Paediatric SDCEP - full guidelines

Question 1

what is plaque scoring grades?

Answer 1

10/10 - perfectly clean tooth
8/10 - plaque line around cervical margin
6/10 - cervical third of crown covered
4/10 - middle third covered

Question 2

what are caries risk assessment factors?

Answer 2

● Clinical evidence
● Dietary habits
● SH
● MH
● Saliva
● Plaque control
● Use of fluoride

Question 3

what are beahvioural management techniques?

Answer 3

● Tell show do
● Positive reinforcement
● Distraction
● Relaxation
● Systematic desensitization

Question 4

what are fluoride regimes?

Answer 4

• 16 year old - 5000ppm
• age under 3 use a smear - standard prevention 1000-1500ppmF - increased risk enhanced prev 1350-1500ppmF
• aged 3 and over use a pea size - standard prev 1000-1500ppmF - increased risk enhanced prev 13500 - 1500ppmF
• over 10 enhanced prev 2800ppmF

Question 5

what is standard prevention for toothbrushing?

Answer 5

At least once a year, remind the child and parent to:
● Brush thoroughly twice daily, including last thing at night
● Use age appropriate toothpaste (1000-1500ppm)
● Spit don’t rinse
● Supervise children until they can brush their teeth effectively
● Demonstrate brushing on child (3 minutes)
● Advise parent to start brushing as soon as the first primary tooth erupts

Question 6

what is enhanced prevention for toothbrushing?

Answer 6

At each recall visit provide standard prevention tooth brushing along with:
● Give hands on brushing instruction (3 minutes) to the child and parent at each recall visit
● Recommend the use of 1350-1500 fluoride toothpaste for children up to 10 years of age
● Prescribe 2800 ppm for children aged 10-16
● Utilize any community/home support for toothbrushing that is available locally (e.g. health visitor, school nurse, childsmile dental health support worker)

Question 7

what is standard prevention for diet?

Answer 7

At least once a year remind the child and parent
● Limit consumption of food and drinks containing sugar
● Drink only water or milk between meals
● Snack on healthier foods: carrot, pepper, breadsticks
● Do not place sugary drinks, fruit juices, sweetened milk or soy formula milk in feeding bottles
● Do not eat or drink apart from tap water after brushing at night
● Be aware of hidden sugars in food
● Be aware of acid content of drinks and restrict fizzy drinks to meal times

Question 8

what is enhanced prevention for diet?

Answer 8

Provide standard prevention at each recall visit
● 3-5 day diet diary with at least one of the days being on a weekend: keep a record of all food and drink consumed
● Alternatively a 24 hour food and drink diary can be completed by the parent whilst in the surgery
● Utilize any community/home support for dietary change that is available locally (e.g. health visitor, school nurse, childsmile dental health support worker)

Question 9

what are fissure sealants you use?

Answer 9

1) Bis GMA resin based sealers (gold standard)
2) Glass ionomer sealers (if moisture control cannot be achieved)

Question 10

what is standard prevention for fissure sealants?

Answer 10

● Place sealants in all pits and fissures of permanent molars as possible after eruption
● Ensure buccal pits of lower first permanent molar and palatal fissures of upper first permanent molars are sealed
● Check existing sealants for wear and integrity at every recall visit
● Top up won or damaged sealants

Question 11

what is enhanced prevention for fissure sealants?

Answer 11

● Same as standard prevention
● Fissure seal palatal pits of upper lateral permanent incisors, and the occlusal and palatal surfaces of D’s, E’s

Question 12

how do you clean tooth before application of a fissure sealant?

Answer 12

● Pumice and water
● Cotton wool pledget
● Toothbrush with no paste
● Probe through the fissures to remove debris

Question 13

when do you use glass ionomer sealant material?

Answer 13

● Pre cooperative child
● Difficulty obtaining moisture control
● Partially erupted tooth

Question 14

what is standard prevention for fluoride varnish?

Answer 14

● Apply sodium fluoride varnish (5%) twice a year to children aged 2 and over
● Can have varnish applied up to four times a year
● If residual varnish is visible or the child has had varnish applied in the past 24 hours, leave application until next visit

Question 15

what is enhanced prevention for fluoride varnish?

Answer 15

● Apply sodium fluoride varnish (5%) four times a year to children aged 2 and over

Question 16

what are contraindication for fluoride varnish?

Answer 16

● Hospitalized for severe asthma or allergy in the last 12 months
● Allergic to sticking plaster (colophony)
● ANUG
● Had fluoride varnish applied 4 times a year already or within the past 24 hours

Question 17

how much fluoride varnish you use?

Answer 17

● 22,600ppmF
● Do not exceed
-0.25mL for children in nursery and primary 1 (2-5 years old)
-0.4mL for children in primary 2 (5-7 years old)

Question 18

what are Instructions given after application of fluoride varnish?

Answer 18

● Soft foods and liquid may be consumed from 30 minutes
● Child should wait at least 4 hours before brushing their teeth or chewing hard foods

Question 19

what are Principle strategies for managing caries in the primary dentition?

Answer 19

● No caries removal, seal using the Hall Technique
● No caries removal and fissure seal
● Selective caries removal and restoration
● Pulpotomy

Question 20

what are other alternatives for managing caries in the primary dentition that are less supported by evidence?

Answer 20

● Site specific prevention (no caries removal)
● Make cavity cleansable and apply fluoride
● Complete caries removal and restoration
● Extraction

Question 21

how do you deal with primary molar teeth with occlusal caries?

Answer 21

● Initial occlusal caries: teeth with non cavitated lesions (white spot lesions, discolored or stained fissures). Minimal cavitation where enamel is beginning to breakdown but no dentine visible
-place fissure sealant (ideally Bis GMA resin but if uncooperative then glass ionomer)
-if the child is uncooperative seal the caries using Hall Technique
● Advanced occlusal caries: teeth with cavitation or dentine shadow and visible dentine
-selective caries removal and restore using composite, RMGI, GI or compomer
-if the child is uncooperative seal the caries using Hall Technique

Question 22

how do you deal with primary molar teeth with proximal caries?

Answer 22

● Initial proximal caries: white spot lesions or shadowing
-If caries is arrested, carry out site specific prevention
-sealing the lesion by placing a sealant or resin infiltration
● Advanced proximal caries: enamel cavitation and dentine shadow or visible dentine
-seal using the Hall Technique
-selective caries removal and restore using composite, RMGI, GI or compomer

Question 23

how do you deal with Primary anterior teeth with carious lesions?

Answer 23

● Initial anterior caries: white spot lesions/areas of demineralisation confined to enamel
-Site specific prevention: only if caries arrested
-Restoration if the lesion is progressing
● Advanced anterior caries: cavitation or dentinal shadow
-selective caries removal and restore using composite, RMGI, GI or compomer or strip crowns
-completely remove caries and restore
-non restorative cavity control- make self cleansable

Question 24

how do you deal with Primary tooth with pain or infection?

Answer 24

● Reversible pulpitis: pain on stimulus (e.g. cold, sweet) and relieved when it is removed. Pain does not affect the child’s sleep. Pulp is vital and tooth is not TTP
-If diagnosis is uncertain, place a temporary dressing and review in 3-7 days later to check symptoms. Resolution of symptoms at review will indicate that the pulpitis was reversible and a Hall crown or restoration can then be placed. If symptoms are worse than extraction or pulpotomy should be considered
-Place a crown using the Hall Technique
-If an occlusal lesion, carry out selective caries removal and restore using composite, RMGI, GI or compomer
-If tooth is close to exfoliation consider applying a dressing
● Irreversible pulpitis: pain occurs spontaneously but if provoked by a stimulus is not relieved when the stimulus is removed. Lasts for several hours and may keep the child awake at night. May be dull and throbbing, worsened by heat and alleviated by cold. No signs or symptoms of infection such as sinuses, abscesses or periradicular pathology. Tooth is usually not TTP
-Apply corticosteroid antibiotic paste under a temporary dressing. Prescribe pain relief then carry out pulpotomy or extraction at a later date
-If cooperative, carry out pulpotomy or extract the tooth

Question 25

how do you deal with Dental abscess/periradicular periodontitis?

Answer 25

● Description: pain, if present, may be spontaneous, will keep the child awake at night and can be easily localized by the child. Increased mobility and will be tender to percussion. Clinical evidence of a sinus, abscess, swelling or radiographic evidence of interradicular pathology
-Extract the tooth, even if the infection is asymptomatic
-In exceptional circumstances consider pulpectomy

Question 26

how do you deal with Carious lesion into the pulp?

Answer 26

● Description: radiograph shows a carious lesion extending into the inner third of dentine and there is no clear band of denitine that separates the carious lesion and pulp
-Where there are no signs or symptoms of pulpal pathology, use the Hall Technique. There should be discussion with the parent about the uncertain prognosis of tooth
-If there are signs and symptoms of pulpal pathology, carry out pulpotomy

Question 27

how do you deal with arrested destinal caries?

Answer 27

● Description: the surface of the tooth will be hard when feeling with a ball ended probe
-Site specific prevention
-non restorative cavity control

Question 28

who is Non restorative cavity control: suitable for?

Answer 28

● Primary tooth with arrested caries
● Tooth is unrestorable
● Tooth close to exfoliation

● Primary tooth with an advanced lesion, where alternatives are not feasible

Question 29

what is Non restorative cavity control?

Answer 29

● If necessary, make the lesion cleansable
● Site specific prevention
-Demonstrate brushing
-Give dietary advice
-Apply fluoride varnish to lesion four times a year
● Record plaque scores
● Review the lesion after 3 months and if active lesion is not arrested or previously inactive lesion becomes active then extract

Question 30

what is Management of caries in permanent teeth?

Answer 30

● Principal evidence based strategies for managing caries in permanent dentition are:
-Site specific prevention
-Selective caries removal and restoration (walls prepared to hard dentine with adequate depth for restorative material)
-Stepwise caries removal and restoration (walls prepared to hard dentine, temporary restoration, permanent restoration after 6-12 months)
-Complete caries removal and restoration
● Less evidence based options:
-No caries removal and fissure seal
● Additional treatment that might be required
-Root canal therapy
-Extraction

Question 31

what is dental amalgam age?

Answer 31

15 years and over

Question 32

how to treat Permanent teeth with occlusal caries?

Answer 32

● Initial occlusal caries: Intact enamel: white spot lesions; discolored or stained fissures
-Place resin fissure sealant
-Monitor lesion clinically and radiographically to ensure it has not progressed
● Moderate dentinal occlusal caries: enamel cavitation and dentine shadow or a cavity with visible dentine
-Selective caries removal or complete caries removal if necessary (there is little risk of pulp exposure)
-Seal the remaining fissures
● Extensive dentinal occlusal caries: cavitation with visible dentine or widespread dentinal shadow. In a radiograph this will extend into the inner third of dentine
-Stepwise caries removal, temporize then restore with a permanent restoration after 6-12 months
-Seal the remaining fissures

Question 33

Why stepwise caries removal?

Answer 33

● To avoid exposing the pulp
● To allow a period long enough for reactionary dentine to be laid down by the pulp in response to the irritant stimulus of caries
● Wet dentine does not provide a sound base for a permanent restoration

Question 34

what is problem for permanent teeth with proximal caries?

Answer 34

● Difficult to diagnose visually

● Orthodontic separators may be used to allow visualization but this requires the child to re-attend after 3-5 days

Question 35

how to treat Permanent teeth with proximal caries?

Answer 35

● Initial proximal caries: white spot lesions or shadowing. Enamel intact
-Site specific prevention (pay particular attention to mesial surface of first permanent molars)
-Monitor with bitewings
-Seal the lesion
● Moderate dentinal proximal caries: enamel cavitation, may be dentine shadowing
-Selective caries removal or complete removal if necessary
-Seal the remaining fissures
● Extensive dentinal proximal caries: cavitation with visible dentine or widespread dentinal shadowing
-Stepwise caries removal, temporize then restore with a permanent restoration after 6-12 months

Question 36

When to extract first permanent molars with poor prognosis

Answer 36

● 8.5-10 years of age
● Bifurcation of the lower 7s
● Second premolars and third molars are present in OPT
● Mild buccal segment crowding
● Class I incisor relationship
-Note: balancing is not necessary and compensating extractions have weak evidence

Question 37

how to treat Permanent anterior teeth with carious lesions?

Answer 37

● Initial anterior caries: white spot lesions, no dentinal caries
-Site specific prevention
-Monitor: only continue prevention if there is no evidence of progression
● Advanced anterior caries: cavitation or dentinal shadowing
-Complete removal of caries and restore or selective caries removal and restore

Question 38

what is Management of permanent tooth with pain/infection?

Answer 38

● Reversible pulpitis on permanent tooth
-Stepwise or complete caries removal and restore (if stepwise use temporary dressing and then permanent 6-12 months later)
● Irreversible pulpitis or dental abscess/periradicular periodontitis
-Root canal therapy or extract the tooth

Question 39

how to treat Unrestorable permanent tooth?

Answer 39

● Extract the tooth
● If non cooperative, temporize the tooth and refer to specialist

Question 40

when do you review lesions?

Answer 40

● After providing site specific prevention review after 3 months to check if the lesion is active or arrested
● Take radiographs every 6 months to monitor proximal lesions

Question 41

When do you use Hall Technique

Answer 41

● Primary tooth with an advanced lesion on the occlusal or proximal surface

Question 42

What is the aim of the Hall technique

Answer 42

● To seal carious lesion and slow or even arrest caries progression

Question 43

what is Hall technique step by step (you will do this in 4th year)?

Answer 43

● Ensure the child is sitting upright
● Assess whether separators are required. If they are, place them, and see child 3-5 days later
● To protect the airway, make a handle for the crown with a strip of sticking plaster or protect the airway with gauze
● Select the correct size PMC: do not seat without cement as it may be difficult to remove
● Ensure the PMC is well filled with a glass ionomer luting cement
● Seat the PMC over the tooth: can ask child to bite down on the crown or on a cotton roll placed on the crown
● Check the crown is seated evenly. Ask them to bite down hard to complete the seating
● Remove excess cement and clear the contacts using floss: avoid cement reaching the tongue because it has a very bitter taste

Question 44

what is Balancing extractions?

Answer 44

● Aim: to minimize center line shift and maintain symmetry
● Consider balancing extractions when:
-One C is to be extracted
-One C has exfoliated prematurely due to eruption of the permanent lateral incisor
-Centre line shift is developing following extraction of one D

Question 45

what is steps of stepwise removal?

Answer 45

• walls prepared to hard dentine
• temporary restoration
• permanent restoration after 6-12 months