paeds Flashcards
aims of primary dentition trauma management
presevre integrity of permanent successor and presver primary tooth where possible
aims of permanent trauma management
preserve vitality of tooth to allow root maturation and resotre crown to prevent function and aesthetic problems
components of trauma stamp
8
sinus/ tender in sulcus
TTP
mobility
colour
displacement
EPT
ECl/thermal
percussion notes
radiographs
factors that influences prognosis after trauma to tooth
root development
injury type
presence of infection
delay in seeking tx
PDL damage
age of child
degree of displacment
associated injuries
primary trauma
concussion
observe only
primary trauma
subluxation
observe only
primary trauma
lateral luxation
extract if occlusal interference
allow spontaneous reposition if not
primary trauma
extrusion
extract
primary trauma
intrusion
parallax
if towards developing tooth germ (lingual) - extract
if not (buccal) leave to reerupt
if not progress after 6 months - XLA
primary avulsion
radiograph to confirm -
DO NOT REPLANT
primary trauma alveoalr bone fracture
reposition and 4wk splint
post trauma complications
primary tooth
4
discolouration
discolouration and infection
disclouration due to loss of vitality
delayed exfoliation
post trauma complications
of primary on permanent dentition
6
enamel defect
delayed eruption
ecotopic eruption
abnormal tooth/root morphology (dilaceration)
arrest of tooth formation
complete failure to form
interceptive methods to prevent dental trauma
interceptive ortho for increased OJ >9mm
mouthguard for contact sports
3 contraindications for immediate replantation after avulsion of permanent tooth
immunocompromised child,
immature lower incisors,
other more serious/concerning injuries that required treatment
periodontal healing outcomes post replantation
4
regeneration
PDL/cemental healing
bony healing (ankylosis)
uncontrolled infection
periodontal healing outcomes post replantation
4
regeneration
PDL/cemental healing
bony healing (ankylosis)
uncontrolled infection
pulpal healing outocmes after replantation
3
regeneration
necrosis
uncontrolled infection
primary tooth features
4
Thinner enamel,
larger pulp horns,
broad contact points/areas,
bulbous crowns,
cervical constriction
leeway space
extra mesio-distal space occupied by primary molars which are wider than the permanent premolars that will replace them. Ideally 1.5mm upper and 2.5mm lower
mixed dentition
from when first permanent tooth erupts until the last primart tooth exfoliates
3 aims of paediatric dentistry
develop and maintain an intact, healthy, functional and aesthetic primary and permanent dentition (as few restored teeth as possible)
free from pain and infection (no active caries)
positive attitude towards future dental care
Caries risk assessment
7
clinical evidence
dietary habits
social history
fluoride use
plaque control
saliva
medical history
caries risk prevention components
7
radiographs - regular (6months high risk)
fluoride varnish
fluoride toothpaste
OHI
diet advice
fissure saelants
f supplements
early childhood caries
due to frequent sugar intake and/or reduced saliva flow (prolonged breast feeding, overnight use of drinking cups/bottles - juice, sugar medication)
upper incisors, first primary molars affected. Lower incisors protected by tongue and saliva
fluroide conc toothpastes and ages
1000ppmF (smear <3yrs old for low risk children)
1350-1500ppmF (<3yrs old for high risk children; all kids >4yrs old)
2800ppmF (0.619% NaF TP - high risk kids >10yrs)
5000ppmF (1.1% NaF TP - high risk individuals >16yrs. Not suitable for kids)
potentially lethal dose F
probable lethal dose F
how to manage
5mg/kg
15mg/kg
<5mg/kg - oral calcium (milk) and observe for few hours
>5mg/kg - oral calcium and go to A&E
fluorosis
long term excessive consumption of fluoride
causes a diffuse mottled pattern on teeth - varies to severe pitting and discolouration
tx - micro abrasion, composite masking
risks early loss primary teeth
space loss
crowding
risk early loss of permanent 6s
rotation and mesial drift 7s
distal drift of 5s
fissure sealant materials
Bis GMA (resin) or GIC
GIC used for poor moisture control, pre cooperative child, has a poorer retention
why fissure seal
material used to provide a barrier to fissure system to prevent caries development
seals fissures so food and debris cannot get caught in them
issues with Stainless Steel crowns
post placment
conventional
Rocking - cervical margin >1mm beyond max curvature
Canting - due to uneven occlusal reduction
Hall crown technqieu
no caries removal and no LA or tooth prep
seals caries in until tooth exfloiates (biological methods)
indications for Hall
2
asymptomatic
no clinical/radiographic signs of pulpal involvement
hall crown procedures
place ortho separators (3-5days)
remove separators
select cwon - check size against tooth but do not seat
fit with GIC - set until contact point engage and ask pt to bite on cotton wool on top
extrude excess GIC
POIG
major failures of Hall crowns
irreverisble pulpitis
abscess
interradicular radiolucency
resotraiton loos and tooth unrestorable
minor failures of hall crown
secondary caries
restoration loss but intervention possible (resotrable)
reversible pulpitis
aims of pulpotmies
stop/control bleeding
disinfect tooth
persever vitality of apical portiuon of radicualr pulp
indication for pulpotomies
Carious/traumatic exposure of bleeding pulp,
marginal pulpal inflammation,
reversible pulpitis, c
aries extending >2/3 into dentine radiographically
signs of pulpotomy failure
Clinical - pathological mobility, fistula/chronic sinus, early exfoliation, pain
Radiographic - increased radiolucency, root resorption, furcation bone loss
aim of behaviour management
To ease fear and anxiety, improve cooperation and promote understanding of the need for good dental health
fear
A normal emotional response to objects/situations perceived as genuinely threatening
anxiety
Occurs without a triggering stimulus present and may be due to unknown danger/previous negative experiences
phobia
A clinical mental disorder that interferes with daily life. Subjects display persistent/extreme fear of objects and/or situations and may demonstrate avoidance behaviour.
behaviour management strategies
7
- Positive reinforcement (praise good behaviour)
- Tell-show-do (explain what you will be doing, show the child the instruments, etc., perform procedure on child)
- Acclimatisation (planned, sequential introduction of environment, people, instruments and procedures)
- Desensitisation (gradual exposure to new stimuli or experiences of increasing intensity)
- Distraction,
- role modelling,
- relaxation/hypnosis/CBT
factors influencing childs behvaiour
4
- Understanding, emotional development,
- previous adverse dental/medical experiences,
- attitudes and previous experiences of family/peers,
- behaviour of the dental team
signs of DFA
Thumb-sucking, nail-biting, nose-picking, fidgeting, clumsiness, stuttering, hiding, dizziness, stomach pain, headache, needing toilet, asking questions
general anaesthsia definintion
Any technique (using equipment or drugs) which produces a loss of consciousness and/or abolition of protective reflexes in specific situations associated with medical or surgical interventions
aims of GA in dentistry
Atraumatic induction,
completion of comprehensive or traumatic dental treatment,
elimination of pain and infection,
establish basis for continued preventive care, short and uncomplicated recovery
stages of GA
Induction, excitement, surgical anaesthesia, respiratory paralysis/overdose
adv of GA
Patient completely still,
improved access and vision,
multiple procedures can be undertaken,
no response to pain,
rapid onset of action
disadv of GA
Death, brain damage, coma,
cost (anaesthetic team, equipment),
location (must have immediate access to ICU/PICU),
minor risks associated with GA (pain, headache, vomiting, nausea, drowsiness),
future outlook to dentistry (does not address DFA),
treatment side effects (pain, bleeding, swelling, bruising)
indications for GA
Child pre-cooperative, extensive treatment required, patients required to be completely still, severe anxiety levels, surgical drainage of acute infected swelling (abscess),
indications for GA
Child pre-cooperative, extensive treatment required, patients required to be completely still, severe anxiety levels, surgical drainage of acute infected swelling (abscess),
contraindications for GA
tx not extensive enough - no sign of pain or infection currently
child protection
any activity undertaken to protect specific children who are suffering, or at risk of suffering, significant harm
safeguarding
Any measure taken to minimise the risks of harm to children
child abuse and neglect
anything which those entrusted with the care of children do, or fail to do, which damages their prospects of safe and healthy development into adulthood
triad needed for child abuse
Significant harm to child,
carer has some responsibility for harm caused,
significant connection between carer’s responsibility for child and the harm caused to the child
4 types of child abuse
Physical, emotional, neglect, sexual, non-organic failure to thrive
key markers of general neglect
Failure to thrive, short stature, developmental delay,
inappropriate clothing, cold injury, sunburn,
ingrained dirt (fingernails), head lice, rampant caries,
withdrawn or attention-seeking behaviour
key piece of legistlation associated with child protection and safeguarding in Scotland
Children and Young People’s Act (Scotland) 2014
SHANARRI indicators
Safe,
healthy,
achieving,
nurtured,
active,
respected,
responsible,
included
vulnerable child examples
<5yrs old,
irregular dental attender,
medical problems, mental and/or physical disabilities, children in care
contributing factors for child abuse
Drugs, alcohol, poverty, mental illness, domestic abuse, unrealistic expectations, crying, soiling, disability, unwanted, failure to live up to expectations, wrong gender, neighbourhood, housing conditions, intergenerational violence, violence towards pets, social isolation
impact of child abuse
short term
long term
Short-term - physical health, emotional health, social development, cognitive development
Long-term - arrest, suicide attempts, major depression, diabetes, heart disease
components of index of suscpicion
7
Delay in seeking help/treatment without good reasons,
vague story of incident lacking in detail and varying with each telling and person,
account not compatible with injury,
abnormal parent mood (preoccupied, detached, concerning),
abnormal child/parent interaction,
child may say something contradictory,
history of previous violence and/or violence within the family
% of head and neck injuries in <1 are non accidental
% of abuse injuries to head and neck
95%
60%
dental neglect defintion
The persistent failure to meet a child’s basic oral health needs, to the extent that this is likely to result in the serious impairment of a child’s oral or general health or development
definition of wilful neglect
Failure to complete treatment after problems/dental neglect is pointed out
components of managing dental neglect
3
Preventive dental team management,
preventive multi-agency management,
child protection referral
4 expectation of dentla team when faced with case of suscpected child abuse
Observe,
record,
communicate,
refer for assessment
signs of abuse
IO
EO
IO - contusions, bruises, abrasions, lacerations, burns, tooth trauma, frenal injuries
EO - facial bruising (ears, triangle of safety), pinch/slap/punch marks, bilateral injuries, burns and bites, choking marks, eye injuries
MIH
what is it
Hypomineralisation of systemic origin.
Usually affects 1-4 permanent molars and is frequently associated with affected incisors
clinical problems associated with MIH
4
Sensitivity,
poor aesthetics,
loss of tooth substance
issues in restoring - poor bond
questions to enquire about MIH and assoc time periods
Pre-natal (pre-eclampsia, gestational diabetes, syphilis),
natal/neonatal (full-term, birth trauma, prolonged/premature delivery, SCBU/NICU involvement),
post-natal (<2yrs - respiratory disease, measles, rubella, varicella, CHD, fluoride intake, nutrition)
tx options for MIH molars
Composite restorations, SSC, extractions
tx options for MIH incisors
Acid pumice micro abrasion, external bleaching, composite masking, veneers
hypomineralisation
enamel formed is of normal thickness but less mineralised
hypoplasia
enamel formed is thinner but correctly mineralised (true or acquired)
how common in MIH
10-20%
hypodontia
developmental abscence of 1 or more teeth
hypodontia in priamry dentition
<1%
hypodontia in permanent dentition
5%
teeth commonly affected by hypodontia
8s,
lower 5s
upper 2s
other dental problems assocaited with hypodontia
microdontia
abnormal shape and form
reduced LFH
deep overbite
conditions associated with hypodontia
CLP
down’s syndrome
ectodermal dysplasia
management options for hypodontia
nothing - accept
space closure with ortho (+/- resotrative camoflage)
space opening with opening and fill gap - RBB, RPD, implant
supernumerary
tooth in addition to normal sequence
1-3%
most common is maxillary midline- mesiodens
supernumerary effect on permanent dentition commonly
delayed eruption
4 types of supernumerary
Conical
Odontome - complex and compound
Supplemental
Tuberculate
management options for supernumeraries
KUO if not affecting permanent dentition
XLA if interfering with eruptions
conditions assoc with supernumeraries
CLP
cleidocranial dysostosis
developmental anomalies of dental shape and size
8
Microdontia, macrodontia, double teeth (gemination or fusion) odontomes, taurodontism, dilaceration, accessory cusps
microdontia
what
how common
teeth commonly affected
Tooth that is smaller than normal.
2.5% permanent, <0.5% primary
upper laterals and 8s
main complaint of microdontia pt
aesthetics - spaces present
macrodontia
what
how common
generalised macrodontia is assoc with what condition
A tooth that is larger than normal.
1%
Hemifacial hypertrophy
types of double teeth
<0.2%;
gemination (one tooth appears to split into 2)
fusion (where 2 teeth appear to fuse into 1)
taurodontism
flame-like appearance of pulp, radiographic elarged and elongated of pulp chamber
high risk exposure of pulp
dilaceration
Distorted crowns or roots (bend in crown/root).
Traumatic intrusion of primary incisor into developing permanent tooth germ.
esp Upper central incisors
tx - crown exposure and ortho alignment or XLA
dens in dente
tx
‘Tooth inside a tooth’.
Fissure seal ASAP,
difficult to root treat so often require extraction
root stucture developmental anaomaly
not dilaceration
shoot root anomaly
due to dentine dysplasia, radiotherapy or accessory roots
3 groups of enamel structure anomalies
Amelogenesis Imperfecta
environmental enamel hypoplasia (systemic, nutritional, metabolic, infection)
localised enamel hypoplasia (trauma, primary tooth infection - Turner tooth)
enquiry periods and questions for generalised environmelta/developmental enamel defects
Prenatal
* rubella, congenital syphilis, cardiac and kidney disease, gestational diabetes, pre-eclampsia
natal/neonatal
* prematurity, anoxia, c setion
postnatal
* otitis media, measles, varicella, TB, respiratory disease, CHD, vitamin deficiencies
diseases assocaied with enamel defects
Downs syndrome,
Prader-Willi syndrome,
epidermolysis bulls,
porphyria,
Hurler’s syndrome,
tuberous sclerosis,
incontinentia pigmentii,
pseudohypoparathyroidism
Turner tooth
Infection of primary tooth leads to a disturbance in enamel and dentine formation of the permanent tooth
4 main types of amelogenesis imperfecta
Hypoplastic,
hypocalcified (hypomineralsied),
hypomaturational,
mixed forms
amelogenesis imperfecta appearance radiographically
No contrast between dentine and enamel
is amelogenesis due to,…
genetic
environmental
both
genetic - familial inheritance
autosomal dominant
genes associated: AMELX, ENAM, KLK4, MMP205
problems associated with amelogenesis imperfecta
Sensitivity,
poor aesthetics,
caries susceptibility,
issues in bonding
delayed eruption,
AOB
management options for amelogenesis impefercta
**Preventive therapy (FS),
composite masking, **
indirect restorations (inlays),
SSC,
ortho
4 dentine structure anomalies
Dentingensis imperfecta
dentine dysplasia
odontodysplasia,
systemic disturbance (nutritional, metabolic, drugs)
dentine dysplasia
what
types
rare disorder characterised by normal enamel but abnormal dentine and pulp morphology
type 1 and 2 and Bradywine
general disorders assoc with dentine defects
5
Osteogenesis imperfecta,
Ehlers-Danlos syndrome,
vit D resistant rickets,
hypophosphatasia,
brachio-skeletal genital syndrome
odontodysplasia
affected teeth appear
Localised arrest in tooth development.
Thin layers of enamel and dentine, large pulp chambers - ‘ghost teeth’
types of dentinogensis imperfecta
features
Type I - associated with osteogenesis impefercta -bone issues, blue sclera
Type II - autosomal dominant, limited to teeth only
Bradywine
clinical and radiographic features of dentinogensis imperfecta
Clinical - opalescent blue/brown hue, bulbous crowns, short roots, abnormal ADJ
Radiographic - pulp chambers almost indistinct (narrow almost obliterated), no contrast between dentine and pulp
problems associated with dentinogenesis imperfecta
Aesthetics,
caries susceptibility,
spontaneous abscess,
poor prognosis
problems associated with dentinogenesis imperfecta
Aesthetics,
caries susceptibility,
spontaneous abscess,
poor prognosis
management of dentinogensis imperfecta
Preventive,
composite veneers,
overdentures,
composite masking,
removable prostheses,
SSC
systemic disorders assocaited wtih cementum anomalies
Cleidocranial dysplasia, hypophosphatasia
causes of hypercementosis
4
response to inflammation,
mechanical stimulation,
Paget’s disease,
idiopathic
concrescence definition
Uniting of the roots of 2 teeth by cementum
premature tooth eruption associated with
3
High birth weight, precocious puberty, natal/neonatal teeth
delayed tooth eruptions associated with
5
Pre-term birth,
low birth weight,
malnutrition,
gingival hyperplasia/overgrowth,
associated systemic disorders (downs, hypothyroidism, hypopituitarism, cleidocranial dysplasia)
reasons for premature exfoliation
6
Trauma,
primary tooth pulpotomy,
hypophosphatasia,
immunological deficiency (cyclic neutropenia),
histiocytosis,
Chediak-Higashi syndrome
reasons for delayed exfoliation
5
infra occlusion (ankylosis)
double primary teeth (gemination/fusion)
hypodontia
ectopic permanent successor
trauma
what are infra occluded teeth
how common
most likely tooth
associated with
Teeth that become ankylosed (fused) to the bone and appear to sink towards the gingiva (submerging teeth) - they don’t grow but everything else grows around them.
1-9%.
Commonly L5
hypodontia in permanent dentition
management of infraoccluded teeth
Usually exfoliate (around 11-12yrs) but not uncommon for them to be retained into adulthood.
Retain as long as possible, extract when 1mm of crown showing supragingivally
