Paediatrics Clinical Sessions Flashcards
what questions would you ask when taking a pain history from a child?
- where is the pain
- what does it feel like
- how long has it been sore
- does it keep you awake
- does anything make it worse or better
- how did the pain start
- are you taking any medicines for the pain
what is the sequence of prevention in primary dentition
- prevention is key
- fissure sealant
- preventative restorations
- simple fillings (think no LA/dental dam)
- fillings requiring LA but not into the pulp (in co operative children)
- pulpotomy/pulpectomy (in the upper arch 1st)
when is LA not required for restorative in paediatrics
when there are minimal caries which can be removed by hand excavation or slow speed burs
what is LA required for paediatrics
when doing any cavity prep which it extensive and cannot be hand excavated
what are some of the positives and negatives of using rubber dam in children?
positives
- there is a high risk of pulp exposure in primary dentition therefore the dam provides protection from infection
- the dam can provide more moisture control which will increase the longevity of restorations and prevent the need for more work to be done in the future
- a split dam technique can be used to aid comfort
negatives
- some children will not be able to tolerate the dam
- the dam can be painful and uncomfortable which may leave the child with a negative image of the dentist
what restorative materials are used in paediatric dentistry
- fissure sealants (bis-GMA resins and GIC)
- temp and permanent dressings e.g. ZOE
- GIC
- RMIGC
- compomer
- composite
- preformed metal crowns
REMEMBER amalgam is not used in under 15s since 2018
what factors may influence your decision making (e.g. what material, dam?, LA?) when restoring a primary molar
- the extent of the caries
- the cooperation of the child
- the longevity of the tooth itself
- the ability to retain moisture control
- the time the child is willing to sit for
what is the order of longevity of restorations in primary teeth?
- preformed metal crowns last longest
- compomer and amalgam last about 3 years (but amalgam not used anymore)
- composite
- RMIGC
- GIC
what instruments are required for placing a stainless steel crown?
- tapered diamond separating bur
- preformed metal crown
- GIC luting cement
- crimping pliers to adapt the crown to the tooth
- curved crown scissors
how would you select a crown for a primary tooth
trial and error, measuring the MD distance or using an impression (however, this takes away the advantage of this being a fast process)
how would you prep a primary tooth for a stainless steel crown
- begin by breaking the contact point
- using side to side sweeping and deliberate motions, go toward the gingival margin
- reduce the level of the occlusal surface by 1-2mm, following the contour of the cusps
- smooth very lightly over any rough edges buccally/palatally/lingually
- overall you are aiming for a rectangle shape with a slight slope on the mesial and buccal aspect
what are some of the common problems for stainless steel crowns
- canting (uneven occlusal reduction so the crown leans to one side)
- rocking (if the maximum bulbosity lies more than 1mm of the cervical margin)
- loss of space (if the carious lesion is extensive the prep may be square)
what are the 2 methods of placing a crown in primary teeth
- conventional stainless steel crown
2. the hall technique
describe the Hall technique
- minimally invasive crown placement
- does not usually require any tooth prep or LA
- can use separators to make more room for the crown
- there is enough tooth tissue left to retain the crown
ideally, how should a preformed crown fit at the gingival margin
it should be subgingival or at least below the margin
how are separators placed
- loop 2 lengths of dental floss through the separator
- floss between the teeth
- the separator should encircle the contact point
- the separator should be removed after 3-5 days to prevent it being painful, stripping the gum or going subgingivally
describe the stages of the hall technique
- have the patient sitting upright incase the crown was to slip
- dry the crown after fitting it
- gill the crown with GIC luting cement and ensure the inside is evenly coated with no air bubbles
- dry the tooth if possible
- partially seat the crown until the contact points are engaged
- ask the patient to bite down for 2-3 minutes to seat the crown in the occlusion, alternatively press using your finger
what may concern the patient after the hall technique is done and how can you reassure them
patient may be concerned that the gingiva is blanched, ensure them that this is good and shows the crown is a good fit and it will dissipate in 24hours
the patient may be concerned that their occlusion feels high, but reassure them this is because the tooth was not reduced and that the occlusion will balance out over the coming weeks
what can cause minor failure of the hall technique
- new or secondary caries
- crown is worn or lost
- the crown has been lost but the tooth can be restored
- there is reversible pulpitis only requiring a pulpotomy
what can cause major failure of the hall technique
- irreversible pulpitis requiring pulpectomy
- abscesses requiring draining/pulpectomy/extraction
- interradicular radiolucency
- the crown is lost but the tooth cannot be restored
what may you use if a patient has had their E’s extracted but their premolars have yet to erupt
a space maintainer
what are the disadvantages of unplanned extraction of primary teeth
- loss of space which increases the risk of malocclusion
- loss of masticatory function
- speech defects
- psychological disturbance
- trauma from LA or surgery
what are indications for pulp treatment in children
- the child is cooperative
- the medial history preludes extraction (e.g. there is a bleeding risk)
- there is a necessity to preserve the tooth as a space maintainer
- the child is under the age of 9 as they still have a long time to go with their primary teeth
what are contra-indications for pulp treatment in primary teeth
- poor cooperation in the child
- poor dental attendance
- cardiac defects (risk of IE)
- multiple cross carious lesions (likelihood of failure)
- advanced root resorption
- severe or recurrent pain or infection
what are the success rates of vital teeth restored with pulp caps
very low
what is the success rate of a vital tooth restored with a pulpotomy
80-100% over 3-5 years
what is the success rate of a non-vital tooth treated with a pulpectomy
90%
what is a pulpotomy
removing all non-vital coronal pulp tissue from a vital tooth to prevent necrosis and preserve the vitality of the tooth
what should ALWAYS be done when doing a pulpotomy
- LA
- remove ALL caries before exposing the pulp
- remove the entire roof of the pulp chamber
- preserve apical or radicular pulp
what is the technique for a pulpotomy
- administer LA
- AMPUTATION
- remove the caries
- remove the roof of the pulp chamber
- remove the coronal pulp using a slow speed or hand held excavator
- place a cotton pledget with ferric sulphate to arrest the haemorrhage
- place ZOE over the pulp chamber and root stumps
- restoration of cavity with GIC
- cover the tooth with a preformed metal crown
what is a pulpectomy
removal of non-vital, hyperaemic pulp or pulp with irreversible pulpits
what is a large giveaway for irreversible pulpitis
a sinus
what is hyperaemic pulp
pulp which bleeds a lot
what are the symptoms suggesting a pulpectomy is required
- irreversible pulpitis
- periodical periodontitis
- chronic sinus
what is an indication for a pulpectomy
excellent patient cooperation
how do you estimate the working length
using periapical radiographs and cutting 2mm of the end to preserve the permanent successor
why would you measure 2mm short on the working length in primary pulpectomy
to prevent damage to the permanent successor
what can be done as first aid for a crown fracture
- take a medical history
- examine the patient
- cover over the dentine with a very thin layer of composite to provide a composite bandage before the definitive restoration
what is the technique for a pulpectomy
- administer LA
- remove all caries
- expose the pulp by removing the roof
- remove coronal pulp
- used files to remove the pulp tissues from all canals 2mm short of the ends
- irrigate the canals with chlorhexidine and dry with paper points
- obturate the canals with vitapex
- seal the canals with ZOE and GIC and cover with a preformed metal crown
what is the anatomy like for primary pulp chambers
very narrow and ribbon shaped
what failures of pulpectomy can be discovered clinically
- chronic sinus forms
- pathological mobility of the tooth
- pain
what possible failures of a pulpectomy can be discovered radiographically
- increased radiolucency
- external or internal resorption of the tooth
- furcation bone loss
how would you manage an enamel fracture in an incisor
smooth down the lesion and provide an acid etch tip
how would you manage an enamel and dentine fracture in an incisor
an acid etch tip with composite or attachment of the fragment
how would you manage a fractured incisor with a plural exposure
pulp cap with CaOH or partial pulpectomy/ total pulpotomy
what can determine the prognosis of a plural exposure from trauma
- an associated PDL injury which could sever the blood supply or luxation (displacement)
- the extent of dentine exposed
- the age of the patient if the apex is open or closed
is the risk of necrosis higher with an open or closed apex
closed apex
when would you place a cap on a vital tooth with an open apex
if the exposure is small and has been open for less than 24hours
how would you do a pulp cap
- arrest the lesion with a damp cotton wool pledget and pressure
- apply CaOH directly into the exposed site
- apply a dressing or definitive restoration over the site
what are your treatment options for an immature tooth (open apex) with non vital pulp
- pulpectomy
- apical barrier formation
- apexification
what is the difference between an apical barrier formation and apexification
an ABF is using MTA to create a gutta percha against which the filing material can be condensed
apexification is apply CaOH into the root canal to encourage the formation of the root over many months
how would you conduct an apical barrier formation using MTA
- inject 5mm of MTA (mineral trioxide) using an applicator or probe
- placement may be aided by a microscope
- wait 24h (15 mine for new technology) for the barrier to set and investigate it radiographically
- then restore the tooth
how would you cause apexification
apply CaOh in the root canal and this will induce the tooth to form over 9months
- some say to use MTa to replace this after 30 days as the CaOH can weaken the tooth and make the root prone to fracture
what are your treatment options for a tooth with a closed apex and pulp exposure
- pulp cap if the exposure is small and less than 24 hours old
- pulpotomy if the exposure is large and more than 24hours old but still vital
- pulpectomy if the exposure is older than 24 hours and necrotic pulp is present
- standard RCT
what are some of the uses of CaOH
- disinfectant for immature root canals as it can reduce microbial load when there isn’t enough root dentine to allow debridement
- form a calcific barrier after a pulpotomy
- induce barrier formation at the apex of no vital immature teeth (usually incisors) this is apexification
why is the use of CaOH only advocated for 406 weeks
it makes dentine brittle and more prone to fracture
what should you suggest to a patient with an avulsed tooth
- the time the tooth spends outside the mouth affects its vitality so make sure you get it back in the socket ASAP if you can
- if you can’t get the tooth back in, place it in milk or saliva so it doesn’t dry out
- try and not touch the root of the tooth only handle it by the crown
- wash it for only 10 seconds gently if it is dirty before reimplanting it
- if it is an avulsed primary tooth don’t put it back in as this could damage the permanent successor
what are the options for an avulsed tooth
- place it back in the socket and secure it with a splint
- start RCT in two weeks if the tooth was out of the socket for more than 30-45 mins otherwise it will become necrotic
- if the tooth was reimplanted quickly just keep an eye on it
what are the 3 split options
- flexible splint for 2 weeks
- flexible splint for 4 weeks
- rigid splint for 4 weeks
when would you place a flexible splint for 2 weeks
when the tooth is avulsed but there is no luxation
when would you place a flexible splint for 4 weeks
when there was a luxation injury and the tooth needs to be surgically reimplanted
OR
if there was an apical or middle 1/3 root fracture
how long would you place a flexible splint for a cervical root fracture
up to 4 months
when would you place a rigid splint
when there is a dento-alveolar fracture
what is the best type of splint
a composite wire splint
what alternative splints are there and when would they be used
- temporary foil splint - only used very temporarily until a proper splint is placed
- acrylic splint - useful when there aren’t many abutments, resemble a retainer
- orthodontic wire splints - used when there is an intrusion injury to pull the tooth back down, often useful when the patient already has an orthodontic appliance
- vacuum formed splint - rarely used, looks like a gumshield, compromises OH
what should all splints be and why
PASSIVE
- this prevents them from exerting forces on the teeth and causing them to move
how would you make and place a composite wire splint
- cut the appropriate length of 0.6mm stainless steel wire
- bend to sit passively on the teeth
- apply acid etch composite to the tooth and abutments
- gently seat the wire in the composite
- mould and smooth the composite around the wire
- cure
- smooth down any exposed wire ends or rough composite
what is fissure sealant
a protective plastic coating used to seal pits and fissure to prevent bacteria and food getting caught and causing decay
what are some indications for fissure sealant
- children with high caries risk should have molars and premolars sealed on eruption
- mentally compromised children, or those with mental or physical disability, should have all teeth sealed
- children with low caries risk may not need sealant, but SDCEP guidance suggests all pits and fissures of 1st PM’s should be sealed ASAP after eruption
what materials are used for fissure sealant
- bis-GMA resins following acid etch
2. GI if indicated
how often should fissure sealant be removed clinically and radiographically
clinically every 4-6 months and radiographically according to CRA (6 months for high risk and 12-18 months for low risk)
what checks should you do once you have placed a fissure sealant
- use probe to make sure it is firmly in place
- check for air bubbles
- check no material has flowed interproximally
- check there is no excess material
what are the staged for placing a fissure sealant
- isolate the tooth using a single tooth dam
- can use dry guards or cotton wool to aid moisture control
- have a nurse aid with retraction and aspiration
- work quickly to reduce the chances of moisture contamination
- apply 35% phosphoric acid to the dried tooth to etch the surface and then wash it directly into the aspirator
- dry the tooth to make sure the surface is chalky
- apply the sealant or resin to the fissure pattern
- use a micro brush of small hand held excavator to smooth and apply the resin
- ensure the material is at the base of the fissure, and that is it not overfilled as this creates retention
- light cure the resin
- wash the surface and clean with pumice and water
what are some indications that a child may require fissure sealant in selected teeth
- if there are occlusal caries in the 1st PM then the 2nd PM must be sealed on eruption
- if there is caries in the 1st PM the other 3 molars should also be sealed
- in high risk children, the buccal pits of lower molars and palatal pits of upper molars should be sealed
- cingulum of upper incisors should be filled in high risk cases
what are idications that GI should be used as fissure sealant
- the child has low cooperation with the dam therefore good moisture control cannot be obtained
- the child has a high sensitivity to the 3 in 1 as they have an enamel development defect
- the molars are partially erupted but high risk and you cannot place a dam
- the child has special needs
how would you place a GI fissure sealant
- dry the tooth as much as possible with air or cotton wool if this is painful
- apply the GI from the applicator
- smooth the GI into the fissures and pits using a thumb or finger
- keep a finger over the GI or apply petroleum jelly until it sets to aid moisture control
what is a stained fissure defined as
a fissure stained brown, black, or opaque white which has no evidence of cavitation
what are some methods you could use t diagnose a stained fissure
- air abrasion
- fibre optic trans illumination
- bitewing radiographs
- probe
- visualise by drying the tooth
how would you treat a stained fissure
- if the lesion is carious restorative Tx required
- if it is a small lesion it may be covered with a resin or sealant restoration to prevent it progressing
- if it is an extensive lesion it must have classic restorative treatment
how would you manage virgin caries in 1st permanent molars
- keep the restoration as small as possible due to risk of plural exposure
- you may wish to use a stepwise technique as the risk of plural exposure is high
- consider the longevity of the tooth
what are some indications to extract a 1st permanent molar
- there is bifurcation of the lower 7’s in radiographic assessment
- the 5’s and 8’s are all present and seem to be in a good position
- there is crowding in the buccal regions
- the patient has a class 1 incisor relationship therefore the risk of malocclusion is lower
