Paeds and Trauma Flashcards
an 8yo child attends with an enamel dentine pulp fracture. You are happy the patient is medically fit with no other injuries.
What two things do you need to know about the injury before you decide whether or not a dirct pulp cap or pulpotomy is the most appropriate treatment?
When did the injury occur? Even if pinpoint exposure, if it had been 24hrs plus, high chance of bacterial ingress
Size of the exposure; more than 1mm pulpotomy is best choice
19yo patient attends on Monday morning having sustained trauma to 11, 12 on Saturday. 12 crown missing and sub alveolar fracture. 11 pulpal exposure of 2mm. Both teeth sensitive. Four steps in management of 11?
*Locate the missing fragment of tooth
*Give LA and apply rubber dam
*Pulpotomy; Access pulp chamber, remove coronal pulp, achieve haemostasis with CWP and water/ferric sulphate, place CaOH, seal with GIC, composite bandage
*If unable to achieve haemostasis, pulpectomy.
19yo patient attends on Monday morning having sustained trauma to 11, 12 on Saturday. 12 crown missing and sub alveolar fracture. 11 pulpal exposure of 2mm. Both teeth sensitive.
Why would a subalveolar fracture 12 deem the tooth unrestorable?
*Lack of coronal tissue to bond to/support/retain restoration.
*Inability to achieve moisture control
*Inability to take impression for indirect restoration.
*Hard to establish marginal integrity/difficulty cleaning
Explain the stages of a pulpotomy for tooth 11
* Apply dental dam
* Remove pulp tissue at 2-3mm radius around the exposed area
* Assess bleeding - if no bleeding, remove more tissue
* Gain heamorrhage control using CWP and saline (NOT ferric sulphate in a permanent tooth as it stains!)
* If hyperaemic, remove more tissue
* Once normal bleeding has stopped, apply non setting calcium hydroxide
* Seal with GI
* Restore with composite restoration
Following a pulpotomy, the patient remains asymptomatic and you are now about to take a 6 month post op radiograph. The pulp has remained vital, what favourable sighs would you expect to see on the radiograph?
* Continued root development
* Continued thickening of dentine in the root walls
* No signs of pathology
Name 4 fluoride supplements and their doses you would give a patient to prevent decalcification
Toothpaste 1450ppmF 2 x daily
Fluoride varnish 22,600ppmF 4 x yearly
Mouthwash 450ppmF 1 x daily
Fluoride tablets, 1mg 1 x daily
Name two methods of preventing decalcifications besides fluoride
OH and diet advice
Fissure sealants
5yo Jodie has been brought in by her mothers boyfriend. She has not been sleeping due to pain. Has never been to dentist before. Facial swelling. Boyfriend vague about MH.
What should you establish prior to examination?
Severity of condition. Thorough MH. Consent - record everything that is said and carried out in notes
5yo Jodie has been brought in by her mothers boyfriend. She has not been sleeping due to pain. Has never been to dentist before. Facial swelling. Boyfriend vague about MH.
Describe in detail one behavioural management technique to get cooperation
Tell. Show. Do
Explain to Jodie what she can expect. Show her the instruments, 3 in 1, medicaments you plan to use. Demonstrate carrying out exam/treatment, get Jodie to help hold mirror etc
5yo Jodie has been brought in by her mothers boyfriend. She has not been sleeping due to pain. Has never been to dentist before. Facial swelling. Boyfriend vague about MH.
Jodie has been uncooperative, what would short term management be?
Drainage
Pain reliefe
ABs (amoxicillin 500mg 3 x daily 5 days)
Tell parent she must be brought back
5 year old child brought to practice with pain and swelling by mums bf. Has never attended dentist before. How would you address previous non attendance?
Ensure up to date contact details
Take accurate and detailed notes
Contact mum by phone (or other guardians)
Discuss with mother the necessity of child attending appts
Inform mum of possibility of child protection involvement if non compliant
Set appt over the phone and arrange appropriate escort
What evidence based brushing advice would you give for a 5yo to prevent caries?
Brush 2 x daily with fluoried TP 1450ppm
Modified bass technique
Brush 2-5 minutes
Use a pea sized amount of toothpaste
Spit dont rinse
What does a BPE score of 3 indicate?
Probing depth of 3.5-5.5mm
What teeth should be probed to obtain a BPE score in a 13yo?
Modified BPE until 17yo. Ramjfords teeth. 16, 11, 24, 36, 31, 44
What is the normal depth from CEJ to crestal bone?
2mm
13yo presents with BPE scores of 3, what medical condition may they have?
Diabetes
13yo patient presents with BPE scores of 3. No relavent MH, what could be the cause?
Aggressive periodontitis
13yo patient presents with BPE scores of 3s from modified BPE score. What other investigations would you want?
PGI.
6PPC
Radiographs
Diet diary
13 yo patient presents with BPE scores of 3s. What is your treatment plan?
Initial non surgical debridement and HPT. Refer to a specialist
A patient has fractured 11. What two questions would you want to ask about the traumatised tooth?
When and how did it happen? Can you account for lost fragments?
List four things that determine the prognosis of a traumatised tooth.
Type of fracture (complicated/not complicated)
Maturity of tooth
Open or closed apex
Tooth mobility
Vitality of the pulp
Following a traumatic tooth injury in a child, what should be discussed with the parents?
Inform them of complications; change in colour, loss of vitality, pain, sinus, infection, damage to adjacent teeth. Inform them of prognosis and treatment options
How would you treat and enamel dentine fracture?
Indirect pulp cap, GI or composite restoration
Patients parents complain about white/yellow/brown staining on teeth. What 8 questions would you want to ask patients mum?
Pregnancy; any illness, difficulties? Anaemia, gestational diabetes?
Perinatal; normal delivery? Complications? Preterm birth?
Postnatal; prolonged BF, medications, fevers.
Childhood infections; chickenpox, measles, rubella
Patients parents complaining of white/yellow/brown spots on childs teeth. List 5 questions to rule out fluorosis.
Excessive use of fluoride toothpaste?
Flouride supplements?
Fluoridated water?
Sibling/parent using high F toothpaste
OH regimen
List 3 potential future problems due to MIH
Caries susceptibility
Difficulty restoring; poor bonding
Poor long term prognosis
Potential requirement for more complex/extensive/expensive treatment
Orthodontic problems
A co-operative 10 year old patient attends with moderate crowding requesting orthodontic treatment, but has poor oral hygiene and cavitated caries into dentine in the first permanent molars.
Describe your management of the case.
History - Full history, Assess if pain/history of pain, Ask the patient about their ortho concerns
Caries risk assessment - diet, fluoride exposure, socio-economic, oral hygiene, medication, saliva quality, MH
OPT & bitewings - other caries risk, Clinical examination, Special tests: vitality testing, Deal with pain first, Dealing with the caries in the 6’s, GA, sedation, LA (risks, benefits, alternatives), Review developing dentition
Prevention regime - 4x fluoride varnish a year, duraphat 2800ppm, OHI, fissure sealants, sugar free medicines
Tell the patient and the parents that ortho treatment is not appropriate at the moment
Why the patient wants ortho (parent/patient), Inform the patient of the risks, That this could be changed in the future with appropriate oral hygiene care. Ensure that the patient knows that this can be changed, Assess child protection/patient neglect
Describe the risk-benefit discussion you would have with the patient and parent regarding ortho treatment with 6s of poor prognosis
Risks of ortho - Root resorption, Relapse, Decalcification, Gingival recession, Other: wear, gingival ulceration, non-completion
Risks of extracting 6’s - Mesial tipping of 7’s, Distal migration of 5’s, Extracting at the right time - Bifurcations of the 7’s, 8’s are present
Risks of GA - Nausea, drowsiness, vomiting, Slow recovery, Death, Permanent brain injury, Malignant hyperpyrexia
7yo with impacted upper 6s, crowded upper 2s. Give 5 possible Tx options for 6s
* Leave and monitor
* Surgical extraction
* Coronectomy
* ABs and analgesics
* Operculotomy
* XLA Es
* Remove distal aspect of Es
* Ortho appliance to bring 6s into arch
* Ortho seperators
What features of the permanent dentition allow for the replacement of primary teeth without crowding?
Growth of maxilla
Proclination of permanent teeth
Extension of dental arch
Presence of space between primary teeth (primate space)
What is leeway space and how does it prevent crowding?
10yo extrudes 11. What materials/splint would you use? How long would you splint for?
Flexible ss wire splint for 2 weeks
Flexible ss wire
Acid etch 37%
Composite resin
Water
What 4 tests would you do at a check up following trauma besides a radidograph?
EPT
Ethyl chloride
TTP
Mobility
Check for displacement
Check for colour change
Check for sinus
What advice should be given over the phone following avulsion of a permanent incisor?
Reassure the patient
Do not handle tooth by the root
Do not reimplant if it is a primary tooth
Gently rinse under slow running cold water for 10 seconds
Reimplant ASAP or store in saliva, milk, saline
Come to GDP ASAP
Pt attends following trauma. What should you check upon arrival?
How and where did the incident occur?
Was consciousness lost? Was there any nausea/vomitting? If yes - A&E!
Account for all tooth fragments
Check tetanus status
What type of splint is advised following avulsion?
EADT <60mins flexible splint for 2 weeks
EADT >60mins flexible splint for 4 weeks
What are some common outcomes following avulsion of a permanent incisor?
Discolouration
Mobility
Necrosis of the pulp
Ankylosis
Root resorption
What are the clinical signs of osteogenisis imperfecta and dentinogenesis imperfecta?
OI Blue sclera, frequent/multiple fractures
DI Loss of enamel. Discolouration. Affects both dentitions. Amber appearance of affected teeth
What are the radiographic signs of dentinogenesis imperfecta?
Occult abcsess
Bulbos crowns
Short and thin roots
Teeth erupt with large pulp chambers but obliterated soon after
What is the clinical management of dentinogenesis imperfecta?
Prevention
Composite veneers
Over denture
RPD
SSC
What are the two modes of action of SDF?
- Promotes arrest and remineralisation of active carious lesions, dentinal caries and teeth with exposed root surfaces causing hypersensitivity.
- Promotes reduced sensitivity in permanent molar teeth with MIH via occlusion of dentinal tubules.
What is the patient selection criteria for SDF?
- Pericooperative children whose behaviour/medical conditions limit invasive treatment.
- Need to delay treatment with sedation/GA
- High caries risk with compromised MH
- Part of biological caries management plan where carious lesions are also brushed twice daily and diet modifications have been made.
What are the contraindications for SDF?
- Signs/symptoms of pulpal involvement.
- Radiographic peri-radicular radiolucency
- Infection/pain from pulpal origin
- Active ulceration
- Pregnant/breastfeeding
- Undergoing thyroid treatment.
- Non compliance with TB/diet
What is SDF?
Silver diamine fluoride.
A colourless, odourless solution of silver, fluoride and ammonium ions.
What is the concentration of SDF?
38%, 44,800 ppm fluoride ions
Give 4 extra oral features of Downs syndrome
Round skull
Atlanto-axial instability
Oblique palperal fissures
Brushfield spots
Cataracts
Thick fissured dry lips
Small midface
Thick neck
Obesity
MH - CLP, CVD, epilepsy, hearing problems
Give 4 intra oral features of Downs syndrome
Large fissured tongue/macroglossia
Maxillery hyperplasia
High arched palate
AOB
Class III skeletal base
CLP
Hypodontia
Microdontia
Increased perio disease due to immunocompromised
Spacing
Following a root fracture, what types of healing can occur
Calcified tissue union accross fracture line
Connective tissue healing
Calcified tissue and connective tissue healing
Following a root fracture, what is considered non healing?
Granulation tissue
How are root fractures managed?
If undisplaced and no mobility - soft diet and monitor
If displaced and mobile - reposition under LA and splint
How would you manage a patient with a root fracture that has lost vitality?
RCT to fracture line (ns CaOH then MTA or extract
What are some signs of fluorosis?
Varies with severity; symmetrical white spots/flecks, brown spots, mottling, pitting
Occlusal surfaces of 6s unaffected
How can fluorosis be managed?
Accept
Microabraision
Composite veneers
Porcelain veneers (over 18)
Bleaching however this may also affect white spots making them more obvious
What are the advantages of non vital bleaching?
Easy
Conservative
Safe
No lab involvement
What are the disadvantages of non vital bleaching?
External cervical resorption
Relapse
May fail
Over bleaching
Crown brittleness
Briefly describe the walking bleach technique
Take pretreatment shade
Take clinical photo
Take radiograph to asses RCT
Dental dam
Access and remove GP below gingival margin
Ensure good coronal seal
10% carbamide peroxide bleach on CWP
Cover with dry CWP and seal with GIC
Renew every 2 weeks up to 10 times until happy with result/shade
Then place temp ns CaOH for 2 weeks to reverse acidity
Definitive restoration
What is the only splint used for primary teeth?
Flexible for 4 weeks for alveolar bone fracture
What is the difference between a flexible and rigid splint?
Flexible 1 tooth either side of trauma
Rigid 2 teeth either side of trauma
