Paediatrics Flashcards
Which number in the CHI number indicates if a person is male or female?
9th number - odd = male
even = female
What information should be written on the inside cover of a child’s main records folder?
Parent/carer’s name and contact number
What/who is effective prevention dependent on regarding a young child?
identifying and reaching all adults with regular care responsibilities of the child
What is pyrexia?
raised body temperature; fever.
If a child is over 7, where do you take the BPE score?
1s and 6s
What BPE codes are used in a child age 7-11?
0, 1, 2
What BPE codes are used in a child ages 12+?
0, 1, 2, 3, 4, *
Name three examples of non-carious opacities
1) fluorosis
2) hypoplasia
3) molar incisor hypomineralisation
What is enamel hypoplasia?
enamel defect characterised by thin or absent enamel
Name three dental anomalies
1) supernumaries
2) palatal pits on laterals
3) peg laterals
regarding carious lesions, what does code E1 mean?
carious lesion in outer half of enamel
regarding carious lesions, what does code E2 mean?
carious lesion into inner half of enamel
regarding carious lesions, what does code D1 mean?
carious lesion into dentine, less than 1/3 through
regarding carious lesions, what does code D2 mean?
carious lesion into dentine, less than 2/3 through
regarding carious lesions, what does code D3 mean?
carious lesion into dentine, more than 2/3 through
regarding carious lesions, what does code P mean?
carious lesion more than 2/3 through dentine, touching pulp
regarding carious lesions, what does a code with + mean?
periradicular pathology present
When charting which teeth have carious lesions on the yellow form, what must you also detail?
M, O or D and also carious code eg. D2
When charting, what does WSL stand for?
white spot lesion
When charting, what does Arr mean?
arrested caries
When charting, what does Op mean?
opacity
When charting, what does RR stand for?
retained roots
When charting, what does FS stand for?
complete fissure sealant
When charting, what does #FS stand for?
partial fissure sealant
In the yellow form, what reasons are given to consider referring a patient to orthodontics for something “missing”?
1) maxillary 3s not palpable at age 9 or older
2) missing 5s or 2s
3) abnormal eruption sequence
In the yellow form, what reasons are given to consider referring a patient to ortho under “overjet”?
1) >6mm and bothered?
2) >6mm, incompetent lips and sporty
In the yellow form, what reasons are given to consider referring a patient to ortho regarding bite?
1) crossbite - anterior or posterior, with displacement?
2) displaced contact points (crowding) - loss of space >4mm
3) overbite - anterior open bite, & bothered? traumatic?
What are the 3 Ps regarding treatment planning?
Pain relief
Prevention
Planned treatment for caries and other conditions
What kind of treatments come under prevention on the yellow form? 4 examples
Brushing advice
Fluoride
Dietary advice
Fissure sealants
Name three “sealing in” caries management techniques classed under planned treatment
1) Fissure sealant
2) PCR
3) Hall crown
What are the four contributors that can facilitate the development of dental caries?
1) time
2) sugar substrate
3) bacterial biofilm
4) susceptible tooth surface
When should a child start brushing their teeth?
As soon as they appear in the mouth
Can all lesions be arrested?
any lesion, at any stage of tissue destruction, non-cavitated or cavitated, can become arrested. Irrespective of age of patient
What do children recieve from Childsmile?
a dental pack containing a toothbrush and tube of toothpaste (at least 1000ppm) on at least 6 occasions by age 5
What does TIPPS stand for?
Talk
Instruct
Practice
Plan
Support
What are the five steps of motivational interviewing?
1) explore current practice and attitudes
2) educational intervention
3) action planning
4) encouraging habit formation
5) repeat at each recall
What does SOARS stand for in the step 1, explore current practice and attitudes, part of motivational interviewing?
Seek permission
Open questions
Affirmations
Reflective listening
Summarising
What are three important factors regarding the patients thinking to work towards success?
Knowledge
Skills
Attitude
Children aged 10-16 at increased risk of caries should be advised to use toothpastes of what concentration?
2800ppm Fl
How often should fluoride varnish be applied in all children?
At least 2x yearly
How much toothpaste should be recommended for a child under 3 years old and how much Fluoride does this contain?
A smear - approx 0.1ml
0.1ml of 1000ppm toothpaste contains 0.1mgF
What volume should a pea sized blob of toothpaste be?
0.25ml
What does a 10/10 plaque score mean at DDH?
10/10 perfect
What does an 8/10 plaque score mean at DDH?
plaque at gingival line
What does a 6/10 plaque score mean at DDH?
1/3 covered in plaque
What does a 4/10 plaque score mean at DDH?
2/3 covered in plaque
Explain the Silness and Loe Plaque Index
0 - tooth surface clean
1 - appears clean but plaque scraped from gingival 1/3
2 - visible plaque along gingival margin
3 - tooth surface covered with abundant plaque
What plaque score should be recorded for each sextant?
The worst score found in each sextant
What is the difference between blue and pink disclosing tablet staining?
blue = old plaque
pink = newer plaque
How long can the first permanent molar take to come into full occlusion?
up to 2 years
What does the evidence recommend regarding flossing?
regular professional quality flossing may reduce interproximal caries risk in young children with low Fl exposure and poor OH
Name 8 techniques that can be used to enhance rapport with patients
1) enhancing control
2) relaxation - breathing
3) tell - show - do
4) positive reinforcement and reward
5) modelling (sibling, parent, teddy)
6) desensitisation
7) structured time
8) hypnosis
List the paediatric treatment plan options in order of least to most invasive
OHI
Diet
Fluoride
Sealants
Hall crowns
Restorations
LA
Extractions
What is the routine topical gel used?
Lidocaine gel (clear)
What is the second type of topical gel that can be used, why is it more expensive and what colour is it?
Benzocaine gel, flavoured (pink/orange/red)
How long should topical be applied to the tissues before administering LA?
2 mins
When is the only time an IANB would be used in a child patient?
Pulpotomy of lower Es
What LA technique is used for extraction of lower Es?
Buccal and lingual infiltration
What should always be administered prior to a palatal infiltration in a child?
Intra-papillary infiltration
What is currently recognised as the ‘gold standard’ LA?
2% lidocaine with 1:80,000 adrenaline
What is the maximum dose of lidocaine?
4.4mg/kg with max of 300mg
2% lidocaine translates to how many mg per ml?
20mg/ml
How many mg are contained in a 2.2ml cartridge of lidocaine?
44mg lidocaine
How many cartridges of lidocaine is the absolute maximum?
6.8 cartridges
What gases are used in inhalation sedation?
nitrous oxide and oxygen
What anaesthetic is generally used for IV sedation?
Midazolam
What is the minimum age that inhalation sedation can be used?
3 years old
how quickly can a patient recover from inhalation sedation?
full recovery within 15mins
What age is IV sedation NOT recommended at?
below 15 years old
How quickly does a patient recover from IV sedation?
not until the next day
How long does “short” general anaesthetic last?
1-5mins
How is “short” general anaesthetic administered?
through naso-pharyngeal airway
how is “long” general anaesthetic administered?
endo-tracheal intubation
What is the largest acidic dietary source in children?
soft drinks
What are intrinsic sugars?
those that are present naturally within the cellular structure of food
What are non-milk extrinsic sugars?
sugar released from fruit when it is blended or juiced, table sugar and sugar that is added to foods such as sugary drinks, confectionery, cakes, biscuits and buns
What can extrinsic sugars be split into?
Milk sugars
Non-milk extrinsic sugars
Is there any evidence that intrinsic sugars or lactose cause caries?
No
What does NCD stand for?
Non-communicable disease
What are NCDs?
Non-communicable diseases are diseases that are not spread through infection or through other people, but are typically caused by unhealthy behaviours
How many deaths are as a result of NCD?
3/4
Caries risk is to be considered significant is someone is exposed to sugar how many times daily?
More than 4 times daily
How many times daily does WHO recommend free sugar exposure?
No more than 4x daily
What three days should a diet diary document?
two weekdays
one weekend day
What personal circumstances may impact or restrict a patient’s dietary choices? 5 examples
1) autistic spectrum disorder - selective of foods
2) medical conditions - sugary medication
3) food intolerances
4) financial concerns
5) education
What are the three requirements for affecting change in health related behaviour?
Knowledge
Skills
Attitude
What type of chewing gum can be recommended?
Xylitol chewing gum
How many g of sugar in 100g of food is considered HIGH sugar?
more than 15g per 100g food
How many g of sugar in 100g of food is considered MEDIUM sugar?
between 5g and 15g per 100g food
How many g of sugar in 100g of food is considered LOW sugar?
5g or less per 100g food
When should acidic drinks be confined to?
Mealtimes
The SDCEP guidelines recommend giving dietary advice how often?
at least once per year
What are the benefits of fluoride? 3 examples
1) inhibits demineralisation, slowing decay
2) increases enamel erosion resistance
3) in high concn can inhibit bacterial metabolism/enzyme activity
What percentage of outer surface enamel is composed of apatite?
approx 85%
When does demineralisation occur?
When there is an imbalance between mineral loss and mineral gain
What is the composition of enamel?
85% apatite
12% water
3% protein
What is the composition of dentine?
47% apatite
20% water
33% protein
How much does the solubility of apatite fall with the drop of 1 pH unit?
10 times
What is formed when H+ combines with PO43- and OH-?
H2PO43- and H20
dihydrogen phosphate and water
When the solution becomes undersaturated and promotes enamel dissolution, what has happened to the concentrations of P043- and OH-?
Reduced
What is the normal pH of saliva?
around 7.0
oral fluids are supersaturated with respect to what?
hydroxyapatite (HAp)
Fluorhydroxyapatite (FHAp)
When the pH of the oral fluids decreases, what happens to concentrations of HAp and FHAp?
saliva and biofilm become undersaturated with HAp while still supersaturated with FHAp.
HAp dissolves from subsurface and FHAp forms in surface layers to provide resistance to subsequent demineralisation
What is the primary mineral in saliva?
Hydroxyapatite (HAp)
When fluoride is added to the oral environment, what happens?
the hydroxyl (OH-) in apatite crystal can be replaced with F- ions to make fluorapatite
Why is the formation of fluorapatite good?
It is less soluble than hydroxyapatite and has higher resistance to caries and erosion
What pH causes dissolution of HAp?
critical pH is 5.5
What is the critical pH of FAp?
4.5
How is fluorapatite formed?
by substitution of OH- with F-
What is a critical pH?
the pH at which a solution is just saturated with respect to a particular mineral. Below this dissolution occurs
What direct bacteria inhibition is caused by fluoride?
interacts with enzyme enolase to reduce acid production
What indirect bacterial inhibition is caused by fluoride?
limits phosphoenolpyruvate, inhibiting/decreasing the amount of sugar entering the cell
What fluoride varnish is routinely used?
Duraphat
What is the concentration of Fl in duraphat?
22,600ppm Fl (2.26%)
What are three contraindications of fluoride varnishes?
1) Asthma
2) allergies to colophony/elasoplast
3) patients with ulcerative gingivitis/stomatitis
According to SDCEP guidelines, how often should sodium Fl varnish be applied in children over 2 (all patients)?
twice a year
A child can receive two applications of Fl varnish per year through Childsmile, is it acceptable to apply a further 2 applications in practice?
Yes, it is acceptable for children to have varnish applied 4x per year
For high risk patients, how often should sodium Fl varnish be applied?
5% sodium fluoride varnish applied an additional 1-2 times per year to children over 2yrs, unless provided via Childsmile
Childsmile offers application of fluoride varnish twice yearly from what age?
18 months
What volume of fluoride varnish should be used in patients aged 2-5?
approx 0.25ml
What volume of fluoride varnish should be used in patients aged 6+?
approx 0.4ml
You should never use more than what volume of fluoride varnish?
never use more than a kernel of sweetcorn
What happens if you ingest too much fluoride?
nausea and vomiting
dental fluorosis
What are the symptoms of fluoride overdose?
abdominal pain
abnormal taste (salty or soapy)
convulsions
diarrhoea
drooling
headache
heart attack, irregular heartbeat
nausea, vomiting
shallow breathing
slow heartbeat
tremors
weakness
What is the toxic dose of fluoride?
5mg per kg bodyweight
If a child weighs 15kg, what is their toxic dose of fluoride?
75mg
How much fluoride is in 1ml of 1450ppm toothpaste?
1.45mg per ml
What do you do in acute fluoride overdose?
minimise absorption by calcium containing solution (milk)
find out weight and how much has been consumed
transfer to A&E
What does fluorosis occur as a result of?
excess fluoride ingestion when teeth are forming
Children aged 10-16 who are at an increased risk of developing dental caries should be advised to use a toothpaste of what concentration?
2800ppmF
Children of what age should be assisted with brushing?
under 7 years
High risk patients under age 10 should be advised to use a toothpaste of what concentration?
1350-1500ppmF
High risk patients over age 16 should be advised to use a toothpaste of what concentration?
5000ppmF
What type of decision maker is a type 1 decision maker?
intuitive, experiential, non-sequential, habitual, non-verbal thinking, right brain
What side of the brain does a “type 1” decision maker use?
Right brain
What type of decision maker is a type 2 decision maker?
sequential, structured, logical, analytical, verbal, left brain
What side of the brain does a “type 2” decision maker use?
Left brain
What is considered an initial occlusal lesion and how will it present clinically and radiographically?
non-cavitated, dentine shadow or minimal enamel cavitiation
radiograph - outer 1/3 dentine
What is considered an advanced occlusal lesion and how will it present clinically and radiographically?
dentine shadow or cavitiation with visible dentine
radiograph - middle or inner 1/3 dentine
What is considered an initial proximal lesion and how will it present clinically and radiographically?
white spot lesions or shadow
radiograph - lesion confined to enamel
What is considered an advanced proximal lesion and how will it present clinically and radiographically?
enamel cavitation and dentine shadow or cavity with visible dentine
radiograph - may extend into inner 1/3 dentine
What is considered an initial anterior lesion and how will it present clinically and radiographically?
white spot lesions but no dentinal caries
What is considered an advanced anterior lesion and how will it present clinically and radiographically?
cavitation or dentine shadow
What is the HbA1c level of a non-diabetic?
ideally 48mmol/mol or below 5.7%
What is the HbA1c level of a diabetic?
6.5% or more
What HbA1c level indicates pre-diabetes?
5.7% to 6.4%
What is HbA1c level?
average blood glucose (sugar) levels for the last two to three months
What can you administer to an unconscious diabetic?
glucagon
What are the signs of reversible pulpitis?
clinical signs of caries
not TTP
no abnormal mobility
no signs of infection
Does the management of reversible pulpitis include pulpal intervention?
No
What are the signs of irreversible pulpitis?
clinical signs of caries
not TTP
no abnormal mobility
no signs of infection
What are the signs of periradicular periodontitis?
clinical signs of caries
increased mobility
TTP
signs of infection - swelling, suppuration, sinus tract
What are the symptoms of reversible pulpitis?
pain short lived
does not linger
pain in direct response to stimuli
What are the symptoms of irreversible pulpitis?
spontaneous pain
prolonged
lingers on removal of stimulus
pt wakes up from sleep
What are the symptoms of periradicular periodontitis?
often acute symptoms gone
dull throbbing pain
can be asymptomatic
Is the pulp proportionally smaller or larger in primary teeth compared to permanent teeth?
larger
Is there a direct clinical way of confirming diagnosis of pulpal status?
no
Which radiographs are ideal for determining pulpal status?
Periapicals - visualise entire tooth as well as periapical tissues
What is an example of vital pulp therapy?
pulpotomy
What is a pulpotomy?
removal of the coronal portion of the pulp of a tooth such that the pulp of the root remains intact and viable
What is an example of a non-vital pulp therapy?
pulpectomy
What is a pulpectomy?
removing the nerve and pulp of a tooth
When is pulp therapy contraindicated?
in immunocompromised patients and those at risk of infective endocarditis
According to SDCEP, what is the aim of pulp therapy?
to enable a primary molar with disease to be retained free from pain and sepsis until exfoliation
Maintaining vital radicular pulp tissue via pulp therapy allows what?
the roots to undergo normal resorption
What does the pulpotomy procedure involve?
the removal of inflamed pulpal tissue leaving an intact radicular pulp tissue to which a medicament is applied before placing a coronal restoration
What is one important reason that pulpotomy may be indicated instead of removal of the tooth?
hypodontia - missing permanent successor
When would we NOT carry out a pulp therapy?
Precooperative child
multiple therapies needed (>3)
close to exfoliation
tooth unrestorable
signs of infection
radiographic signs of infection
medically contraindicated
What is the difference between primary and permanent 2nd molars regarding enamel cap?
cap of primary molars thinner and has more consistent depth
What is the difference between primary and permanent 2nd molars regarding dentine thickness?
greater thickness in primary teeth over pulpal wall at the occlusal fossa
What is the difference between primary and permanent 2nd molars regarding pulp horns?
higher in primary molars, especially mesial horns and pulp chambers are proportionally larger
What is the difference between primary and permanent 2nd molars regarding cervical ridges?
cervical ridges are more pronounced particularly on the buccal aspect of primary first molars
What is the difference between primary and permanent 2nd molars regarding enamel rods?
enamel rods at the cervix slope occlusally instead of gingivally as in permanent teeth
What is the difference between primary and permanent 2nd molars regarding the shape of neck?
primary molars have a more constricted neck
What is the difference between primary and permanent 2nd molars regarding roots?
primary molars have longer roots which are more slender than permanent roots
What is the difference between primary and permanent 2nd molars regarding flare of roots?
roots of the primary molars flare out nearer the cervix than those of the permanent teeth
What are the main steps involved in carrying out a pulpotomy? 4
1) rubber dam (split dam for ease)
2) remove roof of pulp chamber
3) remove coronal pulp
4) apply medicament to radicular pulp stumps
Name a haemostatic agent and explain how it arrests bleeding
Ferric sulphate (15.5%)
forms ferric ion protein complex when interacts with blood, this arrests bleeding by sealing vessels
Name three possible medicaments used for haemostasis during pulpotomy
1) ferric sulphate (15.5%)
2) saline
3) LA with vasoconstrictor
If haemostasis is not achieved and there is continuation of bleeding, what is done?
extraction or pulpectomy
What are the steps that are followed when haemostasis is achieved in pulpotomy?
1) apply medicament to radicular pulp stumps
2) fill pulp chamber with zinc oxide eugenol cement
3) restore tooth with stainless steel crown
What are the advantages of using MTA (mineral trioxide aggregate) as the medicament following pulpotomy?
biocompatible and produces very little inflammation
induces hard tissue formation
good success rate
What are the two recommended medicaments for the pulp floor following pulpotomy?
MTA or Ferric sulphate
If a pulpectomy is indicated in a child, what is the tooth restored with?
canals filled with non-setting calcium hydroxide
restore pulp chamber with GI core
Restore with stainless steel crown
Why is non-setting calcium hydroxide used as the obturating material in a paediatric patient instead of gutta percha?
Gutta percha is a non-resorbable material
What is a large danger of pulpectomy in primary teeth?
Extrusion of files or materials into periapical tissues damaging developing tooth germ
What are 5 potential complications of primary molar pulp therapy?
1) early resorption leading to early exfoliation
2) over-preparation
3) infection
4) caries
5) pulpectomy
What are the clinical signs of successful pulp therapy?
absence of symptoms
no infection, sinus or swelling
no mobility or tenderness
retention of tooth
natural exfoliation
What are the radiographic signs of successful pulp therapy?
no bone loss in furcation region
no evidence of internal resorption
What are the signs of infection in a pulp therapy treated tooth?
radiographic
inter-radicular radiolucency
TTP in non-exfoliating tooth
alveolar tenderness, sinus or swelling
non-physiological mobility
What are the signs of clinical failure following pulp therapy?
pathological mobility
fistula/chronic abscess
pain
When should signs of clinical failure following pulp therapy (fistula/chronic abscess, pathological mobility, pain) be reviewed?
6 monthly
What are the signs of radiographic failure following pulp therapy?
increased radiolucency
external/internal resorption
furcation bone loss
How often should the radiographic signs of failure be re-radiographed?
12-18 monthly
If we have a precooperative patient, what can we do to manage a reversible pulpitis?
crown?
can it be kept clean?
can be remove the stimulus or alter the environment?
How would you treat a non-cavitated lesion with radiographic occlusal caries involvement 1/3 into dentine?
fissure seal then fluoride or fluoride then seal
How would you treat a non-cavitated lesion with radiographic occlusal caries involvement 2/3 into dentine?
fissure sealant and fluoride
How would you treat a non-cavitated lesion with radiographic occlusal caries fully through dentine?
Fissure sealant, monitor, OHI, diet advice, Fl toothpaste
How would your treatment differ between cavitated and non-cavitated lesions?
Cavitated lesions would receive stepwise removal
Explain the stages involved in stepwise caries removal
1) slow speed to remove soft caries until hard leathery dentine is reached but still carious
2) etch, prime and bond
3) liner - vitrebond (glass ionomer)
4) restore - composite, resin composite or amalgam
5) monitor
6) at 6 months can re-enter and remove more caries as pulp shrinks but this is mainly historical
How is the treatment of a proximal lesion different from an occlusal lesion?
matrix band required
need to remove contact point
much bigger margin, more likely to fracture
What is the main sign of successful inferior alveolar block?
Numb lip on same side as block
What is the maximum LA dose in children per kg?
5mg/kg
