Paediatric Dentistry Flashcards
Patient attends clinic after experiencing dental trauma. what special investigations should you undertake?
mobility
colour
TTP
sinus
Percussion note
Radiograph
EPT
Ethyl chloride
what advice would you give to the patient/parent following emergency treatment of dental trauma?
analgesia
soft diet for 10-14 days
brush teeth with soft toothbrush after every meal
chlorhexidine 0.12% mouthwash 2x daily for one week
warning regarding infection
14 year old child attends your practice following an enamel-dentine fracture of tooth 21. how would you treat?
cover all exposed dentine with glass ionomer or composite
- either restore lost tooth structure immediately or at a later visit
How would you restore a root fracture where the coronal fragment has been displaced and is excessively mobile?
either
- extract loose coronal fragment
- reposition the loose coronal fragment and splint for 4 weeks
Patient attends clinic for a trauma review after previously experiencing trauma to the 11 a few months ago. they are worried about the colour of the tooth in question, as it is now an opaque yellow colour. the tooth is asymptomatic and there are no signs of necrosis or infection. what would be the most likely reason for this discolouration?
pulp canal obliteration
vital pulp response
pulp lays down tertiary dentine as a response to trauma
- leads rot narrowing of the canal walls
Possible consequences of trauma to the primary tooth (how can the primary tooth be affceted)
discolouration
infection
- tooth can become non-vital
- sinus
- increased mobility
- radiographic evidence of periapical pathology
delayed eruption
Potential complications of trauma in primary dentition to the permanent successor
enamel defects
abnormal crown/root morphology
- e.g. dilaceration
delayed eruption
ectopic tooth position
complete failure of tooth to form
odontome formation
indicators of dental neglect
obvious dental disease
- practical care has been offered yet child has not returned for treatment
examples of dental neglect
after dental problems have been pointed out:
- irregular attendance, related failed appointments or late cancellations
- failure to complete treatment
- returning in pain at repeated intervals
- repeated GA for extractions
extra-oral signs of physical abuse
bruising of face
abrasions and lacerations
burns and bites
choke marks on neck
eye injuries
hair pulling
fractures
- nose
- mandible
- zygoma
intra oral signs of physical abuse
contusions
bruises
abrasions and lacerations
burns
tooth trauma
frenal injuries
Physical abuse checklist questions
could the injury have been caused accidentally and if so how?
does explanation for injury fit age and clinical findings?
if there has been delay in seeking advice, has there been good reasons for this?
What is expected of the dental team in suspected cases of abuse?
observe
record
communicate
refer
NOT expected to diagnose
treatment options for discoloured teeth
enamel micro abrasion
bleaching
- vital
- non vital
resin infiltration
localised composite restoration
veneers
- composite
pre-operative records required for all discoloured teeth
clinical photos
shade
sensibility testing
diagram of defect
radiographs if clinically indicated
patient assessment
Enamel micro abrasion - steps that must be taken prior to applying HCL
PPE worn
patient must be wearing glasses and bib
clean teeth with pumice and water
apply petroleum jelly to gingivae
place rubber dam
place sodium bicarbonate guard
have more sodium bicarbonate available
micro abrasion technique - steps
HCL pumice slurry in slowly rotating rubber cup for 5 seconds
- maximum 10 x 5 second applications
wash directly into aspirator after every application
apply fluoride varnish
- e.g. Profluorid (not Duraphat)
polish with finest sandpaper disc
final polish with toothpaste
suitable cases for microsbrasion
post orthodontic demineralisation
fluorosis
trauma to primary incisors
advantages of microabrasion
easily performed
conservative
inexpensive
teeth need minimal subsequent maintenence
fast acting
effective
results are permanent
can be used before or after bleaching
removes yellow-brown, white and multi-coloured stains
disadvantages of microabrasion
removes enamel
HCL acid = caustic
requires protective apparatus for patient, dentist and dental nurse
prediction of treatment outcome is difficult
must be done in dental surgery
post op instructions following microabrasion
warn patient to avoid highly coloured food and drinks for at least 24 hours
when would you review a patient following microabrasion? what must you do on review appointment
within 4-6 weeks after treatment
and take post op photographs
what are the 2 methods of non-vital bleaching?
walking bleach technique
inside out method
walking bleach technique - steps
access cavity opened
root filling removed to just below gingival margin
cotton wool with bleaching agent placed in access cavity
- covered with dry cotton wool
seal with GIC
bleach renewed no more than 2 weeks between appointments
- no more than 3-4 renewals
combination/inside out bleaching method - steps
open access cavity
custom made mouthguard made
- windows cut in guard of teeth that you don’t want to bleach
patient applies bleaching agent to back of tooth and tray
access cavity must be kept clean
- gel changed every 2 hours or so expect at night
- changing gel removed food debris
mouthguard to be worn at all times except eating and cleaning
- 1-2 weeks
How would you restore the pulp chamber after inside out bleaching?
non setting calcium hydroxide paste for 2 weeks and seal with GIC
then either
- white GP and composite resin
or
incrementally cured composite
potential complications of non vital bleaching
external cervical resorption
spillage of bleaching agents
over bleaching
failure to bleach
brittleness of tooth
hypodontia prevelence in primary dentition
0.1-0.9%
conditions associated with hypodontia
ectodermal dysplasia
Down syndrome
cleft palate
Ellis Van Creveld syndrome
hurler’s syndrome
incontinentia pigmentii
anomalies of size and shape - give examples
microdontia
Microdontia
double teeth
odontomes
- complex or compound
taurodontism
- 6.3% in uK - flame shaped pulp
dilaceration
accessory cusps e.g. talon cusps
what is ameliogenesis imperfecta? name the types of ameliogenesis imperfecta
genetic enamel anomaly
affects all teeth within dentition
thin to no enamel, normal dentine and pulp
types:
hypoplastic
hypomaturational
hypocalcified
mixed forms
taurodontism features
vertically elongated pulp chamber and short roots
linked to type 4 ameleogenesis imperfecta
what is dilaceration?
an abnormal bend in the root
usually due to traumatic injury to primary tooth
localised enamel hypoplasia - questions to ask patient/parent
- trauma to primary tooth
or - infection in primary tooth
generalised enamel defects - types
fluorosis
MIH
MIH cause
associated with childhood illness or chronological hypo-mineralisation e.g liver or kidney failure
amelogenesis imperfecta - types
hypoplastic
hypocalcified
hypomaturational
mixed forms
dentine dysplasia features
normal crown morphology
amber radiolucency
short constricted roots
pulpal obliteration
What is dentinogenesis imperfecta?
a genetic disorder of tooth development affecting dentine
features of teeth with dentinogenesis imperfecta
bulbous crowns
pulpal obliteration (initially large pulps)
- abscess formation
short roots
dentinogenesis imperfecta problems
aesthetic
acid susceptibility
spontaneous abscess
neo-natal teeth are–
teeth that are present within 8 weeks of birth
indications for extracting Neo natal teeth
- poses aspiration risk
- causes issues breastfeeding
In regards to dental trauma, how would you describe the term ‘concussion’?
Tooth is tender to touch but has not been displaced
In regards to dental trauma, how would you describe the term ‘subluxation’?
Tooth is tender to touch, has increased mobility but has not been displaced
What is extrusion?
When the tooth has been partially displaced from its socket
what is intrusion?
when the tooth is displaced through the labial bone plate
What is avulsion?
When a tooth is completely out of its socket
What does a mild grey discolouration following dental trauma indicate?
intra pulpal bleeding
- still vital tooth
Cvek pulptomy steps
Trauma stamp and radiographic assessment
LA and rubber dam
clean area with saline then disinfect with sodium hypochlorite
remove 2mm of pulp with high speed round bur
-place saline soaked cotton wool pellet over exposure until haemostasis achieved
apply CaOH then GI or white MTA
restore with composite resin
partial pulpotomy success rate
97%
full coronal pulpotmy succes rate
75%
aim of a pulpotomy
keep vital pulp tissue within canal to allow normal root growth
indications for Endodontics in child
good co-operation
avoid GA
medical history precludes extraction
- e.g. bleeding disorder
ortho considerations
- space preservation
pulp treatment in children - contraindications
poor co-operation
medical history precludes pulp treatment
- immunocompromised
ortho considerations
- space closure desired
advanced root resorption
pus in pulp chamber
gross bone loss
eruption sequence of upper permanent teeth
6, 1, 2, 4, 5, 3, 7, 8
what is the eruption sequence of lower permanent teeth?
6, 1, 2, 3, 4, 5, 7, 8
premolars typically erupt at around age…
10
first permanent molars typically erupt at around age…
6
second permanent molars typically erupt at around age…
12
lower central incisors typically erupt at around age…
6
upper central incisors typically erupt at around age…
7
lower lateral incisors typically erupt at around age…
7
upper lateral incisors typically erupt at around age…
8
upper canines typically erupt at around age…
11
lower canines typically erupt at around age…
9
following eruption of a permanent tooth, how long does root formation typically take to complete?
around 3 years
outline the pain mechanisms of MIH
dentine hypersensitivity
- porous enamel or exposed dentine facilitates fluid flow within dentine tubules to activate a-delta nerve fibres
peripheral sensitisation
- underlying pulpal inflammation leads to sensitisation of C-fibres
central sensitisation from continued nociceptive input ?
MIH aetiology - potential post natal factors
prolonged breast feeding
dioxins in breast milk
fever and medication (childhood infections)
SES
rural vs urban
childhood infections liked to MIH development
Rubella
chicken pox
measles
MIH clinical problems
loss of tooth substance
- breakdown of enamel
- tooth wear
- secondary caries
sensitivity
appearance
Treatment options for MIH affected molars
Composite/GIC restorations
stainless steel crowns
adhesively retained copings
Extraction
- 8.5-9.5 years old
treatment options for MIH affected incisors
acid pumice microabrasion
resin infiltration
external bleaching
localised composite placement
combination of above
full composite veneers
What concentration fluoride is durophat varnish?
22600ppm
nursing bottle caries pattern
affects
- maxillary incisors and molars usually affected
- lower incisors usually spared due to tongue
nursing bottle caries prevention
- never use feeding bottle as pacifier
- try not to put child to bed with bottle
- if bottle used, make sure it contains plain water instead of milk, juice or formula
how often should bitewings be taken in a high caries risk patient?
every 6-12 months
how often should bitewings be taken in a low caries risk patient?
every 2-3 years
how often should check-ups be done in a high caries risk patient? What else should be done?
every 3 months
fv application every 3 months
from what age can you prescribe a child 2800ppm fluoride toothpaste?
10
components of a caries risk assessment
clinical evidence of previous disease
dietary habits
oral hygiene habits
exposure to fluoride
social history/SES
saliva
medical history
SDF fluoride concentration
44,800ppm
How does silver diamine fluoride work?
occludes dentinal tubules
silver is antibacterial
fluoride encourages remineralisation
advantages of SDF
safe
simple, easy and quick - 5 mins
non AGP
non invasive
evidence based
SDF disadvantages
stains caries black
can cause temporary tattoo
relatively expensive
metalic taste
amalgam is contraindicated in what groups of people?
under 15s
pregnant women
breastfeeding women
When would you refer a child to paediatric dental service?
anxiety and phobia
GA extractions
sedation
special needs
vulnerable groups
conscious sedation indications
child is anxious but co-operative
treatment is straight forward
treatment is not likely to damage child’s attitude toward treatment in the future
conscious sedation contraindications
severe dental anxiety where child is not ready or willing to co-operate
required treatment is too complex for maturity of the child
child too young to understand how to use IS
child cannot breathe through their nose
general anaesthetic indications
child needs to be fully anaesthetised before dental procedures can be attempted
surgeon needs the child fully anaesthetised before dental treatment can be carried out
what is intrusion?
when the tooth is displaced through the labial bone plate
what is lateral luxation?
When the tooth is displaced in a palatal/lingual or labial direction
What is a complicated crown fracture?
A crown fracture that involves the pulp
What emergency advice would you give a patient that has an avulsed permanent tooth?
- hold tooth by crown, do not handle root
- wash off any debris with cold water
- store tooth in milk or saliva until it can be re-planeted
Extrusion splinting time
2 weeks
intrusion splinting time
4 weeks
avulsion splinting time
2 weeks
lateral luxation splinting time
4 weeks
dento-alveolar fracture splinting time
4 weeks
treatment for lateral luxation injury
if minimal or no occlusal interference
- allow to reposition spontaneously
if displacement severe
- extraction
- or reposition and splint
Treatment for intrusion injury in primary dentition
allow to spontaneously reposition, irrespective of direction of displacement
extrusion management
not interfering with occlusion
- allow for spontaneous repositioning
excessive mobility or extruded >3mmm
- extract
