PAEDS Flashcards
1
Q
A 13-year-old new child attends the surgery with a BPE score of 333 / 332?
1. What does a BPE score of 3 mean? (1)
A
- Pocketing 4-5mm or probing depth 3.5-5.5mm (only partially visible black band)
2
Q
- What teeth should be probed in a 13-year-old to obtain BPE scores? (1)
A
- Modified BPE including probing of 16,11,26,36,31,46 (up until age 17)
3
Q
- What is the normal depth from ACJ to alveolar bone crest?
A
Around 2mm
Biological width
4
Q
What medical condition would cause a 13-year-old to have BPE scores of 3?
A
Epilepsy - tx with phenytoin
Immunosuppression - tx with cyclosporin
Calcium channel blocker treatment reduce blood pressure and symptoms of angina
Diabetes
OFG, leukaemia, agranulocytosis, cyclic neutropenia, granulomatosis
Ciclosporin (cyclosporin, also known as Neoral) is used to attempt to induce remission in acute severe ulcerative colitis. It is used in hospital when patients have not responded to standard treatment for inflammatory bowel disease, including steroids.
5
Q
- If this patient isn’t on medication what might this be if they have BPE of 3 at 13?
A
Aggressive periodontitis early stages
6
Q
- What investigations should you do when a child presents with BPE 3? (3)
A
- Full periodontal assessment- 6PPS, MP&BS, (S3 guidelines state carry out localised 6PPC for the areas of BPE of 3 at the end of treatment)
- Radiographs- bitewings or periapical
- Diet diary
7
Q
- What is the treatment plan
A
- HPT- OHI & prevention, diet advice, modifications of risk factors and behavioural change, Supra PMPR, (refer to specialist- only at score 4), review after 3 months
8
Q
Caries & Pulpal Pathology-
A 6-year-old child present with pain in lower right quadrant due to grossly carious 85 and buccal swelling. Patient also suffers from haemophilia A.
1. What is the likely diagnosis?
A
Periapical abscess due to gross caries
Need pulp diagnosis - Necrotic pulp
Apical diagnosis - PA abscess
9
Q
6-year-old child present with pain in lower right quadrant due to grossly carious 85 and buccal swelling. Patient also suffers from haemophilia A.
2. What is the treatment of choice for this patient and why?
A
Pulpectomy with SSC placement as want to avoid XLA if possible due to increased chance of bleeding as a result of their bleeding disorder
Ex if required - refer to specialist centre (need to liaise with haemotologist for coagulation factor replacement or use of tranexamic acid )
As an interim measure may perform caries excavation and sediative dressing first.
10
Q
- List the stages involved in primary pulpectomy
A
- LA
- Dental dam
- Removal of caries and roof of pulp chamber to gain access
- Remove coronal pulp with sterile excavator or large round steel bur
- Extripate the pulp to 2mm short of the apex to prevent damage to the permenant tooth germ (if isolation effective irrigate with sodium hypochlorite and if not use CHX)
- Obturate the canal with calcium iodoform paste
- Restore with GIC core and SSC
11
Q
Name two haemostatic agents?
A
- Surgicel (oxidised cellulose)
- Tranexamic acid
- LA as vasocontrictor
- Resorbable gelatine sponge - gelfoam
- Ferric sulphate
In dentistry, ferric sulfate is used as a pulpotomy medicament to control pulpal bleeding, as an antibacterial agent and as a hemostatic reagent for restorative dentistry, for postextraction hemorrhage and for periradicular and endodontic surgery.
12
Q
6-year-old child present with pain in lower right quadrant due to grossly carious 85 and buccal swelling. Patient also suffers from haemophilia A.
5. If this patient were to require an extraction what measures would need to be put in place?
A
- Consult with haemotologist prior to Ex
- may require pre-op tranexamic acid and factor 8 replacement available DDAVP
- Atraumatic technique
- Infiltration aesthesia generally used over blocks
- Ensure clot, using local haemostatic agents and suture the socket
- Review within a week
DDAVP is a drug used to effectively increase the concentration of factor VIII in the blood and to increase the clumping together of platelets to stop bleeding. It does not come from human plasma and it carries no risk of infection
13
Q
Trauma & Splining-
1. What is the only occasion on which a splint should be used for primary teeth?
A
Flexible splint for 4 weeks for an alveolar bone fracture
14
Q
What type of duration of splint treatment should be used for an avulsed tooth?
A
- Flexible splint for 2 weeks if EADT < 60 minutes
- Flexible splint for 4 weeks if EADT > 60 minutes
??
15
Q
- What is the difference between a flexible and rigid splint?
A
Flexible splint attaches to one tooth either side
Rigid splint attaches to 2 teeth either side
16
Q
- If EADT < 60 minutes what is you endodontic management?
A
- If open apex then chance of revascularization (30%) therefore leave alone and monitor; if loss of vitality (as opposed to continued root growth) then extirpate the pulp place NSCaOH and refer)
- If closed apex than RCT 0-10 days (sooner the better)after reimplantation with intracanal antibiotic-steroid (ledermix) paste for 2 months then replace intra-canal medicament with non-setting calcium hydroxide
- Within 3 months obturate with GP- sooner the better
17
Q
- IF EADT > 60 minutes what is your management?
A
- For open apex don’t root treat tooth but replant and monitor (the same as you would do for EADT< 60 minutes)
- If closed apex scrub necrotic pulp from tooth and carry out extra-oral endodontics then replant tooth under LA and flexibly splint for 4 weeks (consider AB prescription)
- If extra-oral endodontics is not carried out then extirpate within 7-10 days of reimplantation and use non-setting calcium hydroxide as initial intra-canal medicament for 4 weeks prior to obturation with GP
18
Q
A patient has avulsion of a permanent incisor.
1. What advice do you give on the phone?
A
- Reassure the patient
- Tell them to hold the tooth by the crown and not the root
- If visibly dirty then run under COLD water for 10s to clear debris
- Reimplant the tooth back into the socket and get them to bite on a piece of tissue (only for permenant tooth)
- Store in a medium (like saliva, milk or physiological saline)
- Seek dentist immediately
19
Q
GIve 3 storage mediums for an avulsed tooth?
A
- Saliva (or buccal sulcus)
- Milk
- Physiological saline
- Blood
20
Q
- What should you check upon arrival of the patient at the dental surgery? A patient has avulsion of a permanent incisor.
A
- The child doesnt have any serious injuries that require more emergency tx. Was the patient unconcious for any period of time.
- Ask how the incident occured
- How long was the tooth out of the mouth and a suitable storage medium(important for EADT)
- Can all of the tooth fragments be accounted for?
- ANy other oral injuries
- MH
- If child has had tetanus prophylaxis
21
Q
What type of splint is advised for an avulsed tooth > and < 60mins EADT?
A
Flexible splint
Open and closed apex <60mins EADT - 2 weeks
Open and closed apex >60mins EADT - 4 weeks
22
Q
What are the most common outcomes for avulsed permenant teeth?
A
- Discolouration
- Mobility
- Necrosis of the pulp
- Ankylosis
- Root resorption
- Pulp canal obliteration or sclerosis
23
Q
- What is EADT?
A
This is the extra avleolar dry time and is the time that the tooth has been out of the mouth and not in an appropriate storage medium
Important as the longer the tooth is out of the mouth or a storage medium the more damaged the PDL gets and the less chance the tooth has of survival.
24
Q
- What medical information is significant? For an avulsed permenant tooth?
A
- Any cardiac defects
- Is the child immunocommprimised
- Any medications
- Have they had a tetanus immunisation
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A 10-year-old patient presents with an extrusion injury of an upper central incisor (11).
1. Draw and label your splint?
* 0.6mm stainless steel wire
* Acid etch 37%, prime and bond and then place composite resin on abutment teeth (bonded to one tooth either side of the extruded tooth)
* Sink contoured, passive wire into composite
* Shape composite over wire and light cure
* Smooth any rough composite and wire ends
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2. How long would you splint the extruded tooth for?
* Flexible splint for 2 weeks
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3. What 4 tests would you do at a check-up apart from a radiograph?
* Sensibility testing- EPT and ethyl chloride thermal
* TTP
* Percussion note
* Mobility
* Colour
* Sinus (tender in sulcus)
* (Displacement)
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4. He has external inflammatory resorption how do you manage this?
* Extirpate the pulp and carry out chemo-mechanical disinfection
* Place non-setting calcium hydroxide for 4-6 weeks to assess if resorption has stopped
* Replace with GP after 4-6 weeks
* If resorption continued, then plan replacement
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5. Radiograph of 11 given, describe what you see, give a diagnosis and mention how you manage this? (3 months)
* Widened PDL space, loss of surrounding lamina dura, irregular apical surface
* Irregular inflammatory root resorption
* RCT with calcium hydroxide setting, apical radicular surgery
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6. What is extrusion
* Partial displacement of the tooth out of its alveolar socket characterised by partial or total separation of the PDL resulting in loosening and displacement of the tooth
* The alveolar bone remains intact but the tooth will usually have some protrusive or retrusive orientation as well as axial displacement
31
A 10-year-old boy present to you after having fallen and banged his upper front tooth. On examination you diagnose a sub-luxation injury.
1. Give three diagnostic features of a sub-luxation injury?
* Increased mobility and TTP
* No disapclement of the tooth
* Bleeding from the gingival tissue
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2. What type of splint would you place, for how long and draw it below? Subluxation
* 2-week flexible splint (spans only onto two adjacent teeth)
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3. When would you review this patient? sub-luxation
* 2 week (splint off), 4 weeks, 6-8 week and 1 year
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4. Name two features you be assessing radiographically at review?
* Continued root development- width and length of canal
* Presence of absence of internal and external inflammatory resorption
* Presence of periapical infection
* (Comparison with opposite side)
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5. How would internal inflammatory resorption present clinically and radiographically, what is its mechanism and what medicament would you place?
* Clinically- Asymptomatic with no clinical signs and will response positively to sensibility testing
* Radiographically- ballooning of root canal which is usually round/oval and fairly uniform and continuous with canal tramlines (will not move with beam shift)
* Mechanism- Coronal pulp is necrotic but apical pulp is vital (needs patent blood supply), outermost protective odontoblast and pre-dentine layer damage resulting in exposure of underlying dentine to odontoclasts (fi left untreated lesion will grow till apical pulp necrotic)
* Management- Canal extirpation, chemo mechanical disinfection and placement of non-setting calcium hydroxide for 4-6 weeks before being replaced with GP
36
Patient attends with a fractured 11?
1. List two questions you would ask in regard to the traumatised tooth?
* When did it happen?
* How did it happen?
* Can they account for the missing fragment of the tooth?
* Any other symptoms
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2. List four things that determine the prognosis of the traumatised tooth? (4)
* Stage of root development (maturity of tooth- open or closed apex)
* Type of injury
* If PDL also damaged
* Time between injury and treatment (the longer before the exposed dentine is covered the more likely the tooth is to become non-vital)
* Presence of infection
* Mobility
* If pulp is exposed (Complicated vs non-complicated)
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3. Where do you suspect the fragment of the tooth is and how do you manage this?
* Swallowed fragment- A&E referral for stomach scan
* Inhaled fragment- A&E referral for chest X-ray
* Embedded in soft tissue- radiograph to confirm then remove and suture (for haemostasis) or refer to oral surgery for removal
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4. Tooth has an enamel-dentine fracture- what is the treatment plan for this type of trauma?
* Account for fragment
* Either bond fragment to tooth (risk of fragment becoming discoloured) or place composite/GI bandage until time for definitive treatment
* Line the restoration first if the fracture is close to the pulp (indirect pulp cap)
* Take 2 PA radiographs to rule our root fracture or luxation (percussion note also useful in checking for root fracture)
* Radiograph any lip or cheek lacerations to rule out embedded fragment if uncounted for
* Sensibility test and evaluate tooth maturity
* Consider definitive restoration- composite build up?
* Follow up 6-8 weeks and at 1 years- check radiographs for root development (thickening of dentine walls and continued root length formation), signs of internal and external inflammatory resorption and any periapical pathologies (comparison with contralateral tooth)
## Footnote
TRAUMA stamp important here
40
5. What do you discuss with the patient regarding treatment of this trauma?
| Enamel dentine fracture
* Inform patient of possible complications- discolouration, pain, sinus formation, infection, damage to adjacent teeth
* Inform the parent of the prognosis of the tooth- 5% risk of pulp necrosis at 10 years if no associated PDL injury
* Inform them on the treatment options available to gain valid consent
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6. Decide to place composite, patient has a heart valve defect- what would you change about your treatment?
* Treatment plan would not change
* If you fear there is pulp exposure may consult with cardiologist and they will inform you whether antibiotic cover is required or not
42
Patient attends with lateral luxation 18 months ago.
1. What 8 things are assessed in a clinical trauma review stamp? (4)
* Colour
* TTP
* Sinus (/tender in sulcus)
* Mobility
* EPT
* Ethyl chloride
* Percussion note
* Radiograph
* (displacement is also checked at first visit but not found on the trauma stamp)
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2. What is lateral luxation?
* Injury to the PDL involving displacement of the tooth (other than axially) in a lateral direction within its socket, usually accompanied by comminution or fracture of the labial or lingual alveolar plate. Characterised by partial or total separation of the PDL. In most cases the apex will be forced into the bone resulting in the tooth being non-mobile
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3. How long is a lateral luxation injury splinted for?
* Flexible splint for 4 weeks
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4. What kind of root resorption can occur with lateral luxation trauma? (1)
* External inflammatory resorption (or internal inflammatory resorption)
46
5. What is the cause of external inflammatory root resorption? (1)
* PDL initially resorbed away as a result of initial damage to the PDL. Resorption is then propagated by necrotic pulp tissue via dentinal tubules (bacteria toxins move up tubules and stimulate osteoclasts to resorb the root and bone)
* (Caused by a prolonged inflammatory stimulus (from necrotic pulp) to the damaged root surface which allows continuation of the process of surface resorption)
* This overall causes progressive resorption of the external root surface
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6. What is the initial, short term and long-term management? of EIRR external inflammatory root resorption.
* Initially need to remove the source of inflammation- RCT to extirpate pulp (or peri-radicular surgery
* Perform chemomechanical disinfection and place of non-setting CaOH for 4-6 weeks
* After 6 weeks obturate with GP
* (NB. If cause is pressure stop ortho od remove impacted tooth)
* Short Term- Monitor and review for continued resorption
* Long Term- Monitor radiographically and if progressive resorption then plan ahead for prosthetic replacement (e.g. extract when temporary denture made then perhaps place bridge when old enough)
Explain to the patient that this RCT will fail in the future so eexplaining their possible treatment options for filling the space and making sure they understand the risk and benefits of each
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7. How would external inflammatory resorption appear clinically and radiographically?
* Clinically- negative response to pulp testing as pulp necrotic, may be TTP, may be mobile
* Radiographically- moth eaten appearance, root surface indistinct (PDL widened and loss of surrounding lamina dura) but internal tramlines of the tooth remain intact, may be shortening and blunting of root apices
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Root Fracture-
1. Following root fracture, what types of healing are possible?
* Calcified tissue union across the fracture union (dentine like tissue)
* Connective tissue union across the fracture union (eburnation)
* Mixture of calcified and connective tissue across fracture union
* Bone/Osseous healing separating each fragment into two separate entities
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2. What is regarded as non-healing? root fracture
* Formation of granulation tissue between two fragments (dark halo around the tooth)
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3. How are root fractures managed?
* If coronal fragment is non-displaced then no treatment is required, simply monitor and give advice re soft diet and careful brushing of the area
* If coronal fragment is displaced them might consider cleaning the area then repositioning and splinting (LA may be required)
* For apical and middle third fractures splint for 4 weeks and for cervical root fracture splint for up to 4 months
* Patient instructions- soft food for 10-14 days, burhs with soft brush after every meal, apply 0.1% topical CHX in affected area with cotton swabs x2 daily for a week, warn about potential complications such as swelling, discolouration of crown, increased mobility and fistula and tell patients to watch for swelling of the gums as a result of associated infection
52
4. How would you manage a patient with a fragment that has lost vitality?
* RCT coronal to fracture line
* Or extract tooth
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Tooth 11 has traumatic exposure of the pulp.
1. What 2 factors would influence your choice of treatment?
* Size of exposure (less or greater than 1mm)
* Time since exposure (less or more than 24hrs)
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2. How would you treat a coronal fracture with pulpal exposure?
* If exposure less than 1mm and less than 24hrs since exposure (not TTP and postivie response to sensibility tests may consider direct pulp cap; LA, rubber dam, clean with water, disinfect with sodium hypochlorite, apply calcium hydrocie or MTA white to pulp exposure, restore tooth with composite
* If exposure more than 1mm or more than 24hrs since exposure carry out partial (Cveck) pulpotomy (progress to full pulpotomy if hyperaemic pulp or inability to control bleeding after removal of 2mm of pulp tissue)
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Coronal 1/3 Fracture.
1. Why does coronal 1/3 fracture have the poorest prognosis?
* Due to difficulty stabilising
* Close to gingival margin so increased risk of bacterial invasion
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Bleaching-
1. What are the advantages of non-vital bleaching?
* Simple procedure
* Tooth conserving
* Original tooth morphology remains
* Gingival tissue are not irritated by restoration
* Adolescent gingival level not a restorative consideration
* No laboratory assistance (no tray) required for walking bleach
57
2. What are the disadvantages of non-vital bleaching?
* Potential complications- spillage of bleaching agents, failure to bleach, over bleaching, brittleness of crown
* Will regress over following years; results only semi-permanent so relapse is an issue
* Possibility for external cervical resorption only with old methods which used heat
* Won’t work where there is a large restoration so would need to replace the restoration
* Won’t work on amalgam intrinsic discolouration, fluorosis or tetracycline discolouration
58
3. Briefly describe the walking bleach technique?
* Open up access cavity of tooth and use miniature rose head bur to remove root filling to below the gingival margin
* 10% carbamide peroxide bleach place on cotton wool and inserted
* Covered with dry cotton wool and then GIC
* Oxidising process allowed to proceed gradually over days
* Bleach is renewed, ideally every week (no more than every fortnight)
* Changed 6-10 times in total till happy with shade
* Place temporary non setting calcium hydroxide for 2 weeks to reverse acidity or instruct patient to stop bleaching 48hrs before the appointment
* Then consider final restoration- white GP and composite resin (gold standard- facility to re-bleach) or incrementally cured composite (no re-bleaching but possibly strengthens tooth)
59
4. Briefly describe the inside-outside bleaching technique?
* Access cavity of tooth opened and left open (GI lining not necessary as bleach is bactericidal anyway)
* Custom made mouthguard with windows in the teeth you want to bleach made by lap
* Patient applied carbamide peroxide 10% to back of tooth and tray and wears mouthguard at all times except on eating or when cleaning the mouthguard
* Gel should eb changes every 2 hours or so
* Final restoration as in walking bleach technique
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Eruption Dates-
1. What are the eruption dates for primary teeth?
* General rules- eruption begins at 6 months and is complete at around 2.5/3 years // lower before upper apart from lateral incisor
* A- 4-6 months
* B- 7-16 months
* D- 13-19 months
* C- 16-22 months
* E- 15-33 months
* From date of eruption it take primary root 1.5 years for primary tooth root to complete apexogensis
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2. What are the eruption dates for permanent teeth?
* General rules- lower before upper apart from 2nd premolars
* 6 years old- lower then upper 6, lower 1
* 7 years- upper 1, lower 2
* 8 years- upper 2
* 9 years- lower 3
* 10 years- lower then upper 4 and upper then lower 5
* 11 years- upper 3
* 12 years- lower then upper 7’s
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3. When do the roots fully form?
* Approximately 2-3 years after the crown erupts
63
Caries-
A 4-year-old patient presents with gross caries across her anteriors including the smooth surface.
1. What is your likely diagnosis?
* Nursing bottle or early childhood caries
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Nursing bottle or early childhood caries
2. How does this occur?
* Occurs as a result of inappropriate use of feeding bottle and cusps- cariogenic drinks (milk or other drink) being fed to the child in bottles either at night, after toothbrushing just before bed or frequently during the day (sugars are inside the mouth for a prolonged period)- bottle used as a pacifier or child put to bed with bottle
* Can also occur if prolonged breastfeeding or child’s teeth not brushed (minimal fluoride exposure)
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3. What is your treatment plan? For early childhood caries, nursing bottle caries.
* Give advice- don’t take feeding cup or nursing bottle to bed at night, only allow the child water after toothbrushing, don’t give soya milk (or similar alternatives) unless for medical demands, try to avoid on demand breastfeeding especially at night, only allow child water (and milk- but gradually try to reduce) between meals, consider sugar free variation of drinks and sweets, if the child insists on sweet foods and drinks then limit them to meal times
* OHI- toothbrushing advice (<7 the parent should help with this), use of 1,000ppm fluoride toothpaste (pea sized= 0.25ml) 2x daily with manual or electric toothbrush
* Fluoride varnish 22,600ppm- 4x yearly
* Complete or partial caries removal with temporisation with GIC or hall technique SSC for posteriors
* Consider GA for extraction if un-cooperative or caries is gross
66
4. What is the classic presentation of nursing bottle caries?
* Affects all the maxillary teeth as smooth surface caries around the gingival margin
* Lower incisors spared due to protection from the nursing position of the tongue (artificial nipple rests against palate while the tongue is extended over the lower incisors) but canines may be affected
* Maxillary incisors are the first to experience the cariogenic challenge and suffer the longest attack because of their early eruption
* If the habit continues the mandibular canines and all of the first primary molars will be subjected in sequence with their eruption order
67
7-year-old high caries risk patient
1. What factors make up the caries risk assessment criteria? (5)
* Clinical evidence
* Diet
* Saliva
* Fluoride
* Plaque
* Medical history
* Social history
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2. How often should you take bitewings for a high caries risk child? (1)
* Every 6 months (12-18 for normal risk)
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3. What toothpaste strength should be used for a 7-year-old? (1)
* 1,350-1500ppm
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4. How often would you place fluoride varnish in a high-risk child? (1)
* 4x year
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5. What is 1 other common delivery method of fluoride suitable for this child? (1)
* Fluoride mouthwash 280ppm
* Oral fluoride 1mg/day tablet
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6. Give another preventive management method for high caries risk, besides fluoride toothpaste, supplements and varnish.
* Dietary advice
* Tooth brushing instruction
* Fissure sealants
* Sugar-free medicines
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7. What fluoride supplement would be indicated in areas of water fluoridation <0.3ppm?
* 1mg/day for 7 year old
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8. What are the general recommendation for toothpaste in children?
* First eruption of tooth- 3 years= 1000ppm smear of paste (0.1ml)
* 3-6= 1,000ppm pea size paste (0.25ml)
* 7+= 1350-1500ppm
* High risk under 10= 1500ppm
* High risk over 10= 2,800ppm
* High risk over 16= 5000ppm
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9. What 8 factors make up a caries prevention plan?
* Radiographs
* Toothbrushing instruction
* Strength of fluoride in toothpaste
* Fluoride varnish
* Fluoride supplements
* Dietary advice
* Fissure sealants
* Sugar free medicines
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10. What are the general recommendations for fluoride tablets in areas where <0.3ppm fluoride in the water supply?
* 6 months- 3 years= 0.25mg
* 3-6years= 0.5mg
* 6+ years= 1mg
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Patients parent complain that the tooth has white/yellow/brown stains on the teeth.
1. List 8 questions you would like to ask the parents mum? (4)
* Any severe illness during pregnancy such as anaemia, gestations diabetes?
* Any problems in third trimester such as pre-eclampsia?
* Was it a natural birth?
* Any trauma during birth such as anoxia or hypocalcaemia?
* Was it a pre-term birth or was the baby full term?
* Was nay time spent in any specific baby units after birth?
* How long did they child breastfeed for?
* Any fever or medications required during post-natal period?
* Any respiratory issues e.g. on steroids to help with breathing in the first two years of life?
* Any infections such as measles, rubella or chicken pox during childhood?
* Any antibiotic prescription before the age of 2?
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2. The teeth effected are all 1st permanent molars and central and lateral what is this condition and is it likely to be inherited? (2)
* Molar incisal hyperplasia
* Unlikely to be inherited
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3. List five questions you would ask to rule out fluorosis? (2.5)
* Does the patient use fluoridated toothpaste? Any excessive use? How often do they use it? What concentration is it? Do you or have you ever caught them eating it?
* How often do they brush their teeth?
* Does the patient use fluoridated mouthwash?
* Does the patient take any fluoride supplement tablets?
* Does the patient drink fluoridated water (where do they live)?
* Are any of the siblings on high fluoride toothpaste? Is there a chance the child may have been using this?
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4. List three potential problem of 16, 26, 36 & 46 in the future? (1.5) MIH
* Sensitivity problems
* Poor aesthetics
* Susceptible to loss of tooth substance; via breakdown of enamel, tooth wear or secondary caries
* Difficult to restore due to poor bonding capability
* Long term prognosis of teeth is poor
* LA may not be as effective or sufficient due to increased pulpal sensitivity
* Potential requirement for more complex treatment
* Potential problems with orthodontic treatment (bonding of brackets to teeth etc.)
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5. What timeframes in a child’s life are implicated in MIH?
* Pre-natal
* Neonatal
* Post-natal
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* Pre-natal
* Neonatal
* Post-natal
6. Why are these timeframes implicated?
MIH
* During these periods the development of 6’s (from 7 months IU) and 1s ( up to 6 months after birth) occurs
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7. What are the treatment options for MIH in incisors?
* Incisors- acid pumice microabrasion // external bleaching // localised placement of composite // full composite or porcelain veneers
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8. What are the treatment options for MIH in molars?
* Molars- composite or GIC restoration // (temporary) stainless streel crown to help with sensitivity // extraction to allow 7’s to drift into space of FPM
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9. What is MIH?
* Hypomineralisation of systemic origin of 1-4 permanent molars, frequently associated with affected incisors
* Hypomineralisation involves the disturbance of enamel formation (especially in mineralisation/maturation stage) resulting in reduced mineral content of present enamel
* This results in a well demarked enamel defect which may be chalky or cheesy in appearance
* Enamel will be of appropriate thickness (secretory phase happens as normal) but will not be as mineralised and so as hard as normal
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Fluorosis-
Child presents to your practice complaining of how their upper front teeth look.
1. What are possible presentations/signs of fluorosis?
* Varies with severity
* Symmetrical opaque/white speck (especially labially) on the teeth
* Mottled patched in mild cases
* Brown spots and pitting of the teeth in severe cases
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2. What is the optimum concentration of fluoride in water?
* 1ppm (1mg/l)
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3. Name 3 source of fluoride in food and drink?
Boney fish
beer
cucumber
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4. How does fluoride work topically?
* Inhibits demineralisation of dentine and enamel and so slows down the development of decay
* Promotes remineralisation (Uptake of fluoride results in formation of fluorapatite which is less soluble and makes the tooth stronger)
* At high concentrations inhibits the production of acid by bacteria
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5. Give three options for treatment of fluorosis and an advantage of each?
* Accept
* Microabrasion- easily performed, conservative, fast acting with permanent results
* Vital bleaching- allows patient to achieve desired colour, simple procedure, can be carried our at home, tooth tissue conserve (might make white spots whiter0
* Composite restoration over defect- tooth tissue conserved, simple and inexpensive
* Composite or porcelain veneers
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Discolouration-
Child attends with a discoloured tooth.
1. What questions would you ask if you were querying previous trauma?
* Are there any traumatic instances to the tooth you can occur or time when perhaps the tooth was knocked?
* When did it happen?
* How did it happen?
* Was there any tooth substance lost? If so where is the fragment(s)
* Were there any other symptoms or injuries from the trauma?
* Did you seek any treatment at the time?
92
2. What diagnostic checks can be used to test for the vitality of a tooth?
* The following test do not check for vitality but for a patent nerve supply (sensibility tests); EPT, ethyl chloride thermal testing
* Vitality tests available re laser doppler
93
3. What are the treatment options for a tooth that has had previous trauma in the form of subluxations?
* Flexible splint for 2 weeks
* Prop open occlusion by placing GI on posterior tooth to give occlusal relief
* Give advice- Instruction of OHI with soft toothbrush after every meal and topical chlorhexidine using cotton wool roll by parents 2xdaily for a week or mouthwash// eating soft diet for 7 days// avoiding contact sports
* Review at 2 weeks (remove splint), 4 weeks, 6-8 weeks & 1 year
94
Child attends with discoloured upper central.
1. What would help you work out the aetiology of the discoloured tooth? (3)
* Sensibility testing
* History from patient
* Type of colour
* Radiograph
* TTP
95
2. What three local factors or things should you check/do before Tx? (3)
| Discoloured central
* Take note of original shade
* Diagram of defect
* Sensibility test
* Radiograph for signs of loss of vitality or resorption which may be causative
96
3. Outline 2 treatment options for discolouration and explain them briefly? (4)
* Microabrasion- HCl and pumice slurry placed and agitated over tooth surface (maximum 5x10 times) in order to move outer enamel layer and hopefully stain (removes top 100 microns)
* Night guard vital bleaching at home- patient is made a mouthguard and given 10% carbamide peroxide gel which they apply to the tray before it is set over the teeth and worn overnight
97
Suspected Child Abuse-
1. What 4 things would make you suspect a non-accidental injury? (4)
* Injuries in the triangle of safety (ears, side of the face and neck, top of the shoulders)
* Injuries to both sides of the body
* Any injury that doesn’t fir the explanation or story given
* Delayed presentation of injury
* Untreated injury
* Injuries to the soft tissue, groin or in repeated explanations
98
2. Give 2 effects of trauma on primary teeth? (2)
* Delayed exfoliation of primary tooth (may not resorb normally)
* Discolouration
* Infection (loss of vitality)
99
3. 4 Effects of trauma on permanent dentition? But the trauma is too the primary teeth (4)
* Enamel defects- hypoplasia or hypo mineralisation
* Abnormal tooth or root morphology (dilaceration or duplication)
* Delayed eruption
* Ectopic tooth position
* Arrest in tooth formation
* Complete failure of tooth to form
* Odontome formation
100
Stainless Steel Crown-
1. What are the indications for a stainless-steel crown?
* More than 2 surfaces affected by caries
* Extensive 2 surface lesions
* Marginal ridge broken down
* After pulpotomy/pulpectomy
* To cover severe MIH or other developmental defects (which may be giving sensitivity)
* As an abutment for space maintainers
* Fractures primary molars
* Where there is a high caries risk/experience or impaired OH
101
2. How is a SSC conventionally placed?
* Select crown- measure mesiodistal width of crown and adjust as needed with band forming pliers
* Tooth preparation under LA and dental dam
* Remove caries (and place indirect pulp cap if risk of exposure)
* 1-2mm occlusal reduction with flat fissure bur, marginal ridge reduction and interproximal preparation- clear contact with fine taper separating bur
* Isolate and dry tooth
* Place GI luting within crown
* Seat crown (partially until crown engages tooth point) with pressure
* Get patient to bite crown down into place (or full seat crown with first finger pressure)
* Gingival blanching is normal
* Remove excess cement with probe and check contacts and occlusion
* Get the patient to continue to firmly bite down for 2-3 minutes
102
3. How else may a SSC be paced (that isnt the convential way)?
* Using the hall technique
* As above but no LA or tooth preparation is performed
* Separators are placed prior to seating visit if tight contacts are a problem
103
4. How can stainless steel crowns be judged to have failed?
* Crown worn, lost or requiring other intervention
* New or secondary caries
* Restoration lost but tooth restorable
* Reversible pulpitis treated without requiring pulpotomy or extraction
*All the above are minor failures
* Irreversible pulpitis (and pain)
* Associated abscess requiring pulpotomy or extraction
* Interradicular radiolucency
* Filling lost and tooth un-restorable
*all the above are major failures
104
Down Syndrome-
1. What 4 medical condition are down syndrome children predisposed to? (4)
* Cardiac defect- ventricular septal defect, tetralogy of Fallot
* Epilepsy
* Leukaemia
* Alzheimer’s/ Dementia
* Hearing defects
* Cleft lip and palate
105
2. What are 4 general extra-oral features of Down syndrome children? (4)
* Small nose and flat nasal bridge (small midface)
* Eyes that slant upwards and outwards (oblique palpebral fissure)
* Small mouth with tongue that may stick out
* Flat back of the head and facial features
* Brushfield spots
* (Below average height)
106
3. What are 6 intra-oral features of down syndrome? (3)
* Maxillary hypoplasia
* Class III occlusion
* Macroglossia and fissured tongue
* Hypodontia / Microdontia (often with retained primaries)
* Anterior open bite
* Predisposition to peridootnal disease
* High arched palate
* Cleft lip and palate
* Spacing
* Delayed eruption of teeth
107
4. 6 examples of how the prevention treatment plan may be altered for down syndrome patient’s? (3)
* Fluoride varnish 22,600ppm x4 yearly (additional 1-2 times yearly)
* Fluoride supplementation
* High fluoride toothpaste- 2,800ppm (10+) & 5,000ppm (16+)
* Consider alcohol free sodium fluoride mouthwash use
* Consider sealing permanent molar and premolars on eruption
* Fissure sealants may be difficult to get moisture control for so GI may be indicated
* Radiographs every 6 months (and recall every 6 months)
* Ensure using sugar free medicines
* Hands on brushing advice at least once a year
* Disclosing tablets used at each visit and given away to use at home
* NB. May require GA
108
Fluoride-
1. Name 4 vehicles of fluoride delivery?
* Toothpaste
* Fluoride varnish
* Mouthwash
* Supplements
* Water
* Milk
109
2. What are the topical effects of fluoride?
* Inhibits demineralisation of dentine and enamel and so slows down the development of decay
* Promotes remineralisation (Uptake of fluoride results in formation of fluorapatite which is less soluble and makes the tooth stronger)
* At high concentrations inhibits the production of acid by bacteria
* (Bactericidal)
110
3. What are the systemic side-effects of fluoride?
* Fluorosis
111
The mother of a young child phones your practice stating that her son had ingested fluoride toothpaste and she is worried.
1. What three questions should you ask the mum? (3)
* How old is the child? / What weight are they?
* What is the strength of the toothpaste they have ingested (fluoride concentration)?
* How much toothpaste have they swallowed?
112
2. What is the toxic dose for fluoride?
* 5mg/kg
113
3. If he has ingested a possible toxic dose what is your advice? (2)
* Generally, give milk (calcium orally) and admit to hospital
* <5mg/kg give calcium orally (milk) and observe for a few hours
* 5-15mg/kg give calcium orally (milk, gluconate, calcium lactate) and admit to hospital
* 15mg/kg+ admit to hospital immediately for cardiac monitoring and I/V calcium gluconate
114
4. What is the most common cause of fluorosis in the UK? (1)
* Fluoridated public water supply > 1ppm
115
5. If the patient is 10 with fluorosis what is your first line treatment? (1)
* Microabrasion
* Other options are leave and minor, composite restoration, veneer and vital bleaching
116
6. Patient are ages 1,4, and 7, that are high caries risk with a <0.03ppm fluoridated water supply. What fluoride supplementation would you advise for each patient? (3)
* Age 1- fluoride drops 0.25mg/0.5ml
* Age 4- fluoride tablets 0.5mg
* Age 7- fluoride mouthwash 225ppm or 1mg/l tablet
117
Microabrasion-
1. What are the indications for microabrasion?
* Fluorosis
* Decalcification after orthodontics
* Trauma during permanent tooth formation
* Molar incisor hypoplasia
* Pre-veneer fit to mask staining
118
2. What are the advantages? of microabrasion
* Easily performed
* Conservative
* Inexpensive
* Teeth need minimal subsequent maintenance
* Fast acting
* Effective
* Removes yellow-brown, white and multi-coloured stains
* Results are permanent
* Can use before or after bleaching
119
3. What are the disadvantages of microabrasion?
* Removes enamel
* HCL acid compounds are caustic- can cause burns if spill etc.
* Require PPE for dentist, nurse and patient
* Prediction of treatment outcome is difficult
* Must be done in dental surgery
120
4. What 3 pre-microabrasion records are required? (3)
* Shade
* Photographs
* Sensibility tests
* Diagram of defect
121
5. Explain the process for carrying out microabrasion? (4)
* Take pre-op shade, photographs and sensibility testing (diagram of defect and radiographs if indicated)
* Ensure patient dentist and nurse are all wearing suitable PPE
* Place Vaseline on gingivae and isolate teeth with dental dam (using wedgets or floss ligatures to keep in place)
* Clean teeth with pumice and water (to remove pellicle)
* Place sodium bicarbonate guard behind teeth for protection (alkaline to neutralise pH if drops)
* HCL pumice slurry rubbed/agitated on tooth with wooden lollipop stick for 5 second
* Washed off directly into aspirator
* Repeat until desired colour change, up to maximum of 10 x 5 second application (stop before this if you see dentine)
* Wash tooth thoroughly
* Remove dam and let patient see
* Place profluroide (colophony free) fluoride varnish
* Instruct patient does not eat coloured staining food for 24-48hrs and is careful with them for the next two weeks
* Review after 4-6 weeks and take post op photographs and new shade note
122
6. What 1 thing should you warn the patient of after the procedure? Microabrasion
* Not to use heavily stained foodstuff or drinks
123
7. One alternative treatment is bleaching what concentration and type of chemical us uased for vital bleaching? (2)
* 10% carbamide peroxide (3.3%H2O2 + 6.6% urea)
124
Autism-
1. Regarding autism, what is the triad of impairment?
* Used to describe the main features that all people with autism have difficulty with to some degree- communication, social interaction and social imagination
125
2. What other features does autism have?
* Sensory sensitivity- hyposensitive or hypersensitive
* Learning difficulties
* Epilepsy
* OCD
126
3. How are autistic patients managed in a dental setting?
* Plan dental visit in advance with social story using PECS (leaflets or pictures alternatively) to prepare the patient (and possibly invite patient for acclimatisation visit)
* Time visits in line with when is best for the patient (when are they most likely to co-operate etc.)
* Be on time and read
* Ensure you know any sensitivity issues (obtain a profile of their likes and dislikes from parent/carer) and control the environment to minimise these are minimise distractions in general (quiet surgery, no clutter, radio off, no interruptions etc.)
* Ensure you understand ahead of visit how the patient prefers to communicate- board marker pictures, symbols, Makaton, widget symbols
* When giving instructions to the patient always give them direct commands as oppose to asking open questions which may confuse them
* Identify likes in the dental surgery e.g. dental unit and use these to pacify the patient but equally identify dislike such as dental light etc.
* Give enhanced prevention- consider unflavoured toothpaste e.g. oranurse where patient doesn’t like the taste, OHI instruction (2x daily using modified bass technique)
* If high fluoride risk consider extra fluoride in forms of 4x yearly fluoride varnish, daily fluoride mouthwash 225pm or high fluoride toothpaste
127
Anxiety-
1. What are the reasons for a child to be anxious before visiting the dentist?
* Emotional development
* Previous adverse dental/medical experiences
* Physiological make up
* Understanding of what will be involved
* Attitude and previous experience of family and peer-group
128
2. How may anxiety be measures in children?
* Modified Child Dental anxiety scale
* Child rates difference aspects of the dental experience form 1 to 5 (each of which correspond sot a different smiley) from relaxed/not worried (1) to very worried (5)
* Allows you to establish base line levels of anxiety
* Quick and easy to use
129
3. Give 8 behavioural management techniques? for anxiety
* Tell show do
* Positive reinforcement
* Acclimatisation
* Systemic desensitisation
* Voice control
* Distraction
* Role modelling
* Enhanced control
* Cognitive behaviour therapy
* Relaxation
* Hypnosis
130
4. How may anxiety manifest?
* Thumb-sucking, nail biting or nose-picking
* Stuttering
* Stomach pain
* Need to go to the toilet
* Headache or dizziness
* Fidgeting
* Clinging to parent or hiding
* No speech
131
Fissure Sealants-
1. What are the indications for placing fissure sealants?
* Children deemed at high risk of caries should have their permanent molars and premolars sealed upon eruption (e.g. if they have experience of caries in the primary dentition)
* Medically compromised children, children with learning difficulties or the physically and mentally handicapped should have all teeth sealed
* Guidance from SIGN 138 suggest all first permanent molars in children should be sealed
* If a FPM has caries the 2nd molars and remaining FPM should be sealed
* When patients have deep fissure pattern and find it hard to clean this may be a indication
132
2. Give two materials that can be used for FS?
* Bis-GMA resin (following acid etch technique)
* GIC
133
3. Describe the technique for placing fissure sealants?
* Isolate the tooth using single tooth dental cam or dry guards and cotton wool (and aspiration)
* Clean occlusal surface- preferably with pumice and water
* Etch with 35% phosphoric acid wash into aspirator and dry tooth (check for white chalky appearance)
* Add the resin to the depths of the dry fissure pattern with brush, micro-brush or small excavator ensuring material is at base of fissure but not overfilled
* Remove excess with a dry micro-brush
* Light cure
* Check sealant firmly adhered with a sharp probe and check no air blows present
* Check no material has flowed interproximally with floss and no excess material in the distal soft tissues
* Review regularly
134
Cerebral Palsy & CF
1. What are the 4 types of cerebral palsy?
* Spastic
* Athetoid
* Ataxic
* Mixed
135
2. How are they further classified? in sub sets of cerebral pulsy. After spastic etc
* Hemiplegia
* Diplegia
* Paraplegia
* Quadriplegia
136
3. What is cystic fibrosis?
* Inherited autosomal recessive condition caused by mutation on CFTR gene on chromosome 7 which causes excessive, thick, sticky mucous in all the secretory organs including the lungs, pancreas and salivary glands (defect in cell chloride channels)
137
4. What are the general signs and symptoms? of Cystic fibrosis
* Troublesome cough
* Repeated chest infection
* Thick saliva
* Shortness of breath
* Cough or wheeze
* Poor weight gain or underdeveloped (difficult absorbing fat soluble vitamins)
* Prolonged diarrhoeas
* Liver dysfunction, diahorrea and constipation
* Prone to osteoporosis, diabetes symptoms and infertility in males
* (Cyanosed lips and blue fingernails)
138
5. What are the dental considerations for cystic fibrosis?
* Thick saliva so decreases caries but increase saliva can cause calculus build up
* Difficulties cleaning and brushing teeth due to respiratory problems
* May struggle to lie back for dental treatment without needing to release excess sputum
* Avoid GA and sedation
* May have delayed eruption and enamel defect due to inherited condition
139
Amelogenesis Imperfecta-
1. Name 4 types of amelogenesis imperfecta?
* 1- Hypoplastic- crystals don’t grow to correct length
* 2- Hypocalcified/hypomineralised- crystals fail to grow in thickness/width
* 3- Hypomaturational- crystals grow normally in length but incompletely in thickness or width with incomplete maturation
* 4- Mixed forms (with Taurodontism)
140
2. What is the cause?
| Amelogenesis imperfecta
* Inherited gene mutation in the genes responsible for the transcription of the proteins needed for normal formation of enamel specifically those involving the enamel extracellular matrix molecules (amelogenin, enamelin and kallikrein)
* Different mutations occur depending on the type of AI
141
3. What problems may occur?
| Amelogenesis imperfecta
* Aesthetics
* Poor Sensitivity
* Susceptibility to caries and or acid erosion
* Delayed eruption
* AOB is commonly associated
142
4. How may it be managed?
| Amelogenesis imperfecta
* Enhance prevention therapy- OHI, fissure sealants, dietary advice
* Composite veneers or composite wash/bonding
* Fissure sealants
* Stainless steal crowns
* Metal onlays
* (Orthodontics for open bites and misalignments)
143
5. Name 3 other causes for enamel defects?
* Fluorosis
* MIH
* Trauma
* Infection of primary tooth
* Systemic infection e.g. measles
144
Osteogenesis and Dentinogenesis Imperfecta-
1. What are the 3 types of dentinogenic imperfecta?
* Type 1- Associated with osteogenesis imperfecta
* Types 2- Autosomal dominant (not associated with osteogenesis imperfecta)
* Type 3- Brandywine
145
2. What are the clinical sings of Dentinogenesis imperfect and osteogenesis imperfecta?
* Dentinogenesis- enamel loss, discolouration, amber appearance of affected teeth, both dentitions affected, (multiple PA abscess due to ‘pulpal strangulation’)
* Osteogenesis- blue sclera of the eye, lots of bone fractures
146
3. What are the radiographic signs of Dentinogenesis imperfecta?
* Bulbous crowns
* Obliterated pulps (erupt with large pulps but obliterated soon after)
* Short and thin roots with rounded apices
* Occult abscess formation /periapical radiolucency without any apparent clinical pathology
* Reduced mineralisation of dentine results in it appearing as radiolucent as the pulp and the two spaces are un-differentiable
147
4. What problems are associated with Dentinogenesis imperfecta?
* Poor aesthetics
* Susceptibility to caries and acidic erosion
* Spontaneous abscess
* Teeth have poor prognosis in general
* (Increased risk of fracture)
148
5. What is the clinical management?
| Dentinogenesis imperfecta?
* Enhanced prevention- OHI, fissure sealants, dietary advice
* Composite veneers
* Overdentures
* Removable prosthesis
* Stainless steel crowns
149
Child Abuse-
An injured child attends your practice with his mother. You are concerned for the child’s welfare. What are some factors which would increase your index of suspicion?
* Delay in seeking help/presentation
* Story is vague, lacking in detail or inconsistent and varies with each telling
* Injuries do not match story/account
* Child contradicts original story
* Previous history of injury
* Abnormal mood for child- unusual interaction with parents
* Unusual mood from parent- preoccupied. May show unprovoked aggression towards staff, refuse to allow proper treatment or hospital admission
* What orofacial injuries are suspicious?
* Bilateral injuries
* Injuries in the ‘triangle of safety- ears, side of face and neck, top of shoulder’
* Injuries to the soft tissue
* Bruises of different vintages- different colours indicate different stages of injury and multiple injuries
* Tattoo bruising- in the shape of the implement that has caused the injury
* Slap, grip or pinch marks- slap will be red lined pattern in between where fingers are, grip in form of four finger shaped bruises on one such as a larger thumb shape bruise on the other
* Bite marks
* Hair pulling- scalloping on the scalp
* Extra orally- bruises of face (punch, slap, pinch), bruises of ears (pinch or pull), abrasions or lacerations, burns and bites, neck injuries (choke or cord mark), eye injuries, evidence of hair pulling, fractures to the nose, mandible and zygoma
* Intra orally- confusions, bruises, abrasions and lacerations, burns and tooth trauma
* You wish to refer the child on. Who do you refer to and how do you do it?
* Observe- assess the child, take a history and perform an examination (if possible take photographs of the lesions)
* Record- everything in the notes
* Communicate- both with senior colleagues and/or child protection unit for advice and, where safe to do so, with the parents regarding concerns
* There is also the option to speak to a health visitor or nurse whom is the named person for the child
* Where there is severe concern then contact social services by phone and fill out the relevant paperwork for onwards referral and assessment of the child
150
A 3-year-old child is brought to your practice by her mother who is worried about blisters on her gums.
1. What is the likely diagnosis?
* Primary herpetic gingivostomatitis
151
2. How might the ‘blisters’ appear? in primary herpetic gingivostomatitis
* Small fiery red vesicles which rupture to form ulcers which are 1-3mm in size (on mucosa and gingivae)
152
3. What other signs and symptoms might be present?
| * Primary herpetic gingivostomatitis
* Painful mouth
* Refusal to eat or brush teeth
* Blood crusted lups
* Halitosis
* Fever
* Malaise
153
4. What is the likely cause?
| * Primary herpetic gingivostomatitis
* Primary infection with herpes simplex virus
154
5. How is the patient managed?
| * Primary herpetic gingivostomatitis
* Supportive care only
* Reassure parent that it will go away- lesions heal spontaneously within 1-2 weeks with acute phase lasting 7-10 days
* Encourage fluid consumption
* Bed rest
* Analgesics as appropriate- paracetamol and/or ibuprofen (good as antipyretic)
* If immunocompromisation may give acyclovir
* Tell parent to take patient to hospital if refusing fluids as risk fo dehydration
155
6. What future issues may this virus cause?
| * Primary infection with herpes simplex virus
* Reactivation of virus causing herpes labials (AKA cold sores) (occurs in 15-20% of patients)
156
Dental Neglect/Child in Pain-
5-year-old Jodi has been brought to your clinic by her mum’s boyfriend. she did not sleep last night as a result of dental pain. Jodi has not been to the dentist before because her mum has a lifelong fear of dentists. Her mother’s boyfriend is vague about Jodi’s medical history and Jodi is small for her age. Jodi is pyrexic, in pain and has a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally diagnose an acute periapical abscess.
1. What should you establish prior to examination of Jodi?
* Severity of condition- is her airway compromised and does she require emergency care; if patient is unable to swallow or to push their tongue forward send to emergency care
* Thorough history- HPC (when did the swelling arise etc.), pain history (SOCRATES- outline in exam), definitive medical history, dental history (OH habits etc.)
* Consent for any treatment
* Also, must consider if mum’s boyfriend has right to consent for Jodi
157
2. Describe in detail 1 behavioural management technique you could use to maximise Jodi’s co-operation?
* Tell, show, do
* Tell- Start by telling Jodi in friendly, non-threatening language that she will understand what you are going to do
* Show- Show Jodi what you are going to do for example by letting her have a look at herself in the mirror before using it in her mouth or demonstrating on her mother’s boyfriend
* Do- Can then attempt to examine Jodi, initiating treatment at a minimum delay
158
3. Jodi has difficulty accepting a full examination, including radiography, and you assess her as being pre-cooperative with regards to operative care. What would your short-term management for Jodi be? (3) (she has facial swelling is 5, in alot of pain, systemic symptoms, gross caries in primary molars and has acute periapical abscess)
* If possible and patient can sit still for long enough attempt to incise intra-oral swelling to provide drainage
* Give advice re pain relief- Ibruprofen preferred as ant-pyretic
* Give advice re rest and keeping child’s fluid intake up
* Prescribe antibiotics as systemic involvement (especially if drainage not achievable)- amoxicillin 500mg x3 daily (or oral suspension 250mg/5ml) for 5 days
* As mother’s boyfriend to bring child back in to be reviewed in 5 days
* Explain that is swelling gets bigger to bring the child to A&E
159
4. How would you address the situation of Jodi’s previous non-attendance?
## Footnote
Jodi has not been to the dentist before because her mum has a lifelong fear of dentists. Her mother’s boyfriend is vague about Jodi’s medical history
* Record notes of this visit accurately
* Inform mother’s boyfriends that you are a bit worried about Jodi’s lack of attendance given today’s presentation and would like to get in touch with Jodi’s mum to disucss this
* Ensure you have the right contact details for Jodi’s mum
* Contact mum and discuss what has happened today and the necessity of Jodi to attend appointments regularly for the sake of her oral and general health and to avoid future situations similar to this one
* Sympathise with the mother about her phobia but make her aware there are issues with consent if she is not present and try to come to an agreement about how to manage this e.g. mother and boyfriend bring Jodi together and mother gives consent but can wait in waiting room while treatment carried out
* Inform mum about the possible child protection implications is non-attendance and non-compliance continues
* Set up a next appointment on the phone that is suitable for all parties
160
5. What evidence-based brushing advice would you give to help prevent further dental caries?
* Brush with 1,000ppm fluoride toothpaste (pea size paste (0.25ml)) twice daily with manual or electric toothbrush
* Modified bass technique holding the toothbrush at 35 degrees to the gingival margin
* Brush teeth for 2 minutes, using a systematic approach to cover all of the surface of the teeth and soft tissues
* As she is under 7, adult should supervise and help with brushing
161
Pulpotomy-
1. What are the indications for a pulpotomy?
* Pulp minimally inflamed with reversible pulpitis
* Marginal ridge destroyed
* Caries extending more than 2/3 into dentine on radiograph
* Any doubt that pulp has been exposed either via caries or iatrogenic damage
* Traumatic exposure >1mm or in trauma case >24hrs since trauma
* General Indications- good co-operation, MH precludes extraction, missing permanent successor, overriding necessity to preserve tooth- space maintainer
162
2. What are the contra-indications for a pulpotomy?
* Non-vital tooth
* Chronic sinus
* Evidence of periapical pulpitis or acute abscess (pulpectomy indicated)
* Irreversible pulpitis
* Advanced root resorption
* Seveer re-current pain or infection
* General Contra-Indications- poor co-operation, cardiac defect, multiple grossly carious teeth (more than 3), congenital heart disease
163
3. Describe how you would carry out a pulpotomy?
* Give LA
* Place rubber dam
* Remove caries and roof of pulp chamber to gain access
* Remove 2mm of coronal pulp with excavator or slow speed
* Attempt to achieve haemostasis and evaluate pulp- if normal bleeding (bright red coloured and good haemostasis achievable) continue with pulpotomy technique if abnormal bleeding (hyperaemic) (deep crimson colour and failure to achieve haemostasis) proceed to full coronal pulpotomy
* Achieve haemostasis by placing saline soaked cotton pledged over root stumps for 20 seconds (primary teeth only for use of ferric sulphate)
* Once normal bleeding has stopped apply non-setting CaOH
* Seal with GI/ place GIC
* Restore tooth with acid etched composite tip for anterior or SCC for posterior in primary teeth
* NB. If exposure >1mm or if more than 24hrs since exposure go straight to describing full pulpotomy- amputate all coronal pulp up to
164
4. How is failure measured clinically and radiographically? for a pulpotomy
* Clinically (review every 6 months)- pain, fistula or chronic sinus, pathological mobility. Tooth is still symptomatic
* Radiographically (review every 12 months)- external or internal root resorption, evidence of periapical periodontitis, furcation bone loss
165
5. What is a partial pulpotomy?
* Involves 2mm removal of pulp tissue surrounding the area of the exposure until healthy pulp is reached and then place calcium hydroxide dressing as a barrier
166
6. How is a pulpectomy carried out?
* Give LA
* Place rubber dam
* Remove caries and roof od pulp chamber to gain access
* Remove coronal pulp with excavator or slow speed (coronal pulp extirpation)
* Prepare root canal to 2mm short of apex (to prevent damage to permanent tooth/germ)
* Irrigate with sodium hypochlorite is dam is effective and if not use CHX
* Obturate with calcium iodoform paste
* Restore with GIC core and SSC
167
7. What are the indication for a pulpectomy?
* Irreversible pulpitis
* Clinical or radiographical signs of periapical periodontitis or acute abscess
* Exposure of non-bleeding or severely hyperaemic pulp
168
8. Describe process of moving from use of a partial pulpotomy to full pulpotomy to full pulpectomy?
* Start with partial pulpectomy- remove 2mm coronal pulp tissue from around site of exposure until healthy pulp tissue is reached
* If hyperaemic pulp and cannot achieve haemostasis proceed to full pulpotomy and remove all of coronal pulp
* If evidence at this stage of necrotic pulp or irreversible pulpitis- no bleeding or hyperaemic pulp then proceed to full pulpectomy
169
Cardiac Defects-
1. What is the most common cardiac defect in children?
* Ventricular septal defect (VSD)
170
Cardiac Defects-
1. What is the most common cardiac defect in children?
* Ventricular septal defect (VSD)
171
2. What condition is this commonly associated with?
| VSD
* Down’s syndrome
172
3. Name four other medical issue commonly seen in Down Syndrome patients?
* Leukaemia
* Epilepsy
* Hypothyroidism
* Periodontal disease
* Alzheimer’s / dementia
* Coeliac disease
* Cataracts
* Hearing problems
173
4. How is this managed in the dental setting?
| A patient with a cardiac defect
* Give enhanced prevention to avoid dental disease, infection and need or treatment- OHI (toothbrushing x2 daily w/ fluoride toothpaste) fluoride varnish 4x yearly, fissure sealants
* Always consult with cardiologist when carrying out high risk treatments (possible antibiotic prophylaxis indicated)
* In the case of avulsion avoid planting tooth or consider antibiotic coverage
* Avoid sedation
* In the case of periapical infection/abscess formation/ irreversible pulpitis XLA indicated instead of endodontic treatment (risk if infective endocarditis)
* Consider medical history re possible anticoagulant prescription
* If sever issues- refer to special care
174
A co-operative 10-year-old attends with moderate crowding requesting orthodontic treatment but has poor oral hygiene and cavitated caries into dentine in the 1st permanent molars.
1. Describe your management of this case? (12)
| Huge answer
* Assessment- take a thorough history from the patient- C/O (ask if (history of) pain and about orthodontic concerns), HPC, MH< DH< SH
* Extra-oral and intra-oral examination
* Caries risk assessment- clinical evidence, dietary habits, social history, fluoride use, saliva, plaque (OH), medical history
* Radiographs- OPT or bitewings to assess caries and any other pathological findings
* Special tests- sensibility testing, marginal free bleeding chart, plaque free chart, modified BPE
* Treatment- Deal with any sources of pain first
* Treat caries in 6’s first- caries removal & RCT in order to try and retain teeth to allow for more options when it comes to orthodontic treatment planning- if co-operative hopefully patient will cope with LA but if not consider sedation (or GA) and discuss the risks and alternatives of each with patient and parent before deciding and proceeding- or alternative extraction
* Review developing dentition as place fissure sealants as appropriate
* Implement enhanced prevention- give OHI, consider prescription of 2,800ppm duraphat toothpaste, fluoride varnish 4x year, diet advice, fissure sealants, sugar free medicines if appropriate (make note of high caries risk and implement appropriate changes with regard to radiograph frequency)
* Discuss orthodontic treatment- Find out why the patient want orthodontic treatment (is it motivated by the parent or patient?), inform them that is it likely not appropriate at the moment until the current disease process can be stabilised, inform the patient of the risk of orthodontic treatment as well as the benefits, make them aware that orthodontic treatment requires high levels of OH and that they should put effort into improving this in order for orthodontic treatment to be considered in the future (as orthodontic appliances act as a further plaque retentive factors which can result in subsequent disease, infection and pain if appropriate OH does not accompany treatment)
* Consider child neglect as a result of the carious 6’s
175
2. Describe the risk-benefit discussion you would have with the patient and parent? (8)
| Ortho tx, XLA 6's, GA and sedation
## Footnote
A co-operative 10-year-old attends with moderate crowding requesting orthodontic treatment but has poor oral hygiene and cavitated caries into dentine in the 1st permanent molars.
* Discuss risks of orthodontic treatment- decalcification (inc. risk if poor OH), root resorption, relapse, gingival recession, enamel loss as a result of trauma from opposing brackets, loss of PD support, soft tissue trauma, loss of vitality, allergy, poor/failed treatment
* Discuss benefits of orthodontic treatment- possible relief of crowding
* Discuss risks of extracting 6’s- pain, bleeding, bruising, swelling, risk of infection, risk of damage to adjacent teeth, mesial tipping of 7’s or distal migration of 5’s- in this case may be advised to extract 6’s but want to do this at a time when the space can maintained/utilised to alleviate crowding
* Benefits of extracting 6’s- ensures caries free permanent dentition, creates space for crowding to be dealt with (NB. Bifurcation of 7’s- age 8/9 so too late)
* Outline risks and benefits of GA/sedation if this is to be considered
