PAEDIATRIC DENTISTRY Flashcards
1
Q
What is the classification Frankl behaviour rating?
A
1 = Definitely negative = refusal of tx; crying; fearful
2 = Negative = reluctance to accept treatment; some evidence of negative attitude e.g. withdrawn
3 = Positive = acceptance of tx; cautiously but willing to comply at times with reservation; follows instructions
4 = Definitely positive = good rapport with
Dentist; interest in procedure; laughter.
2
Q
What is systemic desensitisation?
A
Graded exposure and relaxation to remove a fear response.
A person is gradually exposed to an anxiety-producing object, event, or place while being engaged in some type of relaxation at the same time in order to reduce the symptoms of anxiety.
3
Q
What are some anatomical features of primary molars? (8)
A
- Thin, uniform thickness of enamel (1mm)
- Smaller crowns with marked cervical constriction.
- Narrow occlusal table
- Broad contact points
- Large pulp, follows the external contour of the tooth
- Large mesio-buccal pulp horn
- Thin pulpal floor
- Early radicular pulp involvement
4
Q
How are permanent molars different to primary molars anatomically? (4)
A
- Variable thickness of enamel 2-3mm
- Thicker layer of dentine
- Proportionally smaller pulps
- Appear more ‘yellow’ or ‘brown’ due to enamel being less porous than primary teeth
5
Q
What are some implications of anatomy of primary teeth for restorations?
A
- Rapid caries progression -due to thinner enamel and dentine.
- Short clinical crowns make matrix bands difficult.
- Need to restore broad contact points
- Thin more porous enamel + less mineralised dentine means less tooth structure protecting pulp so pulp exposure more common and due to large pulp chamgers (especially mesial buccal pulp horn).
5, Mesio-buccal pulp horn large - exposure easy! - Long, flared roots make pulpectomy difficult!
6
Q
What alternative radiographs can be used if intra-orals not possible in children?
A
Oblique laterals or dental panoramic radiographs
7
Q
What is the radiation risk to the child compared to an adult?
A
- <10 years of age multiplication factor for risk is x3 (compared to a 30-year-old adult)
- Risk of harm due to ionising radiation is greater in children since their tissues are more radiosensitive and their life spans are longer.
- In general, young children are at about 2-3 times the risk of developing a radiation-induced cancer than adults in their thirties of the same effective dose.
- Radiation dosage should be kept as low as reasonably practicable (ALARP)
8
Q
What are the common forms of radiographs taken in children? (+ uses)
A
Bitewings – best for interproximal caries
PAs – useful for dental trauma
DPT – useful for assessing the development of the dentition (e.g. supernumerary and missing teeth)
Lateral obliques – only useful for the posterior teeth due to crowding and superimposition
Occlusal radiographs – can show trauma, unerupted teeth and pathologies.
9
Q
How much larger does the cavity appear clinically compared to the radiograph and what % demineralisation is required to see a radiolucency?
A
Appear 1/3 larger
50% demineralisation is required
10
Q
What are the main practical tips in taking radiographs in young children? (4)
A
Use smaller film sizes (e.g. sizes 0 for children 4-10 and size 2 for 10-12)
Use differing film holders depending on age (for 4-7 may use a tab, 7-10 use a holder and 10+ use a holder)
Use the modified bisected angle technique
Demonstrate the equipment prior to using it. Use simple language to engage children and distract them (TELL, SHOW, DO)
11
Q
In what order do the cranium vault, maxilla and mandible grow?
A
Cranium vault is completed before the maxilla, which is completed before the mandible
12
Q
What does the alveolar ridge look like at birth?
A
Well developed alveolar ridge with swellings containing primary teeth
13
Q
What is teething and what does it cause?
A
> Localised reddening of the alveolar ridges
Increased salivation
Discomfort and pain prior to eruption
14
Q
How do you manage teething?
A
Analgesics and soothing aids
15
Q
What is Dental Check by One?
A
National campaign to make sure everyone has examination by 1
16
Q
What do you do on the first visit to the dentist by age 1?
A
OHI and information regarding feeding, teething and habit assessment
17
Q
What do you do in the early visits to the dentist, by the age of 3 or younger?
A
Encourage to stop sucking habits by the age of 3 or younger to prevent long-term problems to developing dentition.
18
Q
Why is tooth wear important to examine and what advice do you give?
A
Young children bruxism = common
Important to establish if attrition or erosion (from diet/gastro-oesophageal reflux)
19
Q
Prominent labial frenulum is a common referral for very young children:
A
The normal fleshy labial frenulum is occasionally pronounced with a larger base attachment to the upper lip with fibrous band to the incisive papilla. Only a concern if eruption of incisors, OH/feeding affected.
20
Q
What are the clinical implications for 6-9 months?
A
Advice regarding tooth eruption, oral hygiene and teething
21
Q
What is separation anxiety?
A
The fear of being away from a primary caregiver – 8 months to 5 years
Object permanence
Tantrums and clinging = act out this fear
Triggers = new situation e.g. the dentist/dental chair, starting nursery/school.
22
Q
Name some types of behavioural management to use with children:
A
Tell-show-do: Give information - demonstrate - perform that part of the procedure
Playful humour: fun labels, turning procedures into stories
Distraction: Direct attention away from a behaviour, thought or feeling onto something else.
Positive reinforcement: Reward for a desired behaviour e.g. stickers
Modelling: Example the desired behaviour e.g. painting NaF varnish on a glove to show how to perform procedure. Siblings complete a dental exam
Shaping: Successive steps to a desired behaviour - lots of praise required
Fading: Providing external means to promote a positive behaviour and then gradually removing e.g. re- moving assistance to a situation over time
Systematic desensitisation: Gradual exposure therapy
23
Q
What is the epidemiology of caries in children from 2013?
A
½ of 8 and 15 year olds have obvious decay
1/3 of the 5 and 12 year olds
The proportion of 12 and 15 year olds with untreated decay into dentine (DT) also reduced, from 29% to 19% in 12 year olds, and from 32% to 21% in 15 year olds compared to the previous survey in 2003.
24
Q
What factors contribute to an individuals caries risk? (6)
A
Medical history
Plaque control
Dietary habits
Fluoride use
Clinical evidence
Social history
25
What features of a medical history make an individual high caries risk? (4)
> Medically compromised
> Physically disables
> Xerostomia
> Long-term cariogenic medicine
26
What congenital defects may result in a higher caries risk in children? (3)
Amelogenesis imperfecta – the incorrect formation of the collagen fibres in enamel results in pitted teeth which will trap food.
Cleft palate – results in plaque formation and food retention
Deep pits and and fissures – will trap food so often give fissure sealants
27
What clinical evidence may make someone high caries risk?
> New carious lesions
> Premature extractions
> Anterior caries/restoration
> Multiple restorations
> No fissure sealants
> Fixed orthodontic appliances – acts as a plaque retentive factor/traps food. Also makes cleaning more difficult.
28
What social factors may make someone high caries risk? (6)
> Social deprivation – can’t afford new brushes etc
> High caries in siblings/parents
> Low knowledge of dental disease
> Irregular attendance
> Readily available snacks
> Low dental aspirations
29
What is tooth moose and what does it do?
CPP-ACP = casein phosphate peptide amorphous calcium phosphate.
It acts as a calcium and phosphate reservoir on the teeth.
30
What is the definition of Early Childhood Caries (ECC)?
Presence of 1 or more decayed (non cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaced in any primary tooth in a child 71 months of age of younger
31
What is the most common pattern of ECC due to?
> BOTTLE FEEDING
> Teeth decay in the order they erupt, but the lower anterior teeth are usually spared. (tongue lies over central incisors when in mouth and salivary glands bathe these incisors and canines)
32
What are some common causes of ECC? (4)
> Bottle caries – due to infrequent consumption of a drink containing sugars in a bottle
> Long periods of exposure to cariogenic substrate
> Low salivary flow at night
> Parental history of active untreated caries
33
How is the pattern of caries distributed in ECC? (2 causes and 3 features)
Causes:
1. The bottle is often used as a pacifier to sleep – and often contains fermentable carbohydrates
2. May also occur with prolonged breast feeding – breast milk contains lactose which is a disaccharide of glucose and galactose.
Features:
A. Rampant caries affecting the maxillary anterior teeth
B. Lesions appear later on posterior teeth
C. Canines are usually less affected because of the later eruption (around 18 months) as well as the lower canines not being affected by bottle caries due to their position)
34
What is the difference clinically between rampant and bottle caries?
Rampant caries affect almost all teeth
Bottle caries or breast feeding – canines and lower incisors less affected.
35
What are the consequences of ECC?
Higher risk of new carious lesions
Increased tx costs and time
Risk for delayed physical growth and development – as don’t eat well.
Loss of school days and increased days with restricted activity.
Diminished oral health-related quality of life
Hospitalisation and emergency room visits.
36
How can ECC be prevented (6)
1. Reducing the parent’s/sibling’s S. mutan levels to decrease transmission of cariogenic bacteria
2. Minimising saliva-sharing activities
3. Implementing oral hygiene measures
4. Avoiding high frequency consumption of foods containing sugar
5. Encourage infants to drink from a cup by 1 yr
6. Weaning from the bottle – 12 to 18 months
37
How can ECC be managed clinically?
> Cessation of habit e.g. bottle caries – water down squash in stages
> Dietary advice
Fluoride application – varnish 22,600ppm
> Review OH practices, twice daily with a smear of 1000ppm F paste. At night nothing to eat or drink afterwards.
> Build up of restorable teeth
> Extractions if required – prevent infection
> Appropriate advice about ECC - do not blame!
> Often tx under GA is required
38
What is the aetiology of ECC?
Multifactorial
Related to frequent consumption of sugared drinks, often in a bottle or dinky cup
Night time usage is associated with increase caries as salivary flow falls and buffering is reduced
Even milk at night is a potential problem
If weaning is difficult, bottle feeding is prolonged as children require extra calories as they growh
Children who do not sleep well are often given a bottle as a “comforter”, breaking the habit can be very hard
Linear enamel defects, may also be associated with an increased risk (amelogenesis imperfecta, cleft palate)
Prolonged on demand breast feeding may also be associated with ECC – as breast milk contains 7% lactose
39
At the 4 months review for a high caries risk child, how will you know if you have been successful? (5)
Bottle has stopped (habit ceased)
OH practices have changed (as well as diet)
No progression of disease
No new lesions
Caries show signs of arrest (become black)
40
How often are radiographs taken in children according to caries risk?
Low = 18 months
Medium = 12 months
High = 6 months
41
What fluoride advise should be given for 0-3 year olds?
As soon as teeth erupt in mouth, brush them twice daily with a fluoridated toothpaste.
Brush last thing at night and on one other occasion.
Use fluoridate toothpaste containing no less than 1,000 ppm fluoride.
USE A SMEAR
42
Fluoride advice 3-6 year olds?
Brush 2 times per day, with a fluoridated toothpaste - more than 1,000ppm F and if high risk 1,350-1,500 ppm.
PEA SHAPED BLOB
Brush last thing at night and at least on one other occasion. Supervised brushing. Spit and don't rinse.
Apply fluoride varnish to teeth more than two times a year for high risk.
43
Fluoride for 3-6 year olds at high risk?
1,350-1,500 ppm F and apply fluoride varnish to teeth more than two times.
44
Fluoride advice 7+
Brush 2 times per day with fluoridated toothpaste more than 1,000ppm and if high risk 1,350-1,500 ppm.
Brush last thing at night and one other occasion. Supervised. Spit, no rinse.
Apply fluoride varnish to teeth more than two times a year for high risk.
45
Fluoride advice high risk 7+ year olds?
1,350-1,500ppm and apply fluoride varnish to teeth more than two times
Fluoride mouth rinse, 0.05% sodium fluoride daily rinse - specify most when use e.g. at lunchtime.
46
What is concentration of fluoride varnish applied to teeth?
2.2% NaF, 22,600ppm
47
What is the concentration of fluoride mouth rinse daily?
0.05% NaF
48
At what age and upwards do you prescribe daily fluoride rinse if they have active caries?
8 years upwards
49
For those 10+ years with active caries what concentration of fluoride toothpaste do you prescribe?
2800ppm or 5000ppm fluoride
50
What are the two types of sodium fluoride mouthwash that can be prescribed?
Sodium fluoride mouthwash 0.05% 10ml daily (preferred)
Sodium fluoride mouthwash 0.2% 10ml weekly.
51
What toothpaste can be prescribed for 10+ years old?
Duraphat toothpaste 2800ppm (0..619% NaF)
52
What toothpaste can be prescribed for 16+ years old?
Duraphat toothpaste 5000ppm (1.1% NaF)
53
When should you not use topical fluoride in patients? (3) (contraindications)
1. ulcerative gingivitis
2. stomatitis
3. history of admission to hospital because of allergy to colophony (including asthma)
54
What is the toxic dose of fluoride for GI upset?
approx 1mg of Fl per kg body weight
55
What is the toxic dose of fluoride for lethal poisoning?
32-64mg of Fl per kg of body weight.
5-10g of NaF for an average weight adult of 70kg.
56
How many mg F/g does 1000ppm and contain?
1mg F/g
57
A 2-year old weighing 10kg swallows 50g tube of 1000ppm
- amount of fluoride ingested?
- F dosage ingested mg/kg?
amount of fluoride = (1mg/g x 50g) = 50mg
F dosage ingested = 50/10 = 5mg/kg
58
What is the lethal dose of fluoride for a child?
16mg F/kg of body weight
59
What is the lethal dose of fluoride for an adult?
32mg F/kg body weight
60
What happens with tooth much fluoride?
- formation of hydrofluoric acid on contact with moisture (burns tissues with low pH value)
- blocks cell metabolism
- interference with calcium metabolism - (which inhibits nerve impulses or nerve functions)
- fluoride forms complexes with calcium leading to hypocalcaemia
61
What do you do if you suspect a child with fluoride overdose?
- get clear history - age and weight
- check condition of patient -> awake or alert
- calculate dose of fluoride per kg
- support vital signs
- calcium - milk or milk of magnesia
- give a glass of milk then sent to A&E
62
How do you manage if overdose <5mg/kg?
Give milk and observe for 4 hours
63
How do you manage if overdose is 5-15mg/kg?
Observe the pt and support vital signs.
Gastric lavage
64
How do you manage if overdose is >15mg/kg?
Calcium gluconate IV
Activated charcoal 1g/kg (max 50g) every 4 hours and gastric lavage
Cardiac monitoring
Life support
65
What is the mechanism for fluorosis?
- affect on enamel maturation by impairing mineral acquisition. Dental enamel will be hypermineralised with porosity of surface and subsurface in comparison with normal enamel. With dentine, tubules can have irregular shape and distribution and these effects will give an appearance ranging from mild to opaque patches of white or yellow to brown mottling of enamel also with pits of enamel fractures.
Can affect primary or adult teeth.
- more likely with high dose bolus or repeated low level
- greatest risk for central incisors 15-30 months
- coronal development completed at 6 years
66
What is the clinical appearance of fluorosis?
Mild = diffuse flecks/patches
Moderate = mottling/striations/yellow-brown
Severe = enamel hypoplasia (porous - less mineral, more proteins)
67
Fluoride in water should be regulated between what ppm?
0.5-1ppm
68
What are 4 common clinical indications for carious FPM?
1. Extensive caries
2. Hypomineralised molars
3. Apical pathology
4. Heavily restored 6's.
69
Should endodontic techniques be used in young permanent molars? Name 4 factors that make it hard?
1. LIMITED COMPLIANCE
> long appointments, LA, rubber dams, PA for working lengths, multiple appointments.
2. IMMATURE ROOT DEVELOPMENT
> root apices not completely closed. Wide apices make apical stops tricky.
3. LACK OF CLINICAL BENEFIT IN RETENTION
> would need repeated attention and restoration for rest of life
> extract and hope for spontaneous space closure.
4. START THE RESTORATIVE CYCLE
70
What 3 questions would you need to ask when making clinical decisions about a poor prognosis FPM? What 3 factors do you need to also look at?
1. Is it worth saving?
2. When should it be extracted?
3. Should any other 6's be extracted?
A. Patient factors. B. Dental factors. C. Orthodontic factors.
71
What are 3 options for managing compromised PFMs?
1. Extract
2. Retain: how?
3. Hold until 'ideal time' for removal.
72
What are some patient factors to consider when deciding tx for FPM caries?
1. Medical factors - bleeder, GA risk.
2. Symptomatic - are they in pain?
3. Behavioural factors/co-operation
4. Motivation, dental awareness
5. Oral hygiene
6. Cost - need to keep repairing throughout life, cost.
7. Patient/parent preference
73
What are some dental factors to consider when deciding tx for FPM?
1. Extent of lesion and restorability
2. Presence and condition of remaining dentition - need DPT!
3. Enamel defects - is it prone to further breakdown - amelogenesis imperfecta and MIH = restorations likely to fail.
4. Vitality - non-vital = extract.
5. Stage of dental development/dental age
74
When is the ideal time to extract FPM?
When the root bifurcation of the unerupted second permanent molars becomes visible = NEED A DPT.
Usually 8-10 years old (dental age 9)
The 7 will drift mesially and lose the gap to take the place of the 6.
75
What happens if you extract the FPM too early?
D and E will drift into space left by the 6. To lead to impaction of the 7s.
Distal drifting of the 4s and 5s.
76
What happens if you extract the FPM too late?
7s don't migrate mesially/no bodily movement mesially.
Therefore leaves a large gap where 6s were.
77
What are the orthodontic considerations when extracting the FPM? (3)
1. MALOCCLUSION - influences timing for removal
2. HYPODONTIA
3. NEED FOR ORTHODONTIC INPUT
- timing if future ortho tx anticipated
- elective extraction of other 6's.
78
What are the benefits of extracting FPM?
1. Immediate resolution of symptoms and infection.
2. "One-off" procedure with favourable cost:benefit ratio (if timed well)
3. Space created may be used to alleviate posterior crowding, reduce overjet, create space for eruption of 8's.
79
What are 4 disadvantages of extraction of FPM?
1. Loss of permanent tooth
2. May necessitate sedation/GA
3. Consequences of early/late extraction
4. Ortho treatment: increase tx time and complexity.
80
What are 3 restorative techniques for vital FPM with deep caries?
1. Indirect pulp capping (preferred)
2. Direct pulp capping
3. Partial pulpotomy
(direct pulp capping and partial pulpotomy are not ideal because teeth that require such large restoration in a young permanent tooth have a poor long-term prognosis.
81
What are the definitive restorative materials usually used for a FPM?
1. Composite and compomer
2. Cast onlay
82
What are the 2 options for non-vital FPMs?
1. RCT, full coverage restoration
2. Extract
(consider long term prognosis and cost)
83
How can you maintain the FPM when future loss is planned?
1. GIC: conventional, RMGIC
> for short term maintenance
> take of sensitivity
2. Stainless steel crown
(put in separator then try on crown).
84
What are the advantages and disadvantages of temporising a FPM with GIC?
Tolerant to moisture contamination, F- release and easy to place.
BUT
poor physical properties. NO full coverage: doesn't help with hypersensitivity
85
What are the advantages and disadvantages of temporising FPM with SSC?
Prevents further breakdown
Relieves sensitivity
Longevity
Relatively quick and inexpensive
Single visit
BUT
Can be technically more challenging
LA often required
Monitor eruption of the 7: potential impaction
Occlusion
86
What is the technique for placement of SSC on FPM?
1.+/- LA
2. Can place separators
3. May need some prep - round over line angles and proximal slice
4. Select crown size
5. Trim and crimp the gingival part of the crown and smooth roughened surface.
6. Isolate and cement.
87
What is MIH?
MIH is a CLINICAL DIAGNOSIS to describe hypomineralisation of SYSTEMIC ORIGIN of one or more of the four permanent first molars, frequently associated and AFFECTED INCISORS.
88
What is the prevalence of MIH?
2.8-40%, 1:6 children worldwide
89
How does MIH present?
Affects one or first permanent molars and/or incisors.
- Demarcated patches
- While-brown, cream
- Post-eruptive breakdown (may look like bits of tooth chipped off)
- Missing 6s due to early extraction.
- Heavily restored, abnormal restorations
- Calculus
90
When do the 1st permanent molars start of form and when do they calcify?
Start to form at 4/12 iu, calcifying at birth
91
What is the secretor phase of amelogenesis?
- Defines the form of the tooth
- Deposition of organic matrix plus small thin crystallites
- Incremental growth in thickness
- Not a continuous process
92
What is the maturation phase of amelogenesis?
Establishes the quality of the tooth
Degradation of organic matrix
Mineralisation
Ameloblasts move Ca2+ and PO43-
Process continues post-eruption
Apoptosis of the ameloblasts
93
What is hypoplasia (unhealthy enamel)?
Disruption of the SECRETORY PHASE
- early in development
- small pits and grooves
- gross enamel surface deficits
it is a reduced number of functioning enamel units (quantitative)
94
What is hypomineralisation (unhealthy enamel)
Disruption in the MATURATION PHASE
- Poor mineralisation of matrix
- Later in development
- White/brown opacities
- White thickness (As normal amount of enamel matrix secreted) but dubious quality of enamel)
95
What do you see down the microscope for hypomineralised enamel?
- Altered Ca/P ratio
- Less distinct enamel rods
- Bacterial penetration of enamel
- Lower hardness of enamel
96
What are 3 differential diagnoses for MIH?
1. Fluorosis
2. Amelogenesis imperfecta
3. Chronological hypomineralisation
97
How can you distinguish MIH from gross caries?
As all surfaces of the tooth will be affected rather than the surfaces usually susceptible to caries such as the occlusal and interproximal areas.
98
What are 4 other differentials to MIH and how can you tell the difference? (BEN)
FLUOROSIS
- chronic excessive fluoride exposure resulting in brown/cream staining. Can tell the difference as all the teeth will be affected unlike MIH.
AMELOGENESIS IMPERFECTA
- incorrect formation of enamel during the deposition stage resulting in pits and grooves. Will afftect all teeth unlike MIH.
TURNERS TOOTH
- an imperfection in the permanent tooth due to periapical disease in the overlying primary teeth caused by either caries or trauma and disrupts normal enamel development. Can tell the difference by noting and diagnosing periapical disease in the primary tooth.
IDIOPATHIC HYPOMINERALISATION
- no known or noted cause - can distinguish as no issues during pregnancy/birth/0-3 years old.
99
What are the underlying causes of MIH?
Results from an INSULT ENAMEL FORMATION from around 37 weeks to 3 years.
TRANSITIONAL AND MATURATION PHASE of enamel is affected - with qualitative disturbance to enamel formation.
MULTIFACTORIAL AND SYSTEMIC FACTORS such as:
> acute or chronic illnesses:
OR
> exposure to environmental pollutants:
--> during the last gestational trimester and first three years of lie
CHILDREN WITH PRENATAL, PERINATAL AND POSTNATAL PROBLEMS show more affected teeth in increasing order.
MULTIPLE POSSIBLE CAUSES:
- respiratory tract infections, perinatal complications, dioxins, oxygen starvation, low birth weight, calcium and phosphate metabolic disorders, frequent childhood diseases, use of antibiotics and prolonged breast feeding.
Possibility of a GENETIC ROLE in the aetiology of MIH, indicating that a genetic variation may interact with systemic factors leading to MIH.
100
How can you classify MIH?
MILD MIH = demarcated opacities located at non-stress bearing areas, no caries associated with the affected enamel, no hypersensitivity and incisor involvement is usually mild if present
MODERATE MIH = the demarcated opacities present on molars and incisors, the post-eruption enamel breakdown limited to one or two surfaces without cuspal involvement, atypical restorations can be needed and normal dental sensitivity
SEVERE MIH = post-eruptive enamel breakdown, crown destruction, caries associated with affected enamel, history of dental sensitivity and aesthetic concerns.
101
How is sensitivity a patient factor of MIH?
- greater innervation in subodontoblastic / pulp horn regions
- increased immune cell density
- increased vascularity in sensitive teeth
- porous enamel --> exposed dentine
- activation of A delta fibres
- underlying increase of C-fibre action.
102
How do A fibres and C fibres differ in feeling pain?
A fibres are mainly stimulated by an application of cold, producing a sharp pain.
Stimulation of C fibres produces a dull aching pain.
103
Describe type A delta fibres:
Detects FAST, localised, somatic pain.
Are the afferent fibres of nociceptors.
They carry information from peripheral mechanoreceptors and thermoreceptors to the dorsal horn of the spinal cord.
First order neurone.
Fast acting and transmit initial sharp pain.
104
Describe C fibres:
Slow conducting are responsible for prolonged burning and aching pain.
They are unmyelinated fibres.
C-fibres are activated only when the stimuli used reach the pulp proper. They respond to intense teating. In human teeth, dull pain is induced at a temperature level corresponding tot eh heat thresholds of intradental C-fibres.
105
What are the restorative factors are challenges for pts with MIH?
- colour
- bonding (less favourable etch pattern due to enamel structure)
immature dentine
- crumbly (weakened structure due to less enamel prisms)
- poor prognosis
- difficult to anaesthetise (hyperalgesic, due to increased vascularity in the tooth)
106
What are the possible causes of MIH? (BEN)?
early childhood illness (severe illness like put in hospital or antibiotics) between the age of 0-3
illness during pregnancy as tooth developments begins within the early foetal stages (5 weeks in utero)
illness/birth complications (whilst giving birth)
107
Name the tx options for molars with MIH? (6)
1. Surveillance
2. Recognition and review
3. Desensitisation - desensitising toothpaste CCP ACP (tooth mousse).
4. Temporisation - GIC, SSC.
5. Restore or extract
6. Orthodontic collaboration
108
How does tooth mousse work?
tooth paste is saturated with calcium and phosphate which is released when the pH is low.
109
What materials can you use for molar restorations in MIH patients?
1. Composite (requires good isolation and compliance)
2. Stainless steel crown (if all surfaces affected and only temporary)
3. Cast onlays: Ni/Cr or gold (if only occlusal surface affected).
110
What are the key points of stainless steel crowns? (MIH tx)
Good longevity
Easy to fit
Separators
Occlusal dimension settles
Gingival health and erupting 7s
111
What are the key points of fabricated onlays (MIH tx)
Well tolerated
Good longevity
No significant different between SSC and gold only at 2 years
Considered permanent
Lab bill
Time
112
What are the rules of balancing/compensating 6s?
Class 1 molars: compensate (balance if crowding)
> require a compensatory extraction of the upper 6
Class 2 molars:
> min crowding: extract upper 6 if likely to overerupt; maintain until 7s erupt if not; no balancing.
> crowding: compensate if upper 6 likely to overerupt; remove before or after 7s erupted; no balancing
> seek ortho advice
Class 3 molars:
> orthodontic advice to be sought; avoid balancing and compensating
113
What are the 4 aesthetic/repair tx options present in the tx of anterior teeth with MIH?
Microabrasion - for brown spot lesions
Bleach - used for white lesions but not used in practice
Composite - good as no tooth material removed
Bleach and composite.
114
How is micro abrasion carried out on anterior teeth with MIH?
Very useful on brown spot lesions
Material: rubber dam, etch the tooth and a rubber cap on handpiece
Isolate tooth with rubber dam. Apply etch. 10s application of the rubber cup 5 times (with a 1:1 mix of 17% phosphoric acid and pumice)
Provide fluoride toothpaste post treatment as will be very sensitive.
115
What is the success rate of micro-abrasions for MIH tx?
successful up to 4 years
116
What is the success rate of composite veneers for MIH tx?
86% up to 2.5 years
117
What is the success rate of micro-abrasion/bleaching and sealant for MIH tx?
successful up to 5 years.
118
What does the Vipeholm study of diet and dental caries show?
Shows sucrose in toffees caused more DMFT than liquid sucrose
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What did the dental caries experience of the children of Hopewood House show?
very low DMFT with very poor Oh but no caries, on strict low sugar diet in the house.
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When analysing diet dairy what do you look for?
Amount of sugar intake
Frequency of sugar intake
Frequency of snack intake
How food and drink are consumed.
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What fluoride toothpaste can you prescribe to 10+ year olds?
2800ppm F. Recommended twice daily.
122
What is the tooth selection criteria for applying fissure sealants?
Children and young people with:
- caries in primary teeth
- deep fissures susceptible to caries
- erupted sufficiently for adequate moisture control
- if occlusal caries affects one permanent molars, other permanent molars should be sealed.
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What must you do before applying fissure sealant to investigate tooth?
Bitewing radiographs to see if in fissures.
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How effective are fissure sealants at preventing caries?
Cochrane systematic review - found that first permanent molar teeth sealed with resin-based sealant had 78% less caries on occlusal surfaces after 2 years and 60% less after 4-4.5 years compared to unsealed molars.
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What materials can be used for fissure sealants?
Resin, GIC, compomer, Fluoride containing sealants
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When do primary central incisors erupt?
6-9 months
lowers --> uppers
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When do primary lateral incisors erupt?
7-10 months
lowers --> uppers
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When do primary first molars erupt?
12-16 months
all same time
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When do primary canines erupt?
16-20 months
lowers --> uppers
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When do primary secondary molars erupt?
23-30 months
lower --> uppers
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How long after eruption of primary teeth is root formation completed?
12-18 months after eruption (for adult dentition 2-3 years)
132
At birth how does the primary dentition occlude? (3)
- Gum pads occlude distally
- Anterior oval opening to allow suckling
- Fleshy labial frenum
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At 6-10 months how does the primary dentition occlude?
The maxillary incisors erupt labial to the mandibular incisors.
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At 36 months, how does the primary dentition occlude?
36 months - primary dentition complete
- incisors vertical and spaced
- deep overbite
- anthropoid spaces mesial to maxillary canines and distal to mandibular canines.
- flush terminal plane (straight line between distal edge of primary molars)
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At 6 years old, how does the primary dentition occlude?
Begin to lose primary teeth with the central primary incisors to go first.
- overbite degreases (permanent teeth are proclined)
- spacing of anterior teeth (make space for larger permanent teeth)
- attrition of incisors (wear and thinner enamel)
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What teeth erupt at 6-7 years old?
Lower 6s and 1s --> upper 6s --> upper 1s
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What teeth erupt at age 7-8?
Lower 2s
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What teeth erupt age 8-9?
Upper 2s
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What teeth erupt 9-11 years old?
Lower 3s
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What teeth erupt 10-12 years?
All 4s --> All 5s.
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What teeth erupt 11-12?
Upper 3s.
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What teeth erupt 11-13?
all 7s
143
What teeth erupt 17-25?
All 8s.
144
What happens when the first permanent molars erupt at age 6?
There is mixed dentition - occlusion
Eruption of the first permanent molar
Mesial migration of primary molars
Anthropoid spaces close
Permanent molars in class 1 or half class 2 relationship
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How does the mixed dentition occlude at age 7-8?
- Maxillary central incisors erupt spaced and more proclined than the primary predecessors.
- Maxillary lateral incisors are often distally inclined
- Maxillary incisors labial to mandibular.
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What is Leeway space and why is it important?
It is the difference between the combined mesiodistal width of the primary canine and molars and the permanent canine and premolars.
CDEs>345s
It is important as the extra space in the permanent arch is required for the larger permanent molars.
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How do the mixed dentition occlude at age 9-12?
Primary canines and molars exfoliate, permanent molars drift mesially into leeway space and form a class 1 relationship.
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What is a key check required at age 10?
Maxillary permanent canines should be palpable buccally by 10 years old - if not, DPT needed.
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What is a key feature of the mixed dentition at age 11-12?
The incisal spacing reduces as the maxillary canines erupt.
(The incisal spacing reduces as the maxillary canines erupt after the premolars causing the distally inclined laterals to return to normal position.)
--> if this origional spacing was not present then crowding may occur
150
What are natal/neonatal teeth?
Tooth like structures present at birth or erupt shortly after (1 month)
usually lower incisors.
usually part of the normal sequence but occasionally a supernumerary tooth.
should be removed if they are extremely mobile so cause an aspiration risk or if they are interfering with feeding or traumatising soft tissues.
(extraction within the first week are an issue as the body has not yet produced enough clotting factors etc so may require vitamin K so consult a specialist)
151
What can early loss of primary teeth cause?
It can cause delay or accelerate the eruption of the successor.
It can also cause space loss and crowding in the permanent arch due to teeth drifting to fill the space left (e.g. early loss of Es cause mesial drifting of the 6 causing the impaction of the 4/5 eruption)
152
What might a delayed exfoliation of primary tooth suggest?
The successor permanent tooth may be missing.
x-ray
153
What may occur if there is delayed exfoliation while the permanent tooth starts to erupt?
The permanent tooth starts to erupt lingually/palatally to the primary teeth as they are yet to exfoliate.
This is common and not usually an issue.
If the primary tooth fails to exfoliate upon further eruption of the permanent if may need to be extracted to make space for permanent dentition to prevent crowding.
154
When should you be concerned regarding eruption dates of teeth?
Eruption dates may vary but the SEQUENCE OF ERUPTIONS SHOULD NOT!
A non, erupting tooth 6 MONTHS AFTER THE ERUPTION OF ITS CONTRALATERAL (SAME ARCH) PARTNER is a concern and requires investigation.
155
Is attrition normal in primary teeth?
Yes. However significant surface loss and exposure of pulps is not. This is pathological non-carious tooth surface loss and the causes should be addressed.
156
Frequency of radiograph for high/moderate/low risk child?
High = 6 months
Moderate = 12 months
Low = 18 months
(permanent dentition 2 years)
(until no new or active lesions are apparent and has entered other risk category)
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Why bother restoring decay?
Eliminate disease
Restore health
Prevent pain
Avoid infection
Preserve space
Maintain function
Positive attitude to oral health.
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What is the crown morphology of primary teeth?
Narrow occlusal table
--> B-L width of cavity needs to be reduced
Broad flat interproximal contact areas
--> problems diagnosing caries
Thinner enamel and dentine layers
--> caries progesses to pulp more quickly
159
What are the advantages/disadvantages of resin based composites?
Adhesive. Aesthetic. Mechanical properties (wear resistance)
Technique sensitive (needs good moisture control). Expensive. Not preventive.
160
How does GIC self cure set?
one setting reaction:
- the acid base reaction between glass and poly (acid)
e.g. Fuji Ix - GC
Riva - SDI
Ketac Molat - 3M/Espe
161
How does GIC - resin modified set?
Dual cured
- the acid base reactions between glass and poly(cid)
- a ligh activated free radial polymerisation of methacrylate groups of the polymer
e.g. Fuji II LC
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What are the advantages/disadvantages of GICs?
Adhesive - conservative cavities
Aesthetic
Preventive (F-)
LC GICs - improved handing and command set
Mechanical properties, poor wear resistance, sensitive to moisture, durability.
163
Compomers - polyacid modified composites:
dual cured
- initial photopolymerisation
- followed by a conventional GIC set > will not set in the dark
> absorb moisture from saliva
> aesthetics and strength of resin
> fluoride leaching property of GIC
> sensitive to moisture but not as much as resin.
e.g.
- Dyract - Dentsply
- Compoglass - Ivoclar Vivadent - Hytac - Espe
- F2000 - 3M
164
Advantages/disadvantages of polyacrylic modified composites?
Adv - handling, radio-opaque, mechanical properties, F- release
Dis - polymerisation contraction, primer, economics.
165
What are the indications for stainless steel crowns? (4)
1. most inter-proximal cavities.
2. 2 or more carious surfaces.
3. All pulpally invovled primary molars - that have been root treated - good coronal seal
4. young children
166
What are contra-indications of stainless steel crowns? (4)
1. non vital tooth - extract
2. small occlusal cavities
3. older children <2 years
4. parental preference - aesthetics.
167
What are parental risk factors to a child? (safeguarding concern)
Substance misuse
Domestic violence
Mental health issues
Parental learning difficulties
Young parents
Parents own childhood
168
What are possible signs of abuse?
Behavioural signs
DNAs
Injuries in babies
Disclosure
Unkept malnourished child
Repeated injuries
Inconsistent history
Poor dental hygiene
Late presentation
Inappropriate sexual knowledge
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What is neglect? (children)
The persistent failure:
> To meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development
> To provide adequate food, clothing and shelter
> To protect a child from physical and emotional harm
> To ensure adequate supervision (including the use of inadequate care-givers)
> To ensure access to appropriate medical care or treat- ment
> It may also include neglect or non-responsiveness to a child's basic emotional needs
170
What patterns of bruising might suggest abuse?
Bruising or injuries in babies and children who are not independently mobile.
Bruises not on bony prominences
Bruising on soft tissues
Bruises to the face, back or abdomen
Multiple or clustered bruising
Imprinting from a pinch mark or that look like a recognisable object.
Symmetrical bruising
171
GMC guidance for safeguarding:
Justify why information is NOT shared
172
GDC standards:
Duty to protect patients
Disclosure of confidental information justified in certain circumstances.
173
What are the 6 typical features of complete primary dentition at completion (age 3)?
1. Spaced anterior teeth
2. Anthropoid spaces
3. Shallow overbite and overjet
4. Vertical inclination of incisors
5. Flush terminal plane
6. Ovoid arch form
174
What 4 changes occur in the primary dentition at age 6 as the mixed dentition starts?
1. Overbite decreases
2. Maxillary incisor attrition
3. Anthropoid spaces closed (due to eruption of 6)
4. Spacing of anterior teeth - even if not spaced before - 'ugly ducking' stage to create space for permanent dentition.
175
What is incisal liability?
The difference between the space needed for eruption of the permanent incisors and the space available.
It is accommodated by:
1. Anterior spacing in primary dentition
2. Growth of alveolus
3. Proclined eruptive path of upper permanent incisors.
176
What are 6 possible causes of median diastema rather than normal physiology (ugly ducking)?
1. Family/racial characteristic.
2. Unerupted supernumerary teeth
3. Basal narrowness of maxilla.
4. Small teeth and large jaws.
5. Developmentally missing lateral incisors.
6. Peg-shaped lateral incisors.
7. Excessive proclination of incisors.
8. Abnormal fraenum.
177
What does a mesial step in the terminal plane indicate for the eruption of the 6s?
The distal aspect of lower second primary molar is mesial to distal aspect of upper primary second molar
>> First permanent molars erupting directly into Class I molar relationship (or in extreme cases class III)
178
What does a distal step in the terminal plane indicate for the eruption of the 6s?
Distal step - the distal aspect of lower second primary molar is distal to distal aspect of upper primary second molar.
>> First permanent molars eruption into Class II molar relationship
179
What occurs during the inter-transitional phase between the ages of 9-10? (3)
1. Continued root development of erupted permanent teeth
2. Root resorption of primary canines and molars
3. Crown heights/emergence of teeth becomes symmetrical
180
What needs to be considered when taking a MH of child?
- medications
- hospital in-patient
- vaccinations
- does the RMH affect dental tx
- does the dental tx affect the RMH?
181
Why is it important to check if a pt is allergic to sticky plasters?
Colophony (rosin) is in sticky plasters and duraphat varnish. Contradindication.
182
What are 3 child specific questions to take during the pain history? (3)
Are they eating normally?
Are they sleeping normally?
How does the child usually cope with treatment? What was good, what was bad?
183
Questions about OH for children?
- how often and how long brush?
- what conc of fluoride?
- Rinse or spit after brushing?
- Is brushing supervised?
184
What are two key checks to make to ensure the childs teeth are developing normally and what age do they come about?
1. AGE 8 - ARE THE MAXILLARY CENTRALS ERUPTED?
2. AGE 10+ = CAN YOU PALPATE CANINES?
185
How do you do a grubby score?
Zigzag. Start with UR6, LR1, UL1, LL6.
Total score of 8 (4 teeth x buccal + lingual/palatal surface --> score 0 or 1)
186
hat happens if the child brushes on the day of dental visit but not other- wise - back up mechanisms called GUM SCORE
The same four teeth are assessed for gingival health on the same eight sites but according to the following scoring system:
healthy, pink, stippled gingiva - 0 marginal reddening, no swelling - 1 reddening with swelling - 2 bleeding on gentle probing - 3
The total for the eight sites is divided by eight to give a maximum of three. Plotting this score visit by visit, along with the Grubby score will explain the occasional lapses as well as the rel refractory cases.
187
What are the preventive measures used in paediatrics?
Oral hygiene advice
Fluoride toothpaste -
> under 3 = 1000ppm
> 3-7 = 1450 ppm for high risk > 10+ = 2800 ppm
> 16+ = 5000 ppm
Fluoride varnish 22,600ppm - apply at every visit up to 4 times a year (remember to say don't eat or drink 30 mins post application)
Fissure sealants - in high risk pt, if the 6s are through and caries free then will fissure seal. May want to seal the palatal pits of the incisors as well as the fissure of any other molars if caries is present in one 6
Diet analysis - use diet diary as an adjunct and ask crucial questions about snacking, bottles and breast feeding
188
What are the medical indications for pulp therapy in primary teeth?
1. Haemophilia/bleeding disorders
2. Conditions involving oligodontia/hypodontia
3. Patients 'at risk' if a GA is required for extraction.
189
What are the dental indications for pulp therapy in primary teeth? (4)
1. Restorable tooth and free of radicular pulpitis.
2. Strategic value of tooth (time to exfoliate)
3. Hypodontia
4. Orthodontic considerations (prevent loss of space)
190
What are the medical contraindications for pulp therapy?
1. Risk of infective endocarditis (congenital cardiac defects)
2. Immune compromise (oncology patient, uncontrolled diabetes)
191
What are dental or social contra-indications for pulp therapy?
1. Tooth close to exfoliating or un-restorable.
2. Extensive root resorption.
3. Acute infection/pathology.
4. Unreliable patient with poor compliance and unfavourable parental attitude.
5. Unable to complete treatment in chair.
192
What are symptoms of reversible pulpitis?
1. provoked pain
2. disappears on removal stimulus
3. short duration
4. relieved with analgesia
5. 'sharp' pain
193
What are symptoms of irreversible pulpitis? (6)
1. spontaneous
2. constant
3. long duration
4. not always relieved with analgesia
5. 'dull throbbing ache'
6. sleep disruption
194
What is indirect pulp treatment?
Carious dentine is deliberately left at the floor of a deep carious lesion to avoid a carious pulp exposure.
Goal is to arrest caries, allow for formation of reactionary dentine, promote healing and maintain vitality.
195
What are the indications for indirect pulp treatment?
1. Vital tooth which is asymptomatic or has symptoms of reversible pulpitis.
2. No radiographic signs of pathology (peri-radicular radiolucency, pathological root resorption)
196
Describe the procedure of indirect pulp treatment?
Remove caries from EDJ with slow speed round bur, remove softened dentine leaving behind some caries on. the floor of the pulp chamber to avoid exposure. May place a line, then restore.
Note that Hall technique is a form of IPT: no caries removal and restore with SSC.
197
What is the definition of a direct pulp cap?
Placement of medicament directly on the site of pulp exposure with the aim of encouraging dentine bridge formation at the point of pulp exposure and preserve vitality.
198
What are indications for direct pulp capping?
Not indicated for carious primary molars (very poor success rates)!!!
Place medicament, usually Ca(OH)2 directly on site of exposure, then restore with good coronal seal.
199
What is the definition of pulpotomy?
Removal of inflamed coronal pulp leaving behind vital, non-inflamed radicular pulp, followed by placement of a medicament and finally a restoration.
Medicaments: ferric sulphate, MTA, and "biodentine".
Goal is to maintain vitality of the tooth.
200
Indications for a pulpotomy?
1. Vital tooth which is asymptomatic or has symptoms of reversible pulpitits
2. Where there has been a carious or mechanical pulp exposure.
201
Indirect pulp capping, direct pulp capping and pulpotomy are contra-indicated if what? Describe these signs.
These treatments are contraindicated if there are signs of symptoms suggestive of irreversible pulpitis or pulp necrosis.
Clinical signs: abscess, sinus, TTP, pathologic mobility.
Radiographic signs: inter-radicular radiolucency, pathological root resorption, extensive caries, extending to the floor of the pulp chamber or subgingivally.
202
This child has only recently developed symptoms of sensitiv- ity with cold from the ULD. No other pathol- ogy is evident clin- ically or on periapi- cal radiograph. How would you classify the pulp status of this tooth and what treat- ment options are avail- able to manage it?
Reversible pulpitis:
reatment options
1) Dressing in stabilization phase (as a temporary/emergency measure)
2) Restore with Hall crown (only if no symptoms or symptoms of reversible pulpitis): This is indirect pulp therapy
3) Caries removal (+/- pulp therapy) and restoration (ideally with PMC)
The preferred treatment for this tooth would be a Hall technique preformed metal crown.
203
Suppose you chose to remove caries prior to restoration and the pulp was exposed dur- ing caries removal. De- scribe the treatment that should be initiated and the steps involved?
When the pulp is exposed, you should complete
a pulpotomy (FS pulpotomy). If haemostasis is not achieved during pulpotomy, then extraction or pulpectomy is indicated, as the radicular pulp is irreversible inflamed.
Note that direct pulp capping is contra-indicated in primary molars due to very poor success rate.
204
Would your treatment be different if this child had a congenital cardiac defect? (mechanical exposure of pulp)
Pulpotomy contraindicated in children with cardiac defects (risk of precipitating IE if residual foci of infection). If the pulp was exposed, extraction would be indicated.
205
What are the two options for a necrotic pulp in primary molar?
Extraction and pulpectomy.
206
Pulpal inflammation occurs at an earlier stage of the caries process in primary molars compared with permanent teeth. Why?
Primary teeth have thinner and more porous enamel plus less mineralised dentine which favours rapid progression of lesions.
Also they have large pulp horns closer to enamel surface in primary teeth.
207
Suggest reasons for failure of the restoration on the LLD
Problems associated with class II restorations in primary molar teeth can occur due to the anatomy of the teeth (cervical constriction etc), inadequate enamel cervically for bonding, gingival floor of cavity preparation is subgingival, enamel
structure of primary teeth yields less favourable etch patterns etc.
In addition there are patient factors that complicate restorative treatment in young children, such as limited co-operation, poor moisture control and the difficulties posed when LA not used (limits cares removal and pain during treatment contributes to loss of co- operation).
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