Paeds Flashcards
11 EDP# immature apex - 8 yr old - Outline procedure to parent of anxious child
● Explain nature of injury in simple terms
○ Enamel dentine pulp fracture or complicated pulp fracture
● Explain treatment : PULPOTOMY (open apex)
○ As this is a large exposure the tx of choice is called a pulpotomy
○ Explain partial removal of pulp
○ Explain that aim is to keep undamaged pulp tissue alive
○ Explain that this is so the tooth stays alive and continues to grow
● Baseline sensibility tests
○ Tests required to see how the nerve in the injured and adjacent teeth respond
○ Tests required as baseline reading for long term monitoring
● LA required
○ Parent informed that LA is required
○ Required to keep patient numb and comfortable
○ Describe that LA involves injection in the gum
● Dental Dam
○ What this is - rubber sheet over tooth acts like mask
○ Why dam is placed - moisture control, protects airway
● Drilling/use of handpiece
○ Drill will be used to remove some pulp tissue
○ Aim is to leave only good tissue
● Dressing
○ Indicate that the tooth will be dressed; Setting CaOH, MTA
● Composite restoration
○ Indicate that a white filling will be placed to regain aesthetics
● Actor marks: Describing tx in an understandable manner, supportive and empathetic regarding injury
Fluoride Varnish - 2 year old child - Talk through parent’s concerns (6 mins)
Why needs fluoride varnish, fluoride toxicity, and asks for OHI after application
● Reassure the patient
○ Fluoride varnish is placed on the tooth and is minimally invasive
○ Promotes remineralisation (hardening of tooth) and prevents demineralisation (softening of tooth)
○ It involves dry the teeth and painting a gel on to the tooth
● Contraindicated in:
○ Severe uncontrolled asthma (hospitalised in the last 12 months)
○ Allergy to colophony (sticking plasters)
■ We can use a colophony free version if needed
● Instructions afterwards
○ Don’t eat/drink for 1 hour
○ Soft diet for the rest of the day
■ No dark coloured foods
○ Avoid fluoride supplements today
● Fluoride toxicity:
○ Very small risk and technically relevant if small child consumes a quantity of toothpaste
○ 5mg/kg: milk
○ 5-15mg/kg: milk and possible referral
○ >15mg/kg: hospital referral
A patient brings her child to the clinic, not feeling well and is distressed - Provided with an image
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and answer any questions the mother may have
● Introduce self & designation (2 marks)
● Take history:
○ No. of days symptoms? (1 mark)
○ Does the child have a fever? (1 mark)
○ Child less active than normal? (1 mark)
○ Analgesia used? (1 mark)
○ Did it work? (1 mark)
■ PHG Signs: lymphadenopathy, malaise, pyrexia, erythematous gingivae, ulceration
■ PHG Symptoms: sore mouth and throat, fever, enlarged lymph nodes
● Diagnosis from photograph:
○ Primary herpetic gingivostomatitis - explanation in lay persons terms (2 marks)
○ Contagious primary infection caused by herpes simplex virus (1 mark)
○ Self limiting and will disappear in 7-10 days (1 mark)
○ High carriage rate in population, common (1 mark)
■ Most often occurs in young children and is usually the first exposure a child has to herpes virus (which is also responsible for cold sores & fever blisters)
○ Most initial infections are subclinical but can present as this florid infection (3 marks)
■ Explain in lay persons terms - usually no symptoms
■ Often will present with blisters on the tongue, cheeks, gums, lips & roof of the mouth. After the blisters pop, ulcers will form.
■ Other symptoms to watch out for are high fever, difficulty swallowing, drooling and swelling.
■ Also, because the sores make it difficult to eat & drink, dehydration can occur.
○ Child may or may not develop cold sores in future (1 mark)
● Management:
○ Push fluid intake (1 mark)
○ Analgesia to control fever/pain (2 marks)
○ Bed rest, take it easy (1 mark)
○ Clean teeth with damp cotton roll or cotton cloth to rub around gums (1 mark)
○ Can use dilute CHX to swab gums (1 mark)
○ As child has had problems for 3 days and is otherwise fit and healthy antiviral medication (Aciclovir) is not recommended is not recommended (2 marks)
● Actor marks: empathetic, supportive and understanding (2 marks)
● Prescription: (if necessary - ie severe or immunocompromised) - NB if under 2ys half dose (100mg):
○ Aciclovir 200mg tablets - 5 day regime, Send: 25 tablets, Label: take 1 tablet 5 times daily
● Refer immunocompromised patients to hospital
Photos of discoloured 61 and labial/buccal segments of an 8 year old. PA of a dilacerated floating 21 that could be anything. Please identify the problem present for this patient and discuss its further investigation/management with your examiner.
● Causes of retained ULA/Unerupted 21
○ Trauma to A - causing damage to the 1
■ Complications: Ankylosis, arrested tooth (21) formation, dilaceration, displacement
○ Lack of permanent successor/Hypodontia
○ Ectopic tooth germ
○ Crowding
○ Supernumerary: tuberculate most common
● Signs:
○ Discolouration of A, retained A
○ Radiographic
○ Lateral erupted before central
● Investigations:
○ Radiographic localisation for ortho treatment
■ Another PA or anterior occlusal, or alternatively OPT and occlusal, CBCT for 3D view
● Management:
○ Always palpate: usually U1 is buccal and central (high)
○ Options:
■ Leave and monitor - inform of possible cyst or resorption
■ Extract retained A (leave U1) and space maintenance (warn of cyst formation risk)
■ Surgical removal of both teeth and space maintenance
■ Refer for orthodontic opinion/Tx - Inform of possible ortho tx benefits/risks
■ Auto-transplantation
○ Other options:
■ Extract retained A and hope spontaneous eruption (very unlikely since dilacerated)
■ Expose (closed or open) +/- bonding/traction (won’t work if dilacerated)
Concerned mother with 2 year old in pain. Take a brief pain history then photo of decayed 52-62 (upper incisors) provided. Explain diagnosis to parent, prevention and management options (GA).
● Brief history:
○ Take pain history
■ How long for? Any analgesia (calpol)? How much analgesia? - within limits
○ Feeding bottle to bed?
○ What is in the feeding bottle?
● Look at pics carefully to identify pattern of decay
○ Pattern is usually upper incisors, D’s and lower canines (lower incisors protected by tongue)
● Advice:
○ Feeder cup replacing bottle from 6 months
○ No feeding at night (lactose in milk - decreased salivary flow and held in mouth)
○ No on-demand breastfeeding
○ No sweetened milk, soy milk (unless medically advised)
○ Milk and water only between mealtimes
○ Sugarfree variations of drinks/foods/medicine (e.g. sugar-free calpol)
○ Safe snacks include, cheese, breadsticks, fruit, plain crisps
○ Toothbrushing:
■ Assist the child until 7yo
■ Brush in the morning and last thing at night
■ No food/ drink except water after brushing
■ Spit don’t rinse
● Management:
○ Extraction of carious teeth under GA: as in pain (discuss GA risk and benefit)
○ GIC remaining teeth and review: if no pain (acclimatisation)
○ Fluoride (supplements + varnish)
● Extra points for empathy
Hall Crown + Separator placement + Child Choking - 2-part station (12 mins)
Part 1: Place a separator (phantom head), remove a pre-placed separator, size a hall crown, and select correct cement (Kalzinol, Ultracal and Aquacem all sitting out).
● Place separators between medial and distal contacts
○ Floss 2 pieces of floss through the orthodontic separator
○ Pull tight and move down between contacts of the tooth (not subgingival)
● Leave in place for 2-7 days
● Remove with a BLUNT probe
● Sit child upright
● Place gauze swab to protect the airway
● Choose the crown: aim to fit smallest size of crown that will seat (use sticky stick)
● Select one that covers all the cusps and approaches the contact points with slight springiness
○ Do not fully seat the crown!
● Dry the crown, fill with GIC (Aquacem)
● Dry the tooth
○ If cavity large: place some GIC in the cavity
● Place the crown over the tooth
● Seat the crown with finger pressure - first method
● Child can seat the crown by biting on it over gauze - second method
● Remove excess cement with CWR
● Get pt to bite down for 2-3mins or finger pressure
● Make sure all excess cement has been removed
● Floss between contacts
Part 2: Child starts choking on hall crown (mannequin) - deal with the emergency appropriately.
● ABCDE
● Are you choking?
● 5 back slaps between shoulder blades
○ Child can be lying on thigh or across knees
● 5 abdominal thrusts between belly button and sternum
● Continually check for object dislodging
● Re-evaluate ABCDE
● BLS if still not resolved
● Call 999 and refer to hospital to check for rib fracture
Orthodontic problems - Ectopic canine, OJ, OB, Peg lateral (6 mins)
○ Increased OJ (1 mark) ○ Increased OB (1 mark) ○ Peg Lateral (1 mark) ○ Ectopic Canine (4 marks) ● Dental Health Implication ○ Risk of trauma from OJ (1 mark) ○ Risk of trauma from OB (1 mark) ○ Risk of root resorption (1 mark) ○ Risk of cyst formation (1 mark) ● Position determination from radiographs provided - detailed use of parallax and explanation (4 marks) ○ Parallax – OPT and oblique occlusal radiograph views - had to explain how you get your answer ■ Vertical parallax - SLOB ■ Explanation: The tube head shifted up from OPT to oblique occlusal, the canine moved together with the tubehead compared to the incisor. According to SLOB rule, the canine is palatal to the incisor.
Primary herpetic gingivostomatitis with systemic involvement - Teen - Aciclovir Prescription (6 mins)
● Aciclovir only prescribed: Immunocompromised or severe infection in the non-immunocompromised
● Primary response to herpes simplex virus
○ Sore mouth and throat, enlarged lymph nodes
○ Also: period of malaise and fever (!!systemic symptoms!!)
○ Happens once (or twice – two types), self-limiting 7-10 days
○ Fluid intake, bed rest, analgesia/antipyretic, CHX, nutritious diet
● Aciclovir prescription:
○ 200mg tablets or oral suspension (200mg/5ml or 100mg/5ml)
○ Send: 25 tablets
○ Label: 1 tablet 5 times daily
■ [5x200mg for >2yo, 5x100mg for <2yo)
State the fracture type most likely from the photo available and clinical history. Perform an E/O exam (on a mannequin) to assess this patient for the facial fracture. Suggest further investigation for this fracture type, what you can see on the investigation, and further management if you had this patient present to you in a standard dental surgery.
● Diagnosis: Fractured right/left mandibular fracture
● Initial General History
○ Headache?
○ Any loss of consciousness?
○ Nausea or vomiting?
○ Numbness of face?
○ Police involvement?
○ Examine and record injuries elsewhere
● E/O:
○ Pain
○ Lacerations
○ Bleeding
○ Swelling
○ Facial asymmetry
○ Palpation of mandible bilaterally (condyle, ramus, body, symphysis)
○ Limitation of mandibular movement? (Reduced interincisal opening)
○ Mandibular deviation on opening and lateral movement?
○ Tenderness of TMJ?
○ Examination of sensation of lower lip/chin region
■ Areas supplied by mental nerve (mandibular division of trigeminal nerve)
● I/O:
○ Lacerations (esp. gingivae)
○ Bruising/swelling/haematoma
○ Occlusal derangement and step deformities
○ Loose or broken teeth
○ Anaesthesia/Paraesthesia of teeth in lower jaw on side of fracture
○ AOB – due to bilateral ramus/sub-condylar fracture
● Classifications
○ Soft tissue involvement: simple, compound, comminuted
■ Fractures involving teeth always expose the periodontium so are always compound
● High risk for infection - need for antibiotics
○ Number: single, double, multiple
○ Site: condylar, subcondylar, body, coronoid, angle, ramus, parasymphyseal, symphyseal, alveolar
○ Side: unilateral/bilateral
○ Displacement: displaced, undisplaced
○ Direction: favourable, unfavourable
○ Specific: greenstick (children’s bones bend), pathological
● Factors influencing displacement of mandibular fractures
○ Pull of attached muscle
○ Angulation & direction of fracture line
○ Opposing occlusion
○ Magnitude of force
○ Mechanism & direction of injury
○ Intact soft tissue
● Further investigations:
○ TWO Radiographs: OPT + PA mandible
○ CBCT most commonly used now
● Identification of relevant radiographic findings
○ Fractures - most possibly more than one
■ Previously parasymphyseal fracture and bilateral condylar fractures
■ Always compare right side from left
● Management:
○ Urgent phone to an OMFS unit or A&E dept for advice and URGENT referral
■ Might not see it urgently if undisplaced
■ Can ask you to prescribe pain relief and antibiotics
○ Surgical management: ORIF (if symptomatic or displaced)
○ Conservative management if undisplaced, asymptomatic or >1-month-old
Ortho - Decalcification (6 mins)
Patient wants you to go back over advice on how to avoid decal. Diet advice. Tooth brushing instruction
● Decal - has the shape of bracket
○ Weakens the enamel to caries
○ Unsightly staining
● Pt selection
○ High risk if caries history evidence of decal, NCTSL
● Oral Hygiene
○ Toothbrushing + single tufted TB for brackets
○ Inter-dental brushes and superfloss
○ O.H.I. should include
■ minimum twice per day VERY thoroughly
● Dry toothpaste, methodical: work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 minutes, spit don’t rinse
■ brushing after meals
as brackets trap food/plaque
■ disclosing tablets to identify missed areas
● Diet advice
○ Limit sugar amount and frequency
○ Avoid snacks between meals – limit sugar intake to <3 times daily
○ Avoid hard/hot foods, fizzy drinks, sports drinks, sticky sweets, chewing gum
○ Ideal drinks are water or milk, crackers, cheese, fruit is acceptable snack but be careful of fat in cheese and natural sugar/acid in fruit
○ Watch out for hidden sugars in foods such as tomato soup and ketchup.
○ Rinse mouth after eating
● Fluoride
○ Toothpaste
■ Duraphat
– 2800 ppm (0.619%)
– 5000 ppm
(1.2%)
■ Twice daily, ordinary toothpaste at other times
■ Warn re overdose and children
○ Mouthwash
■ Daily 0.05% fluoride mouthwash (225ppm)
■ Use IN-BETWEEN brushing, NOT after
○ F Varnish
■ Proflurid (22600ppm) - not duraphat
■ Every 4 months
● *This is for prevention - F varnish isn’t used for tx of decal as it seals it in
● Prescriptions:
○ Sodium Fluoride Toothpaste 0.619% (2800ppm)
■ Send: 75ml
■ Label: brush teeth for 1 minute after meals using 1cm before spitting out, twice daily
○ Sodium Fluoride Toothpaste 1.1% (5000ppm)
■ Send: 51g
■ Label: brush teeth for 3 minute after meal using 2cm, before spitting, 3x daily
Paeds – Caries - Risk assessment and management (6 mins)
Diagnose Caries on Bitewings, Explain prevention and TB advice to mum
● Caries risk assessment: 7 things
○ clinical evidence, diet, MH, SH, saliva, plaque control, fluoride exposure
● Prevention: 8 things
○ radiographs, diet advice, tooth brushing instruction, strength of fluoride in toothpaste, fluoride supplement, fluoride varnish, fissure sealant, sugar free medicine
● Prevention: High risk
○ Toothbrushing advice:
■ Assist child with brushing until able to brush independently (7yrs)
■ x2 daily with fluoride toothpaste
■ Demonstrate on child 6 monthly, get parent to demonstrate in front of you
■ Methodical approach:
● work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 minutes, spit don’t rinse
○ Diet advice
■ Avoid sugar snacks/drinks
■ Snack on healthier foods: carrot sticks, breadsticks, fruit in moderation
■ Milk and water only (between meals)
■ If nursing bottle: no bottle to bed at night, no soy milk or sweetened milk, no on demand breastfeeding
■ Do not eat or drink after brushing teeth at night
○ Fluoride:
■ Varnish: x4 yearly to children >2yrs (5%, 22600ppm)
■ Toothpaste: x2 daily - 1450 ppm (smear < 3yo pea > 3yo)
● >10yrs: 2800ppm, >16yrs: 5000ppm
● Avoid rinsing mouth, drinking or eating for 30 mins after use
● Advice that this TP is a medicine and should only be used prescribe
■ Mouthwash: x1 daily for >6yo - (0.05%)
● Preferentially at different time from brushing
● Avoid rinsing mouth, drinking or eating for 15 mins after use
Paeds Trauma - Subluxation - 18-month old knee to knee (12 mins) Fake child (doll) who fell down, knee to knee exam, subluxation of upper centrals, explain management to father, possible consequences to permanent.
● Introduce self and designation
● Reassure father everything will be ok
● Knee-to-knee examination
○ Explain to the parent what you intend to do
○ Sit across from the parent with your knees touching theirs
○ Bring your knees together and ask the parent to do the same
○ Ask the parent to sit the child with their legs round the parents waist
○ Lower the child down into your knees and ask the parent to hold the child’s arms
● Trauma stamp:
○ Colour, EPT, EC, TTP/percussive note, mobility, displacement, radiograph, sinus
● Subluxation signs:
○ TTP, mobile, bleeding from gum, no displacement
● Explain nature of injury in simple terms
○ Subluxation of the upper central baby teeth
○ This is an injury to the supporting structures of the tooth
● Explain treatment: JUST OBSERVATION
○ No treatment required
○ Only that can be done today is clean tooth with saline or CHX wipe with gauze due to age.
● Explain home care:
○ Instruct soft food for 1 week
○ Important to keep the area clean and plaque free for good healing
■ OHI - Brush with a soft brush after every meal
■ CHX 0.2% with cotton swab to area x2 per day for 1 week
● Explain possible complications to primary tooth:
○ Pain, swelling, dark discolouration, increased mobility, delayed exfoliation, infection
■ Child may not complain of pain, however, infection may be present and parent should watch for signs of swelling on the gums and bring the child in for treatment.
● Explain possible complications to permanent tooth:
○ Premature or delayed eruption, enamel hypoplasia/ hypomineralization, crown/root dilaceration, failure to erupt, failure to form, odontome formation
● Follow up: 1wk and 6-8wks
● Actor marks for describing tx in an understandable manner, supportive and empathetic regarding injury
Treatment Planning for Child - Parent considering complaint (12 mins)
Mucocele, Caries, PA pathology, Hypodontia
Parent considering taking legal action as previous dentist never took radiographs or advised on treatment
● Explain treatment required
○ Caries management
■ List carious teeth
● Sed/GA referral vs GDP management
■ Start working with least invasive restorations - fissure sealant to then LA procedures
○ Prevention:
■ Assign caries risk
■ 8 things: radiographs, diet advice, tooth-brushing instruction,F toothpaste, F supplements, F varnish, sugar free medicine, fissure sealant
● Mucocele:
○ Leave and review vs referral for surgical removal
○ Explain the procedure: LA around site of swelling, cut in gum and removal in its entirety, sutures
○ Risks: pain, swelling, bleeding, bruising, infection, numbness, sutures
● Hypodontia:
○ Potential problems: space, drifting, overeruption, aesthetics, functional problems
○ Space maintenance: URA
○ Referral to orthodontist at 6-7yrs
○ Tx options in future:
■ Nothing
■ Restorative only: composite, veneers, RBB, RPD
■ Ortho only
■ Restorative + ortho: space closure and reshape teeth to camouflage
● Deal with complaint:
○ ‘I can’t give comment because I don’t know the full story’
○ ‘I can only offer you this treatment at this present time’
○ ‘Whatever was offered previously, will not change what treatment is required now’
○ Tell mum if she is intended to complain, she can go back to the practice, they will have a standard complaint procedure = only if the patient asks (do not offer!)
○ ‘It will be unhelpful for me to be involved in this matter as I don’t know the background behind treatment that was or wasn’t done and would be unfair for me to speculate on it’
Ortho - URA: Faults, activation, delivery checks and care instructions (6 mins)
Required to fit upper removable appliance to a 9-year old. Examine the prescription and the appliance, look for defects and answer the examiners question. Asked about FABP, show how to make adjustments to adams clasps and activate palatal finger spring. Prior checks before delivery and care instructions.
● Component faults:
○ Z-spring encased in acrylic, UR6 adam’s clasp arrowhead fault, UL6 adam’s clasp flyover fault
● Prescription faults:
○ Southend clasp included meaning appliance won’t work, Adam’s clasp on ULC not ULD, FABP instead of PBP.
● How would you rectify these errors?
○ Re-make appliance by taking new impressions
● Activating palatal finger spring:
○ Using spring former pliers – 1-2mm activation
● Fitting a URA
○ Check that the appliance if for the correct patient o Check the appliance is asked for
○ Run finger over all surfaces to check for protruding wires and sharp acrylic
○ Check wirework integrity (if overworked)
○ Fit the appliance
○ Check for any blanching or trauma
○ Check posterior retention
■ Flyovers (first as influence the arrowheads)
■ Arrowheads • Activation
○ Activate to produce 1mm movement per month: spring formers
○ Demonstrate to patient about insertion and removal
○ Ask patient to demonstrate insertion and removal
○ Review: 4-6 weekly
● Instructions to patient
○ Will feel big and bulky
○ Likely to impinge on speech
■ Start reading a book aloud to prevent this by speeding up adjustment of
Teeth
○ May have ‘mild discomfort’ - particularly on teeth being moved - but this is a sign
that the appliance is working
○ Initial increase in saliva – 24-48 hours
○ Wear 24 hours/day including meal times
○ Can remove the appliance to clean with a soft brush after each meal or when taking part in active/ contact sport – store in a safe place
○ Avoid hard and sticky foods
○ Be cautious with hot food and drinks as base plate acts as an insulator
○ Non- compliance will lengthen treatment
○ Give an emergency contact number – do not wait till next appt. if there is a problem
Deal with parent and child with staining or missing teeth? reassure parent - 12 minutes
● Staining:
○ Causes:
■ MIH, fluorosis, decal, tetracycline, trauma, dentinogenesis/amelogenesis imperfecta
○ Treatment:
■ Microabrasion: easy to be done, effective, removal of tooth structure, use of acid
■ Vital external bleaching: may not work, gingival recession, sensitivity, will not bleach restoration, relapse, overbleach
■ Localised composite addition: add bulk to tooth, may not mask totally
■ Comp/porcelain veneer: good aesthetic, tooth prep needed, need to wait until 18 for stable gingival level
■ MCC: destructive
● Missing teeth:
○ Causes:
■ Hypodontia, trauma causing arrested tooth formation, ectopic, dilaceration, supernumerary
○ Treatment:
■ RBB, Essix retainer, RPD, Implant if above 18y/o, Ortho space closure
