Paediatric Dentistry Flashcards
Molar incisor hypomineralisation defintion?
Hypomineralisation of systemic origin of between 1-4 permanent molars, frequently associated with affected incisors
What is the definition of enamel hypomineralisation?
Is a qualitative defecient, with reduced mineralisation resulting in discoloured enamel in a tooth of normal shape and size
What is the definition of enamel hypoplasia?
Is a quantities defect of the enamel presenting as pits and grooves, missing enamel or smaller teeth
What is the aetiology of molar incisor hypomineralsation (MIH)?
Enamel defect
Unknown aetiology
But occurs within 4 months of gestation
- no longer linked to final trimester mother illness
What is linked to peri and postnatal health to the cause of MIH?
Perinatal - linked to natal hypoxia
- caesarian, hypoxia
Postnatal - high temperature within the 1st year of birth
- measles, UTI, bronchitis, otitis and asthma
Linked to many different factors working synergistically
Genetic factor
How prevalent is MIH? In the UK
Average is 15%
What to expect for a tooth with MIH?
Large demarcated opacity
Yellow/brown in colour
May or may not have post eruption enamel breakdown
With hypersentivitiy
Can de difficult to anaesthetise (low stimuli threshold)
Rapid caries progression (they avoid brushing)
Who to diagnose a tooth with MIH?
Relate to age
Clean and wet the tooth with cotton wool roll
Qualitative defect of enamel effecting enamel translucency
Very discolured - yellow/brown
Differential diagnosis for MIH?
Enamel hypoplasia
Fluorosis
Amelogenesis Imperfecta
Defintion of Amelogenesis Imperfecta
Affects all teeth
Enamel doesn’t form properly
Rare
How to classify MIH? Tools?
On a spectrum
Mild, moderate and severe
Can be done per tooth
How affected by stimuli
- research based
MIH classification- TNI The Wurzburg Concept?
Won’t be tested on an exam but can be used in research studies
How to treat a patient with MIH?
- Remineralisation and desensitisation - primary
- Prevention - considered high caries risk
- Direct restoration
What is included for remineralisation treatment for a MIH patient? Overall treatment?
- High Fluoride toothpaste
- Tooth mousse - aids with desensitisation and allows remineralisation
- GIC to seal the affected molar (no prep and Fl leached)
What is included for remineralisation treatment for a MIH patient? Specifically molars?
Fissure sealants
- all in one etch and bond system to reduce need to wash and dry
- or use flowable composite
What is included for direct restorations treatment for a MIH patient? Specifically molars?
Initial stage
- GIC
- RMGIC
- Not suitable for loading bearing surfaces, but can be used as sealants
Cavity design
- minimal removal
- composite
Temporary crowns
- PMC for temporary until 18 (protection) for future permanent treatment
What is included for extractions for a MIH patient?
Extractions
- if poor prognosis just extract
- planned extraction
- class I ortho relationship
- timing is key
- no crowding
- OPT to check bifurcation of lower 7 developing (similar time to eruption of lateral incisors upper) - to close the gap
- around age 10
Class II with crowding + MIH –》speak to local ortho and decide when to remove the affected 6s
Treatment summary for MIH?
Best practice for MIH graphic
What is included for anterior tooth treatment for a MIH patient?
- Desensitiation with tooth mousse
- Microabrasion max 10, in cycles of 3
- Bleaching
- Masking with composite
Works best for mottling and milky brown
Post-OP - fluoride varnish that is tooth coloured
What is included for anterior tooth treatment for a MIH patient - For bleaching?
Only for adult patients
What is included for anterior tooth treatment for a MIH patient? Masking with composite?
Add flowable composite over the lesion
- affected by shine through or changed morphology
What is included for anterior tooth treatment for a MIH patient? Direct restorations?
Cut the lesions out and replace with composite - needs replacing and care
What is included for anterior tooth treatment for a MIH patient? Removal and resin infiltrate?
A composite that is incorporated into the enamel
- not sure about long term effects
- all research sponsored by the company
What is included for anterior tooth treatment for a MIH patient? Full composite veneer?
Trim off the first layer of enamel
- then fill composite over
Full veneer after 18/19 as teeth are still growing - will give poor enamel margins
Treatment summary for anterior MIH
Best practice for MIH
- start with least invasive
What issues arise when dealing with MIH?
Anxeity
- increased level of fear and anxiety and due to excessive treatment when younger
Ortho vs resto costs
- balance between extractions and ortho compared to restoration costs
Ask patient’s opinion
What to include for an initial assessment of the paediatric patient?
Skeletal pattern
Anterior Posterior
Ask patient to sit up right
(Stare out of the window)
Philtrum should be 1mm infront of the dip under the bottom lip
What to include for the vertical dimension assessment of the paediatric patient?
Upper and lower segments of the face should be approximately 50:50
If patient has a reduced lower facial height what does that show?
Deep overbite
If a patient has an increased lower facial height what does that show?
Anterior open bite
What measurement does mild crowding should?
<4mm
What measurement does a moderate crowding show?
4-9mm
What measurement does severe crowding show?
> 9mm
Check to see if the centre lines match
Incisor to incisor
How to record an accurate centreline?
A plus sign, with measurements for deviation
Deviations for the left or the right
Name the classifications for Angle’s classification?
Class I
Class II
- division I
- division II
Class III
Describe Class I classification for Angle’s classification?
The lower incisor edges occlude with or lie immediately below the cingulum plateau (middle part of) the upper central incisors.
Describe Class II classification of Angle’s classification?
The lower incisor edges lie posterior to the cingulum plateau of the upper central incisors. There are two divisions:
Division 1— there is an increase in the overjet and the upper central incisors are usually proclined.
Division 2— the upper central incisors are retroclined. The overjet is usually minimal but may be increased.
Describe Class III classification of Angle’s classification?
The lower incisor edges lie anterior to the cingulum plateau of the upper central incisors. The overjet is reduced or reversed.
Overbite?
Distance from top of lower incisors and top of upper incisors
Overjet?
The distance between the overlap of the upper and lower incisors
Measured as a percentage
What skeletal pattern does a class II malocclusion show?
Retroganthic
Retruded chin
What skeletal pattern does Class III show?
Prognathic
Underbite
Molar occlusion?
Upper should be distal to lower
Class I - upper distal to lower
Class II - upper very mesial to lower
Class III - upper very distal to lower
Molar class I occlusion?
Class I - upper distal to lower
Molar class II malocclusion
Class II - upper very mesial to lower
Molar class III malocclusion?
Class III - upper very distal to lower
How to measure crowding?
Eye ball or use ruler
How much would you need to move the teeth to put them back into the curve of spee
Check where the frenal attachment is
Should be between the central incisors
Index of orthodontic treatment need - IOTN
Fill in from slide
Graded from 1-5
Aesthetic scale from 0-10
What are the grades for IOTN score?
5 - needs treatment
4 - needs treatment
3 - borderline
2 - little
1 - none
How to identify the aesthetic score?
Compare the aesthetic chart to the patients dentition
What is involved for anterior cross bite?
Mandibular displacement
Mobility
Gingival recession
Attrition
Check for:
- skeletal pattern (CI or CIII)
- space (adequate space)
- overbite (positive)
Possibly due to the tooth germ grown in the wrong place which then doesn’t resorb the primary tooth
Age 4 typical teeth?
Spaced
Slight overjet
Can slide into class III malocclusion due to attrition
How to treat an anterior crossbite with a problematic UR1?
Numbers are the teeth
Adams clasp 6/6
C clasp 1/ or labial bow
Z spring /1
2mm posterior capping to allow anterior opening
When to review patient after paediatric anterior bite appliance?
Review in 6 weeks
If needs more time, review in another 6 weeks
If no resolution, refer to ortho and remove the appliance
Name the aetiology of unerupted central?
Supernumerary
Dilaceration
Explain the management of an unerupted central incisors due to supernumerary?
If less than 9, and 1 incomplege root developed:
- Remove obstruction
- Space creation
- Monitor eruption 18/12
- Expose and bond if non eruption in 18/12
9 YO and complete or nearly complete root development:
- Remove obstruction
- Space creation
- Monitor eruption 18/12
- Expose and bond if non eruption in 18/12
Older than 10:
- Remove obstruction
- Expose and bond
Describe a mesodens supernumerary tooth?
Mesodens most common, supernumerary at the midline, conical in shape
What to think about when a 9 YO child arrives in your clinic?
Threes
Sixes
And fives
How to manage a paediatric patient with poor prognosis for their permanent first molars?
Due to gross caries or MIH
Assess at age of 8-10 YO
Take an OPG
For a Class I occlusion, check for bifurcation of the lower 7s, to give an idea of when to extract the 6s
Compensation extractions?
What is the main cause of dilaceration of permanent teeth?
Trauma to permanent tooth germ
Describe impacted canines?
Palpable by age 10
Palatally found in 85% of cases
Risk of causing root resorption
Take a parallax and OPG to identify location
Name the 4 treatments for patients with impacted canines?
Leave in situ
Surgical treatment and ortho
Expose and align
Transplant
Explain what would occur with leave in situ for an impacted canines?
Significant displacement
Patient unwilling to have ortho or surgery
Removal is a risk to adjacent teeth
Requires long term surveillance
Explain what would occur for surgical removal and ortho for a patient with impacted canines?
Associated pathology
Poor position for alignment
Explain what would occur for expose and align for a patient with impacted canines?
Patient willing and capable
Canine position favourable
<50% past the midpoint of the central
Apex in the midline with space for alignment
Ortho treatment for alignment > 2 years
Complications such as discolouration, resorption or potential relapse
Explain what would occur for transplant for an impacted canines?
Poor prognosis for alignment
Adequate space
Very technique sensitive
Superceded by implant
What is the defintion of infra occluded molars?
Primary teeth that have remained in their relative position in the arch while other teeth continue to erupt
Often associated with congenitally missing premolars
Can become ankylosed
Resorption may or may not take place
Take radiograph and assess root resorption/presence of premolar
What risks does an increased overjet cause and how to treat it?
Trauma
Functional appliance
Sports mouthguard
Consider early referal
What treatment is advised for an intra occluded primary molar, if the permanent successor is present?
Monitor, as it will exfoliate, but if subgingival extract
What treatment is advised for an intra occluded primary molar, if the is NO permanent successor is present?
Monitor
Assess for root resorption
And consider composite build up
Only extract if almost subgingival
Name the 6 common complications of dental trauma?
Pulpal necrosis
Resorption
Ankylosis
Canal obliteration
Discolouration
Pulpal concussion
Trauma follow up?
Add
Give a splinting summary for each injury category?
Subluxation - 2 weeks
Lateral luxation - 4 weeks
Intrusion - 4* weeks
Extrusion - 2 weeks
Avulsion - 2 weeks
Root fracture - 4 weeks to 4 months
Dento-alveolar fracture - 4 weeks
All flexible
Name the diagnosis categories for trauma? Trauma stamp?
Tooth
Sinus
Colour
TTP
Mobility
EPT
ECL
P. Note
Radiograph
What observations can be carried out for dental trauma?
Percussion
Tenderness
Percussion note
Transillumination
Exam of soft tissues
Mobility
What is the defintion of sensibility testing?
Ability to respond to a stimulus and hence this is an accurate and appropriate term for the typical and common clinical pulp tests such as thermal and electric tests - they do not detect or measure blood supply to the dental pulp
Why isn’t thermal and electric pulp tests considered sensitivity testing?
They are not sensitivity testing, eventhough are used as sensitivity tests.
Attempting to diagnose a root with pulpits since such teeth are more responsive than normal
Explain how to carry out a sensibility test using ethyl chloride or EPT?
Ethyl chloride pledger soaked
Dry tooth and hold with tweezer
Check all teeth in arch
EPT:
- dry tooth and use toothpaste as medium
Hold on tooth get patient to complete the circuit
Tell patient to let go when feel a response
What is the defintion of resorption?
Reaction is osteoclast to a stimulus
Name 3 things that can cause tooth resorption?
Trauma to PDL
Bacteria
Trauma to pulp
Name the 4 types of resorption?
Internal
External inflammatory
External cervical
External replacement
What is the defintion of ankylosis?
Follows periodontal ligament damage
After long extra oral drying time
Intrusion injuries
How to diagnose ankylosis?
P note
Radiogrsphic evidence of loss of PDL
Not advantageous in developing or growing mouths
What is the defintion of canal obliteration?
Deposition of hard tissue in the canal
Deemed as pulpal repair
Side effect of yellowing of the crown
RCT can be difficult
25% of traumatised incisors develop pulp canal obliteration
75% are symtpom free
Name the 3 causes of discolouration?
Medicaments from RVT
Degraded pulp tissues in dental tubules
Pulpal obliteration
What is the treatment for tooth discolouration?
Composite masking
Veneers
Bleaching
What is the defintion of concussion?
Heavy impact to the tooth, causing pain without visible damage
How to diagnose tooth concussion?
Use the trauma stamp
Vitlsity testing
ECL
Need 2 separate signs of pulpal necrosis
What are the symptoms of transient apical breakdown and how to deal with it?
Colour change
Loss of vitality
TTP
Apical area
If open apex - Monitor:
- look for return of colour, vitality and healing
What is the defintion of immature incisor?
Central incisors normally erupt 6-8 years
Root competition after 2+ years
Incomplete apexification:
- wide canal
- open apex
- wide vasculad bundle
What are the pros and cons of a wide canal immature incisor?
Easy to prepare but difficult to obturate
However, its more likely to fracture
And difficult to restore
What are the pros and cons of an open apex for immature incisors?
Extrusion of material
Difficult to seal
Potential for revascularisation
What is the treatment for immature incisor?
If pulpal necrosis use MTA plug or heated GP
What is the treatment for immature incisor with a comlication crown fracture?
Partial pulpotomy
Which maintains vitality
Allows for continued root development
What is the deifntion of Intrusion injuries?
Tooth movement upwards
Severs apical nerve
Massive cursing injury to PDL
Poor prognosis
What are the treatment options for Intrusion injuries?
Open apex - if no movement within 4 weeks refer to ortho
Closed apex - pulpal necrosis- RCT completed after repositioning
Soft died for 1 week
Chlorhexidine rinsing
At what Intrusion injury severity can the dentist wait for spontaneous repositioning for an open apex?
Up to 7mm and over 7mm between 6-11 YO
At what Intrusion injury severity can the dentist wait for spontaneous repositioning for a closed apex?
12-17
- up to 7mm allow spontaneous movement
- over 7mm orthodontic or surgical repositioning
Over 17 YO
- up to and over 7mm orthodontic or surgical repositioning
What is the definition of conscsious sedation?
A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation
Describe the esculator of anxiety management?
GENERAL ANAESTHETIC
IVS within hospital
POLYPHARMACY IVS
COMBINED ROUTES
I.V. MIDAZOLAM
INTRANASAL MIDAZOLAM
ORAL SEDATION
INHALATION SEDATION
ORAL PREMEDICATION
DISTRACTION/ RELAXATION
GENTLE HANDLING
PATIENCE/ EMPATHY
EFFECTIVE COMMUNICATION
What is the comparison between conscious sedation and GA?
Conscious Sedation
- Pt conscious, co-operative
Protective reflexes intact
- Risk very low
- Available in Primary Care environment
- Dental Operator may perform sedation
- May be ineffective for some patients
- May use freely on multiple occasions
- More opportunity to provide timely & more conservative dental care
Dental anxiety prevalence in society?
DFA- 13.8%
High DFA- 11.2%
Severe DFA- 2.6%
Other indications for inhalation sedation?
Learning Disability
Involuntary Movements
Medically Compromised with increased GA risk
Exaggerated Gag Reflex
Unusually Traumatic Procedure
Repeated Fainting/ Failed Local Anaesthetic
Describe medical NO2?
Colourless gas
Pleasant sweet smell
Weak anaesthetic agent
Analgesic properties
Minimal depressant effect on respiration and myocardium
Presented in blue cylinders
Why is NO2 a good sedation agent?
- Smooth induction
- Titrated easily
- Rapid induction/ recovery
- Non pungent, non irritant
- Low blood gas solubility
- Relatively wide margin between sedative and anaesthetic dose
- Analgesic properties
- NO needles
- Wide age spread
- Easily discontinued
- Level of sedation maintained
- Administration and excretion through lungs- no metabolic demands
- Some analgesia
What are the disadvantages of NO2?
- Lack of potency- needs psychological reassurance
- Nasel hood may not be tolerated
- Bulky equipment and scavenging needed
- Clear nasel airway needed
- Chronic exposure/ abuse
- Relative amount of patient compliance required
- OCCUPATIONAL HEALTH HAZARDS – Both active scavenging and ventialltion needed when in use
- Exposure to be kept withing 100ppm over 8 hour period
- Implicated in bone marrow depression
- Liver, renal, neurological disease
- Carcinoma of the cervix
Indications for inhalation sedation?
Anxiety
Needle phobia
Excessive gag reflex
Liver or kidney disease or preclusion to benzodiaepine
Contraindications for inhalation sedation?
Nasel obstruction
Patient unco-operative to whole dental environment
1st trimester of pregnancy
Patients with some psychiatric disorders
Inability to communicate to provide necessary reassurance
-age
-understanding
Guidelines for inhalation sedation?
NICE 2010
SDCEP Conscious sedation in Dentistry 2017
IACSD 2020
Sedation for Children and young people
What is included for the assessment appointment?
Medical History
ASA Status
Dental History
Anxiety Questionnaire
Have initial assessment appointment to allow discussion of fears and worries and “unburdening”
Written pre and post op instructions
What is essential after an inhalation appointment?
Escort:
- Essential at first visit
- Not mandatory at subsequent visits but can be a good support
- Always for children
If no escort or driving patient to be kept on premises for longer
Is consent necessary for inhalation sedation?
Written consent mandatory
Must be valid
Signed before treatment/ sedation begins
If consciousness impaired it is invalid
How is inhalation sedation delivered?
Mixer head
Provide varying but controllable mix of nitrous oxide and oxygen
To ensure that oxygen content of the gas is at least 30%
To reduce pressure of gases to acceptable levels
What is the safety system for inhalation sedation?
Safety features- automatic nitrous cut off of O2 flow interrupted
Oxygen flush
Active scavenging system
What are the active and passive safety systems for inhalation sedation?
ACTIVE: Removal of waste gases thru low power suction of breathing circuit (dental suction or AGSS terminal - vented outside building)
PASSIVE: Good ventilation - creating draught by opening doors/ windows.
Check system for leaks
Mechanised ventilation systems at ground level
Discouraging patient from talking
Planes of analgesia?
Be aware of them
What is the technique for inhalation sedation?
- Consider trial appointment
- If anxious try on hood with tell show do
- Start at 10%
- Increase in 5% increments every 1-2 minutes
- Use semi hypnotic suggestion
- Explain that there is a lag effect
- Describe how they will feel
- Tingling in extremities
- Light or heavy
- Relaxed
- Floaty
- Semi Hypnotic Suggestion
- Reassuring
- Build on what they are feeling
- Describe the feeling in positive terms
- Consider visualisation
- One person talking
Symtpoms of successful inhalation sedation?
Tingly hands and feet
Light headed
Remote from environment
Changed perception/ less aware of surroundings
Relaxed knuckles
Reduced blink rate
Charlie Chaplin feet
1000 yard stare
Slowed responses
Giggling
Describe the airway management of inhalation sedation?
Shared area of operation
Need to protect airway
Supressed Gag reflex
Ensure patient not oversedated
Consider Rubber dam/ airway protection
How to monitor the patient under sedation?
Watching breathing
Watching eyes
Watching signs of over sedation
Shared responsibility dentist/ nurse
How to monitor the patient under sedation?
Watching breathing
Watching eyes
Watching signs of over sedation
Shared responsibility dentist/ nurse
What is included for sedation recovery?
Steady reduction
O2 for 2mins
10 mins until discharge
Team work- Post op instructions to escort
Nurse monitors
Post op instructions to patient
Allow at least 10 minutes from finishing sedation to discharge
Assess with co-ordination tests
Can you walk across the room
Can you put your own coat on
“How do you feel”
What documentation is key to cover after sedation?
RECORD:Dental Treatment as usual
Start Time for gases
Percentage of gases given
Finish time for gases
Confirm 2 minutes oxygen
Quality of sedation
AT DISCHARGE: Time of discharge
Tests performed
Comment on condition of patient Eg. Alert and well orientated
Post Sedation Instructions Given
What documentation is key to cover after sedation?
RECORD:Dental Treatment as usual
Start Time for gases
Percentage of gases given
Finish time for gases
Confirm 2 minutes oxygen
Quality of sedation
AT DISCHARGE: Time of discharge
Tests performed
Comment on condition of patient Eg. Alert and well orientated
Post Sedation Instructions Given
What are some complications involved with inhalation sedation?
Ineffective sedation
Patient can’t breath through nose
Patient talks too much
Patient pulls off nasel hood
Ineffective assessment of sedation
Oversedation
What to do if inhalation sedation is unsuccessful?
Conscious sedation doesn’t work on everyone
In children consider another attempt or ref GA
In adults consider another attempt or IV
