Paeds Flashcards
PHG w/ systemic involvement in a teen what prescription
aciclovir only prescribed - immunocompromised or severe infection in the non immunocompromised
primary response to herpes simplex virus:
- sore mouth, throat & enlarged lymph nodes
- period of malaise & fever (systemic symptoms)
- happens once self limiting 7-10days
- fluid intake, bed rest, analgesia, CHX, nutritious diet
aciclovir prescription;
200mg tablets or oral suspension 200mg/5ml or 100mg/5ml
send 25 tablets
label 1 tablet x 5 daily for 5 days
5x200 for >2yrs & 5x100 for <2yrs
concerned mother with 2yo in pain. take brief pain hx, decayed 52-62, explain dx to mother, prevention & management options
pain hx = SOCRATES with attention to how long for / any analgesia i.e. calpol / how much / feeding bottle to bed / what is in bottle
pattern of nursing caries = upper incisors, ds & lower canines (lower incisors often protected by tongue
advice -
- feeder cup free flow spout replacing bottle from 6mths
- no feeding at night; lactose in milk; decreased salivary flow & held in mouth
- no on demand breast feeding
- no sweetened or soy milk unless medically advised
- milk & water only between meals
- sugarfree variations of drink / food / medicine
- safe snacks = cheese, breadsticks, fruit
toothbrushing = assist until 7yrs / brush in morning & last thing at night / no food or drink except water after brushing / spit don’t rinse
mx -
XLA of carious teeth under GA as in pain
GIC remaining teeth & rv if no pain
fluoride varnish
child with PHG - tx & answer qs from mother
- introduce self & role
- hx - no of days symptoms, does child have fever, child less active than normal, analgesia used & did it work
- PHG signs = lymphadenopathy, malaise, pyrexia, erythematous gingivae, ulceration
- PHG symptoms = sore mouth & throat, fever, enlarged lymph nodes
- dx from photos = contagious primary infection caused by herpes simplex virus, self limiting & will disappear in 7-10 days, high carriage rate in population & common, most often occurs in young children & is usually the 1st exposure child has to herpes virus which is also responsible for cold sores. most initial infections are subclinical but can present as this florid infection. often present with blisters on tongue, cheeks, gums, lips & roof of mouth. after blisters pop ulcers will form. other symptoms inc high fever, difficulty swallowing, drooling & swelling. sores make it difficult to eat etc so likely to be dehydrated. child may or may not develop cold sores in future.
- mx = fluid intake, analgesia for fever / pain, bed rest, clean teeth with damp CW roll or cotton cloth, can use dilute CHX to swab gums
- as child has had problems for >3 days & otherwise fit & healthy antiviral is not recommended
- if severe / immunocompromised aciclovir 200mg 5 x 5 send 25 tablets
- refer immunocompromised pts to hospital
non accidental trauma - signs & taking action
EO signs = bruising of face / ears, abrasions, lacerations, burns, bites, marks on neck, eye injuries, hair pulling, # nose > mandible > zygoma
IO signs = contusions, bruises, abrasions, lacerations, tooth trauma, frenal injuries
index of suspicion = delay in seeking help, story vague, lacking in detail, vary with each telling & person to person, account not compatible with injury, parents mood abnormal, parent behaviour is a cause for concern, child appearance & interaction with parent is abnormal, child says something contradictory, hx of prev injury or hx of violence in family
taking action = provide any urgent dental tx, tell parent unless this will put child at risk, explain your concerns honestly and that these types of injuries have to be reported, seek parents consent to share info, record incident & conversation, refer to social services / police be specific about reasons, confirm referral acted upon, arrange dental follow up, be prepared for reporting in case of court, always discuss with a colleague
child with stained / missing teeth discuss
staining -
causes -> MIH, fluorosis, decal, tetracycline, trauma, dentinogenesis imperfecta, amelogenesis imperfecta
tx ->
1. microabrasion; easy done, effective, use of acid, removal of tooth structure
2. vital external bleaching; may not work, risk of gingival recession, sensitivity, will not bleach restorations, relapse, overbleach
3. localised composite addition; adds bulk to tooth, may not mask totally, will require eventual replacement
4. comp / porcelain veneer; good aesthetic, tooth prep needed, need to wait until at least 18 for stable gingival level
5. MCC - destructive
missing teeth -
causes -> hypodontia, trauma causing arrested tooth formation, ectopic, dilaceration, supernumerary
tx ->
1. RBB
2. essix retainer
3. RPD
4. implant if >18yrs
5. ortho space closure
txp for child. pt considering complaint as prev dentist did not take radiographs. mucocele, caries, PA pathology, hypodontia
explain tx required
caries mx = list carious teeth, sed / GA referrals vs GDP mx, start with least invasive such as FS to then LA procedures
prevention = assign caries risk, CRA = radiographs, diet advice, OHI, f- toothpaste, f- supplements, f varnish, sugar free medicine, FS
mucocele = leave & rv vs referral for surgical excision. explain procedure i.e. LA around site of swelling, cut in gum, removal in its entirety & sutures. risks = pain, bleeding, swelling, bruising, numbess, infection, recurrence
hypodontia
potential problems = space, drifting, overeruption, aesthetics, functional problems
space maintenance = URA
referral to orthodontist at 6-7yrs
tx options in future = do nothing, restorative only i.e. composite, veneers, RBB, RPD, ortho only or ortho & restorative; space closure & reshape teeth to camouflage
deal with complaint - can’t comment as don’t know full story, can only offer tx at this present time, if mother asks can refer her to old practice & tell her they will have a complaints procedure in place but only if she asks & unhelpful for you to be involved as don’t know background behind tx that was or was not done & would be unfair to speculate on it
paeds trauma, subluxation of upper centrals, knee to knee exam & explain mx to parent as well as possible consequences
introduce self & designation
reassure everything will be alright
k2k exam = explain to parent what you intend to do, sit across from parent with your knees touching theirs, bring knees together, ask parent to do same, ask parent to sit child with their legs around parents waist, lower child on to your knees & ask parent to hold child’s arms
trauma stamp = sinus, colour, mobility, TTP, percussion note, mobility, displacement, radiograph, sinus, EPT / EC
subluxation signs = TPP, mobile, bleeding from gum, no displacement
explain = subluxation of upper central baby teeth, unlikely to have damaged permanent successor, this is an injury to the supporting structures of the tooth
tx = NO TX observation only, all done today is to clean with saline
home care = soft diet 1wk, keep clean & plaque free for good healing, CHX 0.2% cotton swab to area x2 daily for 1wk
poss complications to primary tooth = pain, swelling, discolouration, increased mobility, delayed exfoliation, infection, child ay not complain of pain but infection could be present & should watch for swelling on gums & bring child back
poss complications to permanent tooth = premature or delayed eruption, enamel hypoplasia / hypomineralisation, crown or root dilaceration, failure to erupt, failure to form, odontome formation
follow up = 1wk & 6-8wks
caries risk assessment & management
CRA - clinical evidence, diet, MH, SH, saliva, plaque control, fluoride exposure
prevention - radiographs, diet advice, OHI, f supplement, f varnish, fissure sealant, f toothpaste, sugar free medicine
TB advice - assist until 7yrs, x2 daily with f- tp, most importantly at night, nothing other than water after brushing at night, demonstrate on child 6mthly, get parent to demonstrate in front of you
diet - avoid sugary drinks / snacks, breadsticks, carrots etc instead, milk & water only between meals, if nursing bottle use free flow spout, no bottle to bed at night, no soy or sweetened milk
fluoride - varnish x4yrly to high risk children >2yrs (22600ppmF 5%), tp 1450ppmF smear for <3 and pea for >3yrs, >10yrs 2800ppmF and >16yrs 5000ppmF, spit don’t rinse, avoid rinsing mouth, drinking or eating for 30mins after use, advise this tp is a medicine that should only be used as prescribed
hall crown & separator placement
place 2 pieces of floss through the orthodontic separator
pull tight & move down between contacts of the tooth (not subgingival)
leave for 2-7 days
remove with blunt probe
sit child upright placing gauze swab to protect airway
chose crown - aim to fit smallest size of crown that will seat using sticky stick
should cover all cusps & approach contact points with slight springiness (do not fully seat crown!!)
dry crown & fill with GIC (aquacem)
dry tooth (if large cavity place some GIC in cavity
place crown & seat with finger pressure
child can seat by biting down on crown with CW roll over the top
remove excess cement with CWR
bite down for 2-3mins / finger pressure
make sure all excess cement has been removed & floss between contacts
consent & referral for GA
will be referred to hospital for specialist to assess & other teeth of poor prognosis may be added to plan to avoid another GA in the future. will involve a day in the hospital as need to monitor to full recovery & need chaperone throughout
RISKS -
common minor risks = headache, nausea, vomiting, drowsiness, sore throat or sore nose from intubation
risks from tx = pain, bleeding, swelling, bruising, infection, loss of space, stitches
rare major risks = brain damage, death; 3 in a million, need machine to breathe during operation & very small risk you will not be able to breathe independently again on waking
upset when coming round & malignant hyperpyrexia (v rare & important to ask for FH)
conditions requiring special care & possibly contraindications = sickle cell, diabetes (can’t fast in same way), down’s, malignant hyperpyrexia, CF or severe asthma, bleeding disorders, cardiac or renal conditions, epilepsy, long QT syndrome
referral letter must inc justification, proposed txp, prev tx details, recent radiographs
assessment appt for txp only & plan may change with specialist opinion
informed consent must be written for GA, GA process, side effects complications, adult escort with no other children, pre op fasting, post op arrangements, post op care & pain control
FV for 2yr old discuss w/ parent concerns re fluoride , fluoride toxicity & f varnish aftercare
reassure:
- FV placed on tooth & minimally invasive
- promotes remineralisation (hardening of tooth) and helps prevent demineralisation (softening of tooth)
- involves drying teeth & painting gel on
contraindicated in:
1. severe uncontrolled asthma i.e. hospitalised in prev 12mths
2. allergy to colophony (sticky plasters) can use colophony free version instead
aftercare:
don’t eat / drink for 1hr, soft diet rest of day, no highly staining foods, avoid fluoride supplements
fluoride toxicity - very small risk & really only happens if consumes large quantity of toothpaste
5mg/kg = milk
5-15mg/kg = ipecac syrup, milk, poss hosp referral
>15mg/kg = hospital referral
why need FV? - clear justification regarding caries, prevention of decay, additional to toothbrushing, for all not just those at risk, x2 yrly for all children, recommendations from SDCEP SIGN etc
too much F is harmful? - minimal use with FV x2 daily brushing with tp. fv quantity carefully controlled, guidance given regarding tp quantity & supervised brushing, poss side effects of fluorosis & mottling but F is naturally occurring in water etc
paeds trauma - 11 EDP# immature apex in 8yr old - outline procedure to parent of an anxious child
introduce yourself & role
explain injury in simple terms i.e. # into nerve of tooth
explain tx which is PULPOTOMY (open apex) as it is a large exposure, partial removal of pulp, aim is to keep undamaged pulp tissue alive so tooth stays alive & continues to grow
baseline sensitivity tests - required to see how the nerve is injured & adjacent teeth respond, test required as baseline for long term monitoring if any changes in future
LA required - to keep pt comfortable & pain free, will require injection into gum
dental dam placement - rubber sheet over tooth to act like mask, for moisture control & airway protection
drilling - to remove some pulp tissue & aim is to only leave healthy tissue
dressing - setting CaOH or MTA as wider at bottom than fully developed adult tooth so medicaments don’t go out
composite rest - white filling to help aesthetics
