4. OpTec Lectures

Question 1

A child should reach adulthood with (4)

Answer 1

An intact dentition
No active caries
As few restored teeth as possible
A positive attitude to their future dental care

Question 2

Operative differences between children and adults (7)

Answer 2

Developmental maturity/behaviour
Constant change
Developing dentition
Operator access
Tooth size and shape
Preventive care
Choice of restoration

Question 3

Sequence of treatment planning and restorations in cooperative children (6)

Answer 3

Prevention
Fissure sealants
Preventive restorations
Simple fillings (shallow cervical cavities)
Fillings requiring LA but not into pulp
Pulpotomies (upper arch first)

Question 4

Summary of restoration longevity (5)

Answer 4

PMC > amalgam = composer > RMGIC > GIC

Question 5

Crown prep. for conventional paediatric PMCs (2)

Answer 5

Occlusal reduction by 1-2mm

Buccal/lingual - peripheral reduction only

Question 6

Common problems with stainless steel crowns (3)

Answer 6

Rocking
Canting
Loss of space

Question 7

When is the Hall Technique used (2)

Answer 7

When no clinical/radiographic signs of plural involvement

Tooth should have sufficient sound tissue left to retain the crown

Question 8

Hall technique crown review minor failures (4)

Answer 8

New/secondary caries
Filling/crown worn, lost or requiring other intervention
Restoration lost but tooth restorable
Reversible pulpitis treated without requiring pulpotomy or extraction

Question 9

Hall technique crown review major failures (4)

Answer 9

Irreversible pulpitis
Abscess requiring pulpotomy or extraction
Interradicular radiolucency
Filling lost and tooth not restorable

Question 10

Disadvantages of unplanned primary tooth extractions (5)

Answer 10

Loss of space causing increased risk of malocclusion
Decreased masticatory function
Impeded speech development
Psychological disturbance
Trauma from anaesthesia

Question 11

Indications for pulp treatment (5)

Answer 11

Good co-operation 
Medical history precludes extraction
Missing permanent successor
Over-riding necessity to preserve tooth (space maintainer)
Child under 9 years of age

Question 12

Contraindications for pulp treatment (6)

Answer 12

Poor co-operation
Poor dental attendance
Cardiac defect
Multiple grossly carious teeth
Advanced root resorption
Severe/recurrent pain or infection

Question 13

Features of vital pulpotomy (2)

Answer 13

Carious or traumatic exposure of a bleeding pulp

Radicular pulp is preserved, and bleeding controlled

Question 14

Vital pulpotomy technique (6)

Answer 14

Always use LA and rubber dam
Remove caries prior to access
Remove entire roof of pulp chamber using sterile diamond fissure bur
Remove coronal pulp with sterile excavator or slow-running large round steel bur
Place a cotton pledget with ferric sulphate for 20 seconds until minimal oozing
Place zinc oxide/eugenol in pulp chamber and restore using a PMC

Question 15

Direct plural evaluation (2)

Answer 15

Normal bleeding – non-inflamed pulp (bright red colour, good haemostasis
Abnormal bleeding – inflamed pulp (deep crimson colour, continued bleeding after pressure (with ferric sulphate))

Question 16

Pulpectomy indications (2)

Answer 16

Non-vital or hyperaemic (increased/excess blood flow) pulp

Irreversible pulpitis

Question 17

Signs of a non-vital primary molar (2)

Answer 17

Hyperaemic pulp (increased bleeding)
Pulp necrosis and furcation involvement

Question 18

Symptoms of a non-vital primary molar (3)

Answer 18

Irreversible pulpitis
Periapical periodontitis
Chronic sinus

Question 19

Aim of a primary molar pulpectomy

Answer 19

Prevent/control infection by extirpation of radicular pulp followed by cleaning and obturation of canals

Question 20

Indication for a primary molar pulpectomy

Answer 20

Excellent patient cooperation

Question 21

Pulpectomy procedure (8)

Answer 21

Non-vital/hyperaemic pulp
Open roof of pulp chamber
Remove contents of pulp chamber
Use files to remove pulpal tissue from canals to 2mm short of estimated working length (EWL)
Irrigate with chlorhexidine and dry with paper points
Obturate canals with Vitapex (CaOH and iodoform paste) or alternatively, a very thin mix of ZOE
Seal with thick mix of ZOE/GI and restore with PMC
Post-treatment radiograph in clinical setting

Question 22

Potential complication of primary pulpectomy (2)

Answer 22

Early resorption leading to early exfoliation

Over-preparation

Question 23

Follow-up of pulpotomy and pulpectomy (2)

Answer 23

Clinical review - 6 monthly

Radiographic review 12-18 monthly

Question 24

Clinical failure of pulpotomy/pulpectomy (3)

Answer 24

Pathological mobility
Fistula/chronic sinus
Pain

Question 25

Radiographic failure of pulpotomy/pulpectomy (3)

Answer 25

Increased radiolucency External/internal resorption Furcation bone loss

Question 26

Types of fractured incisor (3)

Answer 26

``` Enamel fracture (E#) Enamel and dentine fracture (ED#) Pulpal exposure (EDP#) ```

Question 27

Management of E# (2)

Answer 27

Selective grinding | Acid etched tip replacement

Question 28

Management of ED# (2)

Answer 28

Acid etched tip replacement | Reattach crown fragment/restoration

Question 29

Management of EDP# (3)

Answer 29

Pulp capping Partial/total pulpotomy Pulpectomy

Question 30

Crown fractures - first aid (4)

Answer 30

History Examination Cover over exposed dentine (compomer/composite bandage - not GI) Definitive restoration - acid-etch composite tip

Question 31

Survival of pulp after exposure depends on (3)

Answer 31

Associated PDL injury Extent of exposed dentine Age of patient (open vs closed apices)

Question 32

Vital immature tooth with pulp exposed (3)

Answer 32

Open apex Pulp cap - <24hrs, small exposure Pulpotomy - large exposure, delay in Tx - maintains vitality of remaining pulp and root formation can continue Pulpectomy

Question 33

Non-vital immature tooth pulp exposure (3)

Answer 33

Pulpectomy Apical barrier formation Apexification

Question 34

Process of pulpectomy for on-vital immature tooth pulp exposure

Answer 34

Remove all necrotic pulp

Question 35

Process of apical barrier formation for on-vital immature tooth pulp exposure

Answer 35

Mineral trioxide aggregate (MTA) used to provide apical barrier against which to condense root canal filling (gutta percha)

Question 36

Process of apexification for on-vital immature tooth pulp exposure (4)

Answer 36

CaOH placed in root canal to induce apical barrier Some concerns regarding long-term use of CaOH inside root canals – reduces mineral content of dentine and makes tooth more susceptible to root fracture Recent research may also suggest that some barriers formed in this manner are full of holes In some cases, apical barrier formation using MTA may be the treatment of choice

Question 37

Process of apical barrier formation (4)

Answer 37

5mm of MTA should be placed at the apical end of the root Placement can be aided by use of a microscope Placement is carried out using obtura probes, disposable MTA carriers or experimentally using a venflon Wait at least 24 hours for MTA to harden then obturate with a heated GP system

Question 38

Vital mature tooth with pulp exposed (4)

Answer 38

Closed apex Pulp cap - small exposure, <24hrs Pulpotomy - large exposure, >24hrs, necrotic pulp Pulpectomy - large exposure, >24hrs, necrotic pulp Conventional RCT

Question 39

Uses of CaOH (4)

Answer 39

Used to induce a calcific barrier following pulpotomy procedures Induces barrier formation at apex of non-vital immature permanent incisors (apexification) - no longer treatment of choice but sometimes only practical option, takes around 9 months to complete Useful for decreasing microbial load in non-vital mature permanent teeth Use now being advocated for 4-6 weeks only (inter-visit dressing) due to fact that CaOH makes root dentine brittle

Question 40

First aid of avulsed permanent teeth (7)

Answer 40

Store in fresh cold milk or saliva Do not allow to dry out Can wash for 10 seconds under cold water while holding only the crown if obvious debris Do not handle to root Re-implant quickly Flexible splint for two weeks Start RCT after two weeks unless the tooth has an open apex and is replanted within 30-45 minutes

Question 41

Types of splinting and involvements (4)

Answer 41

Flexible 2 weeks - avulsion Flexible 4 weeks - luxations and apical and middle third root fractures (up to four months for cervical) Rigid 4 weeks - dento-alveolar fractures

Question 42

Placing a trauma splint procedure (4)

Answer 42

Cut and bend 0.6mm stainless steel wire Apply composite resin to traumatised tooth and those adjacent Sink the contoured, passive wire into the composite Shape and cure composite Smooth rough composite and wire ends

Question 43

Definition of fissure sealant

Answer 43

Protective plastic coating used to seal fissures and pits to prevent food and bacteria getting caught in them and causing decay

Question 44

Why are fissures vulnerable to caries (2)

Answer 44

Fissures are less protected by fluoride than interproximal or smooth surfaces It is not possible to clean the base of fissures with a toothbrush

Question 45

Materials used for fissure sealants (2)

Answer 45

Bis-GMA (mostly) | Occasionally GIC

Question 46

Indications for fissure sealant placement (5)

Answer 46

High caries risk kids (permanents molars/premolars should be sealed on eruption) Medically compromised children Children with learning difficulties Physically and mentally handicapped Recent SIGN 138 - all FPM in kids should receive FS

Question 47

Fissure sealants and low cares risk kids

Answer 47

If a child is of low caries risk they do not need to have their first permanent teeth sealed routinely, rather these fissures should be closely monitored

Question 48

Fissure sealant tooth selection (5)

Answer 48

Greatest benefit on occlusal surfaces of permanent molar teeth Should also seal cingulum pits of upper incisors, buccal pits of lower molars and palatal pits of upper molars Sealing of primary molars may be advised in high caries risk children A child with caries in one first permanent molars should have the other three sealed immediately Occlusal caries in first permanent molars indicates that second permanent molars must be sealed on eruption

Question 49

Fissure sealant placement procedure (6)

Answer 49

``` Isolation Acid etch Wash Placement Check placement Review ```

Question 50

Fissure sealant tooth isolation procedure (5)

Answer 50

Single tooth dental dam Dry guards and cotton wool Retraction and aspiration (dental nurse) Work with efficient speed to decrease the chance of moisture contamination Clean occlusal surface – preferably with pumice and water

Question 51

Fissure sealant acid etch procedure (2)

Answer 51

Use 35% orthophosphoric acid to etch enamel surface | Avoid any etch touching the soft tissues, if it does rinse immediately as it could cause a burn

Question 52

Fissure sealant wash procedure (3)

Answer 52

Wash etch directly into aspiratory and dry the occlusal surface (3-in-1 syringe) Check that the etched surface has a chalky-white/frosted appearance when dry Any etched enamel not eventually covered with the sealant will remineralised within 24 hours

Question 53

Fissure sealant placement procedure (7)

Answer 53

Add the resin to the depths of the dry fissure pattern Can use a brush, microbrush or small excavator Ensure that material is in base of fissure Avoid overfilling as this will decrease long-term retention Excess material can be removed with a dry microbrush Should be ‘spidery’ not ‘swimming pools’ Light cure the resin in accordance with manufacturers instructions

Question 54

Fissure sealant checking placement procedure (4)

Answer 54

Check sealant is firmly adhered (use sharp probe to try to dislodge) Check there are no air-blows present. If present, remove part of the sealant and re-do Check that no material has flowed interproximally – if it has, remove with a sharp probe and dental floss Check that there is no excess material distal to the tooth in the soft tissues

Question 55

Fissure sealant review procedure (2)

Answer 55

Review clinically every 4-6 months | Review radiographically as per the patient’s caries risk assessment

Question 56

Indications for glass ionomer fissure sealant (2)

Answer 56

Where good moisture control cannot be achieved | Where there is a high degree of sensitivity die to developmental or hereditary enamel defects

Question 57

Types of kids where good moisture control cannot be achieved, so GIC FS should be used (3)

Answer 57

High risk children with partially erupted molars Special needs children Poorly cooperating children

Question 58

Features of GIC FS (3)

Answer 58

Useful as release F Poorly retained Require regular reapplication

Question 59

GIC FS placement procedure (4)

Answer 59

Attempt to dry tooth with air or cotton wool Apply GI from applicator Smooth into fissures using gloved finger or thumb Keep finger over GI until set or place Vaseline to decrease moisture contamination until set

Question 60

Definition of stained fissure (2)

Answer 60

Fissure that is discoloured, brown or black Fissures where there is an area of white or opaque enamel (Normal translucency is lost but it has no evidence of surface breakdown - cavitation)

Question 61

Components of a diagnosis of stained fissure (7)

Answer 61

``` Visual (dry tooth) Probe/explorer Bitewing radiographs Electronic Fibre optic transillumination CO2 laser Air abrasion (Greater accuracy when 2 or 3 methods are used together) ```

Question 62

Treatment of stained fissure (4)

Answer 62

FS and monitor if just enamel caries If inconclusive diagnosis, clean the FS If small lesion, preventive resin restoration/sealant restoration (PRR/SR) If large defect, conventional restoration required

Question 63

Management of virgin caries in FPMs (5)

Answer 63

Maximise prevention Always prioritise FPM’s in any mixed dentition treatment plan (i.e. restore 6’s prior to dealing with lesions in primary molars) Caries most commonly affects the pits and fissures of the FPM’s but may also develop interproximally below the contact point When caries in the FPM’s is extensive always consider the long-term prognosis Remember that the pulp is much more likely to be exposed on caries removal due to its size (may wish to consider stepwise caries removal in order to induce calcific barrier formation over the pulp)

Question 64

Indications for appropriate time to remove FPMs (4)

Answer 64

Beginning of bifurcation of the lower 7 is seen to be forming on an OPT (typically around 8.5-10 years of age) 5’s and 8’s are all present and in a good position on the OPT Mild buccal segment crowding Class I incisor relationship