OSCE DOC - Paeds Flashcards
Trauma (6 mins)- 21 marks
A parent with an 8-year-old child (Molly) attends an emergency appointment at your surgery.
Molly sustained dental trauma whilst playing on her trampoline. You have examined her and observed the injury in the photo provided.
You have taken the periapical radiograph provided. The child has just stepped out of the surgery for a moment.
When you step into the bay, the parent will tell you their concerns (these include Molly’s apprehension about treatment, pain and concerns regarding aesthetics). The parent will then ask you to:
Explain the nature of the child’s injury
- Enamel dentine pulp fracture or complicated pulp fracture (1 mark)
- Simple explanation parent can understand (1 mark) - All three layers of tooth involved including the nerve
Trauma (6 mins)- 21 marks
A parent with an 8-year-old child (Molly) attends an emergency appointment at your surgery.
Molly sustained dental trauma whilst playing on her trampoline. You have examined her and observed the injury in the photo provided.
You have taken the periapical radiograph provided. The child has just stepped out of the surgery for a moment.
When you step into the bay, the parent will tell you their concerns (these include Molly’s apprehension about treatment, pain and concerns regarding aesthetics). The parent will then ask you to:
Explain, step by step in detail, what treatment is required for the child today only (the patient is mildly anxious and the parent would like this information so that they can support their child through the treatment in the best way possible)
You are happy with all aspects of the child’s trauma and medical history and you do not need to ask any further questions regarding this.
Explain treatment
* Pulpotomy (open apex)
* As this is a large exposure, the treatment of choice is called a pulpotomy (1 mark)
* Explain partial removal of pulp (1 mark)
* Explain that aim is to keep undamaged pulp tissue alive (1 mark)
* Explain that this is so that the tooth stays alive and continues to grow (1 mark)
(open apex allows blood in)
Baseline sensibility tests
* Tests required to see how the nerve in the injured and adjacent teeth respond (1 mark)
* Tests required as baseline reading for long term monitoring (1 mark)
- It means putting something cold on the tooth and noting how the tooth responds and then trying an electrode on the tooth to see pulp response
- LA required
Parent informed that LA is required (1 mark)
- Why LA is required- required to keep patient numb and comfortable (1 mark)
- Describe that LA involves injection of the gum (1 mark)
Dental dam
- What this is- rubber sheet over tooth, acts like a mask (1 mark)
- Why dam is placed- moisture control, protects airway (1 mark)
- All explained in language the parent will understand (1 mark)
Drilling / use of handpiece
- Drill will be used to remove some pulp tissue- shouldn’t feel any pain but might feel vibration (1 mark) (tickle)
- Aim is to leave only good tissue (1 mark)
- Then use cotton wool pledget to control bleeding
Dressing
- Indicate that the tooth will be dressed- setting CaOH, MTA (1 mark)
- Exposed dentine sealed with GIC or composite
Composite restoration
- Indicate that a white filling will be placed to regain aesthetics (2 marks)
(clinical and radiographic review after 6-8 weeks and 1 year)
Actor marks
Describing treatment in an understandable manner, supportive and empathetic regarding injury (2 marks)
Fluoride Varnish (6 mins) – 25 marks
2-year-old child- talk through parent’s concerns.
Why they need fluoride varnish, fluoride toxicity, asks for OHI after application
A parent, Mrs Ina Fleur, was seen by the dental nurse with her 2-year-old child Sarah for application of fluoride varnish, but wants to ask you (the dentist) about it first.
You are going to have a brief chat with her, and deal with any of her concerns.
Good communication skills
Some a bit patronising- this is an adult you are talking to
Childsmile is the programme, not the evidence
Childsmile is both universal and targeted- in practice it is universal
Safety- mottling is more common than death!
Fluoride isn’t ‘magic’
Reassure the patient
Fluoride varnish is placed on the tooth and is minimally invasive
Promotes remineralisation (hardening of the tooth) and prevents demineralisation (softening of tooth)
It involved drying the teeth and painting the gel onto the tooth
(indications- treatment of hypersensitivity, caries prevention)
Contraindicated in
Severe uncontrolled asthma (hospitalised in the last 12 months)
Allergy to colophony (sticking plasters)- we can use colophony free version if needed
Ulcerative gingivitis, stomatitis, allergy (past fluoride varnish), allergy to elastoplast
Instructions afterwards
Don’t eat / drink for 1 hour
Soft diet for the rest of the day
- no dark coloured foods
Avoid fluoride supplements today
SDCEP- no soft food for 30 mins, no hard food or toothbrushing for 4 hours; Childsmile says don’t brush that night
What are the dangers with fluoride toxicity and what treatment should you carry out if you suspect it?
Fluoride toxicity
Very small risk and technically relevant if small child consumes a quantity of toothpaste
In terms of fluoride varnish- 2 y/o would have to swallow about 50mg of fluoride- and the amount we place on teeth is 5.65mg (0.25ml contains 5.65mg fluoride, 0.5ml contains 11.3mg fluoride) (under 6 is 0.25ml, over 6 is 0.4ml)
5mg/kg- give calcium orally (milk) and observe for a few hours
5-15mg/kg- give calcium orally (milk, calcium gluconate, calcium lactate) and admit to hospital
>15mg/kg- admit to hospital immediately, cardiac monitoring and life support, IV calcium gluconate
(fluoride varnish suitable in children aged 2 and over)
Nursing Bottle Caries (6 mins)
Concerned mother with 2-year-old in pain. Take a brief history then photo of decayed 52-62 (upper incisors) provided.
Explain diagnosis to parent, prevention and management options (GA).
Introduce self and greet patient by name
Brief history:
- Take pain history
- Where is the pain?
- When did the pain come on?
- Probably unable to describe character
- Any problems elsewhere?
- How long does the pain last?
- Any analgesia? How much? Within limits?
- Feeding bottle to bed?
- What is in the feeding bottle?
- Look at photos carefully to identify pattern of decay:
- Pattern is usually upper incisors, Ds and lower canines
Advice:
- Feeder cup replacing bottle from 6 months- so child doesn’t have to suck
- No feeding at night (lactose in milk- decreased salivary flow and held in mouth)
- No on-demand breastfeeding
- No sweetened milk, soy milk (unless medically advised)
- Milk and water only between meals
- Sugar free variations of drinks, foods, medicine (e.g., sugar-free calpol)
- Safe snacks include- cheese, breadsticks, fruit, plain crisps
Toothbrushing
- Assist the child until 7 y/o
- Brush in the morning and last thing at night
- No food / drink except water after brushing
- Spit don’t rinse
Management:
Extraction of carious teeth under GA- as in pain (discuss GA risk and benefit)
GIC remaining teeth and review- if no pain (acclimatisation)
Fluoride (supplements and varnish)
Extra points for empathy
Consenting parent for GA extractions on 3 year old patient
- Explaining the procedure and risks (6 mins)
- Explain alternative treatment options
- Introduce self and greet patient by name
Process - Discussion of GA risks / benefits and all other alternative options
- Referral to hospital for specialist to assess- if any other teeth of poor prognosis they will be added to this plan to avoid future GA
- GA will involve day in hospital- need to monitor for full recovery
- Need of chaperone throughout
Risks
Very common minor risks - Headache, nausea, vomiting, drowsiness
- Sore throat or sore nose / nosebleed from intubation
Risks from treatment - Pain, bleeding, swelling, bruising, infection, loss of space, stitches
- Damage to mouth from intubation, allergy, malignant hyperpyrexia (ask about FH), slow recovery from anaesthetic, prolonged apnoea, awareness, laryngospasm, coughing / moving during procedure, prolonged bleeding
Might do extra extractions if clinician notices any other teeth of questionable prognosis
Rare major risks - Brain damage
- Death (1 in 100,000 - need a machine to breathe during operation and there is a very small risk that you will not be able to breathe independently again on waking- i.e., never waking again)
- Upset when coming round- can make underlying anxiety worse
Benefit
- Can get the patient out of pain
- Remove source of infection
Other options
Prevention only
Biological caries management
LA +/- IHS, IV, LA only
Conditions requiring special care (can be contraindications)
Sickle cell disease (or any hypoxia)
Diabetes- can’t fast in same way
Down’s syndrome
Malignant hyperpyrexia
CF or severe asthma
Bleeding disorders
Cardiac or renal conditions
Epilepsy
Long QT syndrome
What must be included in GA referral form?
- Patient name
- Patient address
- Patient / parent contact numbers (landline and mobile)
- Patient medical history
- Patient GP details
- Parental responsibility
- Justification for GA
- Proposed treatment plan
- Previous treatment details
- letter must include- recent radiographs or, if not available, an explanation of why (e.g., patient not cooperative)
Caries- Risk Assessment and Management (6 mins)
Diagnose caries on bitewings, explain prevention and give advice to mum
- What is included in the caries risk assessment?
- What prevention can be given?
Caries risk assessment
* Clinical evidence
* Diet
* Medical history
* Social history
* Saliva
* Plaque control
* Fluoride exposure
Prevention
* Radiographs
* Diet advice
* Toothbrushing instruction
* Strength of fluoride in toothpaste
* Fluoride supplement
* Fluoride varnish
* Fissure sealant
* Sugar free medicine
Toothbrushing advice
* Assist child with brushing until able to brush independently (7 years)
* 2x daily with fluoride toothpaste
* Demonstrate on child 6 monthly, get parent to demonstrate in front of you
* Methodical approach
* - work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 mins, spit don’t rinse
Diet advice
* Avoid sugar snacks / drinks
* Snack on healthier foods- carrot sticks, breadsticks, fruit in moderation
* Milk and water only (between meals)
* If nursing bottle- no bottle to bed at night, no soy milk or sweetened milk, no on demand breastfeeding
Fluoride
* Varnish 4x yearly to children >2 years (5%, 22600ppm)
* Toothpaste 2x daily- 1450ppm (<3 y/o smear, >3 y/o pea)
* - >10 y/o 2800ppm, >16 y/o 5000ppm
* - avoid rinsing mouth, drinking or eating for 30 mins after use
* - advise that this TP is medicine and should only be used by child
* Mouthwash 1x daily for >6 y/o (0.05%)
* - preferentially at different time from brushing
* - avoid rinsing mouth, drinking or eating for 15 mins after use
Treatment Planning for Child- Parent Considering Complaint (12 mins)
Patient has
* Caries
Explain how you would treatment plan this child?
Explain treatment required:
Caries management
- List carious teeth- sedation / GA referral vs GDP management
- Start working with least invasive restorations- fissure sealant to then LA procedures
Prevention
- Assign caries risk to patient based on caries risk assessment
Begin prevention
- Radiographs, diet advice, toothbrushing instruction, fluoride toothpaste, fluoride supplements, fluoride varnish, sugar free medicine, fissure sealant
Treatment Planning for Child- Parent Considering Complaint (12 mins)
Patient has
* Mucocele
Explain how you would treatment plan this child and how you would consent them for removal?
Mucocele:
* Leave and review vs referral for surgical review
* Explain the procedure- LA around site of swelling, cut in gum and removal in its entirety, sutures
* Risks- pain, swelling, bleeding, bruising, infection, numbness, sutures
* Explain that it is due to damage of minor salivary glands due to trauma, and that removal could also cause damage to these glands, and that there is always potential for the mucocele to reappear even after removal
Treatment Planning for Child- Parent Considering Complaint (12 mins)
Mucocele, caries, PA pathology, hypodontia
Parent considering taking legal action as previous dentist never took radiographs or advised on treatment.
How do you deal with this patients mother that is trying to file a complaint?
Deal with complaint:
* ‘I can’t give comment because I don’t know the full story’
* ‘I can only offer you this treatment at this present time’
* ‘Whatever was offered previously, will not change what treatment is required now’
* Tell mum if she is intended to complain, she can go back to practice, they will have a standard complaint procedure- only if patient asks (do not offer)
* ‘It will be unhelpful for me to get involved in this matter as I don’t know the background behind treatment that was or wasn’t done and would be unfair for me to speculate on it’
Treatment Planning for Child- Parent Considering Complaint (12 mins)
Patient has
* hypodontia
Explain how you would treatment plan this child?
Hypodontia:
Potential problems- space, drifting, overeruption, aesthetics, functional problems
Space maintenance- URA
Referral to orthodontist at 6-7 years
Treatment options in future:
- Nothing
- Restorative only- composite, veneers, RBB, RPD
- Ortho only
- Restorative and ortho- space closure and reshape teeth to camouflage (space closure plus)
- Implants
Trauma- Subluxation (12 mins)
18-month-old. Knee to knee.
Fake child (doll) who fell down, knee to knee exam, subluxation of upper centrals.
Explain what a knee to knee examination is?
- Introduce self and designation
- Reassure father everything will be okay
- Knee-to-knee examination
- Explain to parent what you intend to do
- Sit across from the parent with your knees touching theirs
- Bring your knees together and ask the parent to do the same
- Ask the parent to sit the child with their legs round the parent’s waist
- Lower the child down into your knees and ask the parent to hold the child’s arms
What is in the trauma stamp?
Colour, sinus, EPT, ECl, TTP, percussion note, mobility, displacement, radiograph (PA or occlusal)
No sensibility tests in primary teeth
What are some signs of a subluxation?
- TTP,
- mobile,
- bleeding from gum,
- no displacement
