Paeds/Ortho Flashcards
what to include in paeds GA referral letter
1 - pt name and address
2- parent/guardian name
3 - contact telephone number
4 - your name,practice address, and telephone
5 - GMP name, practice address and telephone
6 - treatment plan/needs
7 - justification for GA (SIGN guidelines)
8 - Medical history
9 - any radiographs
elements of CRA
7
MHx
SHx
clinical evidence
saliva
plaque control
fluoride use
diet
caries prevention methods
8
toothbrushing technique - 2xdaily, modified bass, spit dont rinse
F varnish - 22600ppm 2xyearly or 4xyearly
F toothpaste - 1450ppm smear when over 3, above 6 pea
F suppliements (NaF mouthwash 5%)
Diet diary
fissure seals
radiographs
sugar free meds
reasons for delayed eruption of permanent tooth
7
- abnormal development position
- supernumerary tooth
- displacement of permenent teeth due to trauma to primary tooth
- dilaceration
- impaction
- eruption cyst
- early loss of primary tooth
signs of supernumerary
5
- delayed eruption
- midline diastema/discrepancy
- crowding of permanent teeth
- displacement of permanent teeth
- rotation of permanent teeth
standard prevention toothbrushing instruction
once yearly advise
brush as soon as first primary tooth erupts
2xdaily, 2mins, morning and last thing at night- no food or drink after
spit dont rinse
assist till 7years, supervise thereafter till child confident and able to do solely
enhanced prevetion toothbrushing
every 4 months give standard advice
+
3mins hands on brushing instruction
disclosing tablets
toothbrushing charts
free toothbrush/toothpaste
fluoride overdose
5.5mg/kg
need to know concentration toothpaste, weight of child and amount consumed
diet standard prevention
1xyearly
reduce frequency of sugars to meal times
be careful re hidden sugars - ketchup, baked beans, soy milk, fruit juice
limit fizzy/carbonated drinks to meal times
sugar free snacks - breadsticks, carrots, oatcakes, cucumbers
water only between meals and for bedtime bottle
diet enhanced prevetion
standard at every recall
+
diet diary - 2 weekdays and 1 weekend
action planning
fluoride varnish dose
5% NaF 22600ppmF 2xyearly
2-5=0.25ml
>5=0.4ml
enhanced- 4xyearly
fissure seals
permenant teeth
L6s buccal pits; U6s palatal pits
GI is pre-coop
check with probe if able to get them off
bitewings from when
around age 5
standard every 2 years
high risk - every 6-12months
how to manage a suspocious fissue in permanent molar
clean - pumice brush but no pumice
dry
good light
magnification
radiograph - see if dentinal caries present
tx
* microcavitation/shadowing in enamel - PRR and fissure seal
* if just stained, no radiographic evidence - FS
options caries management in primary dentition
1 - complete caries removal and restoration
2 - partial caries removal and restoration
3 - no caries removal and seal#
4 - no caries removal, prevention, make self cleansing
5 - XLA
index of suspicion for child neglect
could the injury been caused accidentally? how?
does explanation of injury fit age and clincal findings?
if explanation is consistent with injury, is this within normally acceptable limits of behvaiour?
is the story consistent? (changing details etc)
if there is delay in seeking advice, are there good reasosn for this?
general demnour
relationship between guardian and child
child’s reaction to people
child’s reaction to any med/dental exam
comments by child/guardian that raise concerns about upbringing
dental neglect markers
5
- nutrition - failure to thrive
- warmth, clothing, shelter - cold injury/sun burn
- hygiene+health care - dental caries, head lice
- stimulation+education - developmental delay
- affection - withdrawn/attention seeking behaviour
primary herpetic gingivostomatitis with systemic involvement
aciclovir only prescribed - immunocompromised or severe infection in the non-immunocompromised
primary response to herpes simplex
* sore mouth and throat, enlarged lymph nodes
* also period of malaise and fever (systemic)
* self limiting 7-10days
* fluid intake, bed rest, analgesia, CHX, nutritious diet
aciclovir 200mg tablets, 1tab 5xdaily for 5days (25 total)
Concerned mother with 2 year old in pain. Take a brief pain history then photo of decayed 52-62 (upper incisors) provided.
Explain diagnosis toparent, prevention and management options
brief hx
* how long pain there for? any analgesia/calpol? how much?
* feeding bottle to bed? what is in it?
pattern of decay - upper incisors, Ds and lower canines (lower incisors protected by tongue)
advice
* feeder cup replacing bottle from 6months
* no feeding at night - lactose in milk, dec saliva flow
* no sweetened milk/soy milk (unless medically advised)
* water between meal times
* sugar free meds (calpol)
* safe snacks - cheese, breadsticks, veg
toothbrushing - assist till age of 7, 2xdaily, spit dont rinse, smear of 1450ppm
management
* extraction carious teeth under GA due to pain - risks: small risk of brain damage, not waking up. benefit - only way out of pain
* GIC remaining teeth and review
* F varnsih
trauma stamp
colour
EPT
ECl
TTP
percusive note
mobility
displacement
radiograph
sinus
trauma complications to primary tooth
pain
swelling
dark discolouration
inc mobility
delayed exfoliation
infection - look out for gum swelling
trauma complications to permanent tooth
preamature or delayed eruption
enamel hypoplasia/hypomineralisation
crown/root dilaceration
failure to erupt
failure to form
odontome formation
how to deal with complaint regarding prev dentist
‘I can’t give comment because I don’t know the full story’
‘I can only offer you this treatment at this present time’
‘Whatever was offered previously, will not change what treatment is required now’
‘It will be unhelpful for me to be involved in this matter as I don’t know the
background behind’
Tell mum if she is intended to complain, she can go back to the practice, they will
have a standard complaint procedure = only if the patient asks (do not offer!)
separator and hall crown placement
Place separators between medial and distal contacts
* Floss 2 pieces of floss through the orthodontic separator
* Pull tight and move down between contacts of the tooth (not subgingival)
Leave in place for 2-7 days
Remove with a BLUNT probe
Sit child upright
* Place gauze swab to protect the airway
Choose the crown: aim to fit smallest size of crown that will seat (use sticky stick)
* Select one that covers all the cusps and approaches the contact points with slight
* springiness
* Do not fully seat the crown!
Dry the crown, fill with GIC (Aquacem)
Dry the tooth
* If cavity large: place some GIC in the cavity
Place the crown over the tooth
Seat the crown with finger pressure - first method
* Child can seat the crown by biting on it over gauze - second method
Remove excess cement with CWR
Get pt to bite down for 2-3mins or finger pressure
Make sure all excess cement has been removed
Floss between contacts
process and risks for GA referral
DWP and paretn of GA risks/benefits and all other alternative options
* Referral to hospital for specialist to assess - if any other teeth of poor prognosis
* they will be added to this plan to avoid future GA
* GA will involve day in hospital - need to monitor for full recovery
* Need of chaperone throughout.
Very common minor risks:
* Headache, nausea, vomiting, drowsiness
* Sore throat or sore nose/nose bleed from intubation
Risks from treatment:
* Pain, bleeding, swelling, bruising, infection, loss of space, stitches
Rare major risks:
* Brain damage
* Death - 3 in a million. Need a machine to breathe during op and there is a
* very small risk that you will not be able to breathe independently
* again on waking - ie never waking again.
* Upset when coming round - can make underlying anxiety worse
* Malignant hyperpyrexia (v. rare - important to ask for FH)
Conditions requiring special care (can be contraindications)
* Sickle cell disease (or any hypoxia)
* Diabetes - can’t fast in same way
* Down’s syndrome
* Malignant hyperpyrexia
* CF or Severe asthma
* Bleeding disorders
* Cardiac or Renal conditions
* Epilepsy
* Long QT syndrome
GA referral
- Patient name
- Patient address
- Patient/Parent contact numbers (landline and mobile)
- Patient medical history
- Patient GP details
- Parental responsibility
- Justification for GA
- Proposed treatment plan
- Previous treatment details
Letter must include:
Recent radiographs or if not available an explanation of why (e.g. pt
uncooperative)
talk through parents concerns re F varnish
Reassure the patient
* Fluoride varnish is placed on the tooth and is minimally invasive
* Promotes remineralisation (hardening of tooth) and prevents demineralisation (softening of tooth)
* It involves dry the teeth and painting a gel on to the tooth
Contraindicated in:
* Severe uncontrolled asthma (hospitalised in the last 12 months)
* Allergy to colophony (sticking plasters) - We can use a colophony free version if needed
instructions afterwards
* Don’t eat/drink for 1 hour
* Soft diet for the rest of the day
* No dark coloured foods
* Avoid fluoride supplements today
Fluoride toxicity:
* Very small risk and technically relevant if small child consumes a quantity of toothpaste
* 5mg/kg: milk
* 5-15mg/kg: ipecac syrup, milk and possible referral
* >15mg/kg: hospital referral
Patient asks - I’m wondering why my younger child needs fluoride varnish?
* Clear justification regarding caries – prevention of tooth decay (fluoride effective), evidence of additional benefit over and above daily tooth brushing
* Recommended for all not just those at risk (universal process)
* Recommended that children get it atleast 2x a year
* Recommendations are evidence based e.g. refer to guidance such as SDCEP,
sign etc
Patient asks I’ve heard that too much fluoride can be harmful, is that true?
* Details know minimal risk with use of fluoride varnish and twice daily use of fluoride toothpaste provided used as recommended
* Fluoride varnish quantity carefully controlled
* Guidance given regarding toothpaste quantity and Supervised brushing
* posible side effects - fluorosis and mottling
11 EDP# immature apex - 8 yr old - Outline procedure to parent of
anxious child (6 mins)
Explain nature of injury in simple terms
* Enamel dentine pulp fracture or complicated pulp fracture
Explain treatment : PULPOTOMY (open apex)
* As this is a large exposure the tx of choice is called a pulpotomy
* Explain partial removal of pulp
* Explain that aim is to keep undamaged pulp tissue alive
* Explain that this is so the tooth stays alive and continues to grow
Baseline sensibility tests
* Tests required to see how the nerve in the injured and adjacent teeth respond
* Tests required as baseline reading for long term monitoring
LA required
* Parent informed that LA is required
* Required to keep patient numb and comfortable
* Describe that LA involves injection in the gum
Dental Dam
* What this is - rubber sheet over tooth acts like mask
* Why dam is placed - moisture control, protects airway
Drilling/use of handpiece
* Drill will be used to remove some pulp tissue
* Aim is to leave only good tissue
Dressing
* Indicate that the tooth will be dressed; Setting CaOH, MTA
Composite restoration
* Indicate that a white filling will be placed to regain aesthetics
Actor marks: Describing tx in an understandable manner, supportive and empathetic
regarding injury
URA for overbite
In order to REDUCE an overbite we must make a baseplate modification by using a FLAT ANTERIOR BITE PLANE which is made by taking measurement of OJ + 3mm. We add 3mm to minimise the risk of lowers going behind uppers and prevents the lower teeth retroclining which makes overbite even worse. A FABP creates POSTERIOR OPEN BITE. We then want to start closing the posterior open bite happens as the lower teeth move to occlude with upper teeth and close then open bite - only happens when teeth are erupting and bone and soft tissues are forming (cant be done in adults or will end up with over eruption and roots exposed so teeth become mobile). We then take out the appliance and have a gap that allow us to force the overjet closed
Aim: Please construct a URA to reduce OJ 22,21,22,12 and reduce OB (done after 4s extracted and canines moved back)
Active components
- 22,21,11,12 Robert’s retract 0.5mm HSSW + 0.5mm ID tubing
Retention
- Posterior retention
o 16+26 Adam’s clasps 0.7mm HSSW
Stops
- 13+ 23 mesial stops 0.7mm HSSW flattened (stops canines relapsing these are passive components)
Anchorage
- Good and bad moving 4 teeth but all have small roots and moving same direction
Base plate
- Self cure PMMA with flat anterior bite plane OJ+3mm
URA for overjet
Active components
- 22,21,11,12 Robert’s retract 0.5mm HSSW + 0.5mm ID tubing
Retention
- Posterior retention
o 16+26 Adam’s clasps 0.7mm HSSW
Stops
- 13+ 23 mesial stops 0.7mm HSSW flattened (stops canines relapsing these are passive components)
Anchorage
- Good and bad moving 4 teeth but all have small roots and moving same direction
Base plate
- Self cure PMMA with flat anterior bite plane OJ+3mm
URA for retracting canines
Aim: please construct a URA to retract 13 + 23
Active components
- 13 + 23 palatal finger springs + guards 0.5mm HSSW
Retention
- Posterior retention
o 16 + 26 Adam’s clasp 0.7mm HSSW
- Anterior retention
o 11 + 21 southend clasp 0.7mm HSSW
Anchorage
- Good as only moving 2 teeth
Base plate
- Self cure PMMA
URA for retracting buccally placed canines
Aim: please construct a URA to retract buccally placed 13 and bring 23 in the line of arch and reduce OB
Active components
- 13 buccal canine retractor 0.5mm HSSW with 0.5mm ID tubing
- 23 palatal finger spring and guard 0.5mm HSSW
Retention
- Posterior retention
o 16+26 Adam’s clasps 0.7mm HSSW
- Anterior retention
o 11+21 southend clasp 0.7mm HSSW
Anchorage
- Good only moving 2 teeth
Base plate
- Self cure PMMA with flat anterior bite plane OJ+3mm
URA to fix anterior crossbite
Aim:Please construct URA to correct anterior cross bite
Active components
- 12 Z spring (or T spring) 0.5mm HSSW
Retention
- Posterior retention
o 16+26 Adam’s clasps 0.7mm HSSW
o 14+24 Adam’s clasps 0.7mm HSSW
Anchorage
- Good only moving 1 tooth
Base plate
- Self cure PMMA with flat posterior bite plane
URA to fix posterior cross bite
Aim: Please construct a URA to expand the upper arch
Active components
- Midline palatal screw
Retention
- Posterior retention
o 16+26 Adam’s clasps 0.7mm HSSW
o 14+24 Adam’s clasps 0.7mm HSSW
Anchorage
- Good only moving 1 tooth
Base plate
- Self cure PMMA with flat posterior bite plane
