Reference Manual Flashcards
What is the treatment of choice for necrotic primary teeth in the absence of root resorption?
Pulpectomy
How often should xrays of pulpectomy treated teeth be taken?
Every 12 months
When should LSTR be chosen over pulpectomy?
When the tooth has root resorption
When the tooth has to be retained for up to 12 months
If a tooth needs a pulpectomy and is expected to be in the mouth for 18+ months, what root canal filling material should NOT be used?
Iodoform
If a tooth needs a pulpectomy and is expected to be in the mouth for 18+ months, what root canal filling material should be used?
zinc oxide/iodoform/CH and ZOE
fillers
True or False:
Inability to control bleeding at the exposure site or canal orifices provides an accurate assessment for the diagnosis of irreversible pulpitis.
False
While rotary instrumentation is faster than manual instrumentation, what are some potential disadvantages of rotary instrumentation?
- Canal space in primary teeth are ribbon shaped, so rotary instruments may potentially leave behind some infected tissue
- Higher cost and need for more training
Does the removal of the smear layer affect the success of primary teeth treated with pulpectomy?
No
Did the of choice irrigation solutions (NaOCl 1-5%, chlorhexidine or water/saline) influence the success of a tooth treated with a pulpectomy?
No statistical significance between the irrigation solutions
Does the choice of obturation material in pulpectomies influence sucess?
YES
1) Zinc oxide/iodoform/calcium hydroxide
2) ZOE
3) Iodoform
Did the type of the final restoration following a pulpectomy affect its success?
No, no statistical difference in SSC vs composite at 12-month period but the 24-month success was higher (90% vs 77%) in SSCs
Did obturation technique (syringe, Lentulo, hand pluggers) influence the success of the pulptomy?
No
Overfiling or underfilling a pulpectomy: which appears to be related with lower success rates in a pulpectomy?
Overfilling
Does the tooth type that is treated with a pulpectomy affect its success?
No - no difference incisor vs molars or in 1st vs 2nd primary molar
In teeth that are necrotic as a result of trauma, are pulpectomies successful?
Success rates similar to pulpectomy done due to caries but success does drop if tooth is retraumatized
When doing LSTR, how do the success rates of using traditional 3Mix with tetracycline compare with alternative 3Mix withOUT tetracycline?
Higher success rates of using alternative 3Mix withOUT tetracycline
Clindamycin, metronidazlone and ciprofloxin
What are the antibiotics in 3Mix and 3mix without tetracycline?
3mix:
Minocycline, metronidazole and ciprofloxin
3mix alternative:
Clindamycin, metronidazoleand ciprofloxin
What are some systemic findings in children with Trisomy 21 that could significantly impact longevity and/or quality of life?
- Congenital heart defects
- Cognitive impairment
- Compromised immune response
- Cervical spine instability
- Thyroid disorders
- Increased risk for leukemia
- Increased incidence of early development of senile dementia
What are 4 characteristic craniofacial features of individuals with Trisomy 21?
- Midface hypoplasia
- Upward slanted palpebral fissures
- Mild microcephaly
- Short neck
What are features of Trisomy 21 that makes these patients poor candidates for outpatient sedation procedures?
- Congenital heart defects
- Obesity
- Obstructive sleep apnea
- Cervical spine instability
- Small nasopharyngeal complex
- Airway anomalies - laryngomalcia, trachreomalacia
- Hypotonia
What is the probable explanation for the increased incidence of early, aggressive periodontal disease in many individuals with Trisomy 21?
Compromised immune response
Name 4 health conditions frequently seen in individuals with Trisomy 21
- Congenital heart defects
- Hypotonia
- Compromised immune function
- Thyroid dysfunction (hypothyroidism)
- Hearing problems
- Skeletal abnormalities
- Increased risk for development of leukemia
- Early development of senile dementia
- Obesity, OSA
If a patient presents with an unclear cardiac history, what questions would you ask the cardiologist?
- Name of cardiac diagnosis
- When diagnosed
- What are associated symptoms
- Hx of past surgeries
- Any planned surgeries
- Any activity limitations
- Any SBE prophylaxis
- Any medications that the patient is taking
What are some common complications of extreme low birth weight that can have long-term sequelae?
- Cerebral palsy
- Congenital heart defects
- Intellectual disability
- Respiratory disorders
- Visual impairment
- Hearing impairment
Name 3 oral/perioral complications, and their etiology, sometimes seen in patients with cerebral palsy
Low muscle tone leading to
- Anterior open bite
- Narrow palate
- Persistent drooling
What is meant by “executive function?”
The mental skills needed to accomplish tasks such as paying attention, managing time, organizing, and minimizing impulsive actions
Is intellectual disability a characteristic of ADHD?
No
What are the behavioral characteristics of ADHD-PHI and how might these behavioral characteristics affect behavior management in the dental setting?
ADHD-PHI = ADHD-Predominantly Hyperactive Impulsive
Fidgety, squirmy, excessive talking, trouble waiting and/or taking turns, always “on the go”
Short morning appointments
Use nitrous
Distraction tools - games, videos
What classes of medications are used to manage ADHD?
How do these medications affect the oral cavity?
Stimulants
Xerostomia
What are some of the comorbidities noted to occur with ADHD?
How might any of these diagnoses affect oral health care?
Oppositional defiant disorder
Anxiety
Depression
Bipolar disorder
Sleep disturbances
Substance abuse
Can interfere with healthy nutrition, consistent home care routine
Medications used to manage these can also cause xerostomia
What are the two main classifications for seizure disorders?
Generalized - abnormal electrical activity affects both cerebral hemispheres
Partial - Seizure activity is limited to a discrete section of the cerebral cortex
What is the definition of epilepsy?
The diagnosis of epilepsy is based on a history of at lease two unprovoked (idiopathic in nature) seizures
What is the most commonly impacted teeth?
1) Third molars
2) Permanent Maxillary Canines
When the cusp tip of the permanent canine is just mesial to or overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine (palatal or labial) impaction usually occurs
When the cusp tip of
the permanent canine is just mesial to or overlaying the distal
half of the long axis of the root of the permanent lateral incisor,
canine PALATAL impaction usually occurs
What is the treatment of choice to correct palatally displaced canines or to prevent resorption of adjacent teeth?
Extraction of the primary canines is the treatment of choice to correct palatally displaced canines or to prevent resorption of adjacent teeth
One study showed that 78%of ectopically erupting permanent canines normalized within 12 months after removal of the primary canines
64% normalized when the starting canine position overlapped the lateral incisor by more than half of the root
91% normalized when the starting canine position overlapped the lateral incisor by less than half of the root.
Does literature support the extraction of primary canines to facilitate the eruption of permanent canines?
A prospective randomized clinical trial demonstrated that extraction of primary canines is an effective measure to correct palatally displaced maxillary canines and is more successful in children with an early diagnosis.
75% will erupt after extraction of the primary canine
The AAOMS recommends that a
decision to remove or retain third molars should be made before what age?
The AAOMS recommends that a
decision to remove or retain third molars should be made before the middle of the third decade
Supernumerary teeth are thought to be related to disturbances in the what stages of dental development?
initiation and proliferation
A supernumerary tooth in the primary dentition is followed by the
supernumerary tooth complement in the permanent dentition in what percent of cases?
33%
Supernumerary teeth are more common what arch?
Maxillary - supernumerary is 10 times more in the maxilla than mandible
Name some complications associated with a mesioden.
-Delayed and/or lack of eruption of the permanent tooth
-Crowding
- Resorption of adjacent teeth
-Dentigerous cyst formation
-Pericoronal space ossification
-Crown resorption
What percent of mesiodens will erupt spontaneously?
25% - most will need surgical intervention
In _____ percent of the cases, extraction of the mesiodens during the mixed dentition results in spontaneous eruption and alignment of the adjacent teeth.
75 percent
If the adjacent teeth do not erupt within six to 12 months, surgical exposure and orthodontic treatment may be necessary to aid their eruption
Bohn’s nodules and epstein’s pearls are found in up to ___ percent of newborns
85%
What is the difference between epstein’s pearls and bohn’s nodules?
Epstein pearls occur in the median palatal raphe area as a result of trapped epithelial remnants along the line of fusion of the palatal halves
Bohn nodules are remnants of salivary gland epithelium and usually are found on the buccal and lingual aspects of the ridge, away from the midline
Gingival cysts of the newborn, or dental lamina cysts, are found wher?
The crests of the dental ridges, and are most commonly are seen bilaterally in the region of the first primary molar
usually go away in the first 1-3 months of life
Congenital epulis of the newborn is most commonly found in males or females?
Females 8:1
Anterior maxilla
Surgical excision, doesn’t recur
Melanotic neuroectodermal tumor of infancy may recur up to ___% of cases after excision
20%
What is your differential diagnosis for a bluish or black rapidly expanding mass of the anterior maxilla?
Melanotic neuroectodermal tumor of infancy
What is the difference betwen natal and neonatal teeth?
Natal teeth: present at birth
Neonatal teeth: erupts within the first 30 days of life
What are important things to consider prior to extracting a natal/neonatal tooth?
Risk of hemorrhage
Infants may be at risk for vitamin K deficiency bleeding (VKDB) if they did not receive a dose of vitamin K shortly after birth (within 6hrs)
Infants can be at risk for VKDB until the age of six months if they do not receive a vitamin K injection
What antibiotics are commonly implicated in emergency room visits associated with adverse antibiotic drug events?
amoxicillin as the most commonly implicated drug in children less than nine years
sulfamethoxazole-trimethoprim in children aged 10-19
The American Heart Association no longer recommends __________ for prophylaxis against infective endocarditis due to frequent and
severe reactions
Clindamycin
Clindamycin has been associated with significant adverse drug reactions related to community-acquired C. difficile infections
____________ is recommended as an alternative to penicillin, cephalosporin, and macrolide allergy
Doxycycline
Short-term use (less than 21 days) of doxycycline had not been associated with tooth discoloration in children under eight years of age
Although Azithromycin is one of the safest antibiotics for patients allergic to penicillin, what is an associated risk that we should be aware of in pediatric patients?
Cardiotoxicity and Increased risk of QT prolongation associated with higher dosage levels
What is most common inflammatory salivary gland disorder in the United States is?
juvenile recurrent parotitis (JRP) - onset of symptoms betweenf ages 3-6
Do antibiotics reduce the hormonal contraceptive effect in birth control?
a 2018 systematic review of drug interactions between non-rifamycin antibiotics and hormonal contraception found that most women can expect no reduction in hormonal contraceptive effect with
the concurrent use of non-rifamycin antibiotics.
rifampin or rifabutin - induce hepatic enzymes that are required for hormonal contraceptive metabolism, which could compromise the contraceptive or antibiotic effectA
Although dental prophylaxis only leads to a short-term reduction in plaque levels, what are other ways it may benefit the patient?
- Introduces dental procedures to patient
- Allows for OHI and proper brushing techniques
- Facilitates clinical examination
Is it necessary to remove plaque/pellicle prior to fluoride application/
Fluoride
Prophylaxis is not required prior to
the topical application of fluoride - no difference in caries rate as plaque and pellicle are not a barrier to fluoride uptake in enamel
When does the AAPD recommend periodontal probing?
After the 1st permanent molars have erupted and if the patient can tolerate it
If there is clinical/radiographic evidence of the presence of periodontal disease in primary dentition, then probe
What are considered normal probing depths in primary dentition?
1 ± 0.5 mm distance from the most coronal portion of the alveolar bone crest to the cementoenamel junction (CEJ) is considered a normal alveolar bone height in the primary dentition
2+mm is considered bone loss
What is the simplified basic periodontal examination?
Recommended for individuals aged seven to 17 years
6 probing sites:
- 4 first permanent molars
- Max right perm. central incisor
- Mand. left perm central incisor
You see a soft painless, pink to white, pedunculated (stalked) lesion on the lower lip. The surface appears to have multiple fingerlike projections and a cauliflower like appearance.
What is your differential?
Squamous papilloma (HPV 1 and 6) or Verruca Vulgaris (HPV 2)
SP: Tongue, lips and soft palate
VV: Tongue, lips, labial mucosa
What is the etiology of recurrent apthous ulcers?
Recurrent aphthous stomatitis is caused by a T-cell mediated immunologic reaction to a triggering agent
Up to ___% of Localized juvenile spongiotic gingival hyperplasia will recur after excision
16%
What is the recurrence rate of pyogenic granulomas after excision?
15%
What are the 3 different forms of periodontal disease?
1) Periodontitis
2) Necrotizing periodontitis
3) Periodontitis as a manifestation of a systemic disease
What are local factors that may increase periodontal disease risk?
Caries lesions, defective restorations, malocclusion, orthodontic appliances, and dental enamel defects as well as other dental anomalies
When are systemic antibiotics indicated in periodontal treatment?
Patients exhibit moderate periodontitis with 3-4mm of
CAL and PPD of less than five mm
What are different antibiotics that have been used in treating periodontitis?
Amoxicillin+metronidazole
Azithromycin in penicillin-allergic pts but be careful of prolonged QT/cardiotoxicity
True or False:
The recommended antibiotic dosage for periodontal treatment is the same as that used for odontogenic infections or endocarditis prophylaxis
No, it is different
What are some side effects/complications of immunosuppressive therapy and/or radiation that affect the periodontium?
-Gingival bleeding
-Soft tissue necrosis
-Salivary gland dysfunction (Health of the periodontium depends on saliva’s mechanical cleansing and antimicrobial properties)
-Opportunistic infections (e.g., candidiasis, herpes simplex virus)
-Oral graft-versus-host disease
Drug-induced gingival hyperplasia have been associated with what 3 types of medications?
Anticonvulsants (Phenytoin)
Immunosuppresants (cyclosporine)
Calcium-channel blockers (nifedipine, veramapil)
What are different treatment options to approach drug-induced gingival hyperplasia?
- Drug change
- OHI/biofilm control
- Address defective restorations/plaque traps/overhangs
- Surgical excision of excess tissue
Both periodontal flap surgery and gingivectomy have been used to treat drug-induced gingival hyperplasia. When is one used over the other?
Gingivectomy - used when there are <6 teeth affected/localized, no CAL or need for osseous surgery
Periodontal flap surgery - when there are >6 teeth affected/generalized, there is CAL and needs osseous surgery
What are contraindications for the use of gingivectomy during surgical therapy of periodontitis?
-Risk of postoperative bleeding is increased
-Access to bone is required
-The zone of keratinized tissue is narrow,
-Esthetics are a concern
What are advantages of laser therapy in periodontal treatment?
improved perioperative visualization from hemostasis, reduced need for sutures, wound detoxification, enhanced healing, better patient acceptance, and postoperative pain control
What age should esthetic crown lengthening be done?
After growth has completed
What is rare malignant counterpart of Ameloblastic Fibroma?
Ameloblastic fibrosarcoma
18% recurrence rate of ameloblastic fibroma so need to f/u
What is your diagnosis if you see punched out radioluncies and floating teeth on the radiograph?
Langerhans cells histiocytosis/histiocytosis x
What is your differential for “floating teeth’ on a radiograph?
Langerhans histiocytosis
Melonotic neuroectodermal tumor of infancy
Burkitt’s lymphoma
What is your differential for an expansile, well-defined unilocular radiolucency with irregular calcifications, possibly associated with an odontoma, in the incisor-canine region?
Calcifying odontogenic cyst/Gorlin cyst
What is your differential for an expansile, well-defined unilocular radiolucency with irregular calcifications, possibly associated with an odontoma, in the molar-premolar region?
Ameoloblastic fibro-odontoma
What are features of McCune-Albright syndrome?
Polyostotic fibrous dysplasia
Cafe-au-lait macules
Endocrine abnormalities
How do compound vs complex odontomas different?
Compound odontoma: looks like mini teeth
Complex odontoma: amorophous mass
What is the most common periapical radiopacity?
Condensing osteitis
What are the AAP’s recommendations regarding juice?
No juice introduced before age 1
Age 1-3: <4 oz
Age 4-6: 4-6oz
Age 7-18: <8oz
How is breastfeeding and caries risk related in terms of age?
<12mos: decreased caries risk
>12mos: increased caries riskQ
What are consequences, other than increased caries risk, of increased sugar-sweetened beverages in adolescence?
Decreased milk consumption, decreased calcium intake, increased risk for osteoporosis
Increased BMI
Congenital epulis:
Males/females?
Maxilla/mandible?
Females
Maxilla - lateral and canine region
CC: “My 8-month old has a swelling up front that is definitely getting bigger.” What is your ddx?
Melanotic neuroectodermal tumor
-Occurs within first year of life
- Floating teeth with sun ray pattern
- 20% recur after excision
How has community fluoridated-water affected number of decay, missing, filled (dmft) in primary and permanent teeth?
Fluoridated water = 35% reduction of dfmt in primary teeth, 26% reduction of dmft in permanent
True or False:
SDF is approved by the FDA as a class II medical device for arresting caries.
False:
SDF is approved by the FDA as a class II medical device for reducing tooth sensitivity.
Caries arrest is an off-label use.
What is the mechanism of action of SDF?
Fluoride: remineralizing
Silver: antimicrobial effect on carious dentin
pH=10, silver and fluoride in alkaline solution decreases dentin degradation
Forms a precipitate that occludes dentinal tubules
What are indications for the use of SDF?
SDF
- Arrest of carious lesions when conventional treatment is not feasible (precooperative children)
- MIH - to reduce sensitivity
What are contraindications for the use of SDF?
SDF
- Signs of irreversible pulpitis or periradicular pathology such as abscess
- Silver allergy
True or False:
38% SDF has almost 6 times more fluoride concentration than 5% sodium fluoride varnish.
False.
There is approximately equivalent fluoride concentration in SDF and NaF varnish, but SDF has 2-3x more fluoride retained than delivered by NaF
~25% silver, 8% ammonia, pH 10
Exposure to one drop of SDF orally would result in less fluoride ion content than is present in a 0.25 mL topical treatment of fluoride varnish.
source: RM
The AAPD SDF panel makes a (strong/conditional) recommendation for the use of 38 percent SDF for the arrest of cavitated caries lesions in primary teeth as part of a comprehensive caries management program
The AAPD SDF panel makes a (conditional) recommendation for the use of 38 percent SDF for the arrest of cavitated caries lesions in primary teeth as part of a comprehensive caries management program
panel felt confident that a conditional recommendation was merited because, although a majority of patients
would benefit from the intervention, individual circumstances, preferences, and values need to be assessed by the practitioner after explanation and consultation with the caregiver
Low quality evidence
Based on the AAPD clinical guidelines, approximately what percent of carious lesions could be expected to be arrested 2 years after SDF application?
68%
SDF has _ % higher success rate in caries lesion arrest compared to controls
SDF has 48% higher success rate in caries lesion arrest compared to controls
After a single application of SDF, what happened to previously arrested lesions at the 6 month mark once it was reevaluated at 24 months?
50% of arrested lesions at 6 months had reverted back to active lesions at 24 months
What does the AAPD Reference manual/guidelines say about application frequency of SDF?
annual application of SDF is more effective than 4x/year application of NaF
Apply initially, then monitor for 2-4 weeks and then consider re-application, then recare based on pt’s caries risk
Does SDF application adversely affect the bond strength of restorative material such as resin?
No
What are some situation you may consider an interim therapeutic restoration (ITR)?
- Uncooperative patient
- Special health care needs patient
- Stepwise excavation
- Partially erupted molars that cannot be adequately isolated
Why is xylitol considered a non-cariogenic sugar substitute?
Because it’s not readily metabolized by oral bacteria
How many times a day must xylitol be used in order to have a protective effect?
At least 3 times a day
optimal results for primary prevention require consistent use of 100% xylitol, chewed or consumed 3-5x/day after meals with a total dose of 5-10 g/day, which may be unrealistic in clinical
practice
current lack of consistent evidence supporting xylitol as a primary caries-preventive agent
Does literature support the use of xylitol as a way to reduce caries?
No, systematic review shows insufficient evidence to show xylitol reduces caries but AAPD supports it as a noncariogenic sugar substitiute
How many frenula are typically in the oral cavity?
7
1) Maxillary labial
2) Mandibular labial
3) Mandibular lingual
4 buccal frena (2 upper and 2 lower)
Explain the different classifications of the maxillary labial frenum with respect to its anatomical insertion level.
1) mucosal (frenal fibers are attached up to the mucogingival junction)
2) gingival (frenal fibers are inserted within the attached
gingiva)
3) papillary (frenal fibers are extending into the interdental papilla)
4) papilla penetrating (frenal fibers cross the alveolar process and extend up to the palatine papilla.
How does the position of insertion of a maxillary labial frenum change with growth/development?
Evidence suggests apical migration of the insertion as the alveolar process grows and descends and the frenulum remains in place
True or false:
Anatomical classification is vital to determining breastfeeding success or difficulty, pain, or maternally reported poor latch.
False:
A prospective study shows no correlation
How can the maxillary frenum contribute to reflux in babies?
The maxillary frenulum can contribute to reflux in babies due
to the intake of air from a poor seal at the breast or bottle
leading to colic or irritability
When is treatment of the maxillary labial frenum recommended when a midline diastema is involved?
1) retracting upper lip causes papilla to blanch
2) midline diastema is >2mm but not recommended prior to permanent canine eruption and following orthodontic closure of the space - if performed too early, may cause replace due to scarring
The WHO recommends breastfeeding infants exclusively until what age?
6 months
What are common symptoms babies experience from a tongue/lip tie?
Poor or shallow latch on the breast or bottle
Slow or poor weight gain
Reflux and irritability from swallowing excessive air
Prolonged feeding time, milk leaking from the mouth due to a poor seal
Clicking or smacking noises when nursing/ feeding
Maternal symptoms include painful nursing
The tongue’s ability to (elevate/protrude)
rather than (elevate/protrude) is the most important quality for nursing, feeding, speech, and development of the dental arches
The tongue’s ability to elevate
rather than protrude is the most important quality for nursing,
feeding, speech, and development of the dental arches
Individuals with ankyloglossia have difficulty articulating what speech sounds?
Consonants and sounds like / s /, / z /, / t /, / d /, / l /, / sh /,
/ ch /, / th /, and / dg / and rolling “r”s
Is it suggested that surgical intervention for ankyloglossia be the first line of treatment when speech difficulties arise?
No, see speech language pathologist first
What are possible clinical manifestations within the orofacial complex has ankyloglossia been associated with?
High arched palate
Reduced palate width
Elongated soft palate
Possible skeletal class III malocclusion but evidence is limited
Localized gingival recession on the lingual of mandibular anteriors
Define:
Frenuloplasty
Frenulectomy
Frenulotomy
Frenuloplasty: an extensive frenulum excision that usually
involves repositioning of aberrant muscle and is closed by Zplasty or a local flap with placement of sutures
Frenulectomy: the complete removal of the frenum/frenulum including its attachment to underlying bone
Frenulotomy: simple cutting or incision of the frenum/frenulum
What are possible complications of the surgical management of a frenum?
Reattachment
Scar tissue formation
Excessive bleeding
Hematoma
Numbness, parasthesia
Lingual nerve passes underneath the fascia under ventral surface of tongue - can get damaged
Mucous retention cyst
Infection
What are advantages of electrosurgery and laser technologies for frenectomies?
Shorter operative time
Decreased post-operative pain/discomfort and complications
Better hemostasis
No need to place sutures
Better patient acceptanceD
Define ECC (early childhood caries)
The presence of 1+ decayed, missing or filled teeth in any primary tooth
Define S-ECC (severe early childhood caries)
<3yo: Any smooth-surfaced carious lesion in a child
Ages 3-5: one or more cavitated, missing (due to caries),
or filled smooth surfaces in primary maxillary anterior teeth
Age 3: dmft >=4
Age 4: dmft >= 5
Age 5: dmft >=6
How has the dmft scores changed in children over the years?
Prevalence is about the same but the filled component is increasing so more children are receiving treatment
What does the AHA say about sugar consumption in young children?
Avoid sugar in foods and drinks in children <2yo
What does the AAP say about juice consumption in toddlers ages 1-3?
No juice before 12 mon, recommends whole fruit consumption instead
Max 4oz of juice per day for ages 1-3
What does the AAPD say about juice consumption before 6 months of age?
Offering juice before solid foods are introduced into the diet could risk having juice replace human milk or infant formula in the diet, which can result in reduced intakes of protein, fat, vitamins, and minerals such as iron, calcium, and zinc.
A smear or rice-size amount of fluoridated toothpaste for children <3 yo contains approximately how many mg of fluoride?
Fluoride
0.1mg
A pea-size amount of fluoridated toothpaste for children ages 3-5yo contains approximately how many mg of fluoride?
Fluoride
0.25mg
How many ppm does 5% fluoride varnish contain?
22,500ppm
How does fluoride reduce caries?
Fluoride
- Remineralizes enamel
- Affects bacterial metabolism
- Reduces the acid byproducts by cariogenic bacteria
Forms fluoroapatite
For children ages 4-6yo, how much juice does the AAP recommend?
4-6oz juice max
For children ages 7-18yo, how much juice does the AAP recommend?
8oz max
What are alternative behavior guidance techniques you could try prior to trying the papoose?
distraction, shaping, modeling, sensory integration, desensitization, and reinforcement
What is protective stablization?
The restriction of a patient’s freedom of movement to decrease the risk of injury while allowing the safe completion of treatment
Differentiate between active vs passive restraint.
Active - involves another person
Passive - patient stabilization device is used
What training is mandated prior to utilizing protective stabilization?
Only one state (Colorado) requires training beyond dental school
What are indications for protective stabilization?
- a patient who requires immediate diagnosis and/or urgent limited treatment (e.g., toddler with acute dental trauma) and cannot cooperate due to developmental levels (emotional or cognitive), lack of maturity, or medical/physical conditions;
- a patient who requires urgent care and uncontrolled movements risk the safety of the patient, parent,
clinician, or staff without the use of protective stabilization. - a previously cooperative patient who quickly becomes uncooperative and cooperation cannot be
regained by basic behavior guidance techniques in order to protect the patient’s safety and efficiently
complete a procedure and/or stabilize the patient; - sedation
*SHCN
What are contraindications to protective stabilization?
- a cooperative nonsedated patient;
- an uncooperative patient when there is not a clear need to provide treatment at that particular visit;
- patient who cannot be immobilized safely due to associated medical, psychological, or physical
conditions (eg osteogenesis imperfecta); - a patient with a history of physical or psychological trauma, including physical or sexual abuse or other
trauma that would place the individual at greater psychological risk during restraint; - a patient with non-emergent treatment needs in order to accomplish full mouth or multiple quadrant dental rehabilitation;
- the practitioner’s convenience; and
- a dental team without requisite knowledge and skills in patient selection and restraining techniques to prevent or minimize psychological stress and/or decrease risk of physical injury to the patient, parent,
clinician, and staff
Can a child decline to consent to protective stabilization?
No but assent should be considered
What are risks associated with protective stabilization?
- Bruises, scratches
- Rigid boards don’t allow for completed extension of neck - important to have neck roll for airway patency during sedation
- Excessive adrenal catecholamine release during high stress may sensitize the heart and cause rhythm disturbance
What documentation must be in the patient’s record if using protective stabilization?
- Indication for protective stabilization
- Informed consent for protective stabilization
- Reason for parental exclusion during protective stablization (if applicable)
- Duration
- Behavior evaluation during protective stabilization
- Any untoward outcomes (eg markings)
- Management implication for future appointments
Name some local anesthetics that are esters
Procaine, tetracaine, benzocaine
Name some local anesthetics that are amides
Lidocaine, mepivicaine, prilocaine, articaine
What are some complications associated with local anesthetic delivery?
hematoma, trismus, intravascular injection
How deep do most topical anesthetics effective to?
2-3mm, helps with needle penetration
Which anesthetics are contraindicated in patients with methemoglobinemia?
Ester: Benzocaine
Amide: Prilocaine
Explain what methemoglobnemia is.
Acquired methemoglobinemia is a serious but rare condition that occurs when the ferrous iron in the hemoglobin molecule is oxidized to the ferric state. This molecule is known as methemoglobin, which is incapable of carrying oxygen and results in a decreased availability of oxygen to the tissues
What patients may be at risk for methemoglobnemia?
Glucose-6-phosphate dehydrogenase deficiency,
Sickle cell anemia
Anemia
Very young patients)
Patients with symptoms of hypoxia
What type of injection is associated with the highest rate of needle breakage?
IANB with 30gauge
What are benefits of buffering the local anesthetic?
2.3x more likely to achieve profound anesthesia
Faster onset time
What is the purpose of vasoconstrictors such as epinephrine in local anesthetic?
Reduces rate of absorption into bloodstream which reduces risk of toxicity
Prolongs the anesthetic action in the area
Name some systemic conditions and drugs that needs judicious use of vasoconstrictors.
Cardiovascular disease
Hyperthyroidism (hypersensitive to stress and α1-adrenergic effects of sympathomimetics)
Diabetes
Substance abuse of stimulants
Pregnancy - preeclampsia
Drugs:
monoamine oxidase inhibitors
tricyclic antidepressants antipsychotic drugs
norepinephrine
phenothiazines
What are the precautions needed with local anesthesia and patients at risk for malignant hyperthermia?
No precautions needed with local anesthesia or epinephrine
How does the presence of an infection affect the action of local anesthesia?
The pH of the extracellular fluid determines the ease with which a local anesthetic moves from the site of its administration into the axoplasm of the nerve cell
Infection lowers the pH of the extracellular tissue, so local anesthetic injected into the area largely exists in the ionized form, which is less able to enter the cell membrane.
Is antibiotic prophylaxis needed when administering local anesthesia?
No
Yes if injection is through tissues that is infected
When do most adverse local anesthetic reactions manifest?
Most adverse drug reactions develop either during the injection or within five to 10 minutes.
What should be included in the patient record when administering local anesthetic?
Type of local anesthetic
Dose
Site administered
Patient’s reaction to injection
Patient’s weight
That POI was delivered with guardian and patient
What are symptoms of local anesthetic systemic toxicity or overdose?
Biphasic reaction to LA in CNS (excitation then depression) and in Cardiovascular system
CNS: Dizziness, anxiety, and confusion–> diplopia, tinnitus, drowsiness, and circumoral numbness or tingling
CV: increased HR and BP –> vasodilatation occurs followed
by depression of the myocardium and a subsequent fall in
blood pressure, bradycardia, cardiac arrest
twitching, tremors, talkativeness, slowed speech, and shivering,
followed by overt seizure activity. Loss of consciousness and
respiratory arrest may occur
How are serious cases of LAST/local anesthetic toxicity treated?
intravenous lipid emulsion therapy
Can you reverse the action of local anesthetics?
Use of phentolamine mesylate injections in patients over age six years or at least 15 kilograms (kg) has been shown to reduce
the duration of effects of local anesthetic by about 47% in the maxilla and 67% in the mandible
What is the mechanism of action for Pentolamine?
Phentolamine mesylate reverses the vasoconstrictor via its antagonistic effect at the α1 receptor, allowing for vasodilation and rapid metabolism of local anesthetic
What are contraindications to Pentolamine mesylate?
Use of phentolamine mesylate is not recommended for patients who are <3 years old or weigh <15 kg (33 pounds).
How is the dosing of local anesthetics adjusted during sedation and GA?
Decreased since it is a CNS depressant
When is the safest trimester to administer local anesthetic to pregnant women?
2nd trimester - organogenesis is complete
Lidocaine is safe during breastfeeding
When should epinephrine be used with caution in pregnant women?
Hypertensive disorders such as pre-eclampsia
may cause contraction of uterine blood vessels and limit blood flow to the placenta
How is dosing of local anesthetics adjusted for patients <6mos old?
The calculated maximum total dose of amide local anesthetics should be reduced by 30 percent in infants younger than six months.
What local anesthetics have an age limitation?
Manufacturers do not recommend articaine use in pediatric dental patients younger than four years.
Use of bupivacaine is not recommended in patients younger than 12 years.
Benzocaine not less than 2yo
What local anesthetic cannot be used in patients at risk for methemoglobnemia?
Benzocaine
Prilocaine
What is the max recommended dose for:
Lidocaine
Articaine
Mepivicaine
Lidocaine: 4.4mg/kg; 34mg/1.7 cartridge of anesthetic
Articaine: 7.0mg/kg; 68mg/1.7 cartridge
Mepivicaine: 4.4mg/kg; 34mg/1.7 cartridge of anesthetic
How is dosage of local anesthetics adjusted for infants <6 months old?
The calculated maximum total dose of amide local anesthetics should be reduced by 30 percent in infants younger than six months
What is the mechanism of action of nitrous oxide?
Analgesic effect: Activates opioid receptors
Anxiolysis: Activates GABA receptors at benzodiazepine site
What does a MAC of 105 for nitrous mean?
Minimum alveolar concentration (MAC) is a measure of potency of inhaled anesthetics - the MAC (%) needed to produce immobility in 50% of subjects exposed to a noxious stimulus like a surgical incision
Sevofluorane: 2%
Nitrous oxide: 105% - need a CRAP ton
What is nitrous oxide’s effect on the cardiovasular system?
Minimal depression of the cardiovascular system and peripheral resistance is slightly increased so BP maintained
Safe for those with cardiovascular considerations
Why is nitrous oxide contraindicated in those with untreated vitamin B12 deficiency?
N2O has been linked with irreversible inactivation of cobalamin (vitamin B12) - concerns for myeloneuropathy and DNA synthesis
What are some adverse effects of nitrous oxide?
Most common: Nausea and vomiting
Others: Oversedation, headaches, dizziness, diffusion hypoxia, filling of gas-filled spaces
What is diffusion hypoxia and how can it be avoided?
Diffusion hypoxia can occur because of rapid release of nitrous oxide from the blood stream into the alveoli, thereby diluting the concentration of oxygen
Avoid by administration of 100% oxygen for at least 5 mins after nitrous is turned off
What monitoring is recommended when using nitrous oxide?
observation of the patient’s responsiveness, color, and respiratory rate and rhythm is recommended
We often run into young patients with rampant caries that need dental intervention and general anesthesia. What are recommended skills that our anesthesiologist should have?
AAPD recommends that the anesthesia provider have focused expertise in pediatric airway management and vascular access if we treat patients under 3yo
The dentist recommended that a patient needs general anesthesia, but who ultimately can determine if the in-office setting is appropriate for the patient?
The CLA (currently licensed anesthesia provider) ultimately determines who can safely be treated in an office setting
Who would be the lead in the event of a perioperative anesthetic adverse event?
CLA (currently licensed anesthesia provider) would assume the lead during the management of any perioperative anesthetic emergencies - dentist would assist
What is the only absolute contraindication to nitrous use?
Lack of consent
Which bronchus is more likely to aspirate - right or left?
Right - it’s more straight compared to the left
What is the pediatric dosing for acetaminophen and ibuprofen for pain control?
<12yo:
Acetaminophen: 10-15 mg/kg/dose every 4-6 hours as needed (maximum daily dose 75 mg/kg, but not to exceed 4,000 mg/24 hours)
Ibuprofen: 10 mg/kg/dose every 6-8 hours as needed (maximum single dose 400 mg)
What medication and dosing would you use to manage nausea/vomiting after GA?
IV Zofran/Ondansetron:
<12 and/or <40kg: 0.1mg/kg, max 4mg
PR Phenergan/Promethazine:
0.25-0.5mg/kg PR, max 25mg
What are some causes for syncope?
Vasovagal: Fear, pain, anxiety
Orthostatic
Hypoglycemic
A patient experiences syncope. What are your next steps to manage this medical emergency?
- Stop treatment, assess and recognize
- Recline, feet up
- Loosen clothing that may be binding
- Ammonia inhaler
- Administer oxygen
- Cold towel on back of neck
- Monitor recovery
- Do not allow pt to drive
What steps do you take in the even of an anaphylactic medical emergency?
This is a true, life-threatening emergency
1. Call for emergency medical services
2. Administer epinephrine (0.01mg/kg every 5 mins; 1mg/mL)
3. Administer oxygen
4. Monitor vital signs
5. Transport to emergency medical facility
by advanced medical responders
What steps do you take for a mild/delayed allergic reaction?
- Discontinue all sources of allergy-causing substances
- BLS with supplemental O2
- Vital signs
- Administer diphenhydramine/benadryl 25-50mg PO or 1mg/kg; can do deep IM 1mg/kg for urticaria or pruritus
Your 5 year old patient with a history of asthma starts showing signs of an acute asthma attack - shortness of breath,
wheezing, coughing. What do you do?
- Stop treatment. Sit patient upright or in a comfortable position
- Vitals - Administer oxygen
- Administer bronchodilator - Albuterol 1-2puffs
- If bronchodilator is ineffective, administer epinephrine EpiPen
- Call for emergency medical services with transportation for advanced care if indicated
Laser if an acronym for what?
acronym for light amplification
by stimulated emission of radiation
How do lasers work?
Within a laser, an active medium (e.g., erbium crystal, CO2 gas, a semiconductor) is stimulated to produce photons of energy that are delivered in a beam of unique wavelength measured in nanometers.
Different tissues have different affinities for the particular wavelength that they absorb
How do erbium and CO2 lasers differ when they target dental hard tissues?
Erbium doesn’t ablate hard tissues directly - tissue undergoes spallation instead
CO2 lasers are capable of ablating hard tissue directly
What are some benefits of lasers in pediatric dentistry?
Can be both selective and precise
Less tissue necrosis than electrosurgery
Hemostasis - less post-operative comfort
Shorter chairtime
Less need for antibiotics- decontaminating and bacteriocidal properties
Analgesic effect on hard tissues - less local anesthesia
How can caries excavation using dental lasers be more effective than a traditional handpiece?
Lasers can remove caries effectively with minimal involvement of surrounding tooth structure because caries-affected
tissue has a higher water content than healthy tissue.
What are disadvantages of lasers?
High startup cost
Additional education/training
May need different lasers depending on wavelength and target tissues/use
Lasers are only end-cutting (burs are side and end-cutting)
Slower cavity preparations and still have to modify prep with handpiece
What is the prevalence of pediatric obstructive sleep apnea? What age group does it typically affect?
1-5%
Ages 2-7yo
Equal gender predilection prepubescence
Males more in adolescence
Central sleep apnea is less common than OSA, but is more commonly associated with what conditions?
Neurological/neurosurgical conditions
Arnold-chiari malformation
Down syndrome
Prader-Willi syndrome
Achondroplasia
Congestive heart failure
Stroke
Premature infants
What are symptoms of obstructive sleep apnea?
- Daytime sleepiness
- Loud snoring >3 nights/week
- Episodes of breathing cessation witnessed by another
person. - Abrupt awakenings accompanied by shortness of breath.
- Awakening with dry mouth or sore throat
- Morning headache.
- Difficulty staying asleep.
- Unusual sleep positions (seat or neck hyperextended).
- Attention problems.
- Mouth breathing.
- Diaphoresis (excessive sweating)
- Restlessness.
- Frequent awakenings.
What are common etiologies for pediatric obstructive sleep apnea?
1) adenotonsillar hypertrophy
2) Inadequate airway size
3) Inadequate neuromuscular tone of the airway muscles
Or both
Anatomic: hypertrophic tonsils and
adenoids, macroglossia, choanal atresia, respiratory tissue
thickening, obesity, craniofacial abnormalities (Pierre-Robin, CL/P)
Neuromuscular disorders and hypotonia: cerebral palsy, muscular dystrophies
What are quick ways we can clinically assess potential airway obstruction in children?
Mallamapti
FTP (friedman tongue position, tongue is in neutral position instead of protuding)
Brodski
Why is aspirin contraindicated for pain management in pediatric patients?
If administered during a viral illness/infection, pt is at risk for Reye Syndrome - swelling of the liver and brain
What were the conclusions on opioids vs acetaminophen/ibuprofen for pain management?
A 2013 systematic review found a combination of acetaminophen and ibuprofen provided effective analgesia without the adverse side effects associated with opioids; the
combination of acetaminophen and ibuprofen was shown to be more effective in combination than either medication alone
What are ways you can make the injection more comfortable for patients?
Topical anesthetic (careful with benzocaine/methemoglobnemia <2yo)
Jiggling the cheeks - alpha-beta fibers
Buffering anesthetic to increase pH
Slow injection technique
What is the rationalization for administering local anesthesia under general anesthesia?
Minimize central sensitization
If no local, we are priming of CNS neurons and increased future pain sensitivity
Name some non-pharmacological approaches to minimize pain.
Distraction
Imagery
Hypnotherapy
Virtual reality
What is the mechanism of action of NSAIDs?
NSAIDs inhibit the COX enzyme, which is responsible for converting arachidonic acid into pro-inflammatory mediators
that drive postoperative pain, swelling, and hyperalgesia
What have been some adverse effects of NSAIDs?
Rash
Inhibition of bone growth and healing
Gastritis with pain and bleeding (increased if pt is using corticosteroids)
Decreased renal blood flow and kidney dysfunction
Reversible inhibition of platelet function
Hepatic dysfunction
Increased incidence of cardiovascular events
What is the mechanism of action of Acetaminophen?
blockade of prostaglandin and substance P production
Which of the following also have anti-inflammatory properties as well?
- Ibuprofen
- Acetaminophen
- Opioids
only ibuprofen
What is the concern regarding asthma and NSAIDs?
NSAIDs may exacerbate asthma due to shift in leukotrienes
What percentage of smokers started in adolesence?
9 out of 10 start smoking by age 18
about 23% of 6th-12th graders have used tobacco
What are some things that infants/children are at increased risk for when exposed to tobacco smoke?
Early childhood caries
Sudden infant death syndrome (SIDS)
Acute respiratory infections (bronchitis, pneumonia)
Middle ear infections
Asthma
Allergies
Poor cardiorespiratory fitness, and infections during infancy
What are some dental implications for children when exposed to secondhand smoke?
Early childhood caries
Enamel hypoplasia
Also:
Oral cancer
Periodontal disease
What is the prevalence of e-cigarette users in adolescents?
2019- about 27% of highschoolers reported e-cig usage
What has been the link between e-cigarettes and traditional cigarette users?
E-cig users are 3.5x more likely to use regular cigarettes despite having less risk factors than traditional cigarette users
What is the possible cause of caries from E-cig use?
some liquids containing sucrose and ethyl maltol
e-cig aerosols may increase the adhesion of Streptococcus mutans to enamel and also promote the formation of biofilm on tooth surfaces
Alcohol use amongst high schoolers has been (increasing or decreasing) in a 2019 survey compared to 2014.
Decreasing - both alcohol use and binge drinking
What is the most commonly used illicit drug amongst teenagers?
Marijuana
Has the trend in the use of misuse of prescription opioids, herione and fentanyl increased or decreased amongst adolescents?
Increased
What considerations do we need to take with local anesthetics and patients who may be abusing stimulant (ie amphetamine) medication?
Vasoconstrictor may have drug interactions with stimulant medication and cause tachycardia, hypertension or hypotension,
palpitations, hyperthermia, cardiac dysrhythmias, myocardial
infarction, and cerebrovascular accidents
What is most common type of
HPV-associated oral and oropharyngeal cancer?
Oropharyngeal squamous cell carcinoma
What is the vaccine schedule for the immunization of HPV?
Immunocompetent children <15yo: two-dose schedule - start at 11-12yo and second dose separated by 6-12months
When is the 3-dose series for HPV immunization recommended?
Ages 9-14 - 2nd dose was received <5 months from the first dose
Age 15+ at the time of the first dose
Immunocompromising conditions
What are common oral consequences of intraoral jewelry?
Lip piercing: 50% had gingival recession
Tongue piercing: 44% had gingival recession
- Increased plaque levels
- Periodontal pathogenic bacteria
- Gingival inflammation and/or recession
- Caries
- Diminished articulation
- Metal allergy
- Permanent tooth injury
What are some oral manifestations of mouth breathing?
development of increased facial height, anterior open bite,
increased overjet, and narrow palate
What are some oral manifestations of OSA?
narrow maxilla, crossbite, low tongue position, vertical growth,
increased overjet, and openbite
What are some populations that OSA may be more prevalent in?
- Obesity
- Craniofacial anomalies (Pierre Robin, CLP, Achondroplasia)
- Down sydrome
- Neuromuscular disorders with hypotonia component (cerebral palsy)
What are the most frequently missing teeth?
1) Mandibular second premolar
2) Maxillary lateral incisor
3) Maxillary second premolar
29>7>4
Hypodontia is more prevalent in which gender?
Females
What are factors that will influence the treatment decision when a permanent lateral incisor is missing?
(1) patient age
(2) canine size and shape
(3) canine position
(4) child’s occlusion and amount of crowding
(5) bite depth
(6) profile
(7) smile line
(8) quality and quantity of bone in the edentulous area
Patients generally prefer space closure over implants
What are some good radiological practices to minimize exposure during dental imaging?
1) Use fastest image receptor (PSP, CCD charge-coupled device, F-speed film)
2) Collimator
3) Proper film exposure and processing
4) Protective aprons/thyroid collars
5) limiting # of images to minimum necessary
How does the radiation dose of extraoral bitewings from panoramic machines compare to traditional intraoral radiographs?
Should only be prescribed in specific instances, NOT as an alternative to intraoral radiographs
Is 3-11 times MORE than traditional bitewing
What are some topics for anticipatory guidance in an adolescent patient?
Adolescent
Caries
Periodontal disease
Oral hygiene
Diet
Occlusal considerations (malocclusion, 3rd molars, TMD)
Bleaching
Dental Trauma
Drug/substance use (tobacco, nicotine, e-cigs)
Oral piercings
Dental implications during pregnancy
Psychosocial considerations (bulimia)
Transitioning to adult care
Why is nutritional counselling so important for a pregnant adolescent?
What are some vitamins that are important prenatally?
Pregnancy
Diet can affect unborn child. Adequate nutrition also helps reduce the risk of low-birth weight babies
- Vitamin D: works with calcium to help bones and teeth of fetus
- Folic acid: helps development of neural tube, brain, spinal cord, helps prevent spina bifida, cleft lip/palate
What are some perinatal deficiencies/diagnoses in a pregnant mother that have been shown to be associated with craniofacial and/or dental anomalies?
Pregnancy
Vitamin deficiency - enamel defects
Gestational diabetes - cleft lip/palate
Folic acid deficiency - cleft lip/palate, spina bifida
Tobacco smoking - cleft lip/palate
Secondhand smoke - cognitive defects
Alcohol - FASD, miscarriage, stillbirth
Avoid certain anticonvulsant medications because of CLP: topiramate, valproic acid
What are some medications that should be avoided during pregnancy?
Pregnancy
Can refer to “dailymed” online for pharmacotherapy recommendations during pregnancy
Anticonvulsant: topiramate, valproic acid
Tetracycline, doxycycline
Diazepam, alprazolam
Ibuprofen, naproxen, aspirin
Many pregnant women experience morning sickness and nausea/vomiting during pregnancy. What instructions would you give the pregnant patient so they can combat dental erosion?
Pregnancy
Rinse with 1 cup water + 1 tsp sodium bicarb after each acid challenge
Avoid brushing teeth for 1 hour after each episode
Encourage fluoride rinse or gel
What are some things regarding pregnancy that may increase the patient’s carie’s risk?
Pregnancy
- Perimyolysis, acid erosion from vomiting
- Frequent snacking, sipping or candy to help with vomiting
- Xerostomia from pregnancy-associated hormonal changes
You have a pregnant adolescent presenting for their dental exam. What are some points that are important for anticipatory guidance for this patient?
Pregnancy
- Diet
- Oral hygiene
- Pharmacotherapy and medications to avoid
- Substance use/abuse
- Nausea/vomiting/morning sickness and effect on dentition
- Xerostomia and effect on dentition
- Periodontal disease and effect on fetus
- Vertical transmission of cariogenic bacteria
When is a pregnant adolescent encouraged to seek professional oral health care if they do not already have a dental home?
Pregnancy
During the first trimester
Is fluoride supplementation for a pregnant mother beneficial for the fetus?
Pregnancy
No, no evidence that fluoride supplementation for a pregnant mother beneficial for the fetus?
Outline the ideal trimester to do dental prophylaxis and treatment.
Pregnancy
First trimester: Dental prophylaxis
Second trimester: Dental treatment, if necessary
Third trimester: Dental prophylaxis
Postpone elective dental treatment until after delivery
When should pregnancy testing be done when considering advanced behavior management techniques?
Pregnancy
In post-menarchal females of child-bearing age when the results would alter the patient’s medical management
What is the correlation of TMD pain in adolescence vs TMD pain in young adulthood?
TMD pain in adolescence triples the risk of developing TMD pain in young adulthood
Name some possible etiologic factors that can tribute to TMD pain.
Macrotrauma: Chin trauma, jaw dislocation, mandibular hyperextension, close reduction+immobilization s/p subcondylar fracture
Microtrauma: Bruxism, clenching, wind instrument use
Systemic: rheumatic disease (juvenile idiopathic arthritis), hypermobility/extensibility in Ehlers-Danlos, Marfan syndrome
What are common side effects of internal and external bleaching:
Internal bleaching of a non-vital tooth: cervical root resorption
External bleaching: marginal leakage of existing restorations
What are components of informed consent?
1) Nature of the dental health problems
2) Proposed treatment
3) Risks and benefits of proposed treatment
4) Treatment alternatives
5) Risks and benefits of alternative treatment, as well as no treatment
What should be included in a written informed consent form?
- legal name and date of birth of patient.
- legal name and relationship to the pediatric patient/legal basis on which the person is granting permission
on behalf of the patient. - patient’s diagnosis.
- nature and purpose of the proposed treatment in simple terms.
- potential benefits and risks associated with that treatment in simple terms.
- professionally-recognized or evidence-based alternative treatment – including no treatment – to recommended therapy and risk(s) of each treatment modality in simple terms.
- place for the parent to indicate that all questions have been asked and adequately answered.
- places for signatures of the parent, dentist, and an office staff member as a witness.
What are some standard precautions that are taken in all patient care?
Hand hygiene
PPE
Sharps safety
Sterile instruments
Cleaning+disinfecting environmental surfaces
Respiratory hygiene/cough etiquette
Osseointegrated implants are typically contraindicated in a growing pediatric patient. Are there any instances where implants can be used?
Recent research suggests that in cases of anodontia, implants are best placed in the mandibular canine region at around 8 to 10 years of age (which is after the period of maximal mandibular transverse growth) to facilitate lower denture retention.
What are some developmental milestones for a 12 month old?
Will play - high five
Wave bye-bye
Call mama/dada by name
Understands no
Pulls to stand
What are some developmental milestones for a 15 month old?
Shows affection - hugs, kisses
Claps when excited
Points to ask for something or to get help
Can take a few steps
Feed self
There are 3 methods of caries removal:
1) complete
2) partial: one-step
3) partial: two-step
What have studies shown to be associated with higher success rates after the tooth was restored?
Partial: one-step
- Significantly fewer pulpal exposures
- More teeth maintain pulp vitality
- Decrease in pulpal complications and post-operative pain
In 2020, the FDA recommended that the use of amalgam be avoided in certain high-risk populations. Who is included in this group?
Pregnant women, women who are planning to become pregnant, women who are nursing, children under 6, those with neurological disorders
With regard to Class II amalgam restorations, when should amalgam NOT be used?
When caries extend beyond the proximal line angles
What are situations where you may not want to use composite as restorative material?
Poor isolation
High caries risk with poor oral hygiene
Large multi-surface restorations
Numerous carious teeth
Demineralization
How do the success rates of composite and amalgam restorations compare in primary teeth after 10 years?
Similar
92% success amalgam after 10 years
90% success composite after 10 years
Secondary/recurrent caries is one of the main reason for restoration failure in both composite and amalgam. Does one material have a higher rate of secondary caries over the other?
Yes - composite has secondary caries 3.5 times greater than amalgam
How does filler size in composites affect its properties?
Smaller filler sizes: more polishability
Larger filler sizes: strength
What are some benefits of GIC (glass ionomer cements) over resin materials?
Chemical bonding to both enamel and dentin
Less moisture sensitive
Uptake and release of fluoride
Biocompatible
Similar thermal expansion to teeth
When would an SSC be indicated for a permanent molar?
Grossly carious
Severe enamel defects
In regards to retention and gingival health, how do SSCs and zirconia crowns compare?
SSCs: Better retention
Zirconia: Better gingival health
What restorative options are there for interproximal caries on an anterior primary tooth?
Class III
Resin strip crowns
Pre-veneered SSCs
SSCs
Zirconia
Explain the concept/philosophy of minimally invasive dentistry.
MID:
1) early identification of the disease
2) identify factors contributing to the disease
3) intervention to arrest the caries
4) surgical intervention for caries when needed
Preserve as much tooth structure and focus on prevention
Requires close monitoring of caries risk, active surveillance and more frequent professional recare
When can you consider resin infiltration as an appropriate intervention for a tooth?
Non-cavitated lesion involving enamel and outer third of dentin
What advantages does mimimally invasive dentistry have over traditional restorations?
- Helpful in pre-cooperative children
- Delays the initiation of the restorative cycle
- Does not generate aerosols
How can one differentiate enamel hypoplasia from the post-eruptive breakdown of molar-incisor hypomineralization?
Enamel hypoplasia: smooth enamel borders and pitted surfaces, whole tooth is affected
PEB of MIH: sharp, irregular enamel due to shearing of weakened enamel
The risk of developing caries is about ___ time higher in MIH-affected teeth than in teeth not affected by MIH
almost 5 times higher (4.6)
What is the prevalence of MIH?
13.5% globally, about 10-13% in the US
How does a protective liner differ from an indirect pulp cap?
Liner: ALL caries have been removed, liner placed on dentin approximating pulp
IPT: Leave caries in the deepest portion next to pulp and place material over to form biological seal
If the tooth is expected to be retained over 24 months, what material is recommended for pulpotomies?
MTA and formo
Others have conditional recommendations
What is the “rule of 10s” when it comes to surgery for infants?
Cleft Lip/Palate
10 weeks of age
10 lbs
>10g/dL hemoglobin
>10,000 WBC
What are some questions you can ask the patient when they report jaw pain?
TMD
- do you have difficulty opening your mouth
- do you hear noises within your jaw joint?
- do you have pain in or around your ears or your cheeks?
- do you have pain when chewing, talking, or using your jaws?
- do you have pain when opening your mouth wide or when yawning?
- has your bite felt uncomfortable or unusual?
- does your jaw ever lock or go out?
- have you ever had an injury to your jaw, head, or neck? If so, when? How was it treated
- have you previously been treated for a temporomandibular disorder? If so, when? How was it treated?
How would you complete a general assessment of the TMJ?
TMD
- Palpate muscles of mastication for tenderness or soreness
- Palpate lateral capsule of TMJ
- Palpate and listen for clicking, popping, crepitus
- Evaluate range of motion
What is the normal interincisal width for adolescents and children?
TMD
Adolescents: 36mm
Children: 32mm
Adults: 40mm
What are other potential signs of TMD intraorally?
TMD
- Scalloping of the lateral borders of the tongue
- Wear on the dentition
- Tooth mobility
- Ridging on the buccal mucosa
Describe the utility of Panoramic imaging, CBCT, MRI and ultrasound in investigating the TMJ.
TMD
- Panoramic: only good for hard tissues, can’t rule out signs of degenerative disease
- CBCT: too much radiation, still only for bony abnormalities
- MRI: contrast-enhanced MRI is gold standard for Juvenile Idiopathic Arthritis - detects hard tissue degradation and joint inflammation
- Ultrasound: can only see superficial and lateral aspects of TMJ
What are some treatment options for TMD?
TMD
- Patient education
- Physical therapy
- Behavioral therapy (stress reduction, cognitive behavioral therapy CBT)
- Pharmacotherapy
- Occlusal spints - teens treated with occlusal splints had less pain than relaxation alone
Should dental sealants, compared to non-use of sealants, be used on sound or non-cavitated molars?
sealants
Yes - sealants reduce the indidence of caries by 76% after 2-3 years of follow up
Strong recommendation, moderate quality of evidence
Was there a difference in the reduction of caries incidence when using sealants vs fluoride varnish?
sealants
Sealants reduced the incidence of caries by 34% compared to sodium fluoride varnish but no statistical significance.
AAPD still recommends its use
Conditional recommendation, low quality of evidence
How does GI compare to resin sealants in terms of caries incidence and retention?
sealants
No difference in caries incidence
GI
GI 5x more likely to have loss of retention at the 2-3 year follow up
How does GI compare to RMGI sealants in terms of caries incidence and retention?
sealants
GI sealants compared with RMGI may increase the incidence of caries by 41% at the 2-3yr f/u but this was not statistically significant
GI 3x more likely to have loss of retention at the 2-3 year follow up
When should you do caries risk assessment (CRA) and periodontal risk assessment (PRA)?
How does the CRA and PRA affect recall frequencies?
CRA: as soon as the first tooth erupts, reassessed periodically
PRA: soon after permanent molars and incisors eruption and as tolerated by the child
High CRA and/or PRA: see recalls more frequent than every 6 months
What are the four categories that are considered in the caries risk assessment?
CRA
- Social/behavioral
- Clinical
- Protective
- Disease
For children 0-5 years old, what factors from the 4 categories place them in high risk?
CRA
Social-4:
* Mother has caries
* Poverty or lower health literacy
* >3 sugar-containing juice/snacks per day
* Bottle/sippy cup between meals and/or at bedtime
Clinical-2
* Visible plaque
* Enamel defects
Disease-3
* White spot lesions
* Visible carious lesions
* Recent restorations/missing teeth
For children >6 years old, what factors from the 4 categories place them in high risk?
CRA
Social-2
* Poverty or lower health literacy
* >3 sugar-containing juice/snacks per day
Clinical-3
* Low salivary flow
* Visible plaque
* Enamel defects
Disease-4
* Interproximal lesions
* New white spot lesions
* New carious lesions
* Restorations that were placed within 3yrs (new patient) or 12 months (patient of record)
For children >6 years old, what factors from the 4 categories place them in moderate risk?
CRA
Social-3
* Recent immigrant
* Special health care needs
* Hyposalivary medication
Clinical-2
* Intraoral appliance
* Defective restorations
Where are the most common sites for inflicted oral injuries in a child?
Abuse
- Lips
- Oral mucosa
- Teeth
- Gingiva
- Tongue
What sexually transmitted disease found within the oral cavity is pathognomonic for sexual abuse?
Abuse
Gonorrhea
If you see a bite that you suspect is human, what are ways you can collect evidence?
Abuse
- Photograph
- Swab bite mark with sterile cotton swab
- Take polyvinyl siloxane impression
- Swab buccal mucosa of victim
