Stewart Flashcards
Communication with children
Actual words, tone and non verbal
Positive reinforcement
Break everything in small steps
Give positive feedback throughout the session
Immediately after good behavior-verbal praise, positive tone modification
Ignore negative -avoid negative reinforcement
Tell, show do
Backbone of paediatric dentistry
Most useful in low anxiety pt
Tell- age appropriate explanation of the procedures, appropriate terminology
Show- demonstrate and let pt feel and touch things we will use, avoid unsheathed needs and high speed
Do-perform the action, positive reinforcement, communication techniques
Treatment planning in children
They have short attention span
Treatment to be broken down in manageable elements
Let them know what are you doing
Prevention
Acclimtisaion
Stabilisation
Reassess
Restore
Features of primary dentation
Incisor spacing
Anthropoid spaces- upper BC, lower CD
Mesio buccal cusp of upper E is in the buccal groove of lower E
Increased MID width of lower E
flush distal plane-both upper an flower Es finish at the same place
Leeway space
Permanent successors to EDC are smaller than the primary teeth
Upper arch- 1.5 mm
Lower arch- 2.5 mm
This space allows first permanent molars to drift mesially and adopt class I occlusion
Difference between primary and permanent teeth
Primary are smaller, whiter, thinner enamel, more bubous molars, wider contact points, bigger pulp to crown ratio, large pulp horns, bigger root to crown ratio, roots splayed
Hypodontia
In primary dentition- Equal in F and M, up to 1%
Permanent dentition - 3.5-6.5%, 4 times more in F than M, bigger chance is hypodontia in primary
Most common- 8,2,5
Associated with cleft, Down, ectodermal dysplasia (fine hair, dry skin, no sweat glands, perioral pigmentation, teeth small and conical and hypodontia)
Supernumerary
In primary dentition -0.2-0.8%
In permanent dentition - 1.5-3%
2 times more in male than female
5times more in maxilla than mandible
75% in upper anterior region
As ca. Be retained
Types: conical (in shape, round roots and mainly in midline), tuberculate (rarely erupt, more than one cusp, need surgical removal), supplemental(duplication of permanent tooth, most common laterals, 5s, 3rd molars), odontome( tumours of odontogenic origin, made of odontogenic tissue, can develop is other areas of the body, compound odontomes-resamble the tooth, can be diffuse mass of disorganized tissue- complex odontome)
Problems arising from supernumerary -no eruption, delayed eruption, rotation or displacement, dilaceration of the root, resorption of surrounding teethz formation of cysts)
Microdontia
Primary dentition -0.2-0.5%
Permanent dentition -2%
More in female than male
Usually upper lateral incisor
Can be linked with hypodontia
Treatment is usually crown or xla
Accessory cusp
Unknown frequency in primary dentition
Permanent dentition -10-60%
Usually on upper 1 and 2-palatal
Or D-mb cusp
E-mp cusp
Or 6-mp cusp
Treatment options:
Nil
Fissure sealants
If in occlusal interference -selective grinding or section and pulpotomy
Invagination (dens in dente)
Primary dentition -1%
Permanent dentition -1-5%
Twice more in male than female
Treatment options:
Fissure sealants, RCT, XLA
Tauradontism
Permanent molars-6% frequency
Features
Increased pulp chamber vertically
Long crown, short roots
Treatment -nil
MIH
6-60%frequency
Mainly 6s and 1s
Treatment -
Incisors- microabrasion and composite
6s-Seal/ PMC/onlays or XLA
Fluorosis
Due to high F- in water (more than 1-2 ppm) or F- ingestion
Presentation- mottling and hypoplasia
Treatment - nil or microabrasion
Amelogenesis imperfecta
Genetic origin
Affects both primary and permanent dentition
1:14000 prevelance
Different types -hypoplastic, hypomineralised or mixed
Dentinogenesis imperfecta
Genetic origin alone or in association with osteogenesis imperfecta
1:18 000 prevelance
Presentation- blue/gray enamel, enamel loss, dentine attrition, pulp exposure
On radiographs- bulbous crowns, short thin roots, large pulps
Treatment options -PMC or XLA
Premature eruption
Natal teeth-present at birth
Neo natal- erupt in first month of life
Treatment -leave and reassure/if risk of inhalation-XLA
Reasons for delayed eruption
Supernumerary
Dilaceration
Cyst
Impaction
Premature loss of primary precursor
Downs syndrome
Endocrine
Treatment
Infra occluded primary molars
Often associated with missing primary premolars
Primary molars ankylose and fail to alter position
If successor is present- leave to exfoliate
If no permanent successor-composite onlay
National dental inspection programme
In P1 and P7 (5,12 years)
They will check dmft as well
Care index in paeds
The care index is a measure of the percentage of decay that has been treated
SIMD-
Scottish index of multiple deprivation
1-most deproved
5-least deprived
Benefits of diagnosing early caries
First-prevention is key (standard and enhanced)
To arrest the caries and to have smaller restorations
Visual diagnosis
Lighting
Clean and dry
Exam all surfaces
Probe-not pits and fissures
Remove debris only
Record ICDAS
ICDAS caries codes
0 sound
1 first visual changes in enamel
2 distinct visual change in ename
3 enamel breakdown, no dentine visible
4 underlying dental shadow (not cavitated in dentine)
5 distinct cavity with visible dentine
6 extensive distinct cavity with visible dentine
Frequently of radiographs
High caries risk in both dentition-6-12 months
Low caries risk in primary dentition -every 12-18 months
Low caries in permanent dentition -every 24 months
Caries risk assessment
Depends on-
Siblings caries
Dietary habits
Brushing habits
SIMD
It should include prevention regime, radiograph review and recall period
4elements of prevention
TB with F- toothpaste
Diet advice
Fissure sealants
Topical fluoride
Standard prevention
Twice a day for 2 min
Am and pm
Nil after pm brushing
Toothpaste-under age of 3-smear of 1000-1500 ppm
Above 3years.old-pea size (1450-1500 ppm)
Spit don’t rinse
Parent brushing until 7years old, then supervision
Small headed brush and soft
Circular movement
Topical fluoride - twice a year (2+years olds) 22600 ppmF
2-5 y old- o.25 ml
Above 5-0.4 ml
Duraphat has colophony- can exacerbate asthma and plaster allergy
(Teeth need to be isolated and dried, no food for 30 min, no brushing for 2 h)
Enhanced prevention
Hands on advice
Disclosing (at surgery and at home)
Toothbrushing charts
Free brush and paste
Flossing
Toothpaste
Less than 3 y -1450-1500 ppm smear
3-6 y- 1450-1500 pea
Above 6-same but can also go higher
3 day diet diary-2 week and one weekend day
Topical fluoride - 4 times a year
Alcohol free mouthwash in 7+ age, at a separate time from brushing!
Fissure sealants- if there is a caries in primary dentition; if deep pits /fissures present; if any enamel defects. Usually 6s,7s or Es
Fissure sealants can be used as a good acclimatised for forther treatment
Different caries removal options
Complete caries removal
Partial caries removal
No caries removal -hall, seal or prevention/self-clensing
Xla
What to consider when deciding on the option to restore
Extent, site and activity of the lesion
Time to exfoliation
Co operation-both child and carer
Your abilities as practicioner
4 outcomes with tooth restorability
Manage caries-restore
Prevention and review
Pulpal therapy
XLA
Active disease management
It is unethical to leave active caries or abscess
We can leave asymptomatic abscess or active caries for up to 3 months until the child is being acclimatised
Complete caries removal na restore
Pros-evidence based, best results
Cons- difficults-LA, isolation, use rotary instruments, need level of co operation- unpredictable, time consuming, high pulp exposure risk due to large pulp horns
Partial caries removal
Removal of the worst soft caries first and then removing caries around the margins
Pros- evidence based, no need for LA, reduced prep time, reduced risk of pulp exposure
Cons-marginal seal needs to be effective
Monitoring and record keeping essential
Gic- only class I, so only single surface
If multisurface-composite (amalgam no longer permitted)
Need good moisture control as seal is crucial
Monitor with radiograph
Inform and document
No caries removal and seal
Pros-no LA, no prep
Cons-weak evidence,quality of seal or caries progression is questionable
In pre complaint PT this is advisable
Remove the debris and clean it
GIC on one finger, and then vaseline on other.
Monitor and inform and document
This technique used to temporarily halt the spread of the caries or minimalise reversible pulpitis or sensitivity
Hall PMC
Pros: no LA, no prep, no iatrogenic damage
Cons: partial fitting/leakage, aesthetics
No caries removal and seal by the crown
- Assess the tooth shape, contact point,assess marginal ridge breakdown occlusion (measure OB prior to PMC placement and after)
- Radiographs
- Airway protection- PT sitting upright and gauze placed
- PMC selection (smallest PMC, need spring back, do not fully seat on try in, try lingual to buccal
- Crown loading with cement (3/4 full, bad taste, GIC luting cement-runnyy mix, 1 scoop powder:2 scoops liquid)
- Crown fit and seating (place lingual to buccalz apply pressure with a thumb, then PT bites on dry cotton roll
- Wipe down excess cement with damp cotton roll
- Final seal and check (cotton roll biting for 2-3 roll, check occlusion and contact points with the floss)
If same arch needs more than one PMC-can fit on same appointments
If opposing teeth-leave 2-3 months between
PT preparation- explain how it will look, feel high, taste of cement, practice biting on cotton roll
No caries removal and prevention
Pros- no prep, no LA etc
Cons- limited evidence based, depends on habits and shape of cavities
Need enhanced prevention-reduced sugar consumption, improved OH, change of oral environment so active caries becomes arrested
Regular check ups and documentation
Diet diary as it is enhanced prevention
Pulpal pain
Managing pain should be a priority
If pulpal involvement -pulpal therapy or XLA (not recommended at the first visit)
Refer for GA/IHS- if pre cooperative, if very young or with multiple abscess or have additional needs
Pain can be coming due to reversible or irreversible pulpitis or dental abscess
Reversible pulpitis
Sharp pain, transient, pain on stimulus-hot and cold, sweet. Resolves when stimulus is removed. Pain is not localised/hard to localise and tooth is not TTP
Management - caries removal and sedative dressing placed (eg. Zinc oxide eugenol) and then replace at next visit with permanent restoration.
Review and record.
Irreversible pulpitis
Throbbing pain
Spontaneous
Can be intermittent or continuous-lingers
Easy to localise
Pain on hot, cold as well but spontaneous
Disturbs sleep
Management - if co-opetative- do pulpal therapy or XLA, or steroid/antibiotic dressing (Ledermix, Odontopaste) plus analgesia and pulpal therapy
If pre cooperative -odontopaste and analgesia and consider referral for HA/IHS
Dental abscess
Severe pain, disturbs sleep, TTP, mobile, swelling, malaise
On X ray- widening of PDL and radicular radiolucency
Vitality in molars are non reliable
Management - if co operative- pulp therapy, or XLA
Pre cooperative - analgesia, antibiotics, referral
Pulpotomy
Removal of inflamed coronal pulp and retention of healthy radicular pulp tissue
Pulpotomy would be a choice if we created vital exposure or tooth has early irreversible pulpitis, traumatic exposure, various exposure
Contraindications -close to exfoliation, unreasonable, multiple pulp treatment, pre cooperation
Pulpectomy
Removal of irreversibly inflamed coronal and radicular pulp, needs to be obturated with resorbable material (non setting CaOH) and tooth willed with zinc oxide eugenol
Indications: irreversible pulpitis, dental abscess
Contra indications: close to exfoliation, unrestorable, multiple pulp treatments , pre co operative
Every primary molar that has pulp therapy needs to be restored with PMC- gives best seal and best chance of success
What can supernumerary teeth cause?
Prevent eruption, displace or rotate teeth above them, dilaceration of roots, resorption of surrounding teeth, develop cyst
Factors to consider in caries management
Time to exfoliation, site and extent of the lesion, the risk of pain/infection, absence/presence of infection, number of teeth affected, preservation of tooth structure, avoidance of treatment-induced anxiety
Assessment of a child need to include:
Parent motivation and responsibility
Patient history
Clinical examination
Caries risk assessment
Fluorosis and severity causing enamel defects depends on
Concentration of fluorides period of using it/consuming and the age of the patient
Common complications following the dental trauma?
Pulpal necrosis
Resorption
Ankylosis
Canal obliteration
Discolouration
Pulpal concussion
Splinting times
Subluxation- 2 weeks
Lateral luxation - 4 weeks
Intrusion- 4 weeks
Extrusion-2 weeks
Avulsion-2 weeks
Root fracture- 4-4 months
D-A fracture- 4 weeks
All are flexible splints
Pulpal necrosis in trauma
Diagnosis is important
Causation -take history
Know the indications
Necrosis diagnosed if:
Colour change
No response to EPT after 3 months
Swelling
Radiographically periapical radiolucency
Observations/tests needed if suspecting trauma
Percussion
Tenderness
Percussion note
Transillumination
Examination of soft tissues
Mobility
Sensibility Vs sensitivity Vs vitality
Pulp sensibility - assessment of the pulps sensory response
Sensibility - ability to respond to stimulus- thermal, EPT- they do not detect /measure blood supply to the dental pulp
E.g. ethyl chloride soaked cotton pledget on the dry tooth and check response-normal, no response or ++response
EPT- dry tooth, tip of EPC to have toothpaste and hold on the tooth- pt to say when can they feel and document the reading
Sensitivity - condition of the pulp being very responsive to a stimulus
Resorption due to trauma
Happening as there is reaction of the osteoclasts to a stimulus
Can happen due to trauma to PDL, bacteria, trauma to the pulp
Resorption types
Internal
External inflammatory
External cervical
External replacement
Ankylosis
Follows PDL injury
Can be due to extra long dry time following the trauma; due to intrusion injury
Diagnosis made depending on:
-P note
- radiograph evidence of loss of PDL
Canal obliteration
Due to pulpal repair and deposition of hard tissue in the canal causing yellow teeth
25% of traumatized incisors develop pulp canal obliteration
75% of these remain symptom free
RCT can be very difficult
Discolouration
Can be caused by:
Medicaments from RCT
Degraded pulp tissue on dentinal tubules
Pulpal obliteration
Treatment:
Composite masking
Veneers
Bleaching
Concussion
Need vitality testing
EPT
At least 2 separate signs of pulpal necrosis for diagnosis - reliability problem
Transient apical breakdown
Colour change
Loss of vitality
TTP
If open apex monitor for: return of colour, return of vitality, healing of apical area
Conscious sedation
A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out but during which verbal contact with the pt is maintained throughout the period of sedation.
PT is conscious and co operative, protective reflexes are intact
Risk is very low
Available in primary care environment
Dental operators can perform sedation
May be ineffective in some pt
May be used freely on multiple occasions
Gives opportunity to provide timely and more constructive dental care
Conscious sedation idications
Learning difficulty
Involuntary movements
Medically compromised with increased GA risk
Exaggerated gag reflex
Unusual traumatic procedure
Released financing/failed LA
Anxiety
Needle phobia
Excessive gag reflex
Liver/kidney disease or preclusion to benzodiazapime
Medical nitrous oxide
Colourless gas’s
Pleasant sweet smell
Weak anaesthetic agent
Analgesic properties
Minimal depression effect on respiration and myocardium
Presented in blue cylinders
30% oxygen is minimum!
Why is nitrous oxide good sedation agent?
Smooth induction
Titrated easily
Rapid induction/recovery
Non pungent, non irritant
Low blood gas solubility
Relatively wide margin between sedative and anaesthetic dose
Analgesic properties
No needles
Wide age spread
Easily discontinued
Level of sedation maintained
Administration and excretion through lungs-no metabolic demands
It does not enter the blood stream so it wears off quickly
Disadvantages of nitrous oxide
Lack of petency- needs psychological reassurance
Nasal hood may not be tolerated
Bulky equipment and scavenging needed
Clear nasal airway needed
Chronic exposure/abuse
Relative amount of pt compliance required
Can be occupational health hazard- active scavenging and ventilation needed when in use!
Implication in bone marrow depression
Love, renal, neurological disease
Carcinoma of cervix
Contraindications for conscious sedation
Nasal obstruction
PT un-cooperative to whole dental environment
1st trimester pregnancy
Pt with some psychiatric disorders
Inability to communicate to provide necessary reassurance due to age or understanding
