior guidance have not been successful
patients unable to cooperate due to psychological or emotional maturity
when sedation may protect developing psyche and reduce medical risk.
What to address in terms of infant feeding? What do you place in bottles?
formulas, breastmilk, or water in infant bottles.
Is milk considered cariogenic?
No, but it is a vehicle for cariogenic substances(chocolate powder)
Is breastmilk alone cariogenic?
No, but prolonged nighttime feeding is associated with increased risk for caries.
WSL in children younger than three classifies them as what?
SECC
What are indications for fluoride OTC rinses?
orthodontic appliances, radiation therapy, prosthetic appliances, high sucrose diet, high CRA
what type of filtration systems typically reduce fluoride levels?
reverse osmosis and distillation
Prevalence of fluorosis increasing or decreasing?
increasing, # of new cases is on the rise due to higher levels of ambient fluoride.
Fluoride toxicity treatment >8mg/kg and
8mg/kg, induce vomiting, give milk, go to ER
frequency of bw radiographs for low caries risk patient?
12 to 24 month interval in primary dentition
18 to 36 month interval in permanent dentition
CBCT benefit?
360 degree scan, can be used to scan specific locations, useful for evaluating bone
major biological risks associated with xrays?
carcinogenesis, fetal effects, mutations
for soft tissue trauma, what radiologic adjustment is made?
use 1/4 normal exposure time
plaque induced gingivitis may be associated with steroid hormones during which situations?
puberty
pregnancy
oral contraceptives
menstruation
these drugs cause gingival enlargement
phenytoin(dilantin) - antiepileptic
cyclosporin(immunosuppressant)
calcium channel blockers(nifedipine, almodipine, diltiazem)
key characteristics of drug induced gingival enlargement?
usually painless growth at interdental and marginal gingiva
regresses after cessation of drug
RELATED to plaque control
does not occur in edentulous areas
key characteristics of a gingival abscess? Treatment of gingival abscess?
painful, localized lesion of marginal or interdental gingiva of sudden onset
caused by embedded object(popcorn hull, fingernail
Treat by establishing drainage and chlorhexidene irrigation
characteristics of vitamin C associated gingivitis?
edematous, spongy gingiva
spontaneous bleeding
impaired wound healing
NUG/NUP characteristics and predisposing factors?
rapid, painful gingivitis with interdental and marginal necrosis and ulceration
peak incidence in late teens and early 20s in developed countries, seen in younger kids in less develop countries
can be febrile
predisposing factors are malnutrition, stress, lack of sleep
Tx is aggressive debridement, OHI, follow up care, NSAIDS for pain and metronidazole and amoxicillin
LAP characteristics in primary dentition?
attachment and bone loss in primary dentition, usually affects primary molars, children are otherwise healthy, inflammation not a prominent feature
LAP characteristics in permanent dentition? Vs GAP characertistics
bone loss
may have minimal plaque and calculus compared to normal child
usually affects perm incisors and molars and no more than 2 other teeth
Tx is metro in combination with amoxicillin and aggressive debridement.
GAP - exhibit marked perio inflammation and high levels of plaque and calculus
Hypophosphatasia features?
Genetic disorder
4 forms:perinatal, infantile, childhood, adult. The earlier the onset, the more lethal the disease
can see premature loss of primary teeth(incisors)
abnormal cementum
large pulp chambers
permanent teeth often not affected
hypophosphatasia diagnosis?
low alkaline phosphatase, phosphoethanolamine in urine
Leukocyte adhesion defect features?
generalized periodontitis in primary and young permanent dentition
frequent respiratory, skin, ear bacterial infections
Leukocyte adhesion defect treatment?
antibiotic therapy, OH, poss extraction of affected teeth
Papillon Lefevre syndrome features?
palmar and plantar hyperkeratosis
premature loss of primary and permanent teeth
Chediak Higashi Syndrome features?
oculocutaneous albinism, photophobia, nystagmus, neuropathy, severe gingivitis and periodontitis
Neutropenia features?
several forms severe gingivitis with ulceration premature loss of primary teeth severe periodontal disease in permanent dentition other soft tissue infections common
Langerhans cell histiocytosis features?
bone lesions may produce “floating teeth”
acute leukemia gingival features?
gingival enlargement due to leukemic infiltrates, usually in AML
Epinephrine and norepinephrine are contraindicated in what patients?
patients with hyperthyroidism
patients on TCA(due to dysrhythmias)
when halogenated gases are used for GA(myocardium sensitized to epi)
You may want to get a consult to use an LA with epi in these patients?
cardiovascular disease thyroid disease diabetes sulfite sensitivity those on MOA, TCA, or phenothiazines
allergy to one amide does not rule out use of another amide but allergy to one ester
rules out use of another ester
Why should local anesthetics without vasoconstrictors be used with caution?
due to rapid systemic absorption which can result in overdose
which local anesthetic can induce methemoglobinemia symptoms, which are?
prilocaine + benzocaine
blue cyanosis of lips, mucous membranes, and nails. Respiratory and circulatory distress
prilocaine contraindicated in what patients?
methemoglobinemia
sickle cell anemia
anemia
patients receiving acetaminophen or phenacetin
LA overdose objective symptoms of the CNS include?
Excitation followed by depression
muscle twitching, tremors, talkativeness, slowed speech, shivering, followed by seizure activity. Unconsciousness and respiratory depression may occur
LA overdose objective symptoms of the CVS include?
HR and BP increase followed by vasodilatation and BP decrease. Bradycardia and cardiac arrest may occur.
LA dose should be adjusted upward/downward when used with opioids?
downward as opioids like demerol also cause CNS depression and lower seizure threshold
what are contraindications to using nitrous oxide?
some COPD
emotional disturbances or drug related dependencies
first trimester of pregnancy
treatment with bleomycin sulfate
cobalamin deficiency
methyltetrahyrdofolate reductase deficiency
Most common adverse effects of nitrous oxide?
nausea, vomiting, diffusion hypoxia
Formocresol method of action in pulpotomys is?
tissue fixation
CaOH and MTA method of action in pulpotomys is?
mineralization
What is the concept of rescue in terms of sedation?
to be able to rescue a patient from a deeper unintended level of sedation
minimal sedation definition?
drug induced state in which patients respond normally to verbal commands
moderate sedation definition?
drug induced depression of consciousness in which patients respond purposefully to verbal commands either alone or with light tactile stimulation(tap on shoulder)
deep sedation definition?
drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated verbal or painful stimlation. May lose protective airway reflexes
the physical exam before sedating a child includes?
airway evaluation looking for
tonsillar hypertrophy
abnormal anatomy like mandibular hypoplasia
effect of herbal medicines on sedation medications?
many herbal medications inhibit p450, prolonging sedative agents.
general rule of thumb to evaluate sedation recovery in a patient?
if a patient is able to stay awake for 20 minutes in a quiet environment, and discharge when they are acting the same way as when they arrived.
The vast majority of sedation complications can be managed with simple maneuvers, like?
supplemental oxygen opening the airway suctioning bag mask valve ventilation OCCASIONALLY endotracheal intubation Laryngeal mask airway(for airway obstruction)
a minimum fasting period of 2 hours is required for these items before sedation?
clear liquids, including water, juices without pulp, carbonated beverages, black coffee and clear tea
a minimum fasting period of 4 hours is required for these items before sedation?
breast milk
a minimum fasting period of 6 hours is required for these items before sedation?
infant formula
cows milk
light meal consisting of toast and clear liquids.
asa class 3?
pt with severe systemic disease(actively wheezing)
asa class 2?
pt with mild systemic disease(controlled reactive airway disease)
Recommended Discharge criteria after sedation?
easily arousable and protective reflexes intact
patient can talk
patient can sit unaided
presedation level of responsiveness is achieved
What are some of the risks associated with sedation of pediatric patients?
hypoventilation apnea airway obstruction laryngospasm cardiopulmonary impairment
Is spontaneous ventilation and cardiovascular function usually maintained in moderate sedation?
yes
Is the ability to maintain ventilatory function present in deep sedation?
Yes, but it may be impaired
Is cardiovascular function usually maintained in deep sedation?
yes
is ability to maintain ventilatory function impaired in GA? Is ability to maintain cardiovascular function impaired in GA?
yes
CVS may be impaired
what are the goals of sedation?
guard patient safety and welfare
minimize discomfort and pain
minimize psychological trauma
control anxiety
control behavior and/or movement to allow safe completion of a procedure
return patient to a state of safe discharge
What type of sedative drug is recommended for painful procedures?
analgesic medications such as opioids
what type of sedative drug is recommended for non painful procedures?
sedative/hypnotics
what patients are candidates for mild, moderate or deep sedation?
asa 1 or 2 pts
what do you do if emergency sedation is required in a patient who just drank liquid or ate food?
weigh the risk of sedation and the possibility of aspiration against the benefits of performing the procedure promptly
which drugs, if combined with midazolam, can prolong sedation?
erythromycin, cimetidine, or any others that inhibit cytochrome p450
what medications can produce drug drug interactions with common sedation drugs used in pediatric dentistry?
HIV meds, anticonvulsants, psychotropic medications. Get a consult, always.
what should be a part of the health evaluation before a sedation?
age, weight, health history including system overview, meds, allergies, any think that may increase potential for airway obstruction(history of snoring/sleep apnea), previous sedations/GAs
what vital signs should be evaluated before and after sedation?
HR
BP
RR
Temperature
what is the SOAPME acronym meaning in terms of being prepared for a sedation emergency?
S = size appropriate suction equipment O = adequate Oxygen supply A = size appropriate airway equipment(endotracheal tubes, bag valve mask) P = Pharmacy(appropriate drugs) M = Monitors(pulse ox, BP cuffs, ECG) E = special Equipment or drugs for particular case(defibrillator)
what type of monitoring is required for minimal sedation?
just observation and intermittent assessment of their sedation
what type of monitoring is required for moderate sedation?
The practitioner - who must be able to perform bag valve mask ventilation(at the minimum) to be able to oxygenate a child who develops airway obstruction or apnea. Have knowledge of PALS
Support personnel to monitor physiologic parameters, have knowledge of BLS
What monitoring is required during moderate sedation?
continuous monitoring of oxygen saturation and heart rate, and intermittent recording of RR and BP at 5 mins
what personnel is required for deep sedation?
1 person to solely monitor patient vital signs, airway patency, adequacy of ventilation and to administer drugs.
1 person trained in PALS
1 support personnel
what equipment is required for deep sedation?
need a pulse ox, heart rate monitor, bp monitor, precordial stethoscope, record RR and an ECG monitor and a defibrillator. Must establish IV line placed for deep sedation
why is capnography useful in monitoring sedations?
helps diagnose the simple presence or absence of respirations, airway obstruction or respiratory depression, particularly in patients sedated in less accessible locations. Measures expired CO2
how many personnel are required for office based deep sedation/GA?
3, anesthesiologist, dentist, office staff
Factors for high caries risk include?
DMFS greater than childs age numerous white spot lesions high levels of MS Low SES high caries rate in siblings/parents diet high in sugar frequent snacking
is it always recommended to place SSC over teeth treated with pulp therapy?
No. Can place amalgam or resin restoration in a tooth with a conservative pulpal access, sound lateral walls and less than 2 years to exfoliation
what is the total etch technique?
3 steps. An etchant to remove smear layer, primer to penetrate the dentin, then a bonding agent.
what is the self etch technique?
2 step technique. The primer and bonding agent are combined, saving a step after etching
when is the most significant window of potential exposure to BPA?
right after placing resin based composites or sealants
how can you reduce BPA exposure ?
remove the residual monomer layer after placement by rubbing with pumiced cotton roll and thoroughly rinsing with an air water syringe
What are properties of GI that make them favorable to use in children?
chemical bonding to enamel and dentin
thermal expansion similar to that of tooth structure
biocompatiable
uptake and release of fluoride
decreased moisture sensitivity compared to resins
When do you use ITR?
very young patients uncooperative patients patients with special health care needs anyone for whom traditional cavity preparation needs to be postponed caries control
ITR and ATR are most successful when applied to what teeth?
single or small 2 surface restorations
GI are recommended for use as?
cements bases and liners cl 1,2,3 and 4 restorations in primary teeth cl 3 and 5 restorations in perm teeth caries control
purpose of resin infiltration?
halt progression of small proximal carious lesions by surrounding them with unfilled resin
what is the technique of resin infiltration?
treat with hydrochloric acid
dry the surface
infiltrate over 2 applications the unfilled resin
polymerize the resin with light
when are resin based composites contraindicated?
cant achieve isolation
patients needing large multi surface restorations in posterior primary dentition
in cl 2 restorations that extend beyond the proximal line angle
in high risk patients who have multiple caries and/or tooth demineralization and poor compliance
when are labial resins or porcelain veneers indicated?
restoration of mostly permanent anterior teeth with fractures, developmental defects, intrinsic discoloration, and/or other esthetic conditions
why are removable prosthetic appliances used?
maintain space
obturate congenital or acquired defects
esthetics/occlusal function
facilitate infant speech development or feeding
when should you take a radiograph of a primary tooth pulpectomy?
right after completion to assess fill and prognosis
indications of a protective liner in a vital primary tooth?
place in a vital primary tooth when all caries has been removed to minimize injury to pulp, promote pulp tissue healing and tertiary dentin formation
Indications of a direct pulp cap in primary teeth?
only done in primary teeth with a normal pulp following a small mechanical or traumatic exposure, NOT IN TEETH WITH A CARIOUS EXPOSURE. Place MTA or CaOH
what are the indications for a direct pulp cap in young permanent teeth?
young permanent tooth with normal pulp that has a small carious or mechanical exposure. Place MTA or CaOH over exposure site.
How do you perform apexification?
in non vital young permanent teeth.
Remove coronal and radicular tissue just short of apex
irrigate with hypochlorite or chlorhexidene
place CaOH for 2-4 weeks
Root end closure done with MTA, or with absorbable collagen wound dressing to allow MTA to be packed in, then obturate with gutta percha
Non nutritive sucking habits can lead to what changes?
excess OJ, decreased overbite, open bite, narrowed maxillary arch, posterior crossbite
what are factors that can lead to bruxism?
emotional stress, parasomnias, TBI, neurologic disabilities, malocclusion, muscle recruitment
what is the management for bruxism?
patient/parent education, occlusal splints, psychological techniques, and medications
what is tongue thrusting and what can it lead to?
abnormal tongue position(forward of the normal resting positon) and deviation from the normal swallowing pattern, associated with open bite, abnormal speech, protruding maxillary incisors
what are some dental treatment modalities for self injurious or self mutilating behaviors?
lip bumpers, occlusal bite appliances, protective padding, and extractions, odontoplasty
Mouth breathers can contribute to what malocclusion?
increased facial height, anterior open bite, increased oj, narrow palate.
OSAS may be associated to what malocclusion?
narrow maxilla, crossbite, low tongue positon, vertical growth, open bite.
excluding third molars, what is the most common missing permanent tooth?
mandibular second premolar followed by maxillary lateral incisor
a congenitally missing tooth can be suspected in what patients?
patients with asymmetric eruption sequence or ankylosis of primary mandibular second molars
Are supernumerary primary teeth followed by supernumerary permanent teeth?
in 1/3 of the cases
Mesiodens are usually found in what position?
palatal/lingual
what is the best way to locate a supernumerary tooth?
parallax or slob rule
recommended treatment for supernumerary primary tooth?
Not done, usually erupts into occlusion and exfoliates normally. Surgical extraction can harm developing permanent incisors
recommended extraction time for permanent supernumerary(mesiodens)
early mixed dentition to allow perm incisors to erupt spontaneously - about 1/2 to 2/3 root development of adjacent permanent teeth.
Later removal reduces chances of spontaneous eruption. If no eruption in 6 months, use ortho extrusion
When can you suspect EE of permanent incisors?
after trauma to primary incisors
pulplly treated primary incisors
with asymmetric eruption
mesiodens
how can distal tipping of permanent molars be accomplished
brass wires(.02 size, pt seen every few days for wire tightening), separators, elastics, fixed appliance with open coil spring, halterman appliance
when is extraction of the primary maxillary canine indicated?
when canine bulge cannot be palpated in the alveolar process and there is radiographic overlapping of the canine with the formed root of the lateral during the mixed dentition
how do you treat ectopically erupting incisors?
extract the necrotic or over-retained pulpally treated primary incisor in the early mixed dentition and align orthodontically when they erupt
ankylosis in the permanent dentition occurs most frequently following what type of trauma?
luxation injuries
when is extraction of an ankylosed primary tooth recommended?
exfoliation usually occurs normally but if tooth is over-retained, then extract
when is the best time to de-rotate teeth, specifically mandibular incisors?
just after emergence in the mouth. Transseptal fibers establish after CEJ passes alveolar crest
when is space maintainence considered for a primary maxillary incisor?
when the child has an active digit habit
What are undesirable effects of space maintainers?
interference with permanent eruption caries plaque accumulation inhibition of alveolar growth pain
what are some space regaining appliances?
fixed or removable appliances including
hawley retainer
lip bumper
headgear
what is a functional shift?
when the midlines undergo a compensatory shift when the teeth occlude in crossbite
how can you correct a simple anterior xbite?
acrylic incline plane
acrylic retainer with finger springs
fixed appliance with finger spring
if space is needed, then expansion appliance also used
facial bones like the maxilla and body of mandible grow by what type of bone formation?
intramembranous
the cranial base and condyle of the mandible grow by what formation?
endochondral
which type of bone formation is more modifiable with dentofacial orthopedics
intramembranous
how does the cranial vault form?
intramembranous
where does appositional growth predominate in the mandible?
posterior border of the ramus with remodeling resorption along anterior border
when do females usually have their growth spurt?
11 - 14 years
when do males usually have their growth spurt?
13.5 - 18 years
features of hypodivergent/brachyfacial face type?
posterior face greater than anterior face height
counter clockwise condylar rotation expressed as flat mandibular plane
deep bite
features of hyperdivergent/dolicofacial face type?
anterior vertical facial growth greater than posterior face height
clockwise condylar rotation expressed as steep mandibular plane
open bite tendency
gummy smile
lip cimpetence
what is the longest growing facial dimension?
depth(antero-posterior)
3 to 6mm of primary spacing results in what spacing/crowding in the mixed dentition?
no transitional crowding
spacing less than 3mm in primary dentition results in what spacing/crowding in the mixed dentition?
20% incisor crowding
no spacing in primary dentition results in what spacing/crowding in the mixed dentition?
50% incisor crowding
mesial step(15%) molar plane usually results in what class in permanent dentition?
cl 1
ftp molar plane(75%) usually results in what class in permanent dentition?
most shift to cl 1, some stay end on or shift to full cl 2
how do you replace prematurely lost primary incisors?
hollywood brige, space loss unlikely if primary canines erupted into occlusion
second primary molar loss results in greater dimensional arch length loss in max or mand?
in max
what appliances can you use in primary dentition to correct functional posterior crossbites?
RPE of haas, hyrax
w arch
quad helix
removable schwartz plate
what appliances can be used to treat a true class 3 anterior crossbite in the primary dentition?
reverse pull headgear/facemask
chin cup
MAY also require maxillary expansion
what age should you consider intervention with a NNS habit and appliance?
before eruption of permanent anterior teeth around 5-6 years of age
what appliances can be used for NNS habits?
cribs
rakes
bluegrass appliance
what molar classification is the most common in mixed dentition?
end on class 2 with majority shifting to class 1 with late mesial shift
what is upper leeway space on avg? lower leeway space?
0.9mm per quad on upper, 1.7mm per quad on lower
what appliances can you use to regain space in the maxillary arch?
headgear
fixed molar “distalizing” appliances - pendulum or distal jet
removable appliance
what appliances can you use to regain space in the mandibular arch?
lip bumper
“active” lingual arch
removable split-saddle
vast majority of children present with what amount of incisor crowding at 8 to 9 yo?
0 to 4mm
if patient has greater than 4mm of incisor crowding and has a hyperdivergent facial profile, what is the likely therapy?
extraction therapy because it deepens the bite
if patient has greater than 4mm of incisor crowding and has a hypodivergent facial profile, what is the likely therapy?
directed toward non-extraction therapy and arch expansion to open the bite
how much space can you gain by disking the ML corner of primary canines?
1 to 2mm per side, indicated when less than 3 to 4mm incisor crowding and when laterals actively erupting
what other treatment can you perform when incisor crowding is greater than 4mm?
can ext primary canines to coincident midlines and place LLHA
how many ectopically erupting permanent molars self correct?
2/3rds
irreversible ectopic molars are diagnosed with lack of self correction by what features?
dental age 7, supraerupting lower first molar above occlusal plane
what appliances can you use to correct ectopically erupting maxillary molar?
brass ligature wire
elastic separators
disking of primary second molar distal end
fixed palatal arch wire from E’s with distalization spring to first molar(Humphrey appliance)
fixed palatal arch wire from E’s with distalization elastics to bonded button on first molar(Haltermann appliance)
what features are usually present in a dental/functional anterior crossbite?
proclined lowers, retroclined uppers
what features are usually present in a skeletal anterior crossbite?
retroclined lowers, proclined uppers
what are features of a functional posterior crossbite in the mixed dentition?
midline shift to crossbite side
cl 2 molars on crossbite side
facial asymmetry - mandible shorter on crossbite side
what appliance/biomechanics can you use to correct isolated/single posterior crossbites in mixed dentition?
cross arch elastics
what appliance can you use to correct posterior crossbites in the mixed dentition?
cross arch elastics for single/isolated posterior xbite. w arch quad helix rpe of haas/hyrax removable schwartz plate
what is the treatment/intervention for excessive mesial orientation of the permanent maxillary canine?
removal of primary canine around the time permanent canine has 2/3 root development
when do you remove supernumerary teeth?
when no harm will come to developing permanent teeth, when 1/2 to 2/3 root development of adjacent permanent teeth
To modify growth(fix xbites, cl 2/3 malocclusions), one must treat during active growth periods, such as when?
in conjunction with pubertal growth spurt or earlier
Cl 2 Div 1 malocclusion features?
normal maxilla
retrognathic mandible
vertical growth tendency
ANB>6
Cl 2 Div 2 malocclusion features?
normal maxilla
mild mandibular retrognathia
deepbite growth tendency
ANB
what functional appliances are used in a Cl 2 malocclusion with a retrusive mandible? When should you not use a functional appliance?
bionator/orthopedic corrector activator frankel herbst(displaces mandible forward, restrains maxilla) mara
They increase lower face height, dont use in dolichofacial growers!
what functional appliances are used in a cl 2 malocclusion with a protrusive maxilla?
cervical pull headgear(opens bite)
high pull headgear(deepens bite)
what functional appliances are used in anteroposterior cl 3 malocclusions?
restrain mandibular growth by:
chin cup therapy
protract maxilla by using:
extraoral reverse pull headgear(facemask)
dont use in dolichofacial growing patterns
indications of general anesthesia?
patients for whom LA is ineffective
extremely uncooperative, anxious, fearful, physically resistant patient
patients with extensive orofacial/dental trauma
patients for whom GA would protect developing psyche
contraindications to GA?
respiratory infection
active systemic disease with temperature
NPO violation
healthy, cooperative patient with minimal dental needs
how do NPO guidelines relate/differ for 3yo?
Both are 2 hours for clear liquids and less than 3 is 6 hours for solids/milks and >3yo is 8 hours for solids/milk
what are ways to manage a childs psyche before general anesthesia?
operating room tour
allowing child to bring favorite toy
allowing parent/guardian to join patient as early as possible in recovery room
asa class 4?
severe life threatening systemic disease or disorder
when is a physical examination required before GA?
within 30 days of procedure
Universal protocol for GA cases include what three topics?
SIGN IN
TIME OUT
SIGN OUT
what is part of the universal protocol of sign out?
hemostasis achieved
mouth thoroughly inspected, foreign bodies removed
throat pack removed
what monitoring equipment is recommended for GA?
precordial stethoscope bp cuff ecg temperature probe pulse ox capnograph monitors
whats the dental preop protocol for patient protection?
tape eyes
shoulder roll and head rest
stabilized endotracheal tube
drape appropriately
function of throat pack?
prevent anesthesia gas backflow and debris backflow
thoroughly irrigate and suction oro/nasopharynx before insertion
use a moist, sterile guaze
what are possible intra-operative complications during GA?
dislodged endo/nasotracheal tube
disconnected or infiltrated IV
nasal bleeding
lips and tongue edema
For post surgical orders, you want to maintain IV until patient is stable. What is calculated IV rate for a 35kg patient?
4-2-1 method. 40+20+15=75ml/hr
when do you discontinue IV fluids after a GA case?
when pt is fully awake, alert, and has taken PO fluids
What are discharge criteria for a patient following moderate/deep sedation and GA?
CV function stable airway uncompromised patient easily aroused with protective reflexes intact pain and bleeding controlled patient adequately hydrated no nausea/vomiting pt can sit unaided and ambulate with minimal assistance presedation level of responsiveness
what does the aldrete post anesthesia recovery scale look at to discharge pts?
Scale where you need >9 to discharge activity - voluntarily or on command respiration ciculation oxygenation consciousness
what post op instructions do you give to patients after sedation/GA?
encourage adequate hydration with clear liquids
soft diet day of surgery
diet as tolerated after 24 hours
limit activity day of surgery
OHI(use moistened gauze or toothettes 1-2 days post op, regular brushing and flossing 1-4 days post op)
what pain management is recommended post op?
OTC childrens tylenol or motrin q4-6 hours prn pain.
Tylenol 10mg/kg q4-6h, max 65mg/kg
Motrin(ibuprofen) 10mg/kg q 4-6h, max 40mg/kg
how do you manage nausea/vomiting post op?
phenergan .25-.5mg/kg PR
zofran IV
what are common post surgical complications immediately post anesthetic and post discharge?
nausea vomiting croup hypoxia bleeding - post discharge: low grade fever(common) sore throat
how can you manage a sore throat post op?
use ice chips or popsicles initially
define dental home
the ongoing relationship between dentist and patient/parent, inclusive of all aspects of oral health
disruptions during the initiation stage of tooth development lead to?
hypodontia or supernumerary teeth
disruptions during the morphodifferentiation stage of tooth development lead to?
anomalies of size and shape, e.g macrodontia microdontia taurodontism dens invaginatus
disruptions during the histodifferentiation, apposition, and mineralization stage of tooth development lead to?
enamel hypoplasia
AI
DI
DD
AI characteristics?
4 types: hypocalcified, hypoplastic pitted, hypoplastic generalized, hypomaturation
accelerated tooth eruption or late eruption
anterior open bite
affects all or nearly all of teeth in both primary and permanent dentition
what are pathologies associated with AI?
enlarged follicles
impacted permanent teeth
ectopic eruption
agenesis of second molars
hypocalcified AI characteristics?
normal thickness
smooth surface
less hardness
hypoplastic pitted AI characteristics?
normal thickness
pitted surface
normal hardness
hypoplastic generalized AI characteristics?
reduced thickness
smooth surface
normal hardness
hypomaturation AI characteristics?
normal thickness
chipped surface
less hardness
opaque white coloration
which collagen type is most associated with DI disorders?
type 1 collagen
what are clinical manifestations of DI?
in all 3 types:
blue-gray to yellow-brown discoloration that appears opalesecent
enamel frequently fractures off due to weak dentin support
Shields type 1 DI characteristics?
All teeth in both dentition affected, primary most severely, then perm molars and incisors bulbous crowns cervical constriction thin roots early obliteration of pulp chambers PARL and root fractures
Shields type 2 DI characteristics?
Primary and permanent dentition equally affected.
Most severe.
Bell-shaped crowns.
Opalescent hue.
“Shell teeth” (esp. primary teeth) w/ short roots + enlarged pulp chambers – LESS common feature.
Only mantle dentin formed.
Rapid wear of primary + permanent crowns.
Permanent tooth pulps small or completely obliterated.
Multiple pulp exposures (esp. primary dentition).
Regular tubules
Enamel pitting.
Shields Type III DI characteristics?
bell shaped crowns
teeth with shell like appearance and multiple pulp exposures
normal thickness enamel with extremely thin dentin
Dentin Dysplasia type 1 characteristics?
aka Radicular Dentin Dysplasia, Rootless teeth
crowns are mostly normal in color and shape
roots are short and constricted
crescent or chevron shaped pulp chambers
PCO
periapical radiolucencies, representing abscesses, granulomas, or cysts
Dentin Dysplasia type II characteristics?
aka Coronal Dentin Dysplasia normal root lengths bulbous crowns cervical constrictions thin roots amber tooth discoloration PCO thistle tube shaped pulp chambers NO PARL present
what disorder has pulpal findings similar to DD Type II?
pulpal dysplasia
thistle tube shaped pulp chambers and multiple pulp stones
what restorative care is considered for AI?
discolored enamel can be bleached or microabraded
composite resins or porcelain veneers if enamel can be bonded
if enamel cannot be bonded, full coverage restorations
what restorative care is considered for DI?
routine restorative care to treat mild to moderate DI, full coverage restorations most successful in teeth exhibiting crowns and roots as close to normal teeth
With loss of VDO, overdenture therapy can be used
bleaching
veneers
Endodontic consult if PARL present
what malocclusion is often present in DI Type 1?
Cl 3 malocclusion
posterior crossbite
open bite
what is the goal of treatment in dentin dysplasia?
to retain teeth as long as possible
what restorative care is considered for dentin dysplasia?
poor crown to root ratios indicate prosthetic replacement including dentures, overdentures, partial dentures, and dental implants.
DD type 2 with normal crown to root ratio can be restored with full coverage restorations, veneers or normal restorative care.
when does the tmj begin developing?
8 weeks after conception
from adolesence to adulthood, what happens to the condyle?
becomes greater in width than length
what are the medical conditions that can mimic TMD?
trigeminal neuralgia cns lesions odontogenic pain sinus pain otological pain neoplasias parotid diseases vascular diseases myofascial pain cervical muscle dysfunction Eagle's syndrome otitis media allergies airway congestion rheumatoid arthritis
alterations in any one or a combination of these can lead to TMD?
teeth PDL TMJ muscles of mastication hard to predict which patients will eventually develop TMD
etiologic factors contributing to TMD are?
trauma occlusal factors parafunctional habits posture changes in freeway dimension of the rest position orthodontic treatment
what are the most common mandibular fractures in children?
unilateral and bilateral intracapsular or subcondylar fractures
what occlusal factors are most associated with TMD?
skeletal anterior open bite overjet greater than 6 to 7mm CR to CO slide greater than 4mm cl 3 malocclusion 5 or more missing posterior teeth
what parafunctional habits in particular can lead to TMJ?
bruxism
clenching
hyperextension
TMDs can generally be classified into what three categories?
disorders of the muscles of mastication
disorders of the TMJ
disorders in other related areas that may mimic TMD
most effective form of treatment of TMD involved active or passive treatment?
both active(involving patient effort) and passive(stabilization splint)
reversible therapies of TMD include?
patient education(relaxation training, behavior coping strategies)
physical therapy(jaw exercises, TENS, massages)
behavioral therapy
prescription medications
splints
irreversible therapies of TMD include?
occlusal adjustment mandibular repositioning(headgear, functional appliances) orthodontics
Untreated odontogenic infections can lead to ?
pain, abscess, and cellulitis
what complaints do patients with infections of the upper face have? What do you need to rule out?
facial pain
fever
inability to eat or drink
rule out sinusitis
infections of the lower face usually involve what complaints?
pain, swelling, and trismus
infections of the lower face usually involve what anatomy?
teeth
skin
local lymph nodes
salivary glands
most odontogenic infections are managed how?
pulp therapy
extraction
I and D
to avoid inadvertent trauma or extraction of a permanent successor during primary tooth extraction, what needs to be evaluated?
primary molars with roots encircling the successors crown may need to be sectioned to protect the permanent tooths location
when does canine palatal impaction usually occur?
when the cusp tip of the permanent canine is overlaying the distal half of the long axis of the root of the permanent lateral incisor
when is extraction of the primary canines the treatment of choice?
when malformation or ankylosis is present
when the risk of resorption of the adjacent tooth is evident
when trying to correct palatally impacted canines
If no improvement in canine position occurs in how long is surgical and ortho treatment recommended?
1 year
what are some post operative complications from removal of third molars?
alveolar osteitis parathesia infection trismus hemorrhage
how often is a supernumerary in the primary dentition followed by one in the permanent dentition?
33 percent
what is a paramolar?
a supernumerary tooth in the maxillary molar area
when is a mesiodens suspected?
asymmetric eruption pattern of maxillary incisors
delayed eruption of max incisors
ectopic eruption of a maxillary incisor
complications of supernumerary teeth include
delayed/lack of eruption
crowding
resorption of adjacent teeth
dentigerous cyst formation
how does treatment of a primary supernumerary mesiodens different from a permanent mesiodens?
removal of primary mesiodens is not usually recommended
when is extraction of unerupted primary and permanent mesiodens recommended?
mixed dentition to allow normal eruptive force of permanent incisor to bring itself into the oral cavity
when adjacent incisors have at least 1/2 to 2/3 root development
when is surgical exposure necessary after extraction of a primary or permanent mesiodens?
if adjacent teeth do not erupt within 6 to 12 months after removal of the mesiodens
characteristics of epsteins pearls?
occur 75-80% of all newborns in median palatal raphe
dental lamina cysts characteristics?
crests of the dental ridges, most commonly seen bilaterally in the region of the first primary molars
bohns nodule characteristics?
remnants of salivary gland epithelium
buccal and lingual aspects of the ridge
epsteins pearls, bohns nodules, and dental lamina cysts typically present as what?
asymptomatic 1 to 3mm nodules or papules.
smooth, whitish, filled with keratin
no treatment necessary, usually disappear in first 3 months of life
congenital epulis of the newborn characteristics?
aka granular cell tumor
seen only in newborns
protuberant mass arising from gingival mucosa
most often found in anterior maxillary ridge
feeding and respiratory problems common
females 8:1 predilection
surgical excision is treatment
eruption cyst(hematoma) characteristics?
most commonly found in mandibular molar region
if the cyst does not rupture spontaneously or lesion becomes infected, roof of the cyst may be opened surgically
mucocele characteristics?
arise from rupture of a minor salivary gland excretory duct
well circumscribed bluish translucent fluctuant swellings
lower lip lateral to midline, buccal mucosa, ventral tongue, retromolar region, floor of mouth(ranula)
when is treatment suggested for maxillary frenum?
when attachment exerts a traumatic force on the gingiva causing papilla to blanch
or if it causes a diastema to remain after eruption of permanent canines. Do frenectomy after ortho closure.
when should the frenectomy be performed if ortho treatment is indicated?
when the diastema is allowed to close as much as possible and after ortho closure.
when should a mandibular labial frenum be treated?
when factors causing gingival/periodontal inflammation cannot be controlled. Early treatment can prevent subsequent inflammation, recession, pocket formation, but if food and plaque is removed and inflammation is controlled, need for treatment decreases
ankyloglossia characteristics?
short, thick lingual frenum
problems with breastfeeding, tongue mobility, speech, malocclusion, and gingival recession
frenuloplasty vs frenectomy?
frenuloplasty - various methods to release the tongue tie and correct the anatomic situation
frenectomy - cutting the frenum
There is little consensus on treatment for ankyglossia, however most professionals agree on?
if a short lingual frenum inhibits tongue movement and creates deglutition problems, frenectomy may be indicated
frenectomy techniques?
involves surgical incision, establishing hemostasis, and suturing of the wound. Dressing placement or the use of antibiotics is not necessary
Recommended to maintain soft diet, OH, and analgesics as needed
natal teeth?
present at birth
neonatal teeth?
present within first 30 days of being born
natal or neonatal molars identified in the posterior region may be associated with systemic conditions or syndromes?
pfieffer syndrome
histiocytosis x
when should natal and neonatal teeth be maintained?
when not causing feeding problems or excessively mobile
what can failure to diagnose riga fede disease lead to?
dehydration and inadequate nutrient intake for the infant
treatment for riga fede disease?
smooth incisal edges. If ineffective, then extract
when is extraction of a natal or neonatal tooth contraindicated?
in newborns due to risk of hemorrhage. Unless child is 10 days old, consult pediatrician
which oral wounds have an increased risk of infection and should be covered with antibiotics?
intraoral lacerations that appear to have been contaminated by extrinsic bacteria
open fractures
joint injuries
what needs to be taken into consideration when prescribing an antibiotic?
when to give it(usually right away) IV vs intramuscular vs oral administration how long(5 to 7 days minimum course)
if a child presents with pulpitis, apical periodontitis, draining sinus tract, or a localized intraoral swelling, are antibiotics indicated?
if no systemic signs of infection(no fever or facial swelling), then No.
if a child presents with an acute facial swelling of dental origin, are antibiotics indicated?
yes, along with treating or extracting the tooth/teeth
which antibiotic is recommended for avulsed permanent incisors(open or closed)
Tetracycline is drug of choice, but can cause discoloration. Can also give Pen V
is antibiotic therapy indicated in pediatric periodontal diseases?
in some cases, yes. Neutropenias, papillon-lefevre syndrome, leukocyte adhesion deficiency), the immune system is unable to control the growth of periodontal pathogens
what is the interaction between antibiotics and oral contraceptive use?
rifampicin, tetracycline, and penicillin antibiotics reduce oral contraceptive effectiveness during therapy and for up to one week after therapy
what are post procedural symptoms of acute infection?
fever, malaise, weakness, lethargy
When is antibiotic prophylaxis recommended?
prosthetic heart valves
previous history of IE
unrepaired or incompletely repaired cyanotic congenital heard disease
completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure
repaired CHD with residual defects at the site
cardiac transplantation recipients with cardiac valvulopathy
what other medical conditions may predispose to IE and may require antibiotic prophylaxis?
patients with compromised immune systems:
HIV
SCIDS
neutropenia
cancer chemotherapy
hematopoietic stem cell or solid organ transplantation
head and neck radiotherapy
autoimmune disease(juvenile arthritis, lupus)
chronic steroid use
diabetes
bisphosphenate therapy
what is the dosage for antibiotic prophylaxis?
oral amoxcillin 50mg/kg
IV ampicillin if unable to take oral meds at 50mg/kg
allergic to penicillins, then take clindamycin at 20mg/kg oral and IV
Is antibiotic prophylaxis recommended for patients with shunts, indwelling vascular catheters(central lines) or medical devices?
No.
Is antibiotic prophylaxis recommended for VA, VC, or VV shunts?
Yes. Ventriculoatrial, ventriculocardiac, or ventriculovenus shunts for hydrocephalus are at risk due to their vascular access.
VP shunts do not require prophylaxis.
what patients with prosthetic joints should be considered for antibiotic prophylaxis?
patients with a prosthetic joint replacement
previous prosthetic joint infection
inflammatory arthropathies(rheumatoid arthritis, lupus)
emophilia
malnourishment
what is the most frequently documented source of sepsis in the immunosuppressed cancer patient?
oral cavity
what are some acute oral sequelae as a result of cancer therapies and HCT regimens?
pain mucositis ulcerations bleeding taste dysfunction secondary infections(candidiasis, herpes simplex virus) caries xerostomia post radiation osteonecrosis trismus craniofacial and dental developmental anomalies oral graft vs host disease
what are the objectives of a dental exam before cancer therapy?
identify and stabilize or eliminate potential sources of infection
communicate with the oncology team regarding the patients oral health status
educate the patient and parents about the importance of optimal oral care
What is part of the initial evaluation before initiating cancer therapy?
medications including bisphosphonates hematological status(CBC) coagulation status immunosuppression status presence of an indwelling venous access line
what is part of the initial evaluation for HCT patients?
type of transplant
HCT source(bone marrow, peripheral stem cells)
matching status
donor
conditioning protocol
date of transplant
presence of GVHD or signs of transplant rejection
what are preventive strategies for cancer patients?
brushing teeth and tongue 2 to 3 times daily regardless of hematological status
patients with poor oral hygiene may use chlorhexidene rinses until mucositis develops. Recommend using a alcohol free chlorhexidene
frequent fluoride varnish application
what are diet recommendations for cancer patients?
recommend a non cariogenic diet and advise patients of high carigenicity of dietary supplements and oral pediatric medicines rich in sucrose
how can one prevent trismus for patients receiving radiation therapy?
oral stretching exercises/physical therapy before radiation begins
what is therapy for trismus ?
prosthetic aids to reduce severity of fibrosis
trigger point injections
analgesics
muscle relaxants
how can one reduce radiation to healthy oral tissues?
use of lead lined stents
prostheses
shields
salivary gland sparing techniques
what are important hematological considerations ANC for dental care?
ANC>2000, no need for antibiotic prophylaxis
ANC 1000-2000, use clinical judgment
ANC
what are important hematological considerations(platelet count) for dental care?
Platelet>75000: no additional support needed
Platelet 40000-75000: platelet transfusions may be considered pre and 24 hours post operatively
Platelet
what are localized and generalized procedures to manage prolonged bleeding?
sutures hemostatic agents pressure packs gelatin faoms microfibrillar collagen topical thrombin aminocaproic acid tranexamic acid
When all dental needs cannot be treated before cancer therapy is initiated, what procedures are prioritized?
infections
extractions
periodontal care
and sources of tissue irritation before treatment of carious teeth, root canal therapy for permanent teeth and replacement of faulty restorations
Is it better to do pulp therapy in primary teeth or extraction before a patient initiates cancer therapy?
May be better to do extraction to provide more definitive therapy, periodically monitor existing pulp and crowns for signs of resorption or furcal radiolucency.
what is the consensus for endodontics in permanent teeth before a patient begins cancer therapy?
symptomatic non vital teeth should receive root canal therapy 1 week before initiating therapy. If not possible, then extraction, followed by 1 week of antibiotic therapy
asymptomatic non vital teeth can receive rct when a patients hematological status stabilizes
what is the consensus on orthodontic appliances before, and cancer therapy?
if a patient has poor oral hygiene or if HCT conditioning carries a risk for the development of moderate mucositis, then they should be removed.
what is the consensus on periodontal therapy before and during cancer therapy?
reduce potential sources of infection such as pericoronitis by cutting the flap if hematological status permits, and extract those teeth with poor prognosis
Consensus on extractions before cancer therapy begins?
Extract teeth before initiating radiation therapy or bisphosphonates for cancer therapy ideally. Includes nonrestorable teeth, root tips, teeth with periodontal pockets >6mm, and consider EXT all third molars before HCT
what are the dental and oral objectives DURING immunosuppression periods?
maintain optimal oral health during cancer therapy
manage any oral side effects that may develop
reinforce patient and parents education regarding importance of optimal oral care
what is recommended if fluoridated toothpaste is burning a patients mucosa during cancer therapy?
switch to a mild flavored non fluoridated toothpaste
what is recommended if a patient cant tolerate a toothbrush during severe mucositis?
use a foam brush or super soft brush soaked in chlorhexidene
how is lip care managed during cancer therpay?
use lanolin based creams and ointments, better than petrolatum based products
how does one approach dental care during cancer therapy?
defer elective dental care and consider emergency treatment after physician consult
How do you manage mucositis during cancer therapy?
good oral hygiene
analgesics
non-medicated oral rinses(0.9 percent saline or sodium bicarbonate rinses 4-6x/day)
Mucosal coating agents like Amphojel
Palifermin(keratnocyte growth factor-1)
Philadelphia mouthwash or magic mouthwash(no signifcant evidence for these however)
how do you manage xerostomia during cancer therapy?
frequent sips of water sugar free chewing gum or candy special dentrifices for oral dryness saliva substitutes alcohol free oral rinses oral moisturizers fluoride rinses or gel recommend placing a humidifier by bedside
when can you resume orthodontic care after cancer therapy is completed?
after at least a 2 year disease free period
when patient is no longer using immunosuppressive drugs
what orthodontic strategies should be used when providing care for patients with dental sequale after cancer therapy is completed?
use appliances that minimize risk of root resorption
use lighter forces
terminate treatment earlier than normal
don’t treat the lower jaw
whats important to consider in any cancer patient who received bisphosphonates or radioation therapy to the jaws?
always receive a consult with oral surgeon/periodontist
what oral complications are correlated with phases of HCT?
oral infections gingival leukemic infiltrates bleeding ulceration TMD
How long is elective dental care usually postponed following HCT?
usually 100 days until immunological recovery has occurred
General rule for dental treatment for HCT patients?
complete it before patient becomes immunocompromised
craniofacial, skeletal and dental developmental issues are some issues seen by cancer survivors, and are more common in what age?
among children who were less than six years of age at the time of their cancer therapy
What are some long term effects of cancer therapy?
tooth agenesis
microdontia
crown disturbance(size, shape, enamel hypoplasia, pulp chamber anomalies)
root disturbances(blunting, early apical closure)
reduced mandibular length, reduced alveolar process height
permanent salivary gland hypofunction/dysfunction
What radiographs are taken for fractures and luxations in permanent teeth?
PA
occlusal view
PA with lateral angulations
what is an infraction injury?
an incomplete fracture(crack) of the enamel without loss of tooth structure
what radigraphic findings are seen in an infraction injury?
no radiographic abnormalities
what is the treatment of an infraction dental injury?
to prevent discoloration of the infraction lines, can etch and seal with resin, otherwise no treatment necessary
what is the follow up procedure for an infraction injury?
no follow up necessary unless it is associated with a luxation injury
in general what presentation provides a favorable outcome for infraction, enamel fractures, enamel dentin fractures, and enamel dentin pulp fractures?
asymptomatic teeth
positive response to pulp testing
continuing root development in immature teeth
in general what presentation provides for an unfavorable outcome for infraction, enamel fractures, enamel dentin fractures, and enamel dentin pulp fractures?
symptomatic teeth
negative response to pulp testing
signs of apical periodontitis
no continuining root development
what radiographs are recommended for an enamel fracture, enamel-dentin fracture, and enamel-dentin-pulp fracture, and why?
periapical, occlusal and eccentric exposures to rule out the possible presence of a root fracture or a luxation injury, and of lip or cheek to search for fragments or foreign materials
what is the typical follow up for an enamel fracture, enamel dentin fracture, and enamel dentin pulp fracture?
6-8 weeks and 1 year
what is the typical treatment for an enamel-dentin fracture?
bond available tooth fragment. Otherwise provisional treatment, covering exposed dentin with GI or a more permanent restoration using a bonding agent and composite resin. If exposed dentin within 0.5mm of pulp, place CaOH and cover with GI
what is the recommended treatment for an enamel-dentin-pulp fracture in young permanent teeth with immature apices and those that just recently matured?
in young patients with immature permanent teeth and in young patients with completely formed teeth, preserve pulp vitality by pulp capping or partial pulpotomy.
what material is placed on the pulp in an enamel dentin pulp fracture?
CaOH
what is recommended treatment for an enamel dentin pulp fracture in patients with mature apical development?
RCT usually the treatment of choice, although pulp capping or partial pulpotomy may be selected. If tooth fragment is available, it can be bonded to the tooth.
What clinical findings are seen in a crown-root fracture without pulp exposure?
a fracture involving enamel, dentin and cementum without exposing pulp
tender to percussion
crown fracture extending below gingival margin
mobile coronal fragment
what radiographic findings are usually seen in a crown root fracture without pulp exposure?
apical extension of fracture usually not visible, take PA, occlusal, and eccentric exposures.
what is emergency treatment for a crown-root fracture without pulp exposure?
temporary stabilize loose segment to adjacent teeth until definitive treatment plan is made
what are non emergency treatment alternatives for a crown root fracture without pulp exposure?
remove the fragment and restore the tooth
remove the fragment, perform endo treatment with a post retained crown. Preceded by gingivectomy, sometimes ostectomy
remove the fragment, perform endo treatment and orthodontic extrusion, then post retained crown
remove the fragment, surgically extrude tooth, splint, perform endo
Decoronate and submerge root for an implant later
Extract tooth with immediate or delayed implant retained crown or a bridge.
what is the follow up protocol for crown-root fracture without pulp exposure?
6-8 weeks and 1 year
what clinical findings are seen in a crown root fracture with pulp exposure?
fracture involving enamel, dentin, cementum, and exposing the pulp
tender to percussion
mobile coronal fragment
what is emergency treatment in a crown root fracture with pulp exposure?
temporary stabilize loose segment to adjacent teeth and in patients with open apices or young patients with completely formed teeth, preserve pulp vitality by partial pulpotomy, using CaOH.
RCT recommended in patients with mature apical development
what is the non emergency treatment of a crown root fracture with pulp exposure?
Fragment removal and gingivectomy - Endo, post retained crown
Orthodontic extrusion - endo, post retained crown
Surgical extrusion - splint, perform endo 4 weeks later
Root submergence-decoronation, for implant placement later
extraction with immediate or delayed implant retained crown restoration or bridge
what clinical findings are seen in a root fracture?
mobile and displaced coronal segment tender to percussion bleeding from gingival sulcus negative pulp test transient crown discoloration(red or gray) may occur
what radiographic findings are seen in a root fracture?
recommend a PA 90 degree angle film and occlusal view
fracture of the root in a horizontal or oblique plane
what is the treatment for a root fracture?
reposition, if displaced asap, check position radiographically
stabilize the tooth with a flexible splint for 4 weeks(if fracture at cervical area, longer split recommended up to 4 months)
monitor pulp healing for at least 1 year to determine pulpal status.
if pulp necrosis develops, RCT of the coronal tooth segment
what is a root fracture?
a fracture confined to the root involving the cementum, dentin and pulp
what is follow up for a root fracture?
4 weeks for clinical and radiographic and splint removal
6-8 weeks for clinical and radiographic
4 months for clinical and radiographic and splint removal for root fractures in cervical thirds
6 months for C and R
1 year for C and R
5 years for C and R
what is a favorable outcome of root fractures?
positive response to pulp testing
signs of repair between fractured segments
what is an unfavorable outcome of root fractures?
symptomatic
negative pulp response
extrusion of coronal segment
radiolucency at fracture line
what are common radiographic findings in an alveolar fracture?
fracture lines may be located at any level, from marginal bone to the root apex, take pa with several angulations, occlusal film, and panoramic
what is the treatment for an alveolar fracture?
reposition and splint, suture gingival lacerations, stabilize splint for 4 weeks
what is the follow up for an alveolar fracture?
Clinical and radiographic follow up at 4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, 5 years
what are favorable outcomes of an alveolar fracture?
positive pulp testing
no signs of apical periodontitis
what are unfavorable outcomes of an alveolar fracture?
symptomatic
negative pulp testing
signs of apical periodontitis or external inflammatory root resorption
what are clinical findings seen in a concussion?
tender to touch or percussion, not displaced or mobile
what is treatment and follow up for a concussion?
nothing, monitor pulpal status for 1 year and follow up after 4 weeks, 6-8 weeks and after 1 year.
what are clinical findings seen in a subluxation?
tender to percussion
mobility
no displacement
bleeding from gingival crevice may be noted
what is treatment for a subluxation?
normally no treatment necessary but can place a flexible splint to stabilize the tooth for patient comfort for 2 weeks
what is follow up for a subluxation?
2 weeks, 4 weeks, 6-8 weeks, 6 months and 1 year
what radiographic findings do you see in extrusive luxation?
increased periodontal ligament space apically
what is the treatment for extrusive luxation?
reposition tooth into socket, stabilize using flexible splint for 2 weeks, RCT is indicated in mature or immature young permanent teeth where pulp necrosis is expected
what is the follow up procedures for extrusive luxation, lateral luxation and intrusive luxation?
2 weeks, 4 weeks, 6-8 weeks, 6 months, 1 year and yearly for 5 years
what are some unfavorable outcomes associated with extrusive luxation, lateral luxation and intrusive luxation?
apical periodontitis
negative pulp response
breakdown of marginal bone(in which case splint for extra 3-4 weeks)
external inflammatory resorption or replacement resorption
what are clinical findings associated with a lateral luxation?
immobile
percussion gives a metallic(ankylosed) sound
fracture of the alveolar process present
what are radiographic findings associated with lateral luxation?
widened periodontal ligament space best seen on eccentric or occlusal exposures
what is treatment for lateral luxation?
reposition and stabilize for 4 weeks with flexible splint, begin RCT if pulp becomes necrotic
what are clinical findings associated with intrusive luxation?
immobile
percussion may give metallic(ankylosed) sound
what are radiographic findings seen in intrusive luxation?
PDL space may be absent from all or part of the root
CEJ located more apically in intruded tooth
what is the treatment for intrusive luxation for teeth with incomplete root formation?
allow eruption without intervention
if no movement within a few weeks, initiate orthodontic repositioning
if tooth is intruded more than 7mm, reposition surgically or orthodontically
what is the treatment for intrusive luxation for teeth with complete root formation?
allow spontaneous eruption if tooth intruded less than 3mm. If no movement after 2-4 weeks, reposition surgically or orthodontically before ankylosis can develop
3-7mm, reposition surgically orthodontically
if >7mm, reposition surgically
pulp will likely become necrotic, RCT using temp filling with calcium hydroxide and should begin 2-3weeks after repositioning
once repositionined surgically or orthodontically, splint for 4-8 weeks
what patient instructions are usually given following TDI?
avoid contact sports
soft diet for up to 2 weeks
brush teeth with a soft toothbrush after each meal
use chlorhexidine or non alcohol mouth rinse twice a day for 1 week
when is replantation of an avulsed tooth not indicated?
severe caries or perio disease
non cooperating patient
severe medical conditions(immunosuppression and severe cardiac conditions)
what would you tell a teacher regarding first aid for an avulsed tooth at the place of accident for one of her students?
pick tooth up by the crown
if tooth is dirty, run under cold water for 10 seconds and reposition it, bite on a paper towel to hold in place
if reposition not possible, place in HBS medium, cold milk or in the cheek and bring to emergency clinic
from a clinical point of view, the condition of the PDL cells of an avulsed tooth should be classified into what three groups?
PDL cells are most likely viable – replanted immediately or after a very short time
PDL cells may be viable but compromised – kept in storage medium(HBSS, saline, milk or saliva) and EO dry time 60min or kept in non physiologic storage medium
what is the treatment for an avulsed permanent tooth with a closed apex that has been replanted?
clean area
suture gingival lacerations
verify positioning clinically and radiographically
splint for 2 weeks
administer systemic antibiotics
check tetanus protection
RCT 7-10 days after replantation but before splint removal
what is the treatment for an avulsed permanent tooth with a closed apex in a physiologic medium with EO dry time less than 60 minutes?
clean root and apex with saline stream and soak tooth in saline
irrigate socket with saline
replant tooth slowly
suture gingival lacerations
verify position clinically and radiographically
splint for 2 weeks
administer systemic antibiotics
check tetanus protection
initiate RCT 7-10 days after replantation and before splint removal
what is the treatment for an avulsed permanent tooth with a closed apex that has a dry time longer than 60 min or other reasons suggesting non viable cells?
remove attached non viable soft tissue carefully with gauze
RCT can be carried our prior to replantantion or 7-10 days after replantation
treat root surface with 2% sodium fluoride solution for 20 minutes(to slow ankylosis) – not an absolute recommendation
irrigate socket with saline
replant tooth
suture gingival laceration
verify position clinically and radiographically
splint tooth for 4 weeks using flexible splint
administer systemic antibiotics
check tetanus protection
what is the goal in delayed replantation(EO>60 mins)?
esthetic, functional and psychological reasons to maintain alveolar bone contour knowing the tooth will likely be lost due to ankylosis and resorption of the root.
when may decoronation be necessary in an avulsed tooth?
when infraposition >1mm is seen
what is the treatment for an avulsed perm tooth with an open apex that has been replanted before the patients arrival at the clinic?
leave tooth in place clean area with saline or chlorhexidine suture gingival lacerations verify positioning clinically and radiographically splint for 2 weeks administer systemic antibiotics check tetanus protection goal for replanting immature teeth is potential revascularization(if does not occur, then initiate RCT)
what is the treatment for an avulsed perm tooth with an open apex where the tooth has been kept in a physiologic storage medium and EO dry time is less than 60 minutes?
if contaminated, clean root surface and apex with saline.
can consider topical application of antibiotics(to enhance chance of revascularization)
remove coagulum in the socket and replant tooth slowly
suture gingival laceration
verify positioning clinically and radiographically
splint 2 weeks
administer systemic antibiotics
check tetanus protection
goal for replanting immature teeth is possible revascularization(if does not occur, RCT recommended)
what is the treatment for an avulsed perm tooth with an open apex where the dry time is longer than 60 minutes or other reasons suggesting non viable cells?
remove attached non viable soft tissue with gauze
treat root surface with 2% sodium fluoride soak for 20 minutes(not absolute recommendation but can slow down ankylosis)
RCT tooth prior to replantation or 7-10 days later
remove coagulum from the socket with stream of saline
replant tooth
suture gingival laceration
verify positioning clinically and radiographically
stabilize for 4 weeks
administer systemic antibiotics
check tetanus protection
eventual outcome will be ankylosis and resorption of the root
what is the first choice for systemic antibiotics after replanting an avulsed tooth?
tetracycline is first choice. If discoloration risk/issue, can give Pen V or amoxicillin as an alternative in the first week after replantation.
what topical antibiotics are suggested for use in replanting an avulsed tooth with an open apex with EO dry time
mino or doxycycline 1mg per 20ml of saline for 5 min soak, aid in pulp revascularization and periodontal healing
when do you refer a patient out for tetanus booster after an avulsion?
if tooth has contacted soil or tetanus coverage is uncertain
what is the follow up protocol for replanted avulsed permanent teeth?
clinical and radiographic follow up 4 weeks, 3 months, 6 months, 1 year and yearly thereafter.
what are favorable outcomes for a replanted tooth with a closed apex?
asymptomatic normal mobility normal percussion sound no radiographic evidence of resorption or periradicular osteitis lamina dura appears normal
what are favorable outcomes for a replanted tooth with a open apex?
asymptomatic normal mobility normal percussion sound radiographic evidence of arrested or continued root formation and eruption pulp canal obliteration is expected
what are unfavorable outcomes for a replanted tooth with a closed apex?
symptomatic excessive mobility or no mobility metallic percussion sound radiographic evidence of inflammatory, infection related or ankylosis related resorption infraposition of tooth
what are unfavorable outcomes for a replanted tooth with a open apex?
symptomatic excessive mobility or no mobility metallic percussion sound radiographic evidence of inflammatory, infection related or ankylotic related resorption) or absence of continued root formation infraposition of tooth
what are treatment options for when a replanted tooth is expected to be lost?
decoronation autotransplantation resin retained bridge denture orthodontic referral
what are some of the consequences that can occur following severe injuries to primary teeth and or alveolar bone?
tooth malformation
impacted teeth
eruption disturbances
white or yellow-brown discoloration of crown and hypoplasia of permanents
what is the most common sequelae following intrusion and avulsion of primary teeth in children?
white or yellow brown discoloration of crown and hypoplasia of permanent incisors
what factors during primary tooth trauma influence treatment selection?
childs maturity and ability to cope with the situation
time for shedding of the injured tooth
the occlusion
what is recommended treatment for a primary tooth enamel fracture?
smooth sharp edges
what is the treatment and follow up for an enamel-dentin fracture in a primary tooth?
place GI over exposed dentin or build up with composite, follow up in 3-4 weeks just clinically
what is the treatment and follow up for an enamel-dentin-pulp fx, crown root fx, in a primary tooth?
preserve pulp vitality if possible with partial pulpotompy and CaOH over pulp, GI over this and then composite or EXT.
F/U 1 week clinically, 6-8 weeks clinical and radiographic, 1 year clinical and radiographic follow up
what are unfavorable outcomes of an enamel dentin pulp, crown root fx in a primary tooth?
apical periodontitis
no continued root formation
what is the treatment for a crown root fracture in a primary tooth?
fragment removal and coronal restoration if fracture involves small part of the root. Extraction in all other situations
what is the treatment for a root fracture in a primary tooth?
if coronal fragment not displaced, no treatment
if coronal fragment displaced, can reposition and splint, otherwise only extract coronal fragment and leave apical fragment
what is the treatment of an alveolar fracture in the primary dentition?
reposition any displaced segment and then splint for 4 weeks.
GA often indicated to accomplish this
what is the follow up for an alveolar fracture in primary teeth?
1 week clinically, 3-4 weeks for splint removal and clinical and radiographic eval, 6-8 weeks C and R, 1 year C and R, and every year after until exfoliation
what is an unfavorable outcome in primary teeth suffering an alveolar fracture?
apical periodontitis or external inflammatory root resorption, signs of disturbances in permanent successors
what is recommended treatment for subluxation in primary teeth?
no treatment, keep clean with soft toothbrush, swab affected area with chlorhexidine 2x/day for 1 week
what are unfavorable outcomes in concussion and subluxation and extrusive luxation in primary teeth?
dark discoloration of crown. No tx necessary unless apical periodontitis develops or a fistula.
what is the recommended treatment for extrusive luxation in primary teeth?
in immature developing primary teeth
what does a yellow discoloration of the crown indicate in primary TDI?
pulp obliteration and has a good prognosis
what is the recommended treatment for lateral luxation in primary teeth?
if no occlusal interference, allow tooth to reposition spontaneously
in case of slight occlusal interference, slight grinding indicated
with more severe occlusal interference, tooth can be gently repositioned
in severe displacement with crown dislocated in labial direction, extraction is treatment of choice
what radiographic findings are seen in intrusion in primary teeth with the apex displaced toward or through the labial bone plate?
apical tip can be visualized and tooth appears shorter than its contralateral
what radiographic findings are seen in intrusion in primary teeth with the apex displaced toward the permanent tooth germ?
apical tip cannot be visualized and the tooth appears elongated
what is the treatment for intrusion in primary teeth?
if displaced towards the labial bone plate, allow spontaneous repositioning
if displaced towards permanent tooth germ, Extract
when is splinting suggested in primary tooth TDIs?
for alveolar bone fractures and possibly for intra-alveolar root fractures
what are instructions given to parents following primary tooth TDIs?
brushing with a soft brush and use of alcohol free chlorhexidine topically on area 2x/day for 1 week
soft diet for 10 days
restrict use of pacifier
what are the general principles for the management of medical emergencies?
- stop treatment and assess situation
- position patient. If unconscious, supine with legs elevated to increase cerebral blood flow or on L side to prevent aspiraton. If status epilectus(protect patient)
- Activate EMS
- ABCs of life support/AED. Airway(head tilt, chin lift), breathing(check respirations), circulation(check pulse quality)
- Supplemental oxygen(nasal hood–> passive oxygen delivery, nonrebreather mask–> can breathe but need more oxygen, bag valve mask–>unconscious
- Calm and comfort patient
- Vital signs
- Drugs
what is the management for syncope?
- Recline, feet up
- Loosen clothing that may be binding
- Ammonia inhales
- Administer oxygen
- Cold towel on back of neck
- Monitor recovery
what is the management for airway obstruction?
stop tx
BLS, head tilt, chin lift, abdominal thrusts for foreign body, supplemental o2 for soft tissue obstruction
EMS transport
what is the management for hyperventilaton syndrome?
stop treatment BLS calm, comfort patient vital signs have patient hold breath for 10 second intervals consider o2 mask (instead of paper bag) EMS if no resolution
what is the management for acute asthma?
- Sit patient upright or in a comfortable position
- Administer oxygen
- Administer bronchodilator
- If bronchodilator is ineffective, administer epinephrine
- Call for emergency medical services with transportation for advanced care if indicated
what is the management of AMS/CVA/TIA
recognize, and stop treatment BLS with supplemental o2 rapid glucose test-treat hypoglycemia ems vital signs
what is the management of chest pain/angina pectoris?
recognize, stop treatment
BLS with supplemental o2
calm patient
vital signs
nitro 0.4mg SL tab or spray(can repeat q5mins to max of 3x) only if systolic BP>100
consider N20
if no relief after 3 doses of nitro, assume MI
what is the management of MI?
recognize, stop treatment BLS with supplemental o2 call EMS vital signs 2 baby aspirin(160mg) chewable nitro 0.4mg SL tab or spray if systolic BP>100 nitrous oxide 50% until EMS arrival
what is the management of cardiac arrest?
recognize, call for EMS
BLS with supplemental o2
AED, defibrillate if indicated
what is the management of an allergic reaction?
recognize and stop treatment BLS with supplemental o2 vital signs benadryl 25-50mg PO or deep IM(1mg/kg) epi 1:1000 IM if anaphylactic, use EpiPen for 5 years and older, EpiPen Jr for younger repeat EPI every 5-10min as needed activate EMS
what is the management of seizures?
- Recline and position to prevent injury
- Ensure open airway and adequate ventilation
- Monitor vital signs
- If status is epilepticus, give diazepam and call for emergency medical services with transportation for advanced care if indicated
what is the management of hypoglycemia?
prevent it by giving light food before an appt stop treatment, position patient BLS with supplemental oxygen rapid glucose test if conscious - Sugar PO if unconscious - glucagon 1mg IM monitor vital signs activate EMS
what is the management of local anesthetic or other drug overdose?
- Assess and support airway, breathing, and circulation (CPR if warranted)
- Administer oxygen
- Monitor vital signs
- If severe respiratory depression due to benzodiazpine OD, establish IV and give flumazenil. If severe respiratory depression due to narcotic OD, administer naloxone.
- Call for emergency medical services with transportation for advanced care if indicated
what is the management of fluoride toxicity or other poison ingestion?
recognize, stop tx and position patient call poison control BLS with supplemental oxygen EMS do not give ipecac monitor vital signs
Review the BLS healthcare flow chart
No seriously, review it.
what is asthma?
chronic inflammatory disorder of the airways
what are triggers for asthma attacks?
viral infections allergens exercise cold air GERD stress
what are examples of controllers(given daily to control chronic asthma and relievers?)
Controllers are: inhaled corticosteroids, leukotriene antagonists
Relievers are: beta agonists like Albuterol
what are some oral findings seen with asthmatics?
poss increased caries and tooth wear
oral candidiasis following steroid use. Rinse with water following steroid dose to reduce candidiasis.
decreased salivary flow following beta agonist use
gingivitis from mouth breathing
what is suggestive of poor asthma control and necessitates referral to childs physician?
use of albuterol > 2x/week
nightime awakening with symptoms >2x/week
concurrent upper respiratory illness causing asthma symptoms
when should you consult with a childs physician regarding their asthma?
systemic gluocorticoids were used in the past month
if patient had >4 oral steroid uses in the past year
what drugs are recommended for sedating an asthmatic and which are to be avoided?
recommended are benzodiazapines and hydroxyzine.
Avoid barbituates and narcotics(meperidine and morphine, can cause bronchospasm)
in which asthmatics is nitrous oxide effective and safe?
in mild to moderate asthmatics
is it safe to use local anesthetics in asthmatics?
LA with vasoconstrictors are safe to use unless a known allergy to betasulfite
what is the usual medical treatment for arthiritis?
NSAIDS and selective cox2 inhibitors are first line therapy
second line therapy are immunosuppressives including methotrexate, corticosteroids, hydroxychloroquine, gold
what are the dental considerations for patients with arthritis?
patients in chronic pain
limited movement so positioning is important
short appointments preferred
possible TMJ involvement with limited opening, decreased mandibular growth, open bite and ankylosis with destruction of condyles
children may refer to TMJ pain as earaches
children with JRA may have difficulty brushing teeth if hands or arms involved
what are the surgical considerations for patients with arthritis?
for children on aspirin, hold 10 days and preferably determine PT and PTT
patients on oral steroids may require steroid supplementation to prevent adrenal suppression
if patient taking gold or pencillamine, perform a CBC
what is wegener granulomatosis?
a systemic vasculitis affecting small and medium arteries, venules, and arterioles,
what clinical findings are seen in wegener granulomatosis?
nasal or oral inflammation with ulceration
subglottic stenosis
what is behcet disease?
vasculitides in children
what are clinical findings of behcet disease?
oral apthous ulcers
genital ulceration
ocular disease
what is treatment of the vasculitidies?
using nsaids, corticosteroids, and cytotoxic agents
what is systemic lupus erythematosus?
chronic inflammatory disorder of unknown cause
multi organ system involvement
can see oral ulcers, arthritis, seizures, hematologic disorders and much more
what medications are usually used to treat SLE?
corticosteroids NSAIDs hydroxychlorquine methothrexate cytotoxic agents
what are dental considerations for patients with SLE?
increased susceptibility to infection
assess need for sbe prophylaxis secondary to heart damage
supplemental steroids to prevent adrenal suppression
assess kidney function as renal complications are common
sjogren syndrome is a complication that has xerostomia
what oral manifestations are seen with t cell defects and neutrophil deficiencies?
oral candidiasis severe gingivitis gingivostomatitis recurrent apthous ulceration recurrent herpes simplex infection premature exfoliation of primary teeth
what clinical manifestations are seen with b cell deficiencies?
few oral complications
recurrent bacterial infections, esp pneumonia and skin infections.
what is the dental management for patients with t cell, b cell, and neutrophil defects or deficiencies?
aggressive prevention
may need CBC, WBC and platelet count before invasive procedure
extraction of pulpally involved teeth to prevent septicemia
acyclovir for recurrent herpes simplex
antifungal - nystatin, amphotericin B
chlorhexidine mouthwash
what is digeorge syndrome cause and effects?
spontaneous 3rd and 4th pharyngeal pouch development defect resulting in T cell defects and other effects. Often has VCF-Syndrome
Catch 22 C-Cardiac anomalies A- abnormal facies T- thymic hypoplasia C- Cleft palate H - hypocalcemia
what are some of the most common cancers in childhood aged 0-19 years?
Luekemias - ALL and AML
CNS Malignancies - Second most common
Lymphomas - third most common, including hodgkins disease and non hodgkins lymphoma
sympathetic nervous system tumors such as neuroblastomas
what is the most frequently documented source of sepsis in the cancer patient?
the mouth
what are some oral complications of chemotherapy and radiotherapy?
mucositis TMD xerostomia dentinal sensitivity secondary infections bleeding craniofacial and dental development abnormalities
what are some craniofacial and dental developmental abnormalities seen in patients receiving chemotherapy and radiotherapy?
tooth agensis microdontia crown disturbance(size, shape, enamel hypoplasia) root disturbances reduced mandibular length reduced alveolar process height
what ANC and platelet hematological parameters should be followed?
> 1000/mm3, no antibiotics necessary
75000, OK but be prepared to handle bleeding
what basic prioritization of procedures takes place in hematological patients?
infections, extractions, scaling, and sources of tissue irritation, followed by carious teeth, root canal therapy, and replacement of faulty restorations.
cardiac defects are associated with which common congenital disorders?
down syndrome turner syndrome marfan syndrome ehler danlos syndrome osteogenesis imperfecta
what are some symptoms seen in congenital heart disease patients?
dyspnea
cyanosis(late in L to R shunting, early in R to L shunting)
polycythemia(increase in hemoglobin concentration)
clubbing of toes and fingers
syncope
weakness
murmur
what are some common congenital heart diseases?
ASD VSD patent ductus arteriosus transposition of great vessels persistent truncus arteriosus(blood from both ventricles moves together through a single valve) Tetralogy of Fallot
what is rheumatic fever?
acute inflammatory condition that develops in some individuals following group a strep infection(strep throat). Thought to arise as an autoimmune reaction
what is rheumatic heart disease?
cardiac damage that can result from rheumatic fever mostly to mitral or aortic valve
how are heart murmurs caused?
through turbulence of blood flow through the valves and chambers of the heart
what are cardiac arrhythmias?
variation in the normal rhythm of the heart beat, due to disturbance in rate, rhythm, or conduction
what is the dental management and considerations for a patient with cardiac arrhythmias?
medical consultation to establish risk classification(low,mod,high)
minimize stressful situations
reduce anxiety with pre-med, nitrous oxide or sedation
short morning appointments
minimize use of epi
avoid GA
avoid electrical equipment that may interefere with a pacemaker
what common medications are used to control cardiac arrhytmias and what are their oral side effects?
verapamil, digoxin, propranolol, quinidine, procainamide, lidocaine and their oral effects are:
ulceration
lupus like syndrome
xerostomia
petechiae
what is the dental management for a patient with congestive heart disease?
avoid procedures that may cause a gag reflex
minimize epi use
prevent orthostatic hypotension
investigate potential bleeding problems from use of anticoagulants
what are oral complications seen in congestive heart failure patients?
infection bleeding petechiae ecchymoses drug related effects: xerostomia, lichenoid mucosal reactions
what dental procedures is antibiotic prophylaxis recommended for IE?
all dental procedures that involve manipulation of gingival tissues, the periapical region of teeth, or performation of the oral mucosa
what are dental/oral findings seen in type 1, 2, 3 and 4 diabetes?
xerostomia increased caries risk oral candidiasis burning mouth or tongue taste alteration inc. periodontal risk poor wound healing acetone breath
What are dental considerations when encountering a child with diabetes?
Get recent blood glucose levels, frequency of hypoglycemic episodes, medications
avoid hypoglycemic episodes by scheduling morning appt, short appointments, eat a light meal and take medications, minimize stress
aggressive periodontal care
what symptoms are seen during a hypoglycemic episode?
weakness, nervous, pale skin, confused, palpitations, increased sweating, hunger, tremors
what is the treatment for a hypoglycemic episode?
stop treatment
administer orange juice or soda or IM glucagon
congenital hypothyroidism aka?
cretinism
acquired primary hypothyroidism aka?
hashimotos disease(autoimmune disease)
what are oral findings associated with hypothyroidism?
enlarged tongue delayed dental development and eruption malocclusion gingival edema delayed skeletal development protruding tongue and thick lips
what are dental considerations/management for patients with hypothyroidism?
good medical history
sensitivity to stress, infection, surgery
sensitive to drugs such as sedatives and opioid analgesics
what is graves disease?
generalized overactivity of the thyroid gland
autoimmune dx
what are oral findings seen in hyperthyroid patients?
osteoporosis of the alveolar bone
dental caries and periodontal disease more likely
teeth and jaws develop more rapidly
premature loss of primary teeth with early eruption of permanent teeth
damaged salivary gland
primary adrenal insufficiency aka?
addisons diease
what are oral findings/complications associated with adrenal insufficiency?
hyperpigmentation of the skin and mucous membranes
delayed healing
infection
what are dental considerations to take into account for patients with adrenal insufficiency?
dental infection can cause adrenal crisis in patients with adrenal insufficiency
children with adrenal insufficiency are high risk patients, obtain medical consult
to avoid adrenal crisis, ask patient to take glucocorticoid as physician prescribes
schedule morning appointment only
For dental extractions or surgery, likely have to inc steroid dose
what syndrome is characterized by hyperadrenalism?
Cushings syndrome
what are some dental findings associated with hyperadrenalism?
osteoporosis
delayed wound healing
what dental management considerations are taken into account for patients with hyperadrenalism?
susceptibility to fracture
implants contraindicated
what oral pathology is seen in hyperparathyroidism patients?
hyperparathyroidism=hypercementosis
loss of lamina dura
decreased density of bony trabeculae, ground glass appearance
loss of cortication of the inferior border of the mandible and the mandibular canal
lyric bone cysts in the jaw
vague jaw pain and sensitivty to percussion
soft tissue calcification of the salivary glands
pulp stones
what oral pathology is seen in hypoparathyroidism patients?
circumoral paresthesia enamel hypoplasia delayed eruption enamel attrition short, blunted roots dentin dysplasia malformed or impacted teeth partial anodontia predisposition to oral candidiasis
what dental findings are seen in hypopituitarism?
decreased linear facial measurements delayed tooth eruption smaller mandible small crowns in the gingivo-occlusal dimension reduced root length crowding and malocclusion due to small dental arch hypofunction of salivary glands and decreased salivary flow at risk for caries and periodontal disease delayed development hypodontia
what are some dental considerations to keep in mind when treating a patient diagnosed with hypopituitarism ?
good medical history,
growth and development assessment as part of early orthodontic evaluation,
dental caries prevention and treatment,
periodontal disease prevention and management
what dental/oral findings are seen in a patient diagnosed with hyperpituitarism?
frontal bossing enlargement of nose and lips – prognathism – malocclusion – increased spacing between the teeth (intradental separation) – macroglossia – temporomandibular arthritis – macrodontia – hypercementosis – radiodense cortical plate
what dental considerations should be taken into account when treating a patient with hyperpituitarism?
- Consult with physician as appropriate
- IE (SBE) consideration
- Management of craniofacial abnormalities
- Sedation considerations: sleep apnea (50% of patients), snoring due to increased soft tissue mass in the airways
what are anemias?
a reduction in the red blood cell volume or hemoglobin concentration below the range or values that occur in healthy people(12-18g/100ml)
what are dental considerations for a low risk anemia patient?
if the cause is known, is being treated, or patient has normal hematocrit, treat as a normal dental patient
what are the dental considerations for a high risk anemia patient?
patient receiving frequent therapy, patient with bleeding problems
get hematology consult
defer elective treatment until stable
treatment goals are aimed at minimizing stress
deep sedation, general anesthesia, and invasive surgical procedures may require hospitalization
what clotting factor is deficient in hemophilia A? B?
8, 9
what drugs can cause platelet dysfunction?
aspirin
ibuprofen
naprosyn
what important topics must be discussed in the oral history for patients suffering from anemias and other bleeding disorders?
Hematology consult
History: frequent nose bleeds; heavy menstrual flow; easy bruisability, family history of bleeding disorders
Physical findings: petechiae and ecchymosis; generalized spontaneous gingival hemorrhage
Lab screening, PT, PTT and platelet count
what management considerations are done for moderate and high risk anemics and other patients with bleeding disorders?
medical consult, may be necessary to treat in hospital
hemophilias treated with factor replacement
Bring to 40-50% normal level for restorative and 80-100% for extractions
Vasopressin acetate(DDAVP) for mild to moderate factor 8 deficiecny
Amicar or cyclokapron as antifibrinolytic supplement post treatment
nasotracheal intubation may be contraindicated
what is usually seen in impetigo contagiosa
self limiting
tiny pustules that rupture without pain, see perioral skin involvement, intraoral lesions are not seen
what are some findings seen in bacterial pharyngitis?
Diffuse erythema and inflammation of the tonsils and their pillars, petechaie of the soft palate, and pharynx with anterior cervical lymphadenopathy
what oral findings are seen in syphilis?
primary chancre (oral mucosa, gingiva, or lips)
mucous patches
oral gummas
congenital dental anomalies(hutchinsons incisors, mulberry molars)
Tuberculosis is associated with what oral findings?
Associated with chronic oral ulcers, granulomas, jaw osteomyelitis, cervical lymphadenitis, and salivary gland involvement
what is seen in hand foot and mouth disease?
Oral vesicles with rapid ulceration, 5-10 in number; occasional regional lymphadenopathy
what is the differential diagnosis for hand foot and mouth disease?
aphthous stomatitis chickenpox erythema multiforme herpes simplex virus herpangina
what oral findings are seen in herpangina?
coxsackie a virus Oropharyngeal vesicles and ulcerations involving soft palate, uvula, tonsils, anterior pillars, posterior pharynx
what is the differential diagnosis for herpangina?
herpes simplex virus, bacterial pharyngitis, infectious mononucleosis, hand-foot-mouth disease
what oral findings are seen in acute herpetic gingivostomatis?
small punctuate vesicles that rupture to form
shallow ulcers with smooth margins surrounded by a red halo;
lesions occur in
all areas of the mouth with gingiva and lips most common;
gingiva shows acute
inflammation
what oral findings are seen in chickenpox and what are the differential diagnosis?
oral vesicles and ulceration DD: contact dermatitis, herpes simplex virus, impetigo, urticaria
condyloma acuminatum papules usually occur where?
on nonkeratinized mucosa i.e. lips, floor of the mouth, lateral and ventral surfaces of the tongue, buccal mucosa, soft palate; rarely on gingiva
the major target cell for infection in HIV is?
CD4 cells
what oral manifestations are seen in HIV patients?
fungal infections with candidiasis most common,
viral infections (HSV infection),
bacterial infections including necrotizing ulcerative
gingivitis and/or periodontitis,
hairy leukoplakia (rarely in children),
non-Hodgkin’s lymphoma,
salivary gland enlargement with parotitis most common, oral bleeding due to thrombocytopenia,
recurrent aphthous stomatitis,
linear gingiva erythema
how do you treat oral candidiasis?
5 to 7 day course, topical nystatin, clotrimazole troches, systemic flucozonale
how do you treat angular chelitis?
topical imidizole cream
how do you treat herpes simplex virus seen in HIV or other immunocompromised patients?
systemic acyclovir
how do you treat linear gingival erythema?
optimal plaque control, chlorhexidine rinses
what oral forms of candidiasis are seen?
pseudomembranous (thrush) or atrophic (erythematous); thrush can involve the lips, tongue, gingiva, buccal mucosa, and palate;
atrophic candidiasis: scraping of
lesions reveals erythema and bleeding at base; glossitis also seen
what is dialysis?
artificial means of removing nitrogenous and other toxic products of metabolism from the blood and to maintain fluid and electrolyte balance
when should dental care be scheduled for dialysis patients?
soon after dialysis and avoided before receiving dialysis
what is the definition of autism?
a disorder of neural development characterized by impaired social interaction and communication, and by restrictive behavior
What are characteristics of asperger syndrome?
relatively strong verbal skills
trouble with social situations and sharing enjoyment
obsessive interests
what are characteristics of autistic children?
– severe language problems – lack of interest in others – repetitive behaviors – resistance to change – irrational routines
what are dental considerations for autistic patients?
desensitization(may take several visits) positive reinforcement keep sentences short and simple music can be an aid use parents help when demonstrating toothbrushing, use patients limbs instead of demonstrating yourself use the same people as previous appointment use the same treatment room
what oral findings are seen in down syndrome patients?
– higher incidence of periodontal disease
– altered eruption and malocclusion(cl 3)
– anomalies in tooth morphology
– drooling
– macroglossia
– clenching and bruxism
– high vaulted palate
what medical history should be asked to parents of children with seizures?
- Type
- date of last seizure, how many
- how well controlled, date of last hospitalization for seizure
- History of injuries from previous seizures
- Duration
- Triggers
- Medications and compliance
- Diet
what is the oral evaluation and management considerations for patients with seizures?
• Make sure patient has taken medications and has eaten
• Schedule when patient has not recently been ill and when seizures are less likely to
occur in the day
• Schedule when well rested
• Xylocaine decreases seizure threshold
• Dental light may trigger a seizure so consider dark glasses
• Avoid sudden unexpected movement
• Aggressive oral hygiene program
what is MELAS?
classic mitochondrial disorder Mitochondrial Myopathy Encephalopathy Lactic Acidosis Stroke Like Episodes
what are common oral findings seen in mitochondrial disorders?
acid erosion due to increased vomiting
when do neural tube defects usually occur?
3-4 weeks in utero, before mom even knows she is pregnant
what are dental considerations for patients with neural tube defects such as spina bifida, arnold chiari malformation?
• Latex allergy precautions
• Consultation with patient’s physician regarding nature of defect and past medical
history
• Some patients with neural tube defects have mental disabilities
• In adolescence, some spina bifida patients develop depression
• Access for wheelchair
• Antibiotic prophylaxis for patients with VA or VV shunt for hydrocephalus
• Consider treatment in wheelchair inclined slightly or in dental chair at more
upright position– supine position may be difficult for patient
• For patients with Arnold-Chiari malformation, consider treatment with patient in a more upright position
define cerebral palsy and what are some characteristics?
- Nonprogressive disorder resulting from malfunction of the motor centers and pathways of the brain
- Characterized by paralysis, weakness, incoordination or other aberrations of motor function
what are characteristics of the spastic type of cerebral palsy?
tightness, stiff or rigid muscles, contractures and lack of control (most common form with 70-80% of all cases)
what are characteristics of the dyskinetic(athethoid) type of cerebral palsy?
slow, writhing, involuntary movements, hypotonia (10-15%
of cases)
what are characteristics of the ataxic type of cerebral palsy?
tremors or uncoordinated voluntary movements (5% of cases)
what clinical manifestations are seen in cerebral palsy?
- Intellectual disablity 60%
- Seizure disorders 30-50%
- Sensory deficits 35%
- Speech disorders
- Joint contractures, hip dislocation, spinal disorders
- Microcephaly frequently present
- GI problems- GERD
- Spasticity
what oral/dental findings are seen in cerebral palsy patients?
- Periodontal disease
- Dental caries-poor oral hygiene
- Malocclusions-anterior open bite, Angle Cl II
- Bruxism
- Increased erosion
- Trauma and injury
- Hyperactive bite reflex
- Increased gag reflex
- Dysphagia
- Increased drooling
- Mouth breathing
what dental considerations are taken into account when treating cerebral palsy patients?
• Assistive stabilization and postural maintenance
– Place and maintain your patient in the center of the dental chair
– Do not force limbs into unnatural positions
– Consider treating in wheel chair
– Stabilize patient’s head during treatment
– Consider supports for limbs
• Use mouth props or finger splints
• Keep patient’s back slightly elevated to minimize swallowing difficulties
• Forewarn patients of stimuli to minimize startle reactions
what are muscular dystrophys and what is the most common one of childhood?
A group of familial disorders in which degeneration of muscle fibers occurs
Duchenne
what are common dental/oral findings seen in muscular dystrophy patients?
- Plaque/gingivitis
- Higher caries rates
- TMD problems
- Poor oral control
- Trauma and injury
what are dental considerations for patients with msucular dystrophys?
- Supports (e.g., mouth props) help with muscle weakness during treatment
- May need transfer to dental chair and postural support
- Sedation and/or general anesthesia
- deficits in protective airway reflexes
- Should not place patient in a supine position
- short appointments
what are common infant soft tissue lesions?
Neonatal cysts such as epstein pearls, bohns nodules, dental lamina cysts
where do you find epstein pearls?
occurs on the palatal midline
where do you find dental lamina cysts?
aka gingival cyst of the newborn, occurs on alveolar mucosa
where do you find bohns nodules?
occurs on junction of hard and soft palate
what do the three neonatal cysts have in common?
white papules that slough off
what are characteristics of riga fede disease?
– chronic trauma from primary incisors
– ulcerated lesion or mass on anterior ventral tongue
what is treatment for riga fede disease?
identify the cause;
modify feeding position and bottle used;
smooth incisal edges;
apply chlorhexidine rinse to ulcer for secondary infection; topical steroids may be indicated
you can see tongue trauma in certain patients? What conditions may have neuropathologic ulcers?
familial dysautonomia Lesch-Nyhan syndrome Gaucher disease cerebral palsy Tourette
what are characteristics of a vascular malformation: an uncommon infant soft tissue lesion?
– present at birth and is persistent
– tends to grow with child
– occurs in the head and neck region, including facial skin
– may be associated with skeletal changes and be intrabony
– red, purple, blue macule, nodule of diffuse swelling
what are characteristics of hemangioma: an uncommon infant soft tissue lesion?
– may involve major salivary glands, usually parotid
– diffuse enlargement of gland
– normal or reddish-blue skin coloration
– regresses with age
what are characteristics of lymphangioma - cystic hygroma: an uncommon infant soft tissue lesion?
– diffuse swelling of cervical region of neck, parotid gland
– compromised airway
– does not regress
– tx: may include surgery
what are characteristics of neonatal alveolar lymphangioma: an uncommon infant soft tissue lesion?
– present at birth
– usually occurs in African American males
– Alveolar ridge; mandible more common than maxilla
– Translucent pink to blue, fluctuant swelling
– tx: none; resolves spontaneously
what are characteristics of congenital epulis; a rare infant soft tissue lesion?
– firm pink to red mass arising from alveolar mucosa at birth
– maxillary lateral and canine region most common site
– females > males
– maxilla > mandible
– tx: excision
what are characteristics of melanotic neuroectodermal tumor of infancy: a rare infant soft tissue lesion?
– smooth surfaced expansile lesion of alveolus
– anterior maxilla most common site
– may be pigmented
– usually occurs in infants under 6 months
– maxilla > mandible
– displacement of teeth
– X-ray: poorly circumscribed radiolucency with floating teeth
– tx: excision
what are characteristics and treatment of hemifacial hypertrophy: an rare infant lesion?
– unilateral oral and facial enlargement, usually evident at birth
– involves soft tissues, bone, tongue, palate, teeth
– teeth may exfoliate and erupt prematurely
– intellectual disability in 25%
– increased incidence of embryonal tumors (Wilm tumor, hepatoblastoma)
– tx: cosmetic surgery; orthodontics
what are characteristicis of hemifacial microsomia(Goldenhar syndrome): a rare infant lesion?
– unilateral microtia, macrostomia(wide mouth) and failure of formation of mandibular ramus and condyle
– unknown etiology
– frequent eye and skeletal involvement
– 50% have cardiac pathology—VSD, PDA
– tx: orthognathic surgery, distraction osteogenesis
what are the types of white oral pathology lesions?
ones that wipe off - nonadherent
ones that don’t wipe off - adherent
what are characteristics of candidiasis and treatment?
– increased susceptibility with long-term antibiotics, corticosteroids, drugs that cause xerostomia, debilitating disease, oral appliances
– oral lesions: multifocal white or red patches that may burn
– pseudomembranous form is white and wipes off
– chronic hyperplastic form is rare; may be associated with endocrine disease; and is red, white and adherent
– tx: nystatin, clotrimazole, ketoconazole, fluconazole, itraconazole
what are characteristics and treatment of the white lesion of leukoedema?
– most prominent in African Americans
– bilateral, filmy white, adherent, wrinkled patches
– stretching of mucosa causes lesion to disappear
– increase thickness of mucosa, intracellular edema of
– tx: none
what are characteristics and treatment of the white lesion of frictional keratosis/cheek and tongue biting lesions?
– white, smooth to shaggy, adherent patches; nontender
– may observe a prominent linea alba on buccal mucosa
– usually on gingiva, buccal mucosa, lateral tongue
– tx: none; reversible lesion
what are characteristics and treatment of the white lesion of mucosal burn(chemical, thermal)?
– thermal burn is common and is due to pizza, soup, etc
– usually occurs on palate and tongue
– chemical burn is caused by a number of agents, including aspirin, formocresol, ferric sulfate, phosphoric acid, phenol
– usually occurs on gingiva, buccal, labial mucosa, perioral skin
– irregular red erosion or white necrotic patch that wipes off; tender
what are characteristics of the white lesion of fordyce granules?
– Ectopic sebaceous glands in oral mucosa
– Becomes more prominent during puberty
– Flat to slightly elevated, submucosal yellow-white papules or plaques
– Common sites are buccal mucosa and lips
– tx: none
what are characteristics and treatment of the white lesion of cinnamon contact stomatitis?
– cause: flavoring agent in oral hygiene products, candy, gum
– occurs on buccal mucosa and lateral tongue
– white, shaggy, adherent patches with erythema; tender
– tx: identify cause and discontinue offending agent
what are characteristics and treatment of the white lesion of smokeless tobacco keratosis?
– chewing tobacco, snuff, snus
– occurs in the vestibular mucosa
– white, wrinkled, adherent plague; gingival recession, stained, sensitive teeth, root
caries, halitosis
– precancerous lesion
– tx: reversible if discontinue the habit; persistent lesions require a biopsy
what are characteristics and treatment of the rare white lesion of white sponge nevus?
– autosomal dominant
– diffuse, white, thickened, adherent and wrinkled oral mucosa; becomes more prominent in adolescence
– present at birth, may involve other mucosal sites
– tx: none; persistent condition
what are characteristics and treatment of the localized gingival lesion of parulis?
– odontogenic or gingival infection; entrapped foreign body
– red or pinkish white nodule with purulence; fluctuates in size
– soft and tender to palpation
– tx: treat source of infection; curette lesion; antibiotics may be indicated
what are characteristics and treatment of the localized gingival lesion of pygoenic granuloma?
– reactive lesion due to irritation
– occurs anywhere in mouth but gingiva is common site
– sessile, red nodule that bleeds freely
– surface ulceration is common
– soft, friable and nontender to palpation
– tx: surgical excision, removal of irritant
what are characteristics and treatment of the localized gingival lesion of irritation fibroma?
– reactive hyperplasia due to chronic trauma
– occurs on buccal mucosa, tongue, gingiva, tongue
– pink, smooth nodule; nontender
– tx: surgical excision
– variant: frenal tag
what are characteristics and treatment of the localized gingival lesion of peripheral ossifying fibroma?
– reactive lesion
– only occurs on the gingiva
– firm, pink or red nodule that begins in the interdental papilla; usually ulcerated
– may displace or loosen teeth
– X-ray may show calcification
– tx: surgical excision down to periosteum
– recurrence rate – up to 16%
what are characteristics and treatment of the localized gingival lesion of eruption hematoma?
– soft tissue dentigerous cyst
– associated with eruption of primary and permanent teeth
– red, purple swelling of alveolar mucosa
– X-ray may show an enlarged follicular space
– tx: none, unless delayed eruption
what are characteristics and treatment of the localized gingival lesion of squamous papilloma?
– caused by human papillomavirus
– occurs on soft palate, tongue and labial mucosa; uncommon on the gingiva
– pink or white papillary, pedunculated nodule
– tx: excisional biopsy
– tx: important to rule out condyloma acuminatum
what are characteristics and treatment of the localized gingival lesion of peripheral giant cell fibroma?
– reactive lesion caused by local irritation
– occurs on gingival or alveolar mucosa only
– red or purple nodule that may bleed
– may cause superficial bone resorption
– tx: surgical excision and remove local irritation
– there is a 10% recurrence rate
– may represent central bony lesion with soft tissue extension
what are characteristics and treatment of the localized gingival lesion of giant cell fibroma?
– fibrous hyperplasia of unknown cause
– occurs on gingiva, tongue, hard palate
– pink, smooth to stippled nodule; nontender
– tx: surgical excision
– developmental variant: retrocuspid papilla
what are characteristics and treatment of the generalized gingival lesion of linear gingival erythema?
– HIV-related gingivitis
– distinct linear band of fiery red and edematous attached gingival that may extend beyond the mucogingival junction
– does not respond to normal plaque control
– tx: chlorhexidine rinse; antifungal agents
what are characteristics and treatment of the generalized gingival lesion of plasma cell gingivitis?
– allergic reaction to multiple allergen including toothpaste, candy, chewing gum, mouthwash
– diffuse enlargement of the attached gingival of sudden onset
– bright red and swollen tissues that burn
– tx: identify and eliminate the allergen; topical steroids
what are characteristics and treatment of the rare generalized gingival lesion of gingival fibromatosis?
– may be familial or idiopathic
– diffuse, multinodular overgrowth of fibrous tissue of gingiva
– autosomal dominant, if familial
– may be associated with several syndromes; may be associated with hypertrichosis
– clinically identical to phenytoin-induced gingival overgrowth
– may delay eruption of teeth and malocclusion
– tx: surgical excision; recurrence is common
what are characteristics and treatment of the rare generalized gingival lesion of leukemia?
– gingivitis secondary to neutropenia
– gingival enlargement due to leukemic infiltrates, especially in myelomonocytic types
– other signs include spontaneous gingival bleeding, mucosal petechiae and ecchymosis, ulcerations, tumor-like growths, mobility of teeth
what are some systemic factors associated with gingivitis?
– hormonal changes, pregnancy – diabetes mellitus – systemic lupus erythematosus – scurvy (vitamin C deficiency) – Down syndrome and other syndromes – immune dysfunction – heavy metal poisoning
what are the two types of pigmented lesions?
- Pigmented lesions that are localized or solitary
* Pigmented lesions that are generalized or multiple
what are common localized pigmented lesions?
- Amalgam/graphite tattoo: grey macule on the gingival and palate
- Melanocytic nevus: common on skin but rare in mouth; usually on the palate
- Melanotic macule: usually brown macule on the lower lip
what are rare localized pigmented lesions?
Melanoma
Melanotic Neurotectodermal tumor of infancy
Oral Melanoacanthoma
what is a common generalized pigmentation?
brown hairy tongue: exogenous staining of elongated filiform papillae
what is an uncommon generalized pigmentation?
Smokers Melanosis: brown patch on anterior gingiva and labial mucosa; usually in females; may be localized
what are characteristics of the rare generalized pigmentation of endocrine disease?
– Addison disease
– adrenal insufficiency
– weakness, nausea, vomiting, low BP, pigmentation
– oral: diffuse grey patches
what are characteristics of the rare generalized pigmentation of peutz-jeghers syndrome?
– autosomal dominant
– melanin hyperpigmentation of lips
– benign polyposis of small intestine; up to 9% become malignant
– buccal lesions less likely to fade than lip lesions
what medications can cause generalized pigmentation of the oral cavity, usually the hard palate and gingiva?
antimalarial drugs (chloroquine),
antibiotics (minocycline),
hormones (estrogen),
tranquilizer (chlorpromazine) produce grey coloration of mucosa
what generalized pigmentation does ingestion of bismuth produce?
gingivostomatitis similar to NUG
blue-black pigmentation of interdental papillae
what generalized pigmentation and characteristics does ingestion of lead produce?
salivary gland swelling and dysphagia
grey pigmentation of marginal gingiva
what generalized pigmentation and characteristics are seen in mercury ingestion?
ropy, viscous saliva
faint grey alveolar gingival pigmentation
periodontal disease similar to NUG
what generalzied pigmentation are seen in silver ingestion?
skin slate grey
diffuse pigmentation
what generalized pigmentation are seen in copper ingestion?
blue-green gingiva and teeth
what generalized pigmentation are seen in zinc ingestion?
blue-grey line on gingiva
periodontal involvement
what generalized pigmentation are seen in hemochromatosis?
• Hemochromatosis—iron storage disease
– bronzing of skin and grey pigmentation of palate
what are characteristics of neurofibromatosis?
generalized pigmentation and café au lait macules and pigmented neurofibromas
what are characteristics of mccune albright syndrome?
café au lait macules, endocrine disease, polyostotic fibrous dysplasia
what are characteristics of the hemorrhagic lesion of heriditary hemorrhagic telangiectasia(aka Osler-weber renu syndrome)?
– autosomal dominant
– multiple dilated capillaries (telangiectasia) of skin and mucous membranes
– lesions blanch with pressure
– arteriovenous fistulas of lung, liver, brain – increased risk for abscesses
– bleeding from mouth secondary only to epistaxis
– all dental manipulation must be atraumatic as possible
– prophylactic antibiotics may be indicated with AV fistulas
what other hemorrhagic lesions are seen and should be included in a differential diagnosis?
acquired coagulation disorders thrombocytopenia Factor 8 deficiency Factor 9 deficiency Von willebrand disease Vitamin K deficiency Liver disease Sturge Weber
what are characteristics of of the hemorrhagic disorder of liver disease?
– diminished absorption of fat soluble Vitamins A, D, E, K (Vitamin K needed for
production of prothrombin, Factors VII, IX, X)
– liver produces all coagulation factors except VIII and possibly XIII
what are characteristics of the hemorrhagic disorder of sturge weber angiomatosis?
– congenital port wine stains of face that follows the trigeminal nerve
– leptomeningeal angiomas
– ipsilateral facial angiomatosis usually
– ipsilateral gyriform calcifications of cerebral cortex
– intellectual disability
– seizures
– hemiplegia(paralysis of one side of the body)
– ocular defects
– bleeding, pyogenic granulomas, gingival hyperplasia and alveolar bone loss with gingival involvement
what are some differential diagnosis for lip and buccal mucosa swellings?
mucocele trauma-hematoma irritation fibroma verruca vulgaris lipoma multifocal epithelial hyperplasia(heck disease) angioedema traumatic neuroma benign mesenchymal neoplasm benign and malignant salivary gland tumors MEN 2B nasolabial cyst
what are characteristics of verruca vulgaris?
– common on skin but uncommon in mouth
– caused by HPV 2, 4,6,40
– occurs on skin, especially hands, face
– oral sites include lip vermilion, labial mucosa anterior tongue
– pink or white stippled to papillary nodules; usually multiple
– tx: excisional biopsy in mouth
what are characteristics of the lip and buccal mucosa swelling of lipoma?
– well circumscribed submucosal mass – soft, freely movable – yellow color – common on buccal mucosa, tongue, floor of mouth – tx: surgical excision
what are characteristics of mulifocal epithelia hyperplasia(Hecks disease)?
– caused by HPV 13, 31
– risk factors include genetics, ethnicity, poverty, malnutrition, poor hygiene, HIV
infection
– numerous pink nodular lesions with a stippled, flat-topped to papillary surface
– labial and buccal mucosa, tongue are common sites
– may be mistaken for condylomas
– tx: excise large lesions; may spontaneously resolve
what are characteristics of multiple endocrine neoplasia 2b besides seeing lip and buccal mucosa swellings?
– autosomal dominant
– Marfanoid body, narrow facies, full lips
– mucosal neuromas of lips, tongue, buccal mucosa and gingiva
– medullary carcinoma of the thyroid
– pheochromocytoma(tumor of adrenal medulla releasing epi and norepi leading to raised bp, palpitations, headaches)
what are characteristics of the nasolabial cyst?
– results from entrapment of epithelium along junction of maxillary, lateral nasal,
and globular process
– females > males
– tx: surgical excision
what are characteristics of vascular malformations besides macroglossia?
– present at birth
– become clinically evident in late infancy or childhood
– may increase in size following trauma, infection, or endocrine changes
– red, purple, blue macule of nodule
– 35% associated with skeletal changes
– may involve the jaws
– important signs: thrill, bruit, warmth, pain, bleeding, ulceration, tooth mobility
what are characteristics of lymphangioma besides macroglossia?
– diffuse vs. cystic – tongue most common site – usually pink in color – surface often papillary and vesicular – usually occur early in life – tx: surgical excision; commonly recurs
what are characteristics of hemangioma besides macroglossia?
– vascular tumor of infancy – flat or raised blue-red lesion – usually develop first year of life – blanches on pressure – usually involutes by adolescence
what are characteristics of granular cell tumor besides macroglossia?
– dorsal tongue most common site
– pale, smooth or slightly stippled nodule
– probably derived from nerve tissue
– tx: surgical excision
what are characteristics of hamartoma and choristoma besides macroglossia?
– tongue is most common site
– may be associated with syndromes such as oral-facial-digital syndrome
– tx: surgical excision
what are characteristics of down syndrome besides macroglossia?
– microdontia, oligodontia(congential absence of 6 or more teeth excluding third molars) – Class III malocclusion – open-mouth posture – fissured tongue – decreased caries (historical) – increased periodontal disease – delayed eruption and over-retained teeth – tooth morphological abnormality – abnormal palate shape (70%) – enamel hypoplasia
what are characteristics of cretinism besides macroglossia?
– congenital hypothyroidism (myxedema in adults)
– intellectual disability, retarded somatic growth
– shortening of cranial base—retraction of nose with flaring
– mandible underdeveloped, maxilla overdeveloped
– tongue enlargement secondary to edema, delayed tooth eruption, exfoliation
– progressive infiltration of skin and mucous membranes by glycoaminoglycans
– tx: thyroid replacement therapy
what are characteristics of the various storage diseases the mucopolysaccharides such as hurlers and hunters syndrome besides macroglossia?
– short stature – coarse facies, large head – decreased IQ – nasal bridge depressed – enlarged lips – open-mouth and protruding tongue after 5 years – widely spaced teeth – localized areas of bone destruction – enlarged dental follicles; delayed tooth eruption
what are characteristics of beckwith wiedeman syndrome besides macroglossia?
– omphalocele or umbilical hernia – cytomegaly of adrenal cortex – renal medullary dysplasia – hyperplastic visceromegaly – postnatal somatic gigantism – mild microcephaly – severe hypoglycemia – neoplasms (nephroblastoma most common)
what are characteristics of lingual thyroid besides macroglossia?
– developmental lesion – ectopic thyroid tissue in tongue – located midline base of tongue – hypothyroidism (33%%) – tx: thyroid replacement therapy; +/- surgery
what are characteristics of raunula besides sublingual swellings?
– mucous retention in oral floor
– dome shaped, painless, soft swelling of normal or blue color
– unilateral; fluctuates in size
– involves submaxillary or sublingual gland
– tx: excision or marsupialization
what are characteristics of sialolithiasis besides a sublingual swelling?
– calcium salts around focal debris in duct
– usually involves Wharton’s duct
– episodic pain and swelling when eating
– yellow-white mass may be seen close to ductal orifice
– X-ray: may aid in detection
– tx: gentle message, salivary stimulation, surgery
what are characteristics of the oral lymphoepithelial cyst besides sublingual swellings?
– entrapped epithelium within lymphoid tissue
– undergoes cystic degeneration
– occurs in oral floor, soft palate, tonsillar region and lateral tongue
– persistent yellow-white nodule
– tx: observe or excisional biopsy
what are common causes of soft tissue neck swellings?
reactive lymphadenopathy - secondary to odontogenic infections or viral infections.
what are uncommon causes of soft tissue neck swellings?
Lipoma
Epidermoid Cyst
Infections Mononucleosis - caused by EBV(see fever, palatal petechia, pharyngitis)
HIV associated salivary gland disease
what are characteristics of cat scratch fever besides soft tissue neck swellings?
– caused by Bartonella henselae
– usually due to scratch or bite from cats
– scratches on face result in submandibular lymphadenopathy or enlarged parotid
lymph nodes
– tx: usually resolves within 4 months; antibiotics may be necessary
what are characteristics of hodgkins lymphoma besides soft tissue neck swellings?
– malignant lymphoproliferative disease
– usually unilateral, painless enlarging mass
– unilateral presentation
– most common nodes are cervical and supraclavicular nodes
– may be associated with fever, weight loss, night sweats, pruritus
– tx: radiation and chemotherapy
can you see a soft tissue neck swelling due to leukemia?
yes, enlarged lymph nodes due to infection and leukemic infiltrates
what are characteristics of thyroglossal duct cyst besides soft tissue neck swellings?
– remnant of thyroglossal duct
– occurs midline anywhere along path of thyroglossal duct
– usually below hyoid
– may move up and down with tongue movement
what are characteristics of mumps besides soft tissue neck swellings?
– usually involves parotid
– paramyxovirus (cytomegalic virus or staph in immunocompromised patient)
– incubation 2–3 weeks
– pain, fever, malaise, headache, vomiting may precede swelling
– xerostomia
– tx: symptomatic
what are characteristics of kawasaki disease besides soft tissue neck swellings?
– Mucocutaneous lymph node syndrome – bilateral conjunctivitis – fissured lips – infected pharynx – strawberry tongue – erythema of palms and soles – rash – cervical adenopathy
what are characteristics of tuberculosis besides soft tissue neck swellings?
– infectious disease that affects the lungs
– caused by Mycobacterium tuberculosis
– clinical findings: weight loss, fever, night sweats, productive cough
– most common extrapulmonary sites in the head and neck region are the cervical
lymph nodes
– tx: multiagent antibiotic therapy
what are characteristics of salivary gland tumor besides soft tissue neck swellings?
– pleomorphic adenoma most common benign lesion
– parotid most common site
– mucoepidermoid carcinoma most common malignant lesion
what are characteristics of branchial cleft cyst?
– area of anterior border of sternocleidomastoid muscle
– soft, movable, poorly delineated mass
what are characteristics of squamous papilloma besides palatal swellings?
– caused by HPV 6, 11
– occurs on the tongue, labial mucosa and soft palate
– it is the most common mass of the soft palate
– solitary, pink or white nodule with multiple fingerlike projections
– tx: none required
what are characteristics of nasopalatine duct cyst besides palatal swellings?
– arises from remnants of nasopalatine duct
– located in midline between roots of maxillary incisors
– may cause root divergence
– may cause fluctuant swelling
– X-ray: oval to heart-shaped radiolucency
– tx: surgical excision/curettage
– rare soft tissue counterpart is the cyst of the incisive papilla
what are characteristics of inflammatory papillary hyperplasia besides palatal swellings?
– reactive hyperplasia of the hard palatal mucosa
– associated with dentures, palatal coverage appliances, high palatal vault, mouthbreathing
– red or pink sheets of papules; nontender
– may be associated with candidal infection, along with trauma from appliance
– tx: antifungal agent, disinfect appliance, may need to decrease the wearing of the appliance; surgical excision
what are characteristics of condyloma acuminatum besides palatal swellings?
– caused by HPV 6,11,16,18
– sexually transmitted disease
– may be infected at birth
– oral sites: palate, tongue, oral floor, labial mucosa
– multiple coalescing, pink nodules; cauliflower surface
– tx: excisional biopsy
what are characteristics of necrotizing sialometaplasia besides palatal swellings?
– reactive lesion of minor salivary glands due to ischemia and infarction
– may start as a swelling that progresses to cratered, irregular ulcer
– usually unilateral but may be bilateral
– ranges from nontender to painful
– tx: incisional biopsy to confirm diagnosis; resolves in about 6 weeks
what are the differential diagnosis for maxillary and or mandibular enlargements?
Sickle cell anemia Albright syndrome Fibrous Dysplasia-monostotic form Cherubism Neoplasm Gigantism Hemihypertrophy Thalassemia
What are characteristics of sickle cell anemia besides mandibular or maxillary enlargements?
– autosomal recessive
– defective hemoglobin S (substitution valine for glutamic acid on beta chain)
– sickling occurs under low O2
– X-ray: stepladder trabeculation, hair on end
– painful crises; may have had splenectomy; may need antibiotics for dental treatment
what are characteristics of albright syndrome besides mandibular and or maxillary enlargements?
– polyostotic fibrous dysplasia
– abnormal skin pigmentation “coast of Maine”
– endocrine dysfunction—precocious deformity
– X-ray—“ground glass” appearance of lesions
what are characteristics of fibrous dysplasia(monostotic form) besides mandibular and or maxillary enlargements?
– benign fibro-osseous lesion of jaw
– begins early in life with gradual painless enlargement, then stabilizes in adulthood
– may obliterate mucobuccal fold
– X-ray: ground glass appearance
what are characteristics of cherubism besides mandibular and or maxillary enlargements?
– autosomal dominant – bilateral fullness of cheeks – hypertelorism – irregularly spaced dentition – lesions similar to central giant cell tumor – multilocular radiolucencies
What are characteristics of gingantism besides mandibular and or maxillary enlargement?
– excess growth hormone
– underlying lesion usually adenoma of the anterior lobe of pituitary
– may be seen radiographically
what are characteristics of hemihypertrophy besides maxillary and or mandibular enlargements?
– nonspecific, may occur in a variety of disorders
– may involve single digit, limb, face, or half of body
– usually evident at birth
– right > left
– males > females
– embryonic tumors may be associated with this disorder
what are characteristics of thalassemia besides maxillary and or mandibular enlargements?
– defect in rate of hemoglobin synthesis – persistent fetal hemoglobin – most commonly involves beta chain – severe hypochromic, microcytic anemia – homozygous: major – heterozygous: minor – hair on end radiographic appearance – tx: transfusions
what are causes of oral ulcers and stomatitis?
Herpes gingivostomatitis Recurrent herpes simplex virus Angular Chelitis Herpangina Apthous Ulcers Trauma Impetigo Hand, Foot and Mouth Disease Erythema Multiforme Varicella(Chickenpox) Chemotherapy NUG Behcet Syndrome Epidermyolysis Bullosa SLE Lesch-Nyhan syndrome
what are characteristics of herpes gingivostomatitis?
– Herpes Simplex Type I
– fever, lymphadenopathy, headache, malaise, intense gingival erythema, and oral vesicles throughout mouth
– vesicles rupture leaving painful ulcers
– widespread ulcers occur on any oral mucosal site and lip vermillion
– cytology: multinucleated giant epithelial cells,
– tx: systemic acyclovir may be warranted; palliative and supportive care
what are characteristics of recurrent herpes simplex infection?
– cause: reactivation of the HSV-1
– prevalence: 20-35%
– types: herpes labialis, facialis, intraoral HSV
– risk factors: UV light, trauma, fever, dental treatment
– site: perioral skin, vermillion, gingiva, hard palate
– duration: 7-14 days
– recurrent, tender lesions, sudden onset, prodrome, clustered vesicles that ulcerate
– complications: scars, erythema multiforme, Bell palsy; blindness
– tx: topical anesthetics, topical and systemic antiviral agents
what are characteristics of herpangina?
– usually coxsackievirus
– multiple small vesicular lesions involving tonsillar pillars, uvula and soft palate
– vesicles rupture leaving ulcers with erythematous borders
– malaise, fever
– most common in young children during summer months
– tx: supportive and palliative care
what is treatment for apthous ulcer?
tx: coating agents, topical anesthetics, steroids
what are characteristics of impetigo?
– most commonly caused by Staphylococcus aureus or in combination with Group A ß-hemolytic streptococcus
– scaly and thick amber crusts that are pruritic localized
– localized disease treated with topical antibiotics
– widespread disease treated with systemic antibiotics
what are characteristics of hand, foot and mouth disease?
– usually coxsackie virus
– common age is infants to age 4
– fever, malaise, lymphadenopathy
– vesicles and ulcers on buccal, labial mucosa, tongue; skin lesions on hands, arms,
feet, and legs
– tx: palliative and supportive resolves in 7–10 days
what are characteristics of erythema multiforme?
– immunologically mediated disease
– triggers: drugs, HSV, Mycoplasma pneumonia, other infections, tattooing, 50% unknown
– site: extremities, palmar and plantar surfaces, neck, face, eyes, lips oral mucosa
– acute onset, fever, sore throat; blood crusted lips, irregular ulcers, erythema
– target lesions on skin
– may have ocular and genital involvement (Stevens-Johnson syndrome)
– tx: identify cause; palliative care
what are characteristics of chemotherapy?
– drug-induced mucositis
– widespread involvement
– pain, bleeding, sloughing, erythema, irregular ulcerations
– tx: supportive and palliative care
what are characteristics of behcet syndrome?
– cause is unknown – rare in children – oral aphthae – genital ulcerations – ocular lesions – tx: steroids
what are characteristics of NUG and treatment of NUG?
– fusiform bacteria, spirochetes, HHVs
– painful lesions, necrosis, ulceration, punched out papillae; halitosis
– predisposing factors: vitamin deficiencies, compromised immune function, stress,
poor oral hygiene, cigarette smoking, viral infections (HIV, EBV, measles)
– rare in young children
– tx: debridement, oral hygiene, antimicrobial oral rinse, +/- systemic antibiotics
what are characteristics and treatment of epidermolysis bullosa?
– hereditary vesiculobullous disease of skin and mucous membranes – multiple types
– EB simplex – most common; autosomal dominant
– junctional EB – severe form; autosomal recessive
– blistering of hands, feet, mouth, in particular
– scarring is common
– oral problems: enamel hypoplasia, microstomia, ankyloglossia, caries, gingivitis
– tx: no satisfactory treatment; caries prevention, minimize trauma
– severe forms are life-threatening
what are characteristics of SLE and treatment of SLE?
– chronic multisystem progressive disorder
– autoimmune disease
– oral ulcerations, erosions and white striations; mimics lichen planus, secondary candidiasis
– skin lesions, arthralgia, hematologic disorders are common
– butterfly rash on face
– tx: steroids, other immunosuppressive agents, antifungal agents
what are characteristics of lesch-nyhan syndrome?
– X-linked
– MR
– spastic CP
– choreoathetosis(involuntary bodily movements)
– bizarre, self-mutilating behavior – including lip destruction with teeth
– absence of hypoxanthine - guanine
– phosphoribosyltransferase (enzyme involved in purine metabolism)
what is the differential diagnosis for multilocular radiolucencies?
Odontogenic Keratocyst Nevoid basal cell carcinoma syndrome Ameloblastoma Ameloblastic Fibroma Central giant cell granuloma Odontogenic myxoma Aneurysmal bone cyst Central Hemangioma/Vascular malformation Cherubism
what are characteristics of odontogenic keratocyst and treatment?
– aggressive odontogenic cyst
– X-ray: expansile unilocular or multilocular with thin sclerotic border
– pericoronal, periapical, central location
– most common in posterior mandible—ascending ramus area
– may be locally aggressive with expansion of bone and root resorption; often
painful; drainage
– 25-40% associated with unerupted tooth
– tx: surgical excision +/- ostectomy
– high recurrence rate of 30%
– associated with nevoid basal cell carcinoma syndrome
what are characteristics of nevoid basal cell carcinoma syndrome?
– enlarged occipitofrontal circumference – mild ocular hypertelorism – multiple basal cell carcinomas – multiple odontogenic keratocysts of the jaws – epidermoid cysts of the skin – palmar and plantar pits – calcified falx cerebri – rib anomalies – spina bifida occulta – hyperpneumatizaton of paranasal sinuses
what are characteristics of ameloblastoma and treatment?
– may occur at any age, although most common between 20–40 years; rare to uncommon under the age of 19
– commonly involves posterior mandible
– arises from remnants of odontogenic epithelium
– clinical findings: usually painless expansion
– X-ray: multilocular radiolucency, may cause root resorption; often associated with unerupted third molar
– tx: surgical excision with marginal block resection; recurrence rate of 15% with this treatment
what are characteristics and treatment of ameloblastic fibroma?
– mixed odontogenic tumor
– commonly found in posterior mandible (70%), often associated with unerupted tooth (75%)
– generally seen in patients under 20 years
– painless expansion
– X-ray: multilocular radiolucency; unilocular when small
– tx: surgical excision but may recur
– ameloblastic fibrosarcoma may arise from the lesion
what are characteristics of central giant cell granuloma?
– non-neoplastic lesion
– aggressive and nonaggressive variants
– commonly involves mandible (70%), may cross midline
– locally invasive
– X-ray: multilocular with smooth or ragged border; unilocular when small
– frequently causes tooth displacement
– tx: surgical excision; recurrence rate – 15-20%
what are some jaw lesions in children with giant cell histology?
hyperparathyroidism
cherubism
giant cell tumor
aneurismal bone cyst
what are characteristics of odontogenic myxoma and treatment?
– uncommon, arises from mesenchyme of tooth germ
– more commonly involves posterior portion of jaws
– slow progressive swellings; may cause facial deformity
– X-ray: unilocular or multilocular radiolucency with faint radiopaque striations (stepladder appearance); margins usually well-defined
– may displace unerupted teeth, most commonly associated with missing or unerupted tooth; may resorb teeth
– tx: surgical excision; recurrence rate of 25%
what are characteristics of aneurysmal bone cyst?
– under 20 years peak incidence
– tender, painful in 50%
– eccentric ballooning of involved area
– X-ray: expansible, cystic, honeycombed, or soap bubble radiolucency; unilocular when small
– tx: curettage; moderate recurrence rate
what are characteristics of central hemangioma/vascular malformation?
– may have soft tissue hemagiomas
– listen for bruit, palpate for thrill
– gingival bleeding, tooth mobility; bony expansion
– X-ray: radiolucency with vague margins; may have a honeycomb appearance; unilocular when small
– potentially life threatening
what are characteristics of cherubism?
– autosomal dominant disorder
– bilateral fullness of cheeks and angles of the mandible
– hypertelorism and upslanting eyes
– malocclusion with displaced teeth
– X-ray: expansile multilocular radiolucencies in all 4 quadrants; displaced toothbuds
– tx: tends to burn out over time; cosmetic recontouring
what is the differential diagnosis for solitary or multiple radiolucencies with indistinct or ragged borders?
Periapical granuloma Langerhans cell histiocytosis Melanotic neuroectodermal tumor of infancy Acute suppurative osteomytelitis Osteosarcoma Ewing sarcoma Central sarcomas of bone Burkitt lymphoma Leukemia(AML) Metastatic lesions
what are characteristics of leukemia(AML)?
– widespread involvement
– gingival enlargement due to leukemia infiltrates
– loss of lamina dura
– X-ray: diffuse, poorly defined radiolucency
– tooth mobility
– occasionally periosteal bone formation
– tx: chemotherapy
what are characteristics of albright syndrome(polyostotic fibrous dysplasia)?
– abnormal skin pigmentation – large café au lait macules
– endocrine dysfunction
– multiple bones are affects
– precocious puberty in females
– X-ray: poorly defined margins, ground-glass appearance
what are characteristics of dentigerous cyst?
– forms around crown of impacted tooth
– may be expansile, painless, tooth eruption failure
– common sites: mandibular molar, maxillary canine
– X-ray: pericoronal, unilocular radiolucency
– tx: enucleation of cyst +/- tooth extraction; recurrence is rare
what are characteristics of adenomatoid odontogenic tumor?
– anterior region; maxilla > mandible
– painless expansion; usually associated with crown of unerupted tooth, especially canine
– may exhibit flecks of opacities
– tx: enucleation; recurrence is rare
what is the differential diagnosis of pericoronal radiolucencies containing radiopacities?
Eruption sequestrum Odontoma Calcifying odontogenic cyst(Gorlin cyst) Adenomatoid Odontogenic tumor Ameloblastic fibro-odontoma Calcifying epithelial odontogenic tumor(Pindborg tumor)
what are characteristics of eruption sequestrum?
– dysplastic cementum in dental follicle
– occurs in the molar region
– X-ray: small opacity in soft tissue overlying an erupting molar
– most spontaneously exfoliate
what are characteristics of odontoma?
– common odontogenic lesion
– delayed tooth eruption is a common sign
– occurs in maxilla more than mandible
– often pericoronal but may be periapical or intraradicular
– X-ray: compound – resembles tooth-like structures; complex – amorphous mass; both have a radiolucent border
– tx: excisional biopsy
– tx: may be associated with calcifying odontogenic cyst, ameloblastic fibroodontoma
what are characteristics of calcifying odontogenic cyst(gorlin cyst)?
– affects both maxilla and mandible; 65% in the anterior region
– 33% associated with unerupted tooth; most are located centrally in bone
– 25% associated with odontomas, especially in children
– may appear peripherally as gingival lesion
– X-ray: well-circumscribed radiolucency with radiopaque flecks or tooth-like structures
– tx: surgical excision
– there are aggressive and nonaggressive variants
what are characteristics of ameloblastic fibro-odontoma?
– mixed odontogenic tumor
– site: posterior mandible is the most common
– usually asymptomatic; involved with an unerupted tooth
– X-ray: usually unilocular radiolucency with variable amounts of calcifications that resemble odontomas
– tx: curettage; does not recur
what are characteristics of calcifying epithelial odontogenic tumor(pindborg tumor)
– mandible, premolar-molar region most commonly involved
– painless swelling of jaw
– often associated with an unerupted tooth
– may have a central location
– well circumscribed radiolucency containing varying sized radiopacities; some are totally radiolucent
– tx: local resection; 15% recurrence rate
what is the differential diagnosis for periapical or central radiolucencies with distinct borders?
Developing tooth bud Periapical(radicular) cyst Nasopalatine duct cyst Simple bone cyst(traumatic bone cyst) Stafne bone defect Median paltal cyst
what are characteristics of periapical(radicular) cyst?
– inflammatory cyst due to nonvital tooth
– uncommon in the primary dentition
– usually asymptomatic but may be tender and cause swelling
– root resorption is common; may displace teeth
– X-ray: unilocular radiolucency with well defined to indistinct borders
– tx: extract primary tooth, enucleate cyst; endodontics for permanent tooth
– multiple periapical granulomas and cysts are associated with dentin dysplasia type 1
what are characteristics of simple bone cyst(traumatic bone cyst)?
– usually in mandible – usually asymptomatic without expansion – teeth vital – may cross midline – X-ray: usually unilocular with scalloping between roots of vital teeth – tx: surgical exploration
what are characteristics of stafne bone cyst?
– usually seen in adolescent males when it occurs in children
– localized below the mandibular canal
– represents the submandibular fossa
– X-ray: cyst-like radiolucency of posterior mandible
what are characteristics of median palatal cyst?
– arises from epithelium entrapped along fusion line of two palatal processes
– ovoid or circular radiolucency that is not associated with the incisive canal
– may cause fluctuant swelling of palate that is posterior to the palatine papilla
– teeth are vital
what is the differential diagnosis with cleft lip and palate?
Cleft Lip/Palate - Isolated Pierre Robin sequence Mandibular dysostosis(Treacher Collins syndrome) Cleidocranial Dysplasia Oral-facial digital syndrome Apert syndrome
what are characteristics of cleft lip and palate?
– Defective fusion of bones and soft tissues
– CL + CP occurs 45%; CP only occurs 30%; CL only occurs 25%
– 400 syndromes associated with CL +/- CP
– genetic and environmental causes for nonsyndromic clefts
– environmental causes: maternal alcohol use, maternal cigarette use, folic acid deficiency, corticosteroid use, anticonvulsants drugs
what are characteristics of pierre robin sequence?
– glossoptosis(retraction of tongue) – micrognathia – cleft palate – 15–25% have heart disease – mandibular growth usually progresses normally
what are characteristics of mandibulofacial dysostosis(treacher collins syndrome)?
– 1st branchial arch, pouch, groove
– downsloping palpebral fissures, depressed cheekbones, deformed pinnae, receding chin, large fish-like mouth
– hypoplastic mandible
– 30% cleft palate
what are characteristics of cleidocranial dysplasia?
– brachycephalic
– frontal & parietal bossing
– depressed nasal bridge
– delayed closure of sutures and fontanelles (wormian bones)
– supernumerary teeth
– clavicular defect
– delayed or failure of exfoliation of 1° teeth
– delayed eruption of 2° teeth
– palate highly arched often with submucous cleft or complete cleft
– roots lack layer of cellular cementum
what are characteristics of oral facial digital syndrome?
– hypoplastic alar cartilages
– hypotrichosis
– brachycephaly
– intellectual disability
– syndactyly(webbed), clinodactyly(curved fingers/toes)
– median pseudo-cleft upper lip
– cleft tongue, cleft palate
– multiple hyperplastic frenae with clefts
– hypodontia: mandibular lateral incisors
– hyperdontia: maxillary canines
– hamartomas/choristomas on tongue
what is the differential diagnosis for craniosynostosis?
Apert Syndrome
Crouzon Syndromr
Pfeiffer Syndrome
Carpenter Syndrome
what are characteristics of Apert Syndrome?
– premature closure of cranial sutures – syndactyly – turribrachycephaly(high prominent forehead) – high steep flat frontal bones – shallow orbits, ocular hypertelorism – parrot nose – 30% cleft palate – intellectual disability – crowded dentition – V-shaped maxilla – Class III with anterior openbite – delayed tooth eruption
what are characteristics of crouzon syndrome?
– premature closure of cranial sutures – brachycephalic – maxillary hypoplasia – ocular hypertelorism – parrot nose – crowded dentition – V-shaped arch – Exophthalmia – no hand anomalies
what are characteristics of pfeiffer syndrome?
– usually normal intelligence
– broad thumbs and great toes
– neonatal and natal primary molars
what are characteristics of carpenter syndrome?
– acrocephaly – soft tissue syndactyly – congenital heart disease – intellectual disability – hypogenitalism – mild obesity
What are characteristics of achondroplasia?
– 80% sporadic, mutations, AD – 1/20,000 live births – short limbed dwarfism – enlarged head – depressed nasal bridge – short, stubby hands – lordotic(curved) lumbar spine – prominent buttocks – protuberant abdomen
what are characteristics of hypopituitarism?
– well proportioned body, fine silky hair, wrinkled atrophic skin
– hypogonadism
– eruption and exfoliation delayed
– malocclusion common due to small dental arch
what are characteristics of chondroectrodermal dysplasia(Ellis van Creveld syndrome)?
– bilateral manual postaxial polydactyly
– 40-50% have cardiac defects
– hidrotic ectodermal dysplasia(pt can sweat)
– fusion of middle of upper lip to maxillary gingival margin; multiple frenae
– 25% natal teeth
what are characteristics of hallerman-streiff syndrome?
– dyscephaly(malformed crnium and face)
– thin beaked nose
– mandibular hypoplasia
– hypotrichosis(abnormal or lack of hair)
– small palpebral fissures(space between upper and lower eyelid)
– bilateral congenital cataracts, microphthalmia
– diminished body growth
– oral findings: high palatal vault, hypodontia, natal teeth, over-retained primary teeth, supernumerary teeth
what are characteristics of turner syndrome?
– 45 X karyotype – females only – near normal IQ – sterile – coarctation of aorta most common cardiac defect – webbed neck – enamel hypoplasia
what are characteristics of osteogenesis imperfecta?
– 4 types – type 1 is most common and mildest form – autosomal dominant – multiple bone fractures – hearing loss – hypermobility of joints – capillary fragility – blue sclera – usually dentinogenesis imperfecta – tx: bisphosphonate therapy may helpful to prevent bone fractures
what are characteristics of hypothyroidism?
– endocrine disease due to dysfunctional thyroid gland or pituitary gland tumor
– dry skin, swollen face and extremities, husky voice
– bradycardia, hypothermia
– swollen lips and tongue
– failure of teeth to erupt
– tx: thyroid replacement therapy or treat the primary cause
which formulas have more fluoride contact? Ready to use infant fomulas or non milk based formula?
Non milk based formula because calcium fluoride is added. Even more when reconstituted with fluoridated water.
how much xylitol is to be consumed to continuously produce positive results?
4-10 grams per day divided into 3 to 7 consumption periods
what are xylitols effects?
reduced plaque formation and bacterial adherence(antimicrobial),
inhibits enamel demineralization(reduces acid production),
direct inhibitory effect on MS
When is ITR most successful?
when applied to single surface or small 2 surface restorations
Define ECC?
presence of 1 or more decayed, missing or filled tooth surfaces in any primary tooth in a child less than 6
Define SECC?
any sign of smooth surface caries in a child younger than 3.
From 3-5, 1 or more cavitated, missing, or filled surfaces in primary maxillary anterior teeth or a dmf score of age+1
what is the consenus on frequent night time bottle feeding with milk and ad libitum breast feeding with ECC?
they are associated with ECC but consistently implicated in ECC. While ECC may not arise fro breast milk alone, breast feeding in combination with other carbohydrates has been found to be highly cariogenic
Regarding the policy on ECC, what preventive strategies are recommended?
Reduce parents/siblings MS levels
Minimize saliva sharing activites
Implement oral hygiene measures
Avoid sugar containing beverages
Infants are not put to sleep wiht a bottle filled with milk or liquids containing sugars
Ad libitum breast feeding should be avoided after eruption of first tooth and when other carbs are introduce
Infants and children exposed to smoke are at risk for?
SIDS acute respiratory infections middle ear infections bronchitis pneumonia asthma allergies Caries in the primary dentition Enamel hypoplasia in primary and perm dentition
intraoral jewelry or oral piercings have been associated with
gingival inflammation recession caries metal allergy pain infection scar formation tooth fractures speech impediment nerve damage
type 1 mouthguard?
custom mouthguard, mostly of maxillary arch. Recommend mandibular mouthguard for class 3
type 2 mouthguard?
mouth formed, or boil and bite, most commonly used
type 3 mouth guard?
stock mouthguards, held in place by clenching
what are the common side effects associated with teeth bleaching vital teeth?
tooth sensitivty and tissue irritation, increased marginal leakage of existing restoration
what are common side effects from internal bleaching of nonvital teeth?
external root resorption and ankylosis
what is the most common side effect of external bleaching of nonvital teeth?
increased marginal leakage of existing restoration
what is the concern with too much dental bleaching?
degradation product is hydroxyl free radical which can cause periodontal damage
current literature supports use of what for bleaching nonvital teeth?
using sodium perborate mixed with water for bleaching nonvital teeth, get less root resorption and side effects.
characteristics of acetaminophen?
non opoid, and is not an NSAID. Does not have any inflammatory properties.
what are characteristicis of diazepam(Valium) including its onset, reversal, contraindications, halflife?
CNS Depression-minimal CV or respiratory effect
amnesia, ataxia(acts in corex, limbic system)
onset 45min, half life 20 hours
0.25mg/kg
Flumazenil reversal dose .01mg/kg
Contraindicated in narrow angle glaucoma
what are characteristics of midazolam(versed) including its onset, reversal, contraindications, halflife? What patients is versed recommended?
CNS depression-minimal CV or respiratory effect amnesia onset 15 min, 30-40 min working time 05-0.75mg/kg to 15 mg total Flumazenil reversal dose .01mg/kg
- 3-4 x more potent than Valium
- Good for autistic and ADHD
- Better for defiant children
- Anterograde amnesia
- Paradoxical effect/excitation
what are characteristics of hydroxyzine(vistaril) including its onset, halflife?
Antiemetic, antihistamine CNS depression: anxiolytic, bronchodilator analgesic causes dry mouth onset in 15-30 min, duration 2-4 hours 1.0mg/kg
what are characteristics of meperidine(demerol) incl onset, reversal, and side effects?
Causes CNS, CV, and respiratory depression
naloxone reversal .1mg/kg(occurs after 1-2min)
causes sedation, analgesia, lowers seizure threshold
Caution in patients with pulmonary complications, head trauma, seizures, hepatic/renal disease, airway obstruction, comcomitant local anesthesia dose important
onset is 30 mins, duration is 2-4 hours
2.0mg/kg max for 50 mg max
metabolized by liver, excreted by kidney
side effects include dizziness, xerostomia, sweating, nausea/vomiting, seizures, respiratory depression
what are common lab values for a PT bleeding screen?
PT(measures extrinsic) - 1-18 sec Prolonged in liver disease and in Vit K deficiency
what are common lab values for a PTT bleeding screen?
PTT values are by lab control(measures intrinsic), prolonged in hemophilia A, B and C and VWF disease
what are normal lab values for platelets?
140k-340k, measures clotting potential, increased in polycythemia, leukemia, severe hemorrhage, decreased in thrombocytopenia purpura
what are lab values for bleeding time?
normal is 1-6 min, measures quality of platelets, prolonged in thrombocytopenia
what is the normal value for INR?
without anticoagulant therapy it is 1, with anticoagulant therapy target is 2-3, measures extrinsic clotting function and is increased with anticoagulant therapy
what is the normal value for hemoglobin and what is its significance?
Hemoglobin measures the oxygen carrying capacity of blood.
12-18g/100ml, low in hemorrhage, anemia, high in polycythemia
what is the normal value for hematocrit?
35-50%, low in hemorrhage and anemia, high in polycythemia and dehydration
what is the normal value for red blood cell count?
4-6 million/mm3, low in hemorrhage, anemia, high in polycythemia, heart disease, pulmonary disease
what is the normal white blood cell count?
Infant is 8000-15000mm3,
4-7yo is 6000-15000mm3,
8-18 yo is 4500-13500mm3,
Low in aplastic anemia, drug toxicity, specific infections,
High in inflammation, trauma, toxicity, leukemia
for traumatic dental injuries, what is included in the history of the injury?
Non-dental injuries LOC? Altered orientation/mental status Hemorrhage from nose/ears HA/nausea/vomiting Neck pain Spontaneous dental pain Pain on mastication Reaction to thermal changes Previous dental trauma Habits?
for traumatic dental injuries, what is included in the extraoral exam?
CN deficit Facial fractures Lacerations Contusions Swelling Abrasions Hemorrhage/drainage Foreign bodies TMJ deviation/asymmetry
for traumatic dental injuries, what is included in the intraoral exam?
Molar classification Canine classification OB OJ Xbite Midline Deviation Interferences
what should be examined on radiographs after acute dental trauma?
Caries/previous restorations Pulp size Root development Root fracture Periodontal ligament space periapical pathology alveolar fracture foreign body developmental anomaly
what is the consensus on presurgical orthopedics for cleft lip and palate patients?
some believe the nasoalveolar molding technique can provide for improved nasal cartilage and increased length of the columella while others believe that infant orthopedics makes no difference
what is the current treatment protocols for phase 1 orthodontic management of cleft lip and palate patients?
Phase 1 includes monitoring the eruption status of teeth, space management, and prevention of ectopic eruption of permanent teeth by removal of primary retained teeth and impacted permanent teeth and then Maxillary expansion at around 7 years
When is maxillary expansion performed in CLP patients in preparation for alveolar bone grafting?
After eruption of 6 year molars and at the time of eruption of maxillary incisors at around 7 years old.
When is bone grafting usually performed in CLP patients?
Around 7 to 10 years before eruption of the permanent canine or when canine has 1/2 to 3/4 of its final root length.
What decision must be made in CLP patients after bone grafting?
Keep the space open for an implant or prepare for cuspid substitution.
what implant properties in order of significance can affect success of an endosseous implant in a grafted cleft site?
Length-13mm or more are more successful
Diameter
Surface Characteristics
what is the current treatment protocol “gold standard” for bone grafting in CLP patients?
filling the alveolar cleft with autogenous marrow
bone harvested from the iliac crest under general anesthesia.
When is an implant typically placed in CLP patients?
Approximately 4-6 months after regraft placement(15-17 years)
Why isn’t an implant placed after the first graft at 8 to 11 years?
Implant may act as an ankylosed tooth and become submerged during rapid growth of adolescence.
When is placement of an endosseous implant into a grafted site in a CLP patient a reliable and predictable treatment option?
when orthodontic treatment and cuspid substitution cannot compensate for the missing lateral incisor
What other ways can you approach treating a patient with CLP and missing incisor?
Fixed Bridges and prosthetic appliances such as dentures
What is the general timing of surgical correction of CLP?
Rule of tens.
10 weeks in age, 10 kg in weight, and a hemoglobin of 10.
What is usually the first and second procedure in CLP surgical repair?
The first procedure is usually to repair the lip and nasal deformity(2 to 5 months). Thereafter, before speech is developed, the palate is repaired and ear tubes placed(10 months).
Children with velopharyngeal insufficiency may require
further surgery to prevent nasal escape causing hypernasal speech(this occurs at 4-5 years along with a revision of the lip and nose)
CL repair occurs at 10 weeks, cleft palate repair occurs when?
Approximately 6-18 months, generally around 10 months, may improve speech but can cause midface retrusion
When is an obturator formed for CLP patients?
Between 0-3 months to facilitate feeding, a new obturator is made after lip repair at 3 months to last until palate repair at 10 months
what areas should be covered in anticipitaory guidance related to oral hygiene?
frequency and duration, a technique
demonstration with the child, review of devices,
dentifrice use, location at home, positioning
ideas, and problem solving such as how to fit
oral hygiene into the family pattern
what is the dietary pattern that is considered normal for a child from 6 months ot 12 months?
A child may be breast or bottle fed into six
months of age. In the next six months,
breastfeeding may be stopped or continued,
depending on the needs and wishes of the
mother and child. Some solid food is introduced
in this period as well and bottle feeding ends
with a transition to a cup at meal times. At 12
months, the child should be feeding himself and
drinking from a cup on a trial basis since the
process is initially messy
what characteristics of fluoride varnish make it the preferred method to deliver fluoride over foams and trays?
Fluoride varnish is ideal for the preschool child
because it can be put on easily and requires
minimal compliance. Today’s formulations taste
good, can be placed on semi-wet teeth, and are
tooth colored. The effectiveness of fluoride
varnish is well established, while the use of
foams or gels in brush-on regimens enjoys little
scientific support
what are important health history questions to ask when deciding to sedate a child?
Any hx of snoring, OSA, mouth breathing?
what is observed during an airway assessment of a child when deciding to sedate?
Obesity Limited Neck Mobility Micrognathia/Retrognathia Macroglossia Tonsillar Obstruction % Limited Oral Opening
What post-op topics are reviewed with parents after a sedation?
Transportation Airway protection/Observation Activity Diet Nausea/Vomiting Fever Rx Anesthetized Tissues Dental Treatment Rendered Pain Bleeding
what is the compression to ventilation ratio in performing BLS for infants and children with a single rescuer and two rescuers?
Single Rescuer 30:2
Two Rescuers 15:2
when is systemically administered fluoride considered for children at high caries risk?
If they are drinking fluoride deficient water(
if a patient walks in with tetralogy of Fallot, what follow up questions are you going to ask?
history of cardiac surgery, respiratory difficulty, medications, symptoms experienced by the patient, limitations or restrictions on any activities
explain what the tanaka johnson analysis is and how to calculate it?
It’s a mixed dentition space analysis used to estimate how much leeway space you will have.
Add up the M-D width of the lower permanent incisors and divide by 2. Add 10.5 for the lower buccal segment and 11mm for upper buccal segment.
Then subtract the number above from the M-D width of the primary molars and primary canine. Gives you estimated leeway space.
mild lower anterior crowding of 1-4mm in the mixed dentition can be managed how?
- Use an LLHA to hold the leeway space until 12 year molar fully erupts(LLHA prevents mesial shift of 2nd molar, allowing mild anterior crowding to re-align into the leeway space
- Disking of select primary teeth(canines)
moderate lower anterior crowding of 5 to 9mm in the mixed dentition can be managed how?
Flaring of anterior teeth, distalization of permanent first
molars, or arch expansion with appliances such as a lip bumper or limited orthodontics with bands on the molars, brackets on the incisors (“2 × 4”) and open coil springs
severe lower anterior crowding of >10mm in the mixed dentition can be managed how?
Serial extraction, or wait until the permanent dentition and consider extraction, followed by full orthodontics
Consider in cl 1 malocclusion, normal OB, and only in the absence of skeletal discrepancies
can a LLHA be used to solve lower anterior crowding of greater than 5mm?
Typically no, it will help alleviate some crowding but it mostly holds only 3 to 5mm of space.
what are the three modalities used to stop NNS habits?
Behavior modification(uses positive reinforcement, rewards calender),
Extra oral(ace bandage around the elbow at night to keep child from bending her arm to place finger in mouth, placing bitter tasting liquids on the digit),
Intra oral appliances(cribs, rakes, bluegrass, spurs)
Deleterious effects on the teeth and supporting structures are minimized if children will stop their digit sucking habits by approximately what age?
before age 6, before eruption of permanent dentition
what kind of appliance do you use to correct a true unilateral posterior crossbite?
Unilateral post xbite has no shift of midlines on closure whereas bilateral posterior xbite HAS a shift of midlines on closure.
You want to use an appliance that only places forces on the maxillary arch side causing the crossbite, not a quad helix, w arch, rpe of haas or hyrax which typically corrects bilateral xbites
patients with what medical history cannot tolerate intra tissue metal extensions space maintainers such as distal shoes?
Those with congenital heart disease, a bleeding disorder, history of heart surgery, or any other immunocompromised situation.
an anterior crossbite with upright incisors is typically of dental/functional or skeletal origin?
upright origin is typically of dental/functional origin. Dental/functional anterior xbite has retroclined uppers and proclined lowers. Skeletal anterior xbite has retroclined lowers and proclined uppers.
what are signs of enamel erosion and how can you treat cases of established erosion of enamel?
Thermal sensitivity and margins of restorations appearing higher than the tooth surface are related to erosion of enamel
Fluoride may be used to minimize hard tissue loss and control sensitivity. A daily neutral sodium fluoride mouth rinse or gel to combat enamel softening by acids and control pulpal sensitivity may be prescribed.
Which ASA patients are routinely accepted for in office moderate sedation?
ASA 1.
ASA 2 patients require a medical consult and are not routinely accepted.
what is the brodksy scale? What is the meaning of a patient who is brodsky +3?
part of the airway assessment that indicates how much space the tonsillar tissue occupies in the pharyngeal area
brodsky+3 means the tonsillar tissue takes up >50% of the space and should thus be considered for GA as airway obstruction complications increase significantly with sedation
what are the fundamental guidelines for monitoring a patient during moderate(conscious)sedation?
- Continuous monitoring of oxygen saturation and heart rate, and intermittent recording of respiratory rate and blood pressure that should be recorded on a time based record
- Frequent checking of restraint devices to prevent airway obstruction or chest restriction
- Frequent checking of the patient’s head position to ensure airway patency
- Presence of a functioning suction apparatus
If a parent of a 3 yo child with SECC does not want to pursue GA, what option can you give them?
attempts could be made to place interim restorations while trying to reduce the patient’s anxiety with short, easy visits
what does the mallampati score evaluate?
assesses the degree to which the practitioner can visualize the uvula during voluntary tongue protrusion. Difficult to obtain in a uncoop child
I = full visibility of tonsils, uvula, and soft palate II = visibility of hard and soft palate, upper portion of tonsils and uvula III = Soft and hard palate and Base of Uvula IV = Only hard palate
what is included as part of the airway assessment for GA and/or bag valve mask ventilation?
brodsky/mallampati micrognathia large tongue short neck limited cervical spine or TMJ mobility children with high BMI or obesity also includes looking for any loose or already chipped/damaged teeth, crowns, bridges, or dentures
what is the fundamental point in providing oxygen therapy to a child suffering respiratory insufficiency?
Many ways to deliver oxygen, but pick the least invasive yet maximally effective route to minimize increasing
the child’s anxiety, which will only serve to increase oxygen demand.
In an unconscious pediatric patient with no
spontaneous respirations, what is the best
airway adjunct choice for initial airway
management to provide ventilation and
oxygenation?
bag valve mask connected to oxygen.
In a conscious pediatric patient exhibiting signs
of respiratory distress, what is the first airway
adjunct that should be attempted?
try a nasal cannula, call 911 and continually monitor respiratory status.
How is a child with a partial airway obstruction
managed?
use a non rebreather face mask. Use bag valve mask for unconscious patient.
these food allergies can alert a practitioner to a latex allergy?
bananas, mangos, avocado, kiwi, and passion fruit
what are signs of an asthma attack?
audible expiratory wheezing hacking, non productive cough dyspnea cyanosis around lips and nailbeds nasal flaring and intercostal retraction tachycardia
craniofacial characteristics of down syndrome include?
Hypoplastic midface and maxilla
Mild microcephaly
Upslanting palpebral fissures
Short neck
a medical history for a down syndrome patient should include these questions about congenital heart disease as 50% of patients have heart complications
History of cardiac problems Symptoms of cardiac problems Any surgeries for cardiac problems Medications for cardiac problems Restrictions on activities
down syndrome patients present with these oral facial and dental anomalies?
Class III malocclusion Macroglossia Delayed dental eruption Hypodontia Microdontia Ectopic eruption and impaction of teeth Periodontal disease
down syndrome patients are at an increased risk for complications associated with sedation and general anesthesia because
Congenital heart defects Small naso-pharyngeal complex Increased incidence of airway anomalies Cervical Spine instability Obesity Obstructive sleep apnea
what are possible intra oral and extra oral concerns in CP patients?
- Hypotonia of the tongue and perioral musculature can result in anterior open bites and constricted palates.
- Immature swallow pattern, with characteristic tongue thrust, can also contribute to anterior open bite.
- A poor swallow reflex, seen in some patients with CP, can result in persistent drooling
how are seizures classified?
Generalized (involve both cerebral hemispheres) and involves loss of consciousness
Partial (limited to a discrete segment of the cerebral cortex) with no loss of consciousness; may have altered
consciousness
Status epilepticus: Prolonged, non-self-limiting seizure activity; can be life threatening
Generalized and partial seizures are subclassified
depending on clinical manifestations
what specific questions do you ask if a patient has a seizure disorder?
Type of seizures Frequency of seizures Date of last seizure Anti-epileptic medications being taken Precipitating factors (if known)
How is aspergers different than autism and how is it the same?
Differ in that children with Asperger’s syndrome have good verbal and cognitive skills and is similar to autism in that they are still subject to many of the sensory issues common to other autistic spectrum disorders. Also, both aspergers and autism tend to like music or hand held video games as distractions.
what occurs in a sickle cell crisis and what are the factors that precipitate a sickle cell crisis?
Affected red blood cells show increased adhesion to vascular endothelium. Intravascular aggregation of cells, inflammation of microvasculature, and vasoconstriction result in the clinical symptoms of sickle cell crisis.
Can affect multiple systems in the body. Sequelae can include tissue anoxia, infarcts, necrosis, and pain.
Precipitated by dehydration, hypoxia, infection, stress, and menstruation.
What are oral considerations in patients with sickle cell anemia?
Enlarged maxilla
Gingival enlargement
Glossitis
Pulpal necrosis in teeth without caries or history of trauma
Facial or dental pain secondary to vaso-occlusive crisis
Osteoporosis or Osteopenia
Osteomyelitis
What further questions are asked during the medical history for a patient with sickle cell anemia?
Vaso-occlusive crises: frequency, duration,
hospitalizations, date of last crisis
Damage to any organ systems?
History of transfusions and any related complications?
Current medication regimens
Current and past infections
Psychosocial issues
What would you do if you had treatment planned a tooth I DO and J MO resin composites but were unable to isolate them effectively?
Either switch them to an amalgam restoration or place Resin modified GI restoration(fuji 2 LC) which is more forgiving in moist environments.
when are class 2 composite restorations indicated?
Small pit and fissure caries
Occlusal caries into dentin
Cl 2 in primary teeth not extending beyond proximal line angle
Cl 2 in perm teeth that extend 1/3 to 1/2 buccolingual width
Cl 3,4,and 5 in prim and perm teeth and strip crowns in prim and perm teeth.
when are class 2 composite restorations contraindicated?
Cant achieve isolation
In teeth requiring large multiple surface restorations in the posterior primary dentition
in high risk patients with multiple caries/tooth demineralization and who exhibit poor OH and whom maintenance is unlikely.
what are indications for ITR?
Uncooperative patients that will be managed
non-pharmacologically
Patients with special needs
Interim restoration for caries control
Instances in which other restorative materials cannot be used
what are questions to ask a hypoglycemic patient?
When was the most recent hypoglycemic
episode and has the patient experienced any complications from being hypoglycemic?
Has the patient been placed on a special or
restricted diet?
in a class 5 prep for a resin which margin is beveled and which is left as a butt margin?
Leave the enamel margin bevelled and the cementum margin butt.
what are questions to ask a patient with a heart murmur?
Documentation of heart murmur status
Follow-up evaluations of heart murmur
Any consults to a pediatric cardiologist
Any need for echocardiograms or chest films
Any symptoms experienced by the patient
Any medications that patient takes for this condition
Any need for antibiotic prophylaxis for subacute bacterial endocarditis
Any limitations or restrictions on any activities
What important questions need to be asked
when taking a medical history from a patient
with congenital heart disease?
Nature of diagnosis (acyanotic or cyanotic),
supportive medications, previous surgical
corrections, future surgical corrections, current cardiac function, physical activity limitations, risk of IE
Why are children with congenital heart disease more likely to develop dental caries in primary teeth?
Enamel is often hypoplastic and susceptible to early childhood caries; high-caloric diet; use of sucrose-rich medications; medications may induce xerostomia; parental indulgence with sweets, juices, sodas, etc.
questions to ask a hemophilia patient?
Type and severity of hemophilia Hemophilia team contact information Compliance with medications Frequency and management of bleeding episodes Inhibitor status History of blood borne diseases such as HIVinfection or hepatitis due to blood transfusions Limitations or restrictions on activities
What is the significance of inhibitors in
hemophilia?
Bleeding episodes continue despite appropriate factor replacement levels. Care for these patients may include use of a bypassing agent such as factor VIIa or activated prothrombin complex
concentrate
What local anesthesia techniques should be
done only after factor replacement?
Infiltrations into a highly vascularized area or
into loose connective tissue, and posterior
superior alveolar and inferior alveolar nerve
blocks.
what local hemostatic agents can be used in hemophiliacs and in other bleeding disorders?
pressure, absorbable gelatin product, cellulose materials, thrombin,
microfibrillar collagen, fibrin glue, cyanoacrylate, acrylic stents, bone wax, electrocautery, resorbable sutures, periodontal dressings, and epinephrine
What important questions need to be asked
when taking a medical history from a patient
with ALL?
Questions regarding the underlying disease, time of diagnosis, modalities of treatment the
patient has received since the diagnosis, planned treatment, surgeries, complications, prognosis, current hematological status, allergies and medications
what are dental considerations in a patient with liver disease?
give less anesthetic due to decreased metabolism
bleeding problems
greenish discolration of teeth due to unconjugated bile pigments being incorporated into teeth
yellow skin
Do not use NSAIDS because they increase chance of GI bleeding. Use acetaminophen in lower doses instead.
what analgesics are used with caution in asthmatics?
aspirin and NSAIDs
high ESR, CRP and platelet count are indicative of what?
an inflammatory process: eg crohns disease. Will see abdominal pain, diarrhea, poor appetite, weight loss, and anemia in crohns patients.
what are oral manifestations seen in crohns disease? What is the key histological finding in crohns disease?
Lip and/or cheek swelling Angular cheilitis Mucogingivitis (inflammation of marginal and attached gingiva), most commonly in the anterior region multiple apthous ulcers
Key histological finding is non necrotizing granulomas.
what questions do you ask a parent of a child with oral inflammation and fever such as herpetic gingivostomatitis infection?
How long has it been since the child was
initially unwell?
Are any other unwell children in the family or has the child come into contact with any other children, relatives, or caregivers who are also unwell or have similar lesions?
When was the last time the child had
something to eat or drink?
When was the last time the child urinated?
Is the child able to sleep at night?
Does anything relieve the pain or discomfort?
what questions are asked for an intra oral lesion such has peripheral giant cell granuloma?
How long has the swelling been present?
When did you first notice it?
Has it changed in appearance (size, shape,
color) recently?
Has there been any spontaneous bleeding from this swelling or only on brushing?
Is the lesion painful? Does it hurt
spontaneously or only when stimulated?
Is there anything that makes it better or
worse?
what are characteristics of MTA? And how does it compare to CaOH?
MOA is mineralization
pulp canal obliteration is common
Compared with Ca(OH), MTA has demonstrated a greater ability to maintain the integrity of pulp tissue, producing a thicker dentinal bridge, less inflammation, less hyperemia, and less pulpal necrosis than Ca(OH)2
what are contraindications to performing a pulpectomy?
in cases of infection involving the crypt of the succedaneous tooth, in teeth with non-restorable crowns, with perforation of the pulpal floor, with internal resorption perforating into the underlying bone, and
with external resorption of more than one-third of the root
What are the radiographic signs of root canal
treatment failure in primary teeth, and how should they be
handled?
Enlargement of a previously existing periapical or inter-radicular radiolucency and the development of a new lesion in a tooth without a pre-operative pathologic radiolucency are real failures and should eventually be extracted. However, in cases in which the pre-operative radiolucency remains unchanged, the patient should be recalled in another six months for
re-evaluation
According to Moskovitz, Sammara, and Holan
(2005), which root-treated teeth are more prone
to failure: the underfilled, flush, or overfilled?
overfilled resulted in more failures, although not stastically significant.
What is more effective for disinfection of the
root canal system in primary teeth: mechanical
or chemical debridement?
because morphology is complicated in primary teeth and difficult to mechanically clean, chemical is more important.
What are the indications for a partial pulpotomy
in a young permanent tooth?
1. A partial pulpotomy is indicated in a young
permanent tooth for a small (
Why are young carious permanent molars good
candidates for conservative treatments such as
partial pulpotomy?
Young permanent teeth are good candidates for this conservative treatment because of their rich blood supply that enhances the healing ability
What are the complications of a partial
pulpotomy failure in an immature permanent
molar?
Failure of a partial pulpotomy may result in pulp necrosis and/or a periapical abscess. Because the apex is not closed it is necessary to start an apexification procedure
What are the possible treatment options for a
pulpotomy on a young permanent molar using
MTA?
(a) Coverage of the radicular pulp stump with
MTA, followed by a temporary restoration with Coltosol and IRM; (b) placement of a wet cotton pellet over the MTA and on the second appointment verification of the setting of the MTA and placement of a permanent restoration; (c) placement of glass ionomer liner over the MTA and permanent restoration of the tooth
in nonvital young permanent teeth, what are the reasons for preferring a single-visit
root closure with MTA rather than apexificationwith Ca(OH)2?
3. (a) Ca(OH)2 apexification is more time
consuming than creating an apical barrier with MTA; (b) Ca(OH)2 was shown to make these teeth more prone to fracture, whereas MTA strengthens the root; (c) it is assumed that MTA creates a better biologic seal; (d) root end closure with MTA is also more predictable
what is the definition of acute apical periodontitis?
Acute periradicular (apical) periodontitis: Inflammation usually of the apical periodontium producing clinical symptoms including painful response to biting and percussion
what is the definition of acute apical abscess?
An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset,
spontaneous pain, tenderness of the tooth to
pressure, pus formation, and eventually
swelling of associated tissues
what is the technique for performing revascularization?
- Make a conservative access opening, followed by a length measurement (radiograph with an endodontic file or a Gutta Percha point). The file should be inserted 2 to 3 mm short of the apical foramen to prevent damage to vital apical tissues
- Rinse with sodium hypochlorite and then chlorhexidine, inserting needle 2 to 3 mm short of apex.
- Dry canal.
- Introduce munce canal projector into orifice and build up space between projector and walls with flowable composite
- Mix mino, cipro, metro with saline, and insert into orifice using sterile syringe 2 to 3mm short of apex
- Clean access cavity, place cotton pellet, seal tooth temporarily for 4 weeks.
- Ensure tooth is asymptomatic, no signs of pathology(sinus tract), place rubber damn, remove temp and cotton pellet, rinse 3mix out with sodium hypochlorite, dry with paper points, insert endo explorer or hand file past apex to induce bleeding, , stop bleeding 2 to 3 mm below level of CEJ, with a moist cotton pellet for 15 minutes, place MTA, followed by a wet cotton pellet and a temporary sealing material.
2 weeks later, remove the temp, place permanent restoration(composite in anterior region)
What are instances in which immediate
extraction of intruded primary incisors would be
indicated?
If a radiograph, such as a lateral occlusal,
indicates that the primary tooth is intimately
associated with the permanent tooth bud,
extraction may be indicated. Any potential
aspiration risk to the child is also an indication
for extraction. Extraction of the intruded incisor
does not necessarily spare the successor from
possible damage
How long should one wait and watch intruded
primary incisors to re-erupt?
While reports note that the majority of intruded
primary incisors will re-erupt within six months,
re-eruption should be assessed monthly and
teeth should demonstrate significant re-eruption
(although not necessarily complete) by two
months. If there is no evidence of re-eruption,
then a careful clinical and radiographic
examination must be completed to re-assess
treatment options such as extraction
If the intruded tooth is asymptomatic at one
week post injury, is the pulp healthy?
No. In the instance of any traumatic injuries,
the pulp may provide false-positive responses
clinically for up to three weeks post injury. Sequelae such as replacement resorption
may not be apparent until six weeks post
injury.
If a root fracture was present in the apical
one-third of the root, is it recommended to
surgically extract the remaining root tip?
If the remaining root tip is intimately related to
the permanent tooth bud, then any treatment
must be approached with the understanding that
there is potential for damaging the permanent
tooth as well
what are complications of dental trauma?
Tooth discoloration is a common post-traumatic
complication
Dark gray discoloration of primary incisors soon
after injury may fade and does NOT warrant
immediate treatment
Discoloration noted soon after injury is not
representative of definitive pulpal diagnosis
(Holan 2004)
Tooth discoloration that first appears well after
the trauma may be indicative of changes in
pulp vitality and potential necrosis (Soxman
et al. 1984)
All teeth involved in injury must be re-assessed
for potential pulpal injury
What are the situations in which extraction of
tooth and/or segments is warranted in root fractures of primary teeth?
As the fracture is placed more coronally, the
prognosis worsens for the tooth. Furthermore,
the aspiration risk must be assessed. Parents
should be made aware of the possibility for the
need to remove the coronal and/or entire
segment at a later date if no treatment is
immediately rendered
Would management differ if discoloration had occurred 26 months after tooth injury?
transient discoloration
immediately following injury is not uncommon. This discoloration is most often reddish or
grayish. Discoloration that occurs well after the
traumatic injury may be indicative of pulpal
necrosis and result in inflammatory resorption
despite the patient remaining asymptomatic
When is splinting of primary teeth indicated?
Splinting primary teeth should be attempted
only after careful risk:benefit analysis, including
patient cooperation and behavior, ability for
adequate isolation if a resin splint is used, and
parental compliance and understanding of the
need for follow-up care. While some studies
have demonstrated success with splinting
primary teeth, full medico-legal considerations
need to be discussed with parents/caregivers
what is the cvek pulpotomy technique?
Isolate tooth with rubber dam
• Gently remove 1.5 to 2 mm of pulp tissue with
sterile bur and copious irrigation with water
(Figure 4.3.4)
• Use wet cotton pellet to control hemorrhage.
• Cover pulp with calcium hydroxide, followed by
glass ionomer
• Assure an excellent seal with composite resin provisional restoration (Figure 4.3.5). Final restoration may be completed at same
appointment if it can be done atraumatically.
However, final restoration should be deferred if tooth is mobile
• Suture gingival lacerations (if indicated). Prescribe over-the-counter acetaminophen or ibuprofen for pain, as needed
Can a tooth treated by a partial pulpotomy be
completely restored immediately?
It may be possible to complete the final
restoration on a tooth treated with a partial
pulpotomy; however, since luxation injuries
frequently accompany such severe crown
fractures, deferring the final restoration until the
periodontal ligament (PDL) has healed is
recommended
what are flexible splint materials?
a fishing line(50lb test) or a light stainless steel crown orthodontic wire(0.16 to 0.18)
What clinical and radiographic signs indicate
successful healing of root-fractured teeth?
Root-fractured teeth may heal with a hard tissue
union, with interposition of connective tissues or
with interposition of bone and connective
tissues. Radiographic signs of success indicate
presence of lamina dura and no signs of bone or
root resorption
ankylosis and replacement resorption often appears after how long after an injury?
2 to 3 months.
What are the most common complications of an
intrusion injury?
Intrusions are serious injuries with a relatively
poor prognosis because of the crushing of the
PDL fibers, pulp tissue, and supporting bone. Ankylosis with resulting replacement root
resorption is common, as is pulp necrosis and
inflammatory root resorption
How does the management of an intruded
immature (open apex) permanent tooth differ
from that of a mature tooth?
Recent evidence indicates that immature teeth
may reposition themselves spontaneously so
they can be monitored for several weeks. If no
movement occurs, repositioning with
orthodontic forces should be initiated. Some
clinicians recommend mildly luxating the tooth
prior to applying the orthodontic force
In children in the early stages of the mixed
dentition, it is sometimes hard to know if an
incisor was intruded or if it had just not erupted
completely. What clinical tests improve the
diagnosis of an intrusion injury?
Intruded teeth are displaced forcefully into the
alveolar bone and will be completely immobile. A percussion test will yield a high-pitched
hollow or metallic sound. The PDL space will not
be visible on radiographic exam
What clinical and radiographic signs indicate
successful treatment of intrusion injuries?
The tooth is in normal position and responds
normally to mobility and percussion tests. Radiographically, no replacement or
inflammatory root resorption is occurring and
intact lamina dura is evidenced around the root
when is decoronation of a reimplanted avulsed tooth recommended?
Decoronation of the tooth to preserve the alveolar
bone is recommended if teeth become ankylosed
and infrapositioned greater than 1 mm.
What is done 7-10 days after reimplantation and splinting of an avulsed permanent tooth with closed apex?
place CaoH in canals for approximately 1-2 months and obturate with gutta percha once no signs of resorption present
what type of sutures are usually used for soft tissue injuries and what can they cause?
Resorbable sutures, such as polygycolic gut or vicryl, are often used. Resorbable sutures may cause localized inflammatory reactions which can delay healing, and thus are not used or recommended on the skin
how do you treat laryngospasms?
with succinylcholine, do not use in children suspected of having MH.
what is included on the admit note before GA?
current medical status
diagnosis
proposed treatment
what is part of the universal procedure of time out?
Patient ID(Two identifiers)
Antibiotics if needed, are given
X-rays displayed
Throat pack placed and time noted
what is microabrasion and what is the technique for it?
Microabrasion- removal of the surface opaque layer of enamel, leaving the normal “yellow” color of the perm crown
Use RD to protect tissues.
Hydrochloric acid/pumice slurry is applied to the affected area using rubber cup for 10 sec only (repeat a max of time 10 times)
what are characteristics of oral electrical burns?
o Often painless due to burn o Eschar sloughs off 7-10 days o Bleeding from facial artery possible o Use fixed appliance to stop contracture of wounds o Wear appliance for 6-12 months
characteristics of child vs adult airway?
• Children have lots of lymph node tissue (usually decreases after age 10)
• Funnel shaped airway
o Narrowest part of adult airway is at vocal cords
o Narrowest part of child airway is at Cricoid (pre-pubertal)
• Large tongue and epiglottis
• Mandible is less developed
• Higher respiratory rate and ventilation
• Smaller tidal volume
• Lower residual functional capacity, therefore easily de-saturate
• Weak chest muscles cause them to breathe more from the diaphragm which further reduces airway capacity
which sedative is contraindicated in a patient taking adderall?
the narcotic Demerol
following trauma, when should you take new PAs as can you see radiographic evidence of a PA lesion or root resorption?
3-4 weeks for PA lesion
6-8 weeks for root resorption
Guidance of eruption? Different from serial extraction! Goal of guidance of eruption is to keep all your teeth and use space maintenance to save as much space as possible.
When crowding greater than 10mm in both arches in cl 1 malocclusion
Ext primary cuspids, wan’t premolar to erupt before before canine, may have to ext D when premolar root 1/2-2/3 formed.
when is protective stabilization indicated?
- patients require immediate diagnosis and/or limited treatment and cannot cooperate due to lack of maturity or mental
or physical disability; - the safety of the patient, staff, dentist, or parent would be at risk without the use of protective stabilization;
- sedated patients require limited stabilization to help reduce
untoward movement.
what is included in the preop workup and consultation before proceeding with GA/hospital dentistry?
Obtain a complete health history including medications and abnormal health history
Consultation with PCP
Identify the CC and obtain clinical and radiographic exam before, if possible.
Discuss with guardian the rationale for GA, risks/benefits associated with GA, anticipated post op behavior and limitation of activities, cost, physical exam, lab tests, admissions process, NPO guidelines and informed CONSENT
what is the operating room protocol on the day of surgery?
Pre-op Evaluation
o Weight
o Review history and physical
o Vital signs
o Airway assessment
o NPO status
Medical Record
o Admit note: current medical status, diagnosis, proposed tx
o H&P reviewed
o Surgical consent
o Pre-op orders
o Lab tests, results, consults, guardianship
“Time Out”- completed immediately prior to start of procedure
o Patient identification (2 identifiers)
o Procedure to be performed
Obtain x-rays prior to scrub in
Place throat pack
Perform thorough debridement , prophy, and detailed oral exam
LA may be used to minimize post-op pain and bleeding
Provide tx with the greatest longevity and requires the least maintenance
when does the primary dentition initiate calcification?
4-6 months in utero.
what syndromes have SN teeth?
cleidocranial dysplasia sturge weber gardner crouzon apert oro facial digital syndrome 1
in what direction does enamel maturation occur?
in two stages, matrix segments are formed and then mature from incisal to cervical, so incisal enamel matures earliest.
at how many months does permanent maxillary central and mandibular incisors(laterals and centrals) begin and end calcification?
3-months - 5yo.
hypoplasia of permanent maxillary central and mandibular incisors in the middle third of the crown suggests an insult to mineralization at what time frame?
14-34 months.
when does calcification begin and end ofr permanent first molars?
at birth, ends at 3 years.
when does calcification begin and end for permanent second molars?
3years - 8 years.
when does calcification begin and end for maxillary lateral incisors permanent
10 mo - 5 yrs
when does calcification begin and end for permanent canines?
4 mo - 6 years
when does calcification begin and end for permanent premolars?
18 mo - 6.5 years
what intubation tube size cheat do you use to figure out which size to use?
(Age/4) + 4
what is the accepted treatment of chronic perio and other periodontal diseases?
SRP
Systemic Drug Administrations
Local Drug Delivery(of tetracycline, chlorhexidine)
Surgical Therapy – to facilitate access to the roots so they can be scaled
Resective therapy(gingivectomy, gingivoplasty)
Regenerative Surgical Therapy – in those with significant attachment loss.
is there a relationship between a missing primary tooth and its permanent successor?
yes, significant correlation.
appearance of erosion in acid consumption, bulimia, GERD?
With acid consumption you see a polished stone appearance on the lingual of maxillary incisors. With bulimia you see generalized erosion from premolar to premolar on the lingual surfaces. With GERD you may see a cupped out appearance on molars, especially primary molars along with lingual erosion.
what recommendations are given to GERD patients?
wait 2 hours to lay down after eating, sleep with your head propped up, avoid over eating, and avoid eating too fast
associated conditions with GERD are?
asthma adhd cerebral palsy failure to thrive premature birth
at what stage of root formation do teeth typically erupt?
mandibular central incisors and 1st perm molars at 1/2 root length.
mandibular canines and 2nd molars erupt soon after 3/4 root completion
all other teeth erupt at 3/4 root development
Ext any primary tooth once its perm successor has 3/4 root development. Overretained
when do you use a transpalatal arch vs a nance?
transpalatal arch causes less tissue irritation and can/should be used when primary molars are missing on one side, not bilaterally. Use a nance when primary molars missing bilaterally
is there an association between dental anomalies such as ectopic eruption of 1st perm molars and hypoplasia?
Yes. The diagnosis of one anomaly may indicate an increased risk of other anomalies. The following are associated per Bacetti
Palatally displaced max canines Enamel hypoplasia Ectopic eruption of max 1st molars microdont/peg max lateral infraocclusion of primary molars missing 2nd perm premolars
how does premature timing loss of primary molar affect premolar eruption?
Before age 5, delayed premolar eruption, after 8, accelerated premolar eruption
characteristics of cystic fibrosis patients?
typically low level of caries due to prophylactic antibiotics that most patients are taking. Also don’t see erosion that often because CF patients typically have higher concentrations of salivary bicarbonate and phosphates.