Paediatrics Flashcards
Trauma (6mins)
A parent with an 8-year-old child (Molly) attends an emergency appointment at your surgery.
Molly sustained dental trauma whilst playing on her trampoline. You have examined her and observed the injury in the photo provided.
You have taken the periapical radiograph provided. The child has just stepped out of the surgery for a moment
- Explain the nature of the child’s injury
- Explain, step by step in detail, what treatment is required for the child today only (the patient
is mildly anxious and the parent would like this information so that they can support their child through the treatment in the best way possible)
- Introduce yourself
- history : when/how did it happen , where and any fragments , any other symptoms and any LOC + tetanus status/ any MH
- Explain nature of trauma
~ enamel-dentine pulp fracture or complicated pulp fracture
~ the fracture involved all three layers of tooth including the nerve - Explain treatment
~ pulpotomy (open apex)
~ As this is a large exposure, the treatment of choice is called a pulpotomy which means partial removal of pulp tissue
~ This aims to keep undamaged pulp tissue alive
~ this is to allow the tooth to stay alive and continue to grow as the apex is still open meaning it allows blood in and give a chance for the tooth to survive - Explain baseline sensibility tests required
~ tests required to see how the nerves respond in the affected tooth and adj teeth
~ Required for long term monitoring
~ this involved testing the reaction of the tooth to cold stimuli and trying an electrode on the tooth to see pulp response - Explain that LA is required
~ inform parent that LA is required to keep patient numb and comfortable , this involves an injection into the gums - Explain the rubber dam is required
~ a rubber sheet isolating the tooth which acts as a mask
~ placed to protect airway and for moisture control - Explain the need for drilling + suction
~ drill will be used to to remove some of the pulp tissue , no pain is felt but may feel the vibration
~ aim is to leave healthy tissue
~ then cotton pledget will be used to control bleeding - Explain dressing
~ the tooth will be dressed with CaOH then with GIC or composite
~ explain that a white filling will be placed to regain aesthetics
Review pt in 6-8 weeks and 1 year
Nursing bottle caries (6 mins)
Concerned mother with 2-year-old in pain
Take a brief history then photo of decayed 52-62 provided
Explain diagnosis to parent, prevention and management options (GA)
- Introduce yourself and greet patient by name
- Take a brief history
~ pain history
~ if they take any analgesia
~ do they take a feeding bottle to bed?
~ what is in the feeding bottle? - Look at photos to identify pattern of decay
~ Usually it is upper incisors, Ds and lower canines
~ explain to pt diagnosis’s of nursing bottle caries
;
“ This happens when the child has a feeding cup with mild at night as the milk contains lactose which is a sugar. As the mild is held in the mouth, the sugar can feed the bacteria which start eating away the teeth causing decay, there is less salivary flow at night which can make it worse” - Give advice
~ Feeder cup should be replaced by bottle after 6 months so child doesn’t havr to suck
~ No feeding at night as reduced salivary flow and there is lactose in mild which is a sugar
~ No on demand breast feeding
~ No sweetened or soya mild unless medically advised
~ Milk and water only between meals
~ use sugar free variations of drinks/foods and medicine
~ Snack on safe snacks such as cheese, crackers, carrots and plain crisps
~ Toothbrushing instructions (smear , 1450 ppm) ; assist the child until 7 Y/O , brush twice once in morning and once at night , no drinks or food except water after brushing ; spit do not rinse ; high fluoride TP - Explain management
~ XLA of carious teeth under GA ( discuss GA risks and benefits) - if in pain - GIC remaining teeth and review - if no pain (acclimitasation)
- Fluoride varnish applications and supplements
- Ask about any questions
What would you discuss with parent of child with nursing bottle caries about GA?
” These teeth are severely decayed and we would not be able to restore them so XLA is the best options under GA as the child is very young and cannot understand what is happening so this is an issue with child cooperation”
” In GA the child is put to sleep so they are unconscious and will not remember the dental procedure, all GA is associated with some risks
Severe
1. Death ( 3 in a million)
2. brain damage
Common
1. pain
2. bleeding
3. sickness “
” Local anaesthesia will be applied to eliminate any pain , so the child might feel some facial numbness / tingling , when this wears off you can use painkillers which will help with the pain afterwards such as calpol”
Fluoride varnish (6 mins)
A parent, Mrs Ina Fleur, was seen by the dental nurse with her 2 year old child Sarah for application of fluoride varnish, but wants to ask you about it first
Have a brief child with her and deal with any concerns
- Introduce yourself and greet patient by name
- Build a good rapport
“ I understand why you are concerned and i would like to reassure you by providing you with some evidence based information as this is what we are here to help for and explain “ - Evidence theme ; ‘ I am wondering why my child needs fluoride varnish’
- Prevention
~ prevention of tooth decay as F remineralises teeth and stop demineralisation , as it is antibacterial
~ there is evidence that F has additional benefit over daily brushing - Recommended for ALL
It is universal as it is not only recommended for high risk pts - Recommended that all children get FV applied at least twice a year
- This is by referring to SDCEP guidance + SIGN
- Harm theme ‘ I’ve heard that too much Fluoride can be harmful is that true? ‘
- Risk
~ low to minimal risk with use FV and brushing twice daily with F tooth paste - FV quantity is carefully controlled
- guidance regarding amount of F ( Smear/ pea)
- Side effects such as Flourosis / presents as mottling ( white/brown/ yellow) spots due to excessive F exposure (aesthetic POV)
- In term of FV , 2yo would have to swallow about 50 mg of F and the amount we place is 5.65 mg (11.3mg for over 6)
What are the contraindications of FV?
- Severe Asthma (hospitalised in the last 12 months)
- Allergy to colophany (sticking plaster) - can use colophany free FV
Instructions after applying FV
- Do not eat or drink for at least 30 mins
- No hard food or toothbrushing for 4 hours
- Avoid F supplements today
- Childsmile says do not brush that night
FV toxicity
- 5mg/kg - give calcium orally and observe
- 5-15mg/kg - give calcium orally and admit to hospital
- > 15mg/kg - admit to hospital immediately, cardiac monitoring and life support , IV calcium gluconate
Consenting and referral to GA (6mins)
- Introduce self and greet patient
- Explain process
~ It is a procedure done in a hospital where specific drugs are used to put child to sleep; these can be delivered using inhalation or IV
~ They will still need LA
~ Todays appointment is to provide info , next one is for assessment and then for the actual GA to be carried out
~ All required tx will be carried out under GA
~ other options include LA ( traumatising , more appointments ) ; under IS ( need older pt who is slightly anxious and able to cooperate) ; under IV ( need to be at least 12 Y/O )
~ after GA done ; vital signs monitored and pt drank and ate ; then can be discharged - Discuss risks
- Common minor risks
~ Headache
~ Nausea
~ Vomitting
~ Drowsiness
~ Sore throat
~ Sore nose and bleeding from intubation - Risks from treatment
~ Pain, bleeding , swelling , bruising , infection, loss of space and sitiches - Rare major risks
~ Brain damage
~ Death ( 3 in a million)
~ Malignant hyperpyrexia ( asl about FH)
- Discuss benefits
~ get them out of pain
~ all treatment is done in one visit
~ aim to make them pain free for at least 5 years - Discuss other options
~ Prevention only
~ Biological caries management
~ LA ± IS , IV , LA only - Discuss contraindications
~ Hypoxia
~ Sickle cell anaemia
~ Diabetes ( cannot fast)
~ Down’s syndrome
~ Malignant hyperpyrexia
~ CF or severe asthma
~ Cardiac and renal conditions
~ Epilepsy
~ Long QT syndrome - Referral
- Explain assessment appointment
~ For treatment planning and may change
~ Consent taken (written)
~ Expain process/risks/benefits
~ adult must escort child with no other children
~ Pre-op fasting ; 6 hours
~ ask if they would like to be referred for assessment
Caries risk assessment and management (6 mins)
Diagnose caries on bitewings , explain prevention and TB advice to mum
Explain where caries is (into E/D/P) , explain how we risk assess caries pts
- Introduce yourself
- Explain how decay forms
“ in order for decay to form it needs several factors ( carbs from diet , plaque bacteria , and time) , when we feed bacteria with sugars it produces acid which therefore eat the tooth structure)” - Caries risk assessment ( Clinical evidence , Diet , MH , SH , F , salive , plaque control )
- Prevention
~ Rx
~ Diet advice
~ TB instructions
~ F TB
~ F supplements
~ FV
~ fissure sealants
~ Sugar free medicines - Give TB advice
~ Assist until age of 7
~ twice daily
~ Let parent demonstrate to you then to child
~ methodical approach ( modified bass technique) - Give Diet advice
~ Avoid sugary drinks and snacks
~ Snack on healtheir foods
~ have mild and water only etween meals
~ avoid letting child to bed with feeding bottle and avoid soya or sweetened milk , no on demand breast feedingn - Give F advice
~ FV 4 times a year ( over 2 years old)
~ Toothpaste twice daily 1450ppm ( under 3 - smear / over 3 - pea) , over 10 yrs 2800 , over 16 5000)
~ do not rinse mouth at least 30 mins after use
~ Mouthwash once daliy at different time from brushing - Treatment depends on caries presenting on BW
Treatment planning for child ( Parent considering complaint) 12 mins
Mucocele , caries , PA pathology, hypodontia
Parent considering taking legal action as previous dentist never took radiographs or advised on treatment
- Introduce yourself
- Start by saying we have 4 problems and are they and how they are caused + explain treatment required
- Caries
~ caused by feeding the plaque bacteria around the teeth with sugars which produces acids , weakening enamel causing decay
~ list carious teeth and explain GA / Sedation/ LA , explain non invasive tx suce as FS , explain the risks of doing nothing
~ Explain how to prevent caries - Mucocele
~ Leave and review if not causing any issues or refer for surgical review ( explain risk of recurrence, stitches, pain and numbness)
~ Explain surgical procedure , site will be numbed up , cut in gums and removal of all the mucocele , then sutures are placed
~ Risks : pain, swelling, bruising, bleeding , numbness , sutures (scar tissue)
~ Explain we have major salivary glands and minor ones in the mouth , mucoceles are a swelling filled with saliva due damage of minor salivary gland ducts causing blockage of salivary flow resulting in a build-up causing a mucocele which can burst
~ explain that removal of it may cause damage to minor salivary glands
~ Explain that it may reoccur
~ Common on the lips but can also happen on FOM and they are completely benign - Hypodontia
~ identify to parent which ones are missing , explain the condition of less teeth at birth , 6% in permanent and 0.9% in primary
~ Potential problems : drifting, space, overreuption, aesthetics and functional problems
~ Explain that for hypodontial there is a MDT working together
~ Tx options ; accept , maintain space with URA , ortho at 6-7 yrs , resorative only , restorative with ortho - PA pathology
~ infection at the bttom of tooth root meaning the tooth is deade
~ Tx options (discuss risks)
1. do nothing ; risk of infection and pain
2 .RCT ( depends on age a cooperation)
3. XLA (under LA, GA, IV, IS)
~ if XLA think about balancing and compensating XLAs of Ds and Cs and space maintainers of Es - Deal with complaint
” I am sorry to hear that this happened to you and i can see that you are upset but i think it would be unhelpful for me to be involved as I do not know the full story”
“ I can only offer these treatment options at this appointment, whatever was offered previously will not change the treatment plan)
“ You can go back to your previous dentist and discuss the matter with them and there should be a complaining procedure “
Tx options for each type of caries in children?
- Occlusal non cavitated
- Occlusal cavitated
- Approximal (early into dentine)
- Approximal ( advanced )
- Anterior cavitated
- Gross without pain or sepsis
- Gross with Sinus / PA pathology
- Occlusal non cavitated
~ Fissure seal
~ complete removal and restore
~ parial removal and restore
~ Prevention alone - Occlusal cavitated
~ Seal with Hall crown
~ Complete removal and restore 9needs cooperation)
~ Partial removal and restore
~ Prevention alone
~ Make lesion self cleansing and prevention - Approximal (early into dentine)
~ Seal with hall crown
~ complete removal and restore
~ partial removal and restore
~ prevention alone - Approximal ( advanced )
~ Seal with Hall crown
~ Complete removal and restore 9needs cooperation)
~ Partial removal and restore
~ Prevention alone
~ Make lesion self cleansing and prevention - Anterior cavitated
~ Complete removal and restore
~ Partial removal and restore
~ Prevention alone - Gross without pain or sepsis
~ XLA
~ prevention - Gross with Sinus / PA pathology
~ XLA
~ Pulp therapy in pts with good cooperation
Deal with parent and child - Staining/missing teeth (12 mins)
Given clinical info and had to reassure parent
- Introduce youself and build rapport
~ Do you have any dental concerns - Assess staining by SHADE guide
- Staining causes
Extrinsic
~ Foods and drinks
~ Smoking
~ Iron tablets
~ CHX mouthwash
Intrinsic
~ MIH
~ Fluorosis
~ tetracycline
~ Trauma
~ Dentinogenesis/ Amelogenesis imperfecta
- Staining treatment
- Do nothing is no concerns reg aesthetics or sensitivity
- Microabrasion ; removal of 100microns of enamel
Adv
~ conservative
~ easy
~ permanent
~ Fast acting
~ best for yellow spots
Dis
~ sensitivity
~ takes away tooth structure
~ Acid used so might cause irritation
~ difficult to predict treatment outcome
- Vital external bleaching ; take imps provide a tray to apply at home at aimed teeth with a bleaching agent ( need to be worn at least 2h overnight)
Adv
~ can be done at home
~ easy to perform
Dis
~ may not be permanent
~ may not work
~ gingival recession
~ sensitivity
~ may over bleach
~ will not bleach restoration
- Composite / procelain veneer
~ good aesthetics
~ tooth prep needed
~ need to wait until age of 18 for stable gingival level
- Composite restoration (localised)
~ may add bulk
~ may not mask totally
~ Can shine through
~ Conservative
~ no tooth prep
~ easy to do
- MCC - destructive
- Missing teeth causes
~ hypodontia
~ Trauma leading to arrested tooth formation ; ankylosis
~ Cyst
~ Retained primary
~ Ectopic
~ Dilaceration
~ Supranumerary - Missing teeth treatment
~ Accept
~ RRB
~ Essix retainer with pontic
~ RPD
~ Implant if over 18
~ Ortho space closure
Non - accidental Trauma (6 mins)
- EO signs
~ Bruising on face (punch - slap - pinch)
~ Bruising of ears ( pinch - pull)
~ Abrasions and lacerations
~ Burns and bites
~ Neck - choke or cord marks
~ Hair pulling
~ Eye injuries
~ Fractures ( nose > mandible > zygoma)
*IO signs
~ Contusions
~ Bruises
~ Abrasions and lacerations
~ Burns
~ Tooth trauma
~ Frenal injuries
- 9 Index of suspicion
~ Delay in seeking help
~ Story is vague and lacking in detail , vary with each telling
~ Account not compatible with injury
~ Parent’s mood is abnormal
~ Parents behaviour causes concern
~ Child appearance and interaction with parent is abnormal
~ Child may say something contradictory
~ history of previous injury
~ History of violence within the family - Taking action
- Preventative dental team management ( Raise concerns , offer suppoer, set targets and keep records for follow up and monitoring progress )
~ Provide urgent dental treatment
~ Explain concerns to parent ; these types of injuries has to be reported , ask for consent to share info
~ record incident and conversation
~ Arrange follow-up
~ Discuss with colleague
- Preventive multi-agency management
~ Liaise with other professionals ( Healthcare visitor, school nurse, GDP , social worker) to see if concerns are shared
~ A child might be subject to common assessment framework
~ Check if child is subject to a child protection plan
~ Agree joint plan of action, review at agreed intervals
- Child protection referral
~ in complex situations
~ Refer to social services by telephone or writing
~ If child in danger right now phone the police
~ Confirm referral and follow up
~ Be prepped to report case in court
Hall crown and separator placement (12 mins)
Part 1 ; Place separator and remove a pre-placed separator , size a hall crown and select correct cement (LAzinol, Ultracal and Aquacem placed)
- Place separators between mesial and distal contacts
~ Floss to pieces of floss through the separator and pull tight between contacts of teeth - Leave in place for 3-7 days
- Remove with a blunt probe
- Sit child upright
- Place gauze swab to
protect airway
*Choose crown - aim to fit smallest size crown that will seat ( use sticky stick)
~ Can use BPE probe to meausure mesial and distal width of tooth and compare this to the crowns available
- Crown ideally should be subgingival or below margins of cavity
- Select the crown that covers all cusps and approached contact points with slight s do not fully seat crown)
- Dry the crown and fill with GIC
- Dry the tooth ( if cavity large place some GIC in cavity)
- Places crown with finger pressure , or by biting on it with gauze
- Remove excess cement
- get pt to bite down for 2-3 mins or fingure pressure
- Remove any remaining cement
- Floss between contacts
- Reassure child and parent
~ Explain that the crown should fit tightly and the gum will adjust by time
~ will get used to the feeling within 24h
~ Occlusion tends to adjust to given contacts bilaterally within weeks
~ Cement tastes like salt and vinegar crisps
What are the advantages of Hall crown and what are some faults associated with it?
- Advantages
1. Non invasive
2. Quick and easy
3. no caries removal or prep
4. biological caries management
Only can be used when there is no pulp involvement , contraindicated in pts with risk of infective endocarditis
- Faults
1. New/secondary caries
2. Crown might wear and can e lost
3. reversible pulpitis
4. irreversible pulpitis ; abscess
5. Tooth might be unrestorable when crown removed
Hall crown and separator placement (12 mins)
Part 2 : Child starts choking on hall crown - deal with the emergency appropriately
- ABCDE
- Are you choking , encourage to cough
- 5 back slaps between shoulder and blades ( child lying down or across knees)
- 5 abdominal thrusts between belly bottun and strenum
- Check ABCDE again
- BLS if not resolved (in case of LOC too )
- Call 999 and refer ti hospital ti check for rib fracture
** cannot do thrusts if child under 1 year **
If infant then put on leg and support jaw by forearm with their face facing down and do the back blows with other hand , for thrusts tilt up while still supporting jaws , then placed two fingers in middle of chest
