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paeds 3rd year (not trauma) Flashcards

1
Q

child protetction

A

activity undertaken to protect specific children who are suffering or are at risk of suffering significant harm

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2
Q

‘children in need’

A

require additional support/services to achieve their full potential

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3
Q

safeguarding

A

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
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4
Q

neglect

A

failure to meet child’s needs

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5
Q

child abuse definition - 3 elements

A

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

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6
Q

child protection legislation and guidance

A

National Guidance for Child Protection in Scotland 2014 - Scottish Gov
Children and Young People’s Act 2014
GIRFEC

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7
Q

parenting capacity - 3 big concerns

A

domestic violence
drug and alcohol misuse
mental health problems

cumulative problems increase likelihood of a negative outcome

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8
Q

aetiology of child abuse - contributing factors

A

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

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9
Q

categories of child abuse

A

physical
emotional
neglect
sexual

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10
Q

vulnerable children

A

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

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11
Q

child’s needs

A 
nutrition 
warmth
clothing
shelter
hygiene
health care
stimulation
education
affection
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12
Q

effects of neglect

A

failure to thrive/short stature
inappropriate clothing, cold injury, sunburn
ingrained dirt (finger nails), headlice, caries
developmental delay
withdrawn/attention-seeking behaviour

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13
Q

short-term damage caused by neglect

A

physical health
emotional health
social development
cognitive development

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14
Q

long-term damage caused by neglect

A

adults neglected as children have higher incidence of:

  • arrest
  • suicide attempts
  • major depression
  • diabetes
  • heart disease
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15
Q

definition of dental neglect

A

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

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16
Q

neglect of neglect

A

less incident focused

less understanding

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17
Q

dental-general neglect

A 
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
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18
Q

current child protection guidance

A

Child Protection and the Dental Team

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19
Q

is dental neglect wilful neglect?

A

after problems pointed out:

  • irregular attendance
  • repeated failed appts
  • failure to complete tx
  • returning in pain at repeated intervals
  • repeated GA for exts
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20
Q

why shouldn’t you make dental neglect assumptions?

A

caries multifactorial
varied individual susceptibility
inequalities in dental health
inequalities in access to dental tx

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21
Q

indicators of dental neglect

A

obvious dental disease
impact on the child
practical care has been offered, yet child has not returned for tx

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22
Q

managing dental neglect stages

A

preventive dental team management
preventive multi-agency management
child protection referral

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23
Q

managing dental neglect - preventive dental team management

A

raise concerns with parent
offer support
set targets
keep records and monitor progress

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24
Q

managing dental neglect - preventive multi-agency management

A

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”

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25
managing dental neglect - child protection referral
complex/deteriorating situations follow local guidelines to SS - usually telephone followed up in writing
26
assessment framework for safeguarding
child's developmental needs family and env factors parenting capacity
27
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 ```
28
what % of injuries in abuse cases are H and N?
60% | 95% serious head injuries in 1st year of life are abuse
29
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 ```
30
non-accidental injuries concerns
``` both sides STs patterns doesnt fit explanation delays in presentation untreated injuries ```
31
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 ```
32
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 ```
33
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
34
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 ```
35
child abuse - what could look similar to cigarette burns?
impetigo
36
child abuse - what could look similar to bruises?
birthmarks
37
child abuse - what could look similar to trauma?
facial infection
38
child abuse - what could look similar to lots of bruising?
coagulation problems
39
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 ```
40
role of dental team in abuse
``` observe record communicate refer - not expected to diagnose ```
41
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
42
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 ```
43
disguised non- compliance
appts booked but always cancel at last min so you never see them
44
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
45
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
46
infections
``` PHG herpangina HFM disease HPV candida ```
47
PHG cause
HSV | - primary infection can be subclinical - often U2s
48
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
49
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
50
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 ```
51
HFM
``` 1 week incubation coxsackie A16 vesicular rash on limbs, fingers and toes oral lesions on tongue/buccal mucosa ulcers shallow, painful, self-limiting ```
52
minor aphthae location
recurrent ulcers on non-keratinised mucosa | - labial, buccal, FOM
53
minor aphthae - prevalence
>2%
54
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
55
ulceration
minor aphthae major aphthae trauma
56
minor aphthae - management
Fe replacement tx symptoms e.g. difflam MW prevent secondary infection
57
minor aphthae - features
``` well-demarcated variable size red halo 1-10 heal 1-3 weeks no scarring more common second decade ```
58
cause of HPV
verruca vulgaris papillomas focal epithelial hyperplasia (Heck's disease)
59
HPV presentation
``` warts on lips and tongue papillomas on gingivae and palate - "cauliflower" appearance - localised - increased incidence in immunocompromised ```
60
eruption cyst location
superficial to crown of an erupting tooth 11% of infants develop over incisors, 30% over canines/molars more prevalent in maxilla
61
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
62
causes of trauma
``` accidents - physical/chemical/electrical assault/NAI self-inflicted - Lesch Nyhan syndrome radiation ```
63
traumatic ulcer
history non-recurrent less well-defined irregular outline
64
causes of self-inflicted trauma
self-harm/accidental mucoceles v common ranula
65
OFG associated disease
Crohns
66
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 ```
67
tx of OFG
``` patch testing (allergies - cinnamaldehyde, E numbers) dietary avoidance systemic steroids ```
68
proliferative conditions - benign
fibroepithelial polyp pyogenic granuloma giant cell granuloma
69
proliferative condiitons - malignant
most common cause of death in childhood leukaemia lymphoma rhabdomyosarcoma
70
fibroepithelial polyp
exaggerated response to "trauma" usually excised - probably wouldn't if need a GA for it squamous epithelium overlying fibrous CT, minimal inflammation
71
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 ```
72
leukaemia
``` peak age 2-5yrs M>F 80% ALL best prognosis F 4yrs gingival bleeding, fatigue etc (like primary herpes) ```
73
congenital/hereditary condiitons
geographic tongue hereditary gingival fibromatosis haemangiomas
74
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 ```
75
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 ```
76
drug induced gingival hyperplasia
phenytoin - epilepsy | cyclosporin - transplant patients
77
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 ```
78
endo in primary molars - consequences of inadequate tx
pain infection (overall growth) damage to permanent successor - hypoplasia loss of space (drifting)
79
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 ```
80
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
81
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 ```
82
endo in primary molars - why would you never do under GA?
not guaranteed success so would just extract
83
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 ```
84
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
85
endo in primary molars - aims of vital pulpotomy
stop bleeding disinfection preserve vitality of apical portion of radicular pulp
86
endo in primary molars - procedures
vital - pulpotomy non-vital - pulpectomy * pulp caps don't work on primary molars like they do on permanent
87
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)
88
endo in primary molars - options for non-vital tooth
extract | pulpectomy
89
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 ```
90
endo in primary molars - how to spot a non-vital molar: signs
hyperaemic pulp | pulp necrosis and furcation involvement
91
endo in primary molars - how to spot a non-vital molar: symptoms
irreversible pulpitis periapical periodontitis chronic sinus
92
endo in primary molars - aim of pulpectomy
prevent/control infection by extirpation of radicular pulp followed by cleaning and obturation of canals
93
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
94
endo in primary molars - potential complications of pulpectomy
early resorption leading to early exfoliation | over-preparation
95
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
96
endo in primary molars - success rates
``` vital - pulp cap poor - pulpotomy 85-100% over 3yrs non-vital - pulpectomy 90% ```
97
endo in primary molars - abscess not at apex
infection coming from floor of pulp chamber - furcation region
98
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 ```
99
perio - 2017 classification 3 main categories
1 - PD health - gingival diseases and conditions 2 - periodontitis 3 - other conditions affecting the periodontium
100
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 ```
101
perio - 2017 classification - 2 - periodontitis
necrotising PDDs periodontitis periodontitis as a manifestation of systemic diseases
102
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 ```
103
perio - 2017 classification mneumonic
``` Please Give Greg Nine Percy Pigs Straight Past Meal Time Tonight ```
104
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
105
perio - staging
IP bone loss at worst site due to periodontitis
106
perio - grading
rate of progression | % bone loss/age
107
perio - current PD status
currently stable currently in remission currently unstable
108
perio - biologic width
base of gingival sulcus to height of alveolar bone
109
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)
110
diagnosis of PD health
BPE | BOP <10%
111
gingivitis
inflammation of gingivae types - dental biofilm induced: localised or generalised - gingival diseases and conditions: non-dental biofilm induced
112
which group are worst for gingivitis?
8-12yr olds 2/3 mixed dentition think they are old enough to brush independently
113
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
114
diagnosis of gingivitis
``` BPE BOP - 10-30% localised - >30% generalised PRFs ```
115
gingivitis predisposing factors (local RFs)
``` malocclusion traumatic dental injury PRFs - tooth anatomy - Rx margins - ortho/pros appliances - incompetent lips - oral dryness ```
116
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 ```
117
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
118
examples of systemic disease which can lead to gingivitis
``` haematological - agranulocytosis - cyclic neutropenia granulomatous inflammations - crohns - sarcoidosis - granulomatosis (AI vasculitis) ```
119
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 ```
120
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 ```
121
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
122
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
123
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
124
what is the only way to get reliable bone loss?
radiographs
125
PD pathogens
p gingivalis | p intermedia
126
periodontitis as a manifestation of systemic disease
``` Papillon-Lefevre syndrome neutropenias Chediak-Higashi syndrome LAD syndrome EDS Langerhans' cell histocytosis hypophosphatasia Down Syndrome ```
127
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 ```
128
full BPE
12-17 yrs when in full adult dentition
129
who is simplified BPE for?
all cooperative 7-11 yr olds
130
advantages of simplified BPE
quick easy well-tolerated avoids false pocketing
131
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
132
simplified BPE codes
0 1 2
133
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
134
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? ```
135
2800ppm F paste age
from 10 yrs
136
5000ppm F paste age
from 16yrs
137
BPE 0 tx
no tx | screen again at routine recall or within 1yr
138
BPE 1 tx
OHI and prevention | screen again at routine recall or after 6m
139
BPE 2 tx
OHI, prevention, scaling, removal of PRF | screen again at routine recall or after 6m
140
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 ```
141
key elements of tx planning
social and behavioural factors stage of dental development clinical findings CRA
142
caries risk
risk of the pt developing new/progressive disease in future
143
7 elements of caries risk
``` clinical evidence dietary habits SH F plaque control saliva MH ```
144
8 elements of preventive programme
``` radiographs TBI strength of F toothpaste F varnish F supplementation diet advice FS sugar-free meds ```
145
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
146
tx planning - dynamic
Prevention Acclimatise Stabilise Reassess
147
<3yrs toothpaste
smear 1000ppm
148
>3yrs toothpaste
pea size adult
149
anxiety
without present triggering stimulus | may be reaction to unknown danger or anticipatory due to previous negative experiences
150
fear
normal emotional response to situations or objects perceived as genuinely threatening
151
phobia
a clinical mental disorder where subjects display persistent and extreme fear of objects or situations with avoidance behaviour and interference of daily life
152
components of DFA
physiological and somatic sensations cognitive features behavioural reactions
153
DFA - physiological and somatic sensations
breathlessness perspiration palpitations feeling of unease
154
DFA - cognitive features
interference in concentration hypervigilance inability to remember certain events while anxious imagining the worst that could happen
155
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)
156
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
157
state anxiety
in the moment
158
trait anxiety
generally how they feel about dental tx etc
159
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 ```
160
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 ```
161
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
162
communication components
verbal 5% paralinguistic 30% non-verbal 65%
163
increasing fear related behaviours
``` ignoring/denying feelings inappropriate reassurance coercing/coaxing humiliating losing your patience with pt ```
164
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 ```
165
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
166
pain and DFA
anxious subjects more likely than non- anxious to report pain - psychological role in pain perception
167
prep for visit
dentist should advise parent (pre-appt letter) rehearsal supportive care prior to each stressful procedure
168
factors that influence pain perception
``` anxiety prev experience expectation anticipation communication control subjective conditioning experiences empathetic and individual approach ```
169
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
170
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 ```
171
parent and child's behaviour
unaffected by parental presence/absence | except <4yrs - behave better with parent there
172
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
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BM techniques
``` positive reinforcement tell show do acclimatisation desensitisation voice control distraction role modelling relaxation/hypnosis ```
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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
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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
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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
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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
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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
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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)
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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
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relaxation
breathe in for 3, out for 3 - good if they keep moving tongue progressive muscle relaxation space exercise
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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
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NLP
listen to if people are talking in feelings, auditory etc - speak in the way they perceive the world
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HOM/HOMAR
``` Hand over mouth - say when they behave you will take it away don't do - psychological effects - parental consent - professional acceptance - litigation ```
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anticipatory anxiety
concern in absence of the feared stimulus - adults - avoidance - children - made to attend - poor behaviour
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FV concentrations
5% NaF 22600ppm 1ml = 50mg NaF = 22.6mg F
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indications for FV
tx of hypersensitivity | caries prevention
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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
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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
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give a factor that increases the effectiveness of Duraphat
stays put for several hours, allowing slow release of F ion
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properties of topical F
desensitising water tolerant adherent sets in presence of saliva
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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
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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
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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
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F safely tolerated dose
dose below which symptoms of toxicity are unlikely to occur | 1mg/kg
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F potentially lethal dose
lowest dose associated with fatality | 5mg/kg
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F certainly lethal dose
survival after consuming this amount is unlikely | 32-64mg/kg
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amount of F in 0.25ml FV
5.65mg
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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
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F toxicity <5mg/kg management
milk to slow absorption
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F toxicity 5-15mg/kg management
induce vomiting Paeds BP (Ipecac syrup) milk, epsom salt or aluminium hydroxide antacid mixture will help slow absorption
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F toxicity >15mg/kg management
urgent PICU - neurological, cardiac and respiratory support
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lidocaine max safe dose
4.4mg/kg
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prilocaine max safe dose
6.6mg/kg
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articaine max safe dose
5mg/kg
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Childsmile components
core nursery school practice
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standard prevention FV
x2 pa
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enhanced prevention FV
additional 1-2 times to 2 and above
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EDDN
toothbrushing demonstrations oral health promotions FV application

paeds (7 decks)

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