paeds 2nd year Flashcards
early problems
gingival cysts
congenital epulis
natal tooth
eruption cysts
when would you extract a natal tooth?
- if mobile - inhalation risk
- feeding problem
- trauma (ulcer)
when would you treat a congenital epulis?
- causing feeding problems
- respiratory problem
what happens to a congenital epulis as you age?
shrinks
what should be done for gingival and eruption cysts?
keep eye
when do teeth start to form?
week 5 IUL
when does hard tissue formation start?
week 13 IUL
what do systemic disturbances during calcification cause?
defects in Enamel which was forming
- birth - 2nd molars
approximate calcification of crowns at birth
1/2 central incisors 1/3 lateral incisors tip of canines 1/2 1st molars 1/3 2nd molars tip of cusps of FPM
multifactorial theories of eruption process
cellular proliferation at apex
localised change in bp/hydrostatic pressure
metabolic activity within PDL
resorption of overlying hard tissue
resorption of overlying hard tissue
due to enzymes in dental follicle - dark halo on radiograph
need remodelling of bone/ primary tooth tissue for eruption
BUT not necessary for tooth to erupt to cause resorption of bone
what happens when the dental follicle is activatedin eruption?
initiate OC activity in alveolar bone ahead of tooth
once crestal bone breached - follicle likely to play lesser role
- into supra-alveolar phase
theories about tooth pushing into mouth that have been discounted as major factors?
root elongation
PDL
local changes in vascular pressure
bone growth at where is essential for eruption?
at base of crypt (socket)
- but could be reactive to tooth movement
when does eruption stop?
when tooth contacts something - usually opposing arch
throughout life - compensate for vertical growth of jaws and tooth wear
primary dentition - lower/upper eruption
generally lowers before uppers except lateral incisors
what may variation in primary dentition eruption be due to?
genetic?
when do contralateral teeth usually erupt in primary dentition?
within 3m of each other
at what age is the primary dentition usually complete?
2.5-3years
very variable - some normal children have no teeth at 1
primary dentition - lower a
6m
primary dentition - lower b
12m
primary dentition - lower c
16m
primary dentition - lower d
13m
primary dentition - lower e
24m
primary dentition - upper a
8m
primary dentition - upper b
9m
primary dentition - upper c
17m
primary dentition - upper d
14m
primary dentition - upper e
25m
order of eruption primary dentition
A B D C E
primary dentition - how is permanent teeth fitting into the arch?
anterior spacing so no crowding in permanent
anthropoid/primate spacing
leeway space
facial growth
proclined path of eruption of permanent incisors - increases AP arch length so more space
primate/anthropoid spacing
- mesial to U 3
- distal to L 3
leeway space
extra MD space occupied by the primary molars and canine which are wider than the premolars and canine which will replace them
leeway space U arch
1.5mm per side
leeway space L arch
2.5mm per side
how does the facial skeleton grow?
downwards and forward
when does the mixed dentition stage begin and end?
when 1st permanent tooth erupts until exfoliation of last primary tooth
usually 6-11/12/13 years
FPM - exfoliation of U3
permanent dentition - order of eruption U arch
1st molars then front to back except canines
6 1 2 4 5 3 7 8
permanent dentition - order of eruption L arch
1st molars then front to back
6 1 2 3 4 5 7 8
permanent dentition - L/U eruption
generally L before U except 2nd premolars
where do permanent incisors develop?
palatal to primary
permanent dentition - L1
6yrs
permanent dentition - L2
7yrs
permanent dentition - L3
9yrs
permanent dentition - L4
10yrs
permanent dentition - L5
11yrs
permanent dentition - L6
6yrs
permanent dentition - L7
12yrs
permanent dentition - U1
7yrs
permanent dentition - U2
8yrs
permanent dentition - U3
11yrs
permanent dentition - U4
10yrs
permanent dentition - U5
11yrs
permanent dentition - U6
6yrs
permanent dentition - U7
12yrs
ugly duckling phase
transient spacing U1s due to
- close proximity of roots to erutping 2s, 3s
- self correct when canine erupts
primary incisor root
may bend towards distal
what do primary incisor edges often show?
considerable wear
primary canines morphology
proportionately larger m-d - bulbous
mesial edge straighter
primary U first molar
irregularly quadrilateral narrower lingually than buccally MD groove 3 roots MB tubercle
primary U second molar morphology
transverse ridge - MP to DB 3 roots 2 distinct fissures - mesial c, distal straight largest cusp usually MB similar to U FPM
primary lower 1st molar
rectangular, broad m-d MB tubercle 4 cusps 2 roots buccal steeply lingually inclined
primary lower 2nd molar
similar to L FPM
3 buccal cusps - largest usually mesial
2 roots
primary incisor crowns
smaller and plumper
E in cervical region bulbous
distal edge of crown flares a bit more
Ls smaller
MIH definition
hypo mineralisation of systemic origin of 1-4 permanent molars, frequently associated with affected incisors
if on other teeth not MIH
MIH appearance
'cheesy molars' patches/whole tooth incisors v well demarcated - white/yellow/brown - not symmetrical
MIH prevalence
10-20%
MIH most commonly affected teeth
4 molars
MIH tx need
10x more tx
fear and anxiety more common
behavioural management problems more common
hypomineralisation
Qualitatative enamel defect.
Reduced mineral content
- problem with amelogenesis
- secretory phase fine, maturation phase problem
bonding to hypo mineralised teeth
may be harder to bond to
hypoplasia
Quantitative defect : reduced bulk/thickness of E
amorphous
- secretory phase of amelogenesis affected
true hypoplasia
E never formed
acquired hypoplasia
post-eruptive loss of E bulk
bonding to hypoplastic teeth
should bond properly
why is it hard to determine the aetiology of MIH?
unclear diagnostic criteria
most parents can’t remember details from 8-10years before
variations in quality and completeness of case records
study pops small
critical period for MIH formation
generally agreed 1st year of life - developmental condition not hereditary
E matrix of crown of FPMs is complete by one
is MIH hereditary or developmental?
developmental
MIH 3 clinical periods of enquiry
pre-natal
perinatal
post-natal
MIH prenatal enquiry
health in 3rd trimester
MIH perinatal enquiry
birth trauma/anoxia
hypocalcaemia
pre-term birth (higher prevalence)
MIH post-natal enquiry
prolonged breastfeeding (past 6m) dioxins in breast milk fever and meds (infections - measles, rubella, chicken pox) SE status rural v urban
yellow brown MIH teeth histology
more porous - whole enamel layer
white/cream MIH teeth histology
inner parts of E affected
how does MIH histology explain why sensitivity/difficult to anaesthetise?
increase in neural density in pulp horn and subodontoblastic region
lots more innervation
MIH histology and immune cells
increase in immune cells, esp with post-eruptive E loss
MIH histology vascularity
increase in vascularity in sensitive MIH samples
MIH 3 pain mechanism theories
dentine hypersensitivity
peripheral sensitisation
central sensitisation
MIH pain mechanisms - dentine hypersensitivity
porous E/exposed D facilitates fluid flow within dentinal tubules to activate A delta nerve fibres (hydrodynamic theory)
MIH pain mechanisms - peripheral sensitisation
underlying pulpal inflammation leads to sensitisation of C fibres
MIH pain mechanisms - central sensitisation
from continued nociceptive input?
MIH clinical problems
loss of tooth substance - breakdown of E - toothwear faster - secondary caries (poor resistance) sensitivity - not all - some - can cause OH problem as may be too painful to brush appearance
MIH tx options for FPMs
composite/GIC Rx
SSCs - much harder on FPM
adhesively retained copings - gold best
extraction around 8.5-9.5yrs
MIH tx of affected incisors
acid pumice microabrasion - removes yellow/brown marks external bleaching - makes rest of tooth whiter so less of a contrast localised composite placement - camouflage full composite veneers full porcelain veneers >20yrs
considerations for extracting HFPMs
dental age - radiograph
skeletal pattern
future ortho needs
quality of teeth e.g. caries
what is ideal to see when timing ext of HFPMs?
calcification of bifurcation of L7s
before L7 erupts starts to drift forwards
like to see developing 8s - not always possible
what do you often ext at the same time as HFPMs?
U at same time (not necessarily now) according to RCS 2023 guidelines
if ortho and crowded dentition when would you ext HFPMs?
keep 6s until 7s erupt - keep space in a crowded dentition to avoid ext of good premolars
jaw relationship at birth
- gum pads widely separated anteriorly (U &L)
- Gum pad contact posteriorly
- tongue resting on L gum pad and in contact with L lip
- AOB
characteristics of primary dentition
incisors spaced and upright
teeth smaller
reduced overjet
whiter
psychology of child development
motor cognitive perceptual language social
why is it suggested that motor development may be genetically programmed?
predictability of early “motor milestones”
when is motor development completed?
in infancy
changes following ability to walk are refinements
two aspects of motor development - eye-hand coordination and walking
walking 9-15m but variations
eye-hand coordination gradually becomes more precise and elaborate with increasing experience
stages of cognitive development
sensorimotor
preoperational thought
concrete operations
formal operations
sensorimotor
until about 2yrs
object permanence
preoperational thought
2-7yrs predict outcomes of behaviour egocentric facilitated by language development unable to understand why areas and vols remain unchanged even though shape and position may change
concrete operations
7-11yrs
logic
see others perspective
still difficult to think in an abstract manner
formal operations
11 years +
logical abstract thinking
perceptual development
most research looks at eye movement
compared to adult a 6yr old will cover less of an object, take in less info and become fixated on details
selective attention by 7yrs
what is needed for language development?
stimulation
language - 1 yr old
understands 20 words, simple phrases, relates objects to words
uses 2-3 words, repetitive babble, tuneful jargon
sounds: b, d, m
language - 2yr old
understands: simple commands, questions, joins in action songs
uses 100 words, puts 2 words together, echolalia
sounds: p, t, k, g, m
language - 3yr old
understands prepositions (on, under), fcts of objects, simple conversations
uses 4 word sentences, what/who/where, relates experiences
sounds: f, s, l
language - 4yr old
understands: colours, numbers, tenses, complex instructions
uses long grammatical sentences, relates stories
sounds: v, z, ch, j
feeding skills - pre 40 wks gestation
28wks - non-nutritive sucking
34wks - nutritive sucking
feeding skills - 0-3m
rhythmical sucking
primitive reflexes
semi-reclined feeding position
liquid diet
feeding skills 4-6m
head control more control of suck/swallow munching move towards semi-solid diet starts babbling
feeding skills 7-9m
sitting feeding position mashed finger food U lip involvement chewing and bolus formation bite reflex
feeding skills 10-12m
lumpy food sustained bite active lip closure chewing - lateralisation cup drinking
feeding skills 24m
mature and integrated feeding pattern
cleft type speech
resonance
articulation
nasal emission
velopharyngeal incompetence
Soft palate doesn’t close tightly against back wall of throat during speech. Causes air to escape through nose
bad effects of the family unit
-enhance child's anxiety behaviour contagion improper preparation discuss tx in hearing of child threatening child with dental tx
knee to knee
infants
Age under 3
parents can hold arms and legs
3 aspects of behaviour management
communication
education
interaction
components of communication
verbal 5%
paralinguistic 30%
non-verbal 65%
language alternatives - cotton wool rolls
tooth pillows
language alternatives - topical
bubblegum/minty gel
language alternatives - probe
pointer/tooth counter
language alternatives - excavator
tooth spoon
language alternatives - HS
tooth shower
language alternatives - SS
“mr bumpy”
tooth scrubber
language alternatives - LA
special spray, sleepy juice
What paralinguistic has to do with
tone
2 reason to exclusion of parents from surgery
Competing with dentist for child’s attention
Convey own anxieties to their child( body language and words)
anxiety in children
more irrational and less restrained than adults
wide variation
may be largely genetically determined
anxiety influencing factors
psychological make up understanding emotional development prev experience attitude of family/friends behaviour of dentist
role of dentist in reducing anxiety
prevent pain
friendly
establish trust
work quickly
calm
give moral support
be reassuring about pain
empathy
stop signals
Q for feeling
what are anxious more likely to report?
pain
Pros of good communication
improves info obtained from pt
enables dentist to communicate info to pt
increases likelihood of pt compliance
reduces pt anxiety
increasing fear related behaviours
ignoring or denying feelings inappropriate reassurance coercing/coaxing humiliating losing patience with pt
aims of paediatric dentistry
- reach adulthood with intact permanent dentition,
- no active caries,
- few Rxs as possible,
- positive attitude to future care
operative differences (Paeds and adults)
developmental maturity/behaviour constant change developing dentition access (small mouths) tooth size and shape preventive care choice of Rx
sequence of tx planning
prevention FS preventive Rxs simple fillings e.g. shallow cervical cavities fillings needing LA but not into pulp pulpotomies - U arch first
factors that influence how caries is managed
age cooperation of child extent of caries tooth type dental attendance
what cavities may not require LA?
minimal
e.g. hand excavation/limited caries removal with SS
lignocaine max dose
4.4mg/kg
prilocaine max dose
6mg/kg
preparing an occlusal cavity
around 1.5mm depth
preserve transverse ridge
maintain MR
straight walls - hold bur at right angle
Primary lower molars occlusal fissure shape
S
upper second molars occlusal cavity shape
D - straight
M - kidney bean
interproximal cavity prep
isthmus 1/2-1/3 width of occlusal surface
axial wall follow contour of tooth
rounded line angles
occlusal extension should be shallower (pulp)
box prep
axial wall follows contour of tooth rounded Line angles no occlusal extension SS rosebud to remove carious D occlusal section no wider than width of bur
material and whether LA depends on
caries extent
longevity of tooth
cooperation of child
most successful material
PMCs
longevity of Rx in primary molars
age (younger less cooperation)
type of tooth (1st molars small, Rxs don’t last as long)
type of cavity - surfaces involved
- occ last longer than IP
fissure sealants
protective plastic coating used to seal pits and fissures to prevent food and bacteria getting caught in them and causing decay
- Bis GMA resin
why are fissures vulnerable to caries?
less protected by F than IP or smooth surfaces
can’t clean base of fissures with a toothbrush - bristle won’t fit
FS materials
bis-GMA resin (after acid etch)
GIC
FS indications
high caries risk
medically compromised
learning difficulties
physical/mental disability
FS tooth selection
greatest benefit on occlusal surfaces of permanent molar teeth
should also seal cingulum pits of U incisors, buccal pits of L molars, palatal pits of U molars
may seal primary molars in high risk
resin FS placement procedure isolation options
single tooth dental dam
dry guards and cotton wool
resin FS placement procedure
clean occlusal surface pumice and water
35% phosphoric acid etch
wash and dry
check chalky/frosted
resin to fissure pattern -brush/microbrush/excavator
remove excess with dry micro brush
spidery not swimming pools
light cure
Check with probe
what happens to any etched surface not eventually covered with sealant?
will remineralise within 24hrs
FS checks
firmly adhered - use probe
no air blows
no material flowed IP - remove with sharp probe and floss
check no excess distal to tooth in STs
FS reviewing
clinically every 4-6m radiographically as per CRA - check no shadowing underneath - high risk every 6m - low risk every 12-18m
indications for GI FS
where good moisture control can’t be achieved
- high risk children with PE molars
- special needs children
- poorly cooperating children
where high sensitivity - developmental or hereditary E defects
- drying tooth can be extremely painful
pros and cons of GI FS
F release
poorly retained, require regular reapplication
- not as durable as composite - wears down over time
GI FS placement
attempt to dry tooth with air/CW
apply GI from applicator
smooth into fissures using a gloved finger
keep finger over GI until set or place Vaseline to reduce moisture contamination
stained fissure
a fissure that is discoloured, brown or black
also includes fissures where area of white/opaque E i.e. normal translucency lost but no evidence of surface breakdown/cavitation
diagnosis of a stained fissure
visual (dry tooth) probe BWs electronic FOTI -Fiber-optic transillumination CO2 laser air abrasion
grater accuracy when 2-3 methods used together
stained fissure - investigation possible outcomes
1 - caries doesn’t enter dentine
2 - inconclusive
3 - into dentine
tx of stained fissure where caries doesn’t enter dentine
FS and monitor
tx of stained fissure where inconclusive
clean stained fissure with small SS bur - if only hard material encountered then FS
tx of stained fissure where into dentine
Rx tx
small PRR or SR - where defect filled with small amount of composite then sealed over the top with a FS
large - conventional composite (/amalgam)
caries in FPMs tx planning
maximise prevention
always prioritise FPMs in any mixed dentition tx plan
pulp much more likely to be exposed on caries removal
ext of poor prognosis of FPMs
if poor prognosis can allow development of a caries free dentition in adolescent without spacing
appropriate removal time
- calcification of bifurcation of L7s forming (8.5-10yrs)
- 5s and 8s all present and in good position on OPT
- mild buccal segment crowding
- class 1 incisors
conventional crown prep - components of reduction
MR reduction
occ reduction
buccal and lingual
conventional crown prep - MR reduction
knife edge
see gingivae
tapered diamond separating bur at 90 degrees
conventional crown prep - occ reduction
1-2mm
follow contour
straight fissure bur
conventional crown prep - buccal and lingual
peripheral reduction only
removing any sharp angles produced
SSC instruments
tapered diamond separating bur PMCs GIC crown crimping pliers curved crown scissors
common problems with SSCs
rocking
canting to one side
loss of space (due to caries removal)
SSCs - rocking
cervical margin >1mm beyond max curvature, difficult to contour margins sufficiently to contact tooth throughout
= open margins and unstable crown
solution - adjust tooth prep - stable crown 0.5mm beyond max curvature
SSCs - canting to one side
uneven reduction of occlusal surface
SSCs - loss of space
extensive caries - drifting of adjacent teeth
ideal - rectangular prep
not ideal - square prep
SSCs crown selection
measure MD width of crown or space with dividers
OR trial and error after crown prep
OR impression and crown prep on model
contouring crown
Ensure tight cervical fit but not snap fit
- pliers
don’t establish contact area (with adjacent tooth) if there wasn’t one present
disadvantages of conventional SSCs
LA and extensive tooth prep
need child cooperation
risk damage to FPM when prepping E
indications for conventional SSC
large multi surface Rxs
abutment for space maintainers
rampant caries
protection of molars in children with Bruxism
Hall technique procedure
dry crown and fill with GIC dry tooth partially seat crown until engages with contact points remove finger and encourage child to bite or fully seat with finger pressure - blanching of gingivae good remove extruded cement ASAP hold/bite (CW) 2-3mins reassurance floss between contacts
Hall technique parent and child reassurance
crown supposed to fit tightly, gum will adjust
will get used to feeling of crown within 24hrs
occlusion tends to adjust to give even contacts bilaterally within a few weeks
Hall technique airway protection
sitting up
sticky material
Gauze in airway
split dam technique
floss - thread through one hole in clamp, tie to secure then wrap floss around bow then through second hole. tie. 2 ends should hang out of mouth - safety feature in case clamp breaks
put clamp in mouth with clamp holders
punch two holes in dam 1cm apart. join with scissors
put in mouth - stretch over clamp until visible
then stretch forward - hold at anterior teeth with wedget elastic
frame - ensure it doesn’t discomfort pt and that they can breathe through nose
what is the Hall technique known as?
biological caries management - no LA/prep
what to call SSC to child
princess/transformer tooth
Iron man helmet
Hall technique - what to do if contacts are an issue
separators - remove 3-5days
cementing crown in Hall technique
GIC
where should Hall technique crown sit?
ideally sub gingival or at least below margins of cavitation
Hall crown sizes
2-7
Hall technique contraindications
pulpal involvement
insufficient sound tissue left to retain crown
dental sepsis
aesthetics
PAP
at risk of endocarditis
how to place separators and where shouldn’t they sit?
2 pieces of floss
not sub gingival
Hall technique indications
non-cavitated/cavitated occlusal lesions if pt unable to accept FS/Rx
proximal lesions - cavitated/non-cavitated
review of hall crown tech - minor failure
new/secondary caries
worn/lost but tooth restorable
reversible pulpitis txed without requiring pulpotomy/ext
review of hall crown tech - major failure
irreversible pulpitis
abscess requiring pulpotomy/ext
interradicular radiolucency
unrestorable
restoration of primary incisors - cervical
hand excavate/SS
wash and isolate - dam/CW
GIC and Vaseline or compomer
restoration of primary incisors - IP
hand excavate/SS
wash and isolate
acetate strip, restore with compomer/composite
space maintainers
band and loop (band on 6’s)
distal shoe retainer (crown on Ds)
band and loop space maintainer
cement with GI
as soon as you see premolar erupting take it off
distal shoe retainer
sits subgingivally to guide 6
disadvantages of unplanned primary extractions
loss of space (malocclusion risk) decreased masticatory function impeded speech development psychological disturbance trauma from anaesthesia/surgery
indications for pulp tx of primary teeth
good cooperation
MH precludes ext - e.g. inherited bleeding disorder
missing permanent successor
need to preserve tooth e.g. space maintainer
child under 9 - otherwise starting to exfoliate
contraindications for pulp tx
poor cooperation poor dental attendance cardiac defect multiple grossly carious teeth advanced RR severe/recurrent pain or infection - ext
endo options for a vital tooth and success
pulp capping - poor
vital pulpotomy - 85-100%
endo options for a non-vital tooth and success
pulpectomy - 90%
potential complications of pulp tx
early resorption leading to early exfoliation
over-preparation
aim of vital pulpotomy
preserve radicular pulp
vital pulpotomy
LA and dam
access - remove caries
amputation
- remove coronal pulp with excavator/SS
- ferric sulphate 20s - control bleeding
pulp stump evaluation - minimal oozing
restore
- ZOE/CaOH
- GIC
- SSC
hyperaemic pulp
continued bleeding
deep crimson
how to spot a non-vital primary molar - signs (after opening pulp)
hyperaemic pulp - bleeding +++
pulp necrosis and furcation involvement
how to spot a non-vital primary molar - symptoms
irreversible pulpitis
periapical periodontitis
chronic sinus
primary molar pulpectomy
EWL: pre-op radiograph access - open roof and remove caries remove coronal pulp RC prep (2mm short of apex) - CHX irrigation obturate with Vitapex (2mm) - CaOH and iodoform paste GIC core SSC post-tx radiograph
follow up of pulp tx - clinical
clinical failure - pathological mobility - fistula/chronic sinus - pain review every 6m
follow up of pulp tx - radiographic
radiographic failure - increased radiolucency - internal/external resorption - furcation bone loss review every 12-18m
direct pulp cap
arrest haemorrhage with pressure (moist CW)
Ca(OH)2
apexification with CaOH2 and cons
induces calcific barrier
But:
porous
makes dentine brittle (reduced mineral content )- root fracture
MTA - apical barrier formation
Mineral trioxide aggregate
5mm
after 24hrs can obturate with heated GP system
place using obtura probes, disposable MTA carriers or experimentally using Venflon
flexible composite splint
0.3mm SSW - bend to ensure passive cut to size etch, bond, apply composite sink wire cure smooth keep away from gingivae one abutment either side
pulpal involvement occurs quickly in primary molars
small
large pulp chambers
broad contact points make caries diagnosis difficult
irreversible pathological changes before pulpal exposure
early radicular pulp involvement
why can’t you use conventional RCT?
roots variable in number, divergent and curved
canals ribbon-shaped
physiological resorption
root morphology changes with age
potential to damage developing permanent successor
small mouths - access restricted
why shouldn’t you keep carious primary teeth under observation?
pain
infection
interference with development of underlying permanent - enamel hypoplasia
potential complications of pulp therapy
early loss
failure to exfoliate
enamel defects of successor
over-preparation - perforation
indications for SSCs
badly broken down teeth following pulp tx severe E hypoplasia on malformed teeth as abutment for space maintainer fractured teeth
what can physiologic mesial drift lead to?
decrease in arch length
FPMs (esp mandibular) exert big force
if space - molars erupt medially and premolars and canines erupt distally
deciduous teeth
molars wider than premolars incisors smaller molars more bulbous whiter roots flare apically pulp - large - horns high occlusally RCs - ribbon shaped thin E, thin coronal D shorter posterior arch length
space maintainers - loss of incisor
none
space maintainers - loss of canine
Band and loop but balancing ext preferable
space maintainers - loss of D
band/crown loop
space maintainers - loss of E
if FPM - band/crown and loop
UE FPM - distal shoe, guides FPM
