Paediatric Dentistry Flashcards
1
Q
Who always has automatic parental responsibility?
A
Mother
2
Q
How does a father acquire parental responsibility?
A
Being married to mother at time of conception or subsequently
Name on birth certificate (since May 06)
Parental responsibility agreement with the mother
Parental Responsibility order from the court
3
Q
When does a step parent have parental responsibility?
A
Parental responsibility agreement with child’s parent
Parental responsibility order from the court
Appointed legal guardian by the court
4
Q
GDC expectations for safeguarding of children
A
All registrants to be aware of the procedures involved in raising concerns about possible abuse or neglect of children and vulnerable adults
Responsibility to raise concerns about the possible abuse or neglect of children or vulnerable adults, know who to contact for further advice and how to refer
5
Q
Child protection
A
Activity undertake to protect specific children who are suffering or are at risk of suffering significant harm
6
Q
Children in need
A
Those who require additional support or services to achieve their full potential
7
Q
Possible measures taken to minimise the risks of harm to children
A
Protecting children from maltreatment
Preventing impairment of children’s health or development
Ensuring that children are growing up in a safe and caring environment
8
Q
Child abuse and neglect
A
Anything which those entrusted with the care of children do, or fail to do, which damages their prospects of safe and healthy development into adulthood
9
Q
3 elements for definition 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
10
Q
The Children and Young People’s Act 2014
A
13 parts
4 major themes - Children’s rights, GIRFEC, early learning and childcare, ‘Looked After’ children
11
Q
Big three concerns for parenting capacity
A
Domestic violence
Drug and alcohol misuse
Mental health problems
12
Q
Child abuse categories
A
Physical
Emotional
Neglect
Sexual
13
Q
What would be most likely to improve the oral health of all pre-school children?
A
Water fluoridation
14
Q
What is always highest priority when making a treatment plan?
A
Relief of pain
15
Q
What should be carried out first?
Anterior tooth restorations requiring LA
Simple restorations in the upper jaw requiring LA
Simple restorations in the lower jaw requiring LA
Pulpotomy in the lower jaw
A
Simple restorations in the upper jaw requiring LA
16
Q
It is important that parents do not show small children what when at the dentist?
A
That they are nervous
17
Q
What is an example of an injury that would not (in isolation) suggest child abuse?
A
Torn upper labial frenulum
18
Q
How many children in Scotland are killed by a parent/parent substitute?
A
10 per year
19
Q
Why might neglect go unnoticed?
A
Neglect is less incident focussed
20
Q
3 stages in managing dental neglect are suggested by Child Protection and the Dental Team
A
Preventative dental team management
Preventative multi-agency management
Child protection referral
21
Q
What proportion of serious head injuries in the first year of life are non-accidental?
A
95%
22
Q
What proportion of injuries in abuse cases are found on the head and neck areas?
A
60%
23
Q
When reading clinical guidelines, what does the strength of a strong key recommendation convey?
A
Based on available information, weighing up balance of benefit versus risk, almost all individuals would choose this option
24
Q
What is motivational interviewing used for and what does the process involve?
A
Translating knowledge into behaviour
Seek permission, open questions, affirmations, reflective listening, summarising
25
Standard prevention for all children includes what at least once per year?
Toothbrushing demo on the child and age appropriate toothpaste advice
Advice to snack on sugar free foods such as oatcakes and be award of acid content in drinks
26
What is the protocol for enhanced prevention for children at increased risk of caries at each recall visit?
Standard prevention and hands on toothbrushing to child and parent/carer
Parents only may require more in depth support to change dietary habits, such as motivational interviewing
27
Which surface is fissure sealed in enhanced preventions if assessed as likely to be beneficial?
2s palatal pits
28
Standard prevention fluoride varnish
5% sodium fluoride varnish twice a year to all children over 2 years
29
Minimum dose of fluoride for toxicity
5mg/kg body weight
30
3 take home messages from the Marimho 2008 review of the evidence for topical fluorides
Additional topical fluorides such as mouthwashes, varnish and tablets used as well as toothpaste further reduce the occurrence of caries
Fluoride toothpaste prevents dental caries
The higher the caries rate, the greater the preventative effect of topical fluorides
31
Lowest amount of fluoride in toothpaste recommended for a 2 year old
1000ppmF
32
Strength of duraphat varnish
22,600ppmF
33
When should topical fluorides (other than toothpaste) be taken?
At a different time than toothbrushing
34
Correct drug information on a prescription to allow a tube of duraphat 2800ppm toothpaste to be dispensed
Sodium fluoride 0.619% toothpaste
35
When should parents start toothbrushing for their child?
First tooth erupts
36
How much toothpaste and what concentration for a 6 month old child at low caries risk
Smear of 1000ppmF twice daily
37
What should be asked if a parent calls to say their child has ingested toothpaste?
Amount and strength of toothpaste
Age/weight of child
38
What should be used to etch before application of fissure sealant?
35-37% ortho-phosphoric acid
39
How is isolation for moisture control best achieved when placed fissure sealant?
Rubber dam
40
When is the ideal time to fissure seal first permanent molars?
Whenever the tooth has erupted sufficiently to allow for adequate isolation/moisture control
41
What is the most common material used for fissure sealant placement?
Bis-GMA resins
42
After placement, fissure sealants should be checked for
Air bubbles
Flash
Non-adherance
43
How often should fissure sealants placed in a child of high caries risk be radiographically reviewed?
6 months
44
What is the major advantage of using a glass ionomer fissure sealant?
It is easier to handle when moisture control is not ideal
45
What should be used to clean the tooth before fissure sealant placement?
Pumice and water
46
How should the occlusal surface of the tooth appear after adequate acid-etch and drying?
Chalky white/frosted
47
Which instrument should be used to check a fissure sealant after placement?
A sharp probe
48
Epidemiology of tooth trauma
Peak incidence 2-4 years old
Male>female
16-40% prevalence
Maxillary primary incisor teeth most common
49
Crown fractures classification
Enamel - fracture involves only enamel
Enamel-dentine - fracture involved enamel and dentine, pulp is not exposed
Complicated - Fracture involves enamel and dentine plus the pulp is exposed
Crown-root fracture - fracture involves enamel, dentine and root, pulp may or may not be involved (complicated or uncomplicated)
50
Concussion
Tender to touch but no displacement, no increase in mobility
51
Subluxation
Tooth tender to touch, has increased mobility but not been displaced
52
Lateral luxation
Tooth displaced usually in palatal/lingual or labial direction
53
Intrusion
Tooth usually displaced through the labial bone plate, or it can impinge on the permanent tooth bud
54
Extrusion
Partial displacement of tooth out of its socket
55
Avulsion
Tooth is completely out of the socket
56
Alveolar fracture
Fracture involves the alveolar bone (labial and palatal/lingual) and may extend to the adjacent bone
57
Most common injury type of primary dentition
Luxation (two thirds)
58
Steps to examination following traumatic injury to primary dentition
Reassurance
History
Examination
Diagnosis
Emergency treatment
Important information
Further treatment and review
59
How to take a trauma history
When/where/how was the injury sustained?
Any other symptoms or injuries?
Lost teeth/fragments?
60
Relevant medical history for dental trauma patient
Congenital heart disease
History of rheumatic fever or immunosuppression
Bleeding disorder
Allergies
Tetanus immunisation status
61
What would a duller percussion note of a tooth indicate following trauma?
Root fracture
62
What does a trauma stamp record in primary dentition?
Mobility +/-
Tooth colour - normal, grey, yellow, pink
TTP - +/-
Sinus - +/-
Percussion note - Normal/Dull
Radiograph taken +/-
63
When is it not appropriate to proceed with observation following a traumatic injury?
Risk of aspiration, ingestion or occlusal interference
64
What is the homecare in a case where the treatment of an injury is observation?
Analgesia
Soft diet 10-14days
Brush with soft toothbrush after every meal
Topical chlorhexidine gluconate 0.12% mouthwash twice daily for one week
65
Treatment for uncomplicated crown fracture
Cover all exposed dentine with glass ionomer/composite
Lost tooth can be restored immediately with composite or at a later visit
66
Treatment options for complicated crown fracture
Partial pulpotomy
Extract
67
Treatment for 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
If unrestorable - extract loose fragments, don't dig
68
Treatment for root fracture
Coronal fragment not displaced - no treatment
Coronal fragment displaced but not excessively mobile - leave coronal fragment to spontaneously reposition even if some occlusal interference
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
69
Treatment for concussion of tooth
None
Observation
70
Treatment for subluxation
None
Observation
71
Treatment for lateral luxation
Minimal/no occlusal interference - allow to reposition spontaneously
Severe displacement - extraction and reposition (+/- splint)
72
Treatment for intrusion injury
Allow to spontaneously reposition, irrespective of direction of displacement
73
Treatment for avulsion (primary dentition)
Radiograph to confirm avulsion
DO NOT REPLANT
74
Radiographs used to determine direction on intrusion displacement
Periapical or lateral premaxilla
Not parallax as only one radiograph is used
75
Treatment for extrusion injury
Not interfering with occlusion - spontaneous repositioning
Excessive mobility or extruded >3mm - extract
76
Alveolar fracture treatment
Reposition segment
Stabilise with a flexible splint to the adjacent uninjured teeth for 4 weeks
Teeth may need to be extracted after alveolar stability has been achieved
77
Sequelae of trauma to the primary tooth
Discolouration
Infection
Delayed exfoliation
78
Asymptomatic discolouration
Vital or non-vital
Mild grey - immediate discolouration may maintain vitality
Opaque/yellow - pulp obliteration
if no signs of pulp necrosis or infection - no treatment
79
Symptomatic discolouration
Non vital
Sinus, gingival swelling, abscess
Increased mobility
Radiographic evidence of periapical pathology
Extract or root treat
80
What is the issue with delayed exfoliation?
Consequences for the developing occlusion
81
Injuries to permanent teeth are more likely when trauma occurs to older or younger children?
Younger
82
Which type of dental trauma causes most disturbance to permanent dentition?
Intrusion
83
What are the possible injuries to permanent teeth following trauma to deciduous dentition?
Enamel defects (44%, most common)
Abnormal crown/root morphology
Delayed eruption
Ectopic position
Arrested development
Complete failure to form
Odontome formation
84
Two possible enamel defects in permanent dentition, caused by deciduous trauma
Enamel hypomineralisation - normal thickness, poorly mineralised, white/yellow
Enamel hypoplasia - reduced thickness but normal mineralisation, yellow/brown
85
Dilaceration
Abrupt deviation of the long axis of the crown or root portion of the tooth
86
Management of crown dilaceration options
Surgical exposure and orthodontic realignment
Improve aesthetics restoratively
87
Root dilaceration management
Combined surgical and orthodontic approach
88
When would you take radiographs for delayed eruption?
If 6 month delay compared to contralateral tooth
89
Ectopic tooth position management options
Surgical exposure and orthodontic realignment
Extraction
90
Treatment for odontome formation
Surgical removal
91
Splinting time for lateral luxation
4 weeks
92
Pulp necrosis is more likely in an intrusion injury of >___mm
3mm
93
An 11 year old presents 48 hours after a complicated crown fracture to tooth 21, what is the treatment required?
Pulpotomy
94
What can happen following root fractures in permanent teeth following dental trauma?
Hard tissue healing
95
Does pulp canal obliteration happen more often in open or closed apices teeth?
Open
96
Needle desensitisation
Teach relaxation, explain LA, practice LA, deliver LA
97
What technique should be used to help a child with a blunting coping style cope?
Explain what will happen and then use distraction techniques
98
What is the ideal tooth for a Hall crown?
Carious lesion with a clear band of dentine between it and the pulp
99
Normal child at 2 years old
Fear of unexpected movements, loud noises and strangers
100
Normal child at 3 years old
Reacts favourably to positive comments about clothes and behaviour
Less fearful of separation from parents
Experience will however dictate reaction to separation
101
Normal child at age 4
More assertive, can be bossy/aggressive
Fear of the unknown and bodily harm is at a peak
Fear of strangers has decreased
With firm and kind direction, will be excellent patients
102
Normal child at age 5
Readily separated from parents
Fears have usually diminished
Proud of possessions
Comments on clothes will quickly establish a rapport
103
Normal child at age 6
Seeks acceptance
Success in this can affect self-esteem
If while at dentist child develops a sense of inferiority or inadequacy, behaviour may regress to that of a younger age
104
Normal child at age 7-12
Learn to question inconsistencies and conform to rules of society
Still have fears but are better at managing them
105
Dental anxiety vs fear vs phobia
Anxiety - occurs without triggering stimulus and may be reaction to unknown danger or anticipatory due to previous negative experiences
Fear - is a normal emotional response to objects or situations perceived as genuinely threatening
Phobia - clinical mental disorder where subjects display persistent and extreme fear of objects or situations with avoidance behaviour and interference of daily life
106
Physiological and somatic sensations during dental fear and anxiety
Breathlessness
Perspiration
Palpitations
Feeling of unease
107
Cognitive features of dental fear and anxiety
Interference with concentration
Hypervigilance
Inability to remember certain events while anxious
Imagining the worst that could happen
108
Behavioural reactions to dental fear and anxiety
Avoidance - e.g. the postponing of a dental appointment, or with children disruptive behaviour in an effort to stop treatment being undertaken
Escape from the situation which precipitates the anxiety
Anxiety may manifest with aggressive behaviour especially in adolescents who are brought by their parents but do not want to be there
109
Subtle signs of dental fear and anxiety
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, fidget or stutter, 'can't be bothered'
110
Factors that influence fear and anxiety
Fear of choking
Fear of injections/drilling
Fear of the unknown
Past medical and dental experience
Dental experience of friends and siblings
Attitudes of parents
Preparation at home before the dental visit
Child's perception that something is wrong with their teeth
111
What scale can be used to assess children's dental fear and anxiety?
Faces Version Modified Child Dental Anxiety Scale
Quick and easy to use
112
Why is inhalation sedation with nitrous oxide useful for anxious children?
Increases suggestibility
113
What group is IV sedation usually used on?
12+
114
Two most commonly used LAs
Lidocaine 2%
Articaine 4%
115
% of children in the UK with a disability
6%
116
Causes of disability
Genetic
Developmental - injury, infection, parental health during pregnancy
Unknown cause
117
Classifications of learning difficulties
Mild
Moderate
Severe
Profound
118
Is ASD more common in males or females?
Males 3:1
119
Autism Spectrum Disorder
Lifelong developmental disorder which affects how people communicate and interact with the world around them
More than 1 in 100 in UK
SPECTRUM - everyone is different, different levels of support required
120
Potential difficulties for people with autism spectrum disorder
Social communication
Social interaction
Repetitive and restrictive behaviour
Over and under sensitivity to light, sound, taste or touch
Extreme anxiety
Meltdowns or shutdowns
121
Strategy for children who do not speak/have limited language
Use preferred mode of communication e.g. Makaton/visual symbols
122
Strategy for children who think people always mean exactly what they say
Concrete language
Direct requests
Avoid jokes/sarcasm
123
Strategy for children who do not understand facial expressions or body language
Avoid body language, gestures or facial expressions without accompanying them with verbal instruction
124
Strategy for children who find busy waiting rooms difficult
1st appt of the day
Quieter clinic
Avoid waiting
Side room to wait
125
Another name for Down Syndrome
Trisomy 21
126
Physical features of Down Syndrome
Large tongue
Mid face hypoplasia
127
Down syndrome increases predisposition to (3)
Cardiac defects
Leukaemia
Epilepsy
128
Dental features of Down Syndrome
Maxillary hypoplasia
Class III occlusion
Macroglossia
Anterior open bite
Hypodontia/microdontia
Predisposition to periodontal disease
129
Incidence of cerebral palsy
2:1000 live births
130
Cerebral Palsy
Non progressive lesion of motor pathways in the developing brain
Caused by brain damage in early development, either foetal, during birth or during first few months of infancy
Can cause abnormalities of movement and posture in various body parts, and delays in motor skills development, poor control over hand and arm movement, weakness, abnormal walking, difficulties swallowing, excessive drooling
131
Other issues often associated with cerebral palsy
Learning difficulties (60%)
Epilepsy (40%)
Visual/hearing impairment +/- speech and language disorders
Joint contractures/scoliosis/hip subluxation
Reflux
Many patients are highly intelligent but may have such severely impaired speech that they appear to have a severe learning impairment
132
3 types of cerebral palsy, and what part of the brain they affect, and their presentations
Spastic (80%) - cortex - increased muscle tone
Ataxic - cerebellum - coordination/balance
Dyskinetic - basal ganglia - uncontrollable movements
133
Types of spastic cerebral palsy
Diplegia - muscle stiffness mostly in legs, arms less/not affected
Hemiplegia - affects only one side of a persons body, usually the arm is more affected than the leg
Quadriplegia - most severe form, affects all four limbs, the trunk and the face. People with spastic quadriparesis usually cannot walk and often have other developmental disabilities
134
Ataxic CP
Problems with balance and coordination
May be unsteady when walking
Might have a hard time with quick movements or controlled movements
Difficulty controlling hands or arms when reaching for something
135
Dyskinetic CP
Problems controlling movement of hands arms feet and legs, difficult to sit and walk
Uncontrollable movements can be slow and writhing or rapid and jerky
Sometimes the tongue and face are affected - difficulty sucking, swallowing, talking
136
Dental considerations of patients with cerebral palsy
Difficulty tolerating dental treatment
Increased malocclusion (usually class II)
Increased dental trauma
Bruxism
Drooling
Poor OH
Pathological oral reflexes - biting
Calculus if peg fed
Periodontal disease
Hyperplastic gingivitis
Self mutilation
Unsafe swallow
137
Incidence of childhood cancer <15 years old
1:450
138
Most common childhood cancer
Leukaemia
139
% of childhood cancers that can be completely cured
82%
140
Leukaemia
Cancer of white blood cells
Can affect lymphocytes or myeloid cells (including neutrophils)
3/4 cases are acute lymphoblastic leukaemia
White blood cell production gets out of control, continue to divide in the bone marrow but do not mature
Fill up bone marrow preventing healthy blood cell synthesis
Pallor due to decreased RBCs
Increased bleeding/bruising due to lack of platelets
Infection due to lack of functioning WBCs
141
Oral manifestations of leukaemia
Gingival swelling
Ulceration
Spontaneous gingival bleeding
Unusual mobility of teeth
Petechiae
Mucosal pallor
Herpetic infections
Candidosis
142
Cancer therapy that may have oral complications
Surgery to head and neck
Chemotherapy
Radiotherapy to head and neck
Bone marrow transplant
143
Dental implications of cytotoxic drugs
Short term
Mucositis
Increased infection risk
Increased bleeding risk
Long term
Affect developing dentition - enamel hypoplasia, microdontia, thin roots
144
Dental relevance of radiotherapy to the head and neck
Short term - mucositis, decreased salivary flow (often permanent, increases caries, infection risk and causes taste disturbance), direct damage to taste buds
Longer term - malocclusion, increased risk of soft tissue neoplasm, risk of osteoradionecrosis, affects to developing dentition (hypodontia, microdontia, enamel hypoplasia, defects of root formation)
145
Incidence of congential cardiac defects
6-8/1000 births
1:125
146
Classifications of congenital cardiac defects
Cyanotic - deoxygenated blood able to enter systemic circulation
Acyanotic - Normal levels of oxyhaemoglobin in systemic circulation
147
Most common acyanotic CCD
Ventricular septal defect
148
Most common cyanotic CCD
Tetralogy of Fallot
149
50% of Down Syndrome patients have
An atrial septal defect
150
Dental implications of congenital cardiac defects
Medications increasing bleeding risk
Higher risk of GA
Careful use of adrenaline containing LA
Increased risk of enamel hypoplasia
Risk of infective endocarditis resulting from an oral bacteraemia
151
Patients at higher risk of infective endocarditis
Acquired valvular heart disease with stenosis or regurgitation
Hypertrophic cardiomyopathy
Previous IE
Structural congenital heart disease, including surgically corrected or palliated structural conditions
Valve replacement
152
Infective endocarditis
IE can occur when bacteria enter the blood stream, causing a bacteraemia and then adhere and multiply on the damaged heart surface, resulting in inflammation of the endocardium - significant morbidity (between 5 and 40%)
153
Sub group of patients at risk of IE, requiring special consideration
Prosthetic valve, including transcatheter valves or where any prosthetic material was used for valve repair
Previous IE
Congenital heart disease - any type of cyanotic CHD, including those repaired with prosthetic material
154
What should be considered for patients requiring special consideration at risk of IE, when carrying out invasive dental procedures?
Antibiotic prophylaxis
155
Guidelines for antibiotic prophylaxis for dental care
Nice Guidelines CG64
156
3 risks of bacteraemia
Poor OH
Dental infection
Invasive dental procedure
157
Invasive dental procedures
Placement of matrix bands
Placement of subgingival rubber dam clamps
Sub-gingival restorations including fixed pros
Endo treatment before apical stop has been established
Preformed metal crowns
Full periodontal exams
Root surface instrumentation/sub gingival scaling
Incision and drainage of abscess
Dental extractions
Surgery involving elevations of a muco-periosteal flap or mucogingival area
Placement of implants
158
Non-invasive procedures
Infiltration or block LA injections in non-infected soft tissues
BPE
Supra-gingival scale
Supra-gingival restorations
Supragingival orthodontic bands and separators
Removal of sutures
Radiographs
Placement or adjustment of orthodontic or removable prosthodontic appliances
159
Most common inherited bleeding disorders
Von Willebrand's disease
Haemophilia A
Haemophilia B
160
Non-inherited bleeding disorders
Warfarin/aspirin use
Chemotherapy induced thrombocytopenia
161
Primary haemostasis
Vasoconstriction after injury
Platelet plug formation
162
Secondary haemostasis
Formation of fibrin through coagulation cascade
163
Tertiary haemostasis
Fibrinolysis
Formation of plasminogen, then plasmin
164
Von Willebrand disease
Inherited deficiency on VW factor
Most common inherited bleeding disorder (1%)
Autosomal dominant
VW factor mediates platelet adhesion and aggregation, and is a carrier of factor VIII
165
Dental considerations of Von Willebrand's disease
Invasive treatment must be carried out in hospital setting
166
Haemophilia A and B effects
Haemophilia A - lack of clotting factor VIII
Haemophilia B - lack of factor IX
167
Categorisation of haemophilia
Haemophilia is classified depending on the amount of clotting factor present
Mild >5%
Moderate 1-5%
Severe <1%
168
Haemophilia gene
X linked recessive
Males with the gene are affected
Women are carriers
169
Impacts of dental disease in children with disabilities
Increased caries risk
Delayed diagnosis
Delayed management
Need for multidisciplinary planning
Pain/infection can be difficult to manage
Health risk posed by dental infection
Risks posed by dental treatment
170
Aims of 2021 Guidelines for periodontal screening and management of children and adolescents under 18 years of age
Outline a method of screening for under 18s during the routine clinical dental exam in order to detect the presence of gingivitis or periodontitis at the earliest opportunity
Provide guidance on periodontal management and when appropriate, treat in practice or refer, optimising periodontal outcomes for children
171
PGGNPPSPMTT 2017 World Workshop classifications of paediatric perio
Periodontal health
Gingivitis - biofilm induced
Gingival diseases and conditions - non biofilm induced
Necrotising periodontal disease
Periodontitis
Periodontitis as a manifestation of systemic disease
Systemic diseases or conditions affecting the periodontal supporting tissues
Periodontal abscesses and endo-perio lesions
Mucogingival deformities and conditions
Traumatic occlusal forces
Tooth and prosthesis related factors
172
Periodontal health
A state free from inflammatory periodontal disease, that allows an individual to function normally and avoids physical or mental consequences due to current or past disease
173
Features of health periodontium
Gingival margin several milimeters coronal to the CEJ
Gingival sulcus 0.5-3mm deep on a fully erupted tooth
In teenagers - alveolar crest is situated between 0.4-1.9mm apical to CEJ
174
Classification of reduced periodontium
Non-periodontal patient - crown lengthening surgery, recession
Periodontal patient - stable periodontitis
175
How can periodontal health be examined in practice
BPE
<10% BOP
176
Gingival conditions
Plaque biofilm induced gingivitis - intact or reduced periodontium
Non plaque biofilm induced gingivitis/gingival lesions
177
Plaque biofilm induced gingivitis
As supragingival plaque accumulates on teeth, an inflammatory cell infiltrate develops in the gingival connective tissue
Junctional epithelium becomes disrupted
Allows apical migration of plaque and increase in gingival sulcus depth
178
Non dental biofilm induced gingival diseases sub-classification
Genetic/developmental disorders
Specific infections
Inflammatory and immune conditions and lesions
Reactive processes
Neoplasms
Endocrine
Nutritional and metabolic diseases
Traumatic lesions
Gingival pigmentation
179
Aetiology of necrotising gingivitis
Fusiformspirochaetal microbial aetiology
Socioeconomic factors - developing countries
Risk factors - smoking, immunosuppression, stress, malnourishment, poor diet
Local factors - root proximity, tooth malposition
Systemic factors - HIV
Underlying undiagnosed pathology in an immunosuppressed host
180
Features of necrotising gingivitis
Pain
Necrosis of interdental papilla - punched out appearance
Ulceration
Spontaneous bleeding
Secondary foetor oris
Pseudomembrane may be present
+/- lymphadenopathy
Fever
Many manifest in teenagers
May progress to necrotising periodontitis
181
Predisposing factors for periodontal diseases
Malocclusion - instanding or rotated tooth, traumatic occlusion
Traumatic dental injury to the PDL - luxation/intrusion/avulsion
Tooth anatomy plaque retentive factors
Restoration overhangs
Ortho/pros appliances
Incompetent lip seal - dry mouth
182
Modifying risk factors for periodontal disease
Smoking
Metabolic factors - hyperglycaemia/T1D
Pharmacalogical agents (cyclosporin)
Nutritional factors (Vit C deficiency)
Increased sex steroids (puberty, pregnancy)
Haematological conditions (Leukaemia)
183
Factors influencing gingival hyperplasia
Systemic and metabolic diseases
Genetic factors
Local factors
Side effect of some medications (cyclosporin, phenytoin, calcium channel blockers)
Puberty
184
Treatment for gingival hyperplasia
Rigorous home care
Frequent PMPR
+/- surgery, especially with drug induced
185
4 main distinguishing factors of periodontitis
Apical migration of junctional epithelium, beyond CEJ
Loss of attachment or periodontal tissues to cementum
Transformation of junctional epithelium to pocket epithelium
Alveolar bone loss
186
Pathogens found in teenagers with periodontitis
Porphyromonas gingivalis
Prevotella intermedia
AA
Tannerella forsythia
187
Features of necrotising periodontitis
Necrosis/ulceration of the interdental papilla
Bleeding of gingival tissues
PDL loss and rapid bone loss
Pseudomembrane formation
Lymphadenopathy
Fever
188
Who is necrotising stomatitis likely to affect?
Severely systemically compromised patients
189
With regards to diagnosing periodontal diseases in mixed dentition, be aware of
false pocketing around erupting permanent dentition
190
Which pathogen is thought to be most associated with molar-incisor pattern periodontitis?
AA
191
Systemic conditions that put children at increased risk of periodontal disease
Papillon lefevre syndrome
Neutropenia
Chediak-Higashi syndrome
Leucocyte adhesion deficiency syndrome
Ehlers-Danlos syndrome
Langerhans' cell histiocytosis
Hypophosphatasia
Down syndrome
192
What should be assessed as periodontal screening in a routine exam
Gingival condition
OH status
Assess if any calculus
Assess local risk factors
193
Who should have the sBPE performed as part of routine exam?
All co-operative children age 7-18
194
What probe is used for sBPE
WHO 621/CPITN probe
0.5mm ball
Black band 3.5mm-5.5mm
195
How much force should be applied to carry out BPE?
20-25g
196
What do the codes for sBPE mean?
0 - health
1 - BOP, black band fully visible
2 - calculus or plaque retention factor, black band fully visible
3 - shallow 4/5mm pocket, black band partly visible
4 - Black band disappears
* furcation involvement
197
Which sBPE codes are used at which ages?
7-11 0,1,2
12-17 0,1,2,3,4,*
198
What are the index teeth for the sBPE?
16,11,26,36,31,46
199
What is the purpose of the sBPE?
Screening tool to identify patients who would benefit from further investigation
200
SDCEP plaque scores
10/10 perfectly clean tooth
8/10 line of plaque around cervical margin
6/10 cervical 1/3 of crown covered
4/10 middle 1/3 of crown covered
201
Where a BPE score of 3 or 4 is measured, what are the next steps?
6ppc (localised to 3 BPE, or full if 4)
Check bone levels with BWs for posteriors, PAs for anteriors, or OPT (esp. if for ortho treatment
202
What must be carried out before ortho treatment?
BPE
203
What technique for toothbrushing should be taught?
Modified bass technique
204
Viral orofacial soft tissue infections
Primary herpes
Herpangina
Hand foot and mouth
Varicella Zoster
Epstein barr virus
Mumps
Measles
Rubella
205
Bacterial orofacial soft tissue infections
Staphylococcal
Streptococcal
Syphilis
TB
Cat Scratch Disease
206
Cause of fungal orofacial soft tissue infections
Candida
207
Primary herpetic gingivostomatitis
Acute infectious disease caused by Herpes Simplex Virus I
Primary infection common in children
Transmission by droplet 7 day incubation
Degree of immunity from circulating maternal antibodies therefore infection rare in first year
Almost 100% of adults carry
208
Signs and symptoms of primary herpetic gingivostomatitis
Fluid filled vesicles - rupture to painful ragged ulcers on gingivae, tongue, lips, buccal and palatal mucosa
Severe oedematous marginal gingivitis
Fever
Headache
Malaise
Cervical lympadenopathy
209
Treatment for primary herpetic gingivostomatitis
Bed rest
Soft diet
Hydration
Paracetamol
Antimicrobial gel or mouthwash
Aciclovir for immunocomprimised children
210
Most common complication of primary herpetic gingivostomatitis
Dehydration
211
Following infection of primary herpetic gingivostomatitis, what happens?
Herpes simplex I remains dormant in epithelial cells
Recurrent 50-70% as herpes labials (cold sores)
Triggered by sunlight, stress, other causes of ill health
Managed with topical acyclovir cream
212
Management of herpes labialis
Topical acyclovir cream
213
Herpangina cause
Coxsackie A virus
214
Hand foot and mouth cause
Coxsackie A virus
215
Herpangina presentation
Vesicles in the tonsillar/pharyngeal region
Lasts 7-10 days
216
Hand foot and mouth presentation
Ulceration on the gingivae/tongue/cheeks and palate
Maculopapular rash on the hands and feet
Lasts 7-10 days
217
Oral ulceration
A localised defect in the surface oral mucosa, where the covering epithelium is destroyed, leaving an inflamed area of exposed connective tissue
218
10 key facts when collecting history on oral ulceration
Onset
Frequency
Number
Site
Size
Duration
Exacerbating dietary factors
Lesions in other areas
Associated medical problems
Treatment so far (helpful/unhelpful)
219
Causes of oral ulceration
Most commonly Recurrect Apthous Stomatitis - No clear underlying cause
Infection
Immune mediated Disorders
Vesiculobullous disorders
Inherited or acquired immunodeficiency disorders
Neoplastic/Haematological
Trauma
Vitamin deficiencies
220
Appearance of recurrent apthous ulceration
Round or ovoid with grey or yellow base amd varying degree of perilesional erythema
Minor <10mm, Major >10mm, Herpetiform 1-2mm, multiple
221
Aetiological factors for RAU
Hereditary predisposition
Haematological deficiency
GI disease
Minor trauma
Stress
Allergies
Hormonal disturbance
222
Investigations following RAU
Diet diary
FBC
Haematinics (folate, b12, ferritin)
Coeliac screen
223
Management of RAU
Diet analysis may suggest exacerbating food groups - manage accordingly
Low ferritin - 3 months of iron supplementation
Low folate/b12 or positive anti-transglutanimase antibody- refer to paediatrician or GI specialist
224
Orofacial Granulomatosis
Uncommon chronic inflammatory disorder
Idiopathic or associated with systemic granulomatous conditions
Average age of onset 11
Males>females
Characteristic pathology is no caseating giant cell granulomas which then result in lymphatic obstruction
May be predictor of future Crohn's
225
Clinical features of orofacial granulomatosis and Crohn's
Features of both are identical
Lip swelling - most common
Full thickness gingival swelling
Swelling of the non labial facial tissues
Peri-oral erythema
Cobblestone appearance of the buccal mucosa
Linear oral ulceration
Mucosal tags
Lip/tongue fissuring
Angular chelitis
226
Orofacial granulomatosis aetiology
Largely unknown
Limited evidence of genetic factors
Numerous associated allergens reported - cinnamon compounds, benzoates, much higher IgE mediated atopy rates compared to general population
227
investigations for OFG diagnosis
Measure growth
FBC
Haematinics
Patch testing to ID triggers
Diet diary to ID triggers
Faecal calprotectin
Endoscopy risky in childhood
Serum angiotensin converting enzyme (raised in sarcoidosis)
228
OFG management
Refer
OH support
Dietary exclusion
Manage nutritional deficiencies
Topical steroids
Topical tacrolimus
Short course oral steroids if severe or unresponsive to topical
229
OFG management
Refer
OH support
Dietary exclusion
Manage nutritional deficiencies
Topical steroids
Topical tacrolimus
Short course oral steroids if severe or unresponsive to topical
230
Most common mucosal lesion of the tongue in children
Geographic tongue
231
Geographic tongue
Shiny red areas on the tongue with loss of filiform papillae surrounded by white margins
Idiopathic non contagious
Can cause intense discomfort in children esp. with spicy food, tomato, citrus fruit/juice
232
Management of geographic tongue
Bland diet during flare ups
233
Common causes of sold swellings
Fibroepithelial polyp
Epulides
Congenital epulis
HPV associated mucosal swellings
Neurofibromas
234
Fibroepithelial polyp
Common
Firm pink lump
Mainly in the cheeks
Once established, constant size
Initiated by minor trauma
Surgical excision is curative
235
Epulides
Common solid swelling of the oral mucosa
Benign hyperplastic lesions
3 main types - fibrous epulis, pyogenic granuloma, peripheral giant cell granuloma
Related to chronic inflammation esp. calculus/plaque
More common in maxilla
Surgical excision to manage, as well as management of exacerbating factors
Majority anterior to molars
Tendency to reoccur
236
Fibrous epulis
Type of epulide
Similar to fibroepithelial polyp
Firm consistency
Similar colour to surrounding gingivae
237
Pyogenic granuloma/pregnancy epulis
Both types of vascular epulis
Identical - only difference pregnancy
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 such as calculus
Tend to recur
238
Peripheral giant cell granuloma
Type of epulide
Pedunculated or sessile swelling
Typically dark red and ulcerated
Usually arises interproximally and has an hourglass shape
Radiographs may reveal superficial erosion of interdental bone
Multinucleate giant cells in a vascular stroma
May recur after surgical excision
239
Congenital Epulis
Rare lesion
Occurs in newborns
Most commonly affect the anterior maxilla
F>M
Granular cells covered with epithelium
Benign
Simple excision is curative
240
HPV associated swellings
Verruca vulgaris
Squamous cell papilloma
241
Verruca vulgaris
Solitary or multiple intra-oral lesions
May be associated with skin wards
Caused by HPV 2 and 4
Most commonly on keratinised tissue - gingivae and palate
Most resolve spontaneously
Can be removed surgically
242
Squamous cell papilloma
Small pedunculated cauliflower like growths
Benign
HPV 6 and 11
Vary in colour pink/white
Usually solitary
Treatment - surgical excision
243
Mucocele
Cyst arising in connection with minor salivary glands
2 variations - normal secretions rupture into adjacent tissues mucous extravasation cyst or secretions retained in an expanded duct mucous retention cyst
Most - minor glands of the lower lip, can affect major or minor glands
Most will rupture spontaneously
Only surgically excise if lesion is causing distress or disturbance
Tendency to recur
244
Ranula
Mucocele in FOM arising from minor glands or ducts of sublingual/submandibular gland
Ultrasound or MRI needed to exclude plunging ranula
Occassionally found to be lymphangioma
245
Bohn's nodules
Gingival cysts seen commonly on the alveolar ridge of newborns
Remnants of dental lamina
Filled with keratin
Usually disappear by 3 months
246
Epstein pearls
Small cystic lesions found along mid palatal line common in newborns
Thought to be trapped epithelium in the palatal raphe
Usually disappear after first few weeks
247
TMJDS
Most common condition affecting TMJ redion
Characterised by pain, masticatory muscle spasm
Limited jaw opening
248
Extraoral exam of TMJDS
Palpation of the muscles of mastication at rest and when clenched to assess tenderness or hypertrophy
Palpation of the TMJ at rest and when opening and closing to assess tenderness and click
Assessment of opening for deviation and extent of opening
249
Normal jaw opening
40-50mm
250
Intraoral examination of TMJDS symptoms
Assessment of any dental wear facets
Signs of clenching/grinding - scalloped lateral tongue surface, buccal mucosa ridges
251
Management of TMJDS
Explain it is due to overworking and misuse of muscles
Management of stress
Avoid habits such as clenching, chewing, nail biting
Bite raising appliance considered if nocturnal grinding
Allow over worked muscles to rest - avoid wide opening, soft diet with little chewing
Ibuprofen for symptomatic relief, hot and col packs
