Paeds XLA Flashcards
What are 5 indications for primary extractions?
- caries
- pain
- infection
- trauma
- orthodontic pruposes
Radiographs can be used to determine what 4 things prior to child XLA?
- size and shape of roots
- amount and direction of root resorption
- position and stage of development of underlying permanent tooth
- any pathology
What are 3 principles of deciduous extractions?
- the painless removal of the whole tooth or root with minimal trauma
- to avoid injury to the soft tissues such as tongue, lips, gingiva and cheeks, support the mandible with non working hand as to avoid dislocation
- to avoid injury to the underlying developing permanent teeth or adjacent teeth, leave retained roots due to permanent tooth being underneath and the potential for damage
What are 4 differences between primary and permanent teeth?
- size: primary teeth are smaller in every dimension compared to permanent counterparts
- shape: crowns of primary teeth are more bulbous, furcation of primary molar root is positioned more cervically than in permanent teeth, roots are more slender
- physiology: roots of primary teeth resorb naturally
- support: the bone of the alveolus is more elastic in the younger patient
What are 2 contraindications for primary extractions?
- medical history
- space maintenance: early extraction of primary teeth may result in drifting of the remaining teeth into the space created, thus prohibiting/ interfering with normal eruption of underlying permanent teeth
What are 6 medical history contraindications for XLAs?
- bleeding disorders
- acute infections (herpetic stomatitis)
- malignancy
- treatment for oral malignancy (radiotherapy)
- renal disease
- cardiac disorders
What are 5 points of parent pre-op preparation prior to deciduous XLA?
- medical history obtained/checked
- radiographs checked for pathology, presence/absence of permanent successor tooth
- consent
- prescription - under prescription in NHS setting
- explanation of procedure
What are 3 points of patient pre-op preparation prior to deciduous XLA?
- appropriate equipment and protective equipment
- behaviour techniques
- topical
What are 3 LA considerations for children?
- buccal, palatal (intrapapillary/transpapillary) and lingual infiltrations
- ID blocks - rule of 10 (age plus tooth number)
- explain difference between pain and pressure
What are 8 examples of behaviour techniques?
- desensitisation - acclimatisation
- tell, show, do
- behaviour shaping - step by step increasing in complexity
- positive/negative reinforcement
- modelling
- behaviour contracts
- preparatory information
- distraction
What is the max dose of lignocaine in children?
4.4mg/kg (a 10th of a cartridge per kg)
How may mg of active agent does a 2.2ml cartridge of 2% lignocaine contain?
44mg
What is the limit of 2% lignocaine for a 3-5 year old child (20kg)?
2 cartridges
4.4mg x 20kg = 88
44mg per cartridge
limit is 2 cartridges
What is the max dose of prilocaine 3% (with felypressin)?
6mg/kg (one seventh of a cartridge per kg)
How many mg of active agent does a 2.2ml cartridge of prilocaine 3% (with felypressin) contain?
66mg
What is the limit of prilocaine 3% (with felypressin) for a 20kg child?
1.8 cartridges
6mg x 20kg = 120
66mg per cartridge
limit is 1.8 cartridges
What is the equation to estimate body weight in kg?
(age + 4) x 2
What is the rule of 10?
the primary tooth to be anaesthetised is assigned a number from 1 to 5
a = 1
b = 2
c = 3
d = 4
e = 5
this number is added to the age of the child in years, if the number is less than 10, infiltration is most appropriate, if the number is over 10, an IDB is likely to be more effective
A child 4 years and younger, where is the foramen located when giving an ID block?
below the plane of occlusion
Where is the foramen of a young child above 4 usually located with giving an ID block?
located on the occlusal plane, as the child matures it moves to a higher position
What are 4 modifications to the extraction technique for children?
- type of forceps: the beaks and handles are smaller, the beaks are more curved to accommodate the bulbous crowns of deciduous teeth
- the wide splaying of the primary roots means that more expansion of the socket is required
- due to the cervical position of the bifurcation in primary teeth, the beaks are not as long or placed as subgingivally (this also prevents damage/extraction to any developing permanent crown)
- any small root fragments can be left in situ to resorb naturally or exfoliate
Which primary tooth are most likely to be ankylosed? (the fusion between cementum and/or dentine and the alveolar bone)
lower Ds
How would an ankylosed tooth appear in the mouth?
tends to appear partially erupted/not fully erupted into the arch
What is the correct elbow height for XLAs?
45 degrees
What is the extraction technique for lower Ds and Es?
push forceps under gingiva, figure of 8 movement
What is the extraction technique for upper molars?
push forceps under gingiva, start with the palatal root on the upper and swing palatal to buccal, pulling the tooth out buccally
What are 4 roles of the non-working hand during XLAs?
- retract soft tissues to allow visibility and access
- protects the tissues if instrument slips
- provides resistance to the extraction forces to prevent dislocation (mandible)
- provides feel to the operator during the XLA to provide info about any resistance to removal
What are the 2 steps following XLA?
- pt should bite on gauze for 10-15 mins to arrest bleeding, firstly squeeze the socket with hands to shape the socket then place bite pack
- check for satisfactory clot formation
What post op instructions should be given to the patient following XLA?
- particular emphasis on biting lip
- avoid poking/probing with tongue/hands
- do not rinse for first 24 hours
What 5 post op instructions should be given to the parent following XLA?
- reinforce instructions already given to child
- not to eat or drink for first 2-3 hours post XLA; no hot drinks/hard foods for 24 hours
- not to partake in vigorous exercise
- pain relief, whatever the child usually takes, avoid aspirin
- commence warm salt water rinses 24 hours post XLA
What post op advice should be given to parents regarding primary haemorrhage?
- some blood oozing from the XLA site is normal
- advise parent that if heavy or persistent bleeding occurs the use of a handkerchief rolled into a sausage shape/cotton wool rolls at the site and get the child to bite on this firmly
- if bleeding does not stop after 30-60 mins then contact the practice
What are complications that may occur during XLA?
- trauma to the soft tissues from XLA or lip biting whilst numb
- loss of tooth or root (pt may have swallowed tooth, risk of aspiration)
- fractured crown/root - if the crown fractures leaving the root or part of the root fractures and is retained in the socket, if visible use fine forceps/elevators to remove. If root not visible then leave to exfoliate or resorb naturally rather than risk damage to permanent successor - record in notes
- haematoma - unusual in deciduous XLAs, when it does usually related to IDB
- accidental extraction of permanent tooth - usually premolars following primary molar XLA, careful positioning of forcep beaks should prevent this, if it doe happen, the extracted premolar should be replanted (avoid touching the root surface) and patient and parent should be advised. Good chance of success esp. lowers and record in notes
- dry socket - not common in deciduous XLAs
What are 4 general contraindications to LA in children?
- immaturity
- mental or physical special needs
- treatment factors
- acute infection
What depth of surface will topical anaesthetise?
2-3mm depth
Manufacturer does not recommend Articaine for use in children of what age?
under 4 years of age
What is the max dose for 2% lidocaine?
44mg
(max dose 300mg)
4.4mg/kg
What is the max dose for 3% citanest (prilocaine)?
400mg
What is the max dose for 4% citanest (prilocaine)?
400mg
What is the max dose for 3% scandonest (mepivicaine)?
66mg
(max dose 300mg)
What is the max dose for 4% articaine (septanest)?
500mg
What is clarks rule to calculate max dose for LA?
weight in kgs divided by 70 X adult dose
What is Youngs rule to calculate max dose for LA?
age of child divided by age + 12 X adult dose
What is the maximum safe dose of lidocaine in children?
one tenth of a cartridge per kg body weight (4.4mg/kg)
What is the maximum safe dose of prilocaine/citanest in children?
one seventh of a cartridge per kg body weight (6mg/kg)
What is a way to estimate body weight in kg?
(age + 4) x 2
What should be included in notes regarding LA?
- local analgesic solution and vasoconstrictor
- expiry and batch number
- drug concentrations
- amount given in cartridges/ml
- site of injection
- any abnormal reactions
- warnings given
What is the gauge and length of an extra short needle used for infiltrations?
30 gauge
10mm
What is the gauge and length of a short needle used for infiltrations?
30 gauge
20mm
What is the gauge and length of a long needle used for IDBs?
27 gauge
35mm
What dose is sufficient for pulpal analgesia of most teeth in children?
0.5-1ml
Thick buttress of bone may be present on the buccal aspect of maxillary posterior teeth, what method can be done to avoid this?
infiltrations mesial and distal to the first molar will usually produce adequate analgesia
What is a maxillary molar block?
valuable when infiltration is not possible due to localised infection, produces profound analgesia of the primary/permanent molars
- the bolus of LA (1.5-2ml) is deposited below the mucosa distal to the zygomatic buttress (A), the LA is then massaged around the distal aspect of the maxilla into the infra temporal fossa (B) and blocking the posterior superior dental nerves
What is a method used to reduce discomfort when giving a palatal infiltration?
inject buccally interdentally, depositing LA and then advance palatally via the buccal papilla, palate will blanch
How does the anatomy differ in children when giving long buccal, mental and incisive nerve blocks?
the mental foramen faces anteriorly in children compared with posteriorly in adults
What are 5 potential reasons for failure of local analgesia?
- acute infection
- incorrect site
- insufficient LA drug
- abnormal nerve supply
- patient immaturity
What are 5 other delivery systems for LA?
- intraligamentary analgesia - caution
- electronic analgesia
- intraoral lidocaine patch
- computerised local analgesia
- needleless local analgesia
What are 5 differences between primary and permanent dentition with XLAs?
- size, smaller but roots form a proportionately greater part of the tooth
- shape: more bulbous crown/roots more splayed
- physiology, root resorption
- support, elastic bone
- presence of permanent teeth, leave small fragment in situ, avoid blind elevation
What is the movement for extracting upper and lower anteriors?
clockwise and anticlockwise rotations
What instrument can be used to extract a buccally placed primary upper canine?
coupland elevator
What is the movement for extracting upper primary molars?
widely splayed roots - considerable expansion of the socket is required
- first movement of forceps is palatal, to expand the socket, then a continuous buccally directed force, which results in delivery
What is the movement for extracting lower primary molars?
removed by buccolingual expansion of the socket
