paeds 3rd year (not trauma) Flashcards
child protetction
activity undertaken to protect specific children who are suffering or are at risk of suffering significant harm
‘children in need’
require additional support/services to achieve their full potential
safeguarding
measures taken to minimise the risks of harm to children
- protection from maltreatment
- preventing impairment of health or development
- ensure growing up in safe and caring env
neglect
failure to meet child’s needs
child abuse definition - 3 elements
1 - significant harm to child
2 - carer has some responsibility for that harm
3 - significant connection between carer’s responsibility for child and harm to child
child protection legislation and guidance
National Guidance for Child Protection in Scotland 2014 - Scottish Gov
Children and Young People’s Act 2014
GIRFEC
parenting capacity - 3 big concerns
domestic violence
drug and alcohol misuse
mental health problems
cumulative problems increase likelihood of a negative outcome
aetiology of child abuse - contributing factors
adult
- drugs, alcohol, poverty, unemployment, marital stress, mental illness, disabled, domestic violence, step-parents, isolation, abused as a child, unrealistic expectations
child
- crying, soiling, disability, unwanted pregnancy, failed expectations, wrong gender, product of forced/coercive/commercial sex
community/env
- housing conditions, neighbourhood
family violence and dysfunctional family
- intergenerational cycle, violence towards pets, social isolation, poverty
categories of child abuse
physical
emotional
neglect
sexual
vulnerable children
U5s
irregular attenders
- repeatedly DNA, return in pain, exposed to GA risks
medical problems and disabilities
- more at risk
- serious impairment of health/development is more likely as a result of untreated dental disease
- ‘looked after’ children
child’s needs
nutrition warmth clothing shelter hygiene health care stimulation education affection
effects of neglect
failure to thrive/short stature
inappropriate clothing, cold injury, sunburn
ingrained dirt (finger nails), headlice, caries
developmental delay
withdrawn/attention-seeking behaviour
short-term damage caused by neglect
physical health
emotional health
social development
cognitive development
long-term damage caused by neglect
adults neglected as children have higher incidence of:
- arrest
- suicide attempts
- major depression
- diabetes
- heart disease
definition of dental neglect
persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development
- broader definition than USA - doesn’t have to be wilful just persistent
neglect of neglect
less incident focused
less understanding
dental-general neglect
severe dental disease can cause: - toothache - disturbed sleep - eating problems - school absence may put child at risk of: - teasing - repeated ABs - repeated GAs - severe infections
current child protection guidance
Child Protection and the Dental Team
is dental neglect wilful neglect?
after problems pointed out:
- irregular attendance
- repeated failed appts
- failure to complete tx
- returning in pain at repeated intervals
- repeated GA for exts
why shouldn’t you make dental neglect assumptions?
caries multifactorial
varied individual susceptibility
inequalities in dental health
inequalities in access to dental tx
indicators of dental neglect
obvious dental disease
impact on the child
practical care has been offered, yet child has not returned for tx
managing dental neglect stages
preventive dental team management
preventive multi-agency management
child protection referral
managing dental neglect - preventive dental team management
raise concerns with parent
offer support
set targets
keep records and monitor progress
managing dental neglect - preventive multi-agency management
liase e.g. HV, school nurse, GP, social worker to see if concerns are shared
may be subject of CAF at this level
check if child subject to child protection plan
agree joint plan, review agreed intervals
letter to HV of <5s who fail appointments and have failed to respond to letter from practice “if this family is known to you, we would welcome working together to promote their oral health”
managing dental neglect - child protection referral
complex/deteriorating situations
follow local guidelines
to SS
- usually telephone followed up in writing
assessment framework for safeguarding
child’s developmental needs
family and env factors
parenting capacity
physical abuse - differentiating
overchastisement (cultural) acute/compassionate (shaking) - spontaneous uncalculated reaction - remorse, takes app action - child's needs priority chronic/pathological (way of life) - help sought but not actively - no remorse - child's needs not priority
what % of injuries in abuse cases are H and N?
60%
95% serious head injuries in 1st year of life are abuse
typical accidental injuries
bony prominences one side match history in keeping with development of child head: parietal bone, occipuit of forehead nose chin palm hand elbows knees shins
non-accidental injuries concerns
both sides STs patterns doesnt fit explanation delays in presentation untreated injuries
non-acccidental injuries regions
black eyes (esp bilateral) ears (esp pinch marks) STs of cheeks IO injuries "triangle of safety" - ears, side of face and neck, top of shoulders forearms (raised to protect self) chest and abdomen inner arms back and side of trunk (except over bony spine) groin/genital inner thighs soles of feet
orofacial signs of abuse: EO
bruising: punch, slap, pinch bruising of ears: pinch, pull abrasions and lacerations burns and bites neck - choke/cord marks eye injuries hair pulling fractures
IO signs of abuse
contusions bruises - can bruise HP themselves but would always want to ask about this injury - force feeding etc abrasions and lacerations burns tooth trauma frenal injuries
about a third prevalence
major clinical features of abuse
skin lesions - bruises, burns, bites, lacerations bone lesions - fractures intracranial lesions - from shaking visceral lesions (intra-abdominal) - blunt trauma bruising of different vintages tattoo bruising grip marks slap marks
child abuse - what could look similar to cigarette burns?
impetigo
child abuse - what could look similar to bruises?
birthmarks
child abuse - what could look similar to trauma?
facial infection
child abuse - what could look similar to lots of bruising?
coagulation problems
index of suspicion
delay in seeking help story vague, lacks detail, varies account not compatible with injury parents mood abnormal e.g. preoccupied parents behaviour concerning child's appearance and interaction with parents is abnormal child may say something contradictory history of prev injury history of violence in family
role of dental team in abuse
observe record communicate refer - not expected to diagnose
physical abuse - final checklist
could injury have been caused accidentally? how?
does explanation fit age and clinical findings?
if explanation is consistent with injury, is this itself within normally acceptable limits of behaviour?
if delay in seeking advice, are there good reasons why?
child’s general demeanour
parent child relationship
child’s reaction to other people
reaction of child to medical/dental exam
any comments by child/guardian that give concern about child’s upbringing or lifestyle
Shared Referral form
your details (designated contact person) referral to subject of referral - language - any disability family details - other adults/siblings summary of concerns reason for referral agreed actions (from phone referral) agency involvement
disguised non- compliance
appts booked but always cancel at last min so you never see them
CYPA and info sharing
duty to share any concern about a risk to a child’s wellbeing with NP
also share info in relation to a child’s plan
not restricted to instances where there is a significant risk of harm
specific provision that info can be shared even where this breaches confidentiality
if making the referral - what to tell parent
should discuss with parent, unless for safety
if dental neglect good to tell them as they will realise it is you
infections
PHG herpangina HFM disease HPV candida
PHG cause
HSV
- primary infection can be subclinical - often U2s
PHG symptoms
widely varying severity
- pyrexic, malaise, loss of appetite
- can cause severe systemic upset
- vesicles on mucosa, rupture - ulcers 1-3mm
- fiery red gingivae
- v painful
- refuse to eat/toothbrushing
- halitosis
PHG tx
supportive only: fluids, analgesics, bed rest
reassurance - self-limiting, resolves 7-10 days
?acciclovir? - only in v early stages or if pt immunocompromised
herpangina
highest incidence in young children 2-9 day incubation fever, malaise, muscle pain pinhead vesicles on tonsils, uvula, SP vesicles rupture to form large ulcers heal 5-7 days no gingivitis less unwell lesions all at the back
HFM
1 week incubation coxsackie A16 vesicular rash on limbs, fingers and toes oral lesions on tongue/buccal mucosa ulcers shallow, painful, self-limiting
minor aphthae location
recurrent ulcers on non-keratinised mucosa
- labial, buccal, FOM
minor aphthae - prevalence
> 2%
minor aphthae - aetiology
? stress FH HLA type immunological (altered T cell ratio)
some go on to develop crohns disease
many have relative Fe deficiency due to increased demands of growing or menstrual blood loss
ulceration
minor aphthae
major aphthae
trauma
minor aphthae - management
Fe replacement
tx symptoms e.g. difflam MW
prevent secondary infection
minor aphthae - features
well-demarcated variable size red halo 1-10 heal 1-3 weeks no scarring more common second decade
cause of HPV
verruca vulgaris
papillomas
focal epithelial hyperplasia (Heck’s disease)
HPV presentation
warts on lips and tongue papillomas on gingivae and palate - "cauliflower" appearance - localised - increased incidence in immunocompromised
eruption cyst location
superficial to crown of an erupting tooth
11% of infants develop over incisors, 30% over canines/molars
more prevalent in maxilla
features of eruption cyst
dilation of follicular space around crown
compressible
can become infected
resolve when tooth erupts
like a blood filled blister ahead of tooth
causes of trauma
accidents - physical/chemical/electrical assault/NAI self-inflicted - Lesch Nyhan syndrome radiation
traumatic ulcer
history
non-recurrent
less well-defined
irregular outline
causes of self-inflicted trauma
self-harm/accidental
mucoceles v common
ranula
OFG associated disease
Crohns
OFG features
2nd-3rd decade presentation lip swelling biopsy shows non-caseating granulomas Langhans type giant cells lymphocytic infiltrate swelling due to oedema cobblestone mucosa deep penetrating ulcers mucosal tags gingivitis pyostomatitis
tx of OFG
patch testing (allergies - cinnamaldehyde, E numbers) dietary avoidance systemic steroids
proliferative conditions - benign
fibroepithelial polyp
pyogenic granuloma
giant cell granuloma
proliferative condiitons - malignant
most common cause of death in childhood
leukaemia
lymphoma
rhabdomyosarcoma
fibroepithelial polyp
exaggerated response to “trauma”
usually excised
- probably wouldn’t if need a GA for it
squamous epithelium overlying fibrous CT, minimal inflammation
pyogenic granuloma
fibro-endothelial growth gingival margin common in children red/purple, v vascular mimic haemangioma ulcerate and can bleed profusely complete excision? - cryo - shrink it
leukaemia
peak age 2-5yrs M>F 80% ALL best prognosis F 4yrs gingival bleeding, fatigue etc (like primary herpes)
congenital/hereditary condiitons
geographic tongue
hereditary gingival fibromatosis
haemangiomas
geographic tongue
2-10% prevalence <4yrs most common red zones of depapillation, move around - snake like appearance white margins due to heavy infiltration no successful tx - benign, doesnt bother child much, can struggle with spicy and minty toothpastes
hereditary gingival fibromatosis
non-specific progressive enlargement may be localised e.g. palatal aspect of the tuberosities, or generalised may be isolated or part of a syndrome teeth don't look fully erupted may do gingivectomy with electrocautery need vvv good OH tends to regrow, may need redone
drug induced gingival hyperplasia
phenytoin - epilepsy
cyclosporin - transplant patients
haemangioma
present at birth or soon after grow rapidly malformations of blood vessels benign tumour, endothelial proliferation capillary/cavernous can occur within bone most will involute spontaneously problems with extracting teeth - need a scan first
endo in primary molars - consequences of inadequate tx
pain
infection (overall growth)
damage to permanent successor - hypoplasia
loss of space (drifting)
endo in primary molars - considerations
rapid caries progression small teeth, large pulp chambers broad contact areas irreversible pathological changes before pulp exposure early radicular pulp involvement
endo in primary molars - at what point is there likely to be pulpal inflammation?
> 2/3 marginal ridge breakdown, likely to be at least pulp horn inflammation, may extend
endo in primary molars - indications
good cooperation avoid GA MH precludes ext - bleeding disorder etc lack of permanent successor - hypodontia pt age ortho considerations - space preservation
endo in primary molars - why would you never do under GA?
not guaranteed success so would just extract
endo in primary molars - contraindications
poor cooperation MH precludes pulp tx - immunocompromised/cardiac pt age ortho - space closure desired severe/recurrent pain space management advanced RR cellulitis pus in pulp chamber gross bone loss
endo in primary molars - clinical indications for vital pulpotomy
pulp minimally inflamed/reversible pulpitis
MR destroyed
caries extending >2/3 into D on radiograph
any doubt that pulp exposed
- caries
- iatrogenic
endo in primary molars - aims of vital pulpotomy
stop bleeding
disinfection
preserve vitality of apical portion of radicular pulp
endo in primary molars - procedures
vital - pulpotomy
non-vital - pulpectomy
* pulp caps don’t work on primary molars like they do on permanent
endo in primary molars - pulpotomy technique
prep - topical, LA, dam
access
amputation - remove coronal pulp, haemorrhage control, evaluate pulp stumps
medication - ferric sulphate on cotton pledget over root stumps for 20s
Rx
- CaOH/MTA
- GIC core
- SSC (no coronal pulp so D dry and brittle, will fracture easily)
endo in primary molars - options for non-vital tooth
extract
pulpectomy
endo in primary molars - direct pulpal evaluation
normal bleeding/uninflamed pulp - bright red - good haemostasis abnormal bleeding/inflamed pulp - deep crimson - continued bleeding after pressure
endo in primary molars - how to spot a non-vital molar: signs
hyperaemic pulp
pulp necrosis and furcation involvement
endo in primary molars - how to spot a non-vital molar: symptoms
irreversible pulpitis
periapical periodontitis
chronic sinus
endo in primary molars - aim of pulpectomy
prevent/control infection by extirpation of radicular pulp followed by cleaning and obturation of canals
endo in primary molars - pulpectomy technique
access
coronal pulp extirpation
RC prep (2mm short of apex) - only work to EWL as too dangerous to take WL radiograph - child may bite down on file which could damage successor underneath
obturation - Vitapex (CaOH iodoform paste)
GIC core
SSC
endo in primary molars - potential complications of pulpectomy
early resorption leading to early exfoliation
over-preparation
endo in primary molars - Ledermix paste
antibiotic/antiseptic dressing
place directly over exposed pulp
dress IRM and review within 1wk
complete pulpectomy once symptoms subside
- good if struggling to achieve anaesthesia
endo in primary molars - success rates
vital - pulp cap poor - pulpotomy 85-100% over 3yrs non-vital - pulpectomy 90%
endo in primary molars - abscess not at apex
infection coming from floor of pulp chamber - furcation region
endo in primary molars - follow up
clinical failure - clinical review 6monthly - pathological mobility - fistula/chronic sinus - pain radiographic failure - PA 12-18monthly (may have no clinical symptoms) - increased radiolucency - external/internal resorption - furcation bone loss
perio - 2017 classification 3 main categories
1 - PD health - gingival diseases and conditions
2 - periodontitis
3 - other conditions affecting the periodontium
perio - 2017 classification - 1 - PD health, gingival diseases and conditions
PD health - intact periodontium - reduced periodontium Gingivitis: biofilm-induced - intact periodontium - reduced periodontium Gingival diseases and conditions - non-dental biofilm induced
perio - 2017 classification - 2 - periodontitis
necrotising PDDs
periodontitis
periodontitis as a manifestation of systemic diseases
perio - 2017 classification - 3 - other conditions affecting the periodontium
systemic diseases/conditions affecting the PD supporting tissues PD abscesses and perio-endo lesions mucogingival deformities and conditions traumatic occlusal forces tooth and prosthesis related factors
perio - 2017 classification mneumonic
Please Give Greg Nine Percy Pigs Straight Past Meal Time Tonight
perio - reduced periodontium
recognises alveolar bone loss or attachment loss due to causes other than peridontitis
i.e. surgical crown lengthening, ortho tx, perio-endo lesions, impacted 8s, Rx margins
perio - staging
IP bone loss at worst site due to periodontitis
perio - grading
rate of progression
% bone loss/age
perio - current PD status
currently stable
currently in remission
currently unstable
perio - biologic width
base of gingival sulcus to height of alveolar bone
PD health - intact peridontium
absence of detectable attachment and/or bone loss
gingival margin may be several mm coronal to CEJ
gingival sulcus may be 0.5-3mm deep
alveolar crest 0.4-1.9mm apical to CEJ (teenagers)
diagnosis of PD health
BPE
BOP <10%
gingivitis
inflammation of gingivae
types
- dental biofilm induced: localised or generalised
- gingival diseases and conditions: non-dental biofilm induced
which group are worst for gingivitis?
8-12yr olds
2/3
mixed dentition
think they are old enough to brush independently
dental biofilm gingivitis pathogenesis
supragingival plaque accumulates
inflammatory cell infiltrate develops in gingival CT
JE becomes disrupted
- allows apical migration of plaque and increase in gingival sulcus depth
= gingival/false/pseudo pocket
reversible
severe inflammation - gingival swelling - deeper false pocket
the most apical extension of the JE is still the CEJ - no PD LOA
diagnosis of gingivitis
BPE BOP - 10-30% localised - >30% generalised PRFs
gingivitis predisposing factors (local RFs)
malocclusion traumatic dental injury PRFs - tooth anatomy - Rx margins - ortho/pros appliances - incompetent lips - oral dryness
gingivitis modifying factors (systemic RFs)
smoking metabolic factors - hyperglycaemia/IDD drugs - cyclosporin nutritional factors - vit C deficiency increased sex steroids - puberty, pregnancy haematological conditions - leukaemia
pubertal gingivitis
increased inflammatory response to plaque
mediated by hormonal changes
teenagers - gingivitis can progress to early periodontitis
local and systemic factors can influence progression
examples of systemic disease which can lead to gingivitis
haematological - agranulocytosis - cyclic neutropenia granulomatous inflammations - crohns - sarcoidosis - granulomatosis (AI vasculitis)
non-dental biofilm induced gingivitis
when main aetiological agent for gingivitis is not plaque genetic - phenotype - hereditary fibromatosis trauma - thermal - chemical - physical manifestations of systemic disease - haematology - immunological - granulomatous inflammation - OFG drug induced - immune complex reactions - cytotoxic - anticonvulsants (phenytoin) - Ca channel blockers - immunosuppressants (cyclosporin) - antiretroviral infective - deep mycoses - viral - fungal
gingival diseases: non-dental biofilm induced
can be - manifestations of systemic conditions - pathologic changes limited to gingival tissues subclassification 1 genetic/developmental disorders 2 specific infections 3 inflammatory and immune 4 reactive 5 neoplasms 6 endocrine 7 nutritonal and metabolic 8 traumatic 9 gingival pigmentation
non-dental biofilm induced gingivitis tx
cases where extent of condition is inconsistent with level of OH observed
unexplained
- gingival enlargement
- inflammation
- bleeding
consider urgent referral to physician - haematinic screening
rigorous OH
frequent scaling
may need surgery (esp drug induced) - refer
periodontitis
chronic, multifactorial inflammatory, dysbiotic plaque biofilms (microbial imbalance)
progressive destruction of tooth-supporting apparatus
multifactorial
- dysbiotic microbiome changes more likely for some pts than for others
- may influence severity
features of periodontitis
apical migration of JE beyond CEJ
LOA of PD tissues to cementum
transformation of JE to pocket epithelium (often thin and ulcerated)
alv bone loss
what is the only way to get reliable bone loss?
radiographs
PD pathogens
p gingivalis
p intermedia
periodontitis as a manifestation of systemic disease
Papillon-Lefevre syndrome neutropenias Chediak-Higashi syndrome LAD syndrome EDS Langerhans' cell histocytosis hypophosphatasia Down Syndrome
perio recording and diagnosis
gingival condition - colour, contour, swelling, recession, suppuration, inflammation, consider use of marginal bleeding free chart OH status - plaque-free scores any calculus - chart location assess local RFs - PRFs - low frenal attachments - malocclusion - incompetent lip seal - reduced upper lip coverage - labial and palatal gingivitis - increased lip separation - mouthbreathing - palatal gingivitis
full BPE
12-17 yrs when in full adult dentition
who is simplified BPE for?
all cooperative 7-11 yr olds
advantages of simplified BPE
quick
easy
well-tolerated
avoids false pocketing
simplified BPE teeth
6 1. 6
6. 1 6
on permanent teeth only
identifies need for further investigation
primary teeth
- PDD rare
- mobility or gingival suppuration - refer
simplified BPE codes
0
1
2
SDCEP plaque scores
perfectly clean tooth 10/10
line of plaque around cervical margin 8/10
cervical 1/3 crown covered 6/10
middle 1/3 crown covered 4/10
tx of plaque-induced gingivitis
brushing systematic - brush DJ app - upstairs, downstairs, L and R - 10s each surface supervised/assisted brushing up to about 7yrs - can they tie their own shoelaces?
2800ppm F paste age
from 10 yrs
5000ppm F paste age
from 16yrs
BPE 0 tx
no tx
screen again at routine recall or within 1yr
BPE 1 tx
OHI and prevention
screen again at routine recall or after 6m
BPE 2 tx
OHI, prevention, scaling, removal of PRF
screen again at routine recall or after 6m
BPE 3/4/* tx
bleeding/plaque charts full PD assessment, radiographs - establish whether false/true pocket scaling, RSD, OHI and prevention scores 4 or * consider referral tx and review after 3m
key elements of tx planning
social and behavioural factors
stage of dental development
clinical findings
CRA
caries risk
risk of the pt developing new/progressive disease in future
7 elements of caries risk
clinical evidence dietary habits SH F plaque control saliva MH
8 elements of preventive programme
radiographs TBI strength of F toothpaste F varnish F supplementation diet advice FS sugar-free meds
high risk caries experience
dmft/DMFT 5 or more
10 or more initial lesions
caries in 6s at 6yrs
3yr caries increment 3 or more
tx planning - dynamic
Prevention
Acclimatise
Stabilise
Reassess
<3yrs toothpaste
smear 1000ppm
> 3yrs toothpaste
pea size adult
anxiety
without present triggering stimulus
may be reaction to unknown danger or anticipatory due to previous negative experiences
fear
normal emotional response to situations or objects perceived as genuinely threatening
phobia
a clinical mental disorder where subjects display persistent and extreme fear of objects or situations with avoidance behaviour and interference of daily life
components of DFA
physiological and somatic sensations
cognitive features
behavioural reactions
DFA - physiological and somatic sensations
breathlessness
perspiration
palpitations
feeling of unease
DFA - cognitive features
interference in concentration
hypervigilance
inability to remember certain events while anxious
imagining the worst that could happen
DFA - behavioural reactions
avoidance i.e. postponing appt, or children disruptive behaviour to stop tx
escape from situation which ppts the anxiety
may manifest with aggression (esp adolescents who are brought by parents but don’t want to be there)
signs of DFA
may be subtle
younger children - time delay by asking Qs
school age - complain of stomach aches, ask to go to toilet frequently
older - complain of headaches/dizziness, may fidget/stutter, can’t be bothered
explain to child their symptoms are normal of anxiety
state anxiety
in the moment
trait anxiety
generally how they feel about dental tx etc
factors that influence DFA
parents attitudes prep at home before visit child's perception that something is wrong with their teeth fear of choking fear of injections/drilling fear of unknown past medical and dental experiences friends and siblings experience
assessing children’s DFA
control-related items - assess pts' desire to influence course of tx - rest breaks - signals to stop - pts need for info assess fear in history - prev tx/experiences - items relating to trust MCDASf - quick and easy - diff aspects dental experience rated - baseline anxiety levels established
advantages of good dentist/patient communication
improves info obtained from pt
dentist can communicate info to pt
increased likelihood of pt compliance
reduces pt anxiety
communication components
verbal 5%
paralinguistic 30%
non-verbal 65%
increasing fear related behaviours
ignoring/denying feelings inappropriate reassurance coercing/coaxing humiliating losing your patience with pt
reducing patient anxiety behaviours
prevent pain friendly and establish trust work quickly calm manner give moral support be reassuring about pain "I will make it as comfortable as possible" empathy tell them to be clever (not brave) just put plastic mirror on tray
facial expressions and pain
can show discomfort
disruptive behaviour may be evidence of sudden pain
pain - screwing up eyes and lowering eyebrows with the mouth open in a squarish appearance
fear - opening eyes widely and raising eyebrows with mouth open and tense
pain and DFA
anxious subjects more likely than non- anxious to report pain
- psychological role in pain perception
prep for visit
dentist should advise parent (pre-appt letter)
rehearsal
supportive care prior to each stressful procedure
factors that influence pain perception
anxiety prev experience expectation anticipation communication control subjective conditioning experiences empathetic and individual approach
role of parent - when to exclude from surgery
unable to refrain from competing with dentist for child’s attention
unintentionally convey their own anxieties
involving parent in planning stages and outlining their role as a passive but silent helper may provide comforting presence
tend to underrate child’s anxiety
Letter to Dentist
how worried how painful do they think tx will be what do they want to happen how will they cope stop signal
parent and child’s behaviour
unaffected by parental presence/absence
except <4yrs - behave better with parent there
benefit of parents with infant/toddler
pt uncapable/unwilling to sit for exam - knee to knee - direct physical and visual contact with parent
parent can witness behaviour clinician must contend with
BM techniques
positive reinforcement tell show do acclimatisation desensitisation voice control distraction role modelling relaxation/hypnosis
positive reinforcement
presentation of a stimulus that will increase the likelihood of a behaviour being repeated
social reinforcers - facial expression, verbal praise, appropriate physical contact
non-social reinforcers - stickers, colouring poster and clever certificates
needs to be specific - the exact thing they are doing well
tell show do
familiarise pt with a new behaviour
tell - age-appropriate explanation of technique
show - demonstrating for the pt aspects of the procedure in a non-threatening way e.g. use a SS to draw a happy face on their nail
do - initiate with minimal delay
acclimatisation
planned, sequential introduction of env, people, instruments and procedures
- integral part of tx plan
e. g. - give dam home on visit before use
- introduce 3:1, suction and CWRs on visit before FS
- SS with prophy cup then bur then HS
- topical visit before LA
systematic desensitisation
relaxation exercise first
based on assumption that repeated non-distressing exposure to an anxiety-provoking stimulus will eventually reduce anxiety
must reassure child they are in control
done in an ordered manner from what they perceive as least to most anxiety provoking, in imagination of in real life until no anxiety is produced
e.g. systematic needle desensitisation
voice control
controlled alteration of voice vol, tone or pace to influence and direct pts behaviour (intonation)
check parents on your side
gain pts attention and compliance
avert - or avoidance behaviour
distraction
diverting pt from what may be perceived as an unpleasant procedure
- pulling the U lip “you’ll feel me holding that lip really tight”
- telling story while LA
- letting an older child bring in music to listen to (only good for mild)
role modelling
similar age and tx
older sibling best for children 3-5yrs
needs to be an anxious child who is mastering their anxiety
- don’t show them a non-anxious child
relaxation
breathe in for 3, out for 3 - good if they keep moving tongue
progressive muscle relaxation
space exercise
hypnosis
interaction between hypnotist and subject
attempts to influence the subjects’ perception, feelings, thinking and behaviour by asking them to concentrate on ideas and images “suggestions”
response experienced by subject as having a quality of involuntariness or effortlessness
relaxed - subconscious prominent brain
stressed - conscious brain
so if relaxed easier to speak to subconscious brain
NLP
listen to if people are talking in feelings, auditory etc - speak in the way they perceive the world
HOM/HOMAR
Hand over mouth - say when they behave you will take it away don't do - psychological effects - parental consent - professional acceptance - litigation
anticipatory anxiety
concern in absence of the feared stimulus
- adults - avoidance
- children - made to attend - poor behaviour
FV concentrations
5% NaF
22600ppm
1ml = 50mg NaF = 22.6mg F
indications for FV
tx of hypersensitivity
caries prevention
contraindications for FV
ulcerative gingivitis
stomatitis
sensitivity to colophony (resin) - cosmetics, adhesives, sun cream, paper
severe asthma - hospitalised recently or uncontrolled asthma
allergy (extremely rare but be cautious in a pt with multiple severe allergies)
allergy to elastoplast
how does topical F work?
more beneficial in caries prevention than systemic ingestion
1 - slows caries progression - stops demineralisation
2 - caries arresting - makes enamel more resistant to acid attack (from plaque bacteria) and speeds up remineralisation (w F ions so tooth surface stronger/less soluble)
3 - caries inhibiting - stops bacterial metabolism (at high concs) to produce less acid
give a factor that increases the effectiveness of Duraphat
stays put for several hours, allowing slow release of F ion
properties of topical F
desensitising
water tolerant
adherent
sets in presence of saliva
application of FV
remove gross plaque
remove excess moisture - air/CW
apply first to L arch where saliva collects more rapidly
apply sparingly in a thin layer using microbrush/CWP
floss can be used to ensure varnish reaches IP areas
amount of FV to use
2-6 primary dentition 0.25ml
>6 mixed 0.4ml
permanent dentition 0.75ml
but don’t have to use it all
POIs
avoid eating and drinking for at least an hour
- if can avoid for longer will have more beneficial impact
eat soft foods for rest of day
brush teeth as normal that night
- or can avoid brushing that night only as recommended in childsmile
don’t take F supplement on day of application or day after (2 days)
tell parent that varnish makes teeth look yellow and this wears off when eating and brushing teeth
F safely tolerated dose
dose below which symptoms of toxicity are unlikely to occur
1mg/kg
F potentially lethal dose
lowest dose associated with fatality
5mg/kg
F certainly lethal dose
survival after consuming this amount is unlikely
32-64mg/kg
amount of F in 0.25ml FV
5.65mg
S and S of fluoride overdose
F absorbed v quickly from stomach - acute F toxicity
nausea and vomiting (diarrhoea and abdo pain)
excessive salivation, abnormal taste, tremors, weakness, convulsions
shallow respirations, NS shock
F toxicity <5mg/kg management
milk to slow absorption
F toxicity 5-15mg/kg management
induce vomiting
Paeds BP (Ipecac syrup)
milk, epsom salt or aluminium hydroxide antacid mixture will help slow absorption
F toxicity >15mg/kg management
urgent PICU - neurological, cardiac and respiratory support
lidocaine max safe dose
4.4mg/kg
prilocaine max safe dose
6.6mg/kg
articaine max safe dose
5mg/kg
Childsmile components
core
nursery
school
practice
standard prevention FV
x2 pa
enhanced prevention FV
additional 1-2 times to 2 and above
EDDN
toothbrushing demonstrations
oral health promotions
FV application
