Paediatric Dentistry Flashcards
1
Q
what is definition of child protection?
A
Activity undertaken to protect specific children who are suffering, or are at risk of suffering, significant harm.
2
Q
what is definition of children in need?
A
Those who require additional support or services to achieve their full potential.
3
Q
what does safeguarding children include?
A
o protecting children from maltreatment
o preventing impairment of children’s health or development
o ensuring that children are growing up in a safe and caring environment
4
Q
what are the 3 elements that must be present of child abuse?
A
- Significant harm to child
- Carer has some responsibility for that harm
- Significant connection between carer’s responsibility for child and harm to child
5
Q
what are the 4 major themes of the children and young people act 2014?
A
Children’s rights (parts 1 and 2)
Getting it Right for Every Child1 (GIRFEC) (parts 3, 4, 5 and 13)
Early Learning and Childcare (part 6)
‘Looked After’ children (parts 7 to 11)
6
Q
what is the aim of the children and young people’s act 2014?
A
unquestionably legitimate and benign
7
Q
what is GIRFEC role in CYPA 2014
A
o Named person for every child as a single point of contact to provide advice and support to families and to raise and deal with concerns about a child’s wellbeing.
o Lead professional where particularly complex needs or where different agencies need to work together. Not legislated for, and will remain a matter of policy and guidance only.
o Single child’s plan - single planning process for individual children who have wellbeing needs
8
Q
when can you share info regarding children?
A
Information can be shared when safety is at risk, or where the benefits of sharing the information outweigh the public and individual’s interest in keeping info confidential
9
Q
what are the 3 big concerns regarding parenting capacity?
A
o Domestic violence
o Drug and alcohol misuse
o Mental health problems
10
Q
who are vulnerable children?
A
o Under 5s
o Irregular attenders
o Medical problems and disabilities
11
Q
what is neglect?
A
Neglect is a significant and under-recognised problem which affects the wellbeing of many children; agencies and their staff need additional professional support in the assessment and intervention with such children and young people. A centre for children’s wellbeing should include a focus on research and on developing a range of interventions that will be effective
12
Q
what are the markers of general neglect and what effect do they have?
A
- nutrition - failure to thrive/short stature
- warmth, clothing, shelter - inappropriate clothing, cold injury, sunburn
- hygiene and health care - ingrained dirty (nails), head lice, dental caries
- stimulation and education - development delay
- affection - withdrawn or attention seeking behaviour
13
Q
what is definition of dental neglect?
A
o is wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection
o the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development
14
Q
what can dental disease put child at risk of?
A
- Teasing due to poor dental appearance
- Repeated antibiotics
- Repeated general aesthetic extractions
- Severe infection
15
Q
what are types of wilful neglect?
A
After dental problems have been pointed out:
* Irregular attendance, repeated failed appointments, repaeated late cancellations
* Failure to complete treatment
* Returning in pain at repeated intervals
* Repeated GA for dental extractions
16
Q
indicators of dental neglect?
A
Obvious dental disease
Impact on the child
Practical care has been offered, yet the child has not returned for treatment
17
Q
what is stage 1 of managing dental neglect?
A
- Stage 1: Preventive dental team management
o raise concerns with parents, offer support, set targets, keep records and monitor progress.
18
Q
what is stage 2 of managing dental neglect?
A
- Stage 2. Preventive multi-agency management
o liaise with other professionals (e.g. health visitor, school nurse, general medical practitioner, social worker) to see if concerns are shared
o A child may be the subject of a CAF (Common Assessment Framework) at this level.
o Check if child is subject to a child protection plan (which replaced the child protection register)
o Agree joint plan of action, review at agreed intervals
o Letter to HV of children < 5 who fail appointments and have failed to respond to letter from dental practice
□ “If this family is known to you, we would welcome working together to promote their oral health.”
19
Q
what is stage 3 of managing dental neglect?
A
- stage 3: child protection referral
o In complex or deteriorating situations
o Follow local guidelines
o Referral is to social services
Usually by telephone followed up in writing
20
Q
what are types of physical abuse?
A
o Over chastisement (cultural)
o Acute/ compassionate (shaking)
Spontaneous uncalculated reaction
Remorse, take appropriate action
Child’s needs are priority
o Chronic/ pathological (way of life)
Help sought but not actively
No remorse
Child’s needs not a priority
21
Q
what bill was passed in 2019 and what did it remove?
A
In 2019 the CHILDREN (EQUAL PROTECTION FROM ASSAULT)(SCOTLAND) BILL was passed which removes the “reasonable chastisement” excuse from law
22
Q
what is expected of the dental team in regards to neglect?
A
o Observe
o Record
o Communicate
o Refer for assessment
NOT expected to diagnose
23
Q
what happens after I refer a child in immediate danger of neglect?
A
o After referral if child is in immediate danger:
Child Protection order
Exclusion order
Child assessment order
Removal by police or authority of a JP
24
Q
when a child is aged 2 what is their behaviour like at the dentist?
A
o Fear of unexpected movements, loud noises and strangers
o The dental situation can produce fear in the child
25
when a child is aged 3 what is their behaviour like at the dentist?
o Reacts favourably to positive comments about clothes & behaviour
o Less fearful of separation from parents
o Experience will however dictate reaction to separation
26
when a child is aged 4 what is their behaviour like at the dentist?
o More assertive but can be bossy & aggressive
o Fear of the unknown and bodily harm is now at a peak
o Fear of strangers has now decreased.
o With firm and kind direction will be excellent patients
27
when a child is aged 5 what is their behaviour like at the dentist?
o Readily separated from parents.
o Fears have usually diminished.
o Proud of possessions
o Comments on clothes will quickly establish a rapport
28
when a child is aged 6 what is their behaviour like at the dentist?
o Seeks acceptance
o Success in this can affect self –esteem
o If while at dentist child develops a sense of inferiority or inadequacy behaviour may regress to that of a younger age
29
when a child is aged 7-12 what is their behaviour like at the dentist?
o Learn to question inconsistencies and conform to rules of society
o Still have fears but are better at managing them
30
what is dental anxiety?
Occurs without a present triggering stimulus and may be a reaction to an unknown danger or anticipatory due to previous negative experiences.
31
what is dental fear?
Is a normal emotional response to objects or situations perceived as genuinely threatening.
32
what is a phobia?
Is a clinical mental disorder where subjects display persistent and extreme fear of objects or situations with avoidance behaviour and interference of daily life.
33
what are the components to dental fear and anxiety?
- Physiological & Somatic Sensations
- Cognitive Features
- Behavioural reactions
34
what is cognitive features? and examples?
- how changes occur in the thinking process
Interference in concentration
Hypervigilance
Inability to remember certain events while anxious
Imagining the worst that could happen
35
what are some subtle signs of dental fear and anxiety in children?
Younger children may time delay by asking questions
School age children may complain of stomach aches/or ask to go to the toilet frequently
Older children may complain of headaches or dizziness, may fidget or stutter, can’t be “bothered”
36
what are the 2 types of behaviour management?
pharmacological and non pharmacological
37
what is inhalation sedation done using?
nitrous oxide
38
what are pharmacological ways of behaviour management?
Local Anaesthetic Techniques
Pre-Medication
Inhalation Sedation with Nitrous Oxide
Intravenous Sedation with Propofol or Midazolam
General Anaesthetic
39
what is intravenous sedation done using?
Propofol or Midazolam
40
how does inhalation sedation work?
will not change child’s wish or want to avoid something but will allow sufficient anxiolysis to increase suggestibility, relaxation and help with ability to tolerate treatment. Works well combined with other Non-Pharmacological techniques.
41
how does intravenous sedation work? what age do they need to be?
good options for complex treatment in anxious adolescents. Depending on maturity and size, usually from 12yo up. Works well with other Non-Pharmacological techniques.
42
what is child behaviour like aged 3-4 months?
Interested in people, places and objects
43
what is child behaviour like aged 6-8 months?
Share and express emotions
Crawling and discover surroundings
Fear and stranger awareness becomes important
Understanding of spoken words and non-verbal communication develops
44
what is child behaviour like aged 9-12 months?
Two-way conversations about feelings. Become aware of others sharing their thoughts and feelings
Separation anxiety begins until 18 months
45
what is child behaviour like aged 1-3 years?
Develop sense of self and explore autonomy
May become noncompliant for the first time as they begin to assert themselves and gain independence
Language develops
Sharing and cooperative play challenging – egocentric play
Fear of movements, strangers, loud noises
Dental environment can invoke fear
Choice of two helpful
Ability to communicate varies
Too young to be reached by words alone – handling objects to understand their meaning helpful. Eg dental mirror, toothbrush
46
what is child behaviour like aged 3 years?
Less egocentric, like to please adults
Active imaginations and like stories
Some capacity for reasoning
Praise for adherence to requests useful
Distraction to capture child’s attention helpful
Less fearful of separation from parents
47
what is child behaviour like aged 4-5 years?
Exploring new environment sand relationships
Prefer one-to-one friendships
Creative – like fantasy and imaginary play
Familiar with ‘please’ and ‘thank you’
Encouraging them to take responsibility for sitting chair for example is important
‘Labelled praise’ – eg. ‘Scott you are doing so well at sitting in the chair like a statue’ helpful
Direct commands helpful
48
what is child behaviour like aged 6-8 years?
Established at school and moving away from security of family
Increasingly independent
Transition to greater independence can cause considerable anxiety and distress
Marked increase in fear responses
Can have a decrease in co-operation in previously coping children
Seek acceptance
49
what is child behaviour like aged 8-12 years?
Part of larger social groups and strongly influenced by them
Growing concerns of embarrassment – careful discussion of oral hygiene, appearance
Become ‘followers’
Can hide their feelings and adopt a ‘cool’ attitude
Intellect becomes important
Respond well to discussions about need to engage in independence
50
what is dental anxiety?
reaction to unknown danger-very common when proposed treatment never experienced before
51
what is dental fear?
reaction to a known danger involves fight-flight freeze response when confronted with threatening situation
52
what is difference between dental phobia and dental fear?
dental phobia much stronger response
53
factors affecting child and adolescent anxiety?
- PMH
- PDH
- SH
- Parental anxiety
- Parenting style
- parental presence
- child awareness of dental problem
- behaviour of dental staff
- child temperament
54
how do you measure dental fear and anxiety?
MCDASf (Modified Child Dental Anxiety Scale – Faces)
55
what are non-pharmacological behaviour management techniques?
o Non-Verbal Communication & Role-Modelling
o Voice control
o Enhanced control
o Behaviour Shaping and Positive Reinforcement
o Use distractions
o Other Behaviour Management Techniques
Magic – Magic Nose, Magic Light
Motivational Interviewing
Gamificiation – Tug of War when placing PMCs
Cognitive Behavioural Therapy – ‘Your Teeth, You Are In Control’
Hypnosis – only trained practitioners and with explicit consent
Snoezelen environment
Systematic desensitsation – specific fears eg. LA, must be able to communicate well
56
what strength topical anaesthetic is used for children?
Usually 5% Lidocaine or 18-20% Benzocaine used – not recommended under 2yo
57
what are types of non-pharmacological pain control?
Hypnosis/Semi-Hypnosis/Relaxation Techniques
Distraction – shaking cheek, counting on fingers, audio and visual, patient’s favourite music or show
Controlled language
Guided imagery
Systematic desensitisation
Computer Controlled LA devices – ‘Wand’
Control parental behaviour – parent squeezing leg, high tone of voice, concern
58
how does the chasing technique work for LA?
Topical anaesthetic buccally
Give buccal infiltration
Allow time for papilla to become anaesthetised
Reposition needle perpendicular to papilla, inject into papilla
Check palatal or lingual side papilla for blanching
Inject into palatal or lingual blanched mucosa
Chase blanched mucosa around until area fully anaesthetised
59
what are the classification of injuries to the primary dentition in regards to dental hard tissues and pulp?
- enamel fracture (uncomplicated crown fracture)
- enamel and dentine fracture (uncomplicated crown
- enamel, dentine and pulp fracture (complicated crown fracture)
- crown - root fracture
- root fracture
60
what are the classification of injuries to the primary dentition in regards to supporting tissues?
- concussion
- subluxation
- lateral luxation
- intrusion
- extrusion
- avulsion
- alveolar fracture
61
what is concussion in regards to injuries to the supporting tissues?
Tooth tender to touch but has not been displaced
62
what is subluxation in regards to injuries to the supporting tissues?
Tooth tender to touch, has increased mobility but has not been displaced
63
what are the types of luxation injuries
- lateral luxation
- intrusion
- extrusion
64
explain lateral luxation?
tooth displaced usually in a palatal/lingual or labial direction
65
explain intrusion?
tooth usually displaced through the labial bone plate or it can impinge on the permanent tooth bud
66
explain extrusion?
partial displacement of tooth out it's socket
67
explain avulsion
Tooth completely out of socket
68
explain alveolar fracture?
Fracture involves the alveolar bone (labial
and palatal/lingual) and may extend to the adjacent bone
69
what are the step to primary trauma examination in regards to patient management?
1. Reassurance
2. History
3. Examination
4. Diagnosis
5. Emergency treatment
6. Important information
7. Further treatment and review
70
what are the steps to history of primary trauma exam?
* A) injury
* B) medical history
* C) dental history
71
what are you looking for in extra oral exam of primary trauma exam?
o Lacerations
o Haematoma
o Haemorrhage / CSF
o Subconjunctival haemorrhage
o Bony step deformities
o Mouth opening
72
what are you looking for in intra oral exam of primary trauma exam?
Soft tissue damage
* Penetrating wounds, foreign bodies
Tooth mobility
* May indicate tooth displacement, root or bone fractures
Transillumination
* May show fracture lines in teeth (crazing), pulpal degeneration, caries
Tactile test with probe
* May help detect horizontal and/or vertical fractures, pulpal involvement
Percussion
* Duller note may indicate root fracture
Occlusion
* Traumatic occlusion demands urgent treatment
73
what would you usually do during emergency treatment considerations of primary trauma injury?
* Observation is often the most appropriate option in the emergency situation
o Unless risk of aspiration, ingestion or occlusal interference
* Provision of dental treatment depends on the child's maturity and ability to cope
74
what would be the homecare for a primary trauma injury?
o Analgesia
o Soft diet for 10-14 days
Normal diet but cut everything small, chew with molars
o Brush teeth with soft toothbrush after every meal
o Topical chlorhexidine gluconate 0.12% mouthrinse applied topically twice daily for one week
o Warn re signs of infection
75
what is the management of an enamel fracture?
Uncomplicated crown fracture
Smooth sharp edges
76
what is the management of an enamel-dentine fracture?
Uncomplicated crown fracture
Cover all exposed dentine with glass ionomer/composite
Lost tooth structure can be restored immediately with composite or at a later visit
77
what is the management of an enamel-dentine-pulp fracture?
Complicated crown fracture
Options:
* Partial pulpotomy
* Extract
78
what is the management of a crown-root fracture?
Remove the loose fragment and determine if crown can be restored
If restorable:
* No pulp exposed: cover exposed dentine with glass ionomer
* Pulp exposed: pulpotomy or endodontic treatment
If unrestorable:
* Extract loose fragments
* Don’t dig!
79
what is the management of a root fracture if coronal fragment not displaced?
no treatment
80
what is the management of a root fracture if coronal fragment displaced but not excessively mobile?
Leave coronal fragment to spontaneously reposition even if some occlusal interference
81
what is the management of a root fracture if coronal fragment displaced, excessively mobile and interfering with occlusion?
* Option A: Extract only the loose coronal fragment
* Option B: Reposition the loose coronal fragment +/- splint
82
management of concussion in regards to injury to supporting tissues?
No treatment
Observation
83
management of lateral luxation in regards to injury to supporting tissues?
Minimal/ no occlusal interference
* Allow to reposition spontaneously
Severe displacement
* 1. Extraction
* 2. Reposition +/- splint
84
management of intrusion in regards to injury to supporting tissues?
Allow to spontaneously reposition, irrespective of direction of displacement
85
what do you do use in terms of radiographs when assessing intrusion?
* Periapical
* Lateral premaxilla (extra-oral film)
86
what must you assess danger of when evaluating intrusion?
Being able to assess the danger to the permanent tooth allows better counselling re prognosis
87
management of extrusion in regards to injury to supporting tissues? what would be severe extruded measurement?
Not interfering with occlusion
* Spontaneous repositioning
Excessive mobility or extruded >3mm
* Extract
88
management of avulsion in regards to injury to supporting tissues?
Radiograph to confirm avulsion
DO NOT REPLANT !!!!!
89
management of alveolar fracture in regards to injury to supporting tissues?
Reposition segment
Stabilize with a flexible splint to the adjacent uninjured teeth for 4 weeks
Teeth may need to be extracted after alveolar stability has been achieved
90
what must you warn parents about in terms of impact of primary tooth trauma?
o Warn parents of possible sequelae (means consequence to a previous injury/disease) to:
Traumatised primary tooth
Permanent successor
91
what would mild grey discolouration from primary tooth trauma tell you?
Mild grey: Immediate discolouration may maintain vitality
92
what would opaque/yellow discolouration from primary tooth trauma tell you?
Pulp obliteration
93
what does discolouration and infection tell you?
Symptomatic (non-vital)
94
what are the possible complications of previous injury to primary dentition?
- discolouration
- discolouration and infection
- delayed exfoliation
95
what causes most disturbances to permanent successor of trauma in primary dentition?
intrusion
96
what are types of enamel defects?
o a) Enamel hypomineralisation
o b) Enamel hypoplasia
97
what does enamel hypominerilsaton mean?
Qualitative defect of enamel
* i.e. normal thickness but poorly mineralised
White/yellow defect
98
what is treatment to enamel hypomineralisation?
* No treatment
* Composite masking +/- localised removal
* Tooth whitening
99
what is enamel hypoplasia?
Quantitative defect of enamel
* i.e. reduced thickness but normal mineralisation
Yellow/brown defects
100
what is treatment to enamel hypoplasia?
Treatment:
* No treatment
* Composite masking
101
what is dilaceration?
Abrupt deviation of the long axis of the crown or root portion of the tooth
102
what are crown dilaceration management options?
Surgical exposure and orthodontic realignment
Improve aesthetics restoratively
103
what are root dilaceration/angualation/duplication management options?
Combined surgical and orthodontic approach
104
premature loss of a primary tooth can result in what in terms of eruption?
Premature loss of a primary tooth can result in delayed eruption of around 1 year due to thickened mucosa
105
when should you take a radiograph if a tooth is delayed in erupting?
Radiograph if > 6 month delay compared to contralateral tooth
106
what treatment is done for delayed eruption?
Surgical exposure and orthodontic alignment may be required
107
what are the options for ectopic tooth position?
Surgical exposure and orthodontic realignment
Extraction
108
what are the options for arrested development?
Endodontic treatment
Extraction
109
what are the options for complete failure of tooth to form?
Tooth germ may sequestrate spontaneously or require removal
110
what are the treatments of odontome formation?
Surgical removal
111
what is the peak period for trauma to permanent teeth?
7-10 years
112
who is trauma to permanent teeth most common in?
people with large overjet
113
what kind of conditions must you be aware in for dental treatment for dental trauma?
o Rheumatic Fever
o Congenital heart defects
o Immunosuppression
114
what must you rule out when doing an intra oral and extra oral exam?
facial/jaw fractures
115
during an exam for dental trauma what does a tactile test with probe look for?
- fracture lines- horizontal or vertical
- pulpal involvement
116
what kind of thermal sensibility test would you do for an IO exam for dental trauma?
ethyle chloride or warm gutta-percha
117
what would you use for an electrical sensibility test?
electric pulp test
118
what must you do for both sensibility tests and viewing root surfaces on radiographs?
Compare injured tooth with the adjacent non-injured tooth.
119
for how long after injury must you continue sensibility testing?
2 years
120
what would percussion testing tell you?
duller note may indicate root fracture
121
what does traumatic occlusion demand?
urgent treatment
122
what is the difference between complicated and non-complicated classes for fractures?
complicated means pulp is involved
123
what does prognosis of dental trauma depend on?
- stage of root development
- type of injury
- if pdl is damaged too
- time. Between injury and treatment
- presence of infection
124
what are general aims and principles of emergency treatment?
- aim to retain vitality of any damaged or displaced tooth by protecting exposed dentine by an adhesive 'dentine bandage'
- treat exposed pulp tissue
- reduction and immobilisation of displaced teeth
- tetanus prophylaxis
- antibiotics
125
what are general aims and principles of intermediate treatment?
- +/- pulp treatment
- restoration
- minimally invasive e.g acid etch restoration
126
what are general aims and principles of permanent treatment?
- apexigenesis
- apexification
- root filling +/- root extrusion
- gingival and alveolar collar modification if required
- coronal restoration
127
how to manage an enamel fracture?
- either: bond fragment to tooth or simply grind sharp edges
- take 2 periapical radiogrpahs to rule out root fracture or luxation
- follow up : 6-8 weeks, 6 months and 1 year
prognosis: 0% risk of pulp necrosis
128
how to manage an enamel dentine fracture?
- account for fragment
- either: bond fragment to tooth or place comp "bandage"
- take 2 periapical radiographs to rule out root fracture or luxation
- radiograph any lip or cheek lacerations to rule out embedded fragment
- sensibility testing and evaluate tooth maturity
- definitive restoration
- follow up: 6-8 weeks, 6 months and 1 year
prognosis - 5% risk of pulp necrosis at 10 years
129
when must you always follow up on fractures?
6-8 weeks, 6 months and at one year
130
what must you use during follow up for fractures?
trauma sticker
131
what do you check radiographs for in relation to fractures during follow up?
root development - width of canal and length
comparison with other side
internal + external inflammatory resorption
peripical pathology
132
how to manage enamel-dentine-pulp fractures?
- evaluate exposure:
- size of pulp exposure
- time since injury
- assocaited PDL injuries
- choose from the following 3 options:
- pulp cap
- partial pulpotomy (cvek pulpotomy)
- full coronal pulpotomy
avoid full extipration unless the tooth is clearly non-vital
133
what happens for a direct pulp cap?
tiny exposure (1mm) - 24 hour window
- trauma sticker and radiographic assessment
- LA and rubber dam
- clean area with water then disinfect area with sodium hypochlorite
- apply calcium hydroxide (dycal) or MTA white to pulp exposure
- restore tooth with quality composite restoration
review - 6-8 weeks, 6 months , 1 year
134
what do you do for partial pulpotomy?
- trauma sticker and radiographic assessment
- LA and Dam
- clean area with saline then disinfect area with sodium hypochlorite
- remove 2mm of pulp with high speed round diamond bur
- place salie soaked CW pellet over exposure until haemostasis achieved
- if no bleeding or can't arrest bleeding proceed to full coronal pulpotomy
- apply CaOh then GI (or white MTA) then restore with quality composite resin
for a larger exposure (>1mm) or 24+ hours since trauma
135
what is a full coronal pulpotomy?
o Begin with partial pulpotomy
o Assess for haemostasis after application of saline soaked cotton-wool
o If hyperaemic OR necrotic proceed to remove ALL of the coronal pulp
o Place calcium hydroxide in pulp chamber
o Seal with GIC lining and quality coronal restoration
136
what is aim of pulpotomy?
to keep vital pulp tissue within the canal to allow normal root growth (apexognesis) both in the length of root and the thickness of dentine
137
what is root treatment for immature incisors? what are options? what is clinical problem?
- if tooth is non vital --> full pulpectomy is requried
- clinical problem - no apical stop to allow obturation with GP
options:
- CaOh placed in canal aiming to induce hard-tissue barrier to form (apexification)
- or MTA/biodentine placed at apex of canal to create cement barrier
- or regenerative endo technique to encourge hard tissue formation at apex?
138
how to pulpectomy of open apex?
o Rubber dam
o Access
o Haemorrhage control - LA / sterile water
o Diagnostic radiograph for WL
o File 2mm short of estimated WL
o Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
o Glass-ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
o Extipate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
o (Problems with CaOH apexification)
o MTA plug and heated GP obturation
o Once obturation complete
o Consider bonded composite short way down canal as well as in access cavity
o Bonded core
o Try to avoid post crown
139
treatment options for crown root fracture with no pulp exposure
- fragment removal only and restore
- fragment removal and gingivectomy
- indicated in crown-root fractures with palatal subgingival extension
- ortho extrupusion of apical portion
- 1. endo
- 2. extrusion
- 3. post crown
- surgical extrusion
- decoronation
- preserve bone for future implant
- extraction
140
treatment options for crown-root fracture with pulp exposure?
- can be temporised with comp for up to 2 weeks
- fragment removal and gingivectomy
- indicated in crown-root fractures with palatal subgingival extension
- ortho extrupusion of apical portion
- 1. endo
- 2. extrusion
- 3. post crown
- surgical extrusion
- decoronation
- preserve bone for future implant
- extraction
141
what are the guidelines that dictate your management of dental trauma?
IADT
142
what are the considerations to have about impact of injury on?
1) Surrounding bone
2) Neurovascular bundle
3) Root surface
143
what would be the clinical findings of concussion?
There is pain on percussion
144
what would be the clinical findings for subluxation?
Increased mobility
Tender to percussion
Bleeding from the gingival crevice may be present
145
what would be the treatment options for subluxation?
Normally not required
Splint if excessive mobility or tenderness when biting
146
what is everything on a trauma stamp?
- sinus
- colour
- mobility
- TTP
- percussion
- ethyl chloride
- EPT
- Radiograph
147
what are the clinical findings of extrusion?
Tooth appears elongated
Usually displaced palatally
Tooth mobile
Bleeding from gingival sulcus
148
what is treatment for extrusion?
Reposition the tooth by gently pushing It back into the tooth socket under local anaesthesia
Splint
149
what are clinical finding of lateral luxation?
Tooth appears displaced in socket
Tooth immobile
High ankylotic percussion tone
May be bleeding from gingival sulcus
Root apex may be palpable in sulcus
150
treatment options for lateral luxation?
Reposition under local anaesthesia
Splint
Monitor
Endodontic evaluation (approx. 2/52 post-injury)
151
what is complete root formation in relation to lateral luxation?
The pulp will likely become necrotic
Commence endodontic treatment
Corticosteroid-antibiotic or calcium hydroxide as intra-canal medicament to prevent the development of inflammatory (infection-related) external resorption
152
what are clinical findings of intrusion?
Crown appears shortened
Bleeding from gingivae
Ankylotic high, metallic percussion tone
153
what is treatment for intrusion of immature root formation?
* Spontaneous repositioning independent of the degree of intrusion
* If no re-eruption within 4 weeks: orthodontic repositioning
* Monitor the pulp condition
* Spontaneous pulp revascularisation may occur
* If pulp becomes necrotic and infected or signs of inflammatory (infection-related) external resorption: endodontic treatment, as soon as possible when the position of the tooth allows
154
what is treatment for intrusion for mature root formation?
* <3mm:
o Spontaneous repositioning
o If no re- eruption within 8 weeks: reposition surgically and splint for 4 weeks OR reposition orthodontically before ankylosis develops
* 3 -7mm:
o Reposition surgically (preferably) or orthodontically
* >7mm:
o Reposition surgically
155
describe intrusion and mature root formation in teeth with complete root formation?
Pulp almost always becomes necrotic
Start endodontic treatment at 2 weeks or as soon as tooth position allows
* Aim to prevent the development of inflammatory (infection-related) external resorption
156
what are clinical finding for avulsion?
Socket empty or filled with coagulum
157
what are the critical factors for avulsion in case of emergency?
Extra-alveolar dry time (EADT)
Extra-alveolar time (EAT)
Storage medium
158
what must you decide on when it comes to an avulsed tooth? in terms of viability?
PDL viable mostly (replanted immediately or v shortly after)
PDL viable but compromised (kept in saline/milk, total dry time <60 mins)
PDL non-viable (dry time >60 mins regardless of what happened after this time)
After dry time of 60 mins or more, ALL PDL cells are NON VIABLE
159
what is the emergency advice for an avulsed tooth?
o 1) Ensure permanent tooth
o 2) Hold by crown
o 3) Encourage attempt to place tooth immediately into socket
If the tooth dirty, rinse it gently in milk, saline or in the patient's saliva and replant
o 4) Bite on gauze/handkerchief to hold in place once replanted
o 5) Seek immediate dental advice
160
types of storage media for avulsed tooth?
Milk
HBSS
Saliva
Saline
Water
161
factors of management of avulsed tooth?
Maturity of root
PDL cell condition
162
what is management of avulsed tooth with closed apex and its been already replanted?
* Clean the injured area
* Verify replanted tooth position and apical status
o Clinical & radiographic
* Place splint
* Suture gingival lacerations, if present
* Consider antibiotics and check tetanus status
* Provide post-operative instructions
* Follow up
163
avulsed tooth with closed apex and EADT < 60 mins?
PDL cells may be viable but compromised
164
what is management of avulsed tooth with closed apex in an emergency management situation with tooth not in for EADT <60 mins?
* Remove debris
* History & examination with tooth in storage medium
* Replant tooth under LA
* Splint
* Suture gingival lacerations, if present
* Consider antibiotics and check tetanus status
* Provide post-operative instructions
* Follow up
165
what if EADT >60 mins?
* PDL cells likely to be non-viable
166
emergency situation with avulsed tooth and EADT > 60 mins?
* Remove debris
* Replant tooth under LA
* Splint
* Suture gingival lacerations, if present
* Consider antibiotics and check tetanus status
* Provide post-operative instructions
* Follow up
167
when would you commence endo tretment on avulsed tooth with eadt >60 mins?
2 weeks
168
what do you use for intracanal medicament? and for how long?
Calcium hydroxide up to 1 month or corticosteroid/antibiotic paste for 6 weeks
169
what do you do for an avulsed tooth with open apex and tooth already replanted?
* Clean the injured area
* Verify replanted tooth position and apical status
o Clinical & radiographic
* Place splint
* Suture gingival lacerations, if present
* Consider antibiotics and check tetanus status
* Provide post-operative instructions
* Follow up
170
for an open apex EAT < 60 mins indicated?
Potential for spontaneous healing
171
what is management in situation for open apex avulsed tooth with EAT < 60 mins?
* Remove debris
* History & examination with tooth in storage medium
* Replant tooth under LA
* Splint
* Suture gingival lacerations, if present
* Consider antibiotics and check tetanus status
* Provide post-operative instructions
* Follow up
172
what is management for avulsed tooth with open apex and EAT > 60 mins?
* Remove debris
* Replant tooth under LA
* Splint
* Suture gingival lacerations, if present
* Consider antibiotics and check tetanus status
* Provide post-operative instructions
* Follow up
173
what does EAT > 60 mins indicate for open apex?
* PDL cells likely to be non-viable
* Likely outcome is ankylosis-related (replacement) root resorption
174
when don't you replant avulsed tooth?
Medical contraindications?
* Child immunocompromised
* Other serious injuries requiring preferential emergency treatment
Dental contraindications?
* Very immature apex and extended EAT (>90mins)?
* Very immature lower incisors in young child finding it difficult to cope?
175
what are clinical findings for dento-alveolar fracture?
Complete alveolar fracture extending from the buccal to the palatal bone in the maxilla and from the buccal to the lingual bony surface in the mandible
Segment mobility and displacement with several teeth moving together
Occlusal disturbance
Gingival laceration
176
what is treatment for dento-alveolar fracture?
o Reposition any displaced segment
o Stabilise by splinting
o Suture gingival lacerations if present
o Monitor the pulp condition of all teeth involved
177
what do you monitor clinically and radiographically for with a dento-alveolar fracture?
Root development including canal width and length, compare with neighbouring unaffected tooth
Resorption
178
when is there a risk of pulp necrosis for dento-alveolar fracture?
o Risk of pulpal necrosis if closed apex is 50% at 5 years
179
what is advice for dento-alveolar fracture?
o Soft diet for 7 days
o Avoid contact sport whilst splint in place
o Careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12%
180
what are properties of a splint?
o Flexible and passive
o Ease of placement/ removal
o Facilitate sensibility testing/ clinical monitoring
o Allow oral hygiene
o Aesthetic
181
what are types of chair-side splint?
Composite & wire
Titanium trauma splint
Composite
Orthodontic brackets & wire
Acrylic
182
what are types of lab made splint?
Vacuum-formed splint
Acrylic
183
what are properties and features of composite and wire splint?
* Stainless steel wire
o Up to 0.4 mm in diameter
* Ensure passive
* Flexible:
o Include one tooth either side of traumatised tooth/teeth
184
what are propeties of titanium trauma splint?
* Rhomboid mesh structure
* 0.2mm thick
* Secured to teeth with composite resin
185
what are the main post trauma complications?
o 1) Pulp Necrosis & Infection
o 2) Pulp Canal Obliteration
o 3) Root Resorption
o 4) Breakdown of Marginal Gingiva and Bone
186
describe pulp canal obliteration?
Response of a vital pulp
Progressive hard tissue formation within pulp cavity
Gradual narrowing of pulp chamber and pulp canal - total or partial obliteration
187
what is treatment for pulp canal obliteratio?
Conservative, only 1% may give rise to PAP
188
what are types of root resorption?
external and internal
189
explain external root resorption in regards to surface?
o Superficial resorption lacunae repaired with new cementum
o Response to localised injury
o Not progressive
190
explain external root resorption in regards to external infection related IRR
o Prev known as external inflammatory resorption
o Non-vital tooth
o Initiated by PDL damage
Propagated by root canal toxins reaching external root surface
o Diagnosis:
Indistinct root surface; root canal tramlines intact
o Rapid
191
what is management for external root resorption with external infection related to IRR?
Remove stimulus
Endodontic treatment
* Non-setting CaOH for 4-6 weeks
* Obturate with GP
Cervical resorption
192
what are types of external root resorption?
* Surface
* External infection related IRR
* Cervical
* Ankylosis related RRR
193
explain external root resorption with ankylosis related RRR?
o Initiated by severe damage to PDL and cementum.
Normal repair does not occur
Bone cells faster than PDL fibroblasts
o Severe luxation or avulsion
o Root involved in remodelling
Radiograph: ‘Ragged’ root outline; no obvious PDL space
o Speed variable
Infraocclusion due to alveolar bone development
194
what is treatment for external root resorption with ankylosis related RRR?
plan loss
195
what is internal root resorption with internal infection related to IRR?
o Prev known as internal inflammatory resorption
196
what is internal root resorption with internal infection related to IRR due to?
o Due to progressive pulp necrosis
Infected material via non-vital coronal part of canal propagates resorption
197
what is treatment of internal root resorption with internal infection related to IRR?
Remove stimulus
Endodontic treatment
* Non-setting CaOH for 4-6 weeks
* Obturate with GP
* If progressive, plan for loss
198
what are the classification of disabilities?
o Intellectual/behavioural
o Physical
o Sensory
o Medically compromised
199
what are types of intellectual/behavioural disabilities?
Learning disability
Autism Spectrum Disorder
Down syndrome
200
what are diff grades of learning disabilities?
o Mild
o Moderte
o Severe
o Profound
201
what do people with autism share difficulties with?
o Social Communication
o Social Interaction
o Repetative and restrictive behaviour
o Over or undersensitivity to light, sound, taste or touch
o Extreme anxiety
o Meltdowns or shutdowns
202
what is down syndrome also known as?
trisomy 21 chromosome
203
what does down syndrome present with ? dental features? medical predispositions?
* Physical features
o Large Tongue
o Mid face hypoplasia
* Learning difficulty
* Increased predisposition to:
o Cardiac defects
o Leukaemia
o Epilepsy
* Dental features
o Maxillary hypoplasia
o Class III occlusion
o Macroglossia
o Anterior open bite
o Hypodontia/microdontia
o Predisposition to periodontal disease
204
if you have down syndrome what are you more predisposed to?
o Cardiac defects
o Leukaemia
o Epilepsy
205
what are types of physical disabilities?
- Cerebral Palsy
- Spastic
- ataxic
- Dyskinetic
206
what are dental consideration to people with cerebral palsy?
o Difficulty tolerating dental treatment
o Increased rate of malocclusion
o Increased risk dental trauma
o High prevalence of bruxism
o Drooling
o Poor oral hygiene
o Pathological oral reflexes – biting
o Calculus if peg fed
o Periodontal disease
o Hyperplastic gingivitis
o Self mutilation
o Unsafe swallow
207
describe cerebral palsy?
* Non progressive lesion of motor pathways in the developing brain.
* It is caused by brain damage early in development, either during fetal life, during the birth process or during the first few months of infancy.
* Cerebral palsy can cause abnormalities of movement and posture in various parts of the body.
* May include delays in motor skills development, poor control over hand and arm movement, weakness, abnormal walking, difficulties swallowing, excessive drooling.
208
what are the 3 types of spastic?
Diplegia
Hemiplegia
Quadriplegia
209
describe spastic?
o People with spastic CP have increased muscle tone.
o This means their muscles are stiff and, as a result, their movements can be awkward.
210
what is diplegia spastic?
* muscle stiffness is mainly in the legs, with the arms less affected or not affected at all.
211
what is hemiplegia spastic?
* affects only one side of a person’s body; usually the arm is more affected than the leg.
212
what is quadriplegia?
* most severe form of spastic CP - affects all four limbs, the trunk, and the face. People with spastic quadriparesis usually cannot walk and often have other developmental disabilities such as intellectual disability; seizures; or problems with vision, hearing, or speech
213
what is ataxic cerebral palsy?
o People with ataxic CP have problems with balance and coordination. They might be unsteady when they walk.
o They might have a hard time with quick movements or movements that need a lot of control, like writing.
o They might have a hard time controlling their hands or arms when they reach for something.
214
at is dyskinetic cerebral palsy?
o People with dyskinetic CP have problems controlling the movement of their hands, arms, feet, and legs, making it difficult to sit and walk.
o The movements are uncontrollable and can be slow and writhing or rapid and jerky.
o Sometimes the face and tongue are affected and the person can have difficulties sucking, swallowing, and talking.
215
types of sensory impairment?
- visual impairment
- hearing impairment
- ASD
216
what are types of medically compromised disabilities?
Oncology
Cardiac
Haemophilia
217
what is most common cancer in children?
Leukaemia
218
what is leukameia and how can it affect?
o Blood cancer of WBC
o Can affect:
Lymphocytes
Myeloid cells (including neutrophils)
o 3/4 cases are Acute Lymphoblastic Leukaemia
o White blood cell production gets out of control and the cells continue to divide in the bone marrow, but do not mature.
o These immature dividing cells fill up the bone marrow and stop it from making healthy blood cells.
219
what does leukaemia present with?
Pallor
Increased bleeding/bruising (lack of platelets)
Infection (lack of functioning WBC)
220
what is cardiac disability classified as?
o Cyanotic
o Acyanotic
221
what is cyanotic cardiac disabiltiy?
Deoxygenated blood able to enter systemic circulation
222
what is acyanotic cardiac disability?
Normal levels of oxyhaemoglobin in the systemic circulation
223
what is most common acyanotic CCD?
Ventricular septal defect
224
what is most common cytanotic CCD?
Tetralogy of Fallot
225
what are dental implications of cardiac disability?
o Medications which increase bleeding tendency: warfarin or aspirin
o Higher risk of general anaesthetic
o Careful use of adrenaline containing LA
o Increased risk of enamel hypoplasia
o Risk of infective endocarditis resulting from an oral bacteraemia
226
in ineffective endocarditis what is there a risk of? and in who?
o Risk of bacteramia:
Patients with poor oral hygiene
Dental infection
Invasive dental procedures
227
it is important patient at risk of ineffective endocarditis to have?
Optimal oral hygiene
Avoid dental infection (close monitoring and early management of caries)
More radical treatment plans to ensure the mouth is kept free from any oral sources of infection (removal of teeth with deep decay/ Hall crowns contraindicated)
Liaison with cardiology to explore need for antibiotic prophylaxis prior to invasive procedures
228
what are most common inherited bleeding condiiton?
von williebrand's diseases
heamophilia A
haemophilia B
229
what are non inheritied bleeding disorders?
- use of blood thinner e.g warfarin/aspirin
- chemotherapy
- thrombocytopenia
230
what is primary bleeding disorder?
- vasoconstriciton after injury
- platelet plug formation
231
what is secondary bleeding disorder?
- formation of fibrin through coagulation cascade
232
what is tertiary bleeding disorder?
- fibrinolysis
- formation of plasminogen, then plasmin
233
what are the 3 ways von willibrand disease acts?
- meidates platelet adhesion
- mediates platelet aggregation
- carrier of factor VII
234
lack of clotting factors = what?
increases bleeding tendency
235
what does haemophilia A affect?
Factor VIII
236
what does haemophilia B affect?
Factor IX
237
dental implications of bleeding disorders?
o Enhanced dental caries prevention
o Dental treatment within Hospital Dental Service
o Close liaison with haematology required prior to any treatment likely to induce bleeding including surgery/ interproximal restorations/ local anaesthetic.
o Haemostatic cover requirements vary by:
Type of Haemophilia
Severity of Haemophilia
Treatment required
238
what are Impacts of dental disease in children with disabilities?
o Increased risk of dental caries
o Delayed diagnosis
o Delayed management
o Need for multidisciplinary planning
o Pain/infection can be difficult to manage
o Health risk posed by dental infection
o Risks posed by dental treatment
239
in children with disabilities you may find an increased prevalence/risk of what?
Anomalies of tooth number
Anomalies of tooth size
Dental trauma
Periodontal disease
Calculus accumulation
Grinding
240
why would children with special needs be at increased risk of decay?
- risk infection would pose e.g ineffective endocariditis
- use of sugar containing medicine
- limited diet/difficulty brushing
- difficulty managing caries
241
what are types of oro-facial soft tissue infections?
Primary herpetic gingivostomatitis
Coxsackie a virus
242
what is primary herpetic gingivostomatis?
* Acute Infectious disease
* Herpes Simplex Virus I
243
what are primary herpetic gingivostomatis signs and symptoms?
o Fluid filled vesicles – rupture to painful ragged ulcers on the gingivae, tongue, lips, buccal and palatal mucosa
o Severe oedematous marginal gingivitis
o Fever
o Headache
o Malaise
o Cervical lymphadenopathy
244
how do you treat primary herpetic gingivostomatis?
o Bed rest
o Soft diet/hydration
o Paracetamol
o Antimicrobial gel or mouthwash
o Aciclovir for immunocompromised children
245
what is most common complication of primary herpetic gingivostomatis?
dehydration
246
how long does primary herpetic gingivostomatis last?
14 days
247
what is primary herpetic gingivostomatis triggered by?
o Sunlight
o Stress
o Other causes of ill health
248
how is primary herpetic gingivostomatis managed?
Managed with topical acyclovir cream
249
what is Coxsackie a virus - Herpangina?
o Vesicles in the tonsillar/ pharyngeal region
o Lasts 7-10 days
250
what is coxsackle a virus - hand, foot and mouth?
o Ulceration on the gingivae/tongue/cheeks and palate
o Maculopapular rash on the hands and feet
o Lasts 7-10 days
251
what is oral ulceration?
A localized defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue
252
what are causes of oral ulceration?
* Infection
* Immune mediated Disorders:
* Vesiculobullous disorders:
* Inherited or acquired immunodeficiency disorders
* Neoplastic/Haematological
* Trauma
* Vitamin deficiencies – Iron, B12, Folate
* Recurrent Apthous Stomatitis
253
what infections can cause oral ulceration?
o Viral: Hand foot and mouth/ Coxsackie Virus/ Herpes Simplex/ Herpes Zoster, CMV, EBV, HIV
o Bacterial: TB, syphilis
254
what immune mediated disorders can causes oral ulcertation?
Crohns, behcets, SLE, Coeliac, Periodic fever syndromes
255
what veicuobullous disorders can causes oral ulceration?
Bullous or mucous membrane pemphigoid, pemphigus vulgaris, linear IgA disease, erythema multiforme
256
what neoplastic/heamotological conditions can cause oral ulceration?
Anaemia/Leukaemia/agranulocytosis/cyclic neutropenia
257
what is most common cause of ulceration in children?
Recurrent Apthous Stomatitis
258
describe Recurrent Apthous Stomatitis?
Typically, aphthous ulcers are round or ovoid in shape with a grey or yellow base and have a varying degree of perilesional erythema.
259
what are the patterns of Recurrent Apthous Stomatitis
Minor - <10mm
Major - >10mm
Herpetiform – 1-2mm
260
what investigations are done for oral ulceration?
initial
- diet diary
- full blood count
- haematinics (follate/B12/Ferritin)
- coeliac screen?
management
- diet analysis
- low ferritin = 3 months of iron supplementation
- low follate/B12 or positive transgulaminase antibodies = referral to paediatrician
261
what vitamin deficiencies can causes oral ulceration?
ferritin
B12
follate
262
how is oral ulceration managed?
Exacerbating factors
* Nutritional deficiencies
* Traumatic factors
* Avoid sharp or spicy food
* Allergic factors:
o Dietary exclusion
o SLS free toothpaste
Pharmacological
* Management in GDP:
o Prevention of Superinfection:
Corsodyl 0.2% Mouthwash
o Protect healing ulcers
Gengigel topical gel (hyaluronate)
Gelclair mouthwash (hyaluronate)
o Symptomatic relief
Difflam (0.15% benzydamine hydrochloride)
Local anaesthetic Spray
263
what is average age of onset for oro-facial ganulomatosis?
11
264
what can oro-facial granulomatosis be a future predictor of?
crohn's disease
265
what are clinical features of OFG?
o Lip Swelling – most common
o Full thickness gingival swelling
o Swelling of the non labial facial tissues
o Peri-oral erythema
o Cobblestone appearance of the buccal mucosa
o Linear oral ulceration
o Mucosal tags
o Lip/ tongue fissuring
o Angular cheilitis
o Deep penetrating ulcers
266
what is a type of mucosal lesion of tongue?
- geographic tongue
267
what is geopgraphic tongue?
* Idiopathic and non contagious
* May be seen at a young age
* Shiny red areas on the tongue with loss of filiform papillae are surrounded by white margins
* Can cause intense discomfort in children
* Discomfort with spicy food/ tomato or citrus fruit/juice
* Management: bland diet during flare ups
* Likely to become less troublesome with age
268
what are types of solid swelling?
Fibroepithelial Polyp
Epulides
Congenital epulis
HPV-associated mucosal swellings
Neurofibromas
269
what is firboepithelial polyp?
* Common
* Firm pink lump (pedunculated or sessile)
* Mainly in the cheeks (along occlusal line); lips or tongue
* Once established remains constant size
* Thought to be initiated by minor trauma
* Surgical excision is curative
270
what is epuildes?
* Common solid swelling of the oral mucosa
* Benign hyperplastic lesions
271
what are 3 main types of epulides?
o Fibrous epulis
o Pyogenic granuloma/pregnancy epulis
o Peripheral giant cell granuloma
272
what is fibrous epulis?
Pedunculated or sessile mass
Firm consistency
Similar color to surrounding gingivae
Inflammatory cell infiltrate and fibrous tissue
273
what is Pyogenic granuloma/pregnancy epulis
Soft, deep red/purple swelling
Often ulcerated
Haemorrhage spontaneously or with mild trauma
Vascular proliferation supported by a delicate fibrous stroma
Probably a reaction to chronic trauma e.g. calculus
Tend to recur after removal
274
what is Peripheral giant cell granuloma?
Pedunculated or sessile swelling
Typically dark red and ulcerated
Usually arises inter-proximally and has an hour-glass shape
Radiographs may reveal superficial erosion of the interdental bone
Multinucleate giant cells in a vascular stroma
May recur after surgical excision
275
what is congenital epuilis?
* Rare lesion
* Occurs in neonates
* Most commonly affect the anterior maxilla
* F>M
* Granular cells covered with epithelium
* Benign
* Simple excision is curative
276
what are 2 types of HPV associciated mucosal swellings?
- verruca vulgaris
- squamous cell papilloma
277
what are types of fluid swellings?
Mucoceles
Ranula
Bohn’s nodules
Epstein Pearls
Haemangiomas
Vesiculobullous lesions
278
what are 2 variants of mucocele?
- mucous extravasion cyst
- mucous retention cyst
279
what can mucocele affect?
minor or major salivary glands
280
what is ranula?
mucocele in floor of mouth
benign tumour of lymphatics
281
what is bohn 's nodules?
- gingival cysts
- disappear in early months of life
282
what are epstein pearls?
- small cystic lesions
- found along palatal mid line
283
what are types of vesiculobullous lesions?
* Primary herpes
* Epidermolysis bullosa
* Erythema Multiforme
284
what is Temporomandibular Joint Dysfunction Syndrome characterised by?
* Pain
* Masticatory muscle spasm
* Limited jaw opening
285
what should Temporomandibular Joint Dysfunction Syndrome extra oral exam include?
o Palpation of the muscles of mastication both at rest and when the teeth are clenched to assess tenderness and/or hypertrophy
o Palpation of the TMJ at rest and when opening and closing to assess tenderness and click/crepitus
o Assessment of opening
Check for any deviation of the jaw
Assess extent of opening (normal = 40-50mm)
286
what should Temporomandibular Joint Dysfunction Syndrome intra oral exam include?
o Assessment of any dental wear facets
o Signs of clenching/grinding:
Scalloped lateral tongue surface
Buccal mucosa ridges
287
what is management of Temporomandibular Joint Dysfunction Syndrome?
o Explain the condition
o Reduction of exacerbating factors:
Management of stress – mindfulness/yoga
Avoid habits such as clenching, grinding, chewing gum, nail biting or leaning on the jaw
A bite raising appliance may be considered if there is nocturnal grinding/clenching
o Allow the over worked muscles to rest:
Avoid wide opening – stifle yawns with a closed fist
Soft diet which required little chewing
o Symptomatic relief:
Use of ibuprofen which has anti-inflammatory action
Alternating use of hot and cold packs
o If these measures are unsuccessful referral for specialist care is indicated.
288
what is 2017 perio conditions classification?
- periodontal health
- gingivitis - dental biofilm induced
- gingival diseases and conditions - non dental biofilm induced
- necrotising perio disease
- periodontitis
- periodontitis as a manifestation of systemic disease
- systemic diseases or conditions affecting periodontal supporting tissues
- periodotnal abscesses and endo-periodontal lesions
- muciogingival deformities and conditions
- traumatic occlusal forces
- tooth and prosthesis related factors
289
what is periodontal health?
A state:
* free from inflammatory periodontal disease
* that allows an individual to function normally
* that avoids physical or mental consequences due to current or past disease.
290
features of health periodontium in children?
* Features:
o Gingival margin several millimeters coronal to the cemento-enamel junction (CEJ).
o Gingival sulcus 0.5 mm – 3 mm deep on a fully erupted tooth.
o In teenagers, alveolar crest is situated between 0.4 mm - 1.9 mm apical to CEJ
291
what is clinical peridontal health?
<10% BOP
292
what are types of gingivitis?
* 1) Plaque biofilm-induced gingivitis
* 2) Non plaque biofilm-induced gingivitis / gingival lesions
293
explain plaque biolfilm induce gingivitis
As supragingival plaque accumulates on teeth, an inflammatory cell infiltrate develops in gingival connective tissue.
Junctional epithelium becomes disrupted
Allows apical migration of plaque and increase in gingival sulcus depth leads to Gingival pocket / false pocket / pseudo pocket
294
what can Non plaque biofilm-induced gingivitis / gingival lesions be?
Manifestations of systemic conditions
Pathologic changes limited to gingival tissues.
295
what are sub classification of Non plaque biofilm-induced gingivitis / gingival lesions?
1) Genetic/Developmental disorders
2) Specific infections
3) Inflammatory and immune conditions and lesions
4) Reactive processes
5) Neoplasms
6) Endocrine
7) Nutritional and metabolic diseases
8) Traumatic lesions
9) Gingival pigmentation.
296
what are predisposing factors of perio conditions?
- Malocclusion
Instanding or rotated tooth
Traumatic occlusion: Low frenal attachments
- Traumatic dental injury
Damage to PDL i.e luxation / intrusion / avulsion
Dental plaque-biofilm retentive factors
Tooth anatomy e.g talon cusp, cingulum, enamel pearl, enamel defects (pits / grooves)
Restoration margins / overhangs /cavities
Orthodontic /prosthodontic appliances (etc).
Incompetent lip seal -> Oral dryness:
-↓ saliva flow
-↓ saliva quality
297
what are modifying factors of perio?
Smoking (Tobacco)
Metabolic factors (hyperglycaemia / Diabetes – type 1
Pharmacological agents (cyclosporin)
Nutritional factors (Vitamin C deficiency)
↑ sex steroids (puberty, pregnancy)
Haematological conditions (Leukaemia)
298
what is gingival overgrowth related to?
o systemic and metabolic diseases
o genetic factors (e.g Hereditary gingival fibromatosis)
o local factors
o side effects produced by some medications (cyclosporin, phenytoin and calcium channel blockers).
o A greater incidence of gingival overgrowth is seen in puberty and the severity is more intense in children than in adults with similar amounts of dental plaque
299
what is treatment to gingival overgrowth?
o rigorous home care
o frequent appointments for professional mechanical plaque removal (PMPR)
o +/- surgery, especially with drug-induced gingival overgrowth
300
what is periodontitis?
A chronic multifactorial inflammatory disease
Associated with dysbiotic (microbial imbalance) plaque biofilms
Characterised by progressive destruction of the tooth-supporting apparatus.
301
what are key features of periodontitis?
- apical migration
- loss of attachment
- transformation of junctional epithelium to pocket epithelium
- alveolar bone loss
302
diagnosis statement of periodontitis?
1. staging
- interproximal bone loss at worst site
2. grading
- rate of progression
- % of bone loss/age
3. assess current periodontal status
- currently stable, in remission or unstable
4. risks assessment
- smoking
- poorly controlled diabetes
303
what are features of molar incisor pattern periodontitis?
rapid attachment loss and bone destruction
patient is otherwise healthy
Onset around puberty
family history
304
what is localised pattern of molar incisor patter periodontitis?
Traditionally localised to incisors and first molars
305
what is generalised molar incisor pattern periodontitis?
Traditionally ≥ 3 permanent teeth other than incisors and first molars
onset is usually older but sometimes under 30 years
Now based on number of sites as per new classification
306
what to record during screening of perio health status?
* 1) Gingival condition
* 2. Assess OH status
* 3. Assess if any calculus present
* 4. Assess local risk factors
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what does labial and palatal gingivitis suggest?
incompetent lip seal
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what does mouth breathing suggest?
Palatal gingivitis
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what teeth are a simplified BPE done on?
16 11 26 36 31 46
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BPE 0/1/2 10-30% BOP =
localised gingivitis
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BPE 0/1/2 <10% BOP =
clinical gingival health
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BPE 0/1/2. >30% BOP=
generalised gingivitis
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what to do if BPE 3?
- radiograph assessment
- initial perio therapy and review in 3 months with localised 6 point pocket chart in involved sextants
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If BPE 3 when will you continue with code 0/1/2
if no pockets >= 4mm and no radiographic evidence of bone loss due to periodontitis
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If BPE code 3 when will you go to code 4
pockets >= 4mm and/or radiographic evidence of bone loss due to perio
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what to do if code BPE 4?
- radiograph assessment
- full periodontal assessment (full mouth 6 point pocket chart)
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what are the 3 results of a full mouth pocket chart on code 4?
- molar incisor patter periodontitis
- <30% teeth - localised periodontitis
- >=30% - generalised periodontitis
you then so staging and grading and get diagnostic statement
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what are plaque scores for kids?
10/10 perfectly clean tooth
8/10 line of plaque around cervical margin
6/10 cervical 1/3rd of crown covered
4/10 middle 1/3rd of crown covered
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what are stages of periodontitis?
%bone loss at worst inter-proximal site
- stage I - early/mild - <15%
- stage II - moderate - coronal third of root
- Stage III - severe - mid third of root
- Stage IV - very severe - apical third of root
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what are grades of peridontitis?
%bone loss / age
- grade A - slow rate of progression - <0.5
- grade B - moderate rate progression - 0.5 - 1
- grade C - rapid rate progression - >1
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what is assessment of current perio status?
- currently stable
- BoP <10%
-PPD <= 4mm
-No BoP at 4mm sites
- currently in remission
- BoP >= 10%
-PPD <= 4mm
- No BoP at 4mm sites
- Currently unstable
- PPD >= 5mm or PPD >= 4m and BoP
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what are risk factors of periodontitis for assessment?
smoking - how many a day
sub optimally controlled diabetes
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what are prevention for periodontitis?
* Oral health messages
o Plaque induced gingivitis / progression of early periodontal disease in children and adolescents can be prevented by affective toothbrushing (careful and regular removal of dental plaque biofilm)
systematically clean all surfaces
Hands on demonstration – supervised toothbrushing
Modified bass technique
Consider disclosing tablets
o Standardised prevention
fluoride advice
o Smoking cessation
paramount importance in teenage years
11% of 15-year-olds reported being a current smoker and 29% reported having ever smoked cigarettes
o Oral health measures
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treatment for BPE codes?
0 - nothing
1 - OHI
2 - OHI and PMPR
3 - OHI as for codes 1 and 2, PMPR in shallow 4-5mm pockets. Remove plaque retentive factors
4 - unusual in young patients. full perio assessment and refer to specialist
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recall for BPE codes?
0 - within 1 year
1 - within 1 year
2 - every 6 months
3 - every 3 months
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what are S3 treatment guidelines?
step 1 - building foundations for optimal treatment outcomes
step 2 - causes related therapy
step 3 - management of non responding sites (>4mm with BoP or >6mm)
step 4 - supportive periodontal care (maintenance)
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in regards to avulsion management whats your follow up times for closed and open apex?
closed
- 4 weeks
- 3 months
- 6 months
- 1 year
annually for at least 5 years
open
- 1 months
- 2 months
- 3 months
- 6 months
- 1 year
annually for at least 5 years
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