Paeds Flashcards
What does IADT stand for?
International Association of Dental Traumatology (IADT)
Trauma: Relevant non-dental injuries to be aware of?
Head injuries
Overdose
Facial fractures
Facial lacerations
Why should splints be flexible and how is this achieved?
To avoid undue stress, and allow for functional tooth movement.
Wire of <0.4mm is used to achieve this.
Trauma sequelae: Yellow/brown
Pulpal obliteration (reparative dentine shining through)
X-ray shows pulpal narrowing
Associated w luxations
Sensibility test;
Vital = manage aesthetics
Non-vital = RCT
—> specialist referral
Trauma sequelae: Grey
Blood products from pulpal haemorrhage
Associated w luxations, avulsions, complicated crown fracture
Non-vital = RCT and aesthetics
…or XLA
Trauma sequelae: Pink area
Shine through of invading tissue, usually from external cervical root resorption (ECRR)
Soon = tooth revascularisation ?Monitor, frequently review, should reverse.
Later = suspect ECRR
Refer to specialist.
Root resorption types: Internal inflammatory resorption
Inflammation within the pulp is breaking down the dentine in the pulp.
How would you manage this sequelae?
This is internal inflammatory root resorption.
RCT and aesthetic management.
If root has perforated, bioactive root filling material may be used (MTA & Biodentine).
Root resorption types: Internal replacement resorption
internal inflammatory resorption —> get replaced with bone.
shows clinically and x-ray as IIR.
Root resorption types: External inflammatory resorption (EIR)
Damage to PDL and root surface stimulates this in trauma.
Vital tooth = reparative process and is self-limiting
Similar symptoms to periapical periodontitis.
X-ray notice root canal is still visible = EXTERNAL resorption process.
Root resorption types: External cervical resorption (ECR)
Osteoclastic cells from the adjacent periodontium are thought to invade the exposed root surface, via gaps in the cementum, and form a fibrovascular lesion (resorption phase), which may ultimately become calcified and develop into a fibro-osseous tissue (reparative phase).
Root resorption types: External surface resorption (ESR)
his is a non-infective, transient, pressure-induced resorption. This resorptive process will stop progressing once the source of the pressure has been removed, resulting in repair of the resorbed root-face with cementum.
Root resorption types: Transient apical breakdown
A non-infected transient resorption of the apical portion of the root and the adjacent bone.
Widening of the apical PDL = resolves within a year.
This phenomenon is essentially an external inflammatory resorption (EIR) with a short resorption phase followed by repair.
What are key features of a splint following trauma?
Passive, flexible and conform to the arch.
0.4mm stainless steel wire
Pulpal canal obliteration (PCO) occurs more frequently in teeth with…
open apices, and is indicative of viable tissue within the root canal.
Tx of fully developed teeth (mature teeth with closed apex) that have been intruded/extruded/laterally luxated. OR fractures (involving the root)
Treat endodontically EARLY.
Calcium hydroxide placed 1-2 weeks after trauma for up to 1 month —> then RC filling.
This is to avoid external inflammatory resorption (associated w infection).
Tx of incomplete developed teeth (immature teeth with open apex) that have been intruded/extruded/laterally luxated. OR fractures involving the root
Regular check ups —> pulp could revascularise!
Weigh this up with the chance of inflammatory root resorption (this will be rapid).
Combined injuries of poorer prognosis may be considered for earlier RCT.
Enamel-dentin fracture with pulp exposure
Complicated crown fracture
—> partial 2-3mm
—> coronal (whole coronal portion, reaching level of orifices)
—> extirpation (pulpEctomy)
Place non-setting calcium hydroxide cement.
Pulp capping
APEXOGENESIS
Vital pulp therapy
within 24 hours of the incident!
If over 24 hours then pulp is likely contaminated and pulpotomy is opted for.
(IMAGE SHOWS PULPOTOMY)
Non-vital immature permanent tooth tx
Mineral trioxide aggregate (MTA) plug of ~4-5mm then normal GP on top.
Sets in the presence of moisture.
Neglect
the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development.
Safeguarding vs child protection
Safeguarding = preventative approach to child protection
Child protection = reactive approach to suspected or known cases of abuse or neglect
What percentage of child victims of physical abuse show signs in the head and neck region?
60%
Key areas of non-accidental injuries occurring
What legislation sets out a statutory statement of parental responsibilities and rights and clarifies the law on guardianship?
Children (Scotland) Act 1995
Gillick Competence
In Scotland, under-16s can consent to medical or dental treatment if a doctor believes they understand the procedure, it’s risks, and alternatives.
Consent in Scotland: mother
Automatically has parental responsibility from birth and therefore can give consent for her child’s dental plan and subsequent treatment.
Consent in Scotland: father
Has parental responsibility if he’s married to the mother when the child is concieved, or marries her at any point afterwards.
If his name is on the child’s birth certificate then this works too even if unmarried.
Consent in Scotland: Same-sex couples
Civil partners at the time of the child’s conception will both have parental responsibility.
Can GAIN parental responsibility by obtaining a parental agreement or become a civil partner.
Consent in Scotland: Adopted parents
Parental responsibility is automatically transferred to the adoptive parents.
Consent in Scotland: Divorced parent
A divorced parent does not always need to get the consent of the other divorced parent for routine decisions.
Consent in Scotland: Step-parents
Only have responsibility if obtained through a court order or legal guardianship.
Consent in Scotland: Grandparents
Only have parental responsibility if obtained through a court order.
Consent in Scotland: Social workers
If under a care order, the local authority may consent, but this is typically done by someone with legal responsibility, not the social worker.
ACE
Adverse Childhood Experiences
What is an adverse childhood experiences?
stressful events during childhood that can have a profound impact on an individual’s present and future health.
________ under 4 years old suffer from sever physical abuse
1 in 1000 children under 4 years old suffer from sever physical abuse
CYP
Children and Young People
What does the GDC state about the dental teams role in safeguarding and child protection?
The dental team have an ethical responsibility to find out about and follow local procedures involved in raising concerns about possible abuse and neglect of children.
What does child abuse encompass?
Physical
Emotional
Sexual
Neglect
What parenting factors should you look out for that might indicate a child is at a greater risk of abuse?
Substance abuse, mental health issues, suffering from domestic abuse.
Professional curiosity
Is a combination of looking; listening; asking direct questions; checking
out and reflecting on information received
• Is about exploring and understanding what is happening with a child,
young person and their family
• Is about enquiring deeper and using proactive questioning and
challenge
• Is about understanding one’s own professional responsibility and
knowing when to act, rather than making assumptions, or taking things
at face value
UNCRC Scotlands Act 2024
United Nations Convention on the Rights of the Child (UNCRC)
Sets out the civil, political, economic, social, and cultural rights that all children are entitled to.
National Guidance for Child Protection Scotland 2021
It sets out the responsibilities and expectations of everyone who works with children. This includes practitioners working in health, police, third sector, local authority or education settings.
GIRFEC
Getting it right for every child .
The aim is to help children and young people to grow up feeling loved, safe and respected so that they can realise their full potential.
Includes SHANARRI indicatiors of wellbeing.
SHANARRI indicators
Safe
Healthy
Achieving
Nurtured
Active
Respected
Responsible
Included
Types of vulnerable children in dentistry (3)
- Under 5s
- Irregular attenders
- Medical problems and disabilities
Looked after children (LAC)
Compulsory measures of care by local authority.
May still be at home but are receiving of care.
Respite care provides short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends.
Dental neglect
Persistent failure to meet a CYP’s basic oral health needs, likely to result in the serious impairment of their oral or general health or development.
Why is the number of carious teeth not used as an indicator of severity of dental neglect?
- Multi-factorial aetiology of dental caries
- Variation in individual susceptibility
- Inequalities in dental health (social class etc)
- Inequalities in access to dental treatment
- Difference in treatment philosophies
Attempting to see which parents aren’t looking after their children, caries might be an innocent mistake.
What should you do if you are suspecting of dental neglect?
- Preventative dental team response —> raise concerns with parents, offer support, set targets and monitor progress.
- Multiagency approach —> contacting other professions who you know are involved with the family.
- Child protection referral
What are you at risk of with four or more ACEs?
Heart disease, type 2 diabetes, mental illness, commit violence, in prison
What is your RESPONSIBILITY as a dentist when suspecting neglect?
Observe
Record
Communicate
Refer for assessment
NOT diagnose
It is illegal to _______ a child on the _______ in Scotland
It is illegal to hit a child on the head in Scotland.
Referrals of concern may elicit three different outcome pathways (3)
- No progression of concern (other services may be necessary)
- Single agency response (further assessment)
- Inter-agency response (investigation —> action —> case conference)
WNB1
WNB2
WNB3
WNB4
Letter to the GP
Who are your local contacts you should be aware of in a case of concern of a child?
- Paediatric consultant on call
- Lead person for child protection
- Social work including out of hours
- Police Public Protection Unit - Telephone 101
- Child protection advice line
How many children in the UK are effected by MIH?
1 in 8
Why might we decide to XLA a SOUND upper 6 if we’re choosing to XLA the opposing carious lower 6???
A compensating XLA
NOT RECOMMENDED unless there is a clear occlusal requirement or likelihood of upper 6 being unopposed for a significant period of time.
Balancing extraction
Removal of a 6 from the opposite side of the same dental arch.
What is the ideal window for extraction of compromised 6s?
When the 7 is developing (8-10 years) - X-ray shows bifurcation mineralised.
More critical to time the lowers.
Too late = already in place but mesial drift causes a tilting of the 7.
Interceptive XLA of 6s: Why might orthodontists want to temporarily maintain maxillary poor prognosis FPMs if a patient has a class II div I incisor relationship?
To use that spacing in the future when repositioning the incisors.
Enamel hypoplasia (hypoplastic) vs enamel hypomineralisation
Hypomineralisation = mineral deficit, occurring at the POST-secretory stage, FAST post-eruptive caries.
Hypoplasia = thickness deficit, occurring at the secretory stage, SLOW post-eruptive caries.
Why is there such hypersensitivity in MIH vs hyperplasia?
As the enamel in MIH is POROUS, the dentine is more exposed, bacteria can penetrate through and this can cause sub-inflammatory reaction in the pulp tissue.
Splint: root fracture apical/mid 1/3
4 weeks
Splinting: concussion
No displacement; no splinting
Splinting: subluxation
2 weeks
Splinting: Luxation extrusive
2 weeks
Splinting: Luxation intrusive
4 weeks
Splinting: luxation lateral
4 weeks
Splinting: Avulsion
2 weeks
Splinting: Root fracture cervical 1/3
4 months
Behavioural management techniques (11)
DEMENT VIC BS
o D – distraction
o E – enhanced control – signalling with hand etc
o M – modelling – older sibling, video of ideal etc.
o E – empathy
o N – non-verbal communication
o T – tell do show
o V – voice control
o I – information (preparatory)
o C – coping strategies
o B – behavioural shaping and positive reinforcement – use of stickers etc
o S – systematic desensitisation
Fluoride varnish (Duraphat) F- ppm
22,600ppm (2.26%)
Toxic fluoride dose is…
5mg per kg.
If you suspected a fluoride overdose…?
Give milk, gather info, A&E.
High risk of caries 10-16 yrs old fluoride dose?
2800ppm
Simplified BPE for children
IV sedation w midazolam age..
not for under 15yrs
Eruption dates: U 1s
7-8 years old
Eruption dates: L 1s
6
Eruption dates: U 2s
8-9
Eruption dates: L 2s
7-8
Eruption dates: U 3s
11-12
Eruption dates: L 3s
9-10
Eruption dates U 4s
10-11yrs
Eruption dates: L 4s
10-12
Eruption dates: U 5s
10-12
Eruption dates: L 5s
11-12
Eruption dates: 6s
6
Eruption dates: U 7s
12-13
Eruption dates: L 7s
11-13
Eruption dates: 8s
17-21
Stepwise caries removal
- Access and remove superficial caries.
- Temporise
- 6-12 months later permanent.
Allows reactionary dentine to be laid down.
Hall crown technique
- X-ray shows clear band of dentine between pulp and cavity.
- Separators placed
- Pt seen 3-5 days later for removal and fit.
- Attempt to size a preformed metal crown (feel spring back - don’t fully seat)
- Dry tooth and fill metal crown w glass-ionomer luting cement.
- SEAT crown - pushing and biting
- Remove excess cement, 2-3 mins of pressure for setting.
- Floss contacts.
Tooth trauma splinting technique
- Bend wire (safety handle)
- Cut wire
- Etch prime and bond (two end teeth first!)
- Ensure happy w position
What conditions are hypodontia associated with?
Ectodermal dysplasia (peg laterals may be seen)
Cleft/lip and palate
Downsyndrome
What are the most commonly absent teeth seen in hypodontia?
upper 2s, 5s, 8s
Types of supernumaries
Supplemental
Conical
Tuberculate
Odontome
Mesiodens and paramolars
Location based classification;
Mesiodens - midline
Paramolars - molar region
What genetic conditions are associated with supernumerary teeth?
Cleidocranial dysplasia, oral-facial-digitial, Gardner syndrome
Microdontia and macrodontia
Anomalies effecting tooth size
Microdontia is associated with ED.
Macrodontia can be a result of either fusion of adjacent tooth-germs or an attempt at separation of a single tooth germ to form two separate teeth (gemination). —> Upper centrals most commonly effected.
What dental treatment may cause tooth root shortening ?
Orthodontic tx
Dens evaginatus vs invaginatus
enamel epithelium invagination into the dental papilla during development.
want to resin sealant these !!
Resin fissure sealant application technique
Dry, etch, and sealant —> then cure.
No bond!
Taurodontism
Taurus = “bull”
Failure of invagination of Hertwig’s root sheath.
Autosomal dominant Amelogenesis imperfecta
— hypomineralisation and hypoplasia
all teeth are affected similarly
Sedation: Inhalation
Nitrous oxide/oxygen
Sedation: IV
Intravenous with Midazolam
Sedation: for needle phobic patients who want Midazolam?
Oral and transmucosal sedation
