paeds 430 Flashcards
caries pattern in children
caries rate in lower 6s higher than in uppers
pit and fissure caries - palatal of upper 6s and 2s and buccal of lower 6s
second molars erupting
host factors i.e. reduced salivary flow and high mutans counts
caries definition
‘‘disease of mineralised tissues; enamel, dentine and cementum, caused by action of micro-organisms on fermentable carbohydrates … In it’s very early stages the disease can bearrested since it is possible for remineralisation to take place”
(Kidd et al, 1987)
caries classification
- Decalcification
- White/Brown spot lesions
- Pit and fissure caries
- Smooth surface caries
- Buccal
- Lingual
- Cervical
- Interproximal
- Early Childhood or nursing bottle caries
- Max incisors, 1st molars, mandibular canines
- lower incisors are protected by the tongue
- Recurrent/Secondary caries
- Arrested Caries
- Rampant Caries
- 10 or more new lesions per year
- Lower anteriors affected
eval of dentition of child
restorability
pt and parent compliance
stage of development
space management (drifting, ortho considerations)
anticipated difficulties
overall prognosis
loss of upper first permanant molars
before complete eruption of 7s
7 rotates
loss of lower first permanent molars
after optimum age
7 tilts mesially
loss of lower first permanent molars
before optimum age
5s drift distally and rotate
rotates to form arbitrary occlusal contact
3 safety reason for rubber dam
damage to soft tissues
risk of inhalation
cross infection
benefits to operator and pt of rubber dam
increase
- isolation and moisture control
- retraction of gingivae and cheeks
- effective inhalation sedation
- pt confidence
- operator confidence
SDCEP caries prevention guidance
Give toothbrushing advice at least once a year:
- Brush at least twice daily, in the morning and last thing at night,
- Use the correct amount of a toothpaste with age-appropriate fluoride concentration:
- Under 3 years old: use a small smear of paste containing not less than 1000 ppm fluoride
- 3–6 years inclusive: use a pea-sized amount of paste containing not less than 1000 ppm fluoride
- 7 years old or over: use paste containing 1350–1500 ppm fluoride
- Spit, don’t rinse.
- Help children under 7 years old and continue to supervise older children until confident in their brushing habits.
In the early stages of providing care give hands-on brushing instruction.
Give dietary advice at least once a year:
- Restrict foods and drinks containing sugar to meal times.
- Drink only water or milk between meals.
- Snack on sugar free snacks (e.g. fresh fruit, carrots, peppers, breadsticks, occasionally a little cheese).
- Do not eat or drink after brushing at night.
Be aware of hidden sugars in some foods and the acid content of drinks. Apply sodium fluoride varnish (5%) twice a year to children over 2 years of age
caries risk factors
General
- Social
- Mother’s Secondary education
- Dental attendance
- Family unit - single parent/social class/employment status
- Systemic Health
- Generally unwell
- Chronic illnesses
- Sugar based medications - often contain sucrose
Local
- Oral Hygiene
- Poor, Irregular brushing, unassisted
- Diet
- 3 or more instances of sugar intake per day
- Fluoride experience
- Infrequent use of F- toothpaste
- Past Caries experience
- dmft - more than or equal to 5
- DMFT - more than or equal to 5
- 10 or more initial lesions
- Caries in 6’s at eruption (6-7 years)
- 3 years caries increments
- Ortho treatment
- fixed appliance therapy
acronym to remember caries risk factors
S ome
S tudents
O ver
D o
F luoride
C ocaine and
O rthodontics
Social Systemic OH Diet Fluoride experience Caries experience Ortho fixed applicances
Caries risk assessment
- clincial evidence
- dietary habits
- social history
- fluoride use
- plaque control
- saliva medical history
8 aspects of prevention plan from CPCS
- radiographs (and frequency)
- toothbrushing instruction
- strength of F- toothpaste (ppm)
- F- varnish (frequency)
- F- supplements
- diet advice
- fissure sealants
- sugar free medications
most common trauma in primary dentition
luxation
most common trauma in permanent dentition
ED#
9mm+ overjet increases chance of trauma
200%
medical hx for trauma red flags
rheumatic fever
congenital heart defects
immunosuppression
EO for trauma look for
- Laceration
- Haematoma (bruise)
- Haemorrhage/CSF - Emergency if straw coloured fluid from nose eyes or ears
- Subconjunctival haemorrhage
- Bony step deformity in mandible
- Mouth opening difficulty
IE for trauma check
soft tissue
alveolar bone
occlusion changes
teeth
tooth mobility can be due to
displacement
root #
bone #
look for fracture lines (horizontal or vertical) and pulpal involvement
dull note on percussion indicates
root #
what requires urgent tx
traumatic occlusion post trauma
emergency management of avulsion
- hold crown only
- wash under running water
- replace in socket
- child bite on tissue or store in milk/saliva/saline
- seek dental advice ASAP
tx if EADT is <1hr
- replant under LA
- flex splint 2 weeks
- antibiotics
- tetanus status
- extirpate pulp unless open apex in <10days
monitor
- non vital - endo tx and 2 month intermediate steroid medicament
tx if EADT >1hr
- replant under LA
- heal by ankylosis
- endo at 7 days
- 4 week splint
if open apex
- might revascularise
- replant under LA
- antibiotic prescription
- watch for necrosis
external surface resorption
damage to PL which subsequently heals
non-progressive
e.g. maxillary canines/laterals through excessive orthodontic forces
external inflammatory resorption
damage to PL intially maintained and propagated with dentinal tubules
root surfaces are indistinct
tramlines of root canal intact
pulp extripation - mechanical and chemical irrigation NSCaOH
internal inflammatory resorption
intiated by non-vital pulp
progressive
dx: tramlines of root canal indistinct, root surfaces intact
tx: extirpation, mechanical and chemical irrigation, NSCaOH
change NSCaOH for 4-6 weeks to try and halt resorption
6 weeks obturate with GP
if resorption continues, plan pros tx
resorption - replacement ankylosis
initiated by severe damage to PL and cementum
normal repair does not occur
bone fused directly to dentine
progressive - tooth gradually resorbed as it is now part of bone remodelling
dx: loss of PL and lamina dura
Tx: nil
immedicate management for all trauma injuries
- soft diet for 10-14 days
- brush teeth with soft toothbrush after every meal
- topical CHX by parent twice daily for one week (CWR for swabbing)
- after intial tx review 1, 3, 6 monthly taking radiographs if possible 6 monthly
- intrusion requires montly review for 6 months, then 6 monthly
enamel #
smooth sharp edges
enamel/dentine #
restore/bandage with composite (not GI)
EDP #
endo therapy or extract
crown and root #
extract coronal fragment, don’t remove any root fragments that aren’t obvious they will be resorbed physiologically
alveolar #
reposition segment
splint to adj teeth (only time for primary trauma where its used)
teeth may need extracted later
concussion/subluxation
observe
lateral luxation
increased PDL space apically
if no occlusal interference - allow it to reposition, if interfering then extract
intrusion
if root displaced labially to tooth germ leave to re-erupt
if palatally toward tooth germ - extract
extrusion
extract
long term effects of trauma on primary teeth
immediate discolouration - vitality maybe maintained
discolouration over weeks - non-vital
- sinus or PAP on radiograph
- no sinus or PAP then leave and review
- opaque - no tx
delayed exfoliation of primary tooth
- XLA needed or permanent successor maybe extopic or not erupt
child abuse definition
- Significant harm to child
- Carer has some responsibility for that harm
- Significant connection between carer’s responsibility to the child and harm to said child
signs of neglect
- Failure to thrive/short stature
- Inappropriate clothing, cold injury, sunburn
- Ingrained dirt finger nails, head lice, dental caries, developmental delay
- withdrawal or attention seeking behaviour
Dental Neglect
➡ Toothache
➡ Disturbed sleep
➡ Difficulty eating/change in food preference (only soft food etc)
➡ Absence from school
management of child abuse/neglect
Preventive dental team management
‣ raise concerns with parents, offer support, set targets, keep records and monitor progress.
Preventive multi-agency management
‣ liaise with other professionals (e.g. health visitor, school nurse, general medical practitioner, social worker) to see if concerns
are shared
‣ A child may be the subject of a CAF (Common Assessment Framework) at this level.
‣ Check if child is subject to a child protection plan (which replaced the child protection register)
‣ Agree joint plan of action, review at agreed intervals
‣ Letter to Health Visitor of children < 5 who fail appointments and have failed to respond to letter from dental practice
๏ “If this family is known to you, we would welcome working together to promote their oralhealth.”
Child protection referral
‣ In complex or deteriorating situations
‣ Follow local guidelines
‣ Referral is to social services
๏Usually by telephone followed up in writing
signs of physical abuse
- Bruising of face - punch, slap, pinch
- Bruising of ears - pinch, pull
- Abrasions and lacerations
- Burns and bites
- Neck - choke or cord marks
- Eye injuries
- Hair pulling
- Fractures (nose>mandible>zygoma)
Misnomers to be aware of
- Impetigo- similar to cigarette burns
- Birthmarks- mistaken for bruises
- Facial infection- mistaken for trauma
- Coagulation problems- bruise easily
expectation of dental team re abuse/neglect
- Observe
- Record
- Communicate
- Refer for assessment
NOT expected to diagnose
plaque induced gingivitis in children
most apical extension of juctional epitheliym is still the CEJ with no periodontal loss of attachment
severe inflammation -> gingival swelling inc -> even deeper false gingival pocket
necrotising ulcerative gingivitis
blunted papillae
malodour
painful gingivae
aetiology
‣ Fusiform and Spirochete bacilli
‣ Patient risk factors
๏Smoking
๏Stress
๏Immunosuppression
๏Poor Diet
๏HIV status
๏Other underlying conditions
๏Common in developing countries
puberty gingivitis
increased inflammatory response to plaque
mediated by hormonal changes
can progress to early perio
local and systemic factors can influence progression
systemic causes of gingivitis
haematological
- *Agranulocytosis** - Acute condition with low white cell count
- *Cyclic Neutropenia** - Low Neutrophil Count, in 3 week cycles lasting 4-6 days
- *Granulomatosis** - autoimmune vasculitis, multi system disorder affecting mouth, URT and kidneys
hyperplastic gingivitis
Genetic factors, local factors
Medication side effects
- Cyclosporin
- Nifedipine
- Phenytoin
Greater incidence in puberty
Tx - rigorous home care, frequent scaling, often surgery required (esp. drug induced)
key features of periodontitis
apical migration of JE below ACJ
loss of attachment fibres of cementum
change from JE to pocket epithelium (often thin and ulcerated)
alveolar bone loss
chronic periodontitis
similar pathogens to adults with chronic perio can be found in subgingival microflora of teenagers with chronic perio
- Porphyromonas Gingivalis
- Prevotella intermedia
- Aggregatibacter Actinomycetemcomitans
aggressive periodontitis
Caused by Aggregatibacter Actinomycetemcomitans
Rapid attachment loss and bone destruction
Otherwise patient healthy
family history
should be referred
Localised
‣ Incisors
‣ First molars
‣ onset at puberty
Generalised
>3 permanent teeth other than incisors and first molar
onset usually older but sometimes <30 y/o
early periodontitis
Typically
- 1-2mm LOA interproximally
- 4-5mm pocket
- 0.5mm horizontal bone loss
perio screening consists of
gingival condition
assess OH status
assess if any calculus present
assess local risk factors
gingival condition in perio screening
colour
contour
swelling/recession
suppuration
inflammation - presence and location
marginal bleeding free chart
OH status assessment in perio screening
description of plaque status
- surfaces covered by plaque
- easily visible?
- dectectable only by probing
- use of plaque free scores
- motivational aid
local risk factors assessment in perio screening
plaque retention factors
low frenal attachments
malocclusion
incompetent lips
reduced upper lip coverage (labial and palatla gingivitis)
increased lip separation
mouth breathing
palatal gingivitis
BPE in primary dentition
Carried out on UR6 UR1 UL6 LR6 LL1 LL6
Start at 7 years when all the index teeth have erupted
Identifies patients who would benefit from further investigation
Primary teeth - perio disease rare
If mobility or suppuration - refer to specialist
codes restricted 0-2 to avoid false pocketing
from ages 11-17 full range of BPE used
BW’s posteriors, PA’s for anteriors
Always take BPE prior to ortho treatment
primary herpetic gingivostomatitis
Variable incubation period
Widely varying severity of symptoms
- Fever, Malaise, Loss of appetite
- Can cause severe systemic upset
Features
- Vesciles on mucosa
- Gingivae are fiery red
- Rupture of vesicles = Ulcers 1-3mm in diameter
- Mouth is very painful
- Refuse to eat
- Refuse toothbrushing
- Halitosis
Treatment
- Fluids
- Rest/Reassure = recover
- NSAIDs
- Aciclovir only in early stages/immunocompromised patient
herpangina
Highest incidence in young children
2-9 day incubation
fever, malaise, muscle pain
pinhead vesicles on tonsils, uvula, soft palate
- lesions all at the back of the mouth
vesicles rupture to form larger ulcers
heal within 5-7 days
No gingivitis
Less unwell
hand foot and mouth
1 week incubation
Cozsackie A16
vesicular rash on limbs, fingers and toes
oral lesions on tongue and buccal mucosa
ulcers are shallow
painful
self limiting
HPV (papilloma)
Cause
‣ Verruca Vulgaris
‣ Papillomas
‣ Focal Epithelial Hyperplasia (Heck’s Disease)
Warts on lips and tongue
Papillomas on gingivae and palate
Appearance
‣ Cauliflower like
‣ Localised
‣ Increased Incidence in Immunocompromised
minor apthae
recurrent apthae on Non-Keratinised mucosa
- Labial, Buccal mucosa and floor of mouth
prevalance >2%
- Stress/Family history/HLA type
- Altered T cell ratio?
- Some develop Crohn’s disease later
- iron def. common in girls from menstrual blood demand - can cause apthae
- Fe Replacement treatment of symptoms - diflam mouthwash
variable size
well demarcated
red halo round lesion
1-10 in number
heal 1-3 weeks
no scarring
more common in 20’s
eruption cysts
dilation of follicular space around crown
compressible
can be infected
resolved when tooth erupts
blueish hue
ranula
present as a swelling of connective tissue consisting of collected mucin (thick and jelly like) from a ruptured salivary gland caused by local trauma
traumatic ulcer characteristics
history
non recurrent
less well defined
irregular outline
radiation mucositis
Mucositis is a common complication of cancer therapy which
significantly affects the mucosa.
Oral mucositis refers to the oral erythematous and ulcerative
lesions commonly observed in patients undergoing cancer
therapy.
They are painful and affect nutrition and quality of life of the patient, and contribute to local and systemic infections
Radiation induced mucositis is initiated by direct injury to basa epithelial cells and cells in the underlying tissue. DNA-strand breaks can result in cell death or injury
orofacial granulomatsis
associated with Crohns disease
High incidence in west of scotland
presents in 2nd or 3rd decade
- Lip swelling
- Biopsy shows non-caeseating granulomas
- Langhans type giant cells
- Lymphocytic infiltrate
- Swelling due to oedema
- Cobblestone mucosa
- mucosal tags
- deep penetrating ulcers
- gingivitis
- pyostomatitis
fibro epithelial polyp
common
exagerrated response to trauma
should usually be excised
squamous epithelium overlying firbous CT, minimal inflammaiton
pyogenic granuloma
‣ Fibro-endothelial growth
‣ Gingival margin
‣ Common in children
‣ Red/purple, very vascular
‣ Mimic haemangioma
‣ Ulcerate and can bleed
‣ profusely
‣ Complete excision ? Cryo
giant cell granuloma (peripheral)
appears in the mouth as an overgrowth of tissue due to irritation or trauma
appears histologically as large number of multinucleated giant cells which can have dozens of nuclei
malignant proliferative conditions in children
Malignacy is most common cause of death in childhood (14% in <15years)
Leukaemia
- Peak age 2-5 years
- Male>Female
- 80% are ALL
- Good rate of cure
- Gingival bleeding, fatigue etc like primary herpes
Lymphoma
- 1% childhood malignancies, older children
Rhabdomyosarcoma- majority are <4 years
geographic tongue
2-10% prevalence
Children <4yrs mostcommon
Red zones of depapillation, move around!
White margins due to heavy infiltration
No successful tx
heriditary gingival fibromatosis
non specific progressive enlargement
maybe localised e.g. palatal aspect of tuberositiess, or generalised
maybe isolated or part of a syndrome
drug induced - nifidipine, cyclosporin, phenytoin
haemangioma
Present at birth or soon after
Grow rapidly
Benign tumour, endothelial proliferation
Capillary/Cavernous
Can occur within bone
Most will involute spontaneously
occlusal cavity restoration
- Occlusal portion no greater than 1.5mm depth with fissure bur or round bur
- Include all pits and fissures but preserve transverse ridges unless undermined
Upper E
- Banana Distal
- Kidney Mesial
Lower E
3. Follow fissure pattern but dont breach marginal ridges (squiggly S)
approximal cavity
- Isthmus should be 1/2 to 1/3
- Axial wall follows contour of tooth
- Don’t encroach onto the occlusal surface
- Remove marginal ridge then sink box
minimal box preparations
- Basically a proximal box with no occlusal portion
- Rounded line angles
- No occlusal extension
- Dam and wedge for good contact pt
- Use narrow fissure bur
cervical caries management
- Hand excavate caries using slow speed with round bur
- Wash and isolate with rubber dam
- Either GIC covered with vaseline or compomer (composite has tendency to #)
anterior caries management
- Hand excavate or use a slow speed round bur
- Wash and isolate preferably with rubber dam
- Acetate into contact pts
Stainless steel crown placement
Instruments Needed
- Tapered diamond separating bur
- Straight fissure bur
- Crown Crimping pliers
- Curved crown scissors
- GI luting cement
Crown Selection - measure M/D length of crown or simple trial and error
Procedure
- Marginal ridge reduction w/ round bur
- Break contact area and produce knife edge finish with tapered separating bur
- Remove any ledges at GM
- Occlusal reduction of 1-2mm
- Reduce crown bucco-lingually
- Test fit crown and should snap fit
- Mix GI and fill up crown
- Seat crown L to B
Problems with Crowns
- Rocking - When cervical margin is >1mm beyond
- Canting - due to uneven reduction of occlusal surface
hall crown technique
Requirements
- No LA, Caries removal or tooth prep
- Child v cooperative
- Right size crown
- No pulpal involvement
- Sufficient coronal tissue left
Instruments
- Essential
- MPT
- Excavator (to remove crown if necessary)
- Flat plastic to load crown with cement
- Cotton wool rolls - to wipe away cement
- Useful
- Ortho biting stick - good for seating the crowns
- Bond forming pliers (especially good if loss of M/D length)
- Gauze for between tooth and tongue
- Elastoplast or sticky microbrush
Separation
- Ortho donut with floss looped through either end
- Held taught and wiggled into contact
- may need to disc the tooth
- Remove at crown fitting appt
Procedure - same as SS crown
follow up for stainless steel crowns
Minor Failure
- Sec. caries
- Crown worn or lost
- Restoration lost but tooth restorable4. Reversible pulpitis treated without pulpotomy or extraction
Major Failure
- Irreversible pulpitis
- Abscess requiring pulpotomy or XLA
- Interadicular radiolucency
- Filling lost and tooth unrestorable
vital tooth pulpotomy
Indications
- Carious or traumatic exposure of a bleeding pulp
- Radicular pulp preserved and bleeding controlled
- Pt able to take LA and rubber dam
Procedure
- Access - High speed bur
- Amputation - Haemorrhage control with Ferric Sulphate 15.5% for 20s (N.B If anterior or permanent then use saline!)
- Restoration - cover with CaOH, GI Core, PFMC
Pulpal Evaluation
- Normal bleeding - Uninflamed - bright red and good haemostasis
- Abnormal bleeding - Inflamed - deep crimson and continued bleeding after pressure
Apexogenesis
- Radicular pulp left
- Calcific barrier formed over the radicular pulp with CaOH
- Permits normal physiological apexogenesis of the root
*Cvek Partial Pulpotomy is indicated where there is a exposed pulp <24 hours
non vital tooth pulpectomy
Indications
- Excellent pt cooperation
- Hyperaemic pulp
- Pulp necrosis
- Caries into furaction
- Irreversible pulpitiis
- PA PDitis
- Chronic Sinus
- N.B if severe infection with facial swelling then AB’s and extraction
Procedure
- Use slow speed bur or excavator
- Remove contents of pulp chamber
- Instrument to 2mm short of apex
- Irrigate with CHX 0.2%
- Dry with paper points
- Obturate with Vitapex - CaOH and Iodoform paste OR MTA (leave for 30 mins to form apical barrier) and Gutta percha
➡ CaOH can dessicate dentinal proteins causing premature root fracture - Seal with mix of ZOE/GI
- Take PA radiograph
- Restore with PFMC
Apexification
- Induces formation of osteocementum in a pulpless tooth via chemical means e.g CaoH or MTA
- very rarely normal root development may take place
- takes 9 months
fissure sealants
- Protective plastic coating used to seal fissures and pits to prevent food and bacterial accumulation that can cause caries
- Isolate under single tooth dam
- Tie ligatures into both holes of the clamp
- Can alternartively use Cotton wool rolls and parotid guard
Indications
- High risk children
- Medically compromised
- Learning difficulties
- Permanent Molars, Cingulum pits upper incisors, buccal pits lower molars, palatal pits upper molars
Procedure
- Etch with 37% Orthophosphoric acid
- Wash off etch
- Bis-GMA resin painted onto fissure pattern
- No air blows
- Cure
- use probe to try and flick off - should be smooth and glassy
XLA of FPMs
- may help with spacing later on if prognosis poor
- optimal occlusal relationship attained when
- Bifurcation of lower 7 is formed on an OPT - 8.5-10 years
- 5’s and 8’s are all pfesent and in good position
- Mild buccal segment crowding
- Class I incisor relationship
16/26
- Loss before complete eruption of 7 - 7 rotates
36/46 >
- Loss after optimum age - tilting 7’s - tilts mesially
- Loss before optimum age - 5’s drift distally and rotate - rotates to form arbitrary occlusal contact
microabrasion
Associated with
‣ Amelogenesis Imperfecta
‣ Trauma related staining
‣ MIH
Procedure
- Dental Dam with ligatures
- Polish the teeth pumice and water
- Apply Sodium bicarbonate to the cervical areas of the dam to create an alkaline barrier
- Apply 18% Hydrochloric acid or Opalustre 6%
- Use wooden popsicle stick to scrub on for 5 secs
- wash off with very good aspiration
- Dry teeth and reapply bicarb and start again
- Gold standard is 10 rounds of therapy
Works best on Brown staining
White stains can actually look worse and go yellowish
Best to do one tooth at a time so as not to over treat with acid, if doing >2 teeth as part of treatment, can remove the labial profile
pulp canal obliteration
- Narrowing of the pulp chamber and or root canal by dentine
- mediated by odontoblasts, but not really known why this is
- It will have a vital response but will be reduced
- Tx - Do nothing but monitor vitality as only 1% form a PA area
- Crown takes a yellow appearance - vital bleaching
sequalae if trauma to primary tooth
Delayed eruption
- Damage to perm tooth germ
- Dilaceration of root
- Odontome formation
- Hypoplasia of enamel
- Hypomineralisation
- Root resorption
- Ectopic eruption
- Absent successor
- Non-vitality
- Sequestrum of successor
amelogenesis imperfecta
