Paeds

Question 0

What questions would you ask mum about antenatal period?

Answer 0

Did you have any infections or illnesses during pregnancy?

Hypocalcaemia, vit. D deficiency or hypertension?

Question 1

What teeth are affected in MIH?

Answer 1

Hypomineralisation of permanent molars (1-4 and affected incisors

Question 2

What questions would you ask mum about birth of child?

Answer 2

How was child delivered?
Was child delivered prematurely?
Were there any complications during birth?

Question 3

What questions would you ask mum about child’s health from birth to 2 years old?

Answer 3

Has child had chicken pox?
Has child had rubella?
Has child had measles?
Any other relevant childhood illness - asthma, cardiac problems, epilepsy?

Question 4

Why do we ask mum about these time periods?

Answer 4

MIH has a higher prevalence amongst children who had pre-natal, natal or post-natal medical problems. Mothers of MIH affected children experienced more disease throughout pregnancy.

Question 5

In MIH, what might the patient complain of?

Answer 5

sensitivity to hot and cold

appearance of teeth

Question 6

Would the dentine be affected in MIH?

Answer 6

Dentine would not be affected by the hypomineralisation. Effects would be felt however - dentine would become hypersensitive as it has become exposed due to porous enamel. This facilitates fluid flow within tubules to activate Adelta nerve fibres (hydrodynamic theory).
Significant increase in neural density in pulp horn and subodontoblastic region. Significant increases in immune cell accumulation especially with post eruptive enamel loss. Significant increases in vascularity in sensitive MIH samples. Underlying pulpal inflammation leads to sensitisation of C fibres.

Question 7

Outline the formation of dentine.

Answer 7

Dentinogenesis is the first feature in the crown stage (late bell stage) of development. Must occur before the formation of enamel. Odontoblasts differentiate from cells of dental papilla. Deposition of dentine matrix (mainly collagen) which is predentine which is later mineralised. Primary dentine formed before root formation and forms the outermost layer of mantle dentine and an inner layer of circumpulpal dentine. Secondary dentine forms after root formation and grows at a slower rate. Tertiary dentine (reparative dentine) forms in response to stimuli such as attrition or caries.

Question 8

Outline the formation of enamel.

Answer 8

Amelogenesis during the crown stage (late bell stage) of tooth development after formation of dentine by internal enamel epithelium cells differentiating into ameloblasts.
Made in two stages: protein matrix is deposited (partially mineralised) and then organic part is removed and mineralisation is completed (maturation).
Secretory stage first and maturation stage occurs to complete enamel formation.

Question 9

What is a flexible splint used for and how long should it be left in situ? What is a rigid splint used for?

Answer 9

Used for a avulsions and luxations.
Should be left in situ for 2 weeks for avulsions
Should be left in situ for 4 weeks for laxations (apical and middle 3rd root fractures)
Should be left in situ for up to 4 months for cervical laxations
Rigid - 4weeks - dento-alveolar fractures

Question 10

Why is CaOH becoming outdated as a treatment for apexification?

Answer 10

Some concerns about long term CaOH use inside root canals - reduces mineral content of dentine and makes tooth more susceptible to root fracture
Recent research may also suggest that some barriers formed are full of holes
Average time for CaOH to harden is 9 months, compared to MTA which is 24hrs

Question 11

What are the advantages of the hall technique?

Answer 11

Allows pre formed metal crown to be placed over carious primary molars - shown to be one of the most successful techniques for restorating primary teeth
Quick and non-invasive
Does not require LA
Does not require any tooth preparation or caries removal

Question 12

What instruments are required for the hall technique?

Answer 12

mirror,
straight probe - removing cement after fitting,
excavator - remove crown if needed,
flat plastic - load with cement
cotton wool - wipe away cement
gauze for airway/elastoplast to secure crown, band forming pliers

Question 13

What teeth are suitable for the hall technique?

Answer 13

primary molars (Ds and Es)

Question 14

How would you choose the stainless steel crown for the hall technique?

Answer 14

choose smallest crown that will cover all cusps, and approaches the contact points, with a slight feeling of ‘spring back’
adjustments may have to be made using Adams pliers
if unsuitable remove crown using excavator before cement sets

Question 15

When would you use separators?

Answer 15

use seperators through contacts that are tight or where there has been loss of mesio-distal width of a tooth due to marginal ridge fracture

Question 17

What are the indications for hall technique?

Answer 17

no radiographical sign of pulpal involvement (i.e. asymptomatic tooth)
sufficient amount of sound tooth tissue
anxious child (about LA)
child is willing to cooperate

Question 18

Describe the hall technique procedure.

Answer 18

sit child upright - gauze swab to protect airway
smallest crown that covers all cusps - DO NOT SEAT - should spring back
dry crown, fill with GI luting cement - no air inclusions
dry tooth if possible
if cavity is large, some cement may be placed within it before placing the crown
place crown over tooth, fully seat crown by either using finger pressure or by partially seating crown until it engages with contact points then asking child to bite down on crown
remove excess cement, hold crown in place for 2-3 mins, floss contacts, give child a sticker

Question 19

What are prevention and patient advice?

Answer 19

brushing, topical fluoride varnish e.g. Duraphat, fissure sealant, dietary advice, reassure patient that they will be used to the feeling within 24hrs, even bite within weeks

Question 20

A parent calls your practice and tells you that their 8 year old daughter has just knocked out her front tooth. What is the dental term given to an injury of this sort?

Answer 20

Avulsion

Question 21

List the instructions you would give the parent on the telephone.

Answer 21

Store in fresh cold milk or saliva - do not allow tooth to dry out
Do not handle root
Can wash for 10s under cold water while holding crown if obvious debris
Re implant if possible

Question 22

The patient has fully erupted lateral incisors. What term best describes the type of splint you would construct?

Answer 22

Flexible splint

Question 23

What are the ideal materials to use to construct a splint and where exactly would you place them?

Answer 23

A splint is constructed using a 0.6mm stainless steel wire, cut to size and then contoured (to make it passive)
Composite resin is then applied to labial/buccal surface of traumatised tooth and those adjacent
Wire is then placed into composite, shaped, cured and smoothed off

Question 24

The tooth subsequently becomes non-vital; it has an incomplete root apex. After the necrotic pulp has been extirpated, what material should be used to fill the canal?

Answer 24

5mm of MTA (mineral trioxide aggregate) should be placed at apical end of root
Wait 24hrs for MTA to harden then obturate with a heated GP system

Question 25

What are you trying to achieve by doing this?

Answer 25

Apexification

Provides apical barrier against which to condense root canal filling (gutta percha)

Question 26

What is the eruption sequence for deciduous teeth?

Answer 26

Lowers before uppers - erupt in order As Bs Ds Cs Es
As = 6-7months
Bs = 7-8months
Ds = 12-15months
Cs = 18-20months
Es = 24-36months

Question 27

What is the normal eruption sequence for the permanent dentition?

Answer 27

6yrs = lower 1s, upper and lower 6s
7yrs = upper 1s, lower 2s
8yrs = upper 2s
11yrs = lower 3s, upper and lower 4s
12yrs = upper 3s, upper and lower 5s, upper and lower 7s

Question 28

What are the minor and major outcomes after a 2 year follow up comparing Hall technique and conventional technique?

Answer 28

minor failures = new/secondary caries, filling/crown worn, lost or requiring other intervention; restoration lost but tooth restorable; reversible pulpitis treated without requiring pulpotomy or extraction
major failures = irreversible pulpitis; abscess requiring pulpotomy or extraction; inter-radicular radiolucency; filling lost and tooth unrestorable

Question 29

What are the disadvantages of unplanned primary tooth extraction?

Answer 29

Loss of space causing increased risk of malocclusion
Decreased masticatory function
Impeded speech development
Psychological disturbance
Trauma from anaesthesia/surgery

Question 30

What are the indications for pulpal treatment?

Answer 30

Good cooperation
Avoidance of general anaesthesia
Medical history precludes extraction eg bleeding disorder
Missing permanent successor
Over riding necessity to preserve the tooth eg space maintainer
Child under 9yrs old

Question 31

What are the contraindications for pulpal treatment?

Answer 31

Poor cooperation
Poor dental attendance
Cardiac defect
Multiple grossly carious teeth
Advanced root resorption
Severe/recurrent pain or infection

Question 32

What are the signs of failure following a review of pulpal treatment?

Answer 32

Clinical failure (clinical review 6 monthly) - pathological mobility, fistula/chronic sinus, pain
Radiographical failure (radiograph review 12-18 monthly) - increased radiolucency, external/internal resorption, furcation bone loss

Question 33

What are the indications for stainless steel crowns?

Answer 33

Badly broken down primary teeth and young permanent teeth (tooth not satisfactory for an amalgam)
Primary and young permanent teeth following a pulpotomy or partial pulpectomy
Severe enamel hypoplasia on malformed teeth
As an abutment for a space maintainer
Fractured teeth

Question 34

What are some dietary and OHI you would give to a patient with a splint?

Answer 34

soft food diet for 2 weeks
chlorhexidine mouthwash
ensure good oral hygiene -> brushing, fluoridated toothpaste
reduce frequency of sugary intake