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