Paeds Flashcards
What is RA?
It is relative analgesia
What do you need to realise about RA?
RA is not a magic bullet as behaviour management skills are still essential.
What is conscious sedations?
It is when the patient maintain airways independently and continuously.
You have intact pharyngeal and laryngeal relfex
What are the goals of RA?
- Facilitate the provision of quality care
- Minimise the extremes of disruptive behaviour
- Decrease anxiety
- Promote patient welbeing and safety
- Return the patient to a psychological state in which safe discharge is possible
What are the indications of RA?
- Anxious patient
- Older children with poor dental experiences
- Complex or long procedures
- Child with special needs
- Fear of needles
- To aid analgesia
- Increased gage reflex
- AND MEDICALLY FIT ASA I AND ASA II
What are the pharmacology of nitrous oxide?
It has very low solubility in blood. It is absorbed rapidly through the pulmonary alveoli and enters the serum. It acts on the cental nervous system through crossing blood brain barrier. Peak effect achieved within 3-5 minutes. Rapid and complete recovery.
What are physiological effects of nitrous oxide?
- CNS euphoric and depressant effect
- Still responds to instruction
- Children are more relaxed and feel happier
What is the theory behind the work of the RA?
Maybe the GABAA receptors or opioid receptors f the CNS.
What are the adverse effects of RA?
Mostly associated with overdose! Following:
- Nausea or vomiting
- Sleep
- Visual disturbance
- Excessive laughing
- Sweating
What are the signs of over-sedation?
- Detachment/dissociation
- Dreaming, hallcination or fantasizing
- Out of body experiences
- Floating or flying
- Inability to move
- Humming
What to do if you feel like you overdoing the RA?
- Slow induction
- Keep N2O concentration below 50%
- Reduce N2O concentration slowly
- Monitor patent closely
What the 3 purposes of reservoir bag?
- Provide a source of additional gas should the patient inspire more gas than is being supplied ◦
- Provides a mechanism for monitoring the patient’s respiration (watch the expansion and contraction of the bag) and for adjusting the flow (not too stretched or collapsed)
- Functions in an emergency as a method of providing positive pressure oxygen
What do you need to do before RA?
- Parents must sign a consent form
- Make sure equipment is set up properly BEFORE the patient comes in
- Patient must cooperate
What is the difference between slow vs rapid induction?
Slow – best suited for inexperienced operators. Increase from 0-30% in 10% intervals every 1 minutes
Rapid – better for young children – jump to higher concertation
What is the technique to get the patient to get off the RA?
5 minutes of pure oxygen
What do you put in a patient record for RA?
- Signed consent form
- Indication of use
- Nitrous oxide dosage
- Patient response
Why do we start in the waiting room to meet the child?
- First impression matter
- Assessment of the child’s behaviour
- To greet the child
- To compliment a child in order to build rapport
How to talk to a child?
- Act natural
- Make an effort
- Find the point of ice breaking such as compliments, pets or school
What are the process of basic examination for children?
- Get their chief concerns
- Take a useful history – utilise the parent and the child
- Past medical history – are there complciations in the child hood or dental development – tell tutor
- Past dental history – attendance patterns, past caries rate, diet, oral hygiene
- Social history – who is looking after the kid, are there any syblings?
- Exam – extra and intraoral, teeth present, restorations, CPI and caries risk
- Other findings – tooth wear, hypomin, dental anomalies, dental development anomalies and occlusion – know histological staging, calcification time, eruption times in both primary and permanent dentitions
- Practice appropriate and effective communication between the child and yourself and parent and yourself
What are contraindication for RA
Pulmonary heart disease
Sever asthma
Blocked nose
Refusal to breathe through nose
CNS disease
Otitis media or middle year disturbance/surgery - only active
Claustrophobia
GI issues
Cystic fibrosis
How do you administer RA?
Use slow induction technique – from zero to desired 10% at a time per minute
Keep N2O concentration below 50%
Reduce concentration N2O
If patient falls asleep, turn O2 to 100%
Avoid fluctuations
Monitor patient closely
Use 100% of oxygen for 5 minutes at the end of the session
What is the equipment for the nitrous oxide machine?
- Gas delivery machine – continuous flow of O2 and N2O, minimum 2.5L/minute, for children 4-5/L
- Nasal hood – various sizes and flavours
- Inflatable bag – provide source of additional gas, mechanisms for patient respiration, in emergency used as a method of providing positive pressure oxygen
- Scavenging system – to trap experied gas by the patient
- O2 flush valve – in emergency to provide jet ventilation, can cause barotrauma
What sould we record in RA notes?
- Signed informed consent
- Indications of Use
- Nitrous oxide dosage in percent of N2O and O2 with flow rates and duration of the procedure
- Patient response
Is it a legal requirement for a dentist to report child abuse?
Yes
What is important about mandatory reporting?
It is in the name, it is mandatory, you need to do it. For anyone under 18.
When can you report child abuse?
Even if you have a suspicion, you can. It is not a crime to be wrong, but a child’s life can be saved. Even if you are not at work, in a car park for example, you should report it.
When would you not report abuse?
- IF there is a reasonable belief that another person has reported abuse
- IF the suspecion was due soley to being informed of the abuse by a police officer or child protection officer
What are some oral signs of abuse on a child?
Bruising, abrasion, laceration
Dental fractures
Jaw fracture
Sever Dental neglect – not the most accurate but could be possible
Signs of sexual abuse like mucosal injuries that are suspecious
Head and neck injuries that are unexplained well and are suspecious
Bite marks
Withdrawn behavior and extreme fear
What are the eruptions times for deciduous teeth?
- Lower central incisors – 6-10 months
- Upper Central inicsor – 8-12 months
- Upper Lateral inicsor – 9-13 months
- Lower lateral incosr – 10-16
- Upper First molar – 13-19 months
- Lower First Molar – 14-18
- Upper Canine – 16-22 months
- Lower canine – 17-23 months
- Lower seond molar – 23-31 months
- Upper Second molar 25-33 months
What are the eruption times for permanent teeth?
1.Lower central incisors – 6-7 years
2.Upper First molar – 6-7 years
3.Lower First molar – 6-7 years
4.Upper Central Incisors – 7-8 years
5.Lower Lateral Incisors – 7-8 years
6.Upper Lateral Incisors – 8-9 years
7.Lower canine – 9-10 years old
8.Upper first premolar – 10-11 years
9.Lower first premolar – 10-12 years
10.Upper second premolar – 10-12 years
11.Upper cannines – 11-12 years old
12.Lower second molar – 11-13 years old
13.Upper second molar – 12-13 years old
14.All third molars 17-21 years old
What are some learning theories?
- Classic: stimulus resposnse ie white coat = needle
- Operant: action reenforced with a rewards or punishment .
- Social: modeling – very good, monkey see monkey do
What is one of the best way to influence a child?
Positive reinforcement – all adults and children are influenced by reinforcement. This is also very relevant for small children. The more consistent the reinforcement, the more likely a desired behaviour is reached. ALWAYS BE PRAISING. PLEASE SAY PLEASE AND THANK YOU. Be specific and consistent with your praise
What are some of the positive reinforcements?
- Motivational advice
- Verbal praise, non-verbal such as smile or STICKERS
What are inappropriate reinforcers in clinic?
1.Sweets or other food as praise.
2.Punishment – literally does not work
What is the Frankl scale?
It is a scale of co-operation and fears. Please put it into notes. Uses ++, +, -, – scale for general idea.
What is the Wrigth scale?
Similar to Frankl scale but it uses: Cooperative, potentially cooperative and lacking in cooperative ability
What are some aspects of child management?
1.Time efficiency – kids do not like to sit in the chair for too long
2.Behaviour management techniques: Modelling for the first visit, Tell-Show-Do to reduce anxiety, Voice control do not yell, Use of appropriate language to the kid like euphemism (sleep juice from a magic wand), monitoring the child for sense of control, distractions with triplex or wrigling the toes, positive reinfocement, systemic desensitazantion (a bit advanced and for older children because they realise that fear is irrational), behaviours shaping where you slowly shape the child behaviour from non-cooperative to cooperative with ability to retrace your steps
3.If the kids is dangerous, you can use aversie conditioning BUT NOT IN AUSTRALIA you can just do GA
4.Do not do the treatment if child does not cope with it, it is about quality treatment and overall positive treatment outcomes
What do you do if during tell-show-do exercise a child retracks their hand fromt eh prophy brush?
1.Retrace your steps. The show componenet needs to be modified
2.Ask the child how they are feeling, if they are withdrawn they are probably just anxious
3.Maybe to give them a more sense of control, do it on your fingernail first
4.Then let a child hold a hand mirror next to your finger to give them a sense of control
5.After do it on their finger
6.And finally on their tooth
7.Praise the child for being brave
8.Promise a sticker if you can do it on al teeth – children love stickers
What are the pharmacological agents used in managing behavior?
1.Conscious sedation
2.Deep sedation
3.General anesthesia
What are factors to consider for pharmacological intervention for behaviour management?
1.Patient age
2.Patienet behaviour
3.Treatment required
4.Medical condiitons
5.Distance travelled
6.Language barrier
7.Risk and benefits
8.Practitioner experience
9.Informed consent
What is improtant to understand pain?
Do not be scared to use LA as pain control is the most improtant part of behavior management. Remember about post-operative pain control aswell.
What is the recommended dose of lignocaine in children?
4.4. mg/kg and one carpule has 44mg. So per every 10 kg you can have 1 carpule max. So for a 25 kg child you can have 2-3 carpule with some interspacing. Also remember about topical.0.1g has about 5 mg!
What are the most common complicationa fter LA for a child?
1.Soft tissue trauma
2.Overdose – CNS depression, seizures, decrease cardiac output and cardiovascular collapse
What is the recommended dose of articaine 4%?
It is half of that of lignocaine, so if you use 3 carpules for ligno, use 1.5 for articaine.
What is a good anesthetic to use for a lower molar restoration in children?
Lower molar IANB with lignocaine 2%
How do we administer local to a kid?
1.Tell them about the taste
2.Supraperiosteal infiltration for upper only
3.Inferior alveolar block with long buccal
4.How is the syringe passed is important – under the chair
5.Inject slowly
6.Use behavior management in conuction with pharmacological one
What is general anaesthesia?
It is a day procedure which is not covered by CDBS. IF you have a very anxious kid who have:
- multiple quadrants treatment need
- Can not cooperate
- Very young
- Have major medical conditions or special needs
- Are country patients
- This might be a good idea. Private insurace might help.
What is the definition of early childhood caries?
Before it was called “nursing bottle caries”. It is the presence of one or more decayed, missing (due to caries) of filled tooth surface in any primary tooth in a child under the age of 6. Around 51% of Australian children have early childhood caries.
What is the etiology of early childhood caries?
Mutants streptococci are associated with early childhood caries. These mutants stretococci do not appear in the childrens mouth from birth, rather they are transmitted vertically (by parebnt via saliva) or horizontally (byu siblings or other kids via saliva). If a child does not have mutants streptococci before the age of 2, they will only develop caries in about 25% of the situations.
What are risk factors for early childhood caries?
1.Previous carious experience – but not when super young lol
2.Visible plaque – remember to screen all children
3.Dietary factors – especially sleeping with a bottle of something sugary and free sugars
4.Breast feeding IS NOT assoicated with ECC – because lactoferin kills MS
5.Enamel developmental defects
6.Low socioeconomic and sociocultural factors
7.Children with medical conditions – such the ones that need to use meidcations causing xerostomia or that predispose them to enamel hyperplasia
What are clinical features of ECC?
1.Follows the pattern of eruption – starts with lagial, gingival and lingual surfaces of maxillary incisors and spread to molars
2.Rapid progression – DO NOT OBSERVE MAY LEAD TO DISASTER
What are the consequences of untreated early childhood caries?
1.Pain
2.Sepsis
3.Space loss
4.Disruption to quality of life
5.Disruption of growth and development
6.Possible disruption of intellectual development
7.Hospitalisation
8.Greater risk of caries
9.Death
What is a great solution for early childhood caries?
Composite resin strip crowns. 80% success rate! Also early screening, prevention or use of silver diamine fluoride, dietary changes, behaviour change, habbit change, fissure sealants and constant use of fluoride.
What can you say about caries trend?
We getting more caries, oh no 🙁. There is a theory that this occurs due to consumption of non-fluoridated bottled water.
What is the order of susceptibility of teeth in permanent dentition?
1.First permanent moalrs
2.Second molars
3.Premolars
4.Upper lateral incisors
What the most common site of caries?
Occlusal pit and fissures followed by interproximal. Usually caries are bilateral especially in molars and anterior.
What is the relationship between ECC and permanent caries?
ECC strongly associate with future caries. Due to mutans streptococci.
What is the correletation between caries on the Es and permanenet first molars?
It is believed that the bacteria from the distal of Es can invade the developing tooth. Thus, the E needs to be restored, especcially the distal. Furthermore, resortive cells may aid in bacterial ingress through the protective dental epithelium causing early tooth colonisartion by bateria, thus premanent tooth needs to be restored as soon as it can.
What is the problem with adolescence?
1.Challenging age group
2.Unique oral health problems
3.Less parental influence
4.Increase in independence
5.Caries susceptibility
6.Erosion risk
7.Smoking
8.Need to update medical history regularly
9.Increase carbohydrate
What kind of caries risk tool can you use for children?
CAMBRA – caries management by risk assessment. It is a questionnaire that recommends tratment. Not good for idnividuals treatment.
Bad caries progression – WREC – whites spots, restorations past 3 years, enamel lesions and cavities
At risk – BAD – bad bacteria, absence of saliva, dietary habits
Protective factors – SAFE – saliva & sealants, antibacterials, fluoride, effective diet
What is the Australian fluoride guide?
6-17 months – no fluoride
18 months – 6 years – childrens toothpaste (400-550ppm) 2x per day spit no rinse
6+ years – normal tooth paste 1000ppms x2 a day spit no rinse
6+ years + high risk of caries – 5000ppm tooth paste 2x times a day spit no rinse
When do you use fluoride gel/foam?
Every 6 months for 4 minutes at 12300 ppm. Not recommended to less than 10 year old.
What is the maximum does of fluoride roxicity?
3-5mg of fluoride/Kg. Toospase has 1mg/g. Meaning a 10kg baby needs about 30mg or 30 grams.
What are some tricky extraction in deciduous teeth?
1.Second deciduous molars with roots
2.Broken down crowns with limited amount for forceps application
3.Complete loss of crown structure
4.Molar teeth with complete lost of the crown
5.Previously pulp[otemised teeth
6.Full rooted deciduous canines
7.Asnkylosed teeth
What kind of LA should youy give for an extraction?
A IANB and a buccal infiltration
What are the mechanisms of exodontia?
Stop if the kid says ouch, especially if they are cooperative and top up
1.Expansion of the bony socket to permit removal of its contained tooth.
2.Use elevators with utmost caution
3.Use three basic mations: wheel and axle (screwdriver), wedge and lever. Alvaolar bone is the fulcrum
4.Support jaw bone with your other hand
5.Use of level and fulcrum principle to force tooth or root out of socket along the path of least resistance
6.Always use the forceps as sungingivally as possible
7.Push buccaly for 3 seconds, then move to figure of 8
8.Repeate until the tooth is out
Up until which point can you perform a pulpotomy?
Up until reversible pulpitis as after, according to the continuum of Pulp Status, an extraction or a pulpectomy is recommended. Followign symptoms are bad:
1.Spontaneous pain kept awake at nigh
2.TTP
3.Abscess
4.Mobility
5.Facial swelling celulitis
When would you try and do pulpal therapy instead of extraction?
1.Haemophilia
2.Von Willebrands disease
3.Platelet disorder
4.Congenital HEart disease
5.Immuno-compromised
6.Poor healing potenrial
7.Special need/disability
8.Behavioural factors
9.Stage of dental development is far from exfoliation and spece management is not of issue
What should you write on your x-ray diagnosis for caries?
1.Extent if 2/3 with initial symptoms, time to perform preventative pulpotomy
2.Position and proximity to pulpal horns
3.Presence and position of the permnent successor
4.Status of root
5.Furcation involvement in abscess
What should we need to confirm for indirect pulp cap?
1.Removal of all caries will cause pulp exposure
2.Absence of pulpal and extra pulpal pathology
3.Good coronal seal can be achieved
What is the goal for a pulpotomy?
1.It is vital therapy
2.Eradicate potential for infection
3.Maintain tooth in a healthy state
4.Capitalisse on regenerative capacity of the pulp
What are some contraindications for a pulpotomy?
1.Irreversible pulpitis
2.Abcess, fistula or cellulitis
3.Uncontrolled pulpal haemorrhage
4.Pathologic resorption of root
5.Resorption of root of more than 1/3
6.Medical rerason like infecgtive endo carditis
What are the practical steps to pulpotomy?
1.Good local anaesthesia
2.Rubber dam
3.Remove caries and do oclcusal reduction
4.Access the pulp chamber and remove entire roof of pulp chamber
5.Remove pulpal tissue with a round bur
6.Achieve haemostasis with dry cotton pellet
7.Place ferric sulphate medicament over ratticular tissue
8.Condense IRM into chamber
9.Restore with GIC
10.Resotre with stainless steel crown – VERY IMPORTANT
What are three modes of medicament action in pulpotomies?
Devitalisation of tissues – formocresol
Preservation – ferric sulphate
Regeneration – MTA
What is the disadvantage of Ferric Sulphate?
1.In combination with Zinc Oxide Eugenol associate with internal resoprtion
2.Really need very good haemostasis
What is considered to be a successful vital therapy?
1.Abscen of pain, fistular, modility and radiographic pathology
2.No sensitivty or pain
3.No evidence of internal resoprtion
4.No breakdown of peri-radicular tissue
5.Recall in 6 months or in emergency
What is a good treatment plan set up?
Session 1:First impression, history, examination, X-rays, consent and tretament plan debridment, improvement in OHI and diet, Prophylaxis and fissure sealants if possible. If too much suggest GA.
Session 2: RA + Q1
Session 3: RA + Q2
Session 4: RA + Q3
Session 5: RA + Q4
3 months recall, more treatment if need
How many appotiments do Hall crowns require?
2 appotiments are essential to teeth with contacts
1st: To place separating elastics
2nd: To place the crown
3rd: Review
How should you perform a hall technique?
1.Elastik to expand the spce
2.Try a crown that just fit and do not go trhough the interproximal
3.Do not use oversize crowns as they can impact eruption
4.Cemenet with FUJI
5.Push hard when cementin or ask child to bite into place
6.Need to work quickly, if failed remove with large spoon excavator quickly
7.Crown will be high but will adjust over the next 30 days
Where should you not apply a halls crown?
1.On adjacent teeth at the same appoitment ie 64 and 65
2.If there is no distal of mesial space (hink elastics first) or it is lost due to caries
3.Opposing occluding teeth
4.If patient is un-cooperative, too young or
5.If there are no x-rays
6.Teeth that need pulpotomy
7.Caries above 1/3 into dentines
What are the most common enamel defects in primary dentition?
- Hypoplasia – quantitative – deficiency in tooth substance due to ameloblast desruption
- Hypomineralisation – qualitative – disturbance in the initial enamel calcification and/or maturation leading to lower mineral content
At which stage of ameloblastic cycle does hypoplasia occur?
At secretory stage
What is molar-incisor hypomineralisation?
It is a qualitative enamel defects of systemic origin, affecting one to four first permanent molars and frequently associated with affected incisors
What is HSPM?
Hypomiralisaed second primary molars is a condition where the second primary molar is hypomineralised. There is association between that and Molar hypomineralisation (MH)
What is the aetiology of developmental defects of enamel?
Ameloblast are exteremly sensetive to any systemic, local or genetic factors. But the insult intesity and timing are important.
Usually:
In primary dention, the insult occurs prenatally or before first eyar of life
Permanent incisors and permanent first molar are more suscpetible in peri-natal and first 3 years of life – consitent with MIH
Permanent canines and second molars around pre-school years
Insults could be cause by:
1.Disease
2.Medications
3.Fluoride
4.Trauma
How would you diagnose DDE?
1.Describe the distinct border
2.Describe the type
3.Resulting enamel – smooth or soft and pourus
4.If there is any unprotected dentine
5.If there is any caries
6.Is there post-eruptive breakdown of the dental hard tissue
7.ALWAYS perform examination on wet teeth as drying teeth may result in pain
What is the problem with hypomineralised enamel?
1.It has an increased instance of enamel fractures
2.It has a decreased ability for retention of adhesive materials
What are the objective of treatment for a patient with DDE?
1.Reduce pain & sensitivity
2.Provide adequate restoration
3.Eliminate need for multiple repeat restorative procedures
4.Minimise dental anxiety and fear
5.Maintain occlusion and minimise cplexity of any furutre ortho treatment
6.Aesthetic rehabilitation
What is the 6 step approach?
1.Risk identification – assess medical history
2.Early diagnosis – examine at-risk molars on radiographs if available
3.Remineralisation and desensitisation – before breakdown, as soon as erupted
4.Prevention of dental caries & post-eruptive breakdown – F/S
5.Restoration or extraction – SSC can be used even for initial stage even in permanent dentition, but especially in deciduous if there is severe-moderate MIH. GIC good for interim
6.Maintanance
When is the ideal age for a lower six to be extracted due to sever MIH for the seven to take it’s place?
When the crown of the 7 is fully complete. But please try and push it until the entire dention is available for comprehensive orthodontic treatment.
What is the first line of treatment for mildly affected MIH teeth?
1.Remineralisation
2.Fissure sealant
What is the first line of treatment for moderatley affected MIH teeth?
Composite resin restorations
What is the first line of treatment for severely impacted MIH teeth?
1.Immediate treatment – desensitising
2.Intermediate treatment – SSC
3.Long-term treatment – extraction or complex restoration
4.Always consider extraction in young patient as it prevent need of life-long maintanance
What is a syndrome?
A pattern of malformations resulting from the action of a single cause on more than one developmental field.
Why should we care about dental anomalies associated with syndromes?
1.Significant oral implications
2.Malocclusion
3.Increase instances of oral diseases
4.Pain and sensitivity
5.Disfiguring
6.Genetic implications
What is hypodontia?
It is the agenesis of less than 6 teeth
What is oligodontia?
It is the agenesis of more than 6 teeth
What is anodontia?
When you have 0 teeth
What are non-sendromic conditons associated with hypodontia?
1.Trauma
2.Infection
3.Radiation
4.Chemotherapy
5.Endocrine disturbances
6.Sever intrauterine disturbances
What is hypodntia associated with?
Impacted maxillary canines and peg-shaped lateral
What are the potential treatment for an impacted canine?
- No treatment
- Orthodontic treatment
- Autotransplanatation
- Prosthetic replacement
- Implant
What is the treatment of hyperdontia?
1.Diagnosis early
2.Surgical removal early if impacting eruption of permanent teeth – usually eruption will then occur in 1.5-3 years
What does the Cledocranial Dysplasia result in?
Multiple supernumerary teeth in permanent dentition. Also delayed resorption and shedding of primary teeth. Early diagnosis and planning for extraction is essential.
What is concrescence?
Joining teeth by cementum. Usually occurs in second molar fused to third, impacted molar
What is fusion?
Joining of teeth by dentine and or pulp
What gemination?
Budding of a second tooth from a single tooth germ
What is a good measure for double teeth?
1.Fissure sealing
2.Surgical separation
3.Ortho, implants, autotransplants or prosthesis
What are Dens Evanginatus?
They are cusp-like elevations of enamel located in central groove or lingual of premolars and molars. They are prone to fractures so early diagnosis is essential. Partial pulpotomy might be beneficial. Can occur in anterior teeth as “talon cusp”, and it should be removed.
What are Dens Invaginatus?
They are deep surface invaginations of inner enamel. Most common in lateral incisors. Needs fissure sealing and maintenance of clean fissures as they are at generally higher risk of pulpal necrosis and abscess.
What is amelogenesis imperfecta?
A group of inherited conditions that adversely affect the development of dental enamel causing anomalies in it’s amount, structure and composition. Distinguished by dental abnormalities + pattern of inheritance. Results from mutation of AMELX, ENAM, and MMP20 gene
How do we diagnose emalogenesis imperfecta?
1.Clinical exam – visual and flaking
2.Family history
3.Radiographic assessment
4.Scanning with electron microscope
What happens in Hypoplastic amelogenesis imprefecta?
Enamel is very hard but abnormaly thin be that in dots or bands.
What happens in hypomaturation amelogenesis imprefecta?
White to yellow-brown in colour. Normal in thcikness, but slightly softer than normal. More radiolucent than normal. May chip away
What happens in hypocalcified amelogenesis imprefecta?
Enamel is chalky, dul or cheesy. Normal thickness but very fucking soft.
What is dentinogenesis imprefecta?
It is essentially effect on type I collagen resulting in opalescence crowns
What is the management of dentinodenesis imperfecta?
1.Prevention of enamel fracture and wear
2.Main vertical dimension
3.Prevent sensitivity and improve function
4.Crown primary dentition
5.High level of oral hygiene
What is radicular dentine dysplasia?
It is a Type I dentine dysplasia. This results in short, sharp conical root with pulp obliteration due to blocked dentinal tubules. Permanent teeth may undergo spontaneous necrosis.
Where are the primate spaces in children?
Maxilla - between lateral incisors and canines
Mandible - between the canines and first molars
What is the difference between Type I and Type II Baume occlusion?
Type I occlusion exhibits spaced dentitions
Type II exhibites closed dentitions
What is the relationship between balance of forces and occlusal relationships.
A series of forces maintains or changes tooth position.
Thus harmonious destribution of force is important when it comes to maintain a favorable occlusion, which can be unstable in exfoliating or early lost teeth.
Drifting of permanent teeth or loss of space for eruption may occur
What is the sequelae of consiquences resulting in premature loss of teeth?
- Decrease in arach length
- Increased overbite
- Ectopic eruption
- Impaction
- Crossbite formation
- Midline discrepancies
- Arch asymmetry
What are the most important factors that may contribute towards the determination of sequelae of consequences of premature loss?
- Degree of crowding - the degree and rate of space loss
- Type of tooth lost - canine centerline shift, molar mesial drift of first permanent molar
- Age of child - the earlier a tooth lost the greater the opportunity for drift
What is the most common complication when loosing an anterior tooth?
Usually, loss of primary canines in the mandible if the result of large permanent incisor and ectopic eruption. This results in lateral shift of incisor teeth and midline discrepancy.
For primary incisors, if primary canine is fully erupted, no major loss of space will occur.
What is the most common complication when loosing an posterior tooth?
First primary molar loss usually result in distal shift of canines and incisors.
Early loss of second primary molar is more significant as ti will result in mesial rotation of the first permanent molar especially in the maxilla. This is greated if the second primary molar lost before the eruption of first permanent molar.
What are space maintainers?
They are fixed or removable appliances used to preserve arch length following premature loss or elective extraction.
Usually used to maintain space after loss of first or second primary molars.
What are the essential factors for a great space maintainer?
- Well maintained dentition with low risk of developing complications like caries
- Small plaque retention
- No impingement on soft tissue
- No interference with eruption of adjacent teeth
- Small possibility of fracture or dislodgement (no sticky lollies)
What are the eruptive consideration for space maintenance?
Premature loss of primary teeth prior to root development of permanent tooth is likely to result in delayed eruption (guide: 1mm eruption is around 4-5 months and eruption will occur when 2/3 of the root development is complete).
So if the tooth is about to erupt, what is the point of the space maintainer?
What are the goals of treatment planning and space maintenance?
- Caries control
- Control the space for the 4 weeks following tooth loss
- Consider a unilateral versus bilateral type of appliance
- Consider growth adn oral developemnt
- Do not refer to orthodontis for space maintenance
What are the contraindications for space maintainers?
- Presence of caries or history of high caries risk rate
- Poor oral hygiene
- No alveolar bone overlying crown of erupting tooth
- Space left is more than mesiodinstal dimension of permanent successor
- Repeated examination show no space loss
- Repeated examination show no space loss
- General lack of dental arch length
- If permanent successor is absent and it is necessary to orthodontically close space
What are the factor influencing the use of space maintainers?
- Available space
- Dental age
- Time since tooth loss
- bone coverage
- Sequence of eruption
- Abnormal oral musculature (soft tissue- hard tisssue synergy)
- Existing malocclusion
- Patient’s age and cooperation
- Applience integrity, maintenance and modifiability
- Other factors
What are some types of space maintainers?
- Band and loop - very good!
- Crown-lopp
- Distal shoe
What is a band and loop maintainer?
It can be lab fabricated or chairside.
Essentially fit a molar band distal to the tooth prior to extraction and take an impression for lab construction of the appliance with the band inside.
Make the loop wide enough B-Li to allow for eruption of permanent premolar
What are the advantages and disadvantages of band and loop appliance?
Advantages:
1. little chair side time
2. Easily adjusted
3. Easy and economical to make
Disadvantages:
1. Provides little functional replacement for the missing tooth
2. Will not prevent supraeruption of teeth in the opposing arch
What kind of space maintainer can you utilise if the abudmnet tooth has extensive caries, maked hypoplasia or been pulpotomised?
SSC with a band and loop band
What kind of space maintainer can you use to provide space for an erupting first permanent molar?
A distal shoe, a metal triangle that can be used when the 6 is erupting (and exposed only). This with prevent mesial drift.
After the 6 has been fully erupted, please replace this maintainer with a band-loop maintainer.
What is the advantage of lower lingual holding arch?
Prevent anterior movement of posterior and anteior teeth bilaterally on the mandible
When can you use a lingual holding arch?
- multiple posterior primary teeth are missing
- Permanent incisors have erupted
What other aplliances can you have for space maintanance?
- Transpalatal arch
- Nance appliance
- Removable appliances
- Bonded space maintainers
What is the most common reason for failure of space maintainers?
Majority occur due to cement failure
What are the 3 P’s when establishing orthodontic treatment using a radiograph?
- Presence
- Position
- Pathology
Associated with the teeth
What are some of the conditions that we should look out for in the primary dentition in term of occlusion?
- general space preservation
- Preventin irrreversible damage to dentition
- Correction of transverse discrepancies (posterior crossbite) and vertical discrepancies
What are the most common ectopic eruptions?
- First molars. 66% of them self-correct but some intervention will be needed at around 7 year old with elastik band separator
- Permanent canines. Check for canine buccal buldge at around 10 years old
How do you correct single tooth anterior crossbite in class I molar patient?
Upper removable appliance, paddle pop stick or patial fixed appliance
How do you correct a powterior or multiple anterior teeth in crossbite?
Rapid maxillary expansion or slow maxillary expansion
How can you treat sever crowding in paediatric patients?
Serial extraction may be required in Class I occlusion
What are the physical indications of abuse?
- Retinal haemorrhage
- Fractured incisors
- Burns on lips & mucosa
- Bruises on lips
- bruises on frenum
What is the step-by-step management of trauma in a paediatric patient?
- Reduce anxiety
- Take good history
- Thorough examination
- Additional testing
- Level of co-operation determination
- Discussion with parents and patient
- Management/referral
- Follow-up
What are most common intra-oral soft tissue injuries for paediatric patient and what is their management?
- Contusions or bruising - treat symptomatically
- Lacerations/ abrasions - follow septic technique and treat appropriate with potential use of IV antibiotic and always suture
3.Degloving injuries - septic technique, suturing, IV antibiotics, oral antibiotics
What are the options of management of crown fractures?
- Leave and review and monitor - adjust the occlusion
- Extraction of pulpal injury occurs to reduce the probability of a facial swelling
- Restoration
- Pulp therapy (very rare)
What are some of the complications that can arise after primary trauma?
- Discoloration of the tooth (red which is transient)
- Calcification of the pulp chamber and root canal
- Loss of vitality, necrosis and facial swelling
- Internal or external pathological resrption
- Ankylosis of the primary tooth
What are the direct and indirect injuries to permanent teeth after dental injuries in paediatric patients?
- Direct - root of the deciduous tooth impinges on the crown of the developing permanent successor
- Indirect - when deciduous tooth becomes non vital, and peri-apical infection can damage the developing permanent successor
What are some of the developmental disturbance of permanent teeth?
- Enamel hypoplasia
- Crown dilaceration
- Odontome formation
- Damage of permanent tooth germ
- Delayed eruption
- Altered path of eruption
What kind of pulpotomy can you perform on a child with some pulp exposure?
Cvek pulpotomy
Why do we want to maintain a vital pulp?
- Promotes continued root development and maturation
- Avoid difficult endodontics
- Reduce the risk of root fracture
