paeds COPY Flashcards
what are Piaget’s four stages of cognitive development?
<2yo sensorimotor
2-7yo preoperational
7-11yo concrete operational
≥12yo formal operational
why is it recommended that toothbrushing is done by parents until at least 7yo?
≤6yo = likely to miss areas and swallow large amounts of toothpastes
what percentage of school children are afraid of the dentist and what consequences does this have?
16%
avoid attending = deterioration of oral health
often need more complicated and traumatic treatment
what are the three most significant risk factors in the development of dental anxiety in children?
- new carious lesions
- toothache
- extractions
give some of the manifestations of dental anxiety in children (~6)
- thumb sucking, nail biting, nose picking
- clumsiness, stuttering
- needing to go to the toilet, stomach pain
- headache, dizziness
- fidgeting, clinging to parent, hiding
- silence
what is behaviour contagion and how could this affect a child’s dental anxiety?
- “tendency of a person to copy certain behaviours of others around them”
- enhances a child’s anxiety (copying parents/family)
when does a parent’s presence help the child in a dental appointment?
<5yo behave better with parent present (separation anxiety)
when would you exclude the parent from a dental appointment?
- competing with dentist for child’s attention
- unintentionally conveying their own anxieties to the child (verbal or non-verbal)
what are the different components of communication and their relative importance?
- verbal communication 5% - language used
- paralinguistic communication 30% - tone, loudness, pitch
- non-verbal communication 65% - behaviour and environment
how might you adjust your verbal communication when speaking to a child?
- avoid jargon and specific terms that the pt may not understand
- avoid emotive language
how might you adjust your paralinguistic communication when speaking to a child?
commands given in a loud voice are better received by children
describe the epidemiology of dental trauma in children (demographic, type)
- males
- peaks at 2-4yo (walking) and 8-10yo (sports)
- more in primary teeth than permanent, especially maxillary central incisors
- crown fractures most commonly
risk factors for dental trauma in children (6)
- activities and environment more important than gender or age
- hyperactivity
- poor motor coordination
- increased OJ (>5mm) and incompetent lips
- anterior open bite
- epilepsy
what needs to be included when taking the history of dental trauma in a child? (6)
- where, when and how?
- attending with?
- loss of consciousness (A&E)
- previous TDIs
- all tooth fragments accounted for?
- NAI - any other injuries, does story match between adult and child, any delays?
describe the EO examination for paediatric dental trauma (3)
- clean face and oral cavity with saline/water
- looking for lacerations, tooth fragments
- exclude facial fractures by palpating facial skeleton and mandible, step deformities, difficulties opening/closing
what is a degloving injury?
traumatic injury where the entire gingiva/alveolar mucosa is separated from the underlying bone
what radiographs may you take following paediatric dental trauma and why? (5)
- PA = open/closed apex, detect root fracture
- USO = parallax with PA, detect root fracture
- DPT = developing dentition, facial fractures
- soft tissue radiograph (30-50% exposure) = tooth fragments
- lateral skull = relationship of teeth to successors
what things may be included in the trauma stamp? (up to 7)
- colour
- mobility
- sinus
- TTP
- percussion
- ethyl chloride (unreliable in primary teeth)
- EPT (unreliable in primary teeth)
how many clinical and radiographic signs do you need before starting endo tx following trauma?
at least 3
define a splint (tooth)
rigid or flexible device/compound used to support, protect or immobilise teeth that have been loosened/replanted/fractured/subjected to certain endodontic/surgical procedures
what are the different materials that can be used for splinting teeth? (5)
- composite/wire
- acrylic ProTemp splint
- soft mouthguard (eg if no teeth to place splint)
- brackets/orthodontic wire (lengthy splinting)
- titanium trauma splint (TTS)
what is the difference between rigid and flexible splinting and which is preferred?
- rigid splint = completely immobilises tooth (≥2 teeth either side, thicker wire), increased risk of ankylosis
- flexible splint preferred = allows some functional movement of teeth (usually 1 tooth either side)
give some features of an ideal splint (5)
- easy to place, remove and maintain (often buccal)
- cleansable
- discourages plaque retention
- does not impinge on gingival tissues
- no occlusal interference
- enables endodontic treatment and sensibility testing
when would you place a splint, what type and for how long? (paeds)
- permanent teeth usually
- 2 weeks flexible = most traumatic dental injuries
- 4 weeks flexible = associated alveolar bone fractures, apical/mid-1/3 root fractures
- 4 months rigid = cervical 1/3 root fractures
describe the procedure to splint a tooth flexibly
1 reposition tooth (usually with LA)
2 use small piece of floss to measure length of splint required, trim wire to length and bend/curve
3 spot-etch in middle of crowns, wash, dry
4 apply bond, dry, cure
5 place small ball of composite on tooth and place wire gently on top, ensuring it runs across the centre of adjacent teeth, cure
6 sandwich the wire with composite, cure
7 place composite balls over ends to ensure no sharp edges, cure
give some generic post-op advice following dental trauma (5)
- 2 weeks = avoid contact sports, soft diet, avoid eating on traumatised teeth
- careful OH +/- soft toothbrush
- topical CHX 0.1% alcohol-free MW/gel BD 7/7
- appropriate analgesia
- if splint debonds, reattend before next review for reattachment
factors affecting prognosis of dental trauma (5)
- age (maturity of roots)
- type and severity of injury
- associated injuries (displacements, fractures)
- time between injury and treatment
- presence of infection
give some possible complications following dental trauma in children (7)
Primary tooth injury
- delayed exfoliation
- delayed eruption of permanent tooth
- injury to permanent successor
Permanent tooth injury
- loss of pulp vitality
- arrest of root development in immature teeth
- root resorption (inflammatory or replacement)
- loss of tooth before adulthood
what possible effects on the permanent successor may be caused by primary tooth trauma? (6)
- delayed eruption
- hypomineralisation
- hypoplasia
- dilaceration (crown or root)
- arrest of development
- odontoma formation
define dilaceration of a tooth (2)
- abrupt deviation of the long axis of the crown/root portion of the tooth
- due to disturbance between the unmineralised and mineralised portions of the developing tooth germ (trauma or developmental)
what s/s may indicate non-vital pulp? (8)
- discolouration
- TTP+
- buccal tenderness
- negative sensibility testing
- sharp pain on thermal stimulus
- sinus tract
- spontaneous pain or pain on biting
- radiograph - PA RL, PDL widening
how soon will signs of loss of pulp vitality appear radiographically following dental trauma?
within 6 weeks (resorption, arrested root development)
how does arrest of root development appear radiographically? (3)
- appears shorter than adjacent uninjured teeth
- failure of pulp canal to mature/reduce in size
- may see calcific barrier across apical area (residual vitality)
give the three types of root resorption that may occur following dental trauma
- transient
- inflammatory (infection-related)
- replacement (ankylosis-related)
describe inflammatory/infection-related root resorption following dental trauma (cause, process, radiograph, tx)
- usually immature teeth, occurs very quickly
- caused by non-vital pulp with severe traumatic injuries and PDL injury
- commonly external RR
- necrosed pulp, damaged cementum –> osteoclast activity on root surface
- seen radiographically from 3 weeks = punched out resorption
- propagated by necrotic pulp so early extirpation and calcium hydroxide dressing helps
describe replacement root resorption/ankylosis following dental trauma (process, clinical, radiograph, management)
- aetiology poorly understood
- damage to root surface –> replacement with bone
- tooth may be lost in 3-7 years in younger patients (fast bone turnover)
- high “metallic” note when tapped, no physiological movement
- loss of radiographic PDL space from 2-12months
- often decoronated to maintain alveolar bone whilst preventing gingival margin discrepancy
how do open and closed apices differ in prognosis following trauma?
- open apex = more likely to survive trauma, harder to RCT (thin dentine walls, poor crown:root)
- closed apex = more likely to lose vitality +/- root resorption, more easily treated endodontically
define luxation injury
displacement injury involving teeth moving in or out of the socket, often requiring splinting
define concussion injury
- mild luxation injury to tooth-supporting structures
- with no mobility or displacement but tender to percussion
concussion clinical and radiographic presentation
- TTP+
- no mobility/displacement
- normal radiograph
concussion management (3)
- no tx
- soft diet 1 week and good OH
- f/u at 1 month, 1 year
(95% pulp survival)
describe concussion presentation and management
- TTP+
- no mobility/displacement
- normal radiograph
- no tx
- soft diet 1 week and good OH
- f/u at 1 month, 1 year
(95% pulp survival)
define subluxation injury
- minor injury to tooth-supporting structures
- bleeding around gingival margin, may be mobile but not displaced, tender to touch
subluxation clinical and radiographic presentation
- gingival bleeding
- mobile but not displaced
- tender to touch
- normal radiograph
permanent tooth subluxation management (3)
- no tx unless discomfort then flexible splint 2 weeks
- 1 week soft diet with good OH
- f/u 2 weeks (splint), 3/6/12 months
(85% closed apex survival)
permanent tooth subluxation presentation and management
- gingival bleeding
- mobile but not displaced
- tender to touch
- normal radiograph
- no tx unless discomfort then flexible splint 2 weeks
- 1 week soft diet with good OH
- f/u 2 weeks (splint), 3/6/12 months
(85% closed apex survival)
define lateral luxation injury
displacement of tooth other than axially (usually palatal)
lateral luxation clinical and radiographic presentation
- displacement +/- communication fracture of alveolar bone
- +/- occlusal interference
- may be non-mobile (locked in)
- radiograph shows fracture, shortened or elongated root
permanent tooth lateral luxation management (3)
- LA and reposition, with flexible splint for 4 weeks
- extirpate if signs of non-vitality
- f/u 2 weeks, 1/2/3/6/12 months then annually until 5 years
(95% open apex, 85% closed apex)
primary tooth lateral luxation management (3)
- allow to reposition spontaneously if no occlusal interference (at least 6 months)
- reposition if minor displacement and occlusal interference
- extraction otherwise
permanent tooth lateral luxation presentation and management
- displacement +/- communication fracture of alveolar bone
- +/- occlusal interference
- may be non-mobile (locked in)
- radiograph shows fracture, shortened or elongated root
- LA and reposition with flexible splint for 4 weeks
- extirpate if signs of non-vitality
- f/u 2 weeks, 1/2/3/6/12 months then annually until 5 years
(95% open apex, 85% closed apex)
define extrusion injury
partial displacement of tooth in the axial direction out of its socket
extrusion clinical and radiographic presentation
- extruded (elongated)
- gingival bleeding
- +/- occlusal interfence
- mobile
- radiograph = increased PDL space apically and laterally
permanent tooth extrusion management
- digital repositioning +/- LA and flexible splint 2 weeks
- antibiotics if severe injury
- corsodyl MW/gel, soft diet
- extirpate if signs of non-vitality
- f/u 2 weeks, 1/2/3/6/12 months and annually until 5 years
(guarded prognosis, 40% open apex, 0% closed apex with RR likely)
permanent tooth extrusion presentation and management
- extruded (elongated)
- gingival bleeding
- +/- occlusal interfence
- mobile
- radiograph = increased PDL space apically and laterally
- firm digital repositioning +/- LA and flexible splint 2 weeks
- antibiotics if severe injury
- corsodyl MW/gel, soft diet
- extirpate if signs of non-vitality
- f/u 2 weeks, 1/2/3/6/12 months and annually until 5 years
(guarded prognosis, 40% open apex, 0% closed apex with RR likely)
primary tooth extrusion management (2)
- allow to reposition spontaneously
- extract if excessively mobile or >3mm extruded
define avulsion injury
complete displacement of tooth out of socket
should you replant primary avulsed teeth?
NO
what factors may you consider before replanting an avulsed tooth? (5)
- permanent teeth only
- MH (5) - tetanus, immunosuppressed, haematology, cardiac defects, allergy
- state of tooth (caries, fractured)
- very immature teeth with prolonged EADT may not survive
- need for immediate medical treatment (takes priority)
what solutions may you keep an avulsed tooth in?
fresh cold MILK > saline > saliva
describe how a permanent tooth may be immediately replanted with LA
1 gently rinse in milk/saline if visible debris
2 remove any bony fragments, flush clots
3 replant with firm digital pressure
4 suture any gingival lacerations
5 check occlusion, check radiograph
6 flexible splint 2 weeks
what antibiotics may be prescribed following avulsion?
(limited evidence, up to clinician)
- penicillin first line
- doxycycline if penicillin allergy (but caution <12yo due to intrinsic discolouration)
(may help prevent IRR)
what immunisation must be checked following avulsion?
tetanus (refer to GP within 48hrs)
what other clinical procedure might you do following replantation of an avulsed tooth?
extirpation within 2 weeks and non-setting calcium hydroxide placed if CLOSED apex
in what scenario may a replanted avulsed permanent tooth survive?
- open apex only
- <60mins EADT
primary tooth avulsion management (3)
- confirm with radiograph
- do not replant primary avulsed tooth
- monitor for permanent tooth eruption carefully
define intrusion injury
displacement of tooth apically into alveolar bone, often accompanied with fracture of alveolar socket
intrusion clinical and radiographic presentation and severity score
- “short” firm tooth or even not visible
- high metallic sound on percussion
- severity = <3mm mild, 3-7mm moderate, >7mm severe
- radiograph = loss of PDL space, more apical CEj
permanent tooth intrusion management
1 allow spontaneous eruption:
- mild with closed apex
- moderate with open apex
- may take up to a year
2 orthodontic repositioning (needs permanent teeth to bond to)
- mild and not spontaneously resolved
- moderate with closed apex
- severe with open apex
3 surgical repositioning and 4 week flexible splint
- severe with open apex
- moderate/severe with closed apex
- extirpate if signs of non-vitality (within 3-4 weeks if closed apex)
- f/u 2 weeks, 1/2/3/6/12 months, annually until 5 years
primary tooth intrusion management (3)
- take USO or PA to ascertain position (elongated = apex towards palatal and may affect permanent tooth germ)
- allow to reposition spontaneously irrespective of direction of displacement (6 months - 1 year)
- warn parent of risk to permanent tooth
define enamel infraction
incomplete fracture/crack of enamel without loss of tooth tissue
enamel infraction management
monitor if no issues
define enamel fracture
fracture confined to enamel with loss of tooth structure
define uncomplicated fracture
fracture confined to enamel and dentine with loss of tooth structure, NOT involving pulp
define complicated fracture
fracture involving enamel and dentine with loss of tooth structure, exposing the pulp
define root fracture (2)
- uncommon fracture involving cementum, dentine and pulp
- apical, middle or cervical third of root
define complicated crown-root fracture
fracture involving enamel, dentine and cementum with loss of tooth structure, involving the pulp
enamel fracture management (4)
- possible reattachment of fragment with flowable composite under LA
- composite restoration
- selective grinding if primary tooth to smooth
- f/u 6-8 weeks and 1 year
(excellent prognosis)
uncomplicated fracture management (4)
- possible reattachment of fragment with flowable composite
- composite restoration
- GIC bandage if poor cooperation
- f/u 6-8 weeks and 1 year
(good prognosis)
complicated fracture management (5)
- direct pulp cap (CaOH, GIC, composite) for pinpoint exposures within 24 hours and not grossly contaminated
- Cvek pulpotomy for small exposures with asymptomatic tooth with non-inflamed pulp - within 9 days
- coronal pulpotomy
- pulpectomy
- extraction if poor compliance
what two factors affect prognosis of a complicated crown fracture?
size and duration of pulp exposure
describe how a Cvek pulpotomy is carried out
1 LA, rubber dam (212 clamp)
2 remove 2-4mm pulp until bright red
3 haemostasis with sterile cotton pledget and saline
4 non-setting CaOH powder/Biodentine/MTA (discolours)
5 GIC to seal
6 composite restoration
how may a cellulose crown form be used to help restore following a Cvek pulpotomy?
1 bevel cavity for retention and aesthetics
2 adjust crown form to shape of tooth with scissors
3 pierce hole in incisal corner of crown form with probe to allow release of excess composite
4 etch, wash, dry
5 bond, dry, cure
6 place composite in crown form and push onto tooth and remove excess, cure buccal and palatal
7 remove crown form and polish until margins are flush
root fracture management (4)
- parallax radiography to visualise fracture line
- excessively mobile and occlusal interference: LA and…
– extract only coronal fragment
– digital repositioning of coronal fragment +/- flexible splint 4 weeks (mid/apical 1/3) or rigid splint 4 months (cervical 1/3) - loss of vitality = RCT up to fracture line (CaOH dressing)
- f/u = 4wks, 2/4/6/12 months and annually until 5 years
how may a root fracture heal and which is more favourable? (2)
- granulation tissue = poor prognosis, difficult to RCT (tissue enters canal)
- hard tissue union = more favourable (less severe injuries)
complicated crown-root fracture management (3)
- extract fragment and assess remaining tooth for restoration (often leave apical portion to be resorbed)
- RCT with MTA if restorable
- f/u = 1 wk, 2/3/6/12 months and annually until 5 years
(poor prognosis, difficult to restore)
alveolar fracture management (3)
- manual/forcep repositioning of displaced segment under GA ideally
- flexible splint 4 weeks
- monitor teeth in fracture line
describe the possible types of discolouration following tooth trauma
- immediate = reddish, may regress or persist (sign of root resorption), may maintain vitality
- intermediate = brown/black due to pulp breakdown products, non-vital tooth
- long-term = yellow/opaque due to pulp calcification
(50% of primary incisors with post-trauma dark discolouration remain asymptomatic until exfoliation)
what are the general follow up intervals following traumatic dental injuries and what are you assessing?
- severe injuries to permanent dentition = 2/4/6/8 weeks, 3-4 months, 12 months, annually for 5 years
- primary dentition = 1/4/8 weeks, 6 months, annually until permanent tooth erupts
- looking for s/s of healing, assessing pt’s perception of aesthetics, any anxiety and effects on QoL
define amelogenesis imperfecta (3)
- group of hereditary conditions affecting the structure and appearance of enamel, often in conjunction with changes in other tissues
- single gene mutations
- affects all teeth in both dentitions
what is the difference between hypoplasia, hypomineralisation, hypomaturation?
- hypoplasia = decrease in quantity of tissue
- hypomineralisation = decrease in quality of tissue/deposition of mineral
- hypomaturation = decrease in quality/deposition of mineral during maturation stage
what are the three stages of amelogenesis?
1 secretory phase = thickness secreted by ameloblasts, lots of organic content and water
2 transition
3 maturation = inorganic ions secreted and exchanged for water and organic material
in what two ways may amelogenesis imperfecta be classified?
- mode of inheritance and specific mutations
- phenotype
name the different phenotypes of amelogenesis imperfecta
- hypoplastic type I (F>)
- hypomature type II (M>)
- hypocalcified type III
- hypomaturation-hypoplastic with taurodontism type IV
what is the most common phenotype of amelogenesis imperfecta?
hypoplastic type I
describe type I amelogenesis imperfecta (what, presentation)
- hypoplastic type I
- decreased enamel thickness but normal colour and contrast
- pitting, grooves
- F>M
describe type II amelogenesis imperfecta (what, presentation)
- hypomature type II
- normal thickness but similar radiographic density to dentine
- enamel tends to flake or chip away from dentine
- multiple brown-yellow local/diffuse opacities +/- snow-capped appearance
- M>F
describe type III amelogenesis imperfecta (what, presentation)
- hypocalcified type III
- extremely soft enamel, less radiopaque than dentine, may be lost soon after eruption
- teeth rapidly worn down and stained
what does a taurodont tooth look like radiographically? (3)
- enlarged body of tooth
- elongated pulp chamber
- root bifurcation displaced apically with short roots
what other dental features are commonly seen with amelogenesis imperfecta? (2)
- delayed eruption
- anterior open bite (esp hypocalcified type III)
differential diagnosis of amelogenesis imperfecta and how to differentiate (5)
- dental fluorosis (chronological, history)
- tetracycline staining (coloured banding)
- enamel chronological hypoplasia (eg vit D dependent rickets; chronological)
- MIH (only molars and incisors)
- trauma (localised)
what are the five aims of amelogenesis imperfecta management?
1 early diagnosis
2 pain management
3 prevention and stabilisation, maintain vertical dimension
4 restoration of any defects, manage aesthetics
5 regular maintenance
what will prevention and pain management of amelogenesis imperfecta consist of? (6)
- education, OHI
- fluoride MW, TP
- tooth mousse (CPP-ACP)
- warm water only
- diet analysis and advice
- shorter recall periods
what are the care principles of the primary dentition with amelogenesis imperfecta? (3)
- treatment should reflect degree of symptoms/wear - aim for function and maintaining arch perimeter
- aesthetic composites for anterior teeth, helps acclimatisation
- SS crowns, GIC for primary molar occlusal surfaces
what are the care principles of the mixed dentition with amelogenesis imperfecta? (3)
- PMCs or gold onlays or SS crowns for first molars
- consider GIC and fluoride on occlusal surfaces due to longer eruption time +/- operculectomy
- composite veneers for permanent incisors (aesthetic, decrease sensitivity/wear)
what are the care principles of the permanent dentition with amelogenesis imperfecta? (2)
- premolars with wear and sensitivity = full coronal coverage restorations (but if no s/s then no intervention)
- canines with wear and sensitivity = composite veneers
options for resorbing teeth in amelogenesis imperfecta (2)
- extraction
- orthodontic extrusion before too much resorption occurs
management for intact but discoloured enamel in AI (2)
- bleaching
- +/- microabrasion
(aesthetic)
describe the morphological differences between primary and permanent dentition
1 primary
- thin uniform layer of enamel, thin layer of dentine, large pulp with fine root canals
- broad proximal contacts
- divergent thin roots
2 permanent
- variable enamel thickness, thicker dentine layer, proportionally smaller pulp
- deeper fissures
why do we restore carious lesions in children? (5)
- prevention and pain relief
- fostering positive attitude to dental health
- general health and well-being
- prevent damage to permanent successors
- prevent adverse consequences of early tooth loss
describe fissure sealants (what, material)
- material placed into pits and fissures of teeth to prevent development of dental caries
- bis-GMA or GIC
- must be retained and monitored to be most effective
fissure sealant (resin) technique
1 clean and dry the tooth
2 isolate
3 etch with 37% phosphoric acid
4 rinse 15s
5 dry 15s
6 bond and dry
7 deposit the resin and light cure
8 check adhesion immediately and monitor in future
what are the different cavity designs we may use in primary teeth? (3)
- occlusal cavity = ≤1.5mm width, preserve the transverse ridge in upper molars
- proximal cavity = isthmus 1/3-1/2 of occlusal surface width, rounded line angles
- minimal box preparation = no occlusal extension
which restorative material has the best longevity in the primary dentition?
metal crowns (conventional technique)
what does the Minamata Treaty advise regarding children?
NO use of amalgam in treatment of deciduous teeth or in children <15yo
(except when strictly deemed necessary by practitioner by grounds of specific medical needs)
disadvantages of early primary tooth loss (5)
- loss of space and risk of malocclusion
- decreased masticatory function
- impeded speech development
- psychological disturbance
- trauma (anaesthesia and surgery)
indications for pulp treatment in children (6)
- good cooperation
- promoting positive attitude to oral health care
- MH precludes extraction (eg haematological)
- missing permanent successor
- maintaining a strategically important tooth
- developmental state of tooth (usually <9yo)
contraindications for pulp treatment in children (6)
- poor cooperation, poor dental attendance
- MH where infection would be risky (eg cardiac defects)
- multiple grossly carious teeth
- advanced root resorption (>2/3) or extensive internal RR
- severe/recurrent pain
- cellulitis, pus in pulp chamber, gross bone loss
considerations with primary tooth endodontics (7)
- compliance
- restricted access
- physiological resorption
- root morphology
- lack of/thin secondary dentine
- porous pulp floor with accessory canals
- risk to permanent successor
describe pulpotomy in children (when/why, procedure)
- when = carious/traumatic exposure of vital pulp, caries >2/3 into dentine on radiograph
- why = preserve radicular pulp, maintain tooth until normal exfoliation
1 LA, isolation, access and caries removal
2 amputation (roof of pulp chamber and coronal pulp)
3 assess pulp status by colour and haemostasis
4 15% ferric sulphate for 15-30s (up to 4x)
5 ZOE base
6 GIC core
7 PMC
how far down from occlusal surface is the pulp of a primary molar?
3mm
what is odontopaste? (components, use)
- clindamycin, triamcinolone, calcium hydroxide
- for emergencies only as intracanal medicament (pt unable to tolerate procedure or failed LA)
describe pulpectomy in children (when/why, procedure)
- when = non-vital/hyperaemic pulp, irreversible pulpitis with excellent cooperation
- why = control or prevent infection
1 LA, isolate, access and caries removal
2 amputation and assess for non-vital/hyperaemic pulp
3 remove pulp with files, preparing to 2mm short of the apex, irrigating with saline/LA/CHX
4 obturate with creamy mix of Vitapex
5 ZOE base
6 GIC core
7 PMC
give some s/s which may indicate irreversible pulpitis in a child
- spontaneous pain, pain on biting, TTP
- excessive mobility not associated with trauma or exfoliation
- “gum boil”
- bad taste
- sinus tract
- discolouration
- facial swelling
- furcation or apical RL
what is Vitapex? (components, use)
- calcium hydroxide and iodoform
- used in obturation in primary teeth as it resorbs with tooth
how far are the canals prepared in pulpectomy in deciduous teeth?
to 2mm short of the apex
what is the theory behind using the Hall technique?
- manipulates plaque environment by sealing and separating from substrate
- bacterial profile changes and lesion does not progress
indications for Hall technique (5)
- any proximal/occlusal lesions that pt cannot tolerate conventional restoration/FS (asymptomatic or reversible only)
- developmental defects (eg hypoplastic)
- restoration of fractured primary molar
- band of sound dentine between lesion and pulp
- high caries risk (eg special needs)
contraindications for Hall technique (7)
- irreversible pulpal involvement
- insufficient sound tooth tissue to retain crown
- > 1/2 root has been resorbed
- MH where infection poses a risk
- nickel allergy
- pt cooperation endangering airway
- parent/child unhappy with aesthetics
describe Hall technique procedure
1 space formation with orthodontic separators 3-5 days beforehand
2 crown selection with airway protection - trial and error
3 cementation with GIC luting cement and pressure
4 remove excess cement and inform that it will feel high for a week
pros and cons of Hall technique
+ = good wear resistance, low failure rate, low incidence of CARS, simple
- = poor aesthetics, unsuitable if nickel allergy, may inhibit eruption of 6
indications for conventional technique with PMC (5)
- extensive caries (multiple surfaces)
- developmental defects (AI, dI)
- following pulpectomy/pulpotomy
- restoring a primary tooth to be used as abutment for space maintainer
- definitive restoration for high caries risk child
different methods of crown selection for conventional technique (3)
- measure M-D width with divider
- trial and error after prep
- impression and crown prep on a model
which Act determines who can consent for a child? who can consent for a child? (7)
The Children Act 1989
- mother
- legally appointed guardian
- person with residency order for the child from a count
- local authority designated in a care order
- father if married at time of birth
- unmarried father who has acquired parental responsibility (married mother, court order)
- unmarried father after 2003 = registered at time of birth, or re-registered and natural father
when can a young person consent?
- ≥16yo can consent without parental/guardian consent (Family Reform Act 1969)
- minors <16yo if deemed Gillick competent or Fraser competent
when should the first dental assessment be conducted for a child?
before 6 months old
general principles of treatment for primary tooth trauma (4)
- do not replant avulsed primary teeth
- leave and monitor if no occlusal interference and not excessively mobile/airway risk
- reposition if occlusal interference but no splint
- extract if airway risk
what should be included in the notes of the first paediatric assessment visit? (10)
- accompanying person
- CO/HPC
- MH
- DH
- SH
- diet
- OH, habits
- EO and IO examinations and special tests
- behaviour (Frankl)
- diagnoses and caries risk
general treatment plan format for paediatric patients
1 emergency/acute (pain relief, prevent further infection, maintain vitality)
2 stabilisation of active disease, including prevention and temporisation, behaviour management
3 corrective (restorative, prosthetic)
4 maintenance (reinforce prevention)
5 regular reassessment (6/12, 3/12 if high risk)
indications for bitewings in children (4)
- detect caries
- dental injuries or trauma
- disturbances of tooth development
- examination of other pathological conditions (other than caries)
describe the Frankl behavioural scale
1 = definitely negative = refuses treatment, forceful crying, fearfulness, other evidence of extreme negativism
2 = negative = reluctant to accept treatment, uncooperative, some evidence of negative attitude but not pronounced
3 = positive = accepts treatment, cautious at times, willingness to comply, at times with reservation but follows directions cooperatively
4 = definitely positive = good rapport with dentist, interest in dental procedures, laughter, enjoyment
what might you ask about when taking a social history for paeds? (3)
- caries experience and dental-related anxiety in parents or siblings (risk assessment)
- school, social workers (safeguarding)
- parental occupation and who takes care of child
what might you ask when taking the past dental history for paeds? (5)
- regular attendance?
- past experiences and treatments
- coping abilities
- any specific difficulties or dislikes
- child and parents’ attitudes towards dental treatment
what might you ask when taking a diet history for paeds? (6)
- bottle feeding (duration, when)
- snacks, treats (frequency, sugar)
- drinks (when, sugar)
- medications (sugar-free)
- lunches (school dinners or packed)
- fruit and veg, 5/day
what can affect a child’s cooperative potential? (4)
- current pain
- dental history, PMH, SH
- level of understanding and potential cooperation
- level of anxiety
what is behaviour management?
the way in which a dentist effectively and efficiently performs treatment for a child
list behaviour management techniques (12)
- positive reinforcement
- appropriate language
- tell, show, do
- acclimatisation
- systematic desensitisation
- voice control
- role modelling
- hand stop signal
- distraction
- appropriate touch
- reward
- hypnosis
(- restraint but not in UK)
describe positive reinforcement (what, how)
- presentation of a stimulus that will increase the likelihood of behaviour being repeated
- important to be clear and immediate
- positive voice modulation, facial expression, descriptive verbal praise
give examples of some appropriate and inappropriate language to use with children
good = buzzy brush, hoover, tooth pillow, raincoat, magic jelly, spoon
bad = sharp, needle, jaw, drill
describe the tell, show, do technique (what, how)
- method of introducing equipment and procedures
1 tell child about instrument
2 show the instrument and describe any sensation that might be felt (+/neutral)
3 do what has been demonstrated without deviation with minimal delay
define acclimatisation
planned sequential introduction of environment, people and instruments and procedures
describe systematic desensitisation (what, how)
- repeated non-distressing exposure to an anxiety-provoking stimulus to eventually decrease the anxiety
- reassure pt, +/- hypnosis
1 construct personalised hierarchy of anxiety-provoking stimuli
2 expose to least anxiety provoking stimulus (imaginary or reality) until no anxiety produced)
3 repeat for next least anxiety-provoking
define voice control
controlled alteration of voice, volume, tone or pace to influence and direct a patient’s behaviour
describe role modelling (what, why)
- using a model to demonstrate similar treatment
- children learn how to act by observing and imitating their peers
what is the hand stop signal?
pt able to raise their hand as a stop signal to give them a degree of control over the dentist’s behaviour
describe distraction (behaviour management) (what, how)
- shifting the pt’s attention from the dental setting to some other situation, or from a potentially unpleasant procedure to some other action
- verbal, short-term distracters, short breaks
from when do the teeth start developing?
5 weeks in utero
in what order do the primary teeth erupt?
A B D C E
what is the first tooth to erupt in the mouth and when?
lower A (7-8 months)
what is the last deciduous tooth to erupt?
upper E (25-33 months)
what is the first permanent tooth erupt?
lower 6
what are the anthropoid spaces?
spaces immediately mesial to UC and distal to LC
what is leeway space?
amount by which the combined M-D width of the CDE exceeds that of the 345
(1.5mm U, 2.5mm L)
give the order and ages in which the permanent teeth erupt
6yo = L1 and L6 (closely followed by U6)
7yo = U1 and L2
8yo = U2
9yo = laterals tilted distally by canine
10yo = L3 and all 4s, U3s palpable in buccal sulcus
11yo = U3, all 5s
12yo = all 7s
what are the 3 main risk factors for developing caries within the next 3 years?
- previous caries experience
- resident in an area of deprivation
- healthcare worker’s opinion (referral)
what clinical findings would indicate low and high caries risk? (5/4)
LOW
- no new lesions, restorations years ago
- no carious extractions
- sound anterior teeth
- fissure sealants
- no appliances
HIGH
- new lesions, premature extractions, multiple recent restorations
- anterior caries/restorations
- no fissure sealants
- appliances
what dietary habits would indicate low and high caries risk?
low = infrequent sugar intake
high = frequent sugar intake (non-milk extrinsic sugars)
what social history factors would indicate low and high caries risk? (5/5)
LOW:
- social advantage
- siblings/parents with low caries
- dentally aware, regular attender
- limited availability of snacks
- high dental aspirations
HIGH:
- social deprivation
- high caries in family
- low dental disease knowledge, irregular attender
- readily available snacks
- low dental aspirations
what OH habits would indicate low and high caries risk? (4/3)
LOW:
- fluoride in drinking water and TP
- fluoride supplements
- frequent effective cleaning
- good manual control
HIGH:
- no fluoride
- infrequent, ineffective cleaning
- poor manual control
what medical history factors would indicate low and high caries risk? (3/3)
LOW:
- no medical or physical problems
- normal salivary flow
- no long term medications
HIGH:
- medically compromised, physical disability
- xerostomia
- long-term cariogenic medicine
what salivary factors would indicate low and high caries risk?
LOW:
- normal flow rate
- high buffering capacity
- low S mutans and lactobacillus counts
HIGH:
- low flow rate (rare)
- low buffering capacity
- high S mutans and lactobacillus counts
what does the caries risk assessment determine? (3)
- preventive interventions
- frequency of review radiographs
- frequency of recall
what are the four pillars of prevention?
- plaque control
- dietary advice
- fluoride
- fissure sealants
give the standard prevention for 0-7+yo as per DBOH
0-3yo:
- breast feeding = best nutrition for babies
- from 6 months should introduce drinking from a free-flowing cup
- from 1yo, feeding from bottle should be discouraged
- sugar should not be added to food/drink
- parents/carers should supervise/do toothbrushing
- brush 2x daily with smear of at least 1000ppm F- toothpaste (last thing at night and one other occasion)
- frequency and amount of sugar
- sugar-free medications
3-6yo:
- supervised brushing at least 2x/day with pea sized fluoride toothpaste >1000ppm
- spit don’t rinse to maintain F- concentrations
- sugary food and drink frequency and amount should be reduced
- fluoride varnish 2.2% NaF 2x/year
7+yo:
- 1350-1500ppm F- TP
- decrease frequency and amount of sugary food/drink
- fluoride varnish 2.2% NaF 2x/year
give the standard prevention for 0-3yo as per DBOH (8)
0-3yo:
- breast feeding = best nutrition for babies
- from 6 months should introduce drinking from a free-flowing cup
- from 1yo, feeding from bottle should be discouraged
- sugar should not be added to food/drink
- parents/carers should supervise/do toothbrushing
- brush 2x daily with smear of at least 1000ppm F- toothpaste (last thing at night and one other occasion)
- decrease frequency and amount of sugar
- sugar-free medications
give the standard prevention for 3-6yo as per DBOH (4)
3-6yo:
- supervised brushing at least 2x/day with pea sized fluoride toothpaste >1000ppm
- spit don’t rinse to maintain F- concentrations
- sugary food and drink frequency and amount should be reduced
- fluoride varnish 2.2% NaF 2x/year
give the standard prevention for 7+yo as per DBOH (3)
7+yo:
- 1350-1500ppm F- TP
- decrease frequency and amount of sugary food/drink
- fluoride varnish 2.2% NaF 2x/year
give the enhanced prevention for 0-6yo as per DBOH (3)
- fluoride toothpaste 1350-1500ppm
- frequent long-term med should be sugar free (liaise with GP)
- professional = decreased recall interval, F- varnish ≥2x/year, diet analysis and good dietary practice in line with Eat Well guide
give the enhanced professional prevention for 7+yo as per DBOH (6)
- resin FS on permanent molars
- F- varnish ≥2x/year
- 8+yo with active caries = daily 0.05% (225-230ppm) F- rinse prescribed
- 10+yo with active caries = 2800ppm TP
- 16+yo with active caries = 2800 or 5000ppm TP
- investigate diet and assist to adopt good dietary practice in line with Eat Well guide
periodontal disease prevention as per DBOH (5)
- OHI to prevent gingivitis, achieve the lowest risk of periodontitis and tooth loss
- correct factors impeding effective plaque control – calculus, open margins, overhangs, contours
12+yo:
- ID plaque control daily before brushing
- small spaces = floss or tape
- larger spaces = ID brushes or single tufted brushes
DBOH recommendations for diet (5)
- restrict sugary food and drink to no more than 4 occasions/day
- grazing on sugary food, sipping soft drinks containing sugar/acid over prolonged periods should be discouraged
- avoid sugar-containing food and drink at bedtime when saliva flow is decreased and buffering capacity is lost
- only water/cow’s milk between meals
- breast feeding best for babies
topical fluoride modes of action (2)
- NaF contacts enamel –> CaF2 and stays on the surface - reservoir of F-, protection against further acid attack
- dentine hypersensitivity relief – CaF2 globules occlude the tubules
which group should not have fluoride varnish?
<3yo with low caries risk
describe how fluoride varnish is applied and post-operative instructions
1 remove XS plaque
2 isolate and dry one quadrant
3 thin layer applied to most susceptible areas of teeth – gingival margins, proximal areas, susceptible occlusal areas
4 repeat with other quadrants
post-op:
- no liquids/eating for 30mins, only soft foods after
- do not brush and avoid chewing for 4 hours
what are the fluoride varnish recommended doses and how is this measured?
visual dispensing pad
- 0.25ml for primary dentition
- 0.4ml for mixed dentition
- 0.75ml for permanent dentition
what concentration is Duraphat fluoride varnish and how much NaF is in 1ml?
- 22.6% or 22600ppm
- 1ml = 50mg of NaF (22.6mg F-)
what is the toxic dose of fluoride varnish?
5mg/kg of F-
contraindications for fluoride varnish (5)
- hypersensitivity to colophony or other constituents
- ulcerative gingivitis
- stomatitis
- bronchial asthma
- pts who are allergic or unable to take alcohol for cultural/religious reasons
what is the colophony for in fluoride varnish?
natural resin for stickiness
radiographic intervals for high risk and low risk
- high risk = 6-12 months
- low risk = 12-18 months (primary), ~24 months (permanent)
define early childhood caries (ECC)
at least 1 carious lesion in any primary tooth (dmfs) in <6yo
define severe early childhood caries (S-ECC) (3)
- smooth surface caries in a child <3yo
- any dmfs affecting primary maxillary anterior teeth <6yo
- dmfs > age for those <6yo
how is a child’s body weight estimated (1-10yo)?
(age + 4) x 2
what are the recommended doses and timings for paracetamol?
- 3-12mo = 60-125mg (0.5-1 tsp)
- 1-5yo = 125-250mg (1-2 tsp)
- 5-12yo = 250-500mg (2-4 tsp)
- 12-18yo = 500mg-1g (4-8 tsp)
(Calpol = 125mg or 250mg/5ml) - every 4-6 hours, max 4 in 24 hours
what is the toxic dose of paracetamol?
150mg/kg for adults (higher for children) = nausea and vomiting
what are the recommended doses, max doses and timings for ibuprofen? (4)
- 3-12mo = 50mg (max 30mg/kg)
- 1-4yo = 100mg (max 30mg/kg)
- 4-7yo = 150mg (max 30mg/kg)
- 7-10yo = 200mg (max 2.4g/kg)
- 10-12yo = 300mg (max 2.4g/kg)
- 12-18yo = 300-400mg
- every 8 hours
contraindications for ibuprofen (4)
- asthma
- liver disease
- renal failure
- bleeding disorders
s/s of ibuprofen overdose (3)
- nausea, vomiting
- epigastric pain (stomach ulcer with prolonged use)
- tinnitus
describe ID block technique in children
- mandibular foramen = below occlusal plane, most posterior and lower than in most adults
1 mouth fully open
2 approach direct from contralateral primary molars, lateral to the pterygomandibular raphe and medial to the ascending ramus at SAME LEVEL of occlusal plane
3 insert 5mm above the occlusal plane (may be lower if younger)
4 advance until bone is hit (~15mm in young, 25mm in older), withdraw slightly, aspirate and deposit 1.5ml
5 withdraw halfway and deposit 0.5ml
describe the Wand (LA) and its advantages and disadvantages
- computer-controlled LA injection with dynamic pressure-sensing technology
+ = looks less threatening, induces less anxiety, precise control of flow rate ensures comfort - = more expensive, longer, more hazardous waste, needs space for machine
what factors will affect whether you will extract or retain a child’s tooth? (6)
- restorability
- caries risk
- relevant MH (oncology, haematology, immunology)
- pt/parent compliance and attitude
- stage of dental development - exfoliation, long term prognosis or permanent tooth
- space management/maintenance
what may be done during the stabilisation phase of paediatric treatment plan? (4)
- stabilisation of restorable lesions (IRM, GIC, RMGIC)
- acclimatisation to dentistry
- removal of unrestorable teeth
- prevention - OHI, diet advice, FS, FV
options for managing caries in anterior primary teeth (4)
- prevention (fluoride)
- proximal stripping
- strip crowns
- extraction
describe proximal stripping (what, 3 indications, +/-, technique)
- opening the ID spaces of primary anterior teeth to allow fluoride to access
- indications = exfoliation close, pre-cooperative but able to use soflex disks, superficial interproximal lesions
+ = simple, quick, self-cleansing allowed - = pulp vitality, food packing, space loss, poor aesthetics
1 create tapered smooth crown form with slow speed soflex discs (or bur)
2 polish + FV
indications for proximal stripping for anterior primary teeth caries (3)
- exfoliation close
- pre-cooperative but able to use soflex disks
- superficial interproximal lesions
describe strip crowns for anterior primary teeth caries management (indications, technique)
- enamel hypoplasia, dental anomalies in a compliant pt
1 LA, rubber dam
2 tapered preparation with high speed diamond (2mm incisal, labial groove)
3 cellulose acetate crown form and composite to restore
when might you take an intraoral radiograph regarding the maxillary central incisors’ development in a child? (3)
- erupted but grossly rotated
- large diastema
- unerupted beyond normal timing (asymmetry >6 months or disturbed order)
what are the differences between the conventional and Hall technique with preformed metal crowns? (3)
- conventional requires LA and tooth preparation and caries removal but Hall does not
- conventional requires excellent pt cooperation, Hall can be done in less compliant pts
- Hall technique can only be used for asymptomatic teeth or reversible pulpitis
describe indirect pulp therapy (why, indication, steps)
- arrest caries process and encourage reactionary dentine formation and remineralisation of remaining carious dentine
- maintain pulp vitality
- indication = teeth with deep carious lesion but no s/s of pulpal pathology
1 LA, rubber dam
2 remove all caries at EDJ
3 remove soft deep carious dentine over pulp with care to avoid exposure
4 appropriate lining (eg RMGIC, CaOH)
5 definitive restoration for coronal seal, ideally PMC
define molar-incisor hypomineralisation
- developmentally-derived dental defect
- involving hypomineralisation of 1-4 first permanent molars
- frequently associated with similarly affected permanent incisors
give the features of mild MIH (3)
- demarcated opacities located in non-stress bearing areas, mild incisor involvement if present
- no caries associated with affected enamel
- no hypersensitivity
give the features of moderate MIH (4)
- demarcated opacities on molars and incisors
- post-eruptive enamel breakdown limited to 1-2 surfaces without cuspal involvement
- atypical restorations may be needed
- normal dental sensitivity
give the features of severe MIH (4)
- post-eruptive enamel breakdown and crown destruction
- caries associated with affected enamel
- history of dental sensitivity
- aesthetic concerns
what age is the critical period for causing enamel defects of FPMs and incisors?
first 2.5 years of life (early maturation)
factors causing MIH (up to 15)
1 prenatal:
- maternal pyrexia
- medication
- prolonged vomiting
2 perinatal (difficult birth):
- c-section
- prolonged or complicated delivery
- hypoxia
- premature, low birth weight
- hypocalcaemia
3 post-natal:
- ENT infections (recurrent and needing antibiotics)
- chicken pox, measles, mumps
- respiratory problems
- pyrexia
- prolonged medication
- antibiotics
- breast feeding
what does the colour of the demarcated opacities indicate in MIH? (Jalevik & Noren 2000)
- yellowish-brownish = full thickness and more porous = more likely to have PEB
- creamy, yellow, whitish = less porous, variable depth
what is the 6 step management of MIH? (William et al 2006)
1 risk identification
2 early diagnosis
3 remineralisation and desensitisation
4 prevention of caries and PEB
5 restorations or extractions
6 maintenance
what does CPP-ACP stand for and which patients might not be suitable?
- casein phosphopeptide-amorphous calcium phosphate
- milk protein - consider those who are lactose intolerant
which restorative materials may be used to restore FPMs for those with MIH? (4)
- RMGIC or GIC = temporary, non-stress bearing areas
- composite = ≥1 surface needs restoration (but may be sensitive and decreased bond strength)
- PMC = must be replaced by cast onlay/crown at some point (teens)
- cast onlays/crowns
what are the 2 approaches that may be taken when restoring MIH-affected teeth and why are they good/bad?
1 remove all defective enamel = loss of more tooth tissue but better bond
2 remove only porous enamel until resistance to bur/probe is felt = less invasive but defective enamel may continue to chip away
factors to consider when extracting molars affected by MIH (4)
- other molars (should definitely be unaffected)
- severity (mild may be acceptable)
- occlusion (other teeth present, minimal crowding, inclination of 5s, stage of 7s, presence of 8s)
- timing
what factors guide the timing for extraction of FPMs in children? (2)
- calcification of bifurcation of the lower 7s (usually ~9yo)
- angulation of 7s (15-30º)
give the factors for consideration of loss of FPMs (6)
- underlying malocclusion
- no missing teeth (including the 8s)
- timing (early means loss of space, late means space not closed)
- extent and location of crowding
- long term prognosis
- which FPM (lowers may need compensation)
what options are there for treating incisors affected in MIH? (6)
- bleaching (>18yo only)
- resin infiltration (ICON)
- microabrasion only
- direct composite restoration
- microabrasion and composite
- porcelain/composite veneers in adulthood
treatment for mildly affected FPMs in MIH (3)
- FV on PE molars
- FS on fully erupted molars
- composite restoration if breakdown or caries
treatment for moderately/severely affected FPMs in MIH (4)
- consider extraction
- FV or GIC on PE molars
- composite restoration for ≤3 surfaces
- PMC/copings for >3 surfaces
indications for inhalation sedation (5)
- mild-moderate anxiety
- special healthcare needs
- pronounced gag reflex
- LA not possible
- cooperative child but challenging/traumatic dental procedure
define conscious sedation
- technique that produces a state of CNS depression to enable treatment to be delivered
- during which verbal contact with the patient is maintained throughout
what are the 3 modes of action of inhalation sedation/nitrous oxide gas?
- anxiolytic (similar to benzodiazepines via GABA A receptors)
- analgesic (stimulates opioid release)
- anaesthetic (non-competitive inhibitor for NMDA-type glutamate recepts)
s/s of ideal sedation in children (up to 10)
- normal relaxed respiration
- peripheral vasodilation
- decreased muscle tone
- pupil dilation, eyelids relax
- delayed response to questions
- tingling/numbness in hands/feet
- warmth
- light-headed, dizziness
- euphoric feeling
- numbness of IO soft tissues
contraindications for IHS (up to 10)
- ASA III+ cannot be done in PDC
- pre-cooperative
- phobic
- nasal obstructions, severe respiratory diseases
- recent medical procedures involving intracranial gases (expansion)
- middle ear infection, recent ENT operation (2wks)
- neuromuscular disorders
- porphyria
- antifolate medication (methotrexate)
- bleomycin chemotherapy
advantages of IHS (up to 9)
- non-invasive, well-tolerated
- titrated
- wide margin of safety
- rapidly absorbed (2-3mins)
- rapidly eliminated (5mins)
- minimal impairment of reflexes
- some analgesic properties esp with semihypnotic suggestion
- reduces anxiety at following visits
- cost-effective alternative to GA
disadvantages of IHS (up to 9)
- lacks potency
- heavily reliant on psychological support
- needs nasal breathing and compliance
- variable post-op amnesia
- nasal hood may impede access
- may still need LA
- nitrous oxide pollution
- can have unfavourable psychological reactions and LOC in some
- headache, vomiting, nausea with higher levels of sedation
give some of the effects of prolonged nitrous oxide exposure on staff (2)
- haematological = impaired RBC production, pernicious anaemia
- reproductive (avoid in first trimester)
what is diffusion hypoxia? (3)
- potential complication during recovery period after IHS
- rapid release of nitrous oxide from blood into alveoli = decreased oxygen concentration leading to hypoxia
- disorientation, headache, nausea, vomiting
how is diffusion hypoxia prevented?
administering 100% oxygen for 3-5 mins after nitrous oxide gas is stopped
pre-operative instructions for IHS (3)
- light meal before treatment
- do not bring other children
- reschedule if child is unwell or nasal obstruction
pre-operative checks for IHS (5)
- suitable escort
- MH, no nasal obstruction
- light meal
- toilet
- second stage consent
what is involved in clinical monitoring of a child during IHS? (5)
- responsiveness
- colour
- respiratory rate and rhythm
- muscle tone
- eyes
risks of GA (up to 10)
- 1/10 headache, nausea, vomiting, dizziness, agitation on waking (1/5), sore nose or sore throat, tummy ache
- allergy 1/10,000
- death <1/100,000
GA indications (4)
- very young child, too anxious or uncooperative for other means
- medically compromised
- difficult or complex dental treatment
- extractions in multiple quadrants
define general anaesthesia
state of controlled unconsciousness during which you feel nothing and can be described as “anaesthetised”
when is GA not appropriate for dental treatment? (3)
- carious asymptomatic teeth with no signs of sepsis
- orthodontic extractions of sound permanent premolars in a healthy child
- pt/carer preference only
describe different types of GA airway management (4)
- McKesson nasal mask - mouth free for access, only for single tooth extractions
- laryngeal mask - sits over vocal cords, for more extensive dental treatment but limited access and easily dislodged
- oral intubation - for longer treatments (more robust) but difficult access
- nasal intubation - more associated complications but less access issues
what does the UN Convention on Rights of the Child 1989 say regarding children’s rights? (2)
- children should be protected from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation
- children have a right to enjoy the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation
what does the Children’s Act 2004 say about safeguarding (in short)?
safeguarding children is the responsibility of everyone
what is “safeguarding” and what does it involve? (4)
- wider range of measures are taken to minimise risks and harm to children
- protecting from maltreatment
- preventing impairment of children’s health or development
- ensuring children grow up in a safe and caring environment
what is “child protection”?
action taken to protect children who are suffering or at risk of harm
define “child abuse” and give the 4 different types
- term to describe a number of ways in which a child can be harmed
- any child, isolated or recurrent
- physical
- emotional
- sexual
- neglect
what environmental factors may increase the risk of child abuse? (5)
- poverty
- social isolation
- poor housing
- domestic violence at home
- poor access to facilities
give some characteristics which may increase the risk of someone being a child abuser (up to 6)
- younger parent
- mental health problem
- drug/alcohol abuse
- victim of abuse themselves
- personality traits - impulsiveness, low tolerance, aggressive tendencies
- unrealistic expectations from a child
give some characteristics which may increase the risk of a child being abused (up to 6)
- younger children
- disabilities
- unwanted pregnancy
- premature/low BW babies
- prolonged separation from mother
- characteristics which evoke negative response (persistent crying, behavioural difficulties)
define physical abuse and give examples (up to 4)
- “deliberate physical injury to a child or failure to prevent physical injury or suffering”
- hitting, shaking, squeezing, burning, biting
- injury from restraining
- harm as a result of giving alcohol, inappropriate drugs or poison
- fabricated or induced illness (FII)
what features of the history taking would raise suspicions of child abuse? (2)
- delayed presentation
- story inconsistent with injury or variation between child vs carer account
describe the differences in features of accidental and non-accidental injuries (3)
- accidental = usually bony prominences, match developmental age/stage of child
- non-accidental = bilateral, soft tissue sites, triangle of safety
- non accidental may also have imprints of fingers, teeth, cigarette-shaped burns
what is the triangle of safety?
- area including ears, side of face, neck and top of shoulders
- unlikely to be traumatised accidentally
define neglect and give examples (up to 4)
- “persistent failure to meet a child’s needs (physical, emotional +/or psychological), likely to result in the serious impairment of the child’s health/development”
- failure to provide adequate diet, make arrangements for health care
- inadequate clothing
- lack of appropriate supervision, stimulation
- leaving child alone at an inappropriate age
give some signs of child neglect (up to 7)
- frequent minor injuries or recurrent infections, lice infestations
- poor hygiene
- abnormalities of hair/skin
- developmental delay
- inappropriate/inadequate clothing for season/weather
- non-attendance at school
- constant hunger/stealing
define emotional abuse and give examples (up to 5)
- “persistent emotional ill treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development”
- persistently withholding love and affection
- constantly shouting at, threatening or demeaning
- being overprotective (child unable to mix with others)
- racial or other forms of harassment undermining a child’s self-esteem
- telling them they wish they were dead
how may the parent and child present if emotional abuse is occurring?
- parent = negative view of child, ignores child, constantly undermining and criticising, ridiculing
- child = low self-esteem, delayed development, no sense of fun, self-harm, constantly seeking approval
define sexual abuse and give examples (up to 3)
- “forcing or enticing a child to take part in sexual activities”
- making a child engage in/observe sexual activities
- showing a child pornographic material
- engaging a child in inappropriate discussion about sexual matters
what are some possible signs of child sexual abuse? (7)
- sudden unexplained changes in behaviour
- running away from home
- self-harm or attempted suicide
- eating disorders
- oral signs (eg STIs)
- alluding to secrets which they cannot reveal
- disclosure
describe how we deal with suspected child abuse (flowchart)
1 assess the child (hx, ex, talk)
2 discuss concerns with appropriately experienced colleague
- local safeguarding board, safeguarding children advisory service telephone helpline
- consultant paediatrician
- child protection nurse
- social services
- HV, GP
STILL HAVE CONCERNS:
3 provide urgent dental care
4 talk to child and parents and explain concerns, inform of intentions to refer and seek consent to share info
5 refer for medical examination if needed, keep full clinical record
6 refer to children’s services, following up in writing within 48 hours
7 confirm referral has been received, arrange dental follow up
NO LONGER CONCERNED:
3 provide necessary dental care
4 keep full clinical records, consider liaison with HV/school nurse
5 arrange dental follow up
when might it not be appropriate to inform the parents about a child protection referral? (4)
- contrary to child’s welfare
- putting yourself or your team at risk
- suspicions of sexual abuse
- suspicions of fabricated or induced illness (FII)
define dental neglect
“the 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”
what are the possible effects of dental neglect? (up to 8)
- toothache
- disturbed sleep
- difficulty eating
- absence from school, interference in performance
- repeated antibiotic use
- exposure to GA-associated morbidity
- Turner’s tooth
- life-threatening systemic illness
what features may raise concerns with regards to dental neglect? (up to 8)
- severe untreated dental disease (obvious to a layperson)
- dental disease with significant impact on the child
- parent/carer has access to but persistently fails to obtain treatment for the child
– irregular attendance
– repeated failed appointments
– failure to complete treatment
– returning in pain at repeated intervals
– requiring repeated GA
what is the tiered response to dental neglect?
1 preventive dental team management
2 preventive multi-agency management
3 child protection referral
- implemented according to level of concern
describe the “was not brought” pathway
1 - reception calls parent within 24 hours for reason for WNB and offer new appointment, also offer discussion about any worries
2a - phone contact success = send WNB1 letter home and document
2b - phone contact failure = send WNB2 letter home, document and wait
- parent contacts = step 1 and documentation
- parent fails to contact within 3 weeks = clinician informed and risk assessment (sharing of information, contact GP) and decide if further action is required, document
give some barriers to the management of dental disease in medically compromised children (3)
- reluctance of GDPs to treat as they may feel inadequately trained
- children may become sensitised to treatment and have increased anxiety
- dental health seen as low priority in the face of other chronic illness demands
list the main types of medically compromising conditions we need to look out for in children (6)
- CV disorders
- haematological disorders
- respiratory system disease
- metabolic and endocrine disorders
- oncology
- organ transplants
what kinds of CV disorders should we be aware of when treating children? (3)
- congenital structural defects = shunts, valve defects
- acquired = rheumatic fever, Kawasaki’s disease, cardiomyopathy, prosthetic valves
- previous IE
how may a child with congenital structural heart defects present? (6)
- breathlessness on exertion
- tire easily
- recurrent respiratory infections
- cyanosis
- finger clubbing
- delayed growth or development
list some congenital structural heart defects (3)
- shunts = atrial septal defects, ventricular septal defects, patent ductus arteriosus
- valve = aortic/pulmonary stenosis
- complex = Fallot’s tetralogy, transposition of the great vessels, coarctation of aorta
list some acquired heart diseases (5)
- rheumatic fever
- Kawasaki’s disease
- cardiomyopathy
- prosthetic valves
- infective endocarditis
describe infective endocarditis (what, fatality rate, risk)
- life-threatening infection of endocardium, especially affecting heart valves
- fatality rate of 30%
- those with some cardiac defects have increased risk
how does infective endocarditis develop?
1 turbulence of blood flow, endothelial damage
2 fibrin and platelet deposition
3 seeding with bacteria
4 colonisation and multiplication
5 increased fibrin and bacteria = vegetations, risk of embolism to lung/brain
which cardiac conditions have increased risk of developing IE according to NICE? (5)
- structural congenital heart disease, including surgically corrected or palliated conditions (excluding fully repaired defects or endothelialised closure devices)
- acquired valvular disease with stenosis or regurgitation
- valve replacements
- hypertrophic cardiomyopathy
- previous IE
what information should be offered to patients at increased risk of IE regarding dental treatment? (4)
- risks/benefits of antibiotic prophylaxis and why it is no longer routinely recommended
- importance of maintaining good oral health
- symptoms that may indicate IE and when to seek expert advice
- risks of undergoing any invasive procedure (inc non-medical)
why is antibiotic prophylaxis not recommended routinely for dental procedures? (3)
- dental procedures not thought to be the main cause of IE (2-3%)
- unclear if prophylaxis actually prevents IE
- side effects (nausea, diarrhoea, allergy, anaphylaxis)
how does dental treatment planning vary for children with CV disorders? (5)
- aggressive prevention (diet, F-, FS,OHI) with regular clinical and radiographic monitoring
- dental disease treated before any cardiac surgery
- no antibiotic cover for routine procedures, consider cover if chronic infection
- more radical treatment planning due to risk of chronic infections and IE
- do not conduct routine dental tx until symptomatic cardiac disease is thoroughly investigated
how may avulsed permanent tooth management differ for children with CV disorders? (2)
- risk of bacteraemia and possible chronic infection = must discuss risk/benefit
- replantation may proceed immediately but do not replant if high risk cardiac pt or poor prognosis (prolonged EADT)
(antibiotics usually indicated anyway)
list some types of inherited haematological disorders (3)
1 clotting:
- haemophilia A (FVIII deficiency)
- haemophilia B (FIX deficiency)
- von Willebrand’s disease
2 platelet = immune thrombocytic purpura (ITP)
3 blood dyscrasias
- thalassaemia (minor or major)
- sickle cell anaemia
describe haemophilia A (what, demographic, effect)
- x-linked recessive, factor VIII deficiency
- males
- varying levels with increased bleeding risk
describe von Willebrand’s disease (what, effects)
- most common inherited bleeding disorder
- dominant, von Willebrand’s factor deficiency
- vascular abnormalities, defective platelets, decreased FVIII
give 2 acquired haematological disorders/conditions
- vitamin deficiency
- anticoagulant therapy (warfarin, heparin)
how does dental treatment planning vary for children with haematological disorders? (6)
- prevention and regular review
- pulp therapy favoured to avoid extractions
- restore early lesions
- liaise with haematologist for any extractions and consider local measures
- infiltrations»_space;, avoid ID blocks (haematoma, airway compromise)
- if blocks required then factor supplements are needed +/- tranexamic acid
(best in hospital setting)
describe sickle cell anaemia (what, effects, s/s, GA)
- autosomal recessive mutation
- RBCs clump together under certain conditions (blockages, necrosis, pain) - eg infection, hypoxia
- pale, tired, weak, breathless, painful joints, growth retardation, increased susceptibility to infection
- risk for GA (need to keep oxygen high)
give 2 respiratory system diseases we should be aware of in children
- asthma
- cystic fibrosis
describe asthma (what, dental triggers)
- obstructive reversible lung disease causing breathlessness, coughing, wheezing - associated with hyperreactivity of airways to various stimuli
- dental triggers = anxiety, dust, aerosols, NSAIDs
how does dental treatment planning vary for children with asthma? (5)
- increased prevention - higher risk for caries, erosion, candida
- decrease anxiety as much as possible, may take a puff before treatment
- medications must be brought to appointments
- normal routine care
- LA and IHS better, avoid GA if possible
describe cystic fibrosis (what, s/s)
- autosomal recessive, multisystem disorder mostly affecting exocrine glands
- thick mucus, especially in the lungs causing obstruction and airway infections, malabsorption
- delayed dental development, enamel opacities, more prone to calculus development
how does cystic fibrosis affect a child’s dental health/treatment? (4)
1 high caries risk
- snack on highly refined carbohydrates (need high calorific intake)
- decreased buffering of saliva
2 clotting defects due to liver cirrhosis
3 antibiotic sensitivities, sometimes prescribed tetracycline (intrinsic staining)
4 avoid GA due to pulmonary involvement
what is the most common endocrine disorder in children?
diabetes (type 1)
how does dental treatment planning vary for children with diabetes? (5)
- intense prevention and regular review
- normal dental tx if well controlled
- early morning or early afternoon appointments
- advise normal insulin and normal eating - glucose drink if hypo
- minimal stress, may refer for GA
oral manifestations of diabetes in children (4)
- xerostomia (salivary gland dysfunction, increased salivary glucose, polyuria)
- increased caries in low risk areas (salivary hypofunction, increased salivary glucose, poor OH)
- candidiasis (salivary hypofunction, underlying deficiencies) - acute pseudomembraneous, angular cheilitis
- periodontal disease (increased pro-inflammatory mediators, increased GCF glucose)
what is the most common malignancy in childhood?
- acute lymphoblastic leukaemia (peak at 4yo)
list some oral complications that child oncology pts may have (8)
- periodontal inflammation
- oral mucositis
- tooth morphology - agenesis, microdontia, short roots, enamel/dentine developmental defects, discolouration
- reduced salivary flow (caries)
- candida infections
- loss of taste (improves over time) - may eat sweets
- difficulty swallowing - Difflam, moist food
- jaw stiffness
how does dental treatment planning vary for children with cancer? (5)
- intense prevention and regular review
- dentally fit before cancer treatment = prioritise infections, extractions and sources of tissue irritation
- pulp therapy not recommended due to immunosuppression - radical treatment planning
- defer elective dental care during therapy, liaise with oncologist for any essential tx
describe autism spectrum disorders (what, up to 5 characteristics)
- group of developmental disorders defined by a significant impairment in social interaction, communication and the presence of unusual behaviours and interests
- impaired communication and socialisation
- difficulty recognising others’ emotions and expressing their own
- lack of social imagination, inability to read social cues
- hyper or hyposensitivity to normal stimuli
- repetitive or restrictive patterns of behaviour
what other comorbidities may a patient with ASD have? (7)
- ADHD
- OCD
- depression
- epilepsy
- dyspraxia
- dyslexia
- insomnia
(etc)
oral features commonly associated with patients with ASD (4)
- poor OH - poor tongue and cheek coordination, hyperreactive to stimuli
- caries
- xerostomia (s/e of medication)
- orofacial pain - bruxism, self-abusive injuries (gingival defects, biting, self-extraction)
how may diet be affected in a child with ASD? (3)
- eating disturbances (“picky eater”)
- preferences for soft, high sugar content food
- pocketing and pouching of food
how may a child with ASD be prepared for the dental visit? (4)
- pre-appointment questionnaire (developmental age, ability to read, toilet training, social interactions, likes and dislikes)
- visual supports eg calendar, pictures
- pre-visit sessions
- social story books
how may your practice change for a child with ASD? (4)
- first appointment of the day (minimise wait time, waiting room)
- double appointment (more time)
- not changing any plan of the appointment once it has been explained
- removing overwhelming sensory stimuli
what is the GDP’s role with oral pathology in children? (4)
- careful examination and diagnosis and documentation
- reassurance to parents
- appropriate treatment or referral to specialist
- provide routine dental care
where is most oral pathology found in children?
soft tissues
give some developmental soft tissue lesions which may present in children (6)
- Bohn’s nodules
- eruption cyst
- tongue tie/ankyloglossia
- geographic tongue/erythema migrans/benign migratory glossitis
- white sponge naevus
- Fordyce’s spot
management of Bohn’s nodules
leave and monitor (should disappear spontaneously by 3 months)
describe eruption cysts in children (what, presentation, management)
- developmental odontogenic
- purple/red swellings of alveolar mucosa which may delay eruption
- radiographically may appear as enlarged follicle
- monitor (burst with spontaneous eruption) or incision if causing significant problems
describe ankyloglossia (what, management)
- lingual frenulum attaching near the tip of the tongue
- excised only if interfering with breastfeeding, speech development, oral hygiene or causing gingival recession
describe geographic tongue (associations, presentation)
- genetic, may be associated with psoriasis or atopy
- defined, irregular smooth/shiny red areas surrounded by distinct yellowish, slightly raised margins on tongue dorsum
- changes in shape, moves around on tongue
- usually asymptomatic, may be sore to acidic foods, cheese, toothpaste
describe white sponge naevus (what, presentation, management, histology)
- inherited AD disorder of keratin, benign
- white soft thickened folded mucosa with undefined margins, usually bilateral on buccal mucosae
- monitored
histology: - “basket-weave” appearance of cell membranes, no dysplasia or inflammation
- hyperkeratosis, thickened epidermis with spongy appearance
describe Fordyce’s spots (presentation, management)
- small yellowish ectopic sebaceous glands
- buccal mucosa, anterior pillar of fauces, lips
- become more prominent in puberty
- no intervention required
list some reactive soft tissue lesions that may be seen in children
- mucocele/mucous extravasation cyst
- infections = primary herpetic gingivostomatitis, ulceration, VZV, candidiasis, squamous papilloma
- gingival enlargements = inflammation, gingival fibromatosis, DIGO, OFG, etc
- ulcerative = RAS (minor)
what is an important differential for gingival enlargement in children?
leukaemia
most common site for pyogenic granuloma in children
maxillary palatal gingiva of incisors/premolars
describe hereditary gingival fibromatosis (cause, presentation, histology, tx)
- genetic (associated with hypertrichosis and LD) or idiopathic
- diffuse, multinodular overgrowth of fibrous tissue of gingiva
- associated with delayed tooth eruption
- histology = epithelial hyperplasia, increased collagen, little/no inflammation
- tx = improve OH, gingivectomy after puberty (recurrence common)
