Paediatrics Flashcards
7 elements of caries risk
clinical evidence
dietary habits
social history
fluoride use
plaque control
saliva
medical history
what clinical evidence relates to high risk for caries
dmft > 5
caries in 6s at 6 years
3 year caries increment
what special investigation can be used to investigate someone’s dietary habits and specify how to use it
4 day diet dairy
write everything down, timings as well and toothbrushing times and record at least one day over the weekend
what are the actions of fluoride
incorporation into enamel crystal to form fluoroapatite
bacteriocidal
interferes with adhesion force of bacteria reducing ability to stick to surface of teeth
8 elements of caries prevention
radiographs
toothbrushing instruction
strength of F in toothpaste
F varnish
F supplementation
diet advice
fissure sealants
sugar free medicine
what diet advice do we give to mothers for their children
feeding cup rather than bottle from 6 months
never put drinks with free sugars in bottles
restrict sugar to mealtimes
do not put to bed with a bottle
water or milk only
if someone is intaking sugary drinks what advice do we give them about them
mealtimes only
dilute as much as possible
take through a straw held at the back of the mouth
name some safe snacks
milk/water
fruit
savoury sandwiches
crackers and cheese
breadsticks
crisps
how much fluoride intake would give a toxic dose
5mg/kg body weight
what do you do if someone ingests <5mg/kg fluoride
give calcium orally and observe for a few hours
what do you do if someone ingests 5-15mg/kg fluoride
give calcium orally and admit to hospital
what do you do if someone ingests >15mg/kg fluoride
admit to hospital immediately
cardiac monitoring and life support
intravenous calcium gluconate
a 4 year old child weighing 15kg has ingested 75mg of toothpaste, what do you do
give calcium orally and admit to hospital
how many mg of fluoride is in a 90g tube of 1000ppmF toothpaste
90mg
how often do you take bitewings for high risk children
every 6 months
how often do you take bitewings for standard risk children
12-18 months
when do you start taking bitewings
4 years old if tolerable
what is in the guidance for standard prevention
fluoride varnish 2x/year to children over 2
sealants in all molars
check sealants at every visit
toothbrushing advice once a year and demonstrate
diet advice once a year
what is in the guidance for enhanced prevention
fluoride varnish 4x/year to children over 2
sealants in molars, laterals and potentially Ds and Es
consider temp GI sealant until fully erupted for resin sealant
hands on brushing and diet advice at each visit
utilise home/community support
how much fluoride in F varnish
22,600ppmF
what are the volumes of fluoride varnish used for children in nursery and primary 1 and then in primary 2 and above
0.25ml - age 2-5
0.4ml - age 5-7
what is the procedure for applying fluoride varnish
isolate and thoroughly dry the tooth a quadrant at a time to optimise adhesion of varnish to the tooth
apply small amount of varnish with microbrush
advise that soft foods and liquid can be consumed 30minutes after
wait 4 hours before brushing teeth or chewing hard foods
what is the procedure for a resin fissure sealant
clean the tooth with cotton wool
isolate with cotton wool, saliva ejector and dry guard
etch 30secs, wash and dry
apply resin and light cure
check sealant with probe
what would be indicative of a leaky fissure sealant
opalescence visible at sealant and tooth interface
when would you consider the use of a glass ionomer material for fissure sealant
pre-cooperative child
moisture control issues
partially erupted tooth
what is the finger press technique for glass ionomer fissure sealants
place small amount of GI on one finger and vaseline on another
wipe tooth surface with cotton wool roll
firmly press with GI finger and keep in place for 2 minutes
place second finger in mouth and switch over so vaseline finger is covering GI
what is the point of vaseline over GI fissure sealant
prevents moisture contamination
what acronym is used for motivational interviewing and what does it stand for
SOARS
Seek permission
Open questions
Affirmations
Reflective listening
Summarising
what are the steps in a conversation about habit formation
1 - SOARS to gain knowledge on situation
2 - educational intervention (provide facts)
3 - action planning (set date/time)
4 - encourage habit formation
5 - repeat at each recall visit
what ideas can we give the parent during a motivational interviewing/behaviour change conversation to get them to incorporate toothbrushing more into their routine
identify convenient time and place when task is to be carried out
identify trigger for child/parent to carry out behaviour
agree date to review
agree action plan and write it down for them
record action plan in child’s notes so it can be referenced at subsequent visits
give further support and review continually
definition of dental neglect
persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development
what is the tiered approach to managing neglect concerns
preventive dental team response
preventive multi-agency response
child protection referral
what do you do in the preventive dental team response to child neglect
raise concerns with parents and carers
explain what changes are needed
offer support
keep accurate records
set targets for improvement
review progress
what do you do in the preventive multiagency management of child neglect
liaise with health visitor/school nurse/GP/paediatrician/social worker and find out if child is known to social services
when should a child protection referral be made
when there is a concern that the child is suffering or is likely to suffer significant harm from neglect
why do missed dental appointments cause concern
alerting feature that a child is being neglected
often found when a child has died or been seriously harmed by maltreatment
should be followed up rigorously
what features give cause for particular concern after parents/carers have been made aware of dental problems and acceptable treatment has been offered
obvious untreated dental disease
evidence that dental disease has resulted in a significant impact on the child’s wellbeing
failure to obtain care despite having access to care
what are the 5 key GIRFEC questions
what is getting in the way of this child’s wellbeing
do i have everything i need to help this child
what can i do now to help this child
what can my agency do to help this child
what additional help may be needed from others
what are the principal strategies for managing caries in the primary dentition
no caries removal and seal with Hall Crown
no caries removal and fissure seal
selective caries removal and restoration
pulpotomy
what would initial occlusal caries look like in a primary molar and what would be the action
teeth with noncavitated lesions (white posts/discolouration/stained fissures)
place fissure sealant
consider hall crown if FS not appropriate
what would advanced occlusal caries look like in a primary molar and what would the action be
teeth with cavitation or dentine shadow and visible dentine
selective caries removal and restore with composite/RMGI
hall crown if pre-cooperative or if proximal lesion present too
SDF if extensive cavitation
what happens if on a radiograph there is no clear band of separation between carious lesion and dental pulp on a primary tooth
seal with hall technique if asymptomatic
pulpotomy/XLA if symptomatic
what do you do if there is initial caries in a primary molar in the proximal site
site specific prevention and monitor at each recall visit
what do you do if there is advanced caries in a primary molar in a proximal site
hall crown
selective caries removal and restore
SDF
what do you do if there is initial caries on primary anterior teeth
site specific prevention
what do you do if there is advanced caries on primary anterior teeth
selective caries removal and restore
SDF
what treatment can be used for reversible pulpitis on a primary tooth
hall crown
selective caries removal and restore
sedative dressing if close to exfoliation
pulpotomy/XLA if symptoms do not resolve
what treatment can be used for irreversible pulpitis on a primary tooth
pulpotomy/XLA
apply corticosteroid antibiotic paste under a temporary dressing
refer for GA
what do you do if a child has a dental abscess on a primary tooth
XLA if cooperative
or refer for GA if precooperative
when do first primary molars exfoliate
9-11 years
when do second primary molars exfoliate
10-12 years
what is the aim of site specific prevention
stop enamel caries progressing and promote remineralisation of initial lesions
what do you do with site specific prevention
show carious lesions
make them aware of responsibility
demonstrate effective brushing
give diet advice
apply fluoride varnish
keep a record of site and extent of lesion
record details of agreed treatment in notes
review after 3 months
enhanced prevention
what do you do if initial occlusal caries in permanent teeth
fissure sealant and review
what do you do if moderate dentinal caries in occlusal surface of permanent tooth
selective caries removal or complete caries removal
seal remaining fissures
what do you do if extensive dentinal caries in occlusal surface of permanent tooth
selective caries removal to avoid pulpal exposure and seal remaining fissures
pulp therapy if caries extended to pulp
what do you do if initial proximal caries on permanent tooth
identify and arrest enamel lesions with site specific prevention and monitor
what do you do if moderate proximal caries on permanent tooth
selective/complete caries removal and restore and seal fissures
define a first permanent molar with poor prognosis
teeth with moderate to severe MIH, advanced caries, symptomatic, dental infection, pulpal involvement, periradicular pathology
what is included in the assessment of first permanent molars of poor prognosis
consider age and stage of development
assess capacity of patient to receive complex dental care
consider availability of services
determine if pain or infection
determine caries risk and suitability for orthodontic treatment
assess occlusion
get OPT
what factors contribute to optimal occlusal outcomes for a child when thinking about extracting FPM’s
age
class 1 incisor and molar relationship
mild buccal crowding or no buccal crowding/spacing
second premolars and third molars present on radiograph
distal angulation of SPM’s
birfurcation of SPM’s
when would you obtain an orthodontic/paeds opinion before extracting FPMs
missing permanent teeth
malocclusion (class 2 div 2/class 3)
signs of generalised developmental defects
if a MIH molar is sensitive what can you do
glass ionomer fissure sealants
preformed metal crown (will need trimmed)
what is the procedure for the hall technique
ensure child sitting upright
assess separator requirement
select correct size of PFM
ensure crown well filled with GI
seat PMC
get child to bite on cotton wool over crown
remove excess cement and floss
what are the steps for ICON resin infiltration
clean teeth with toothbrush/prophy
place icon-etch and leave for 2 minutes
remove syringe and dry for 30 seconds
use icon-dry for 30 seconds and dry
place icon infiltration syringe and leave for 3 minutes
remove excess and light cure for 40 seconds
repeat last 2 steps
what are the properties of SDF
silver is bacteriocidal and disrupts the cariogenic biofilm
fluoride promotes remineralisation of tooth surface
what are the contraindications to SDF usage
irreversible pulpitis/dental abscess/sinus
allergy to silver and metals
active ulceration, mucositis, stomatitis
pregnant or breastfeeding
patients undergoing thyroid gland therapy or on thyroid medication
what is the procedure for SDF
make aware of discolouration and obtain valid consent
pre-op photos and radiographs to allow monitoring
clean teeth
apply vaseline to soft tissues and gingiva
dry carious lesion
carefully apply SDF solution
wait for 3 minutes if possible
blot teeth dry using cotton wool roll
review 2-4 weeks after
how often can SDF be reapplied
6 monthly
how does a preformed metal crown differ from a hall crown
need to remove caries and shape the tooth if preformed metal crown (occlusal reduction and interproximal separation)
when is a pulpotomy on primary teeth suitable
irreversible pulpitis
advanced caries on a primary molar that goes into the pulp
technique for pulpotomy on primary teeth
LA and dam
cut large access cavity and de-roof pulp chamber
remove contents of pulp chamber with slow speed/excavator
irrigate with sterile saline/NaOCl
arrest bleeding with ferric sulphate (posterior tooth)
place MTA/ZOE cement on floor of pulp chamber
fill with ZOE cement and place PMC
what is the procedure for a pulpotomy for a permanent tooth
LA and dam
disinfect tooth with NaOCl
remove caries
disinfect access cavity with cotton wool pellet and NaOCl
access pulp chamber
enlarge access and deroof pulp chamber
disinfect pulp chamber with NaOCl
remove coronal pulp tissue incrementally
apply pressure with sterile cotton wool pellet and NaOCl to gain haemostasis
identify all canal orifices and ensure that the canal pulp tissue is healthy
gently dry pulp chamber
place biomaterial up to ADJ
restore with direct restoration (probably composite)
what is the advice to the child and parent after having a pulpotomy
may be some discomfort when anaesthesia wears off and they may need analgesia
if symptoms do not settle within 48 hours or increase in intensity then may require RCT
what is the review time frame for after pulpotomy on permanent tooth
annually for 4 years
what would the local measure be for a primary tooth that has an abscess/periapical periodontitis symptoms
use hand excavation of carious tissue to drain infection without local anaesthetic
this achieves open communication with necrotic pulp chamber
(DO NOT place sedative dressing unless the tooth was tender prior to drainage)
what is the local measure for a permanent tooth that has an abscess/periapical periodontitis symptoms
access pulp chamber to remove necrotic pulp and/or achieve drainage
undertake incision of swelling
what is a balancing extraction
extraction of a contralateral tooth in order to minimise a centre line shift to maintain symmetry of the developing occlusion
when do you consider a balancing extraction
one canine is to be extracted/has exfoliated prematurely due to eruption of lateral
a centre line shift is developing after extraction of a D
when are balancing extractions not necessary
loss of primary incisors
loss of first primary molars
loss of second primary molars
how do you minimise iatrogenic damage to adjacent teeth when restoring a proximal cavity
leave the marginal ridge intact when preparing cavity and then remove ridge with excavator/gingival trimmer so high speed is not near adjacent tooth
what techniques can be used to reduce the discomfort of LA use
topical anaesthesia
distraction
suction to remove excess anaesthetic and to aid retraction of the tongue
a very slow injection technique
intrapapillary injections before palatal injections
what does the wand allow
constant slow flowrate of anaesthetic solution
name some behaviour management techniques used in paediatric dentistry
enhancing control
tell, show, do
behaviour shaping and positive reinforcement
structured time
distraction
relaxation
systematic desensitisation
what is enhancing control
stop and go signals
what is behaviour shaping and positive reinforcement
positive reinforcement of desired behaviour increasing probability of that behaviour being repeated while ignoring undesirable behaviours to avoid drawing attention to them
what are effective ways of distracting children when considering behaviour management techniques
cartoons
pulling lip as LA is given
raising legs when radiography/impressions
verbal distraction
what relaxation techniques can you show a child to help with behaviour management
ask child to place a hand on their tummy
ask them to breathe in slowly and deeply
watch to see if their tummy rises
ask them to do this 3 times
how do you perform systematic desensitisation with children
discuss with child how to recognise signs of stress and anxiety
teach child how to manage their anxiety
teach child how to describe their level of anxiety from scale of 1-10
break procedure down into stages and describe all stages to the child
give control then try the first stage asking the child at the end of it to describe their anxiety level
what must you do before referring a child for treatment with sedation or GA
relieve pain
provide prevention
attempt caries treatment using behavioural management techniques and local anaesthesia if indicated
what do you do at each recall appointment
oral health review (toothbrushing and diet habits)
enquire about compliance with agreed action plans
closely monitor lesions managed with prevention
check fissure sealants
reassess childs caries control
treatment for enamel fracture
bond fragment or restore with composite
follow up 6-8 weeks then 1 year
treatment for enamel-dentine fracture
bond fragment, rehydrate first by soaking in water or saline for 20 minutes
cover exposed dentine with GI and composite resin
follow up 6-8 weeks, 1 year
symptoms of complicated crown fracture
sensitive to stimulus but otherwise normal and no mobility
treatment for complicated crown fracture
PARTIAL PULPOTOMY
non setting CaOH placed on exposure
if fragment is available it can be bonded back on to the tooth after rehydration or cover dentine with GI and use composite
follow up 6-8 weeks, 3 months, 6 months, 1 year
symptoms of an uncomplicated crown-root fracture
sensibility tests positive
TTP positive
mobile fragments
treatment for uncomplicated crown-root fracture
temp stabilise loos fragment (consider removal of this)
cover dentine with GI/composite
ortho extrusion
surgical extrusion
RCT and restoration
extraction
follow up 1 week, 6-8 weeks, 3 months, 6 months, 1 year, yearly for 5 years
treatment of complicated crown-root fracture
stabilise fragment temporally
immature teeth = partial pulpotomy
mature teeth = RCT
ortho extrusion
surgical extrusion
extraction
follow up 1 week, 6-8 weeks, 3 months, 6 months, 1 year, yearly for 5 years
symptoms of root fracture
coronal segment mobile/displaced
TTP
bleeding from sulcus
negative sensibility testing initially
radiographs used for root fractures
one PA
occlusal
parallax
treatment of root fracture
reposition coronal fragment (check with xray) and splint for 4 weeks
monitor pulp and healing root for 1 year
endo of coronal fragment if necrotic pulp
if very mobile coronal fracture then remove piece, RCT and place post
follow up 4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, yearly for 5 years
clinical findings of alveolar fracture
segment mobility and displacement with several teeth moving together
occlusal disturbances
unresponsive to sensibility testing
treatment of alveolar fracture
reposition displaced segment and splint for 4 weeks
suture gingival lacerations
do not RCT at emergency visit
monitor pulp of all teeth involved to see if endo needed
follow up 4 weeks, 6-8 weeks, 4 months, 6 months, 1 year, yearly for 5 years
clinical findings with percussion
TTP
treatment for concussion
none
monitor pulp for 1 year
follow up 4 weeks, 1 year
clinical findings of subluxation
TTP
increased mobility
bleeding from gingival crevice
may not respond to pulp sensibility testing
treatment for subluxation
none
passive flexible splint to stabilise tooth for up to 2 weeks if excessive mobility/tenderness
monitor pulp 1 year
follow up 2 weeks, 12 weeks, 6 months, 1 year
clinical findings of extrusion
elongated tooth
increased mobility
no response to pulp sensibility tests
treatment of extrusion
reposition tooth by gently pushing it back into tooth socket
stabilise for 2 weeks
monitor pulp
follow up 2 weeks, 4 weeks, 8 weeks, 12 weeks, 6 months, 1 year, yearly for 5 years
unfavourable outcomes of extrusion
symptomatic
pulp necrosis
apical periodontitis
breakdown of marginal bone
external inflammatory resorption
clinical findings of lateral luxation
tooth displaced palatally/lingually
associated fracture of alveolar bone usually
ankylotic percussive note
no response to pulp testing
treatment of lateral luxation
reposition tooth and stabilise for 4 weeks
monitor pulp
make endo evaluation at 2 weeks (immature may revascularise spontaneously, mature likely need RCT)
follow up 2 weeks, 4 weeks, 8 weeks, 12 weeks, 6 months, 1 year, yearly for 5 years
how do you reposition a tooth which has suffered lateral luxation
palpate gingiva to feel apex of tooth, then use another finger or thumb to push tooth back into its socket
clinical findings of intrusion
tooth displaced into alveolar bone
ankylotic percussive tone
no response to pulp testing
treatment of intrusion
immature = spontaneous repositioning, ortho repositioning (after 4 weeks), monitor pulp
mature = <3mm then spontaneous repositioning, 3-7mm surgical/ortho repositioning, >7mm surgical reposition, RCT after 2 weeks
follow up 2 weeks, 4 weeks, 8 weeks, 12 weeks, 6 months, 1 year, yearly for 5 years
why do you dress the tooth with CaOH between endodontic appointments
prevent development of inflammatory external resorption
treatment of enamel fracture of primary tooth
smooth sharp edges
unfavourable outcomes of enamel fracture, enamel-dentine fracture, complicated fracture, crown-root fracture in primary teeth
symptomatic
crown discolouration
signs of pulp necrosis and infection
no further root development of immature teeth
treatment of enamel-dentine fracture in primary teeth
cover all exposed dentine with GI/composite
follow up 6-8 weeks
treatment of complicated crown fracture in primary tooth
periapical radiograph
preserve pulp by partial pulpotomy
follow up 1 week, 6-8weeks, 1 year
treatment of crown-root fracture in primary tooth
periapical radiograph
restorable = cover dentine with GI, if exposed pulp then pulpotomy
unrestorable = extract loose fragments/entire tooth
follow up 1 week, 6-8 weeks, 1 year
when a child has had an injury that has gingival lacerations what should the parents do to clean it
clean affected area with soft brush or cotton swab combined with alcohol free 0.1-0.2% chlorhexidine mouthrinse applied topically twice a day for 1 week
treatment of root fracture in primary tooth
extract loose coronal fragment
gently reposition loose coronal fragment
and stabilise for 4 weeks
follow up 1 week, 6-8 weeks, 1 year
treatment of alveolar fracture in primary teeth
reposition and splint for 4 weeks
refer to child orientated team
follow up 1 week, 4 weeks, 8 weeks, 1 year, follow up at age 6 to assess permanent teeth
treatment of concussion of primary tooth
no treatment and observe
follow up 1 week, 6-8 weeks
unfavourable outcome of concussion, subluxation, extrusion, lateral luxation, intrusion of primary teeth
symptomatic
signs of pulp necrosis
no further root development
negative impact on development of permanent successor
treatment of subluxation of primary tooth
no treatment and observe
follow up 1 week, 6-8 weeks
treatment of extrusion of primary tooth
spontaneous reposition if not interfering with occlusion
if mobile/>3mm then extract
follow up 1 week, 6-8 weeks, 1 year
treatment of lateral luxation of primary tooth
spontaneous reposition
extract if severe displacement or gently reposition and splint for 4 weeks
follow up 1 week, 6-8 weeks, 6 months, 1 year
treatment of intrusion of primary tooth
spontaneous reposition
refer to paeds
follow up 1 week, 6-8 weeks, 6 months, 1 year
treatment of avulsion of primary tooth
do not reimplant
clean gingiva with CHX
follow up 6-8 weeks and at 6 years of age
first aid for avulsion
pick up by crown
rinse in milk/saline/saliva and reimplant or store in milk
bite on gauze
see dentist immediately
when are PDL cells most likely viable after avulsion
if tooth has been reimplanted within 15 mins
when are the PDL cells maybe viable but compromised after avulsion
tooth kept in storage medium and EDT is <60mins
when are the PDL cells likely to be non-viable after avulsion
EDT >60 mins
treatment for avulsion when the tooth has already been reimplanted
clean area
verify position clinically and radiographically
leave tooth/teeth in place
administer LA
stabilise with splint for 2 weeks
suture gingival lacerations
initiate root treatment within 2 weeks after replantation
check tetanus status
post op instructions
consider ABX
requirements of a splint for avulsion
2 weeks
passive, flexible wire
0.4mm
if an avulsed tooth has not been reimplanted and it has a closed apex what do you need to do
start RCT within 2 weeks (especially if EDT >60mins)
if an avulsed tooth has not been reimplanted and it has an open apex what do you need to do
reimplant and allow it to revascularise but keep under observation
patient instructions after avulsion has been reimplanted
avoid contact sports
maintain soft diet for up to 2 weeks
brush teeth with soft toothbrush after each meal
CHX 0.12% mouthrinse twice a day for 2 weeks
