paediatrics Flashcards
Five year old Jodi has been brought to your clinic by her mother’s boyfriend. She did not sleep last night because
of dental pain. Jodi has not been to the dentist before because her mother has had a lifelong fear of dentists.
Jodi’s mother’s boyfriend is vague about Jodi’s medical history. Jodi is small for her age. Jodi is pyrexic, in pain
and has had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally
diagnose acute periapical abscess.
What should you establish prior to examination of Jodi? (3 Marks)
Thorough History (Pain/MH/DH)
Determine if airway is compromised
establish who has parental responsibility - Obtain consent for treatment.
Five year old Jodi has been brought to your clinic by her mother’s boyfriend. She did not sleep last night because
of dental pain. Jodi has not been to the dentist before because her mother has had a lifelong fear of dentists.
Jodi’s mother’s boyfriend is vague about Jodi’s medical history. Jodi is small for her age. Jodi is pyrexic, in pain
and has had a swollen left side of face associated with gross caries in all primary molar teeth.
Describe in detail one behavioural management technique you could use to maximise Jodi’s cooperation (4 Marks)
Tell show Do- To familiarise the patient with a new procedure
Tell- so explain the technique in an age appropriate way.
e.g. we want to make the tooth happy
Restoration- it is a bit like going to the hairdressers. The wash and blow dry is a bit noisy.
Show- Demonstrate aspects of the procedure in a non-threatening setting
Do- Now I would like to do this on your tooth (initiate with minimal delay)
5 year old brought to clinic with mums boyfriend, she did not sleep due to dental pain. She has never been to the dentist before due to the mothers fear. The Mums BF is vague about medical history and she is small for her age. She is pyrexic, in pain and had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally diagnose acute periapical abscess.
Jodi had difficulty accepting a full examination, including radiography, and you assess her as being pre-cooperative
with regard to operative care.
What would be your short term management for Jodi? (3 Marks)
Provide Pain relief
Drainage
Antibiotics: Penicillin V 2x250mg 4times a day for 5 days,
Tell boyfriend to bring jodi back in 5 days for review
If the swelling gets worse (A&E)
Five year old Jodi has been brought to your clinic by her mother’s boyfriend. She did not sleep last night because
of dental pain. Jodi has not been to the dentist before because her mother has had a lifelong fear of dentists.
Jodi’s mother’s boyfriend is vague about Jodi’s medical history. Jodi is small for her age. Jodi is pyrexic, in pain
and has had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally
diagnose acute periapical abscess.
How would you address the issue of Jodi’s previous non-attendance? (5 Marks)
Preventative dental team management:
* Discuss concerns with the parents - Ensure up to date contact details and contact mum by phone or any other guardians
Discuss :
1. The necessity of jodi to come (with someone able to consent)
2. Inform mum possibility of child protection getting involved due to non-compliance & non attendance
- Offer treatment - Set the next appointment on the phone ensuring that it is suitable for the family and ensuring an appropriate escort attends with
- Set targets and reminders
- Keep records
- monitor progress
Preventative Multiagency management:
* liaise with other HC professionals
- health visitor
- social work
- GP
- School nurse
* Investigate whether they are already part of a protection plan
* If child < 5 fails to attend appointments and the family do not response to letters from the practice contact the health visitor
5 year old brought to clinic with mums boyfriend, she did not sleep due to dental pain. She has never been to the dentist before due to the mothers fear. The Mums BF is vague about medical history and she is small for her age. She is pyrexic, in pain and had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally diagnose acute periapical abscess.
What evidence based brushing advice would you give to help prevent further dental caries? (5 marks)
Brushing for 2 minutes twice a day.
Using the modified bass technique (45 degree angle to the tooth brushing from the gums to the biting surface)
Using a pea sized amount of 1450ppm fluoride toothpaste.
Spit don’t rinse your mouth out.
Given the child is aged 5- they should be observed brushing their teeth until they are aged 7.
Patient has a fracture of tooth 11.
List two questions you would ask in regards to the traumatised tooth?
When/ how/ where did the fracture happen?
Are there any other more significant injuries/did they lose consciousness?
MH: Rheumatic fever, immunosuppressed, cardiac defects, tetanus status
Do we have the missing part of the tooth (and if so what has it been stored in?)
Patient has a fractured of tooth 11.
List 4 things that determined the prognosis of the traumatised tooth
pulp exposure - Type of fracture, complicated or not complicated,
Maturity of the tooth: apex closed or open,
Associated PDL injuries
vitality of the pulp,
mobility
Time between injury and treatment.
Patient has a fracture of tooth 11.What should we discuss with the parents? (4)
Inform of the complications - discolouration, pain, sinus, infection, risk of non-vitality,Risk of losing the teeth.
Inform them of theprognosis,
Inform them of the treatment options
Inform them we will review the tooth to check for these symptoms/
Patient has a fractured of tooth 11.
Where do you suspect the fragment of the tooth and how you would you manage this? (3)
Swallowed: A+E,
Inhaled: A+E for chest X-ray,
Embedded in soft tissue: Radiograph to confirm. Remove and suture for haemostasis or refer to oral surgery.
Patient has a fractured of tooth 11. It is ED#,
how would this change your treatment plan? (1)
Complete trauma stamp
Clean area
Disinfect with chlorhexidine
If fragment intact = Bond fragment to the tooth
or
place a composite bandage.
if exposed dentine is within 0.5mm of the pulp and a pink shadow can be seen - place a calcium hydroxide lining first and then cover with GI
Patient’s parents complained that the patient has white/yellow/brown stain on her teeth.
List 8 questions you would ask the patient’s mum. (4)
Prenatal - Severe illness of mum during pregnancy, gestational diabetes, congenital syphillis anaemia, Rubella.
Perinatal - natural birth, Birth trauma/anoxia, Preterm birth,
Postnatal - childhood infections (ottitis media/ measles/ chickenpox) or Long term health problems e.g. organ failure
Do any of your family members have this staining?
Was the staining on her primary and her permanent teeth?
Any trauma to her primary teeth?
Does it cause the child any pain? (or sensitivity)
The teeth affected are all first permanent molars, all central and lateral incisors. Is this condition likely to be
inherited and what condition do you think it is? (1)
No- because an inherited condition tends to affect the primary dentition aswell
Molar Incisor hypomineralisation - caused by childhood illness
List 5 questions you would ask to rule out fluorosis. (2.5)
Do they use fluoridated toothpaste?- do they spit it out?
Do they live somewhere with fluoridated water?
Do they take fluoride supplements?
What is their oral hygiene regime?
Do any of their siblings use high fluoride concentration toothpaste?
Are their 6s affected/ primary teeth- If fluorosis- primary teeth and 6s would not be affected- Primary teeth & 6s are formed before birth so fluoride exposure could not have happened.
List pottential problems of MIH of 16 26 36 46 in the future? (8)
Increased Caries susceptibility
Increased wear susceptibility
Increased sensitivity - from increased neural tissue within the pulp (more innervation- more difficult to LA)
Difficulty to restore: poor bonding
Poor appearance = psychological implications
Long term prognosis is poor,
Potential requirement of more complex/extensive/expensive treatment
Orthodontic problems
A co-operative 10 year old patient attends with moderate crowding requesting orthodontic treatment, but has
poor oral hygiene and cavitated caries into dentine in the first permanent molars.
Describe your management of the case. (12 marks)
History - C/O, pain history and (HPC & orthodontic concerns )
MH DH SH
Extra & intraoral examination.
Caries risk assessment - Evidence. Diet. Fluoride use. Plaque control. Saliva. Social history. Medical history
Radiograph (OPT & bitewings - to assess caries & other clinical findings),
Special tests: Sensibility testing,
Treatment plan:
Deal with pain first- analgesia advice.
1. Treat the caries in the 6 (Removal of caries/ RCT or XLA dependent on cooperation level)
- Review developing dentition (Fissure sealants)
- Prevention
Radiographs. Toothbrush instruction. Diet advice. Fluoride strength in toothpaste. Fluoride varnish application (x4 year). F supplementation. Fissure sealants. Using sugar free medication. - Ortho treatment- explain that orthodontic treatment tis not an option until patient oral hygiene improves & is not appropriate at this time due to age and dental development
- Find out why the they want ortho treatment. Inform the patient of the risks of fixed apliances (root resorption/ gingival recession/ relapse. and decalcification)Ensure the patient understands the importance of good OH if they ever want orthodontic treatment in the future.
- Assess child protection and patient neglect (due to carious lesion of the 6s.
A co-operative 10 year old patient attends with moderate crowding requesting orthodontic treatment, but has
poor oral hygiene and cavitated caries into dentine in the first permanent molars. Describe the risk-benefit discussion you would have with the patient and parent regarding their treatment 8 marks)
Risks of ortho - Root resorption, Relapse, Decalcification, Gingival recession, soft tissue trauma, wear/enamel fracture, gingival ulceration, loss of periodontal support, poor/failed tx
Benefits- Orthodontic treatment could solve the problem the patient is complaining of? improve aesthetics, function and psychological = improve self esteem and quality of life
Risks of extracting 6’s - Mesial tipping of 7’s, Distal migration of 5’s,
Benefits of extracting now - Extracting at the right time - Bifurcations of the
7’s formed & 8’s are present
Risks of GA - Nausea, drowsiness, vomiting, Slow recovery, Death, Permanent brain injury, Malignant hyperpyrexia
Benefits- we get the carious teeth removed.
Patient is 10/11 years old and they had extrusion of their 11.Draw and label your splint, also what materials would you use? (2 marks)
(4 teeth)
0.3mm Flexible stainless steel wire
Acid etch 37%
Composite resin
Water
Patient is 10/11 years old and they had extrusion of their 11.
How long would you splint for? (1 marks)
2 weeks
Patient is 10/11 years old and they had extrusion of their 11.What 4 tests would you do at a check-up apart from a radiograph (4 marks)
Electric pulp test, Ethyl chloride, Sinus, Colour, Mobility , TTP, Displacement
Patient is 10/11 years old and they had extrusion of their 11. Radiograph of 11 given, describe what you see, give a diagnosis and mention how you manage this (3 marks)
Periapical Radiolucency
Tramlines of RC intact
Widened PDL space
Loss of Lamina dura
External inflammatory root resorption- When the pulp is necrotic causing damage to the PDL (necrotic pulp tissues and toxins are reaching the external surface via dentinal tubules)
Treatment:
Remove cause of inflammation:
RCT with NS CaOh 4-6 weeks then obturate .
RCT( Pulp extirpate+ Mechanical debridement+ irrigation +NS CaOH 4-6 weeks then obturate)
A pt has an avulsion of a permanent incisor- what advice do you give over the phone?
Reassure pt,
Handle tooth by crown only (the part that you see in the mouth)
If it is dirty- rinse with milk/ saline (not for contacts) or in patient saliva.
Reimplant & bite onto hankerchief to hold tooth into place.
If you can’t reimplant it- store in saliva, milk, saline
come to GDP ASAP.
A pt has an avulsion of a permanent incisor-Give 3 storage media ranked best first
milk, hanks balenced salt solution, saliva, saline/
A pt has an avulsion of a permanent incisor-What should you check upon arrival? (8)
How the incident occurred
Where incident occurred
When did the incident occur
Any witnesses
Any more significant injuries - Was the child unconscious or vomit/nausea (concussion) → A&E
Account for all tooth fragments,
Do they have tetanus immunisation (in case of bacterial wound infections)
MH: do they have congenital heart defects, immunocompromised or rheumatic fever (would consider
assess socket?
If reimplanted - verify position?
A pt has an avulsion of a permanent incisor-What type of splint is advised?
EADT <60 mins (open or closed apex) flexible splint for 2 weeks
EADT >60 mins (open or closed apex) Flexible splint for 2 weeks.
Patient has an avulsed permanent incisor
What are the common outcomes?(4)
discoloration, mobility, necrosis of pulp, ankylosis, root resorption
PDL: regeneration, PDL/Cemental healing, bony/osseous healing, uncontrolled infection
Pulp: regeneration, controlled necrosis, uncontrolled necrosis
What are the clinical signs of dentinogenesis imperfecta and osteogenesis imperfecta? (8)
OI – blue sclera, lots of bone fractures
DI (uncommon)
* Both primary and permanent dentition affected
* Bulbous crowns
* Obliterated pulps
* loss of enamel & dentine (type 1)
* Just loss of dentine (type 2)
* Teeth appear amber and translucent/grey
* Occult abscess formation
What are the radiographic signs of dentinogenesis imperfecta?
Bulbous crown
Obliterated pulp
Occult abscess,
short and thin roots,
What is the clinical management of dentinogenesis imperfecta? (5)
(problems - poor aesthetics, caries, spontaneous abscesses = poor prognosis)
You want to cover them as soon as possible:
Composite veneers
overdentures
Stainless steel crowns
Removable prosthesis.
Prevention (High caries risk )
Give 4 E/O features of Down’s syndrome.
Epicanthic eye fold.
Broad flat face
Slanting eyes
Short nose
Flat back of head
Thick unstable neck
6 Intra Oral features of Down’s syndrome?
large fissured tongue/macroglossia,
Maxillary hypoplasia,
High arched palate,
AOB,
class III,
CLP,
hypodontia,
microdontia,
increased periodontal disease due to immunocompromised,
spacing
What are the restorative options for treatment of a patient with down’s syndrome? (3)
Preventative protocol (Fissure sealants- moisture control may be difficult to achieve so- GI/ chlorohexidine for perio treatment)
If complaint treat using LA (caution with atlantooccipital instability- support is vital)
May require GA
Take caution with consent & capacity- other associated medical conditions (Alzheimers/ Intellectual impairement) may have a welfare guardian
Following root fracture, what types of healing are there?
Calcified- Ideal healing with a dentine like material which is almost indistinguable on the radiograph.
Connective tissue healing- Fracture lines remaining visible & edges of the fracture show eburnation (where the corners of the fracture are rounded off)
Osseus healing- Bony healing (Two parts of the boen become unique entities that don’t connect- bone is clearly seen between fragments.
What type of tissue is regarded as non healing?
Granulation tissue (radiographically- radiolucent area around the fracture line )
How are root fractures managed
apical 1/3 and mid 1/3- reposition and 4 week splint.
Don’t initiate RCT at emergency apt
If pulp necrosis develops during monitoring - RCT to fracture line (can use an MTA stop coronal to fx line)
Coronal 1/3- reposition and 4 month splint.
How would you manage a patient with a tooth fragment of the fracture that has lost vitality?
- Remove pulp up to the fracture line
- Dress with nonsetting- CAOH (temporary)
- Create apical barrier using MTA or biodentine
- Backfill from fracture line using GP.
- The apical part of the root tends to stay alive (as it hasn’t been displaced)
a. So it can be left unless infected
b. if infected use- Antibotics and an apicectomy (surgical removal)
(Extraction is also a pottential treatment option)
What are the signs of fluorosis?
Symmetrical diffuse white marks on the teeth (Brown marks if more severe)
Unaffected 6s- formed before birth so unaffected by fluoride exposure.
Name 4 vehicles of fluoride delivery
toothpaste - 1450,2800,5000ppm
varnish - 22,600ppm
mouthwash - 225ppm
supplements - 0.25mg-1mg
GIC (fluoride releasing)
SDF - 44,800ppm
How can you manage fluorosis? (4)
Accept
Microabrasion
Veneers (Composite/ porcleain if >18)
Vital bleeching- riks that it may leave white spots whiter aswell.
What are the advantages of non-vital bleaching? (5)
Easy, conservative, safe,
no lab assistance for walking bleach (i.e. trays)
high patient satisfaction
What are the disadvantages of non-vital bleaching (5)
External cervical resorption
Spillage of bleaching agents
Failure to bleach
Overbleaching
Brittleness of the tooth
Briefly describe the walking bleach technique (9)
- For records: Record the initial shade
- Isolation with rubber dam
3.Create access & Remove GP to below the level of the CEJ - Clean pulp chamber with ultrasonic
- Apply bleaching agent on a cotton pledget and place it in the tooth.
- Seal with GIC or RMGIC
Appointment 2 (No more than 2 weeks between appointment)
* renew bleach
* If no change after 3-4 renewals stop.
* 6-10 changes in total
* There will be regression of 50% between 2-6 years.
Once shade is achieved:
Restore the pulp chamber:
NS CaOH paste for 2 weeks sealed in with GIC- prevents any cervical resorption.
After 2 weeks:
-Place white GP and composite resin restoration
-Incrementally cured composite
When do we use a splint for primary teeth and what splint?
a 4 week flexible splint for alveolar bone fracture.
What splint is selected for an avulsed adult tooth ?
2 week flexible splint
What is the difference between a flexible and rigid splint?
A flexible splint has 1 tooth on either side of the trauma.
A hard splint has 2 teeth on either side.
The patient has attended with an avulsed tooth- the EADT <60 minutes what is your endodontic management?
- LA
- irrigate socket with sterile saline
- Reimplant the tooth with slight distal pressure
Open apex- Aim for revascularisation & monitor continued root growth.
If closed apex(remove pulp as soon as possible & leave antibiotic steroid paste for 2 weeks before using CaOH for 4 weeks - interfeeres with PDL healing )
- Use a flexible splint for 2 weeks
- Antibiotics
- Check pt tetanus status
The patient has attended with an avulsed tooth- the EADT >60 minutes what is your endodontic management?
1.LA
2.Irrigate socket with sterile saline
3. Reimplant the tooth under LA
4.
For open apex- replant tooth under LA & splint (2 week flexible) & monitor for signs of necrosis.
For closed apex
remove any obviously damaged PDL.
Reimplant the tooth under LA
Extirpate at 7-10 days using NSCaOH as an intracanal medicament for 4 weeks before obturation. Corticosteroid / AB paste for 6 weeks.
5.Then use a 2 week flexible splint.
6.Antibiotics
7. Check tetanus status
Mum phones dentist telling them that their child has swallowed fluoride toothpaste and is worried.
What 3 questions should the dentist ask the mum? (3 marks)
How old is the child?
weight of the child?
How much of the toothpaste bottle has been swallowed?
Concentration of toothpaste?
If the child has ingested a toxic dose, what advice should the dentist give? (2 marks)
Toxic dose- 5mg/kg
Give calcium orally and go to the hospital.
<5mg/kg - Give calcium orally (milk) and observe for a few hours
5-15mg/kg - Give calcium orally (milk, calcium gluconate, calcium lactate) and admit to hospital
>15mg/kg - Admit to hospital immediately, cardiac monitoring and like support, intravenous calcium gluconate
What is the most common cause of fluorosis in the UK, underline 1 of the 4 following answers (1 mark)
Fluoride in public water supply?
If the child with fluorosis is 10 years old what would your first line of treatment be, underline 1 of the 4 following answers (1 mark)
Microabrasion. Composite veneer. Monitor. bleaching
Microabrasion? **
Patients are aged 1, 4 and 7, that are high caries risk with a 0.3ppm-fluoridated water supply. What fluoride supplementation would you advise for each patient? (10 marks)
Age 1:
fluoride toothpaste (1000ppm)
fluoride tablet 0.25mg
age 4:
fluoride toothpaste (1450ppm pea sized) &
0.25ml 22,600ppm fluoride varnish 4x per year
0.5mg fluoride tablet
age 7:
fluoride mouthwash 225ppm
1mg fluoride tablet
0.4ml fluoride varnish 4x per year
1450ppm toothpaste
****
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. What is the likely diagnosis?
Primary herpetic gingivostomatitis
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. How might these blisters appear?
Small fluid filled vesicles which rupture to form ulcers around 1-3mm in size.
Found on the gingivae, tongue, lips, buccal and palatal mucosa.
Severe oedematous marginal gingivitis
They last about 10-14 days.
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums.What other signs and symptoms may be present?
Fever
malaise
Headache
Severe oedematous marginal gingivitis
Vesicles and ulceration elsewhere in the mouth.
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. WHat is the likely cause of primary herpetic gingivostomatitis?
Primary infection of Herpes simplex virus I
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. How do we treat this patient?
Reassurance
Bed rest
Soft diet/ hydration
Paracetamol
Antimicrobial (Chlorohexidine gel 1% or mouthwash 0.2%)
Give advice to parent re infective nature of disease.
What future issues should the herpes simplex virus cause?
Reactivation of the herpes simplex virus- herpes labialis (15-30% of patients) or bell’s palsy.
What timeframes in a child’s life are implicated by MIH?
Pre-natal (rubella, congenital syphilis, thalidomide, Fluoride, maternal A&D deficiency, cardiac & kidney disease.)
Neo-natal- (prematurity, meningitis.)
Post-natal (otitis media, measles, chickenpox, TB, pneumonia, diphtheria, deficiency of Vits A,C&D. heart disease. Long term health problem e.g. organ failure)
Why are those time periods implicated in MIH?
Because the 6s develop 7-12 weeks in Utero and the 1s develop 6-12 weeks after birth
What signs and symptoms does someone with MIH present with. (6)
poor aestehtics = symmetrical well demarcated lesions - white, yellow, brown
sensitivity
High caries
Poor bonding
Ineffective LA
Anxiety
Give the treatment options for MIH incisors?(4)
Acid pumice micro-abrasion
External bleaching
Localised composite placement
Full composite veneers when patient is older.
Give the treatment options for MIH molars? (4)
Direct Restore:
Composite (bonding difficulties)
GIC (benefit of fluoride release)
SSC- if tooth is sensitive/ broken down
Adhesive retained copings- gold to keep teeth long term.
Extraction
What fluoride toothpaste would you advice for low and high risk patients?
<3 years 1000ppm smear
>3 years 1450ppm pea sized
High risk >10 2800ppm pea sized
high risk >16 5000 ppm pea sized
(Answers were saying smear for >3 years rather than peasized)
What are the topical effects of fluoride?(2)
Preventative measure used topically to reduce decay rates by increasing the contact time with fluoride and the tooth surface.
The fluoride ions replace the OH- ions in hydroxyapatite within the tooth to produce fluoroapetite which is less susceptible to demineralisation and acid attack.
Fluoride can also inhibit bacterial pathways which leads to less acid production
Speeds up remineralisation
What are the systemic effects of fluoride?
Fluoride toxicity (>5mg per kg)
Answer says fluorosis but check to see
What are the effects of primary tooth trauma on a primary tooth?
Loss of vitality
Discoloration
Delayed exfoliation - trauma preventing normal exfoliation.
May need extraction
What are the effects of primary tooth trauma on a permanent tooth?
Delayed eruption
Ectopic eruption
Damage to crown development
-crown dilaceration
-hypomineralisation
-hypoplasia
-Damge to root development
-odontome
-undeveloped tooth germ.
What are the eruption dates for the primary dentition?
Upper
8-12/9-13/16-22/13-19/25-33 months
Lower
6-10/10-16/17-23/14-18/23-31 months
What are the eruption dates for secondary dentition?
Upper: 7, 8, 11, 10, 10, 6, 12 years
Lower: 6, 7, 9, 10, 10, 6, 12 years
When do roots fully form?
Approx 2-3 years after the crown erupts.
An injured child attends your practice with his mother. You are concerned for the child’s welfare. What are some factors in your index of suspicion?
- A delay in seeking help
- A vague story which varies each time.
- The story is not compatible with injury.
- Parent behaviour gives you cause for concern (i.e. abnormal mood/ not interested in what’s happening to their child)
- Abnormal interaction between child and parent.
- History of previous injuries
- Contradictions
You are concerned about a child and have referred the child on.
As a result of this onward discussion what THREE different courses of action may take place?
- If the child is in immediate danger- Removal by police. Child protection order/ exclusion order/ child assessment order.
- Further investigations to decide if the child is at risk of significant harm.
From this can be:
A-. No further child protection action deemed neccessary
B- joint investigation (interview of the child by the police and social worker).
You wish to refer the child on. Who do you refer to and how do you do it?
A - Assess
H - History
E - Examination
T - Talk to the child and parent about concerns (if you feel safe)
D - Document: everything and in the patients own words
M - multiagency (Contact senior colleague and/or e.g. dental protection for advice.)
R - refer: Send a notification of concern to Social services. Ensure you follow up within 48hours. You send a copy to Child protection services.
If possible take photographs with permission. Consider contacting police if you feel child is in immediate danger.
What are the indications for a pulpotomy? (4)
Good child cooperation
Medical history
-Haemophilia (avoid extraction)
-Missing permanent successor
-Tooth is needed for space maintenance
-Child is <9years old.
This is done when there is carious or traumatic exposure of a bleeding pulp. We aim to preserve the radicular pulp and control the bleeding.
>1mm pulp exposure or exposure for >24 hours.
Try this before pulpectomy
To avoid extraction (space maintenance- we want to keep it if no permanent successor)
What are the contraindications for a pulpotomy? (7)
Poor-cooperation
Poor dental attendance
Cardiac defect
immunocompromised (best to extract as patient at greater risk of infection)
Multiple grossily carious teeth (the tooth is too bad to restore so we have to extract it )
Advanced root resorption (no point undergoing pulp therapy if the tooth won’t be around for long)
Severe/recurrent pain or infections.
Describe how you would carry out a pulpotomy
It can be a partial pulpotomy (only necrotic coronal pulp) or full coronal pulpotomy. (all of coronal pulp)
- Apply Local anaesthetic
- Isolate the tooth with rubber dam.
- Clean the exposed area with saline
- Disinfect with Sodium hypochlorite.
- Remove the pulp to a depth of 1-2mm using a round diamond bur
- Place a slaine moisted cotton pellet upon the pulp wound & Check haemostasis.
- Apply calcium hydroxide or non staining calcium silicate sealed cement.
- Seal exposed dentine with GIC or composite
- Restore tooth with composite
How is failure of pulpotomy measured clinically and radiographically?
Clinically- Colour/ Pain/ Sinus / Mobility.
Radiographically-Has the root continued to develop (Walls thicker)
Any radiolucency (Periapical pathology)
Any resorption (Internal inflammatory is related to non-vitality)
What is a partial pulpotomy?
When the necrotic coronal pulp is removed and then a barrier of CaOH is placed. (The healthy coronal pulp tissue is left)
How does external inflammatory resorption present on a radiograph? (3)
The root surfaces are indistinct (- loss of lamina dura/PDL???)
tramlines of the root canal are intact
PA radiolucency
Patient attends after lateral luxation of the tooth 18 months previously. This is the radiograph. What type of resorption has occured and what is the mechanism for this?
External inflammatory Resorption- Damage to Periodontal ligament. Maintained and propagated by necrotic pulp tissue (and toxins) reaching the external root surface via the dentinal tubules.
