Module 1 Flashcards
what are the aims of providing dental care for children
Prevent disease
Reduce risk of child experiencing pain or infection or needing treatment-induced dental anxiety if caries does occur
Got child to grow up feeling positive about their oral health and with skills and motivation to maintain it
what are the priorities for the dental team
Involve both the child and their parent in decisions regarding the child’s oral health care
Encourage the child’s parent to take responsibility for the child’s oral health
○ Implement advice given on prevention
○ Bring their child for dental care
Ensure valid consent is obtained
Relieve pain or infection
Apply preventative measures to the highest standard possible based on an assessment of the child’s caries risk
Focus on prevention of caries in permanent dentition
Diagnose caries early and manage appropriately - permanent dentition
Manage caries in primary dentition using an appropriate technique
○ Maximise chance of tooth exfoliating without causing pain or infection
○ Minimise the risk of treatment-induced anxiety
Identify where there is a concern about a parent’s ability to comply with dental health preventative advice, support or treatment uptake, and to contact and work collaboratively with other professionals
what is involved in clinical assessment
Assess child’s plaque levels
Assess child / parents toothbrushing skills and knowledge - discuss
Assess dentition
○ Including visual examination for the presence of caries on clean and dry teeth using a tooth by tooth approach
Consider taking bitewing radiographs to accurately diagnose the extent of any caries, including proximity to the pulp
Assess activity of each lesion
○ Use radiographs to assess progression over time
○ Assume that all caries are active unless there is evidence that they have arrested
Primary dentition: assess risk of carious lesions causing pain / infection prior to exfoliation to inform a suitable management strategy
Assess any hypomineralised molars independently to determine the extent of disease and likely prognosis
Discuss findings with child and parent
classify initial and advanced carious lesions on occlusal surfaces (primary teeth)
initial = Non-cavitated, dentine shadow or minimal enamel cavitation
Radiograph: outer 1/3 dentine
advanced = Dentine shadow or cavitation with visible dentine
Radiograph: middle or inner 1/3 dentine
classify initial and advanced carious lesions on proximal surfaces (primary teeth)
initial = White spot lesions or shadow
Radiograph: lesion only in enamel
advanced = Enamel cavitation and dentine shadow or cavity with visible dentine
Radiograph: may extend into inner 1/3
classify initial and advanced carious lesions on anterior surfaces (primary teeth)
initial = White spot lesions but not dentinal caries
advanced = Cavitation or dentine shadow
explain pulpal involvement in carious primary teeth
Any tooth with clinical pulpal exposure or no clear separation between carious lesion and dental pulp radiographically
explain near to exfoliation in primary teeth
Clinically mobile
Radiograph: root resorption
explain arrested caries i
Any tooth with arrested caries and where aesthetics is not a priorit
explain unrestorable primary teeth
Crown destroyed by caries or fractured, or pulp exposed with pulp polyp (pain / infection free)
classify initial, moderate and extensive caries on occlusal surfaces (permanent teeth)
initial =
moderate =
extensive =
classify initial, moderate and extensive caries on occlusal surfaces (permanent teeth)
initial = Non-cavitated enamel carious lesions
White spot lesions
Discoloured or stained fissures
Radiographs: up to the EDJ or not visible
moderate = Enamel cavitation and dentine shadow or cavity with visible dentine
Radiograph: up to and including middle 1/3 dentine
extensive = Cavitation with visible dentine or widespread dentine shadow
Radiograph: inner 1/3 dentine
classify initial, moderate and extensive caries on proximal surfaces (permanent teeth)
initial = White spot lesions or dentine shadow
Enamel intact
Radiograph: outer 1/3 dentine
moderate = Enamel cavitation or dentine shadow
Radiograph: outer or middle 1/3 dentine
extensive = Cavitation with visible dentine or widespread dentine shadow
Radiograph: inner 1/3 dentine
classify initial, moderate and extensive caries on anterior surfaces (permanent teeth)
initial = White spot lesions
No dentinal caries
moderate =
extensive = Cavitation or dentine shadow
explain pulpal involvement permanent teeth
Any tooth with clinical pulpal exposure or no clear separation between carious lesion and dental pulp radiographically
explain unrestorable permanent teeth
Crown destroyed by caries or fractured, or pulp exposed with pulp polyp (pain / infection free)
what is caries risk assessment
= assess whether or not the child is at an increased risk of developing caries
how do you carrying out a CRA
- Patient history
- Resident in an area of relative disadvantage
- DMF / dmf (missing due to caries)
Use this CRA to inform the frequency of review radiographs
Reassess the child’s risk at each assessment
How can you manage a child’s anxiety level with the use of BMT
○ Communication ○ Enhanced control ○ Tell, show, do ○ Behaviour shaping and positive reinforcement ○ Structured time ○ Distraction ○ Relaxation ○ Systematic desensitisation
what factor is most likely to improve the oral health of all pre-school children?
Water fluoridation
Ideally if all children used 1450ppm toothpaste it would be the most efficient way to ensure their teeth received the fluoride they need
Unfortunately those who most need it do not use it, they may not even brush their teeth at all
which treatment is of the highest priority in the following plan?
relief of pain
This comes as a higher priority than OHI, restoration of pain free permanent teeth and restoration of pain free primary teeth
when planning treatment which of the following should be carried out first?
simple restoration requiring LA in the upper jaw
This should be the first choice over pulpotomy in the upper jaw, anterior tooth restoration needing LA or simple restoration requiring LA in lower jaw
which of the following would not alter your treatment plan?
need for prevention
Need for GA, child with congenital cardiac disease and allergy to latex would alter your treatment plan
what factor does not need to be considered in the mixed dentition phase?
size of maxillary sinuses
In the mixed dentition stage we should consider development of all permanent teeth, developing malocclusion and the growth of the child
what is the first component of any treatment plan?
relief of pain
This comes before restorative treatment, diet advice and OHI and prevention
which of the following is not a major factor in a preventive treatment plan for a child?
water fluoridation
OHI, fissure sealing and fluoride therapy are major factors in a preventive treatment plan for a child
in what order should care be provided
○ Manage pain (if present)
○ Provide caries prevention
○ Manage caries / asymptomatic infection (if present)
what should be obtained after explaining the child’s oral health needs and any proposed treatment options
obtain valid consent for the agreed care plan from the child where possible and / or the parent / care
when should a child be referred to be assess for suitability for treatment under sedation or GA
If a child is pre-cooperative, unable to cooperate or has multiple affected teeth, consider referral to assess suitability for treatment under sedation or GA
What are reversible symptoms of pulpitis
- pain to cold / sweet
- tooth not tender to percussion
- resolves on removal of stimulus
- tooth difficult to localise
what is the treatment of reversible pulpitis
restore
or place a dressing and restore later
what are irreversible symptoms of pulpitis
- spontaneous pain wakens child at night
- does not resolve on removal of stimulus
- pain to hot / cold
- does not resolve with placement of a temporary dressing
what are the symptoms of dental abscess / periradicular periodontitis
- spontaneous pain wakens child at night
- tooth mobile and tender to percussion
- swelling
- malaise
how should a pre-cooperative child with irreversible pulpitis be treated
try to dress with sub-lining of corticosteroid-antibiotic paste
prescribe pain relief
primary teeth: refer for treatment / extraction with sedation or GA
permanent teeth: carry out root canal therapy or extraction. if the child remains uncooperative refer for specialist care
when should antibiotics be prescribed
Antibiotics should only be prescribed if there is evidence
- of spreading infection (swelling, cellulitis, lymph node involvement)
- or systemic involvement (fever, malaise)
when should fissure sealants be placed
For all children, place fissure sealants on the permanent molars as early as possible after eruption
when should sodium fluoride varnish be applied
For all children, aged 2 or older, apply sodium fluoride varnish at least twice per year
if the child is at an increased risk of developing caries, what sort of prevention should they receive
If the child is at increased risk of developing caries , in addition to standard prevention, ensure they receive enhanced prevention, unless there is a valid reason not to
In this case, ensure this is documented in the patient’s notes
what amount of toothpaste should be recommended for a child under the age of 3
use a smear
what amount of toothpaste should be recommended for a child over the age of 3
use a pea-sized amount
what concentration of fluoride toothpaste is recommended in standard prevention
1000-1500ppmF
1450ppmF
what concentration of fluoride toothpaste is recommended in enhanced prevention
under 10s: 1350-1500ppmF
over 10s: consider 2800ppmF
what advice is included in standard prevention for all children
• Give toothbrushing advice at least once a year
○ Brush thoroughly twice daily, including last thing at night
○ Use age-appropriate amount of toothpaste
○ Fluoride concentration: 1000-1500ppm F
○ Spit don’t rinse
○ Supervise children until they can brush effective
• Demonstrate brushing on the child for around 3 minutes annually
• Give dietary advice at least once a year, advise or remind the child and parent about how a health diet can help prevent caries, including
○ Limit consumption of food and drinks containing sugar
○ Drink only water or milk between meals
○ Snack on healthier foods, which are low in sugar
○ Do not place sugary drinks, fruit juices, sweetened milk or soy formula milk in feeding bottles or pacifiers
○ Do not eat or drink, apart from tap water, after brushing at night
○ Be aware of hidden sugars in food and the acid content of drinks
• Place sealants in all pits and fissures of permanent molars as soon as possible after eruption
○ Resin-based sealants are the first choice of material
○ Ensure the buccal pits of lower first permanent molars and the palatal fissures of upper first permanent molars are sealed
○ On fully erupted teeth where the child is uncooperative, use glass ionomer fissure sealants and ensure that fluoride varnish application is optimal
- Check existing sealants for wear and integrity / leakage at every recall visit
- Top up worn or damaged sealants
- Apply sodium fluoride varnish (5%) twice a year to children aged 2 years and over
list healthier snacks which are low in sugar
§ Fresh fruit § Carrots, peppers § Breadsticks § Oatcakes § Occasionally a small amount of lower far cheese
what advice is included in enhanced prevention for children at an increased caries risk
In addition to standard prevention
• At each recall visit, give hands on brushing instructions for around 3 minutes to the child and parent
• At each recall visit, give dietary advice as described for standard prevention
• Consider providing additional preventive interventions depending on the child’s circumstances, for example:
○ Recommending the use of 1350-1500ppm F toothpaste for children up to the age of 10 years old
○ Prescribing 2800ppm F toothpaste for children aged 10-16 years for a limited period [Regular review needed]
○ Keeping a food and drink diary, which is reviewed in practice and advice offered
○ Keeping a toothbrushing chart to record each time teeth are brushed as a reminder
○ Action planning to encourage change
- Consider using GI as a temporary sealant on partially erupted first and second permanent molars until the tooth is fully erupted
- Fissure seal palatal pits on upper lateral permanent incisors, and the occlusal and palatal surfaces of Ds, Es and first and second permanent molars, if assessed as likely to be beneficial
• If unable to give fissure sealants (eg due to the child being pre-cooperative or having a learning disability) then ensure that fluoride varnish application is optimal and attempt again as cooperative improves
• Ensure that sodium fluoride varnish is applied 4 times per year to children aged 2 years and older
○ Some applications may be provided through Childsmile
• Utilise any community / home support for preventive interventions that is available locally
○ Eg health visitor
○ School nurse
○ Childsmile dental health support worker
what is the potential problem with using duraphat
most varnishes contain colophony eg Duraphat
A child who has been hospitalised due to severe asthma or allergy in the last 12 months or who is allergic to sticking plaster may be at risk of an allergic reaction to colophony
In these cases, consider using colophony-free varnish (licensed for caries prevention in the UK) or suggest the use of alternative age-appropriate fluoride preparations (eg fluoride mouthwash or higher concentration fluoride toothpaste)
what should be done for For a child with a carious lesion in a primary tooth
choose the least invasive, feasible caries management strategy, taking into account: ○ the time to exfoliation, ○ the site and extent of the lesion, ○ the risk of pain or infection, ○ the absence or presence of infection, ○ preservation of tooth structure, ○ the number of teeth affected, ○ avoidance of treatment-induced anxiety
what should be done for a child in pain due to pulpitis in vital primary tooth with irreversible symptoms and no evidence of dental abscess
consider carrying out a pulpotomy to preserve tooth and to avoid the need for an extraction
what indicates infection
signs or symptoms of abscess, sinus, inter-radicular radiolucency, non-physiological mobility
how can a primary tooth associated with infection be managed
either by extraction, or in certain circumstances consider referral for pulpectomy
In some cases local measure to bring the infection under control may be appropriate
what does arrested caries look like
enamel: smooth
dentine: hard, lesion likely to be dark in colour
management for carious primary teeth when there are no clinical or radiographic signs of pulpal involvement:
what is the technique used when the tooth is near to exfoliation
- site specific prevention
- non-restorative cavity control
management for carious primary teeth when there are no clinical or radiographic signs of pulpal involvement:
what is the technique used for any tooth with arrested caries (aesthetics is not a priority)
- site specific prevention
- non-restorative cavity control
management for carious primary teeth when there are no clinical or radiographic signs of pulpal involvement:
what is the technique used on initial and advanced occlusal lesions
initial:
- site specific prevention
- no caries removal and seal using the hall technique (but other options would be considered preferable)
- no caries removal and seal with fissure sealant (or infiltration)
advanced:
- no caries removal and seal using the hall technique (but other options would be considered preferable)
- selective caries removal and restoration
- non-restorative cavity control (due to a lack of supporting evidence, this approach is only appropriate for these types of lesions if no alternative is feasible. document the use of this approach and rationale in the patient’s record)
management for carious primary teeth when there are no clinical or radiographic signs of pulpal involvement:
what is the technique used on initial and advanced proximal lesions
initial:
- site specific prevention
- non caries removal and seal with fissure sealant (or infiltration) (an emerging technique with a developing supporting evidence base)
advanced:
- no caries removal and seal using the hall technique
- selective caries removal and restoration (due to a lack of supporting evidence, this approach is only appropriate for these types of lesions if no alternative is feasible. document the use of this approach and rationale in the patient’s record)
- non-restorative cavity control (due to a lack of supporting evidence, this approach is only appropriate for these types of lesions if no alternative is feasible. document the use of this approach and rationale in the patient’s record)
management for carious primary teeth when there are no clinical or radiographic signs of pulpal involvement:
what is the technique used on initial and advanced anterior lesions
initial:
- site specific prevention
advanced:
- selective caries removal and restoration
- non-restorative cavity control (due to a lack of supporting evidence, this approach is only appropriate for these types of lesions if no alternative is feasible. document the use of this approach and rationale in the patient’s record)
- complete caries removal and restoration
management for carious primary teeth when there are no clinical or radiographic signs of pulpal involvement:
what technique is used for an unrestorable tooth (pain/infection free)
- non-restorative cavity control
- extraction
when is caries considered to have arrested
when there is demonstrable evidence of non-progression of lesions over several months using a recording system, such as photographs or ICDAS codes
how should caries be managed in permanent teeth
For a child with carious lesion in a permanent tooth, choose the least invasive, feasible caries management strategy taking into account: ○ The site and extent of lesion ○ The risk of pain or infection ○ Preservation of tooth structure ○ The health of the dental pulp ○ Avoidance of treatment induced anxiety ○ Life time prognosis of tooth ○ Orthodontic considerations ○ Occlusal development
what teeth are most vulnerable to decay in the permanent dentition in children and teenagers
The permanent molars are the most vulnerable to decay in childhood and adolescence
○ Caries most commonly develop at just 2 sites on the permanent molars
§ Base of pits and fissures
§ Proximal surfaces, just below the contact point
Both these sites present challenges to the clinician in terms of diagnosis and caries management
what might be done if the first permanent molar is assessed as having a poor life time prognosis
If a FPM is assessed as having a poor life time prognosis (whether from caries or MIH) and the second permanent molar is not yet erupted, then it may be in the child’s best long term interests to extract the FPM to allow the second permanent molar to erupt in its place
can dental amalgam be used in all permanent teeth
Dental amalgam should not be used in the permanent teeth of a child or young person under 15 years of age unless exceptional circumstances can be justified
what needs to be considered for first permanent molars with molar-incisor hypomineralisation
If there are carious lesions which are
§ Not severe
§ Not sensitive
§ Do not need restoration, and are unlikely to in the future
Then provide enhanced prevention, including fissure sealants and monitor
If there is good quality enamel with small defects that require restoration, use adhesive restorative materials
§ Indirect restorations extending onto sound enamel have better longevity, and it may be necessary to modify the cavity shape to achieve this
If the molars are sensitive then use GIC as a fissure sealant
Management options for carious permanent teeth where there are no clinical or radiographic signs of pulpal involvement:
what technique should be used for initial, moderate and extensive occlusal lesions
initial:
- no caries removal and seal with fissure sealant (or infiltration)
moderate:
- selective caries removal and restoration
- complete caries removal and restoration
extensive:
- stepwise caries removal and restoration
Management options for carious permanent teeth where there are no clinical or radiographic signs of pulpal involvement:
what technique should be used for initial, moderate and extensive proximal lesions
initial:
- site specific prevention
- no caries removal and seal with fissure sealant (or infiltration)
moderate:
- selective caries removal and restoration
- complete caries removal and restoration
extensive:
- stepwise caries removal and restoration
Management options for carious permanent teeth where there are no clinical or radiographic signs of pulpal involvement:
what technique should be used for initial and advanced anterior lesions
initial:
- site specific prevention
advanced:
- complete caries removal and restoration
- selective caries removal and restoration (may be appropriate in some circumstances for anterior teeth, although evidence derived from studies on posterior teeth)
Management options for carious permanent teeth where there are no clinical or radiographic signs of pulpal involvement:
what technique should be used on unrestorable teeth
- extraction
what should be done before referring a child for treatment
First relieve pain
Provide prevention
Attempt caries treatment using BMT and LA
consider the need for temporary dressings to reduce the chance of further pain
what should be considered when referring a child for treatment
• For children who live in a different locality to your practice, be aware that you should refer to the service local to the child
○ This may be different to the service you routinely refer to
• Ensure all the relevant information is included in the referral communication (either electronic or letter)
○ A checklist provided in full guidance
• If referring a child for sedation or GA, follow your local protocol if there is one in place
○ Diagram below is helpful is deciding whether or not to refer a child for treatment under sedation or LA
• If a child is referred for care, ensure that you provide their continued dental care
what should be done at each recall visit
At each recall visit:
• Carry out a focused oral health review, including
○ Asking again about toothbrushing practice and diet
○ Asking about compliance with any agreed action plans
○ Checking the condition of fissure sealants
○ Monitoring any lesions managed with prevention alone
○ Reassessing the child’s caries control and caries risk
- Provide standard prevention to all children and additionally enhanced prevention if the child is assessed as at increased risk of developing caries
- If caries is not being effectively controlled, consider alternative management options and the need for additional community / home support
- Create a new personal care plan as required and maintain comprehensive records
