Paediatric dentistry

Question 1

What is the average eruption date for As?

Answer 1

6-9 months

Question 2

What is the average eruption date for Bs?

Answer 2

6-9 months

Question 3

What is the average eruption date for Cs?

Answer 3

16-18 months

Question 4

What is the average eruption date for Ds?

Answer 4

12-14 months

Question 5

What is the average eruption dates for Es?

Answer 5

20-30 months

Question 6

What is the average eruption date for upper 1s?

Answer 6

7-9 years old

Question 7

What is the average eruption dates for lower 1s?

Answer 7

6-8 years old

Question 8

What is the average eruption date for upper 2s?

Answer 8

7-9

Question 9

What is the average eruption dates for lower 2s?

Answer 9

6-8 years old

Question 10

What is the average eruption date for upper 3s?

Answer 10

11-12 years old

Question 11

What is the average eruption dates for lower 3s?

Answer 11

9-10 years old

Question 12

What is the average eruption date for upper 4s?

Answer 12

10-11 years old

Question 13

What is the average eruption date for lower 4s?

Answer 13

10-12 years old

Question 14

What is the average eruption date for upper 5s?

Answer 14

10-12 years old

Question 15

What is the average eruption date for lower 5s?

Answer 15

11-12 years old

Question 16

What is the average eruption date for upper 6s?

Answer 16

6-7 years old

Question 17

What is the average eruption date for lower 6s?

Answer 17

6-7 years old

Question 18

What is the average eruption date for upper 7s?

Answer 18

11-13 years old

Question 19

What is the average eruption date for lower 7s?

Answer 19

11-13

Question 20

What is the average eruption date for upper 8s?

Answer 20

17-21 years old

Question 21

What is the average eruption date for lower 8s?

Answer 21

17-21 years old

Question 22

What are preventive strategies for ECC?

Answer 22

1. Diet modification
2. Oral hygiene instructions
3. Fluoride TP
4. Fluoride varnish
5. Fissure sealants
6. Adjust review interval and RGs.
7. Prevention of transmission of S. mutans
8. CPP-ACP

Question 23

How can you explain tooth decay (dental caries) simply?

Answer 23

Tooth decay is damage to a tooth that happens when decay-causing bacteria in your mouth make acids that attack the tooth’s surface, or enamel.
This can lead to a small hole in a tooth, called a cavity.
If tooth decay is not treated, it can cause pain, infection, and even tooth loss.

Question 24

How can you explain caries, more complicated.

Answer 24

Caries is caused by fermentation of carbohydrate to organic acids by microorganisms in the plaque.
This causes rapid acid formation and a drop in pH below the critical level, leading to enamel being dissolved.
Caries happens when demineralisation is greater than remineralisation.

Question 25

What can make a pt high caries risk?

Answer 25

1. Medical history: disabled, xerostomia (could be due to polypharmacy), medically compromised, cariogenic medicine.
2. Dietary habits: frequency and volume of sugar intake
3. Clinical evidence: development of new carious lesions
4. Plaque control: oral hygiene (grubby score)
5. Use of fluoride: no toothpaste, fluoride varnish, chlorhexidine use.
6. Social history: low SES, parental caries, mixed home living situation, parental risk factors, poor attendance, low motivation, pain driven attendance.

Question 26

What are the 4 pillar os dental caries prevention?

Answer 26

1. Plaque control
2. Diet
3. Fluoride
4. Fissure sealants

Question 27

What are non-fluoride prevention methods? (6)

Answer 27

1. Diet modification
2. OH and dental health education
3. Fissure sealants
4. Sugar free medicine
5. Chewing gum contain xylitol
6. Chlorhexidine

Question 28

What are the zones of enamel caries? (4)

Answer 28

1. Translucent zone
2. Dark zone
3. Body of lesion
4. Surface zone

Question 29

What are the 4 zones of dentine caries?

Answer 29

1. Zone of sclerosis (vital reaction of odontoblasts to irritation)
2. Zone of demineralisation
3. Zone of bacterial invasion
4. Zone of destruction

Question 30

What medical history can make a pt high caries risk? (4)

Answer 30

Medically compromised
Physical disability
Xerostomia
Long-term cariogenic medication

Question 31

What dietary habits can increase caries risk? (2)

Answer 31

Frequent sugar intake
Frequent between-meal snacking

Question 32

What clinical evidence can make someone high caries risk? (6)

Answer 32

• New carious lesions
• Premature extractions
• Anterior caries/restoration
• Multiple restorations
• No fissure sealants
• Fixed orthodontic appliance

Question 33

What plaque control can cause high caries risk? (2)

Answer 33

• Infrequent and/or inefficient cleaning
• Poor manual control

Question 34

What fluoride use cause high caries risk? (3)

Answer 34

• Drinking water not fluoridated
• No/low fluoride toothpaste
• No fluoride supplements

Question 35

What social history can cause high caries risk? (6)

Answer 35

1. Social deprivation
2. High caries in siblings/parents
3. Low knowledge of dental disease
4. Irregular attendance
5. Readily available snacks
6. Low dental aspirations

Question 36

How should a diet be modified to reduce caries risk?

Answer 36

Reduction in extrinsic sugar intake, both in frequency and volume. Especially non-milk extrinsic sugars.

COMA report 1989. Committee on medical aspects of food policy. They conclude that caries is positively related to frequency and amount of NME (non-milk extrinsic) sugar consumption

• Frequency and amount of sugar should be reduced and restricted to mealtimes only
• Limit consumption of foods and drinks with added sugar to max 4x day (Vipeholm)
• Sugars should provide <10% of total energy in the diet or <60g per day
• Drink only water and milk outside mealtimes
• Snack on sugar free foods (cheese and carrot sticks etc)
• Nothing to eat or drink after brushing

Question 37

What 2 studies can you recall for the relationship of sugar on dental decay?

Answer 37

1. Vipeholm Study of Diet and Dental Caries
2. Dental Caries Experience on the Children of Hopewood House

Question 38

Why can selection of non-cariogenic food be difficult?

Answer 38

Sugar content labelling not always clear
Access to healthy food
Sugar industry resources for marketing are vast
Few families stick to the 3 square meals day trend and tend to graze throughout

Question 39

What evidence is there to support brushing preventing caries?

What advice should you give?

Answer 39

Little evidence to support tooth brushing prevents caries but fluoride toothpaste is of benefit.

• Plaque forms on uncleaned tooth surfaces and is apparent after 2-3 days of no brushing
• Tooth brushing 2x day with 1000ppm fluoride paste
• Spit toothpaste out and do not rinse with water
• Children <2 should use a smear of toothpaste
• Children aged 2-7 should use small pea sized quantity of toothpaste (1350-1500ppm)

Question 40

What is the purpose of fissure sealants?

Answer 40

Material placed in the pits and fissures of teeth to prevent caries development on occlusal surfaces of permanent molars.

Should be placed on all child patients despite the state of caries risk (in accordance to SDCEP 2018)

Question 41

Who should have fissure sealants? Tooth selection?

Answer 41

Should be placed on all child patients despite the state of caries risk (in accordance to SDCEP 2018)

Patient selection = children and young people with impairments and or caries in primary teeth

Tooth selection
- Deep fissures susceptible to caries
- Erupted sufficiently
- Adequate moisture control achievable
- One permanent tooth has occlusal caries then all other permanent molars should be sealed

• First permanent molars
• Palatal pits of permanent lateral incisors.

Question 42

How do you place a fissure sealant?

Answer 42

1. Investigate a stained fissure before sealing (radiograph and visual inspection), and then isolate.
2. Etch with 30-40% phosphoric acid for 20-40 seconds.
3. Wash and dry the tooth
4. Place the fissure sealants and cure for 20 seconds.

Question 43

What are the types of fissure sealants?

Answer 43

Resin
GIC, useful in high caries individual as temp sealant and partially erupted teeth where isolation is an issue (Fuji Triage - no isolation, no bonding required, high F- released (6x more than normal GIC, released F- up to 24 months), there is a conditioner and coating which can be used after application of Fuji Triage)
Compomer
Fluoride containing sealants

Question 44

What type of medicine should be prescribed to children to prevent decay?

Answer 44

Clinicians should prescribe sugar-free medicines whenever possible and should recommend the use of sugar-free forms of non-prescription medicines

Question 45

How does chewing gum have anti-caries properties?

Answer 45

Chewing gum containing xylitol and sorbitol have anti-caries properties through salivary stimulation.

Xylitol: studies have demonstrated that substitution of xylitol for sugar in the diet results in much lower caries increments. Dietary advice to patients should encourage use of non-sugar sweeteners.

Note: Sugar-free does mean calories free. There is a calorific value which needs to be taken into consideration. Xylitol is a form of polyols, it doesn’t get metabolised by the oral bacteria but also does not get break down in the GIT, hence excessive consumption can lead to laxative effect.

Question 46

Can Chlorhexidine be used for caries reduction?

Answer 46

Chlorhexidine prophylaxis in the form of a rinse, gel or paste can achieve on average 46% reduction in caries.

Careful! Anaphylaxis and staining!

Question 47

At what age can fluoride mouth rinse daily (0.05% NaF) be prescribed?

Answer 47

Age 8

Question 48

What is fluoride MoA?

Answer 48

Low concentration of F in saliva, creating fluorapatite crystals.
Critical pH 5.54
Resistant to acid dissolution, decreasing the rate of demineralisation

“Fluorapatite is more resistant to acid than hydroxyapatite, with a critical pH of 4.5 compared to 5.5 for hydroxyapatite.”

“Fluoride can protect teeth from acid erosion by replacing some of the carbonate and hydroxide in enamel with fluoride ions. This makes the enamel surface partially fluorapatite, which is more resistant to acid.”

Question 49

What are different fluoride application tools?

Answer 49

Toothpaste
Mouthwash
Varnish (22 600 ppm)

Question 50

What are the fluoride requirements for all children up to 3?

Answer 50

As soon as teeth erupt:
- Smear of toothpaste
- containing at least 1000ppm fluoride
- twice a day
- last thing at night and on one other occasion

Question 51

What fluoride requirement for all children aged 3 to 6?

Answer 51

Brushed by parent or carer/assisted when get older:
- pea sized amount with toothpaste
- containing at least 1,000 ppm fluoride
- spit out after brush
- 2xday (last thing at night and on at least one other occasion)

Apply fluoride varnish (2.26% NaF) to teeth 2 times a year

Question 52

What fluoride requirement for high caries risk children aged up to 6?

Answer 52

Use toothpaste containing 1,350 to 1,500 ppm fluoride

Apply fluoride varnish (2.26 NaF) to teeth 2 or more times a year

Question 53

What are the fluoride requirements for children 7 to 18 years old?

Answer 53

Toothpaste 1,350 to 1,500 ppm.

Apply fluoride varnish to teeth 2 times a year (2.26% NaF)

Question 54

What are the fluoride requirements for high caries risk children 7 to 18?

Answer 54

From age 8: Prescribe fluoride mouth rinse (0.05% NaF; 230 ppmF) at a different time to brushing until dental caries risk is reduced.

From age 10: Prescribe 2800 ppm fluoride toothpaste until caries risk is reduced.

From age 16: Prescribe 2,800 or 5,000 ppm fluoride toothpaste until dental caries risk is reduced.

Apply fluoride varnish to teeth 2 or more times a year (2.26%)

Question 55

What is the risk of enamel mottling by age? 0-4, 4-6, 6+?

Answer 55

0-4 years, child at risk of fluorosis on permanent incisors and first molars (15-30 months is susceptibility window)

4-6 years, premolars and second permanent molars are calcifying and maturing, less aesthetic risk of mottling

6+ years, risk for enamel mottling is negligible, with exception of third molars.

Question 56

Which patient should you not use topical fluoride varnish (2.26% NaF, 22,600ppm)?

Answer 56

Ulcerative gingivitis
Stomatitis
Allergic responses

Question 57

What can fluoride overdoses cause and at what quantity?

Answer 57

Acute overdose
Fluorosis
Toxic dose

GI upset approx: 1mg F/kg

Lethal poisoning 32-64 F/kg

Too much F causes cell
metabolism to be blocked,
calcium metabolism to be interfered and reductions in nerve-impulse and conduction.

Symptoms of toxic dose of Fluoride:
- Nausea, vomiting and diarrhoea
- Excess salivation, tears, mucus and sweat (endocrine production increased)
- Headache
- General weakness and malaise

Question 58

What is the management of fluoride overdose?

Answer 58

<5mg/kg, give milk and monitor for 4 hours

5-15 mg/kg, send to A&E, observe vital signs, gastric lavage given and milk

> 15mg/kg, send to A&E immediately, calcium gluconate IV, with activated charcoal 1g/kg every 4 hours, as well as gastric lavage and cardiac monitoring.

Question 59

What can fluorosis appear like?

Answer 59

Mild: diffuse flecks and patches
Moderate: mottling, striations and yellow-brown appearance
Severe: enamel hypoplasia

Question 60

What are the quantities of fluoride varnish that should be applied at a time, depending on the dentition?

Answer 60

• Primary dentition: Up to 0.25 mL of varnish per application
• Mixed dentition: Up to 0.40 mL of varnish per application
• Permanent dentition: Up to 0.75 mL of varnish per application

Question 61

What is early childhood caries?

Answer 61

Presence of one or more decayed, missing or filled tooth surface in any primary tooth in a child 71 months or younger.

Question 62

What are 4 causes of early childhood caries?

Answer 62

1. Frequent bottle feeding = tooth decay in the upper anterior dentition
2. Long exposure to cariogenic substrate (e.g. bottle at night)
3. Low salivary flow rate at night
4. Parental history of active untreated caries.

Question 63

What is prevention of ECC?

Answer 63

Reduce saliva sharing activities due to transmission of S.mutans, cariogenic bacteria.

Oral hygiene measures.

Avoid high frequency sugar consumption.

Infants drink from a cup by 1 year.

Question 64

How do you manage ECC?

Answer 64

Cessation of habits causing ECC

Diet modifiecation

Fluoride application via smear of 1,000 ppm F (1350 > 3yo) and duraphat

XGA where required

Restorations where required

Question 65

What are reasons for restoring ECC?

Answer 65

Eliminate disease
Restore health
Prevent pain and infection
Preserve space
Maintain function
Positive attitude

Question 66

What are the risks if ECC is left untreated?

Answer 66

If not treated can cause pain, sepsis, functional problems and issues with schooling.

Question 67

How does paediatric crown morphology impact caries detection, spread and restoration?

Answer 67

Crown morphology:

Narrow occlusal table mean B-L width of cavity needs to be reduced.

Broad flat interproximal areas cause issues diagnosing caries (10% caries in 10-year old is interproximal)

Thin enamel and dentine layers mean caries progresses to pulp rapidly.

Large pulp horn (MB) pulp horn means risk of pulp exposure greater.

Question 68

What is operative management dependent on in children?

Answer 68

• Child’s ability to cope with treatment
• Family support for prevention
• Presence of infection
• Number and size of lesions
• Time to exfoliation of the primary teeth

Question 69

What factors affect restorative material choice in children?

Answer 69

1. Patient factors - caries status, general health, parafuntion, age, diet and cooperation.
2. Tooth factors - location, cavity design, if pulpal involvement, dentition, occlusal load and tooth quality
3. Operator factors - material properties, quality of finish, moisture control, expertise and anaesthesia

Question 70

Which dental materials for direct restorations are used in children?

Answer 70

Amalgam is not used in paediatrics due to worries over toxicity, safety and aesthetics.

Composite is favoured under rubber dam

RMGIC and compomers are used regularly is no rubber dam available.

Question 71

When are SSC / Hall crowns / Hall technique favoured?

Answer 71

Indication: used for most inter-proximal cavities with 2 or more carious surfaces.

Contraindications: non-vital tooth, irreversible pulptitis, not enough tissue structure to retain crown, patient risk of bacterial endocarditis, small occlusal cavities, teeth close to exfoliation and aesthetics concerns, uncooperative child, pathological mobility, buccal sinus, dental abscess.

Question 72

What is the anatomy of primary molars?

Answer 72

Thin uniform enamel thickness (1mm)
Smaller crowns with marked constriction
Narrow occlusal table
Broad contact areas
Large pulp and large mesio-buccal pulp horn
Thin pulpal floor
Early radicular pulp involvement

Question 73

What are difficulties for restorative dentistry in primary dentition?

Answer 73

• Rapid caries progression.
• Short clinical crown makes matrix bands and isolation difficult.
• Need to restore broad contact points.
• Thin enamel with less tooth structure protecting the pulp, can be difficult to restore without pulpal involvement.
• Easy to expose mesio-buccal pulp horn, requires use of shouldered or round diamond bur when investigating fissure present.
• Pulpectomy difficult due to long, flared roots.

Primary teeth can be restored effectively if anatomy is considered when choosing the material and technique

Question 74

What type of radiograph is favoured for children?

Answer 74

Intra-oral radiography is the first choice for young children in deciduous and mixed dentition.

Increase of 1.5-8 for number of carious lesions detected on radiograph compared to just visual examination when all risk groups are considered.

Oblique laterals or dental panoramic radiographs (DPT)
- <10 years of age multiplication factor for risk x3 compared to a 30-year-old adult.

Question 75

By what factor and why is ionising radiation risk more harmful to children?

Answer 75

<10 years of age multiplication factor for risk 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

ALARP principle should be employed

Question 76

Selection criteria for dental radiography

Answer 76

• Radiographs should be preceded by a clinical exam to be justified
• Assignment of caries risk should be prior to radiograph
• Obtain any previous radiographs
• Referral to specialist treatment should be alongside radiographs
• Bitewings have significant diagnostic yield even in absence of clinically detectable decay

Question 77

What are the EAPD guidelines for bitewing radiography?

Answer 77

High caries risk = 6-month intervals, or until no new or progressing lesions are evident.

Moderate caries risk = posterior bitewings at one-year intervals

Low caries risk = 12-18 month intervals in primary dentition, 2-year intervals in mixed and permanent dentition.

Question 78

Why is a radiographic assessment needed for general anaesthesia (GA)?

Answer 78

Tx planning for children requiring GA should be comprehensive to avoid the risk of repeat anaesthesia, radiographic assessment must be completed for this.

If no radiograph is taken before GA then this can cause smaller, restorable cavities that my have been undiagnosed pre-referral and consequently:
- more teeth were extracted
- GA was delayed facilitating further restorations.

Question 79

What are indications for radiographs in children?

Answer 79

• Detection of caries in primary, mixed and permanent dentition with approximal contacts
• Dental trauma
• Disturbances in tooth development and growth
• Examination of pathological conditions

Question 80

What are limitations to radiographs in diagnosis of caries in children?

Answer 80

• Age and cooperation limitations
• Anatomical difficulties (narrow arch and shallow palate)
• Occlusal caries may not be visible
• May have overlap

Question 81

What are practical tips for child radiography?

Answer 81

• Use size 0 film or phosphor plate with a tab for children aged 4-7
• Use size 0 film or phosphor plate with a holder for children aged 7–10 years
• Use size 2 film or phosphor plate with a holder for children in the mixed dentition age 10-11 and when the second molars have erupted aged 12

Question 82

What % do pit and fissure lesions account for in new lesion in adolescents?

Answer 82

Pit and fissure lesions account for 85% of all new lesions in adolescents, fluoride has helped in smooth surface lesion.

Question 83

What are risk factors for caries in young permanent dentition?

Answer 83

• Early permanent dentition still calcifying and mineralising more at risk.
• First year post eruption
• Partially erupted and difficult to access teeth, hard to clean
• Deep fissures
• Enamel hypoplasia or hypo calcification

Question 84

What are the pros and cons of resin vs GIC sealant?

Answer 84

Resin sealant
- Better retention
- Technique sensitive
- Longer time to apply
- Acts as barrier for bacteria

GIC sealant (Chemfil superior or Fuji Triage)
- Poorer retention
- Easier application
- Short time to apply
- Release of fluoride

Question 85

What are different restorative material options for operative caries management? (site lesion, depth and choice of restoration)

Answer 85

> Occlusal fissure and enamel caries = fissure sealant and prevention

> Occlusal D1 caries = preventive resin restoration

> Occlusal D3 caries = composite resin

> Interproximal caries = composite or amalgam

> Incisal edge caries = composite

> Cervical caries = composite, RMGIC

Question 86

What is a preventive resin restoration? (PRR)

Answer 86

Conservative removal of existing carious tissue from the fissure, whilst preventing further decay.

• Requires LA, rubber dam and a clean occlusal surface.
• Fissure is investigated using a small high-speed diamond bur
• Caries identified and removed from ADJ, no other extension into unaffected fissures is carried out
• Place thin layer of bonding resin, then restore cavity with composite
• Fissure sealants placed on all occlusal surface
• Occlusion checked

Question 87

What is a GIC sealant restoration (GSR)?

Answer 87

Glass ionomer cement used to replace dentine

Rationale = improved chemical bond and fluoride leaching prevents further decay

Question 88

When may a restoration fail?

Answer 88

Secondary caries
Fracture
Marginal deficiencies
Wear
Post-operative wear and sensitivity

Question 89

What are deep caries management? (not sure about this content, check!)

Answer 89

Crowding = ortho, applies to both painful and non-painful lesions

No crowding and pain
> Pulpitis = pulpotomy
> Non-vital = RCT

No crowding and no pain = indirect pulp cap with coronal seal (Cvek)

Question 90

What is stepwise caries removal?

Answer 90

Stepwise technique - you leave caries behind, seal on top, wait about 6 months, go back in and remove the rest of caries. This this is a temporary measure.

Question 91

What is Frankl behaviour rating scale?

Answer 91

1. Definitively negative = refusing treatment, forceful crying, fearful
2. Negative = reluctance to accept treatment, evidence of negative attitude
3. Positive = accepting treatment, cautious, willing to comply, reservations, follows instructions
4. Definitely positive = good rapport with dentist, interest in procedure, laughter and enjoyment

Question 92

What is the BSPD classification for behaviour?

Answer 92

Lacking cooperative ability, very young or with specific disabilities
Potentially cooperative
Cooperative

Question 93

What is the Houpt scale for behaviour?

Answer 93

Crying
1. screaming
2. continuous crying
3. mild, intermittent crying
4. no crying

Cooperation
1. violently resists/disrupts treatment
2. movement makes treatment difficult
3. minor movement/intermittent
4. no movement

• Apprehension
  1. Hysterical/disobeys all instructions
  2. Extremely anxious/disobeys some instructions/delays treatment
  3. Mildly anxious, complies with support
  4. Calm/relaxed/follows instruction

Sleep
1. Fully awake
2. Drowsy
3. Asleep/intermittent
4. Sound asleep

Question 94

What are non-pharmacological behaviour management techniques?

Answer 94

Tell-show-do
Voice control
Modelling (learn through observation)
Enhance the child’s control, give them the option for a stop signal and choose which tooth to seal first.
Distraction techniques
Negative reinforcement, strengthening behaviour by removing a stimulus perceived to be unpleasant.
Positive reinforcement
Desensitisation
Clinical holding
Restraint
Hypnosis
Snoezelen environment for people with autism, dementia, brain injury and learning disabilities.

Question 95

What are pharmacological behaviour techniques

Answer 95

Sedation, such as oral, inhalation and IV

General anaesthesia

Question 96

What are fundamentals of behaviour management?

Answer 96

Child centred approach
Positive attitude
Work as a team
Organisation
Honesty
Flexibility

Question 97

What is Molar-incisor hypomineralisation (MIH)?

Answer 97

Hypomineralisation of systemic origin of the permanent first molars, as well as affected incisors.
- Affects one of more of the first permanent molars and/or incisorsW

Question 98

What is the clinical appearance of molar-incisor hypomineralisation?

Answer 98

Affects one or more of the first permanent molars and/or incisors.

Demarcated patches

White-brown or cream colour

Causes post-eruptive breakdown

If treated will be missing their 6s or heavily restored, abnormal restorations with excessive calculus deposits.

Question 99

What are differential diagnosis for MIH?

Answer 99

Fluorosis
Amelogenesis imperfecta
Turner teeth
Idiopathic hypomineralisation

Question 100

What is hypoplasia?
Clinical appearance?

Answer 100

Disruption in secretory phase, causing qualitative defects.

Early development
Small pits and grooves form on the surface, with gross enamel surface defects.

Question 101

What is hypomineralisation?
Clinical appearance?

Answer 101

Disruption to the maturation phase causing poor matrix mineralisation

Later in development

Causes white and brown opacities, normal thickness but dubious enamel quality

Question 102

What are the microscopic affects of hypomineralisation? (check if this is correct)

Answer 102

Altered Ca/P ratio
Less distinct enamel rods
Bacterial penetration and lower hardness of enamel

Question 103

What are causes of MIH?

Answer 103

Multiple putative factors, such as timing of insult, pyrexia, hypocalcaemia and hypoxia.

• Exposure to chemicals
• Peri-natal problems (time of conception to 1 year after birth)
• Neonatal problems
• Childhood illness and medically compromised children between the ages 0-1 (crown complete of 6s finishes at 3 yo)

Question 104

What are the challenges for treating patients with MIH?

Answer 104

• Aesthetic factors
• Sensitivity to treatment, greater innervation in sub odontoblastic and pulp horn regions.
• Porous enamel –> porous dentine and increase vascularity
• Activation of A6 and C-fibres more easily (difficult to anaesthetise)
• Behaviour management (present young 6,7,8)

Question 105

Why can stainless steel crowns be a good temporary treatment?

Answer 105

Good longevity
Easy to fit
Separators
Occlusal dimension settles
Gingival health not compromised and allows proper eruption of 7s

Question 106

What are balancing extractions?

Answer 106

Balance = extraction of a tooth from the opposite side of the same arch, designed to minimise centreline shift

Question 107

What are compensating extractions?

Answer 107

Extraction of a tooth from the opposing quadrant to the enforced extraction.
Designed to minimise occlusal interference by allowing teeth to maintain occlusal relationships as they drift.

Question 108

What are the rules for Class I, II and II molars?

Answer 108

Class I molars = compensate (balance if crowding present)

Class II molars =
> minimum crowding: extract U6 if likely to over erupt; remove before or after 7s erupted; no balancing
> Crowding: compensate if U6 likely to over erupt; remove before or after 7s erupted; no balancing

Class III: orthodontic advice to be sought; avoid balancing and compensating

CHECK ACTUAL GUIDELINES FOR THIS!!!

Question 109

What treatment is there for MIH?

Answer 109

• Micro abrasion for management of MIH affected incisors
• Etch-bleach-seal
• Bleaching
• Composite use, both for prevention and aesthetic demands of patients.

Question 110

What are symptoms of reversible pulpitis?

Answer 110

Provoked by stimuli, pain disappears with removal of the stimulus.
Short duration of pain
Relieved by analgesics
Sharp pain

Question 111

What are symptoms of irreversible pulpitis?

Answer 111

Spontaneous and constant pain
Long duration and dull throbbing pain
Sleep disruption
Not relieved by analgesia

Question 112

What are clinical findings associated with pulp necrosis?

Answer 112

Sinus formation
Swelling (intra and extra-oral)
Extent of caries
Grey colour tooth

Question 113

What special investigations do we do on primary teeth?

Answer 113

Vitality testing NOT BENEFIT in primary teeth

Mobility
TTT
Colour
Sinus formation

Radiograph: caries extent, inter-radicular radiolucency, resorption

Question 114

What medical factors would sway you to retain a tooth?

Answer 114

Bleeding disorders e.g. von Willebrands, Haemophilia

Pt risk under GA

Question 115

What medical factors would sway you to extract a tooth?

Answer 115

Immunocompromised (oncology, uncontrolled diabetes)

Cardiac disorders (risk of IE)

Question 116

What behaviour and social factors need to be taken into account when deciding whether to extract or restore a tooth?

Answer 116

Compliance related to age and complexity of treatment

Dental awareness

Motivation

Pattern of attendance

Age, how long till the tooth exfoliates

Question 117

What dental factors influence our decision whether to extract or restore a tooth?

Answer 117

Gross dental neglect

Restorability of dentition

Acute infection present

Time to exfoliation and amount of root resorption
> Due to exfoliate <1 year and advanced root resorption - extract?
> Due to remain in function >1 year and minimal root resorption - restore?

Hypodontia

Effect of developing dentition and value of tooth

Avoiding potential future crowding

Pulp status

Question 118

What are treatments for vital teeth?

Answer 118

Pulp capping - indirect (direct not successful in primary teeth)
Pulpotomy
Restorable crown, extent of caries

Need to have only reversible pulpitis, absence of sinus and abscess and no spontaneous pain or signs of irreversible pulpitis
No radiographic pulp resorption or inter-radicular bone loss.

Question 119

What are the treatment options for non-vital primary teeth?

Answer 119

Pulpectomy or
Extraction

Question 120

What is pulp capping?

Answer 120

Maintains vitality of pulp by placing a dressing either directly on to exposed pulp or onto residual dentine left over a nearly exposed pulp.

Aiming to promote pulp healing.

Question 121

What are indications for direct pulp capping in paediatric teeth?

Answer 121

Promote dentine bridge formation over exposure and preserve vitality
Ca(OH)2 medicament used.

NOT RECOMMENDED IN PRIMARY DENTITION DUE TO POOR SUCCESS RATE.

Question 122

What is indirect pulp capping?

Answer 122

Arrest caries by removal of active caries.
Allow formation of reactionary dentine and promote pulp healing.
Preserve vitality:
- Used for symptoms free primary teeth with large occlusal lesions
- Used for symptom free primary teeth with moderate approximal lesions
- Deep carious lesions with no pulpal pathology

Requires coronal seal (SSC)

Question 123

What is a pulpotomy?

Answer 123

Removal of coronal part of pulp tissue only
Assuming its irreversibly inflamed
Intention to maintain vitality of radicular pulp

For vital, asymptomatic or transient pain patients with no radiographic pathology.

Remove coronal pulp –> ferric sulphate (to arrest bleeding) –> ZOE –> Cement restoration –> SSC

Question 124

What are 4 different pulpotomy medicaments?

Answer 124

1. Ferric sulphate - haemostatic agent, agglutinates blood proteins, forming a barrier
2. Formocresol (not used any more)
3. Calcium hydroxide
4. MTA

Question 125

Why is zinc oxide a useful medicament as a temp filling or cement material for close to the pulp chamber?

Answer 125

Zince oxide eugenol (ZOE) = temp filling or cement material used close to the pulp chamber, as it sedates the pulp.

Question 126

What happens if bleeding doesn’t arrest during a pulpotomy?

Answer 126

When open the primary tooth pulp chamber and remove the coronal pulp, apply ferric sulphate for 15seconds. If bleeding hasn’t stopped, apply it once again and if unsuccessful, proceed to pulpectomy

Question 127

What is a pulpectomy?

Answer 127

Extirpation of soft tissue content from the coronal pulp chamber and canals.

Followed by placement of resorbable dressing (ZOE, iodoform, Ledermix, Ca(OH)2)

Indicated with irreversible pulpitis, pulp necrosis and hyperaemic pulp

Question 128

How can you tell if a pulpotomy has succeeded or failed?

Answer 128

Clinically:
Success = absence of signs/symptoms of pathology

Failure = pain, swelling, sinus, mobility

Radiolucency:

Failure = radiolucency in bone, pathologic resorption.

Question 129

How common are caries in permanent dentition (FPM)?

Answer 129

> 50% of children aged >11 have caries affecting FPMs

• Normally due them being hypoplastic
• Requires a comprehensive clinical and radiographic examination

Options for tx = extract, retain and restore

Question 130

What orthodontic considerations must you make for compromised FPMs?

Answer 130

Malocclusion - affects timing for removal

Hypodontia

Orthodontic input - elective extraction of other 6s

Question 131

What does the loss of FMP depend on?

Answer 131

Extent of crowding
Presenting malocclusion
Stage of dental development (patient age)
Maxillary or mandibular molar

Question 132

What are the advantages of extracting FPMs? (4)

Answer 132

1. Immediate resolution of symptoms or infection
2. One off procedure, cost effective
3. Space created to be used for orthodontic
4. Time right extractions allows 7s to move into their space

Question 133

What are the disadvantages of extractions of FPMs? (4)

Answer 133

1. Loss of permanent tooth
2. May require sedation of GA
3. Consequences of early/late extraction
4. Ortho treatment time and complexity might increase

Question 134

When is the ideal time to remove FPMs?

Answer 134

Root bifuration of the 7s forming, usually 8-10 years.

Question 135

What is the implication for extraction 6s early?

Answer 135

Eruption of 5s to migrate distally

Question 136

What are the implications for extraction of 6s late?

Answer 136

Too late can cause 7s to remain fixed and not migrate mesial

Question 137

What are the issues with RCT of young non-vital FPM? (3)

Answer 137

1. Immature roots and open apices present
2. Poor long-term prognosis
3. Lifelong maintenance of compromised 6.

Question 138

How does direct to indirect trauma differ in injuries?

Answer 138

Direct trauma - anterior teeth

Indirect trauma - posterior teeth

Question 139

What are the stats for paediatric trauma?

Answer 139

18% of all preschool injuries are orofacial.

Trauma to primary dentition: 31-40% of boys, and 16-30% of girls aged 5

Trauma to the permanent dentition at age 12: 12-33% boys, 4-19% of girls.

Question 140

What is the most common injury in primary dentitions vs permanent dentition?

Answer 140

Primary = luxation injury

Permanent = crown #

Question 141

What are predisposing factors to dental grauma?

Answer 141

Class II div 1 malocclusion
- teeth further forward with a lack of soft tissue coverage
- Greater the overjet, the greater the frequency of trauma to upper incisors
- Overjet >6mm 3x frequency

Medical and physical impairments
- cerebral palsy
- autism
- epilepsy

Accident prone children

Question 142

What injury is usually caused by high velocity impact vs low?

Answer 142

High velocity impact tends to cause crown fractures with less damage to PDL.

Low velocity impact tend to cause damage to the supporting structures, the PDL.

Question 143

What injury is caused by a sharp object vs a blunt one?

Answer 143

Sharp objects give clean fractures with little luxation.

Blunt objects have forces spread over a wider area, so tend to cause luxation injuries.

Question 144

What questions would you ask after trauma?

Answer 144

How did it happen? – indicated type and extent of injury that may have occurred. Direct/indirect trauma, High/low velocity, Sharp/blunt object.

Where? – Potential contamination of wound. Medico legal reasons.

When? – Critical for avulsion injuries and pulpal exposures as the prognosis of the tooth becomes much worse over time. Luxated teeth are harder to move after 24 hours. Delayed presentation could indicate NAI.

Loss of conc – headache, amnesia, nausea? – Head injury?

Previous injury – may explain RG findings like PCO.

Disturbed occlusion – may indicate condylar fracture, jaw fracture, alveolar fracture or tooth luxation.

Thermal reactions – thermal sensitivity implies dentine has been exposed and indicates need for dentinal coverage.

Question 145

What do you look for in the extra-oral exam for trauma injury pt?

Answer 145

> Survey for injuries outside the head and neck region
Look for asymmetry (best observed from behind)
Palpate the facial skeleton for fractures
clean up any debris and dried blood with wet gauze
TMJ (deviation and asymmetry)
Facial injuries: laceration, contusion, swelling, abrasions

Question 146

What do you look for in the intraoral exam of trauma pt?

Answer 146

Soft tissues:
> Lacerations (with potential embedded foreign body/tooth fragment)
> Abrasions
> Contusion (bruising)
> Degloving injury (need to lift lips to look at mucogingival fold)

Hard tissues:
> missing, fractured, displaced, mobile teeth

Occlusion:
> any changes to the occlusion

Question 147

What is in a paediatric trauma grid?

Answer 147

Colour - yellow PCO, grey necrosis

Mobility - luxation

TTP = apical pathology and damage to PDL

Percussion = tone and damage to PDL

Cold/EPT vitality test

Sinus - pulp necrosis

Radiographs - radiolucencies such as apical pathology of #

Photos/drawings may also be useful

Question 148

What may mobility of several teeth together mean?

Answer 148

of the alveolar process

Question 149

What does excessive mobility of a tooth indicate?

Answer 149

Root fracture or tooth displacement of a luxation injury?

Question 150

Should you percuss freshly traumatised teeth in a child?

Answer 150

No unless you want to listen to tone (if doubt of concomitant luxation etc.)

Question 151

What determines if pulp will necrose or recover?

Answer 151

Blood supply to the pulp

Vitality or sensibility test measures nerve impulses. Not an indicator for if pulp will necrose or recover.

Question 152

Is it common for there to be a decrease in response, immediately post trauma?

Answer 152

Yes, particularly following luxation injuries.

Question 153

Will teeth exhibit reactions when root formation is incomplete?

Answer 153

Teeth may exhibit little or no reaction.

Question 154

Why are taking radiographs important for trauma cases?

Answer 154

Radiographs provide valuable information and form an important record of the condition and status of affected teeth at baseline.

Increasingly there is a medico-legal requirement to obtain baseline radiographs
> Some # won’t appear radiographically at first presentation so need something to back you up.

Question 155

What factors do you have to consider when sensibility testing children’s teeth (mixed dentition)? (4)

Answer 155

Decrease in response after trauma is very common.

Teeth may not exhibit a reaction if root development is incomplete.

Teeth being moved orthodontically will have higher excitation thresholds.

Little value in testing primary teeth

Question 156

What are 6 different types of hard tissue injury?

Answer 156

Crown infraction =
Uncomplicated crown # =
Complicated crown # =
Uncomplicated crown/root # =
Complicated crown/root # =
Root # =

Question 157

What is an enamel infraction?

Answer 157

= An enamel crack, without loss of tooth structure.

Question 158

What is an uncomplicated crown #?

Answer 158

A fracture with loss of tissue confined to enamel/enamel and dentine only, without pulp exposure.

Question 159

What is a complicated crown #?

Answer 159

= A fracture confined to the enamel and dentine with pulp exposure.

Question 160

What is an uncomplicated crown/root #?

Answer 160

Uncomplicated crown/root # = A fracture involving enamel, dentine and cementum, with no pulp involvement.

Question 161

What is a complicated crown/root #?

Answer 161

Complicated crown/root # = A fracture involving enamel, dentine, cementum and the pulp.

Question 162

What is a root fracture?

Answer 162

= A fracture of the root involving dentine, cementum and pulp. Fracture lines may be horizontal, oblique or a combination of both.

Question 163

What are 6 types of periodontal tissue injury?

Answer 163

1. Concussion
2. Subluxation
3. Extrusive luxation
4. Intrusive luxation
5. Lateral luxation
6. Avulsion

Question 164

What is a concussion injury?

Answer 164

= No mobility or displacement of the tooth but TTP.

Question 165

What is subluxation injury?

Answer 165

= An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth.

Question 166

What is intrusive luxation?

Answer 166

= Displacement of the tooth in an apical direction into the alveolar bone.

Question 167

What is extrusive luxation?

Answer 167

= Displacement of the tooth out of its socket in an incisal/axial direction.

Question 168

What is lateral luxation?

Answer 168

= Displacement of the tooth in any lateral direction, (usually associated with a fracture or compression of the alveolar socket wall or facial cortical bone.)

Question 169

What is avulsion?

Answer 169

= Complete tooth displacement out of the socket.

Question 170

What are different fractures that could occur to bone in paediatric trauma? (4)

Answer 170

1. Socket wall #
2. Alveolar process #
3. Maxilla #
4. Mandible #

Question 171

What are 4 injuries to gingivae or mucosa?

Answer 171

1. Laceration
2. Contusion
3. Abrasion
4. Degloving

Question 172

What is laceration?

Answer 172

Tear or cut of the soft tissues (usually sharp object)

Question 173

What is contusion?

Answer 173

Bruise with no mucosal break (usually blunt object)

Question 174

What is abrasion?

Answer 174

Superficial wound from rubbing or scraping mucosa

Question 175

What is a degloving injury?

Answer 175

When top layers of skin and tissue are torn away from the underlying muscle, connective tissue or bone.

Question 176

What to sensibility tests test?
Why may they be unreliable?
Are they still worth doing?

Answer 176

• Sensibility testing refers to tests (cold test and electric pulp test) used to determine the condition of the pulp.
• Sensibility testing assesses neural activity and not vascular supply.
• Testing might be unreliable due to a transient lack of neural response or undifferentiation of A-delta nerve fibers in young teeth.
• The temporary loss of sensibility is a frequent finding during post-traumatic pulp healing, especially after luxation injuries.
• Thus, the lack of a response to pulp sensibility testing is not conclusive for pulp necrosis in traumatized teeth.

Despite this limitation, pulp sensibility testing should be performed initially and at each follow-up appointment in order to determine if changes occur over time.

It is generally accepted that pulp sensibility testing should be done as soon as practical to establish a baseline for future comparison testing and follow up. Initial testing is also a good predictor for the long-term prognosis of the pulp.

Question 177

How do the speed of nerve fibres differ?

Answer 177

A delta fibers, or Aδ fibers, are a type of sensory fiber. They respond to stimuli such as cold and pressure, and as nociceptors stimulation of them is interpreted as fast/first pain information.

They are thinly myelinated, thus they send impulses faster than unmyelinated C fibers, but more slowly than other, more thickly myelinated “A” class fibers

They are thin (2 to 5 μm in diameter), myelinated axons with a moderate conduction velocity, or speed of travel of a nerve signal (2 to 30 m/s). These nerve fibers are associated with acute (sharp) pain and therefore constitute the afferent portion of the reflex arc that results in “pulling away” from noxious stimuli (e.g., retracting your hand away from a hot stove). A certain proportion of Aδ fibers are also associated with sensations of temperature (also known as ‘cold receptors) and pressure. Slowly conducting, unmyelinated C fibers, carry slow, burning pain.

Question 178

Should Abx be used in trauma?

Answer 178

There is limited evidence for the use of systemic antibiotics in the emergency management of luxation injuries and no evidence that antibiotics improve the outcomes for root-fractured teeth.

Question 179

What are parent instructions for trauma?

Answer 179

• Meticulous OHI, use soft brush
• Use of anti-bacterial agents 0.12% Chlorhexidine topically as mouthrinse on the
  affected area 2 x day for one week, to reduce bacteria load, plaque and food debris
• Soft food for 10 days
• Restriction in use of intra-oral pacifier
• Advise the parents of potential complications
• No participations in contact sports

Exercise care when eating as not to further traumatise the injured tooth while encouraging a return to normal function as soon as possible.

Encourage gingival healing and prevent plaque accumulation by parents cleaning the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 week.

Question 180

What information about possible complications post-trauma should be given to parents?

Answer 180

Parents and caregivers should be advised about possible complications that may occur, such as swelling, increased mobility, or a sinus tract. Children may not complain about pain, but infection may be present. Parents or caregivers should watch for signs of infection such as swelling of the gums. If present they should take the child to a dentist for tx.

• Pulp necrosis and infection
• Pulp space obliteration
• Root resorption
• Breakdown of marginal gingiva and bone
• Sinus tract
• Tooth mobility
• Swelling

Question 181

Why is it important to preserve pulp vitality especially in immature permanent teeth?

Answer 181

Allow continued root development and apex formation

Question 182

Do you reimplant primary teeth after avulsion?

Answer 182

No! potential damage to permanent successor.

Question 183

What are complications that can arise from injury to deciduous teeth?

Answer 183

Delayed eruption
Dilaceration of permanent successor tooth
Hypoplasia yellow-brown-white opacity) caused by distrubance in matrix formation; characterised by pitted, grooved, or thin enamel, tooth more susceptible to decay, sensitivity.
Partial or incomplete malformation of permanent tooth
Sequestration of permanent tooth
Turner tooth (term used to describe the affect of a disturbance of enamel and dentine formation by an INFECTION from overlying primary tooth; tx as for hypoplasia)

Question 184

Which injury causes the most disturbances to success teeth?

Answer 184

Intrusive luxation

Question 185

When do changes in mineralisation and morphology of crown occur? (unsure about this)

Answer 185

> White or yellow-brown hypomineralisation, injury at 2-7 yo

> Crown dilaceration, injury at 2-7 yo

> Root duplication, injury 2-5 yo

Question 186

What is dilaceration?

Answer 186

An abrupt deviation along the long axis of a crown or root portion of tooth/tooth with distorted crown or root.

There are two types: developmental and traumatic (caused by primary incisor intrusion resulting in the developing permanent tooth germ displacement).

Question 187

What tooth morphology considerations need to be made about newly erupted teeth?

Answer 187

Short roots
Apices are wide and often diverging
Dentine walls of the entire tooth are thin and relatively weak

Non-vital immature teeth have a higher # risk due to crown-root ratio

Question 188

What are 3 types of vital immature exposed tooth (apexogenesis)

Answer 188

1. Direct pulp capping
2. Cvek pulpotomy
3. Cervical pulptomy

Question 189

What are 3 materials that could be used for non-vital immature exposed tooth apexification?

Answer 189

1. Non-setting CaOH (hypocal)
2. Mineral trioxide aggregate (MTA)
3. Odontopaste

(not actually sure about this)
(missed slides after this as unsure)

Question 190

What are 3 ways you can describe a root fracture?

Answer 190

1. Cervical, middle and apical #
2. Vertical, horizontal and oblique #
3. Displaced and un-displaced #

Question 191

What are the prognostic factors which impact root fracture prognosis?

Answer 191

Apical # are better prognosis, coronal # worse.

Most common in middle or apical third of root

Coronal fragment often extruded or luxated.

End-approximated before a fibrin clot can form

Apical fracture difficult for bacteria to penetrate and infect.

Initial displacement of the coronal portion of root # most important indicator of prognosis.

Question 192

Why is it important to have some functional movement when splinting a tooth?

Answer 192

Prevent ankylosis

Question 193

How does the splint time differ for the location of the root #

Answer 193

> Cervical root # = placed for 4 months

> Middle or apical root # splint applied for 2-4 weeks

Question 194

What is transient apical breakdown?

Answer 194

Transient Apical Breakdown (TAB), phenomenon in which luxation injuries heal by mimicking apical inflammation

Question 195

What are the requirements for splinting?

Answer 195

— 0.4mm wire in diameter by using flowable composite (IADN trauma guide)
— Wire must sit passively on the teeth, do not bond and then bend
— Keep composite and bonding agents away from the gingiva and proximal areas to avoid plaque retention and secondary infection
— Cannot use preformed arch wire due to lack of pre-formed natural arches on teeth
— Flexible splint = one either side
— Rigid splint = two either side

2 X SEA: subluxation, extrusive luxation and avulsion 2wks of splinting

4 x RL: root # and lateral luxation 4wks of splinting

4 months for cervical root # and associated alveolar #

Question 196

What is pulp canal obliteration?

Answer 196

Condition which can occur in teeth where hard tissue is deposited along the internal walls of the root canal and fills most of the pulp system leaving it narrowed and restricted.

Question 197

What are the treatment aims for luxation injuries?

Answer 197

> Minimised damage to the PDL
- prompt emergency tx
- reposition and splint

> Maintain vitality
- protect exposed dentine

> Prevent inflammatory resorption
- maintain vitality
- OR extirpate necrotic pulp

Question 198

Permanent teeth: tx for enamel infraction

Answer 198

In case of severe infractions, etching and sealing with bonding resin should be considered to prevent discolouration and bacterial contamination of the infractions.

Otherwise, no treatment is necessary.

No F/U:

Question 199

Permanent tooth: uncomplicated crown # enamel only tx

Answer 199

If the tooth fragment is available, it can be bonded back on to the tooth.

Alternatively, depending on the extent and location of the fracture, the tooth edges can be smoothed, or a composite resin restoration placed

F/U:
- 6-8 weeks
- after 1 year

Question 200

Permanent teeth uncomplicated crown # enamel and dentine tx:

Answer 200

If the tooth fragment is available and intact, it can be bonded back on to the tooth. The fragment should be rehydrated by soaking in water or saline for 20 minutes before bonding.

Cover the exposed dentine with glass-ionomer or use a bonding agent and composite resin.

If the exposed dentine is within 0.5mm of the pulp (pink but no bleeding), place a calcium hydroxide lining and cover with a material such as glass-ionomer.

F/U:
- 6-8 weeks
- 1 year

Question 201

Permanent teeth: complicated crown # tx

Answer 201

In patients where teeth have immature roots and open apices, it is very important to preserve the pulp. Partial pulpotomy or pulp capping are recommended in order to promote further tooth development.

Conservative pulp treatment (e.g. partial pulpotomy) is also the preferred tx in teeth with completed root development.

Non-setting calcium hydroxide or non-staining calcium silicate cements are suitable materials to be placed on the pulp wound.

If a post is required for crown retention in a mature tooth with complete root formation, RCT is the preferred treatment.

If the tooth fragment is available, it can be bonded back on to the tooth after rehydration and the exposed pulp is treated.

In the absence of an intact crown fragment for bonding, cover the exposed dentine with glass-ionomer or use a bonding agent and composite resin.

F/U:
- 6-8 weeks
- 3 months
- 6 months
- 1 year

Question 202

Permanent tooth uncomplicated crown root fracture tx:

Answer 202

• Until a treatment plan is finalized, temporary stabilisation of the loose fragment to the adjacent tooth/teeth or to the non-mobile fragment should be attempted.
• If the pulp is not exposed, removal of the coronal or mobile fragment and subsequent restoration should be considered.
• Cover the exposed dentine with glass ionomer or use a bonding agent and composite resin.

Further treatment options:
The treatment plan is dependent, in part, on the patient’s age and anticipated co-operation. Options include:
> Orthodontic extrusion of the apical or non-mobile fragment, followed by restoration (may also need periodontal re-contouring surgery after extrusion).
> Surgical extrusion
> Root canal treatment and restoration if the pulp becomes necrotic and infected.
> Root submergence
> Intentional replantation with or without rotation of the root.
> Extraction
> Autotransplantation.

F/U: After 1 week
After 6-8 weeks
After 3 months
After 6 months
After 1 year
Then yearly for at least 5 years.

Question 203

Permanent tooth complicated crown-root fracture tx:

Answer 203

• Until a treatment plan has been finalized, temporary stabilisation of the loose fragment to adjacent tooth/teeth or to the non-mobile fragment should be attempted.
• In IMMATURE teeth with incomplete root formation, it is advantages to preserve the pulp by performing a partial pulpotomy. Rubber dam isolation should be tried.
  > Non-setting calcium hydroxide or non-staining calcium silicate cements are suitable materials to be placed on the pulp wound.
• In mature teeth with complete root development, removal of the pulp is usually indicated.

-Cover the exposed dentine with glass-ionomer or use a bonding agent and composite resin.

Future treatment options: - (depends on age and co-operation)
- Completion of root canal treatment and restoration
- Orthodontic extrusion of the apical segment (may also need periodontal re-contouring surgery)
- Surgical extrusion
- Root submergence
- Intentional replantation with or without rotation of the root
- Extraction
- Autotransplantation

F/U:
After 1 week
After 6-8 weeks
After 3 months
After 6 months
After 1 year
Then yearly for at least 5 years

Question 204

What is the treatment for root fracture?

Answer 204

• If displaced, the coronal fragment should be repositioned ASAP.
• Check repositioning radiographically.
• Stabilise the mobile coronal segment with passive and flexible splint for 4 weeks. If the fracture is located cervically, stabilisation for a longer period of time (up to 4 months) may be needed.
• Cervical fractures have the potential to heal. Thus, the coronal fragment especially if not mobile, should not be removed at the emergency visit.
• No endodontic treatment should be started at the emergency visit.
• It is advisable to monitor healing of the fracture for at least one year. Pulp status should also be monitored.
• Pulp necrosis and infection may develop later. It usually occurs in the coronal fragment only. Hence, endodontic treatment of the coronal segment only will be indicated. As root fracture lines are frequently oblique, determination of root canal length may be challenging. An apexification approach may be needed. The apical segment rarely undergoes pathological changes that require treatment.
• In mature teeth where the cervical fracture line is located above the alveolar crest and the coronal fragment is very mobile, removal of the coronal fragment, followed by RCT and restoration with a post-retained crown will likely be required.

Additional procedures such as orthodontic extrusion of the apical segment, crown lengthening surgery, surgical extrusion or even extraction may be required as future treatment options (similar to those for crown-root fractures outlined above).

F/U:
after 4weeks S*
After 6-8 weeks
After 4 months S**
After 6 months
After 1 year
Then yearly for at least 5 years

Question 205

Tx of alveolar fracture:

Answer 205

Reposition any displaced segment.
Stabilise the segment by splinting the teeth with a passive and flexible splint for 4 weeks.
Suture gingival lacerations if present.
Root canal treatment is contraindicated at the emergency visit.
Monitor the pulp condition of all teeth involved, both initially and at follow ups, to determine if or when endodontic treatment becomes necessary.

F/U:
After 4 weeks S*
After 6-8 weeks
After 4 months
After 6 months
After 1 year
Then yearly for at least 5 years

Question 206

What is the treatment for concussion in permanent teeth?

Answer 206

No treatment is needed.
Monitor pulp condition for at least one year, but preferably longer.

F/U:
After 4 weeks
After 1 year

Question 207

Permanent teeth subluxation tx:

Answer 207

Normally no treatment is needed.
A passive and flexible splint for up to 2 weeks may be used but only if there is excessive mobility or tenderness when biting on the tooth.
Monitor the pulp condition for at least one year, but preferable longer.

Analgesia when required, soft diet, avoid contact sports.
Relief of occlusal interference.

F/U:
After 2 weeks S*
After 12 weeks
After 6 months
After 1 year

Question 208

Permanent teeth extrusive luxation tx:

Answer 208

• Reposition the tooth by gently pushing it back into the tooth socket under local anaesthesia.
• Stabilise the tooth for 2 weeks using a passive and flexible splint. If breakdown/fracture of the marginal bone, splint for an additional 4 weeks.
• Monitor the pulp condition with pulp sensibility tests.
• If the pulp becomes necrotic and infected, endodontic treatment appropriate to the tooth’s stage of root development is indicated.

F/U:
After 2 weeks S*
After 4 weeks
After 8 weeks
After 12 weeks
After 6 months
After 1 year
Then yearly for at least 5 years.

Question 209

Permanent teeth lateral luxation tx:

Answer 209

• Reposition the tooth digitally by disengaging it from its locked position and gently reposition it into its original location under local anaesthesia.
  > Method: Palpate the gingiva to feel the apex of the tooth. Use one finger to push downwards over the apical end of the tooth, then use another finger or thumb to push the tooth back into it socket.
• Stabilise the tooth for 4 weeks using a passive and flexible wire splint. If breakdown/fracture of the marginal or alveolar socket wall, additional splinting may be required.
  Monitor the pulp condition with pulp sensibility tests at the follow-up appointments.
  At about 2 weeks post-injury, make an endodontic evaluation.
• Teeth with INCOMPLETE root formation:
  > Spontaneous revascularisation may occur
  > If the pulp becomes necrotic and there as signs of inflammatory (infection-related) external resorption, root canal treatment should be started as soon as possible.
  > Endodontic procedures suitable for immature teeth should be used.

Teeth with COMPLETE root formation:
> The pulp will likely become necrotic.
> RCT should be started, using a corticosteroid-antibiotic or calcium hydroxide as an intra-canal medicament to prevent the development of inflammatory (infection-related) external resorption.

F/U:
After 2 weeks
After 4 weeks S*
After 8 weeks
After 12 weeks
After 6 months
After 1 year
Then yearly for at least 5 years

Question 210

Permanent teeth intrusive luxation tx:

Answer 210

• Teeth with INCOMPLETE root formation (immature teeth):
  > Allow re-eruption without intervention (spontaneous repositioning) for all intruded teeth independent on the degree of intrusion.
  > If no re-eruption within 4 weeks, initiate orthodontic repositioning.
  > Monitor the pulp condition.
  > In teeth with incomplete root formation, spontaneous pulp revascularisation may occur. However, if it is noted that the pulp becomes necrotic and infected of that there are signs of inflammatory (infection-related) external resorption at follow-up appointments, RCT is indicated and should be started asap when the position of the tooth allows. Endo procedures suitable for immature teeth should be used.
  > Parents must be informed about the necessity of follow-up visits.
• Teeth with COMPLETE root formation (mature teeth):
  > Allow re-eruption without intervention if the tooth is intruded less than 3mm. If no re-eruption within 8 weeks, reposition surgically and splint for 4 weeks with a passive and flexible splint. Alternatively, reposition orthodontically before ankylosis develops.
  > If the tooth is intruded 3-7mm, reposition surgically (preferably) or orthodontically.
  > If the tooth is intruded beyond 7mm, reposition surgically.
  > In teeth with complete root formation, the pulp almost always becomes necrotic. Root canal treatment should be started at 2 weeks or as soon as the position of the tooth allows, using a corticosteroid-antibiotic or calcium hydroxide as an intra-canal medication. The purpose of this treatment is to prevent the development of inflammatory (infect-related) external resorption.

F/U:
After 2 weeks
After 4 weeks S*
After 8 weeks
After 12 weeks
After 6 months
After 1 year
Then yearly for at least 5 years.

Question 211

What is the percentage prognosis of an immature (open apex) vs mature (closed apex) tooth that has experienced a traumatic injury to the periodontal tissues?

Answer 211

Concussion:
OA = 100%, CA = 96%

Subluxation:
OA = 100%, CA = 85%

Extrusive luxation:
OA = 95%, CA = 45%

Lateral luxation:
OA = 95%, CA = 25%

Intrusive luxation:
OA = 40%, CA = 0%

Avulsion:
OA = 30%, CA = 0%

Question 212

What are the recommended instructions for when there has been an avulsion to give to a parent?

Answer 212

1. Keep the patient calm
2. Find the tooth and pick it up by the crown (the white part). Avoid touching the root. Attempt to place it back into the jaw.
3. If the tooth is dirty, rinse it gently in milk, saline or in the patient’s saliva and replant or return it to its original position in the jaw.
4. It is important to encourage the patient/guardian/teacher/other person to replant the tooth immediately at the emergency site.
5. Once the tooth has been returned to its original position in the jaw, the patient should bite on gauze, a handkerchief or a napkin to hold it in place.
   > If replantation at the accident site is not possible, or for other reasons when replantation of the avulsed tooth is not feasible (e.g. unconscious pt), place the tooth, asap, in a storage or transport medium that is immediately available at the emergency site. This should be done quickly to avoid dehydration of the root surface, which starts to happen in a matter of a few minutes. In descending order of preference, milk, HBSS, saliva (after spitting into a glass), or saline are suitable and convenient storage mediums. Although water is a poor medium, it is better than leaving the tooth to air-dry.
6. The tooth can then be brought with the patient to the emergency clinic.
7. See a dentist or dental professional immediately.

Question 213

What is the treatment of choice for an avulsed permanent tooth dependent on?

Answer 213

The maturity of the root (open or closed apex)

The condition of the periodontal ligament (PDL). This is dependent on:
> The time out of the mouth
- Minimising the dry time is critical for the survival of the PDL cells.
- After and extra-alveolar dry time of 30 minutes, most PDL cells are non-viable.
> The storage medium the avulsed tooth was kept in.

Question 214

Do you prescribe systemic antibiotics for avulsion injuries?

Answer 214

• The periodontal ligament of an avulsed tooth often becomes contaminated by bacteria from the oral cavity, the storage medium, or the environment in which the avulsion occurred. Therefore, the use of systemic antibiotics after avulsion and replantation has been recommended to prevent infection-related reactions and to decrease the occurrence of inflammatory root resorption.
• Additionally, the pt’s medical status or concomitant injuries may warrant antibiotic coverage.
• In all cases, appropriate dosage for the pt’s age and weight should be calculated.
• Amoxicillin or penicillin remain the first choices due to their effectiveness on oral flora and low incidence of side effects. Alternative Abx for penicillin allergies.
• Tetracycline or doxycycline are generally not recommended for pts under 12, due to risk of discolouration of permanent teeth when administered in young pts

Question 215

Should avulsed teeth be splinted? And with what? How long?

Answer 215

Avulsed teeth always require stabilisation to maintain the replanted tooth in its correct position, provide patient comfort, and improve function.

Current evidence supports short-term, passive and flexible splints for stabilisation of replanted teeth.

stainless steel wire up to a diameter of 0.016” or 0.4mm or with nylon fishing line (0.13-0.25mm), and bonded to the teeth with composite resin.

Replanted permanent teeth should be stabilised for a period of 2 weeks.

The wire and composite should be paced on the labial surfaces to avoid occlusal interference and to enable palatal/lingal access for endodontic procedures. Keep the composite and bonding agents away from the marginal gingiva and interproximal areas to avoid plaque retention and secondary infections and to allow relatively easy cleaning by the patient.

Question 216

What patient instructions should be given post avulsion?

Answer 216

1. Avoid participation in contact sports
2. Maintain a soft diet for up to 2 weeks, according to the tolerance of the patient.
3. Brush their teeth with a soft toothbrush after each meal.
4. Use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks.

Question 217

What are the follow up procedures for replanted teeth after avulsion closed apex?

Answer 217

After 2 weeks S*
After 4 weeks
After 3 months
After 6 months
After 1 year
Then yearly for at least 5 years.

Question 218

Follow-up procedure open apex teeth avulsion?

Answer 218

After 2 weeks S*
After 1 month
After 2 months
After 3 months
After 6 months
After One year
Then yearly for at least 5 years.

Question 219

Closed apex: the tooth has been replanted at the site of injury or before the patient’s arrival at the dental clinic.

Answer 219

1. Clean the injured area with water, saline, or chlorhexidine.
2. Verify the correct position of the replanted tooth both clinically and radiographically.
3. Leave the tooth/teeth in place (except where the tooth is malpositioned; the malpositioning needs to be corrected using slight digital pressure).
4. Administer LA, if necessary, and preferable with no vasoconstrictor.
5. If the tooth or teeth were replanted in the wrong socket or rotated, consider repositioning the tooth/teeth into the proper location up to 48 hours after the traumatic incident.
6. Stabilise the tooth for 2 weeks using a passive flexible splint such as wire of diameter up to 0.016” or 0.4mm bonded to the tooth and adjacent teeth. Keep the composite and bonding agents away from the gingival tissues and proximal areas. In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks.
7. Suture gingival lacerations if present.
8. Initiate root canal treatment within 2 weeks after replantation.
9. Administer systemic antibiotics.
10. Check tetanus status.
11. Provide post operative instructions.
12. Follow up: 2 weeks S*, 4 weeks, 3 months, 6 months, one year, yearly for at least 5 years.

Question 220

Closed apex: the tooth has been kept in a physiologic storage medium or stored in non-physiologic conditions, with the extra-oral dry time less than 60 mins

Answer 220

1. If there is visible contamination, rinse the root surface with a stream of saline or osmolality-balanced media to remove gross debris.
2. Check the avulsed teeth for surface debris. Remove any debris by gently agitating it in the storage medium. Alternatively, a stream of saline can be used to briefly rinse is surface.
3. Put or leave the tooth in the storage medium while taking a history, examining the patient clinically and radiographically, and preparing the patient for the replantation.
4. Administer local anaesthesia, preferable without a vasoconstrictor.
5. Irrigate the socket with sterile saline.
6. Examinate the alveolar socket. If there is a fracture of the socket wall, reposition the fractured fragment into its original position with a suitable instrument.
7. Removal of the coagulum with a saline stream may allow better repositioning of the tooth.
8. Replant the tooth slowly with slight digital pressure. Excessive force should not be used.
9. Verify the position of the replanted tooth both clinically and radiographically.
10. Stabilise the tooth for 2 weeks using a passive, flexible wire of a diameter up to 0.016” or 0.4mm. Keep the composite and bonding agents away from the gingival tissues and proximal areas. In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks.
11. Suture gingival lacerations if present.
12. Initiate RCT within 2 weeks after replantation.
13. Administer systemic antibiotics.
14. Check tetanus status.
15. Provide post-operative instructions (contact sports, soft diet for 2/52, soft toothbrush after every meal, chlorhexidine gluconate 0.12% MW 2x/day 2/52.
16. Follow up: 2 weeks S*, 4 weeks, 3 months, 6 months, 1 year, then yearly for at least 5 years.

Question 221

Closed apex: extra-oral dry time longer than 60 mins

Answer 221

1. Remove loose debris and visible contamination by agitating the tooth in physiologic storage medium, or with gauze soaked in saline. Tooth may be left in storage medium while taking a history, examining the patient clinically and radiographically, and preparing the patient for the replantation.
2. Administer local anaesthesia, preferably without vasoconstrictor.
3. Irrigate the socket with sterile saline.
4. Examine the alveolar socket. Remove coagulum if necessary. If there is a fracture of the socket wall, reposition the fractured fragment with a suitable instrument.
5. Replant the tooth slowly with slight digital pressure. The tooth should not be forced back to place.
6. Verify the correct position of the replanted tooth both clinically and radiographically.
7. Stabilise the tooth for 2 weeks using a passive flexible wire of a diameter up to 0.016” or 0.4mm. Keep the composite and bonding agents away from the gingival tissues and proximal areas.
8. Suture gingival lacerations if present.
9. RCT should be carried out within 2 weeks.
10. Administer systemic antibiotics.
11. Check tetanus status.
12. Provide post-operative instructions (avoid contact sports, soft diet 2/52, soft toothbrush after meals, chlorhexidine gluconate 0.12% 2x/day 2/52.
13. Follow up: 2 weeks S*, 4 weeks, 3 months, 6 months, 1 year, then yearly for at least 5 years.

Question 222

Why does delayed replantation have a poor long-term prognosis?

Answer 222

• The periodontal ligament becomes necrotic and is not expected to regenerate.
• The expected outcome is ankylosis-related (replacement) root resorption.
• The goal, in these cases is to restore, at least temporarily, aesthetics and function while maintaining alveolar bone contour, width, and height.
• Therefore the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes.
• Replantation will keep future treatment options open. The tooth can always be extracted, if needed, and at the appropriate point following prompt inter-disciplinary assessment.

Question 223

What do immature teeth have the potential to do after avulsion?

Answer 223

• There is the potential for spontaneous healing to occur in the form of new connective tissue with a vascular supply.
• This allows continued root development and maturation.
• Hence, endodontic treatment should not be initiated unless there as definite signs of pulp necrosis and infection of the root canal system at follow-up appointments.

Question 224

Open apex: The tooth has been replanted before the patient’s arrival at the clinic

Answer 224

1. Clean the area with water, saline, or chlorhexidine.
2. Verify the position of the replanted tooth both clinically and radiographically.
3. Leave the tooth in the jaw (except where the tooth is malpositioned; the malpositioning needs to be corrected with slight digital pressure.
4. Administer local anaesthesia, if necessary, and preferable with no vasoconstrictor.
5. If the tooth or teeth were replanted in the wrong socket or rotated, consider repositioning the tooth/teeth into the proper location for up to 48 hours after the trauma.
6. Stabilise the tooth for 2 weeks using a passive and flexible wire of a diameter of 0.016” or 0.4mm. Short immature teeth may require a longer splinting time. Keep the composite and bonding agents away from the gingival tissues and proximal areas. In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for 4 weeks.
7. Suture gingival lacerations, if present.
8. Pulp revascularisation which can lead to further root development, is the goal when replanting immature teeth in children. The risk of external infection-related (inflammatory) resorption should be weighted against the chances of revascularisation. Such resorption is very rapid in children.
   > If spontaneous revascularisation does not occur, apexification, pulp revitalization/revascularisation or root canal treatment should be initiated as soon as pulp necrosis and infection is identified.
9. Administer systemic antibiotics
10. Check tetanus status
11. Provide post-operative instructions (avoid contact sports, soft diet for 2/52, soft toothbrush after meals, chlorhexidine gluconate 0.12% 2x/day 2/52.
12. Follow ups: 2 weeks S*, 1 month, 2 months, 3 months, 6 months, 1 year, and then yearly for at least 5 years.

Question 225

Open apex: the tooth has been kept in a physiologic storage medium or stored in non-physiologic conditions, and the extra-oral time has been less than 60 mins.

Answer 225

1. Check the avulsed tooth and remove debris from its surface by gently agitating it in the storage medium. Alternatively, a stream of sterile saline or a physiologic medium can be used to rinse its surface.
2. Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
3. Administer local anaesthesia, preferably without vasoconstrictor.
4. Irrigate the socket with sterile saline.
5. Examine the alveolar socket. Remove coagulum if necessary. If there is a fracture of the socket wall, reposition the fractured segment with a suitable instrument.
6. Replant the tooth slowly with slight digital pressure.
7. Verify the correct position of the replanted tooth both clinically and radiographically.
8. Stabilise the tooth for 2 weeks using a passive and flexible wire of a diameter of up to 0.016” or 0.4mm. Keep the composite and bonding agents away from the gingival tissues and proximal areas. In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left for about 4 weeks.
9. Suture gingival lacerations if present.
10. Pulp revascularisation which can lead to further root development, is the goal when replanting immature teeth in children. The risk of external infection-related (inflammatory) resorption should be weighted against the chances of revascularisation. Such resorption is very rapid in children. If spontaneous revascularisation does not occur, apexification, pulp revitalization/revascularisation or root canal treatment should be initiated as soon as pulp necrosis and infection is identified.
11. Administer systemic antibiotics
12. Check tetanus status
13. Provide post-operative instructions (avoid contact sports, soft diet for 2/52, soft toothbrush after meals, chlorhexidine gluconate 0.12% 2x/day 2/52.
14. Follow ups: 2 weeks S*, 1 month, 2 months, 3 months, 6 months, 1 year, and then yearly for at least 5 years.

Question 226

Open apex: Extra-oral time longer than 60 mins

Answer 226

1. Check the avulsed tooth and remove debris from its surface by gently agitating it in the storage medium. Alternatively, a stream of sterile saline can be used to rinse its surface.
2. Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation.
3. Administer local anaesthesia, preferably without vasoconstrictor.
4. Irrigate the socket with sterile saline.
5. Examine the alveolar socket. Remove coagulum if necessary. If there is a fracture of the socket wall, reposition the fractured segment with a suitable instrument.
6. Replant the tooth slowly with slight digital pressure.
7. Verify the correct position of the replanted tooth both clinically and radiographically.
8. Stabilise the tooth for 2 weeks using a passive and flexible wire of a diameter of up to 0.016” or 0.4mm. Keep the composite and bonding agents away from the gingival tissues and proximal areas. In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left for about 4 weeks.
9. Suture gingival lacerations if present.
10. Pulp revascularisation which can lead to further root development, is the goal when replanting immature teeth in children. The risk of external infection-related (inflammatory) resorption should be weighted against the chances of revascularisation. Such resorption is very rapid in children. If spontaneous revascularisation does not occur, apexification, pulp revitalization/revascularisation or root canal treatment should be initiated as soon as pulp necrosis and infection is identified.
11. Administer systemic antibiotics
12. Check tetanus status
13. Provide post-operative instructions (avoid contact sports, soft diet for 2/52, soft toothbrush after meals, chlorhexidine gluconate 0.12% 2x/day 2/52.
14. Follow ups: 2 weeks S*, 1 month, 2 months, 3 months, 6 months, 1 year, and then yearly for at least 5 years.

Question 227

How do you treat avulsed primary teeth?

Answer 227

• An avulsed primary tooth should not be replanted.
• Reasons include a significant burden (including replantation, splint placement and removal, root canal treatment) for a young child as well as the potential of causing further damage to the permanent tooth or to its eruption.
• The most important reason is to avoid medical emergency resulting from aspiration of the tooth.
• Careful follow up is required to monitor the development and eruption of the permanent tooth.

Question 228

Primary teeth enamel fracture tx:

Answer 228

• Smooth any sharp edges
• Parent/patient education:
• Exercise care when eating not to further traumatise the injured tooth while encouraging a return to normal function asap.
• Encourage gingival healing and prevent plaque accumulation by parents cleaning thee affected area with a soft brush/cotton swab combined with an alcohol-free 0.1 to 0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 week.

F/U: No clinical or radiographic follow up recommended

Question 229

Primary teeth, E-D # no pulp exposure tx:

Answer 229

• Cover all exposed dentine with glass ionomer or composite.
• Lost tooth structure can be restored using composite immediately or at a later appointment.
• Patient/parent education:
• Exercise care when eating as not to further traumatise the injured tooth while encouraging a return to normal function as soon as possible.
• Encourage gingival healing and prevent plaque accumulation by parents cleaning the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 week.

F/U: 6-8 weeks

Question 230

Primary teeth complicated crown fracture:

Answer 230

• Preserve the pulp by partial pulpotomy. LA is required. A non-setting calcium hydroxide paste should be applied over the pulp and cover this with GIC or composite. Cervical pulpotomy is indicated for teeth with large pulp exposures.
• Treatment depends on the child’s maturity and ability to tolerate procedures. Therefore, discuss different tx options (including pulpotomy) with the parents. Each option is invasive and has the potential to cause long-term dental anxiety. Treatment is best performed by child-oriented team with experience and expertse in the management of pediatric dental injuries. Often no treatment may be the most appropriate option in the emergency situation, but only when there is the potential for rapid referral (within several days) to the child-oriented team.
• Patient/parent education:
• care eating, cotton swab/soft brush w alcohol-free 0.1-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 week.

F/U:
1 week
6-8 weeks
1 year

Question 231

Primary tooth crown-root # tx:

Answer 231

• Often no treatment may be the most appropriate option in the emergency situation, but only when there is the potential for rapid referral (within several days) to a child-oriented team.
• If treatment is considered at the emergency appointment, LA will be required.

-Remove the loose fragment and determine if the crown can be restored.

Option A:
-> If restorable and no pulp exposed, cover the exposed dentine with GIC.
-> If restorable and the pulp is exposed, perform a pulpotomy (see crown fracture with exposed pulp) or RCT, depending on the stage or root development and the level of the fracture.

Option B:
If unrestorable, extract all loose fragments taking care not to damage the permanent successor tooth and leave any firm root fragment in situ, or extract the entire tooth.

Treatment depends on the child’s maturity and ability to tolerate procedures.
Parent/pt education:…

F/U:
1 week
6-8 weeks
1 year

Question 232

Primary tooth root fracture tx:

Answer 232

• If the coronal fragment is not displaced, no treatment is required.
• If the coronal fragment is displaced and is not excessively mobile, leave the coronal fragment to spontaneously reposition even if there is some occlusal interference.
• If the coronal fragment is displaced, excessively mobile and interfering with occlusion, two options are available, both of which require local anaesthesia.
  Option A:
  > Extract only the loose coronal fragment. The apical fragment should be left in place to be resorbed.
  Option B:
  > Gently reposition the loose coronal fragment. If the fragment is unstable in its new position, stabilise the fragment with a flexible splint attached to the adjacent uninjured teeth. Leave the splint in place for 4 weeks.

Treatment depends on the child’s maturity and ability to tolerate procedures

Parent/pt education: …

F/U:
Where there is no displacement of coronal fragment, clinical examination after:
1 week
6-8 weeks
1 year and where there are clinical concerns that an unfavorable is likely.

If the coronal fragment has repositioned and splinted, clinical examination after:
1 week
4 weeks for splint removal
8 weeks
1 year

Question 233

Primary teeth alveolar # tx:

Answer 233

• Reposition (under local anaesthetic) any displaced segment which is mobile and/or causing occlusal interference.
• Stabilise with a flexible splint to the adjacent uninjured teeth for 4 weeks.
• Treatment should be performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries.
• Parent/patient education:
  > Exercise care when eating as not to further traumatise the injured teeth while encouraging a return to normal function as soon as possible.
  > To encourage gingival healing and prevent plaque accumulation, parents should clean the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 week.

F/U:
1 week
4 weeks for splint removal
8 weeks
1 year
Further follow up at 6 years of age is indicated to monitor eruption of the permanent teeth.

Question 234

Primary teeth concussion tx:

Answer 234

No treatment is needed
Observation
Parent/patient education:

F/U:
1 week
6-8 weeks

Question 235

Primary teeth subluxation:

Answer 235

No treatment is needed.
Observation
Patient/parent education:

F/U:
1 week
6-8 weeks

Question 236

Primary teeth extrusive luxation:

Answer 236

• Treatment decisions are based on the degree of displacement, mobility, interference with the occlusion, root formation, and the ability of the child to tolerate the emergency situation.

> If the tooth is not interfering with the occlusion – let the tooth spontaneously reposition itself.

> If the tooth is excessively mobile or extruded >3mm, then extract under local anaesthesia.

• Treatment should be performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries. Extractions have the potential to cause long-term dental anxiety.

Parent/patient education:

F/U:
1 week
6-8 weeks
1 year

Question 237

Primary teeth lateral luxation tx:

Answer 237

• If there is minimal or no occlusal interference, the tooth should be allowed to spontaneously reposition itself.
  -> Spontaneous repositioning usually occurs within 6 months.

In situations of severe displacement, two options are available, both of which require local anaesthesia:
Option A:
> Extraction when there is a risk of ingestion or aspiration of the tooth.
Option B:
> Gently reposition the tooth.
If unstable in its new position, splint for 4 weeks using a flexible splint attached to the adjacent uninjured teeth.

Treatment should be performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries. Extractions have the potential to cause long-term dental anxiety.

Parent/patient education:

F/U:
Clinical examination after:
1 week
6-8 weeks
6 months
1 year
If repositioned and splinted, review after:
1 week
4 weeks S*
8 weeks
6 months
1 year

Question 238

Primary teeth intrusive luxation:

Answer 238

• The tooth should be allowed to spontaneously reposition itself, irrespective of the direction of displacement.
• Spontaneous improvement in the position of the intruded tooth usually occurs within 6 months.
  In some cases it can take up to 1 year.
• A rapid referral (within a couple of days) to a child-oriented team that has experience and expertise in the management of pediatric dental injuries should be arranged.

A parent/patient education:

F/U:
1 week
6-8 weeks
6 months
1 year

Question 239

Primary teeth avulsion tx:

Answer 239

Avulsed primary teeth should not be replanted

A parent/patient education:
Exercise care when eating as not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible.

To encourage gingival healing and prevent plaque accumulation, parents should clean the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1%-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 week.

F/U:
6-8 weeks
Further follow up at 6 years of age is indicated to monitor eruption of the permanent tooth.

Question 240

What are 4 common discolorations from trauma? What injury does each colour represent?

Answer 240

Red – occur after luxation (bleeding)
Yellow – pulp canal obliteration
Pink – internal resorption (gingiva/pulp shines through)
Dark – pulp necrosis

Question 241

Why do luxated teeth sometimes discolor red? Why can these teeth eventually turn blue/brown over time?

Answer 241

Due to the venous microcirculation being severed by the tooth movements, releasing blood.

When the blood decomposes it can cause the tooth to burn blue/brown.

Question 242

What is the process of tooth tuning pink and why?

Answer 242

A tooth turns pink because when there is internal resorption of the tooth, the dentine is replaced by hyperplastic vascular pulp tissues.

The pink becomes visible when the pulp nears the external surface of the tooth.

Question 243

Why do teeth become dark weeks/months after trauma?

Answer 243

As the tooth is necrosed, over time there is breakdown of pulpal tissue and blood incorporated into dentine.

Question 244

Why is discoloration just at the cervical margin worth worrying about?

Answer 244

It is usually late presentation of cervical resorption.

When present with pink discoloration at neck of the tooth, it is often well advanced and extraction may be the only possible treatment.

Question 245

What does the treatment for discoloration depend upon? What acute development regarding a traumatised tooth indicates a need for intervention?

Answer 245

1)Depends on the cause (e.g. necrosis require XLA or extirpation).

2) Does not necessarily need treatment.

3) Need to monitor carefully – clinically and radiographically for signs of infection.

4) The formation of a sinus or swelling indicates infection/pulpal necrosis therefore needs treatment.

5) Monitor for signs of pulpal sclerosis.

Question 246

What is the mechanism behind pulp necrosis? What feature of a traumatised tooth makes it more prone to necrose and why?

Answer 246

a. Occurs when there is disruption of the blood supply at the apical foramen = ischaemic necrosis (infarction)

b. Infection related liquefactive necrosis.

c. Higher incidence in - Traumatised teeth with complete root development are more likely to necrose as the apex is closed so cannot revascularise and in concussion, subluxation and lateral luxation.

Question 247

When do concussion injuries tend to lead to necrosis vs lateral luxation/intrusion?

Answer 247

Concussion within 3 months
Lateral luxation/intrusion – after 2 years

Question 248

Upon dentine exposure, what is it key to place and why?

Answer 248

Need to place a composite bandage to seal the dentinal tubules to prevent ingress of bacterial through the dentinal tubules to the pulp.

This is to prevent bacterial infiltration and consequent inflammation of the pulp (leading to necrosis). – is an important factor in success of pulp survival.

Question 249

What is the criteria for a pulp necrosis diagnosis? What are the signs and symptoms? (8)

Answer 249

Diagnosed by AT LEAST 2 SIGNS AND SYMPTOMS:
a. Persistent grey colour
b. Radiographic signs of periapical inflammation (radiolucency or widened PDL)
c. TTP
d. Sounds ‘dull’ percussion test as no vital tissues.
e. Sinus/swelling
f. Mobility
g. Suppuration
h. Lack of vitality response after 3 months post trauma.

Question 250

What should you discuss if a patient refuses treatment for pulp necrosis?

Answer 250

1. Colour of tooth might change and get worse.
2. Might develop pulpal sclerosis or obliteration – this may make RCT impossible at later date as can’t enter root canal, and tooth becomes unrestorable.
3. Draining sinus is a chronic situation, and through may be asymptomatic now, can get acute exacerbation of chronic infection. May result in swelling, pain and spreading infection.
4. Tooth may become symptomatic and unrestorable at later date.
5. Discuss options at each review appointment. – document if still don’t want tx.

Question 251

Where is internal root resorption found? Why do you want to identify it asap?

Answer 251

It is resorption found within the root canal.

If you identify it early as possible you can fill the deficiency with a good obturation system.

Tend to refer these patients to specialists in moderate to advanced cases as difficult to clean and fill.

Question 252

Where is external root resorption found? What are the 5 main forms?

Answer 252

It is located along the root surface.

1. Surface resorption – this is transient and is tooth repair related. It is self-limiting in nature.
2. External inflammatory resorption – associated with infection/necrotic pulp.
3. External replacement resorption – associated with ankylosis following the death of PDL cells.
4. Cervical resorption – manifests at cervical aspect of the tooth and is due to damage to the PDL and sub-epithelial cementum.
5. Transient apical resorption.

Question 253

What 2 features of a tooth make inflammatory external resorption more likely?

Answer 253

1. Mature apex
2. A significant injury e.g. intrusions/avulsions.

Question 254

How is inflammatory and replacement resorption treated?

Answer 254

Inflammatory – extirpate the pulp
Replacement – no successful treatment

Question 255

What is the aetiology of root resorption in general? When does it tend to present?

Answer 255

Root resorption is normally a result of significant amount of damage to the PDL or pulp due to trauma.

Tend to present early – well within 2-3 years of avulsion.

Open apices lead to increased occurrence.

Question 256

What are the two possible predisposing factors for cervical resorption? What patients is it more prevalent in? why is early detection key in determining the prognosis?

Answer 256

Trauma (damage to the PDL or sub-epithelial cementum) or idiopathic.

More common in pts who are older at the time of injury.

Early detection is key as tend to be asymptomatic until reach the pulp.

Question 257

What are the treatment options for cervical resorption? (4)

Answer 257

1. May be able to repair and may not need RCT.
2. External repair +/- RCT – where MTA/BIODENTINE is used to repair the external defect. – often involves raising a flap to expose area of resorption.
3. Internal repair and RCT – when conducting the RCT will place MTA/biodentine where the resorption defect is.
4. Internal replantation – where you remove the tooth, conduct required treatment then re-implant and accept ankylosis. – will then need RCT.
5. Extraction.

Question 258

What are the clinical and radiographic features of pulp obliteration? (3)

Answer 258

4-24% of traumatised teeth will have some degree of pulpal obliteration.

1. Symptomatic (inflammatory symptoms) or asymptomatic
2. Loss of pulpal space radiographically
3. Yellow discolouration of crown

Question 259

Why are RCTs v difficult in pulpally obliterated teeth? What endo emergency are they prone to?

Answer 259

As there is excessive calcified material within the canal.

Very prone to perforations as accessing canal very difficult. – when access may not drop into the canal.

Refer to specialist.

Question 260

Why may ankylosis not be an issue? What are three possible long term consequences?

Answer 260

If there are no aesthetic issues or symptoms then the tooth can be retained as it is no different to an osseointegrated implant.
If resorption is a problem this will need to be addressed.

Complications:
i. resorption of the tooth may lead to eventual loss of the tooth.
ii. Tooth may become discoloured due to necrosis
iii. Tooth may become infra occluded and become an aesthetic concern

Question 261

When is replacement resorption usually diagnosed? What aesthetic defect is it associated with? What is decoronation and when is it indicated? What feature of a patients smile may make infraocclusion less of a concern?

Answer 261

1. Ankylotic root resorption – replacement resorption. Radiographically diagnosed within the first 2-3 years of avulsion.
2. Associated with infra occlusion where the tooth becomes shorter than other teeth as doesn’t grown.
3. Decoronation – removal of the crown leaving the roots to preserve alveolar bone.
   Decoronation may be necessary when there is 1+mm of infra position.
4. If a patient has a low smile line then aesthetics tends to be less of a concern.

Need to discuss rate at which resorption is occurring and advise appropriately. Could be retain tooth and saving for implant.

Question 262

What are possible pulp healing post trauma?

Answer 262

1. Survival
2. Pulp canal obliteration
   > successful re-vascularisation
   > deposition of hard tissue along pulp canal walls
3. Pulp necrosis
   > inflammatory resorption

Question 263

What factors affect pulpal healing?

Answer 263

• Initial pulp status
• Status of apex
  > open apex increases chance of survival due to high vascularisation
  > extent of injury, concomitant damage to PDL
• Time since injury - the longer duration increases chance of necrosis
• Concurrent injuries - PDL damage increases chance of necrosis

Question 264

What is external inflammatory (infection-related) resorption?

Answer 264

• Necrotic pulp + PDL damage
• Luxation + necrosis = inflammatory resorption
• Treatable by extirpating pulp in pts to prevent inflammatory resorption
  Prolonged insult to PDL leading to continued pathology
• Due to infection in the pulp causing loss of vitality and necrosis

Question 265

What is external replacement resorption (ankylosis)?

Answer 265

• Caused by death of PDL cells
• More likely to happen in more severe injuries such as Luxation or Avulsion
• XGA or Coronectomy
• Tooth tissue is resorbed and replaced with bone
• Extra-oral dry time is biggest indicator of replacement resorption risk
• More likely to happen in re-implantation cases in open apices as more growing
  potential present, more bony remodeling

Question 266

What is surface resorption?

Answer 266

• Asymptomatic
• Transient apical breakdown
• Repair related, undergoes healing and should be monitored only (no Tx)
• Self-limiting process, often an incidental radiographic finding
• Caused by localised and limited injury to root surface or surrounding tissue
• 2—3 weeks of osteoclast activity before healing then occurs
• If cementum alone is involved in the resorptive process then complete healing will occur, but if dentine is involved there will be re-contouring

Question 267

What is internal resorption?

Answer 267

• Related to repair and transient breakdown of the pulp chamber
  > If pulp becomes necrotic the resorption will cease unless lateral canals present
  > Internal resorption starts within the pulp chamber of a tooth
  > Internal resorption can occur only on vital (or partially vital teeth)

Question 268

What is apexogenesis?

Answer 268

> Preservation of vital pulp tissue so that continued root development with natural apical closure can occur in patients with an open apex

> Cvek Pulpotomy, removal of all infected and damaged pulp, dressed in CaOH
Cervical pulpotomy

> Patient: vital pulp, immature root with an open apex

Question 269

What is pulp revascularisation?

Answer 269

ability of residual pulp and apical and periodontal stem cells to differentiate???

Question 270

What is apexification?

Answer 270

• Inducing a calcified barrier at the apex of a non-vital tooth (MTA) with incomplete root formation

> Need a microscope to place the MTA

> To facilitate endodontic obturation in patients with no growth potential

Question 271

How can you identify an ankylosed tooth?

Answer 271

• Has different sound from a normal tooth when it is percussed (often described as cracked china sound)
• Lack periodontal membrane space on a radiograph
• Has no physiological mobility
• May become infraoccluded as the jaw grows around it
• Replacement resorption causes considerable damage to the PDL and bone remodeling, resulting in loss of alveolar height

Question 272

What are the 4 types of supernumerary teeth?

Answer 272

1. Mesiodens = conical shape complete tooth in anterior maxilla, commonly unerupted, normally in midline (75%)
2. Tuberculate = barrel shaped tooth, more than one cusp, incomplete roots, normally palatal to U3s usually paired (12%)
3. Supplemental = resembles normal tooth shape and size, appears as normal tooth, upper lateral incisors and lower premolars (7%)
4. Odontoma = (compound odontoma) hamartoma of odontogenic origin, irregular mass of denticles, anterior maxilla/posterior mandible (6%)

Question 273

How do supernumerary teeth form?

Answer 273

Occur due to budding of dental lamina, either sporadically or because of a syndrome.

Question 274

How do you manage supernumerary teeth?

Answer 274

Extraction if:
- impeding eruption of adjacent teeth
- causing displacement
- interfere with tx (orthodontics)
- associated pathology

Otherwise monitor if symptomless or adjacent teeth still forming.

Question 275

What are the 3 classification of missing teeth?

Answer 275

Hypodontia = missing teeth

Oligodontia = >6 missing teeth

Anodontia = missing all teeth

Question 276

What are the most common missing teeth in hypodontia?

Answer 276

8s > 5s> 2s> 1s

Question 277

What causes teeth to be missing in the mouth?

Answer 277

Caused by obstruction or disruption of dental lamina, with a failure of dental epithelium to initiate or function.

• space limitation for tooth germ
• environmental factors (teratogen)
• genetic
• syndromes

Question 278

What may retained primary teeth allude to?

Answer 278

No success - look via radiograph

Question 279

Which syndromes are affected by hypodontia?

Answer 279

Ectodermal dysplasia: disorder affecting outer layer of tissue of the embryo (ectoderm)

Cleft lip and palate, due to abnormal induction and proliferation of the mesenchym

Question 280

What is macrodontia?

Answer 280

Tooth larger than normal type, usually affects single tooth.

Single teeth = unknown cause, due to isolate disturbance of development

Generalised = due to hormonal imbalances

Question 281

What is microdontia? How can you manage it?

Answer 281

Small than normal tooth

Usually 8s and 2s.

Aetiology unknown, generalised microdontia v rare.

Management of microdontia:
- build up with composite resin
- porcelain veneer
- extract and then replace with orthodontics, implant or autotransplantation.

Question 282

What is the definition of fusion?

Answer 282

Joining of adjacent tooth germs

Question 283

What is the definition of gemination?

Answer 283

Developmental separation of a single tooth germ

Question 284

What is dens invaginatus?

Answer 284

Infolding of the dental papilla

Mild = deep cingulum pit
Severe = abnormal crown

enamel often very thin, leading to caries and an increased potential for pulpal necrosis

Question 285

What is dens evaginatus?

Answer 285

Enamel covered tubercle on crown of tooth

43% may contain pulpal
Mandible > maxilla

Commonly on occlusal surface of premolar

Treatment to avoid occlusal interferences and any problems associated with this

Question 286

What is the different types of accessory cusps?

Answer 286

1. Cusp of carabelli, bilateral maxillary 6s.
2. Talon cusps in the cingulum of permanent incisors

Treatment:
> Seal groove between accessory cusp and tooth
> If occlusion affected, then selective reduction and removal of cusp possible.

Question 287

What is taurodontism?

Answer 287

Morpho-anatomical change in the shape of a tooth.

Enlarged body and pulp chamber seen radiographically.

Apical displacement of the pulpal floor

Due to failure of the HERS to invaginate properly, causing short roots, enlarged body and enlarged pulp with normal dentine.

Question 288

What is the secretory phase of enamel development?

Answer 288

Matrix production and initial mineralisation

Question 289

What is the maturation phase of enamel development?

Answer 289

Increase in mineral content

Question 290

What is hypoplastic enamel?

Answer 290

Reduced QUANTITY of enamel.
Secretory phase affected so disturbance in the formation of the matrix of enamel which give rise to pitted and grooved enamel (no normal volume of matrix).

Results in irregular shaped teeth, gross enamel deficit.

Disturbance occurs during secretory phase.

Question 291

What is hypomineralised enamel?

Answer 291

Reduction in QUALITY of enamel

Distrurbance during maturation phase

White/brown opacities

Normal thickness but dubious quality enamel

Question 292

What is hypocalcification?

Answer 292

condition in which the tooth enamel has an insufficient amount of calcium. Teeth have white opaque and chalky appearance.

Question 293

What are the local causes of enamel defects? (4)

Answer 293

1. Infection
2. Idiopathic
3. Trauma
4. Irradiation

Infection or trauma that affects a deciduous tooth can result in hypoplasia or hypomineralisation of permanent successors.

Question 294

What are generalised causes of enamel defects?

Answer 294

Genetics:
- Down syndrome
- Ectodermal dysplasia
- Epidermolysis bullosa
- Occulo-dento-osseous dysplasia

Environmental
- prenatal: rubella and syphilis
- neonatal: premature birth, hypocalcaemia, hypoxia
- postnatal: measles, chickenpox, vitamin deficiency

Chronological

Systemic

Question 295

What is amelogenesis imperfecta?

Answer 295

Generalised enamel defects affecting all or most teeth of the primary and permanent dentition.

Question 296

How can you classify amelogenesis imperfecta by mode of inheritence?

Answer 296

Autosomal dominant: 50% chance of passing AI

Autosomal recessive

X-linked: M more severely affected and uniformly affected, F have vertical ridges and grooves

Sporadic cases

Question 297

What is the classification of amelogenesis by phenotype?

Answer 297

Phenotype used to described way it looks.

Hypoplasia (type 1)
Hypomaturation (type 2)
Hypocalcification (type 3)
Hypomaturation-hypoplasia with taurodontism (type 4)

Question 298

What is molar incisor hypomineralisation?

Answer 298

Clinical hypomineralisation of systemic origin affecting one or more of the four first permanent molars and any incisors.

— Demarcated patches
— White-brown, cream or yellow colour
— Aetiology: peri-natal and neo-natal problems and common childhood illnesses mainly
— Management: recognition, review, desensitisation, temporisation and then restoration

Question 299

How can you treat MIH?

Answer 299

1. Prevention
   > Fl
   > Desensitising toothpaste
   > CPP-ACP products
   > Fissure sealants
   > Oral hygiene
2. Temporisation
   > GIC
   > Fill in deficit
   > Stainless steel crown (SSC)
3. Definitive tx
   - molars - composite, SSC, gold or cobalt chrome onlays, XLA

• incisors -
  > microabrasion
  
  • pumice (abrasion) + 18% HCL (erosion)
  • pumice (abrasion) + 37% phosphoric acid (erosion)
    > etch-bleach-seal* - 60s etch –> NaOCl 5% (5-10 mins) –> re-etch –> fisure sealant
    > Bleach
    > Bleach and composite
• GDC (May, 2014) - use of hydrogen peroxide (0.1-5%) not permitted under the age of 18 except for the purpose of treating or preventing disease.

Question 300

What is dentinogenesis imperfecta?

Answer 300

An autosomal dominant condition affecting formation of dentine.

Dentine consists of a reduced number of wide irregular tubules, with areas of atubular dentine. Loss of scalloping at ADJ. Teeth have opalescent bluish appearance. Teeth wear rapidly as enamel is lost.

Translucent, discoloured greyish brown teeth with a glassy appearance.
Often associated with significant tooth wear (attrition).

Question 301

What are the 3 types of dentinogenesis imperfecta?

Answer 301

Type I associated with osteogenesis imperfecta (blue sclera, increased bony fractures, long limbs).

Type II is similar to type I but no osteogenesis imperfecta.

Type III has marked attrition and pulp exposures (often called shell teeth due to radiographic appearance).

Question 302

What are radiographic features of teeth with dentinogenesis imperfecta?

Answer 302

Radiographically, teeth can have bulbous crowns, short roots and/or pulp obliteration in many teeth.

Question 303

What is dentinal dysplasia?

Answer 303

Autosomal dominant, both dentitions affected

Normal enamel but atypical dentine with abnormal pulp pathology

Type I: radicular type, with short roots and barely any pulp
Type II: coronal type, with enlarged pulps

Question 304

What environmental? cause dentine defects?

Answer 304

Local trauma may affect dentine formation
Infection
Nutritional deficiencies
Cytotoxic drugs or tetracycline

Question 305

What are the types of dentine?

Answer 305

Primary dentine
> formed before eruption of tooth
> mainly consist of circumpulpal dentine

Secondary dentine
> physiological type of dentine after full length of root has formed
> regular dentine that is formed during the life of the tooth and laid down in the floor and ceiling of the pulp chamber

Tertiary dentine - two types dentine formed as a result of noxious stimuli
–> reactionary dentine - dentine laid down in response to mild stimuli
–> reparative dentine - irregular dentine laid down directly beneath the path of injury as a response to strong stimuli
>

Question 306

What are the defects of cementum?

Answer 306

Hypercementosis
- periapical inflammation
- mechanical stimulation

Hypocementosis
- cleidocranial dysplasia
- hypophosphatasia

Question 307

What is regional odontodysplasia?

Answer 307

Abnormality of all dental tissues, due to arrested development of the tooth germ

Question 308

What are the 3 main difficulties for children with autism?

Answer 308

Autism spectrum disorder (ASD) is a neurological and developmental disorder

1. Social communication
   > may have unusual, delayed or lack of spoken language
   > difficulty understanding non-verbal communication
   > take language literally
   > use of makaton sign language to communicate
2. Social interaction
   > decreased interest in others and wider world
   > difficulties recognising and understand other people’s emotions and feelings
   > difficulties expressing their own emotions
3. Restrictive and repetitive behaviours
   > may have obsessive type behaviours
   > intense and highly focused interest
   > resistant to change
   > enjoy routine

Question 309

What is Asperger syndrome?

Answer 309

A form of autism spectrum disorder

Do not have delay in language and cognitive development
Find social communication and interpretation difficult

Question 310

Who consents for paediatric patients?

Answer 310

Child Protection Act 1989

Biological fathers that have parental control (if on birth certificate)

Parental responsibility can be given to grandparents and step-parents by court order

Gillick competence can be applied

Any child can consent for a check-up as is non-invasive

Question 311

Invasive tx on a child requires consent from someone with parent responsibility:

Answer 311

• November 2003, law changed that allowed parents unmarried to jointly be on the birth certificate
• Prior to Nov 2003 both parents had to be married to have joint parental responsibility
• Same sex relationships are the same with regards to civil partnerships and marriage
• Surrogates have parental responsibility until the child is adopted

Question 312

Are people aged 16-17 allowed to consent for tx?

Answer 312

People aged 16-17 are technically able to consent for treatment

• If not acting prudently or rationally consent cannot be given
• Patient must have clarity of thought before consenting and fully understand the
  complications and benefits of treatment

Question 313

Odontogenic tumours are relatively rare in paeds, however ? and ? occur predominantly?

Answer 313

Adenomatoid Odontognic tumour (AOT)
Ameloblastic fibroma

Question 314

What is primary herpetic gingivostomatitis caused by?

Answer 314

Herpes Simplex Virus 1

Question 315

What causes a cold sore?

Answer 315

Herpes simplex virus 1

> Occurs in labial area
Presents as a vesicular lesion that ruptures and produces crusting

> Reactivation of HSV-1 (which is the primary infection PHG)

Question 316

What clinical features does mumps have?

Answer 316

Bilateral enlargement of the parotid glands with flu-like symptoms

Question 317

What clinical features does measles have?

Answer 317

Intra-oral manifestation are Kolpik’s spots on the buccal mucosa, alongside malaise

Question 318

What is herpangina and its clinical features?

Answer 318

Cocksackie virus

Child febrile, irritable, loss of appetite, with general malaise

Vesicles in tonsillar region with cervical lymph node enlargement

Lesions do not coalesce

Question 319

What is hand, foot and mouth disease caused by and its clinical features?

Answer 319

Cocksackie virus

Maculopapular rash affecting tongue and oral mucosa, as well as fingers and toes.

Vesicles rupture and produce painful ulceration

Condition lasts 10-14 days

Question 320

What is chicken pox caused by and its clinical features?

Answer 320

Varicella Zoster virus

Vesicular rash on the skin
Intraoral lesions resemble primary herpetic infection

Highly contagious

Question 321

What is Shingles caused by and its clinical features?

Answer 321

Herpes Zoster

Vesicular lesions develop within periphery of trigeminal nerve.
High contagious

Question 322

What is erythema multiforme caused by and clinical features?

Answer 322

Infections (herpes) or drugs (sulphonamides)

Causes macules to blister in anterior mouth, blood stained and crusted lips

Lesions of squamous epithelium happen concurrently

Question 323

What is oral thrush? Which children are at risk? Clinical features?

Answer 323

Acute pseudomembranous candidiasis

New-borns, immunocompromised and long-term antibiotics

Candida Albicans causative

Large white plaques on buccal, labial and gingival mucosa

If white plaque removed results in raw, bleeding, underlying mucosa.

Where normal oral flora has been altered.

Question 324

What clinical features do acute odontogenic infections have?

Answer 324

Pyrexia
Red, swollen face
Anxious and distressed
Unwell child

Question 325

What clinical features does chronic odontogenic infection have?

Answer 325

Sinus present
Mobility
Halitosis
Discolouration

Question 326

What is an eruption cyst?

Answer 326

Fluctuant, fluid cyst that appears 2-3 weeks prior to eruption of a tooth

As eruption takes place the cyst may be blood filled and purple in colour

Usually asymptomatic and resolve

Shouldn’t incise lesion as to avoid infection

Question 327

What is a haemangioma?

Answer 327

Present at birth, may develop with the infant but regresses over time.
Often completely disappear
No treatment required, monitor

Question 328

What is the appearance and clinical features of Sturge-Webber syndrome?

Answer 328

Ipsilateral facial haemangioma and meninges calcification.

Contralateral focal epileptiform seizures with paralysis

Mental retardation

Red wine skin appearance

Question 329

What is an extravasation mucocele?

Answer 329

Minor salivary gland trauma normally located on lower lip

Bluish swelling with keratinised surface

Mucous retention cyst, similar appearance but lined by epithelium

Most common non-infective cause of salivary gland swelling in children

Question 330

What is a ranula?

Answer 330

Bluish swelling on the floor of the mouth
Arises from sublingual salivary gland

Question 331

What are gingival cysts?

Answer 331

New-born lesions
Small white or grey lesions
Gingival cysts arise from remnants of the dental lamina
Dental lamina grows into ectomesenchyme
Located within connective tissue between crown of developing tooth and oral mucosa

Cyst lined by keratinised stratified squamous epithelium

Present in 80% of neonates
> Epstein Pearls = hard palate raphe
> Bohns nodules = alveolar ridge

Question 332

What is a congenital epulis?

Answer 332

New born lesion (80% female)

Soft round, exophytic swelling on upper alveolar ridge.

Surgically drained to maange.

Question 333

What is a pyogenic granuloma?

Answer 333

Occurs in anterior maxilla gingiva

Reaction to chronic trauma, normally from subgingival calculus.

Question 334

What is a melanotic neuroectodermal tumour?

Answer 334

• Biphasic neoplasm of neuroblast and melanin producing epithelioid cells of neural crest origin
• 60% anterior maxilla
  Rapid growth and locally aggressive

Question 335

What is a squamous papilloma?

Answer 335

Benign condition
Small pedunculated cauliflower like growths,
white or pink in colour

Caused by HPV

Question 336

What is a fibroepithelial polyp?

Answer 336

Found inside the cheeks/lips/tongue
Very common, firm, pink, painless swelling found mostly in the cheeks, no discharge, doesn’t grow in size with time.

Caused by trauma
Sharp teeth
Cheek/lip biting habits

Treatment: can be left but normally are surgically removed under LA/GA. Tend to recur

Question 337

What is a fibrous epulis?

Answer 337

Well defined
Sessile
Next to tooth with pathology (plaque/caries)
Treatment
Remove the cause
Remove epulis by excision and send for analysis
Improve pt OH

Question 338

What 3 medications can cause gingival enlargement/hyperplasia?

Answer 338

Phenytoin
Cyclosporin
Nifedipine (Ca channel blockers)

Question 339

What is Riga-Fede ulcer?

Answer 339

Ventral surface of the tongue caused by rubbing of the tongue on the newly erupted sharp incisal edges of mandibular anterior teeth.

Management: requires smoothing the incisal edges

High incidence in children with familial dysautonomia and cerebral palsy

Question 340

What is partial ankyloglossia?

Answer 340

New-born pathology whereby the lingual frenum has a short attachment to the floor of the mouth.

Surgically corrected if presenting an eating or speech problem.

Question 341

What can recurrent aphthous ulceration?

Answer 341

• Erythema multiforme
• Stevens-Johnson syndrome
• Bechet’s syndrome
• Epidermolysis bullosa
• Lupus erythematosus
• Neutropenic ulceration

Question 342

What systemic diseases can predispose to periodontitis?

Answer 342

Acute myeloid leukaemia
Neutropenia
Thrombocytopenia
Down syndrome
Ehler-Danlos syndrome

Question 343

What is the critical pH for dental demineralisation in carious process?

Answer 343

pH 5.5

Question 344

What is the critical pH for dental erosion?

Answer 344

Dental erosion has no critical pH as it depends on saturation of the solution.

Question 345

What is the pH of saliva and what does it contain for buffering capacity?

Answer 345

pH 7

Bicarbonate: The primary buffer in activated saliva
Phosphate: The primary buffer in non-stimulated saliva
??

Question 346

What is the aetiology of dental erosion?

Answer 346

Extrinsic acids
> Dietary acids: frequency more important than quantity

Intrinsic acids
> Chronic regurgitation of gastic acid (GORD)
> Eating disorders: anorexia and bulimia nervosa, linked with psychiatric problems
> Rumination syndrome: repetitive regurgitation of recently ingested food

Question 347

What are the early signs of erosion?

Answer 347

a. Loss of surface features
b. teeth become smooth and shiny
c. incisal edges become more translucent.

Question 348

What are the later signs of erosion?

Answer 348

a. thinning and chipping of incisal edges
b. darkening of teeth
c. dentine sensitivity
d. cupping of occlusal surfaces (perimolysis)
e. dentine exposure
f. proud restorations

Question 349

What are features of advanced erosion?

Answer 349

a. Teeth shorten
b. Exposure of pulp
c. Periapical pathology and abscess formation

Question 350

Which can erosion be quicker in children?

Answer 350

Enamel and dentine thinner in primary dentition, erosion able to progress rapidly

Question 351

What are the treatment options for dental erosion?

Answer 351

1. Resolve sensitivity
2. Restore missing tooth surface
3. Prevent further tooth tissue loss
4. Maintain balanced occlusion

Primary dentition
- Asymptomatic, minimaI TSL- restorative treatment not indicated
- Small areas of exposed dentine causing sensitivity- cover with composite/GIC
- Larger areas of exposed dentine- composite crowns (anterior) or SSC (posterior)
- Exposed pulps- pulp therapy/extract

Question 352

What is involved in paediatric sedation?

Answer 352

Mainly inhalation sedation with local anaesthesia.

Only for children with complex oral needs or who cannot be managed with either:
- behaviour managment
- local anaesthesia and midazolam (no midazolam for children <12)

Question 353

Why is IV BZD not used in children?

Answer 353

Cause paradoxical reactions and have narrow therapeutic index

Question 354

At what age can propofol be used?

Answer 354

In patients <16