Paedriatric Dentistry Flashcards
What are the indications for Inhalation Sedation in Adults and Children? (6)
Anxiety
Needle phobia
Gagging
Traumatic procedures
Medical conditions aggravated by stress
Unaccompanied adults requiring sedation
What are the contraindications of Inhalation Sedation in Adults and Children? (7)
Common cold
Tonsillar/Adenoidal enlargement
Severe COPD
First trimester of pregnancy
Fear of ‘mask’/ Claustrophobia
Patients with limited ability to understand
Obstruction of the operation field by mask
What are the components of the equipment utilised in Inhalation Sedation? (7)
Gas cylinders
Pressure reducing valves
Flow control meter
Reservoir bag
Gas delivery hoses
Nasal hood
Waste gas scavenging system
What is the purpose of the Flow Control Meter in the equipment used in Inhalation sedation?
Measures flow rates of up to 10 l/min
Blue= nitrous oxide
Clear= oxygen
Accuracy +/- 5%
What is the function of the Reservoir bag component of the Inhalation Sedation equipment?
2-3 litre bag; rubber or silicone
Should move visibly with each breath and must not collapse
Monitors respiration
What is the diameter of the gas delivery hose component of the Inhalation Sedation equipment?
2.5cm
What is the function of each hose of the gas delivery hoses in the Inhalation Sedation equipment?
One hose: delivers fresh gases from the machine
One hose: delivers waste gas to scavenging system
What are examples of Safety features of Inhalation Sedation equipment?
Pin Index System
Diameter Index System
Minimum Oxygen Delivery
Oxygen Fail Safe
Air entrainment valve
Oxygen flush button
Oxygen monitor
Reservoir bag
Colour coding
Scavenging System
Oxygen and Nitrous oxide pressure dials
Pressure reducing valves
One way expiratory valve
Quick fit connection for positive pressure oxygen delivery
What is the function of a Pin Index System in Inhalation Sedation?
Prevents the wrong cylinder being attached to the
What is the function of the Diameter index system in Inhalation Sedation?
Prevents cross connection of piping
What is the minimum oxygen delivery in Inhalation Sedation?
30%
When does the oxygen fail safe kick in in Inhalation Sedation?
When oxygen pressure <40 psi
What are the advantages of Inhalation Sedation? (9)
Rapid onset (2-3mins)
Rapid peak action (3-5mins)
Flexible duration
Rapid recovery
No injection (for sedation not LA)
Few side effects on patient
Drug not metabolised
Some analgesia (better for ischaemic > inflammatory pain)
No amnesia
What are the disadvantages of Inhalation Sedation? (8)
Expensive equipment
Expensive gases
Space occupying equipment
Environmental concerns
Requires ability to breath through nose
Chronic exposure risk (potentially)
Staff addiction
Difficult to accurately determine actual dose
What are the signs of adequate sedation? (10)
Patient relaxed/comfortable
Patient awake
Reduced blink rate
Laryngeal reflexes unaffected
Vital signs unaffected
Gag reflex obtunded/reduced
Mouth open on request
Decreased reaction to painful stimuli
Decrease in spontaneous movement
Verbal contact maintained
What are the symptoms of adequate Inhalation Sedation? (10)
Mental and physical relaxation
Lessened awareness of pain
Paraesthesia: lips, fingers, toes, legs, tongue
Lethargy
Euphoria
Detachment ‘floating feeling’
Warmth
Altered awareness of time
Dreaming
Small controllable ‘fits of giggles’
What are the signs and symptoms of over sedation (Inhalation Sedation)? (9)
Mouth closing
Spontaneous mouth breathing
Nausea/Vomiting
Irrational and sluggish responses
Decreased cooperation
Incoherent speech
Uncontrolled laughter/tears
Patient no longer enjoying effects
Loss of Consciousness
What are the pre-operative instructions prior to Inhalation Sedation? (8)
Have a light meal before appointment
Take routine medications
Child accompanied by competed adult
Adults must be accompanied on their first appointment
Do not drink alcohol on day of appointment
Wear sensible clothing
Arrange care of children during and after appointment
Plan to remain in clinic up to 30 minutes after treatment
Discuss Inhalation Sedation Technique:
Set up
Select nasal hood and connect hoses
Set dial to 100% O2
Set flow to 5-6l per min and position on patient nose
Encourage nasal breathing and verify reservoir bag movements
Reduce O2 by 10%
One min later reduce O2 by 10%
Reduce by 5% per minute until patient ready
What should you do to the O2 concentration when patient is over sedated?
Increase O2 in 5-10% increments
What should you do to the O2 concentration if the patient is under sedated?
Decrease O2 in 5% increments
What should you do to get to the recovery phase of Inhalation Sedation?
Increase O2 to 100%
Administer 100% for 2-3 minutes
Remove hood and turn gas flow off
Return patient up right, praise and reassure
Why do you leave the O2 at 100% for 2-3 minutes in Inhalation Sedation?
To prevent diffusion hypoxia
What is the success rate for Inhalation Sedation and why does it vary?
50-90%
Patient populations, greater success with orthodontic extractions, poorer in patients with pain
What are the important aspects of a social history for IV sedation assessment?
Nature of fear
Phobia vs anxiety
General vs Specific
Anxiety questionnaire
Occupation
Escort
Alcohol
Responsibilities
Transport
Age
What are the important aspects of a dental history for IV sedation assessment?
Referral source
Previous bad experiences
Previous sedation/GA
Symptoms
Proposed procedure
What are the important aspects of a medical history for IV sedation assessment?
Drug history/allergy
Recreational drug use
Which drugs increase the sedative effect of midazolam?
Alcohol
Opioids
Erythromycin
Antidepressants
Antihistamines
Antipsychotics
Recreational drugs
What is ASA 1?
Normal healthy patient
Non smoker
Minimal alcohol
What is ASA 2?
Mild systemic disease
What is ASA 3?
Severe systemic disease
Limits activity but not incapacitating
What is ASA 4?
Severe systemic disease
Constant threat to life
What is ASA 5?
Moribund
Not expected to live >24 hours
What is ASA 6?
Brain dead for organ donation
Which ASA can be treated in primary care?
1 and 2
Which ASA can be treated in secondary care?
3 and 4
What questions should you ask an asthmatic in regard to IV sedation?
What drugs do they take and how often?
Have they been hospitalised?
Is it exacerbated by stress?
What is the definition of pharmacodynamic interactions?
Interactions between drugs which have similar or antagonistic pharmacological effects or side effects
What is the definition of pharmacokinetic interactions?
One drug alters the absorption, distribution, metabolism or excretion of another thereby increasing or reducing the amount of drug available in the system
What ASA category does pregnant put a person in?
ASA 2
What are the important features of a general examination for IV sedation?
Signs of anxiety
Discomfort with surroundings
Eye contact
Speech
Vital signs
What are the vital signs?
Heart rate
Blood pressure
Oxygen saturation
BMI
What is the BMI for underweight?
<18.5
What is the BMI for healthy weight?
18.5-24.9
What is the BMI for overweight?
25-29.9
What is the BMI for obese?
30
What is the BMI cut off for sedation?
35
What is a good working time for IV sedation patients?
45 minutes
What are the ideal features of an IV sedation agent?
Anxiolysis
Sedative effect
Ease of administration
Non-irritant
Quick onset
Quick recovery
No side effects
Amnesia
Low cost
What is the mode of action of benzodiazepines?
Acts on receptors in CNS to enhance effect of GABA
Prolongs the time for receptor repolarisation
Mimics effect of glycine on receptors
What allows benzodiazepines to attach to receptors?
Benzene ring
Why do sedative agents cause respiratory depression?
CNS depression and muscle relaxation
Decreases cerebral response to increased carbon dioxide
Synergistic relationship with other CNS depressants
Increased respiratory depression in already compromised patients
How do sedative agents affect the cardiovascular system?
Decrease blood pressure by muscle relaxation decreasing vascular resistance
Increasing heart rate due to baroreceptor reflex compensating for blood pressure fall
What are the side effects of sedative agents?
Tolerance
Dependance
Sexual fantasies (increases with dose)
Why is diazepam not given in water?
It is insoluble in water
What is the elimination half life of diazepam?
43 hours
What is the dosage of diazepam?
0.1-0.2mg/kg
What is the current gold standard sedative?
Midazolam
What is the elimination half life of midazolam?
90-150 minutes
Where is the metabolism of midazolam?
Liver and extra hepatic
What are the advantages of midazolam over diazepam?
Painless
Quicker onset
Quicker recovery
More reliable
Who makes up the sedation team?
Operator; sedationist
Second sedation trained person: dental nurse etc
How often is sedation training?
Annually
Why is the dorsum of the hand a cannulation site?
Accessible
Superficial and visible
Poorly tethered
Affected by peripheral vasoconstriction so may need to warm up hand
What is the second choice for cannulation area?
Antecubital fossa
What is ametop gel?
A topical anaesthetic
When must the assessment for intravenous sedation be carried out?
On a separate day
What must be done pre-operatively to intravenous sedation?
Pulse and blood pressure
Reconfirm consent
How is a patient monitored during intravenous sedation?
High volume aspiration
Pulse oximeter
Non invasive blood pressure (NIBP) measurements every 5-10 minutes
What emergency drugs should be prepared during intravenous sedation?
Flumazenil (antagonises benzodiazepines)
What is the drug administration of midazolam?
2mg bolus
1mg increments every minute
What is the drug administration of midazolam?
2mg bolus
1mg increments every minute
What is the end point of intravenous sedation?
Slurring and slowing of speech
Relaxed
Delayed response to commands
Willingness to accept treatment
Vergil’s sign ptosis
Eves sign-loss of motor coordination
What is the maximum dose of midazolam?
7.5mg
What makes the therapeautic dose of midazolam change?
Sleep
Alcohol
Stress
Drugs
What makes the therapeautic dose of midazolam change?
Sleep
Alcohol
Stress
Drugs
What are the steps for managing respiratory depression?
Talk, shake, hurt
Head tilt, chin lift, jaw thrust
O2 (2l/min via nasal cannulae)
O2 (5l/min via Hudson mask)
Flumazenil
Ambu bag
Airways
What is the preparation and dose of Flumazenil?
500mcg in 5ml
Dose; 200mcg then 100mcg increments every minute until a response is seen
What is the half life of Flumazenil?
50 min
What is anéxate?
Flumazenil
What is the meaning of Child Protection?
Activity undertaken to protect specific children who are suffering, or are at risk of suffering harm
What is the meaning of Children in Need?
Those who require additional support or services to achieve their full potential
What is the meaning of Safeguarding Children?
Measures taken to minimise risks of harm
What are three methods of safeguarding children?
Protecting children from maltreatment
Preventing impairment of children’s health or development
Ensuring children grow up in a safe and caring environment
What are the three factors of child abuse?
Carer has some responsibility for the harm
Significant connection between the carer’s responsibility to the child and the harm to the child
Significant harm to the child
What are the features of a wellbeing wheel?
Achieving
Active
Healthy
Included
Nurtured
Respected
Safe
Responsible
Which three features can decrease parental capacity?
Domestic abuse
Drug and alcohol misuse
Mental health problems
What 4 factors are associated with vulnerable children?
Under 5’s
Irregular attenders
Medical problems and disability
Looked after children
What 4 factors are associated with vulnerable children?
Under 5’s
Irregular attenders
Medical problems and disability
Looked after children
What are the five types of neglect?
Nutrition
Warmth, clothing and shelter
Hygiene and healthcare
Stimulation and education
Affection
What are the short term effects of childhood neglect?
Physical health
Emotional health
Social and cognitive development
What are the long term effects of child neglect?
Increased arrests
Suicide attempts
Major depression
Diabetes
Heart disease
What are three indicators of dental neglect?
Obvious dental decay
Impact on child
Practical care offered, child does not return for treatment
What are the three stages of management for child neglect?
Preventive Dental Team Management
Preventive Multi-agency Management
Child Protection Referral
What are the ten features of the Index of Suspicion?
Delay in seeking help
Story is vague, lacking in detail and varies from person to person
Account is not compatible with the injury
Parent’s mood is abnormal
Parents behaviour is a cause for concern- refusal of treatment or hospital admission, aggression to staff
Child’s appearance and interaction with parent is abnormal
Child may contradict parents
History of previous injury
History of violence within family
What are the expectations of the dental team when dealing with child neglect?
Observe
Record
Communicate
Refer
X
What percentage of abuse injuries are found in the head and neck area?
60%
What is motivational interviewing and how is it conducted?
Translating knowledge into behaviour
Seek permission, open questions, affirmations, reflective listening, summarising
What is standard prevention?
Tooth brushing demo once a year
OHI and diet advice
What is enhanced prevention?
Tooth brushing demo and diet advice each appointment
Where should fissure sealant be placed in enhanced prevention?
2’s palatal pits
What is the toxic dose of fluoride?
5mg/kg body weight
What % of 2800 ppm toothpaste is fluoride?
0.619%
What age does tooth trauma most commonly occur?
2-4 years
What gender is mostly affected by tooth trauma?
Male
Which teeth are mostly affected by tooth trauma?
Maxillary incisors
What are the features of a concussed tooth?
Tender to touch
No displacement
No increased mobility
What are the features of subluxation?
Tender to touch
No displacement
Increased mobility
What are the features of lateral luxation?
Tooth displaced in palatal/lingual/labial direction
What are the features of lateral luxation?
Tooth displaced in palatal/lingual/labial dirección
What are the features of intrusion?
Tooth displaced apically
What are the features of extrusion?
Partial displacement of tooth out of socket
What are the features of extrusion?
Partial displacement of tooth out of socket
What are the features of avulsion?
Tooth completely out of its socket
What are the four features of a paediatric patient assessment?
History
Patient factors
Goals
Treatment plan
What do patient factors consist of?
Understanding
Co-operation
Coping style
What does MCDASf stand for?
Modified child dental anxiety scale (faces)
What are the options of methods of pain and anxiety management?
Non-pharmacological behaviour management
Local anaesthesia
Sedation
General anaesthetic
What is used for inhalation sedation?
Nitrous oxide and oxygen
What are the indications of inhalation sedation in paeds?
Age (must be amenable to hypnotic suggestion, understand nasal breathing)
Anxiety level (mild to moderate)
Management of gag reflex
Medical considerations
Previous dental history
Dental needs
What are the contraindications for inhalation sedation in paeds?
Age (under 4)
Anxiety level
Medical considerations
Previous dental history
Dental needs
Patient choice
What is the consenting procedure for inhalation sedation in paeds?
Check understanding
Written pre-operative and post-operative instructions
What are the important factors of providing inhalation sedation in paeds?
Keep talking to patient
Ensure child avoids mouth breathing
What are the important factors of providing inhalation sedation in paeds?
Keep talking to patient
Ensure child avoids mouth breathing
Monitor
Post op instructions
What drugs are used for IV sedation in paeds?
Midazolam
Propofol
What are the indications for IV sedation in paeds?
Age
Anxiety level
Medical considerations
Previous dental history
Dental needs
What are the contraindications for IV sedation?
Age
Anxiety level
Medical considerations
Dental needs
What does TCI mean?
Target controlled infusion
When is TCI Propofol used?
For very long and short procedures
Mean rapid onset and recovery
What is the consenting procedure for IV sedation in paeds?
Check understanding
Written pre and post op instructions
What are the alternative sedative techniques to IV and inhalation sedation?
Oral and transmucosal sedation
What are the 9 features of a trauma stamp?
Radiograph
TTP
Colour
Ethyl Chloride
Thermal
Sinus
Mobility
Displacement
Percussion
What are the radiographic signs of tooth trauma?
Periapical radiolucency
Internal inflammatory resorption
External inflammatory resorption
Ankylosis
What is the definition of a strong recommendation?
Based on available information, weighing up balance of benefit vs risk, almost all individuals would choose this option
What is the aim of pads dental treatment?
To reduce the risk of the child experiencing pain, infection or treatment-induced anxiety
What does a comprehensive assessment include?
Patient history
Clinical examination
Caries risk assessment
What are the five factors of motivational interviewing?
Seek permission
Open questions
Affirmations
Reflective listening
Summarising
Where should fissure sealant be placed in enhanced prevention patients?
2’s palatal pits
What are the components of silver diamine fluoride?
Silver
Fluoride
Ammonium ions
What are the indications for use of SDF?
Asymptomatic cavitated carious lesions in primary teeth
Non-restorable dentinal lesions
Root caries
Pre-cooperative children and adults whose behaviour/medical conditions limit invasive restorative treatment
What are the contraindications for use of SDF?
Not able/willing to brush teeth
Potassium iodide contraindicated in pregnant/breast feeding women, patients undergoing thyroid surgery/medication
Patients with ulceration, mucositis, stomatitis
Allergy to silver, fluoride or ammonia
What method can be used for needle desensitisation?
Teach relaxation
Explain LA
Practice LA
Deliver LA
What prevention should be carried out alongside providing SDF?
Dietary advice
OHI
Topical fluoride application
What are the causes of child dental anxiety?
Parental anxiety
Difficult medical experiences
Difficult dental experiences
What are some physiological and somatic associations with dental anxiety?
Breathlessness
Perspiration
Unease
What is concussion?
An injury to the tooth supporting structures without increased mobility or displacement
Pain to percussion
What are three signs of a brain injury?
Amnesia
Vomiting
Nausea
How long should an avulsed primary tooth be under review?
Until eruption of the permanent
What is the role of dental professionals in regard to neglect?
Know how to refer concerns about abuse or neglect
Know who to contact for further advice about abuse or neglect of children
Raise concerns about the possible abuse or neglect of children
What is the definition of child protection?
Activity undertaken to protect specific children who are suffering or at risk of suffering significant harm
Which act made it illegal to smack a child?
The Children (Equal Protection from Assault) (Scotland) Bill
What are three examples of factors that can decrease parenting capacity?
Domestic violence
Drug/alcohol misuse
Mental health problems
How many children per year are killed by a parent/parent substitute?
10
Why does neglect of neglect occur?
Neglect is less incident focused
What are three long term effects of child neglect?
Greater incidence of heart disease
Greater incidence of diabetes
Greater incidence of neglect
What are the three stages in managing dental neglect?
Preventive dental team management
Preventive multi-disciplinary agency management
Child protection referral
Which % of serious head injuries in the first year of life are non-accidental?
95%
What % of abuse injuries are found on the head and neck?
60%
At what age range do primary teeth erupt?
6 months to 2.5 years
What is the order of primary tooth eruption?
a b d c e
What are four factors of primary tooth occlusion?
Upright incisors
Spaced
Terminal E’s: flush terminal plane
Class I molar relationship
How common are natal teeth?
1 in 3000
What are the three phases of tooth eruption?
Pre-eruptive phase
Eruptive phase
Post-eruptive phase
What happens during the pre-eruptive phase?
Crown formation
What happens during the eruptive phase?
Crown reaches occlusal plane
What are the two stage of the eruptive phase?
Intra-osseous
Extra-osseous
What happens during the post-eruptive phase?
Tooth movement/eruption
What are the three stages of the intra-osseous phase?
Root formation
Movement occlusally or incisally
Reduced enamel epithelium fuses with the oral epithelium
What are the three stages of the extra-osseous phase?
Penetration of crown through epithelium
Crown moves until contact with opposing tooth
Environmental factors: muscles from cheeks, lips and tongue determine final position
What is the gubernacular cord?
Remnant of the dental lamina that allows the permanent tooth to retain contact with the lamina propria of the oral mucosa
What are the roles of the dental follicle?
Initiates resorption of the bone overlying the tooth
Creates eruption pathway
Promotes alveolar bone growth
What are the radiographic signs of a non-vital tooth on a radiograph?
Furcation bone loss
External and Internal resorption
Radiolucencies
Periapical periodontitis
What is the treatment for an enamel-dentine fracture?
Bond fragment/composite bandage
2 Periapicla radiographs to rule out root fracture/luxation
What is the treatment for an enamel-dentine fracture?
Bond fragment/composite bandage
2 Periapicla radiographs to rule out root fracture/luxation
What does preventive dental team management involve?
Single unit approach
Raise concerns with parents
Offer support
Set targets
Keep records
Monitor progress
What does preventive multi-agency management involve?
Liase with other professionals to see if concerns are shared
Child may be subject to common assessment framework (CAF)
Check if child is subject to child protection plans
Agree joint plan of action; to be reviewed at agreed intervals
Letter to health visitor of child under 5 who fails to respond to letter from practice
What does a child protection referral involve?
Follow local guidelines
Refer to social services if required
What does a child protection referral involve?
Follow local guidelines
Refer to social services if required
What are the long term effects of trauma on the permanent dentition?
Discolouration
Delayed exfoliation of primary
Enamel defects (44%)
Abnormal tooth/root morphology
Crown or root duplication
Delayed eruption (1%)
Ectopic tooth position
Arrest in development
Complete failure in permanent tooth formation
Odontome formation
Undeveloped tooth germ
What does immediate vs delayed discolouration suggests?
Immediate- vital tooth
Delayed- non-vital tooth
What is the treatment for hypomineralisation?
Mask with composite
Localised removal and restore with composite
External bleaching
What is the treatment for hypoplasia?
Repair with composite or porcelain veneers when gingival level is stabilised at 16 years old
What is the treatment for crown/root dilacerations?
Surgical exposure and orthodontic treatment
Why can primary tooth trauma lead to delayed permanent tooth eruption?
Premature loss of primary teeth
Delayed eruption due to thickened mucosa
What is the treatment for delayed permanent tooth eruption?
Surgical exposure and orthodontic treatment
What is the treatment for delayed permanent tooth eruption?
Surgical exposure and orthodontic treatment
When should you not replant an avulsed tooth?
Immunocompromised
Other more serious injuries
Very immature apex and >90 mins EAT
Very immature lower incisors in young people finding it difficult to cope
What are the clinical findings of dentó-alveolar fracture?
Complete fracture from buccal to lingual
Segment mobility and displacement with several teeth moving together
Occlusal disturbance
What is the treatment of a dentó-alveolar fracture?
Reposition any displaced segment
Stabilise by splinting for 4 weeks
Suture gingival lacerations if present
Monitor pulp condition of all involved teeth
How long should a lateral luxation be splinted?
4 weeks
What is the sequel are of trauma to primary teeth?
Discolouration
Infection
Delayed exfoliation
What is dilaceration?
Abrupt deviation of the long axis of the crown or root portion of the tooth
What are the contraindications for preformed metal crowns?
Irreversible Pulpitis
Periapical pathology
Insufficient tooth tissue to retain crown
What are the contrindications to fluoride varnish?
Hospitalised due to severe asthma
Allergy in last 12 months
Allergy to sticky plasters/ colophony
What is the difference between a trauma splint and an orthodontic wire?
Trauma splint- 0.4mm
Ortho wire- 0.7mm
What are the SDCEP plaque scores?
10: perfectly clean tooth
8: line of plaque around cervical margin
6: cervical 1/3 crown
4: middle 1/3 crown
How long should a mid/apical root fracture be splinted?
4 weeks
What is the treatment of an enamel fracture?
Bond fragment or smooth
Take 2 periapicals
When should an enamel fracture be reviewed?
6-8 weeks
6 months
1 year
What is the treatment of an enamel dentine fracture?
Bond or composite bandage
Take 2 periapicals
When should an enamel dentine fracture be reviewed?
6-8 weeks
6 months
1 year
What is the treatment of an enamel dentine pulp fracture if less than 1mm?
Pulp cap
What is the treatment of an enamel dentine pulp fracture if more than 1mm or untreated for 24 hours?
Partial pulpotomy
What is the treatment of an enamel dentine pulp fracture if the tooth is non vital?
Pulpotomy
When should an enamel dentine pulp fracture be reviewed?
6-8 weeks
6 months
1 year
What is the treatment of a crown root fracture?
Post crown
Fragment removal
Decoronate
What is the treatment of a concussion?
No treatment
When should you review a concussion?
4 weeks
1 year
What is the treatment of a subluxation?
No treatment or splint
When should you review a subluxation injury?
2 weeks (SR)
12 weeks
6 months
1 year
How long should you splint for a subluxation injury?
2 weeks
What is the treatment for a lateral luxation?
Reposition under LA
Splint
How long should you splint a lateral luxation?
4 weeks
When should you review a lateral luxation?
2 weeks
4 weeks (SR)
8 weeks
12 weeks
6 months
Annually
What is the treatment for intrusion of an immature tooth?
Spontaneous reposition
Orthodontic reposition after 4 weeks
What is the treatment of <3mm intrusion of a mature tooth?
Spontaneous reposition
Reposition after 8 weeks
What is the treatment of a 3-7mm intrusion of a mature tooth?
Surgical or orthodontic repositioning
What is the treatment of a >7mm intrusion of a mature tooth?
Surgical repositioning
How long should you splint for an intrusion?
4 weeks
When should you review an intrusion injury?
2 weeks
4 weeks (SR)
8 weeks
12 weeks
6 months
1 year
What is the treatment of an extrusion injury?
Reposition and splint
How long should you splint an extrusion injury?
2 weeks
When should you review an extrusion injury?
2 weeks (SR)
4 weeks
12 weeks
6 months
1 year
Annual
What is the treatment of an avulsion of a tooth with a closed apex?
Replant and splint
Endo after 2 weeks
When should you review an avulsion on a closed apex tooth?
2 weeks (SR)
4 weeks
3 months
6 months
1 year
Annually
How long should you splint an avulsion?
2 weeks
What is the treatment of an avulsion of an open apex tooth?
Replant
When should you review an avulsion on an open apex tooth?
2 weeks (SR)
1 month
2 months
3 months
6 months
1 year
Annually
What is the treatment of an alveolar fracture?
Reposition and splint
How long should you splint an alveolar fracture?
4 weeks
How long should you splint an alveolar fracture?
4 weeks
When should you review an alveolar fracture?
4 weeks (SR)
6 weeks
4 months
6 months
1 year
Annually
When should pulp treatment be carried out in paediatrics?
MH excludes extraction
Good cooperation
Good attendance e
How does pulp treatment failure present?
Furcation bone loss
Internal inflammatory resorption
External inflammatory resorption
PAP
What are methods of anxiety management?
Distraction
Tell-show-do
Acclimatisation
Desensitisation
Role modelling
Positive reinforcement
How does post replant resorption present?
Internal inflammation
External inflammation
External surface resorption
Replacement ankylosis
What teeth are affected by early childhood caries and why?
Upper anteriors and molar teeth due to inappropriate use of feeding cups and bottles
How can early childhood caries be prevented?
Diet: promote and support breast-feeding
Fluoride: no benefit of fluoride supplements during pregnancy
Oral hygiene
What dietary advice should be given to prevent early childhood caries?
Use of a feeding cup rather than bottle from 6 months (free-flow spout)
Drinks containing free sugars should never be put in a bottle
Children should not be put to bed with a feeder bottle or cup
Soya milk is potentially cariogenic
Avoid sweetened drinks
Food and confectionary containing free sugars should be minimised and restricted to meal times
Non sugar sweeteners recommended
Plain water or milk between meals
Sugar free medications
What advice should be given for the consumption of sweetened drinks if they are going to be drank?
Meal times only
Diluted
Drink through a straw (to back of mouth)
What are examples of good non-cariogenic snacks?
Cheese
Milk
Fruite
Savoury sandwiches
Crackers
Breadsticks
What should be included in a diet diary?
Everything eaten
At least one day must be a Saturday/Sundat
What are the modes of getting fluoride?
Fluoridated water
Toothpaste
Supplements: drops, tablets, mouthwash
Professional delivered: varnishes
When should toothbrushing begin?
As soon as the first primary tooth erupts
What age lacks the dexterity to independently brush their teeth effectively?
Under 8
What concentration of fluoride is in children’s toothpaste?
1000ppm
What age is children’s toothpaste used?
First tooth - 3 years
What is the fluoride concentration of standard toothpaste?
1400-1500ppm
What is the fluoride concentration of enhanced toothpaste?
2800 or 5000ppm
What advice should be given to parents once their childs first tooth has erupted?
1000ppm toothpaste
Smear of toothpaste
Spit out don’t swallow
Small headed toothbrush
From what age should a pea sized amount of toothpaste be used?
> 3 years
What is the level of fluoride toxicity?
5mg/kg body weight
What is the management for a fluoride accident if <5mg/kg administered?
Give milk (calcium) and observe for a few hours
What is the management for a fluoride accident if 5-15mg/kg administered?
Give milk and admit to hospital
What is the management for a fluoride accident if >15mg/kg administered?
Admit to hospital
IV calcium gluconate
Cardiac monitoring and life support
How often do high risk children get radiographs?
6 months
How often do standard risk children get radiographs?
12-18 months
What are the disadvantages of a primary tooth extraction?
Loss of space; increased malocclusion
Decreased masticatory function
Decreased speech development
Psychological disturbance
Trauma
What are the indications for paediatric pulp treatment?
Good co-operation
Medican history precludes extraction
Missing permanent successor
Need to persevere tooth as a space maintainer
Child under 9 years old
What are the contraindications for paediatric pulp treatment?
Poor co-operation
Poor dental attendance
Advanced root resorption
Cardiac defect
Multiple grossly carious teeth
Recurrent pain/infection
What are the stages of a pulpotomy?
Remove roof of pulp chamber
Remove coronal pulp with sterile excavator/slow large round steel bur
Place a cotton pellet with ferric sulphate for 20 seconds
Place zinc oxide/eugenol in pulp chamber and restore using metal preformed crown
What are the stages of pulpectomy?
Remove roof of pulp chamber
Remove contents of pulp chamber
Use files to remove pulpal tissue (-2mm of length)
Irrigate with chlorhexidine, dry with paper points
Obturate canals with vitapex (CaOH) and iodoform paste
Seal with ZOE/GIC and restore with preformed metal crown
What are the indications for pulpectomy over pulpotomy?
Non-vital pulp
Irreversible pulpits
What are clinical signs of pulpectomy failure?
Pathological mobility
Fistula/chronic sinus
Pain
What are radiographic signs of pulpectomy?
Radiolucency
External/internal resorption
Furcation bone loss
What traumas are splinted for 2 weeks on a flexible splint?
Avulsion
What traumas are splinted for 4 weeks on a flexible splint?
Luxation
Root fracture
What traumas are splinted for 4 weeks on a rigid splint?
Dento-alveolar fracture
What are the advantages of the hall technique?
No LA needed
Not invasive
Less stressful for patient
Effective
Retains tooth
What instruments are used for the placement of hall crowns?
Preformed metal crowns
GI luting cement
Diamond tapered separating bur
Crown crimping pliers
Curved crown scissors
What factors are considered when sizing up SS crowns?
Trial and error
Measuring m-d length
What are the indications for hall technique?
No pulp involvement
Remaining tooth tissue
What are the treatment options for intrinsic discolouration in permanent anterior teeth in children and adolescents?
Enamel microabrasion
Bleaching
Resin infiltration technique (ICON)
Localised composite restoration
Veneers (direct/indirect)
What pre-op records should you have for discoloured teeth?
Standardisation of recording of aesthetic procedures
Clinical photos
Shade
Sensibility testing, check for sensitivity
Diagram of defect
Radiographs if clinically indicated
Patient assessment e.g VAS
What should be considered when carrying out HCL pumice technique?
PPE worn
Patient wearing glasses and bib
Clean teeth with pumice and water
Petroleum jelly to gingiva
Rubber dam placed
Sodium bicarbonate guard (and excess available)
What is the technique for HCL pumice?
HCL pumice slurry in slowly rotating rubber cup (5 secs)
Maximum 10 x 5 second applications
Wash direct into aspirator after every 5 second application
10 x 5 secs completed on anterior teeth
Fluoride varnish application
Polish with finest sandpaper disc
Final polish with toothpaste
What is the benefit of using sandpaper discs?
Changes the optical properties of the enamel so that areas of intrinsic discolouration become less perceptible
What is the benefit of using sandpaper discs?
Changes the optical properties of the enamel so that areas of intrinsic discolouration become less perceptible
How much enamel is lost when using prophy with toothpaste?
5-10 microns
How much enamel is lost when prophy with pumice?
5-50 microns
How much enamel is lost when ortho bracket bonding/debonding?
5-50 microns
How much enamel is lost when acid etching?
10 microns
How much enamel is lost when 10 x5 secs HCL pumice microabrasion?
100 microns
What is in the proprietary kits for microabrasion?
Opalustre (ultradent)- 6,6% HCl acid and silicone carbide particles in a water soluble paste
Prema Kit 10% HCL acid in a prep of fine grit silicon carbide particles in water soluble paste
What are the advantages of microabrasion?
Easily performed
Conservative
Inexpensive
Teeth need minimal subsequent maintainance
Fast acting
Removes yellow-brown, white and multicoloured stains
Effective
Results are permanent
Can be used before or after bleaching
What are the disadvantages of microabrasion?
Removes enamel
HCl acid compounds are caustic
Requires protective apparatus for patient, dentist and dental nurse
Prediction of treatment outcome is difficult
Must be done in dental surgery
Cannot be delegated
How should microabrasion be reviewed?
Warn patient to avoid highly coloured food and drinks for at least 24 hours
Review patient 4-6 weeks after and take post-op photographs
What are the options for external vital bleaching?
Chairside power bleaching
Night guard vital bleaching at home
What are the options for non-viral bleaching?
Inside out technique
Walking bleach technique
What % of hydrogen peroxide is used for vital chairside bleaching?
15-38%
What is night guard vital bleaching?
10% carbamide peroxide gel
Tray
What fluoride is applied post microabrasion and why
Profluoride
As duraphat is yellow and may stain
What are the instructions to patients receiving night guard vital bleaching?
Brush teeth thoroughly
Apply a little gel to tray
Set over teeth and press down
Remove excess
Rinse gently, do not swallow
Wear overnight or for at least 2 hours
Remove, brush and rinse with cold water
Discuss the carbamide peroxide reaction?
10% carbamide peroxide
—>
3% hydrogen peroxide, 7% urea
—>
Water, ammonia and CO2
What are the advantages of non-vital bleaching?
Simple
Tooth conserving
Original tooth morphology
Gingival tissues not irritated by restoration
Adolescent gingival level not a restorative consideration
No laboratory assistance for walking bleach
What are the tooth selection factors for non vital bleaching?
Adequate root filling- no clinical disease, no radiological disease
Anterior teeth without large restorations
Not amalgam intrinsic discolouration
Not fluorosis or tetracycline discolouration
What is the walking bleach method?
Oxidising process allowed to proceed gradually over days
What is the inside out bleaching method?
10% carbamide peroxide gel, can seal in if cooperation is an issue
What are the factors of frequency and regression for the walking bleach method?
Renew bleach- ideally no more than 2 weeks between appointments
If no change after 3-4 renewals- stop
6-10 changes total
Regression 50% at 2-6 years
What are the stages of combination ‘inside-out’ bleaching?
Access cavity of tooth open
Do not necessarily need GI lining
Custom made mouth guard (cut windows in guard of the teeth you don’t want to bleach)
Patient applies bleaching agent to back of tooth and tray
Patient keeps access cavity clean- replacing gel, removing food debris
Worn all the time except eating and cleaning
Gel changed every 2 hours except over night
10% carbamide peroxide used
How is the pulp chamber restored following internal bleaching?
Non-setting calcium hydroxide paste for 2 weeks, seal in with GIC then:
White GP and composite resin- facility to re-bleach
Or
Incrementally cured composite- no re-bleaching but stronger tooth
(Veneer or crown prep if regression)
What are the potential complications of non-vital bleaching?
External cervical resorptions
Spillage of bleaching agents
Failure to bleach
Over bleach
Brittleness of tooth crown
What is the function of a layer of cement of GP in internal bleaching?
Prevents bleaching agent from getting to external surface of root
Can prevent adequate bleaching of cervical area
Why is non setting calcium hydroxide applied two weeks before final restoration in internal bleaching?
Reverses any acidity
What is the effect on soft tissue in cases of short term exposure to bleaching in pulp?
Minor ulcerations/irritation
Plaque reduction
Aids wound healing
What is the effect on soft tissue of long term exposure of bleaching in the pulp chamber?
Possible delayed wound healing
Possible periodontal harm
Mutagenic potential
What is Recaldent?
CPP-ACP (casein phosphopeptide-amorphous calcium phosphate) milk derived protein
What is resin infiltration?
Infiltration of enamel lesions with low-viscosity light curing resins
Surface layer is eroded, lesions desiccated and president infiltrant is applied
Resin penetrates lesion driven by capillary forces
Infiltrated lesions lose their discoloured appearance and look similar to sound enamel
What factors should be considered in regard to tooth prep in paediatric patients needing veneers?
Aesthetics
Relative tooth position
Masking dark stain
Age
Psyche
Plaque removal
What is the dentists’ fee per month based on age?
0-2 years £2.40
3-5 years £3.20
6-12 years £5.50
13-17 years £7.15
18-64 years £1.40
What is the enhanced fee for SIMD 1?
30p
How much do you earn for enhanced preventive advice and treatment?
£19.60 every 3 months
How much do you earn for fissure sealants?
£12.70 per tooth
What does enhanced prevention advice and treatment include?
OHI
TBI and interdental cleaning demo
Food and drink advice
Application of fluoride varnish
PMPR
What is the cost of a single surface filling?
£15.90
What is the cost of a 2 single surfaces on one tooth
£31.80
What is the cost of a 2 surface filling?
£22.25
What is the cost of a 3 surface filling?
£33.90
What is the cost of a PMC?
£45.60
What is the enhanced fee for SIMD 1?
10% increase
What the composite supplement for 1 filling on anterior teeth?
£10.60
What the composite supplement for 2 fillings on 1 tooth on anterior?
£21.20
What is the composite supplement for 1 filling on a posterior tooth?
£33.90
What is the the composite supplement for 2 fillings on 1 tooth?
£67.80
What is the fee of a sedation assessment?
£37.10
What is the sedation fee per visit?
£111.30
What is the role of GDP for children?
Management of dental caries
Emergency dental care
Monitoring the developing dentition
Treating MIH
Orthodontic care
Child protection
What legislation is involved in child protection?
Department of Health
BSPD
GDC
RCPCG
The Scottish Government
What is the role of the department of health in child protection?
Child protection and the dental team
What is the role of BSPD in child protection?
A policy document on dental neglect in children
What is the role of the GDC in child protection?
Child protection and vulnerable adults
What is the role of RCPCG in child protection?
Safeguarding children and young people
What is the role of the Scottish Government in child protection?
National guidance for child protection in Scotland
What is the role of the GDP in orthodontic care?
Simple orthodontic treatment- removable appliances, fixed appliances, aligners
What are the symptoms of MIH that require management?
Hypersensitivity
Crumbling back teeth
Aesthetic concerns regarding incisors
What are the management options for MIH?
Seal
Restore with plastic restoration
PMC
Extraction and timing
Aesthetic management of incised opacities
Seek specialist opinion
What are the roles of the GDP in monitoring the developing dentition?
Important milestones- 3, 6, 9 and 12 years
Monitor sequence of eruption- up to 12 months between matching lower and upper teeth, up to 6 months between matching teeth on other side
Monitor developing malocclusion- IOTNB
What are the roles of the GDP in emergency dental care?
Emergency dental care
Acute dental care
Management of dental trauma
What is the role of the GDP in the management of dental caries?
Prevention alone
Biological management in addition to prevention
Minimally invasive tx
Conventional restorative options in addition to prevention
Extraction
What are the factors involved in caries development?
Personal factors- poverty, OH
Oral environment factors- saliva
Caries developmental factors- time, tooth, bacteria, carbohydrates
What are the components of dental prevention?
Caries risk
Behaviour modification
Tooth protection
What are the factors affecting saliva as a caries risk factor?
Diabetes- high blood sugar levels
Xerostomia
Beta 2 agonists and corticosteroids
Anticonvulsants
Antihistamines
Urinary incontinence meds (desmopressin)
Acne treatment- isotretinoin
What can behavioural modification affect?
Attendance patterns
Tooth brushing habits
Use of home fluoride
Drinkning and dietary habits
Acclimatisation
What is motivational interviewing?
Collaborative, goal orientated style of communication with particulate attention to the language of change
Strengthens personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change with an atmosphere of acceptance and compassion
What are the factors that play a role in tooth protection?
Application of 5% (22,600ppm) sodium fluoride varnish (50mg/ml)
Placement of fissure sealants
Prescription of 2,800ppm F (0.619%) toothpaste
Silver diamine fluoride
What are the properties of fluoride varnish?
Colourless 38% solution (RIVA STAR)
44,800ppm fluoride
Synergistic effects- occludes dentinal tubules, silver is antibacterial, fluoride encourages remineralisation
What are the advantages of SDF?
Safe
Simple/quick/easy (5mins)
Non-AGP
Non-invasive
Evidence based
What are the disadvantages of SDF?
Stains caries black
Can cause a temporary tatto
Relatively expensive (£80 for 12) or £110 for 1.5ml
Not in the SDR as an item of service fee
Metallic taste
What are the features of primary molars affecting caries?
Wider contact points
Larger pulps
Faster spread of caries into pulp
What % of caries in primary molars is missed if no radiograph taken?
Up to 50%
What age should bitewings be considered from?
4 years
What are the available options for caries interventions?
Non-invasive: biofilm management, mineralisation control, dietary control
Micro-invasive: sealing, infiltration
Minimally invasive: ART
Conventional restorative
Mixed: non restorative cavity control, hall technique
What its the median survival times for conventional restorative tx?
Less than 3 years: 11.1 months
3-5 years: 23
5-7 years: 33
7-9 years: 44
9-11 years: 70
What is the success rate of posterior restorations in primary teeth?
Class I: 92.4
Class II: 85.3
Class I and II: 87.8
PMC: 96.1
What are the important variables in caries intervention?
Caries risk
Age of child and ability to cope
Length of time until tooth exfoliates vs survival rates
Choice of material- ease of use, survival rate
Minimally invasive options can be considered first
What are the reasons for referral to PDS?
Anxiety and phobia
GA extractions
Sedation
Special needs
Vulnerable groups
What are the reasons for referral to orthodontic services?
Developing malocclusion
Dental anomalies
What are the reasons for referral to HDS?
Management of severe caries
Medical conditions
Trauma
Dental defects
MDT care
What are the reasons to referral for non-dental service?
Child protection
Social services
What are the indications for conscious sedation?
Child is anxious but co-operative
Treatment is straight forward
Treatment is not likely to damage the Childs attitude towards treatment in the future
What are the contraindications to conscious sedation?
Severe dental anxiety where the child is not ready or willing to co-operate
Treatment required is too extensive or complex for the maturity of the child
Child is too young to understand IS
Child cannot breath through their nose
What are the guidelines for conscious sedation?
IACSD
SDCEP
What are the indications for GA?
The child needs to be fully anaesthetised before dental treatment can happen
The surgeon needs the child to be fully anaesthetised before dental treatment can be performed
What are the considerations for GA?
Co-operation
Degree of anxiety
The degree of surgical trauma anticipated
The complexity of the operative procedure
The medical status
What are the common reasons for GA?
Acute soft tissue swelling requiring removal of the infected tooth/teeth
*Surgical drainage of an acute infected swelling
* Single or multiple extractions in a young child unsuitable for conscious
sedation
* Moderately traumatic or complex extractions
* Teeth requiring surgical removal or exposure
* Post operative haemorrhage requiring packing and suturing
* Severe pulpitis and acute infection are by far the most common
conditions treated under GA
UK National Clinical Guidel
What are the negative impacts of covid?
Longer waiting times from referral to treatment for GA
Treating smaller numbers on GA
Concern about repeated need for analgesics and antibiotics and the QoL issues on the child and family unit
What are the positive covid impacts?
Development of a new CBT programme to aid children age 1-10 and above to avoid the need for GA
Employing SDF to manage caries and limit active treatment to the only most severely damaged teeth, reducing need for LA
Use of wand STA system to deliver LA
What are the 3 golden rules?
Effectively manage the disease in a way that the child can cope with
Ensure the treatment plan is achievable for the parent
Promote a positive dental attitude
