Prep for clinic Flashcards
primary eruption sequence
- lower centrals
- upper centrals
- upper laterals
- lower laterals
- upper 1st molars
- lower 1st molars
- upper canines
- lower canines
- lower 2nd molars
- upper 2nd molars
primary lower centrals erupt
6 months
primary upper centrals erupts
8-12months
primary upper laterals erupt
9-13 months
primary lower laterals erupt
10-16 months
primary upper 1st molars erupt
13-19 months
primary lower 1st molars erupt
14-18 months
primary lower canines erupt
17-23 months
primary upper canines
16-22 months
primary lower 2nd molars
21-23 months
primary upper 2nd molars
25-33 months
general rule of eruption
lowers before uppers (except primary canines)
permanent eruption sequence:
6 years - all 6s, lower centrals
7 years - upper centrals, lower laterals
8 years - upper laterals
11 years - lower canines, all first premolars
12 years - rest - upper canines, all second premolars and second molars
4 functions of primary dentition
- reserve space for permanent
- development speech
- ease mastication
- healthy start to permanent dentition
contraindications to duraphat
ulcerative gingivitis or stomatitis or known sensitivity to colophony (1-7%)
not for ingestion during application
not for systemic Tx
on day of application other F preparations should not be used (e.g. gels) and routine regiments of F tablets should be suspended for several days after Tx
adverse reactions to duraphat
- oedematous swellings reported in rare instances
- attacks of dyspnoea in extremely rare asthmatics
- nausea in sensitive stomachs
remove by brushing and rinsing in cases of intolerance
duraphat is
5% sodium fluoride solution
indication for F varish
hypersensitiy Tx
caries prevention
most beneficial caries prevention
topical F application /varnish (more than systemic ingestion)
F varnish works in 3 ways
slows down development of carious lesions by stopping demineralisation - SLOWS CARIES PROGRESSION
makes enamel more resistant to acid attack from plaque bacteria and speeds up remineralisation, does so with F so more strong/less soluble - CARIES ARRESTING
stops bacteria metabolism at high concentrations - CARIES INHIBITING
4 properties of topical fluoride
desensitising
water tolerant
adherent
sets in presence of saliva
method of application of topical fluoride
remove gross plaque
remove excess moisture from teeth with cotton wool roll or air syringe
apply first to lower arch where saliva collects more rapidly
dispense correct amount of duraphat into dappens dish (0.25-0.5ml per application/mouth)
apply sparingly in thin layer - do not need to use all
paint varnish onto dry, isolated teeth with microbrush
dental floss can be used to ensure varnish reaches interproximal areas
advice to parents after topical fluoride application
avoid eating or drinking for at least one hour (longer period more beneficial)
eat soft foods for rest of day
brush teeth as normal
do not take F supplement on day of application
makes teeth appear yellow but will wear off with eating and brushing
safely tolerated F dose STD
STD
dose below which symptoms fo F toxicity are unlikely to occur
1mg/kg
potentially lethal F Dose PLD
PLD
lowest dose associated with fatalisty
5mg/kg
certainly lethal F dose CLD
CLD
survival after consuming is unlikely
32-64mg/kg
how many application per cartidge of childsmile duraphat
cartridge = 1.6ml
recommend 0.25-0.5ml per application
so 6 applications of 0.25ml for 3-5 year olds in cartridge
F in 0.5ml duraphat
11.3mg
F in 0.25ml duraphat
5.65mg
F in 1.6ml cartridge duraphat
35.84mg
estimated F toxic dose
5.15mg/kg
estimated F toxic dose for 10kg child
50mg F
estimated F toxic dose for 15kg child
75mg F
estimated F toxic dose for 20kg child
100mg F
symptoms and signs of F overdose
F fast absorbed from stomach
nausea and vomitting, diarrhoea and abdominal pain
excessive salivation, abnormal taste, tremors, weakness and convulsions
shallow breathing and nervous system shock
management of F toxicity
<5mg/kg
Give calcium orally (milk) and observe for a few hours
management of F toxicity
5-15mg/kg
Give calcium orally (milk, calcium gluconate, calcium lactate) and admit to hospital
management of F toxicity
>15mg/kg
Admit to hospital immediately, cardiac monitoring and like support, intravenous calcium gluconate
rule for toothbrushing
spit don’t rinse
toothpaste for less than 3 years old
smear
1000ppmF
toothpaste for 3-9 years old
pea size
1350-1500ppmF
1450ppmF for high risk - any age
toothpaste for 10 years+
2800ppmF (less likely to swallow)
toothpaste for 16+ high risk
5000ppmF
fluoride varnish strength
22600ppmF
roughly 20x stronger than toothpaste
Silver diamine fluoride strength
44,000ppmF (double F varnish)
periodontal status
plaque scores
10/10 perfectly clean tooth
8/10 line plaque around cervical region
6/10 cervical 1/3 of crown covered
4/10 middle third of crown covered
periodontal status
BPE
0 healthy
1 bleeding on probing
2 calculus or other plaque retention factors
3 shallow pocket 4/5mm
4 deep pocket 6mm+
- furcation involvement
ramjford’s 6 index teeth
16, 11, 26 and 36, 31, 46
BPE score options in children 7-12
0, 1, 2
when are full range BPE scores used?
13-17 years
- record if not done due to poor co-op
probe for BPE
WHO 612 probe
- 0.5mm ball ended
- black band 3.5-5.5mm, 8.5mm - 11.5mm
black bands on BPE probe
3.5-5.5mm, 8.5mm - 11.5mm
refer to periodontal specialist for child if
agressive periodontitis diagnosis
incipient chronic periodontitis not responding to Tx
systemic medial condition associated with periodontal destruction
medial Hx that significantly affects periodontal treatment or requiring multi-disciplinary care
genetic conditions predisposing to perio destruction
root morphology adversely affecting prognosis
non-plaque induced conditions requiring complex specialist care
cases requiring diagnosis/ management of rare complex clinical pathology
drug induced gingival overgrowth
cases requiring evaluation for periodontal surgery
SIGN 47
primary prevention
keeping children’s teeth healthy before disease/caries occur
clinical evidence of high risk caries
new lesions
premature extractions
anterior caries/restorations
multiple restorations
No FS
fixed appliances/ortho
partial dentures
clinical evidence for low risk caries
no new lesions
no extractions for caries
sounds anterior teeth
no/few restorations
restorations present are old
FS
no appliances
dietary habits for high caries risk
frequent sugars
dietary habits for low caries risk
infrequent sugars
social history for high caries risk
deprivation
high caries risk siblings
low knowledge of dental disease
irregular attender
ready available snacks
low dental aspirations
social history for low caries risk
advantaged
low caries risk family
dentally aware
regular attender
limited snacks
high dental aspirations
use of F for high caries risk
wanter not fluoridated
no F supplements
no F toothpaste
use of F for low caries risk
water fluoridated
F supplements
F toothpaste
plaque control for high caries risk
infrequent, ineffective cleaning
poor manual control
plaque control for low caries risk
frequent and effective cleaning
good manual control
saliva for high caries risk
low flow rate
low buffering capacity
high S mutans and lactobacillus counts
saliva for low caries risk
good manual control
normal flow rate
high buffering
low S mutans and lactobacillus counts
medical history for high caries risk
medically compromised
physical disability
xerostomia
long term cariogenic medicine
medical history for low caries risk
no medical issues
no physical issues
normal salivary flow
no long term cariogenic medicines
what caries risk if not clear fit low or high
moderate
primary prevention in children of high caries risk involves
behaviour modifications
tooth protection
consistent preventative message reinforced by dental practice team and other HCP
behaviour modifications as primary prevention in children of high caries risk
dental health education advice provided to individual at chair-side
brush teeth twice daily using toothpaste (at least 1000ppmF)
spit don’t risk
restrict sugary food and drink consumption
advise of non sugar sweeteners (esp Xylitol)
sugar free chewing gum (esp Xylitol) when can
sugar free medications when possible and sugar free forms of non prescription medicines recommended
tooth protection as primary prevention in children of high caries risk
sealants applied and maintained in pits/fissures high risk
- review at check ups condition
- GI sealants when resin sealants unsuitable
F tablets (1mg daily) for sucking for considered high decay
F varnish - duraphat - every 4-6months in high risk
chlorohexidine varnish option for preventing caries
secondary prevention of caries
limiting impact of caries at early stage
tertiary prevention of caries
rehabilitation of decayed teeth with further preventative care
diagnosis dental caries confirmed by
bitewing radiographs
- essential adjunct to first exam
- frequency further radiograph based on caries risk
management of carious lesions needs to be
both operative and preventative
- operative alone will fail to prevent future disease
- primary preventative care needs to be continued
re-restoration of lesion
secondary caries diagnosis hard and clear evidence of involvement of active disease needs ascertained before replacement restoration
if only part of restoration is judge to have failed consideration repairing rather than replacement
management of carious lesions
- occlusal
- extends clinically to dentine
carious dentine removed and tooth restored
management of carious lesions
- occlusal
- only part of fissure system involved
use composite sealant
management of carious lesions
- occlusal
when to use amalgam
effective
but not permitted in under 16s
management of carious lesions
- approximal
preventative care (e.g. topical F varnish) rather than operative recommended when confined to enamel
management of carious lesions
- smooth surface
- non cavitated
manage like approximal - preventative - if confined to enamel
DMFT/S
Decayed
Missing
Filled
Teeth/ Surfaces
dmft/s for primary
SIGN 138
key recocomendations
oral health promotion intervention should be facilitate twice daily toothbrushing with F toothpaste
resin based fissure sealants should be applied to permanent molars of all children as early after eruption as possible
standard risk F strength
up to 18
1000-1500ppmF
increased risk F strength (10-16)
2800ppmF
2 approaches to caries prevention
population based - water fluoridation
targeted - based on risk
risk indicators for caries (5/6)
diet
oral hygiene
microbiological (step mutans)
sociodemographics (low economic)
previous caries exposure
saliva? - if reduced than increased caries risk
7 things to consider when assessing caries risk
clinical evidence of previous disease
diet (esp frequency sugar)
social history
fluoride use
plaque control
saliva
medical history
why should F toothpaste use by children be supervised
to reduce the risk of fluorosis
behaviour management
continuum of interaction with a child/pt directed towards communication and education
goals of paeds behaviour management
ease fear and anxiety
promoting an understanding of the need for good dental health
normal childhood development
age 2
fear of unexpected movements, loud noises and strangers
dental situation can produce fear in child
normal childhood development
age 3
reacts favourably to positive comments about clothes and behaviour
less fearful of separation from parents (due to nursery)
experience will dictate reaction to separation
normal childhood development
age 4
more assertive - bossy/aggressive possible
fear of unknown and bodily harm is now at peak
fear of strangers can be slightly decreased
with firm, kind direction can be excellent pts
normal childhood development
age 5
readily separated from parents
fears usually diminished
proud of possessions - use to engage and build rapport
comments on clothes - quickly establishes rapport
normal childhood development
age 6
seeks acceptance
success in acceptance can affect self-esteem
if child develops feeling of inferiority or inadequacy at dentist then behaviour may regress to that of younger age
normal childhood development
age 7-12
question inconsistencies and conform to rules of society - engage
still have fears bit better at managing them
- ask obvious Qs to see if they can be addressed e.g. why do you dislike the chair? (maybe movement when in, so can move into position prior)
when are anxiety, behaviour and compliance linked in development
ages 3-8
older children able to use assessment tools MCDAS
dental anxiety
occurs without a present triggering stimulus and may be a reaction to an unknown danger or anticipatory due to previous negative experiences
dental fear
normal emotional response to objects or situations perceived as genuinely threatening
phobia
clinical mental disorder where subjects display persistent and extreme fear of objects or situations with avoidance behaviour and interference in daily life
- avoid going to dentist
3 components of dental fear and anxiety
- physiological and somatic sensations
- cognitive features
- behavioural reactions
physiological and somatic sensations components of DFA
breathlessness
perspiration
palpitations
feeling of unease
cognitive features of DFA
how changes occur in thinking process
- interference in concentration
- hypervigilence (swivel heads)
- inability to remember certain events when anxious (mind racing)
- imagining worse that could happen
behavioural reaction of DFA
avoidance i.e. postpone dental app, child disruptive behaviour
escape from situation which precipitates anxiety
anxiety may manifest as aggression - esp adolescents
- feel not listened to
- explain will not do anything until we know that they are comfortable and how they are - dentistry is 2nd to them
dentist should always ensure safety of pt and staff
Signs of DFA
some easy
some subtle
- time delay asking Qs
- stomach aches/need to go to toilet
- headaches, dizziness
- fidget
- stutter
- ‘can’t be bothered’
factors that influence DFA
fear of choking fear of injection/drilling fear of unknown past medical/dental experience dental experience of family/friends attitudes of parents preparation at home before appt child's perception that something is wrong with teeth
useful to know so can specifically reassure
control related measure to assist DFA
rest breaks
stop signals
pt need for info
MCDAS
modified child dental anxiety scale
can get faces version
8+
base line DFA established
good dentist/pt communication allows (4)
improved information obtained from pt
- more you know the better the Tx as more adapted
enable dentist to communicate information with pt
increases likelihood pt compliance - feel safe, listened to
decrease pt anxiety
behavioural management techniques (7)
positive reinforcement
tell show do
acclimatisation
voice control
distraction
role modelling
relaxation/hypnosis
Building Tx plan for children - general guide
simple -> complex
OHI, FS, upper before lower for restorations
Paeds Tx plan
- exam, Fluoirde varnish, diet sheet given, toothbrush to bring on next visit, explain/take radiographs
- brush teeth with their brush, invite on chair, check diet, radiographs
polish teeth and dry (slow speed + air syringe),
explain FS - FS, introduce saliva injector
- remove carious tissue with hand excavator if immediate temporisation needed
Use slow speed for small buccal and cervical carious lesions
introduce topical and give rubber dam home - restore uppers with LA (topical then injection)
- restore lower teeth with LA
- pulp Tx then extractions if pt pain free e.g. if pulpotomy needed, do before extractions
F toxicity threshold dose
5mg/kg
- depends on tooth paste strength and weight child
F toxic dose for 2yo (average weight 12kg)
60mgF
2/3 (60g) of a 90g 1000ppmF tube (90mgF/tube)
1/4 (21g) of a 75g 2800ppmF tube (210mgF/tube)
F toxic dose for 4 yo (average weight 15kg)
75mgF
5/6 (75g) of a 90g 1000ppmF tube (90mgF/tube)
1/3 (27g) of a 75g 2800ppmF tube (210mgF/tube)
F toxic dose for a 6yo (average weight 20kg)
100mgF
more than a tube (100g) of a 90g 1000ppmF tube (90mgF/tube)
1/2 (36g) of a 75g 2800ppmF tube (210mgF/tube)
biggest F toxicity risk
small children ingesting high strength toothpaste
so keep toothpastes out of young children’s reach esp high strength duraphat (2800ppmF or 5000ppmF)
