Paeds/Ortho Flashcards
You are a GDP. A 2yo patient is brought by their mother. The parent is unsure about fluoride varnish and would like you to answer her questions about it.
She has a 6yo child as well, who did not receive fluoride varnish.
She wants to know why her younger child needs fluoride varnish.
She has also heard that too much fluoride could be harmful and would like to know if this is true or not.
Please answer her questions
6 mins
MOSCE
Introduction - name and designation. Greet patient by name.
Fluoride varnish is a varnish containing high-strength fluoride, around 15x strength of normal toothpasteIt is non-invasive and painted on the teeth. It helps to prevent tooth decay by interacting with enamel (the outer layer of tooth) to promote hardening (remineralisation) and prevent softening (demineralisation). It helps to increase strength of teeth and provides resistance to acids and bacteria. There is evidence to show that placing this has an additional benefit over and above daily tooth brushing.
It is recommended for all children, not just those most at risk. The frequency is risk-based, but all children should be receiving it at least twice a year. These recommendations are based on evidence - there is guidance developed by groups that research interventions in dentistry, called SDCEP and SIGN. These are Scottish networks of dental and other healthcare professionals that look at different interventions to determine if there is a benefit to patients and then recommend implementing them.
Because it is applied to the tooth directly, the risk of harm being caused by fluoride is minimal. It is the same with using fluoride toothpaste as recommended - using a smear of toothpaste for under 3s and a pea-sized amount for those aged 3 and over. Brushing should be supervised by an adult until the child can do it themselves, usually around 7 or 8 years old. Also the fluoride varnish quantity is carefully controlled and only a minimal amount is placed.
Possible side effects include fluorosis (mottling on teeth), which look like small white/discoloured marks on teeth that are still growing (adult teeth). This can be managed later if this occurs (whitening). There is an extremely small risk of fluoride toxicity, which would only occur if your child swallowed a lot of toothpaste, straight from the tube. If this happened, you can phone us or NHS24 who will provide you with advice.
We don’t place it on children who have been hospitalised with asthma in the past year or those with an allergy to a substance called colophony in stick plasters, but there is an alternative varnish that can be used for those with an allergy.
To place it, we dry the tooth and paint it on. We advise not to have any food or drinks for an hour after it’s placed, to have a soft diet for the rest of the day and not to have any dark coloured foods.
Does that all make sense? Do you have any other questions?
Communication marks - active listening, rapport/empathy, non-verbal communication, clear use of language
Prompting - information given freely with minimal/no prompting
You are a GDP. A 6yo child is brought in by their mum. You notice they have had previous restorative work on their primary dentition.
Give OHI to this child and their parent
6 mins
Introduction - name and designation
CRA - high (due to clinical evidence). Therefore enhanced prevention is required (as per SDCEP)
OHI - brush thoroughly for at least two minutes twice a day including last thing at night. Spit the toothpaste out, don’t rinse your mouth when you’re finished brushing. Start brushing as soon as the first tooth erupts, parent-supervised/assisted brushing until at least 7yo. Use a pea-sized amount of toothpaste on a dry brush.
Use an adult toothpaste, with normal strength fluoride in it (1350-1500ppm - normal 1450ppm). If >10yo - 2800ppm Duraphat
Can use a fluoride-containing alcohol-free mouthwash (225ppm) if >7yo at a different time to brushing if they want (after lunch is good).
No food/drink/rinsing for 30mins after brushing or 15mins after using MW
Diet advice - complete a diet diary. Limit intake of sugary food/drinks. Only drink pain unflavoured water/milk between meals and try to stick to healthy snacks that are low in sugar (fresh fruit (limit), carrots, peppers, breadsticks, oatcakes, low fat cheese in moderation). Avoid sugary drinks/fruit juice/soy/sweetened milk in bottles/cups. No food/drink (except occasional tap water) after brushing at night. Be aware of hidden sugars in food (tomato soup/sauce) and acid content in drinks. Keep sugars to mealtimes - better all at once than little and often.
Get child to demo brushing technique at each appt and correct technique.
Extra prevention - FS Ds, Es, 6s, 7s, 2s. FV x4/yr
Does that all make sense? Do you have any questions?
You are a GDP. A distressed mother brings in her 2yo son, who appears distressed and in pain.
Clinical photos are provided -
photos 2
Take a brief pain history, provide a diagnosis to the mother and outline your proposed plan for managing this
6 mins
Introduction - name and designation
I can see your son is quite distressed. I just have a few questions before we talk about what we can do to try and treat it, if that’s ok?
Hx - how long has it been sore? Have you used any pain relief? How much? Has it worked? Is he feeding normally? Is he sleeping normally? Any other symptoms - feeling hot, sweaty, shivering?
Do you give him a bottle/drinking cup with him to bed? What is in it? Does/did he breastfeed? Did you keep to a routine or was he fed on demand? When did he stop brastfeeding?
Does he take any medications?
Photos show decayed upper incisors, possibly Ds, lower Cs. Lower incisors are sound.
Diagnosis - nursing bottle caries/early childhood caries.
Explain - your son has a form of dental decay, known as nursing bottle caries. It is caused by frequent sugar intake with/without reduced saliva flow. It is caused by prolonged breastfeeding, overnight use of drinking cups or medicines containing sugars. Essentially the teeth are bathed in sugary liquids for a prolonged period of time. The decay targets the top front teeth, and some of the back teeth on the top and bottom. The reason that the lower front teeth aren’t affected is that they are protected by the tongue and saliva that is expressed into the mouth through channels just behind them on the floor of your mouth.
Prevention - use a feeder cup (not a bottle) from 6mths old, no overnight feeding/drinking, no on-demand breastfeeding, plain water and milk between meals only, speak to GP about getting sugar-free meds. Brush teeth with a smear of toothpaste containing fluoride for 2 mins, twice a day. Enhanced prevention.
I think the best option for your son would be to take out the decayed teeth that are causing him problems. We could try this in the dentist using local anaesthetic, but I think due to his age and ability to cooperate and how many teeth are affected, it would be better to have it done under GA. There are some risks associated with this, including some very rare major risks (headache, nausea, vomiting, drowsy, upset, sore nose/throat, nose bleed; death, coma, brain damage).
For the teeth that aren’t sore, we can try to nurse them along. In the meantime, using pain relief such as Calpol or Nurofen as described on the bottle will help to reduce the distress he’s in. Make sure he keeps drinking water and doesn’t get dehydrated and is eating as normal. If you think he is dehydrated, phone NHS24.
I will write a referral to the dentists who will be removing the teeth under GA and ask them to see you to discuss it in more detail. I’ll also arrange a review appt with you in a week or so to see how things are.
Does that all make sense? Do you have any questions?
You are a GDP. A 10yo girl is brought in by her mum, who would like a second opinion. Her previous GDP had said that all 4 of her 6s need extracted.
After completing an examination, you determine that the 36 is unrestorable and will need extracted.
The patient has a class I incisor relationship, with mild buccal segment crowding.
Discuss you findings with the patient and her mother and explain how you intend to proceed
6 mins
Introduction - name and designation
Concerns - what was said before.
Have completed your exam and have some findings that you would like to discuss with them if that would be alright?
Tooth 36 - bottom left back tooth has extensive decay in it. Due to sugars sticking to tooth, not being removed, becoming acidic and wearing away/burrowing into the enamel, causing decay. Because it is so extensive, needs to be removed.
The other 3 corresponding teeth are fine. Removing this tooth at the correct time may reduce the risk of future crowding - removing it when the roots of the tooth behind it being to form, normally around 9-10yo. Tooth can erupt forward into the space.
Other dentist may have spoken to ortho/have ortho experience, but I don’t and don’t have the notes, so can’t say why he had said they have to come out. There is not much benefit for removing these teeth to prevent other teeth shifting about or the tooth above it continuing to erupt further than it should.
Plan - XLA 36, refer for ortho opinion. They may request other teeth to be extracted, which we can do.
Does that make sense? Do you have any questions?
You are a GDP. A 7yo boy is brought in by his dad.
You complete an examination and take left and right bitewings. You can see caries on the bitewings on teeth 55, 65 and 74.
Describe how you would assess his caries risk and create a prevention plan.
6 mins
VOSCE
Introduction - name and designation
Explain you have some findings that you wish to discuss.
There is some decay on some of his teeth - one top right, one top left and one bottom left. Decay occurs due to sugars sticking to tooth, not being removed, becoming acidic and wearing away/burrowing into the enamel, causing decay.
It’s caused by sugars in the diet and not removing them from tooth brushing.
Because there is evidence of decay, we would say he is at high risk of developing further decay and so we would look to treat the decay and implement some methods of preventing the decay that I’d like to discuss with you if that’s alright?
OHI - brush thoroughly for at least two minutes twice a day including last thing at night. Spit the toothpaste out, don’t rinse your mouth when you’re finished brushing. Start brushing as soon as the first tooth erupts, parent-supervised/assisted brushing until at least 7yo. Use a pea-sized amount of toothpaste on a dry brush.
Use an adult toothpaste, with normal strength fluoride in it (1350-1500ppm - normal 1450ppm). If >10yo - 2800ppm Duraphat
Can use a fluoride-containing alcohol-free mouthwash (225ppm) if >7yo at a different time to brushing if they want (after lunch is good).
No food/drink/rinsing for 30mins after brushing or 15mins after using MW
Diet advice - complete a diet diary. Limit intake of sugary food/drinks. Only drink pain unflavoured water/milk between meals and try to stick to healthy snacks that are low in sugar (fresh fruit (limit), carrots, peppers, breadsticks, oatcakes, low fat cheese in moderation). Avoid sugary drinks/fruit juice/soy/sweetened milk in bottles/cups. No food/drink (except occasional tap water) after brushing at night. Be aware of hidden sugars in food (tomato soup/sauce) and acid content in drinks. Keep sugars to mealtimes - better all at once than little and often.
Get child to demo brushing technique at each appt and correct technique.
Extra prevention - FS Ds, Es, 6s, 7s, 2s. FV x4/yr
Does that all make sense? Do you have any questions?
You are a GDP. A 6yo child is brought in by their mum. You notice they have had previous restorative work on their primary dentition.
The mother asks about fissure sealants and the benefits of placing them.
Please discuss fissure sealants with the mother and answer any questions that she might have.
6 mins
Introduction - name and designation. Greet patient by name.
Ask if they have any information on fissure sealants and where they got their information?
A fissure sealant is a thin coating placed on the teeth to make it easier to clean them, and prevent decay developing. They are placed on puts and fissures - these are grooves/narrow valleys in the teeth between the cusps (mountains). These grooves are very difficult to get brush bristles right down to the bottom of them, so sugar and bugs aren’t removed and this causes decay. Fissure sealants seal over the groove, making the valley shallower and easier to clean.
They are recommended for all children, not just those most at risk. What teeth are sealed is based on risk of developing decay though. These recommendations are based on evidence - there is guidance developed by groups that research interventions in dentistry, called SDCEP and SIGN. These are Scottish networks of dental and other healthcare professionals that look at different interventions to determine if there is a benefit to patients and then recommend implementing them.
All children should have their first back adult teeth (molars) sealed when they have erupted fully. Children who are at higher risk of decay (previous decay, fillings in the past) can have more teeth sealed - a few primary teeth and then the second back adult teeth and some of the inside surfaces of some teeth at the front.
Procedure - to place them, we pop in some cotton wool rolls and a Dryguard - a sticker inside the cheek to help prevent saliva getting onto the tooth. We clean the tooth with a drill (polish like scale and polish) and then wash and dry it. We paint on something called etch - this is an acid that roughens the tooth surface, helping the sealant lock in place and preventing it from being dislodged. Then wash that off after 20 seconds. We dry the tooth again, place the sealant on (liquid) and then cure it with a light for 20s to harden it. We then check to make sure it’s well placed and there are no problems.
It won’t change the bite and generally it’s forgotten about about a few minutes.
It’s not placed in sites with existing decay - this needs to be removed and filled with a different material.
If cooperation is difficult, we can use a different material to help provide some protection - it’s placed on the surface and then we press on it with our finger and cure it. These are better than nothing, but not as good as the first method.
Does that all make sense? Do you have any other questions?
You are a GDP. An 8yo female is brought in by her mother for an emergency appointment, after being hit with a hockey stick during training, injuring one of her upper front teeth.
After completing the examination, you take a PA x-ray
Clinical photos and the PA x-ray are provided - photos 3
Provide a diagnosis and outline your management to the patient’s mother.
No further history is required, and there are no other more serious injuries.
6 mins
MOSCE
Introduction - name and designation
Dx - EDP#. > pin prick exposure.
Explanation - the tooth has 3 layers - the outer white layer, a middle layer and the centre which contains blood and nerve endings. These are enamel, dentine and pulp. What has happened is that this tooth has broken through all 3 layers, which we call an enamel-dentine-pulp fracture. Does that make sense?
What we do with it depends on how much pulp is exposed. As this is a large exposure, the treatment of choice is called a pulpotomy. This is when we remove some of the pulp. The aim is to remove the infected pulp (exposed part that will have had bugs move in), leave undamaged pulp tissue alive so that the tooth stays alive and continues to grow.
We’ll need to do some tests to see how the nerve in the injured and adjacent teeth respond - these are called sensibility tests. We test the nerve with a machine that causes a tingling sensation and also with something that should feel cold. This is so we can monitor the tooth long-term by repeating the tests to see how it has responded to the treatment.
We’ll need to use local anaesthetic to numb up the tooth as it would be a very uncomfortable procedure without because we are in the centre of the tooth where the nerves are. This will involve an injection into the gum, but we can use a gel on the gum to reduce how uncomfortable this is.
Once everything is nice and numb, we need to stretch over a rubber sheet called dental dam. This is a sheet of rubber that covers the mouth to help reduce any moisture contamination from saliva (keeping it clean) and provide some protection to the airway.
We’ll then use a drill to remove some pulp tissue. The aim is to leave only good pulp tissue, so we’ll remove a little bit at a time until we’re happy that all that is left is healthy tissue.
Once that’s done and the bleeding has stopped, we’ll put a seal over the top of the pulp to ensure it stays clean and alive. We’ll then put a white filling over the top of the tooth to help regain aesthetics.
Does all that make sense? Do you have any questions?
Actor marks - 2 marks for describing treatment in understandable manner, supportive and empathetic regarding injury. 1 mark if partially. 0 marks if not at all
You are a GDP. A 10yo male is brought in by his mum after knocking one of his front teeth when he fell. He has no other associated injuries.
After examination and x-ray, you diagnose a lateral lunation of tooth 11.
Construct a trauma splint for this tooth (describe)
6 mins
Cut length of 0.5mm flexible stainless steel wire. Length so that the ends of the wire finish at the centre of the adjacent teeth.
Flexible splint, so teeth to be splinted are affected tooth (11) and one tooth either side (12 and 21)
Bend the wire into shape, so that it is passive (contacting all teeth surfaces). Clean teeth, etch, wash, dry.
Place small ball of composite in the middle of the labial surface of each tooth. Sink the wire in to the composite, ensuring it stays passive. Cure the composite.
Place a larger ball of composite over the top of each smaller ball to keep it in place, covering the ends of the wire. Cure this. Smooth as required
OHI - keep clean with soft brush, ID cleaning (super floss), soft diet for 2/52, can use CHx MW for a week if needed.
R/V and remove splint in 4/52
2/52 splint - subluxation, extrusion, avulsion
4/52 splint - lateral luxation, intrusion, avulsion, dento-alveolar fracture (primary and permanent)
You are a GDP. A 3yo child is brought in by their mother. They have an avulsed 61 that has been brought in milk.
Describe how you intend to proceed
6 mins
Introduction - name and designation
Brief Hx - what happened, where, when, how?
Rule out head/brain injury - LoC, headache, nausea, vomiting, dizzy, confused, irritable, light/noise sensitivity, amnesia, balance issues, CSF leak
Rule out other injuries - ribs, limbs, internal bleeding
If any Sx - send to ED
Mx - Baseline trauma stamp - sinus/tender in sulcus, colour, TTP, mobility, displacement, EPT, thermal test (ECl), percussion note, radiographs
Ensure tooth complete (no #). Leave out, do not replant.
View socket - #s, gingival tears. Consider irrigating and suturing.
Take PA XR to check permanent successor
Pain relief advice - Calpol/Nurofen
Ask about tetanus status - need a booster? Consider ABx if immunocomp or very dirty injury
Explain to mum - it’s a baby tooth, so is expected to fall out in the next few years. The reason we don’t replace it is that this could cause damage to the permanent tooth that will replace it.
Trauma to the baby tooth can cause problems to the permanent successor - enamel defects (enamel discoloured/less quantity or quality), abnormalities in shape/size/angle of tooth or root, delayed eruption, ectopic position (tries to erupt incorrectly and gets stuck). It may stop forming now or earlier than usual. If any of these things happen, we’ll manage it accordingly - this may include referring for a specialist opinion.
Does all of that make sense? Do you have any question?
You are a GDP. A 13yo male is brought in by his father. He injured his 21 playing football.
You have completed an examination and taken a PA XR which shows an apical root #.
Discuss your management with the father.
There are no other associated injuries and no need to ask any more questions for a history.
6 mins
Introduction - name and designation
Dx - the tooth is fractured in the root. This is the part that sticks in the socket and holds the tooth into the bone.
Because it is mobile, we have to splint it in place to give it a chance to heal. We do this by placing a think wire over the front of the tooth and one either side, held in place by a small amount of white filling material. This should stay in place for 4/52. Will need LA (injection into the gum to numb up tooth, gum and bone) and will clean gum around it too (with salty water)
Baseline trauma stamp - sinus/tender in sulcus, colour, TTP, mobility, displacement, EPT, thermal test (ECl), percussion note, radiographs
We’ll need to do some tests to see how the nerve in the injured and adjacent teeth respond - these are called sensibility tests. We test the nerve with a machine that causes a tingling sensation and also with something that should feel cold. This is so we can monitor the tooth long-term by repeating the tests to see how it has responded to the stabilisation and see if it requires any further treatment. If it fails to heal in a good way, we might need to undertake root treatment to keep the tooth and prevent it causing any pain or symptoms.
We’ll review in 4/52 to remove the splint and then 6-8/52, 6/12 and 12/12 and then regular checkups after that at least once a year.
Instructions - keep nice and clean with soft brush, soft diet for 7/7, analgesia as required, CHx for 7/7.
Does that all make sense? Do you have any questions?
Signs of healing - calcified and/or CT union across # line.
4/52 splint - middle third, apical third
12/52 splint - coronal third
You are a GDP. A 14yo female is brought in by her mother. She injured his 21 playing hockey 45 minutes ago.
You have completed an examination diagnosed a crown #.
Discuss your management options with the examiner.
There are no other associated injuries and no need to ask any more questions for a history.
6 mins
Introduction - name and designation
Account for missing fragment - if not found, XR soft tissues, consider if it has been swallowed/inhaled (ED for CXR).
Examine other soft tissue injuries, irrigate and suture if required.
Rx of tooth depends on type of # - XR to determine this and any damage to supporting structures.
E# - selective grinding/bond fragment/composite
ED# - bond fragment/composite bandage
EDP# - if pin prick/<60min - pulp cap (non-setting CaOH). If >60min and/or > pin prick - partial pulpotomy (high-speed to remove pulp, leave healthy pulp, dress, composite).
Baseline trauma stamp - sinus/tender in sulcus, colour, TTP, mobility, displacement, EPT, thermal test (ECl), percussion note, radiographs
Advice - Instructions - keep nice and clean with soft brush, soft diet for 7/7, analgesia as required, CHx for 7/7.
R/V - 6-8/52, 3/12, 6/12, 12/12, annually for 5yrs. If signs of failure/necrosis - discolouration, sinus, swelling, resorption, will require RCT
You are a GDP. A dad brings in his 18 month old child, who had fallen down, causing an injury to the 51.
Clinical photos are provided - photos 4.
Perform a knee-to-knee exam, discuss the management of this tooth and the consequences to the permanent dentition with the father
There are no associated injuries.
6 mins
Introduction - name and designation
Reassure - I can imagine it’s been stressful, but you’ve done the right thing coming in and we’ll help as best we can.
Explain - to examine your child, I’ll need to have a look at the tooth and inside the mouth. I’ll need your help with this, to help me perform a knee-to-knee exam. What we’ll do is sit across from each other with out knees together. I’ll get you to sit your child on your lap, facing you with their legs around your waist. If you can hold onto their hands/arms and lower them down, so that their head is in my lap, that will mean I can have a look and you have control of their arms and legs and they can look up and see you. Does that make sense?
Perform knee-to-knee exam
Baseline trauma stamp - sinus/tender in sulcus, colour, TTP, mobility, displacement, EPT, thermal test (ECl), percussion note, radiographs
Look for ST damage/damage to adjacent teeth.
Dx - subluxation. The tooth has been bumped/knocked and the supporting structures that hold the tooth in place have been bruised. There’s some bleeding from the gum, the tooth is slightly wobbly and sensitive to touch, but it’s not been pushed out of line, so we manage this by doing nothing and keeping it under review. We would recommend a soft diet for 7/7 and keep it clean with a soft toothbrush. If it is too sensitive to brush, you can clean it with CHx MW and a soft brush/swab x2/day. Pain relief as necessary
R/V - we’ll see you again in 7/7 and then again in 6-8/52 to see how it is healing. Signs that it isn’t healing well include swelling around the gum, a hole in the gum that may or may not extrude pus, discolouration of the tooth or gum or it becoming more wobbly. If any of these happen, get in touch and we’ll manage it as we have to.
There is a risk of damage to the adult tooth that will replace this tooth. It’s currently developing in the bone beyond the end of the tooth and may have been bumped when the baby tooth was bumped. This could lead to enamel defects (enamel discoloured/less quantity or quality), abnormalities in shape/size/angle of tooth or root, delayed eruption, ectopic position (tries to erupt incorrectly and gets stuck). It may stop forming now or earlier than usual. If any of these things happen, we’ll manage it accordingly - this may include referring for a specialist opinion.
Does that all make sense? Do you have any questions?
You are a GDP. You receive a telephone call from a distressed parent, who’s 10yo child has lost an upper front tooth. It fell out while roller-skating.
The mother has the tooth, but doesn’t know what to do with it.
Give advice to the mother.
6 mins
Introduction - name and designation
Keep patient calm.
Information required - what tooth? (count from front), what happened? How old is the child? When did it happen? How did it happen?
Tooth condition - do you have it? Is it whole or broken into more than one piece?
Rule out head/brain injury - LoC, headache, nausea, vomiting, dizzy, confused, irritable, light/noise sensitivity, amnesia, balance issues, CSF leak
Rule out other injuries - ribs, limbs, internal bleeding
If any Sx - send to ED
MH - is child taking any medications/suffering from any medical conditions (immunocomp - C/I to replanting)
Tetanus booster - last one? New one required?
Would you be happy to try to put it back in? If so, handle by the crown (smooth white hard), gently rinse it in milk/pt saliva/saline for 20s. Replant the tooth, with the smooth white side facing forward. Bite on gauze/handkerchief, get to dentist ASAP.
If not happy to replant, store in milk/saliva and get to dentist ASAP.
When arrives, do not remove if replanted. If in mild/saliva, rinse for 20s, LA, replant. Handle crown only.
2/52 flexible splint, trauma stamp.
Irrigate and suture any wounds.
R/V - 2/52, 4/52, 3/12, 6/12, 12/12 and annually for 5yrs. Aiming for revascularisation - if not, RCT
POI - soft diet 2/52, avoid contact sports, soft TB after meals, CHx x2/day 7/7.
Prescribe ABx - pen V 250mg tablets, 2 QDS, 5/7
Does that all make sense? Do you have any questions?
Describe the procedure of performing a pulpotomy in a vital primary tooth
6 mins
LA + dam
Caries removal (high-speed, slow-speed, excavator)
Access with high-speed to remove roof of pul chamber
Remove coronal pulp with slow-speed/excavator until able to see pulp stumps
Arrest bleeding with saline-soaked pledget
Assess bleeding (ferric sulphate, 20s)
If poor haemostats/infected –> pulpectomy
If good haemostasis - ZOE/CaOH/MTA dressing, GIC in pulp chamber, SSC
You are a GDP. A 14yo girl attends with her mum, C/O stained teeth.
Using the photos and x-rays provided, give a Dx and discuss management options with the parent and patient.
Clinical photos and x-rays - photos 5
No further history taking is required.
6 mins
Introduction - name and designation.
Dx - MIH
Molar-incisior hypomineralisation is a condition where the enamel and dentine (outer and middle layers) are softer than normal and can lead to tooth decay. It affects the adult front teeth and molars (back teeth) and sometimes back baby molar teeth. Around 20% of the population have the condition in one form or another, some people just won’t realise it.
It’s thought to be caused by a disturbance in tooth development around the time of birth, or in the first few years of life. We don’t know what causes it, but it’s been suggested that illness in early childhood or a traumatic birth may be linked.
MIH causes affected teeth to be more sensitive, look different (have poor aesthetics). The teeth tend to be more broken down/break down more easily (loss of tooth substance).
We would encourage a good prevention plan, to prevent any further breakdown and reduce the risk of decay. This includes brushing x2/day F TP (consider 2800ppm Duraphat), having FV applied x4/yr, diet low in sugars, ID cleaning, F MW.
We can treat the front teeth to improve sensitivity and poor appearance and improve surface breakdown. Options we can use are:
Tooth whitening - aim to lighten the teeth to the colour of unaffected teeth. Easy and usually has good results, but can cause sensitivity, relapse and gingival irritation
Microabrasion - uses acid and a polishing powder to remove the outer layer of enamel to improve the appearance. Because of this, it may not improve the appearance of deeply stained teeth. Minimal damage to enamel
Internal/combo bleaching - for root treated teeth only. Good results, bleach from inside/inside and outside. Good success, risk of cervical resorption
Localised composite placement/veneer - placing a thin layer of white filling material over the top of the tooth, to fill in any areas of breakdown as well as masking the staining. No drilling but adds bulk to tooth.Has to be thin, so sometimes doesn’t cover very dark stains.
Veneer/crown - destructive prep, excellent aesthetics, restorative cycle, risk of failure and tooth loss, unstable gingival margin level.
Management of molars
Like the front teeth, the back teeth can be sensitive and can also be broken down. Treatments we could look at include:
Fissure sealants - thin coating over grooves to protect the tooth if mildly affected
GI/comp - filling in the tooth to provide support and hold the tooth together ± drill to prep.
SSC - silver coloured cap if extensive breakdown - provides support to the tooth by covering it
XLA - if the tooth is of poor quality and prognosis, it may need to be taken out. Done at the right time, this can allow other adult teeth to move into the gaps. It also provides relief from further sensitivity and breakdown, and allows for more focus on keeping the healthy teeth healthy.
Does that all make sense? Do you have any questions?
You are a GDP. A 14yo girl attends with her mum, C/O stained teeth. You suspect she has MIH.
Take a history for suspected MIH
What other differential diagnoses would be considered along with MIH
6 mins
Questions - what teeth, how long, other Sx, any problems with baby teeth, fluoride use in pregnancy.
MH - any conditions or medications/previous medications (tetracyclines)
Periods of enquiry - pre-natal (pre-eclampsia, gestational diabetes, syphilis), peri-natal (premature/full-term/late, SCBU/NICU involvement, prolonged delivery, birth trauma), post-natal (until 2yo - measles, rubella, varicella, rest diseases, CHD, fluoride use, nutrition)
Fluorosis, tetracycline staining, ortho decal, trauma, AI/DI, enamel defects
You are a GDP. A mother attends with her 3yo child, who is ill and distressed. The mother is also distressed.
You undertake an examination. Clinical photos are provided.
Clinical photos - photos 6
Take a history, provide a diagnosis to the mother and discuss your proposed management options
6 mins
Introduction - name and designation
I can see that your child is quite upset. What seems to be the problem?
Hx - how long have they had symptoms for? Do they child have a fever? Have they been less active than normal? Have they been managing to eat and drink as normal? Have you tried any pain relief? Has it worked? Have they been able to sleep as normal?
Dx - primary herpetic gingivostomatitis
Explain - this appears to be something called primary herpetic gingivostomatitis. This is the initial infection, or first exposure, to the herpes simplex virus, the same virus that causes cold sores. It happens mainly in children. It’s very common - around 67% of the worlds population carry it. It is contagious and will disappear within 7-10 days. Once this has happened, the virus may lay dormant in a nerve that supplies your face. In the future this virus may or may not reactivate and cause cold sores (30% recurrence). This occurs due to a number of reasons, including trauma, stress, sunlight exposure or medical compromise.
Normally this first exposure has no symptoms - only about 20% of all cases show symptoms which include a blisters all over the mouth - on the cheeks, gums, lips, roof of the mouth and tongue. These blisters will burst and form ulcers and make the mouth sore and red raw. Other symptoms to look out for include a high fever, difficulty swallowing, drooling and swelling. Because the blisters and ulcers make it difficult to eat, dehydration can occur.
This is what we call a self-limiting condition - this means it tends to resolve itself without us intervening. Management tends to be relieving symptoms - so making sure to keep drinking/keep fluid intake up to prevent dehydration, using pain relief (Calpol) to control the pain and any fever and bed rest - rest up and take it easy.
You can clean the teeth with a damp cotton roll or cotton cloth to rub around the gums if it’s too sore to brush. You could also dilute some CHx mouthwash and do the same thing.
Because the child is otherwise fit and healthy, and the symptoms are X days old, medication that would fight the virus is not recommended. Just making sure to use Calpol as directed and make sure to keep them drinking lots of water.
Does all of that make sense? Do you have any questions?
