paediatrics Flashcards
1
Q
Five year old Jodi has been brought to your clinic by her mother’s boyfriend. She did not sleep last night because
of dental pain. Jodi has not been to the dentist before because her mother has had a lifelong fear of dentists.
Jodi’s mother’s boyfriend is vague about Jodi’s medical history. Jodi is small for her age. Jodi is pyrexic, in pain
and has had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally
diagnose acute periapical abscess.
What should you establish prior to examination of Jodi? (3 Marks)
A
Thorough History (Pain/MH/DH)
Determine if airway is compromised
establish who has parental responsibility - Obtain consent for treatment.
2
Q
Five year old Jodi has been brought to your clinic by her mother’s boyfriend. She did not sleep last night because
of dental pain. Jodi has not been to the dentist before because her mother has had a lifelong fear of dentists.
Jodi’s mother’s boyfriend is vague about Jodi’s medical history. Jodi is small for her age. Jodi is pyrexic, in pain
and has had a swollen left side of face associated with gross caries in all primary molar teeth.
Describe in detail one behavioural management technique you could use to maximise Jodi’s cooperation (4 Marks)
A
Tell show Do- To familiarise the patient with a new procedure
Tell- so explain the technique in an age appropriate way.
e.g. we want to make the tooth happy
Restoration- it is a bit like going to the hairdressers. The wash and blow dry is a bit noisy.
Show- Demonstrate aspects of the procedure in a non-threatening setting
Do- Now I would like to do this on your tooth (initiate with minimal delay)
3
Q
5 year old brought to clinic with mums boyfriend, she did not sleep due to dental pain. She has never been to the dentist before due to the mothers fear. The Mums BF is vague about medical history and she is small for her age. She is pyrexic, in pain and had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally diagnose acute periapical abscess.
Jodi had difficulty accepting a full examination, including radiography, and you assess her as being pre-cooperative
with regard to operative care.
What would be your short term management for Jodi? (3 Marks)
A
Provide Pain relief
Drainage
Antibiotics: Penicillin V 2x250mg 4times a day for 5 days,
Tell boyfriend to bring jodi back in 5 days for review
If the swelling gets worse (A&E)
4
Q
Five year old Jodi has been brought to your clinic by her mother’s boyfriend. She did not sleep last night because
of dental pain. Jodi has not been to the dentist before because her mother has had a lifelong fear of dentists.
Jodi’s mother’s boyfriend is vague about Jodi’s medical history. Jodi is small for her age. Jodi is pyrexic, in pain
and has had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally
diagnose acute periapical abscess.
How would you address the issue of Jodi’s previous non-attendance? (5 Marks)
A
Preventative dental team management:
* Discuss concerns with the parents - Ensure up to date contact details and contact mum by phone or any other guardians
Discuss :
1. The necessity of jodi to come (with someone able to consent)
2. Inform mum possibility of child protection getting involved due to non-compliance & non attendance
- Offer treatment - Set the next appointment on the phone ensuring that it is suitable for the family and ensuring an appropriate escort attends with
- Set targets and reminders
- Keep records
- monitor progress
Preventative Multiagency management:
* liaise with other HC professionals
- health visitor
- social work
- GP
- School nurse
* Investigate whether they are already part of a protection plan
* If child < 5 fails to attend appointments and the family do not response to letters from the practice contact the health visitor
5
Q
5 year old brought to clinic with mums boyfriend, she did not sleep due to dental pain. She has never been to the dentist before due to the mothers fear. The Mums BF is vague about medical history and she is small for her age. She is pyrexic, in pain and had a swollen left side of face associated with gross caries in all primary molar teeth. You provisionally diagnose acute periapical abscess.
What evidence based brushing advice would you give to help prevent further dental caries? (5 marks)
A
Brushing for 2 minutes twice a day.
Using the modified bass technique (45 degree angle to the tooth brushing from the gums to the biting surface)
Using a pea sized amount of 1450ppm fluoride toothpaste.
Spit don’t rinse your mouth out.
Given the child is aged 5- they should be observed brushing their teeth until they are aged 7.
6
Q
Patient has a fracture of tooth 11.
List two questions you would ask in regards to the traumatised tooth?
A
When/ how/ where did the fracture happen?
Are there any other more significant injuries/did they lose consciousness?
MH: Rheumatic fever, immunosuppressed, cardiac defects, tetanus status
Do we have the missing part of the tooth (and if so what has it been stored in?)
7
Q
Patient has a fractured of tooth 11.
List 4 things that determined the prognosis of the traumatised tooth
A
pulp exposure - Type of fracture, complicated or not complicated,
Maturity of the tooth: apex closed or open,
Associated PDL injuries
vitality of the pulp,
mobility
Time between injury and treatment.
8
Q
Patient has a fracture of tooth 11.What should we discuss with the parents? (4)
A
Inform of the complications - discolouration, pain, sinus, infection, risk of non-vitality,Risk of losing the teeth.
Inform them of theprognosis,
Inform them of the treatment options
Inform them we will review the tooth to check for these symptoms/
9
Q
Patient has a fractured of tooth 11.
Where do you suspect the fragment of the tooth and how you would you manage this? (3)
A
Swallowed: A+E,
Inhaled: A+E for chest X-ray,
Embedded in soft tissue: Radiograph to confirm. Remove and suture for haemostasis or refer to oral surgery.
10
Q
Patient has a fractured of tooth 11. It is ED#,
how would this change your treatment plan? (1)
A
Complete trauma stamp
Clean area
Disinfect with chlorhexidine
If fragment intact = Bond fragment to the tooth
or
place a composite bandage.
if exposed dentine is within 0.5mm of the pulp and a pink shadow can be seen - place a calcium hydroxide lining first and then cover with GI
11
Q
Patient’s parents complained that the patient has white/yellow/brown stain on her teeth.
List 8 questions you would ask the patient’s mum. (4)
A
Prenatal - Severe illness of mum during pregnancy, gestational diabetes, congenital syphillis anaemia, Rubella.
Perinatal - natural birth, Birth trauma/anoxia, Preterm birth,
Postnatal - childhood infections (ottitis media/ measles/ chickenpox) or Long term health problems e.g. organ failure
Do any of your family members have this staining?
Was the staining on her primary and her permanent teeth?
Any trauma to her primary teeth?
Does it cause the child any pain? (or sensitivity)
12
Q
The teeth affected are all first permanent molars, all central and lateral incisors. Is this condition likely to be
inherited and what condition do you think it is? (1)
A
No- because an inherited condition tends to affect the primary dentition aswell
Molar Incisor hypomineralisation - caused by childhood illness
13
Q
List 5 questions you would ask to rule out fluorosis. (2.5)
A
Do they use fluoridated toothpaste?- do they spit it out?
Do they live somewhere with fluoridated water?
Do they take fluoride supplements?
What is their oral hygiene regime?
Do any of their siblings use high fluoride concentration toothpaste?
Are their 6s affected/ primary teeth- If fluorosis- primary teeth and 6s would not be affected- Primary teeth & 6s are formed before birth so fluoride exposure could not have happened.
14
Q
List pottential problems of MIH of 16 26 36 46 in the future? (8)
A
Increased Caries susceptibility
Increased wear susceptibility
Increased sensitivity - from increased neural tissue within the pulp (more innervation- more difficult to LA)
Difficulty to restore: poor bonding
Poor appearance = psychological implications
Long term prognosis is poor,
Potential requirement of more complex/extensive/expensive treatment
Orthodontic problems
15
Q
A co-operative 10 year old patient attends with moderate crowding requesting orthodontic treatment, but has
poor oral hygiene and cavitated caries into dentine in the first permanent molars.
Describe your management of the case. (12 marks)
A
History - C/O, pain history and (HPC & orthodontic concerns )
MH DH SH
Extra & intraoral examination.
Caries risk assessment - Evidence. Diet. Fluoride use. Plaque control. Saliva. Social history. Medical history
Radiograph (OPT & bitewings - to assess caries & other clinical findings),
Special tests: Sensibility testing,
Treatment plan:
Deal with pain first- analgesia advice.
1. Treat the caries in the 6 (Removal of caries/ RCT or XLA dependent on cooperation level)
- Review developing dentition (Fissure sealants)
- Prevention
Radiographs. Toothbrush instruction. Diet advice. Fluoride strength in toothpaste. Fluoride varnish application (x4 year). F supplementation. Fissure sealants. Using sugar free medication. - Ortho treatment- explain that orthodontic treatment tis not an option until patient oral hygiene improves & is not appropriate at this time due to age and dental development
- Find out why the they want ortho treatment. Inform the patient of the risks of fixed apliances (root resorption/ gingival recession/ relapse. and decalcification)Ensure the patient understands the importance of good OH if they ever want orthodontic treatment in the future.
- Assess child protection and patient neglect (due to carious lesion of the 6s.
16
Q
A co-operative 10 year old patient attends with moderate crowding requesting orthodontic treatment, but has
poor oral hygiene and cavitated caries into dentine in the first permanent molars. Describe the risk-benefit discussion you would have with the patient and parent regarding their treatment 8 marks)
A
Risks of ortho - Root resorption, Relapse, Decalcification, Gingival recession, soft tissue trauma, wear/enamel fracture, gingival ulceration, loss of periodontal support, poor/failed tx
Benefits- Orthodontic treatment could solve the problem the patient is complaining of? improve aesthetics, function and psychological = improve self esteem and quality of life
Risks of extracting 6’s - Mesial tipping of 7’s, Distal migration of 5’s,
Benefits of extracting now - Extracting at the right time - Bifurcations of the
7’s formed & 8’s are present
Risks of GA - Nausea, drowsiness, vomiting, Slow recovery, Death, Permanent brain injury, Malignant hyperpyrexia
Benefits- we get the carious teeth removed.
17
Q
Patient is 10/11 years old and they had extrusion of their 11.Draw and label your splint, also what materials would you use? (2 marks)
A
(4 teeth)
0.3mm Flexible stainless steel wire
Acid etch 37%
Composite resin
Water
18
Q
Patient is 10/11 years old and they had extrusion of their 11.
How long would you splint for? (1 marks)
A
2 weeks
19
Q
Patient is 10/11 years old and they had extrusion of their 11.What 4 tests would you do at a check-up apart from a radiograph (4 marks)
A
Electric pulp test, Ethyl chloride, Sinus, Colour, Mobility , TTP, Displacement
20
Q
Patient is 10/11 years old and they had extrusion of their 11. Radiograph of 11 given, describe what you see, give a diagnosis and mention how you manage this (3 marks)
A
Periapical Radiolucency
Tramlines of RC intact
Widened PDL space
Loss of Lamina dura
External inflammatory root resorption- When the pulp is necrotic causing damage to the PDL (necrotic pulp tissues and toxins are reaching the external surface via dentinal tubules)
Treatment:
Remove cause of inflammation:
RCT with NS CaOh 4-6 weeks then obturate .
RCT( Pulp extirpate+ Mechanical debridement+ irrigation +NS CaOH 4-6 weeks then obturate)
21
Q
A pt has an avulsion of a permanent incisor- what advice do you give over the phone?
A
Reassure pt,
Handle tooth by crown only (the part that you see in the mouth)
If it is dirty- rinse with milk/ saline (not for contacts) or in patient saliva.
Reimplant & bite onto hankerchief to hold tooth into place.
If you can’t reimplant it- store in saliva, milk, saline
come to GDP ASAP.
22
Q
A pt has an avulsion of a permanent incisor-Give 3 storage media ranked best first
A
milk, hanks balenced salt solution, saliva, saline/
23
Q
A pt has an avulsion of a permanent incisor-What should you check upon arrival? (8)
A
How the incident occurred
Where incident occurred
When did the incident occur
Any witnesses
Any more significant injuries - Was the child unconscious or vomit/nausea (concussion) → A&E
Account for all tooth fragments,
Do they have tetanus immunisation (in case of bacterial wound infections)
MH: do they have congenital heart defects, immunocompromised or rheumatic fever (would consider
assess socket?
If reimplanted - verify position?
24
Q
A pt has an avulsion of a permanent incisor-What type of splint is advised?
A
EADT <60 mins (open or closed apex) flexible splint for 2 weeks
EADT >60 mins (open or closed apex) Flexible splint for 2 weeks.
25
Patient has an avulsed permanent incisor
What are the common outcomes?(4)
discoloration, mobility, necrosis of pulp, ankylosis, root resorption
PDL: regeneration, PDL/Cemental healing, bony/osseous healing, uncontrolled infection
Pulp: regeneration, controlled necrosis, uncontrolled necrosis
26
What are the clinical signs of dentinogenesis imperfecta and osteogenesis imperfecta? (8)
OI – blue sclera, lots of bone fractures
DI (uncommon)
* Both primary and permanent dentition affected
* Bulbous crowns
* Obliterated pulps
* loss of enamel & dentine (type 1)
* Just loss of dentine (type 2)
* Teeth appear amber and translucent/grey
* Occult abscess formation
27
What are the radiographic signs of dentinogenesis imperfecta?
Bulbous crown
Obliterated pulp
Occult abscess,
short and thin roots,
28
What is the clinical management of dentinogenesis imperfecta? (5)
(problems - poor aesthetics, caries, spontaneous abscesses = poor prognosis)
You want to cover them as soon as possible:
Composite veneers
overdentures
Stainless steel crowns
Removable prosthesis.
Prevention (High caries risk )
29
Give 4 E/O features of Down's syndrome.
Epicanthic eye fold.
Broad flat face
Slanting eyes
Short nose
Flat back of head
Thick unstable neck
30
6 Intra Oral features of Down's syndrome?
large fissured tongue/macroglossia,
Maxillary hypoplasia,
High arched palate,
AOB,
class III,
CLP,
hypodontia,
microdontia,
increased periodontal disease due to immunocompromised,
spacing
31
What are the restorative options for treatment of a patient with down's syndrome? (3)
Preventative protocol (Fissure sealants- moisture control may be difficult to achieve so- GI/ chlorohexidine for perio treatment)
If complaint treat using LA (caution with atlantooccipital instability- support is vital)
May require GA
Take caution with consent & capacity- other associated medical conditions (Alzheimers/ Intellectual impairement) may have a welfare guardian
32
Following root fracture, what types of healing are there?
**Calcified**- Ideal healing with a dentine like material which is almost indistinguable on the radiograph.
**Connective tissue healing-** Fracture lines remaining visible & edges of the fracture show eburnation (where the corners of the fracture are rounded off)
**Osseus healing**- Bony healing (Two parts of the boen become unique entities that don't connect- bone is clearly seen between fragments.
33
What type of tissue is regarded as non healing?
Granulation tissue (radiographically- radiolucent area around the fracture line )
34
How are root fractures managed
apical 1/3 and mid 1/3- reposition and 4 week splint.
Don't initiate RCT at emergency apt
If pulp necrosis develops during monitoring - RCT to fracture line (can use an MTA stop coronal to fx line)
Coronal 1/3- reposition and 4 month splint.
35
How would you manage a patient with a tooth fragment of the fracture that has lost vitality?
1. Remove pulp up to the fracture line
2. Dress with nonsetting- CAOH (temporary)
3. Create apical barrier using MTA or biodentine
4. Backfill from fracture line using GP.
5. The apical part of the root tends to stay alive (as it hasn’t been displaced)
a. So it can be left unless infected
b. if infected use- Antibotics and an apicectomy (surgical removal)
(Extraction is also a pottential treatment option)
36
What are the signs of fluorosis?
Symmetrical diffuse white marks on the teeth (Brown marks if more severe)
Unaffected 6s- formed before birth so unaffected by fluoride exposure.
37
Name 4 vehicles of fluoride delivery
toothpaste - 1450,2800,5000ppm
varnish - 22,600ppm
mouthwash - 225ppm
supplements - 0.25mg-1mg
GIC (fluoride releasing)
SDF - 44,800ppm
38
How can you manage fluorosis? (4)
Accept
Microabrasion
Veneers (Composite/ porcleain if >18)
Vital bleeching- riks that it may leave white spots whiter aswell.
39
What are the advantages of non-vital bleaching? (5)
Easy, conservative, safe,
no lab assistance for walking bleach (i.e. trays)
high patient satisfaction
40
What are the disadvantages of non-vital bleaching (5)
External cervical resorption
Spillage of bleaching agents
Failure to bleach
Overbleaching
Brittleness of the tooth
41
Briefly describe the walking bleach technique (9)
1. For records: Record the initial shade
2. Isolation with rubber dam
3.Create access & Remove GP to below the level of the CEJ
4. Clean pulp chamber with ultrasonic
5. Apply bleaching agent on a cotton pledget and place it in the tooth.
6. Seal with GIC or RMGIC
Appointment 2 (No more than 2 weeks between appointment)
* renew bleach
* If no change after 3-4 renewals stop.
* 6-10 changes in total
* There will be regression of 50% between 2-6 years.
Once shade is achieved:
Restore the pulp chamber:
NS CaOH paste for 2 weeks sealed in with GIC- prevents any cervical resorption.
After 2 weeks:
-Place white GP and composite resin restoration
-Incrementally cured composite
42
When do we use a splint for primary teeth and what splint?
a 4 week flexible splint for alveolar bone fracture.
43
What splint is selected for an avulsed adult tooth ?
2 week flexible splint
44
What is the difference between a flexible and rigid splint?
A flexible splint has 1 tooth on either side of the trauma.
A hard splint has 2 teeth on either side.
45
The patient has attended with an avulsed tooth- the EADT <60 minutes what is your endodontic management?
1. LA
2. irrigate socket with sterile saline
3. Reimplant the tooth with slight distal pressure
Open apex- Aim for revascularisation & monitor continued root growth.
If closed apex(remove pulp as soon as possible & leave antibiotic steroid paste for 2 weeks before using CaOH for 4 weeks - interfeeres with PDL healing )
4. Use a flexible splint for 2 weeks
5. Antibiotics
6. Check pt tetanus status
46
The patient has attended with an avulsed tooth- the EADT >60 minutes what is your endodontic management?
1.LA
2.Irrigate socket with sterile saline
3. Reimplant the tooth under LA
4.
For open apex- replant tooth under LA & splint (2 week flexible) & monitor for signs of necrosis.
For closed apex
remove any obviously damaged PDL.
Reimplant the tooth under LA
Extirpate at 7-10 days using NSCaOH as an intracanal medicament for 4 weeks before obturation. Corticosteroid / AB paste for 6 weeks.
5.Then use a 2 week flexible splint.
6.Antibiotics
7. Check tetanus status
47
Mum phones dentist telling them that their child has swallowed fluoride toothpaste and is worried.
What 3 questions should the dentist ask the mum? (3 marks)
How old is the child?
weight of the child?
How much of the toothpaste bottle has been swallowed?
Concentration of toothpaste?
48
If the child has ingested a toxic dose, what advice should the dentist give? (2 marks)
Toxic dose- 5mg/kg
Give calcium orally and go to the hospital.
<5mg/kg - Give calcium orally (milk) and observe for a few hours
5-15mg/kg - Give calcium orally (milk, calcium gluconate, calcium lactate) and admit to hospital
>15mg/kg - Admit to hospital immediately, cardiac monitoring and like support, intravenous calcium gluconate
49
What is the most common cause of fluorosis in the UK, underline 1 of the 4 following answers (1 mark)
Fluoride in public water supply?
50
If the child with fluorosis is 10 years old what would your first line of treatment be, underline 1 of the 4 following answers (1 mark)
Microabrasion. Composite veneer. Monitor. bleaching
Microabrasion? **
51
Patients are aged 1, 4 and 7, that are high caries risk with a 0.3ppm-fluoridated water supply. What fluoride supplementation would you advise for each patient? (10 marks)
Age 1:
fluoride toothpaste (1000ppm)
fluoride tablet 0.25mg
age 4:
fluoride toothpaste (1450ppm pea sized) &
0.25ml 22,600ppm fluoride varnish 4x per year
0.5mg fluoride tablet
age 7:
fluoride mouthwash 225ppm
1mg fluoride tablet
0.4ml fluoride varnish 4x per year
1450ppm toothpaste
| ******
52
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. What is the likely diagnosis?
Primary herpetic gingivostomatitis
53
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. How might these blisters appear?
Small fluid filled vesicles which rupture to form ulcers around 1-3mm in size.
Found on the gingivae, tongue, lips, buccal and palatal mucosa.
Severe oedematous marginal gingivitis
They last about 10-14 days.
54
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums.What other signs and symptoms may be present?
Fever
malaise
Headache
Severe oedematous marginal gingivitis
Vesicles and ulceration elsewhere in the mouth.
55
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. WHat is the likely cause of primary herpetic gingivostomatitis?
Primary infection of Herpes simplex virus I
56
A 3 year old child is brought to your practice by her mother who is worried about blisters on her gums. How do we treat this patient?
Reassurance
Bed rest
Soft diet/ hydration
Paracetamol
Antimicrobial (Chlorohexidine gel 1% or mouthwash 0.2%)
Give advice to parent re infective nature of disease.
57
What future issues should the herpes simplex virus cause?
Reactivation of the herpes simplex virus- herpes labialis (15-30% of patients) or bell's palsy.
58
What timeframes in a child's life are implicated by MIH?
Pre-natal (rubella, congenital syphilis, thalidomide, Fluoride, maternal A&D deficiency, cardiac & kidney disease.)
Neo-natal- (prematurity, meningitis.)
Post-natal (otitis media, measles, chickenpox, TB, pneumonia, diphtheria, deficiency of Vits A,C&D. heart disease. Long term health problem e.g. organ failure)
59
Why are those time periods implicated in MIH?
Because the 6s develop 7-12 weeks in Utero and the 1s develop 6-12 weeks after birth
60
What signs and symptoms does someone with MIH present with. (6)
poor aestehtics = symmetrical well demarcated lesions - white, yellow, brown
sensitivity
High caries
Poor bonding
Ineffective LA
Anxiety
61
Give the treatment options for MIH incisors?(4)
Acid pumice micro-abrasion
External bleaching
Localised composite placement
Full composite veneers when patient is older.
62
Give the treatment options for MIH molars? (4)
Direct Restore:
Composite (bonding difficulties)
GIC (benefit of fluoride release)
SSC- if tooth is sensitive/ broken down
Adhesive retained copings- gold to keep teeth long term.
Extraction
63
What fluoride toothpaste would you advice for low and high risk patients?
<3 years 1000ppm smear
>3 years 1450ppm pea sized
High risk >10 2800ppm pea sized
high risk >16 5000 ppm pea sized
| (Answers were saying smear for >3 years rather than peasized)
64
What are the topical effects of fluoride?(2)
Preventative measure used topically to reduce decay rates by increasing the contact time with fluoride and the tooth surface.
The fluoride ions replace the OH- ions in hydroxyapatite within the tooth to produce fluoroapetite which is less susceptible to demineralisation and acid attack.
Fluoride can also inhibit bacterial pathways which leads to less acid production
Speeds up remineralisation
65
What are the systemic effects of fluoride?
Fluoride toxicity (>5mg per kg)
Answer says fluorosis but check to see
66
What are the effects of primary tooth trauma on a primary tooth?
Loss of vitality
Discoloration
Delayed exfoliation - trauma preventing normal exfoliation.
May need extraction
67
What are the effects of primary tooth trauma on a permanent tooth?
Delayed eruption
Ectopic eruption
Damage to crown development
-crown dilaceration
-hypomineralisation
-hypoplasia
-Damge to root development
-odontome
-undeveloped tooth germ.
68
What are the eruption dates for the primary dentition?
Upper
8-12/9-13/16-22/13-19/25-33 months
Lower
6-10/10-16/17-23/14-18/23-31 months
69
What are the eruption dates for secondary dentition?
Upper: 7, 8, 11, 10, 10, 6, 12 years
Lower: 6, 7, 9, 10, 10, 6, 12 years
70
When do roots fully form?
Approx 2-3 years after the crown erupts.
71
An injured child attends your practice with his mother. You are concerned for the child’s welfare. What are some factors in your index of suspicion?
* A delay in seeking help
* A vague story which varies each time.
* The story is not compatible with injury.
* Parent behaviour gives you cause for concern (i.e. abnormal mood/ not interested in what’s happening to their child)
* Abnormal interaction between child and parent.
* History of previous injuries
* Contradictions
72
You are concerned about a child and have referred the child on.
As a result of this onward discussion what THREE different courses of action may take place?
1. If the child is in immediate danger- Removal by police. Child protection order/ exclusion order/ child assessment order.
2. Further investigations to decide if the child is at risk of significant harm.
From this can be:
A-. No further child protection action deemed neccessary
B- joint investigation (interview of the child by the police and social worker).
73
You wish to refer the child on. Who do you refer to and how do you do it?
A - Assess
H - History
E - Examination
T - Talk to the child and parent about concerns (if you feel safe)
D - Document: everything and in the patients own words
M - multiagency (Contact senior colleague and/or e.g. dental protection for advice.)
R - refer: Send a notification of concern to Social services. Ensure you follow up within 48hours. You send a copy to Child protection services.
If possible take photographs with permission. Consider contacting police if you feel child is in immediate danger.
74
What are the indications for a pulpotomy? (4)
Good child cooperation
Medical history
-Haemophilia (avoid extraction)
-Missing permanent successor
-Tooth is needed for space maintenance
-Child is <9years old.
This is done when there is carious or traumatic exposure of a bleeding pulp. We aim to preserve the radicular pulp and control the bleeding.
>1mm pulp exposure or exposure for >24 hours.
Try this before pulpectomy
To avoid extraction (space maintenance- we want to keep it if no permanent successor)
75
What are the contraindications for a pulpotomy? (7)
Poor-cooperation
Poor dental attendance
Cardiac defect
immunocompromised (best to extract as patient at greater risk of infection)
Multiple grossily carious teeth (the tooth is too bad to restore so we have to extract it )
Advanced root resorption (no point undergoing pulp therapy if the tooth won't be around for long)
Severe/recurrent pain or infections.
76
Describe how you would carry out a pulpotomy
It can be a partial pulpotomy (only necrotic coronal pulp) or full coronal pulpotomy. (all of coronal pulp)
1. Apply Local anaesthetic
2. Isolate the tooth with rubber dam.
3. Clean the exposed area with saline
4. Disinfect with Sodium hypochlorite.
5. Remove the pulp to a depth of 1-2mm using a round diamond bur
6. Place a slaine moisted cotton pellet upon the pulp wound & Check haemostasis.
7. Apply calcium hydroxide or non staining calcium silicate sealed cement.
8. Seal exposed dentine with GIC or composite
9. Restore tooth with composite
77
How is failure of pulpotomy measured clinically and radiographically?
Clinically- Colour/ Pain/ Sinus / Mobility.
Radiographically-Has the root continued to develop (Walls thicker)
Any radiolucency (Periapical pathology)
Any resorption (Internal inflammatory is related to non-vitality)
78
What is a partial pulpotomy?
When the necrotic coronal pulp is removed and then a barrier of CaOH is placed. (The healthy coronal pulp tissue is left)
79
How is a pulpectomy carried out?
Pulpectomy- when the whole pulp is removed.
Indicated- non vital teeth. Extremely hyperaemic or Irreversible pulpitis.
Give LA and isolate with a rubber dam
1) We estimate the working length on a pre-operative radiograph. (EWL)
2) Remove caries from the tooth
3) Identify the root canals and floor of pulp chamber
4) Clean out the root canals with a file- spin it round the canal
There is a stopper positioned on the file 2mm short of the EWL
5) Wash out the canals via filing with sodium hypochlorite
6) Dry the canals with paper points- these are absorbant.
7) **Primary teeth** Introduce Vitapex (CaOH and Iodoform) into the canal using a Vitapex delivery system (with a rubber stop 2mm short of the EWL
8) Fill the pulp chamber with zinc oxide eugenol
9) Restore tooth using a performed crown.
**Permanent teeth**
Apexification with CaOH (4-6 weeks) or MTA. (15 minutes)
Obturate with Heated gutta percha
Restore.
80
Name 4 types of amelogenesis Imperfecta
* Hypoplastic type - Enamel crystals do not grow to the correct length
* Hypomineralised - Crystallites fail to grow in thickness and width
* Hypomaturational - Enamel crystals grow incompletely in thickness or width but to normal length with incomplete mineralisation
* Mixed forms with Taurodontism (enlarged flame shaped pulp chamber)
81
What is the cause of amelogenesis imperfecta?
An inherited gene mutation (autosomal dominant ususally) for making the proteins needed for
enamel extracellular matrix molecules amelogenin, enamelin, kallikrein 4. (Normal enamel formation)
82
What problems are caused by amelogenesis imperfecta?
Aesthetic
Sensitivity
Caries and acid susceptibility.
Poor oral hygiene.
Delayed eruption
Anterior open bite
83
How do we manage amelogenesis imperfecta?
Prevention (high risk of caries)
Cover affected teeth (Veneers or composite wash/ SSC/ onlays)
Extraction of any teeth of poor prognosis.
Fissure sealants.
84
Name 4 causes of enamel defects
Fluorosis
Molar incisor Hypomineralisation
Trauma
Amelogenesis imperfecta.
85
A 4 year old patient presents with gross caries across her anteriors, including the smooth surface.
What is your likely diagnosis and how does this usually present?
Early childhood/ Nursing bottle caries
Usually maxillary anteriors, 1st molars and mandibular canines are affected.
Lower incisors are protected by the nursing position of the tongue.
This usually affects the smooth surface near the gingival margin.
86
A 4 year old patient presents with gross caries across her anteriors, including the smooth surface.
How can nursing bottle caries occur?
Putting a child to bed with a feeder bottle = prolonged exposure as the liquid remains and lingers within the mouth.
Salivary flow low at night too
(containing carciogenic liquids including milk = lactose= sugar)
Prolonged use of a feeding bottle > 6 months old
Not using a bottle with a free flowing spout
87
A 4 year old patient presents with gross caries across her anteriors, including the smooth surface. What is your treatment plan?
Diet Advice-
Not taking milk to bed (or drinking throughout the day)
- if feeding bottles used at night ensure it is with water only
Drink water between meals and gradually reduce milk intake to meal times.
Remember that flavoured water and milk contains sugar, use sugar free variations of food or drink.
Don't give children soya milk unless for medical indications.
Treatment:
Complete/ partial caries removal/ temporisation with GIC or hall SSC for posteriors.
May need Referall for GA extraction if gross caries or uncooperative child
Prevention:
Prevention:
Fluoride - 1450ppm toothpaste 2x daily for 2 mins before bed and when child wakes up.
Fluroide varnish 22,600ppm 4x yearly.
0.5mg fluoride supplement
88
Name 3 types of dentinogenesis imperfecta
Type 1- Associated with osteogenesis imperfecta
Type 2 - Autosomal dominant (no underlying medical conditions)
Type 3-Brandywine (incest)
89
A patient has dentogenesis imperfecta. What can be seen radiographically? (4)
bulbous crowns.
Obliterated pulps
Occult abcesses
Reduced root length with round apices.
90
A patient has dentogenesis imperfecta.What problems are associated with dentinogenesis imperfecta?
* aesthetics
* caries / acid susceptibility
* spontaneous abscess
* Poor long term prognosis
91
A patient has dentogenesis imperfecta.
How do we manage dentinogenesis imperfecta?
You want to cover the teeth before anything happens to them:
* composite veneers
* overdentures
* removable prostheses
* stainless steel crowns
& Provide prevention- to reduce caries risk.
92
What are the indications for a stainless steel crown? (7)
* When there. are>2 surfaces affected with extensive lesions
* Impaired oral hygiene or high carIes rate.
* If we want to maintain the space.
* In poorly co-operating children that wouldn't co-operate with LA & conventional restorations.
* After pulpotomy/ pulpectomy
* In severe MIH/ enamel defect cases.
* >severe MIH/enamel defects,
93
How do we place a stainless steel crown conventionally ? (8 steps)
1. LA & Dental dam.
2. Interproximal separation of the contact points (tapered separating bur)
2. Occlusal reduction with flat fissure bur 1-2mm
3. Peripheral reduction
4. Add cement into the crown and seat lingually or palatally first- allows excess cement to flow buccally.
5. Press down evenly on both sides to seat it.
6. Remove excess cement with a probe.
7. Contour the crown margin with pliers to ensure a tight cervical fit.
94
What other technique can we use to place a crown?
The hall technique- Sealing decay under preformed metal crowns without local anaesthetic/ tooth preparation or caries removal.
95
What are the signs that a crown has failed? (7)
Crown fallen off
crown cracked or broken,
crown rocking/canting,
2° caries,
pulpitis,
abscess,
radiolucency
96
What are the advantages of planned extraction of first permanent molars? (3)
Spontaneous space closure
caries free dentition
reduction in possible orthodontic needs.
Prevents tilting/rotation/distal drift of 5's ??
Relieves mild-moderate crowding ??
97
What signs are indicative of suitability for planned extraction of first permanent molars? (5)
Calcification of bifrucation of 7s.
Assess if 8’s are forming within the gum (if 6 extracted before 8 years- the 8s don't form)
Lateral incisors have erupted.
Examine to see if the 5’s have erupted as they use the position of the 6’s to erupt into the correct place.
Class I incisor relationship (class II would make planning more difficult as we also want space or correction of crowding)
Mild buccal crowding. (WHY)
98
Name 2 disadvantages of planned extraction of 1st permanent molars. (2)
Can traumatise the child (Demanding procedure)
May require GA - in children with associated risks.
If not extracted at the correct time
Early extraction of lower 6 = distal drift of the 5s.
Late extraction = poor space closure
Pt may be loosing caries free teeth due to compensation
99
What is the most common cardiac defect in children?
Ventricular septal defect (VSD)
100
What condition is a ventricular septal defect commonly associated with?
Down Syndrome
101
Name 6 other medical issues commonly seen in Down Syndrome patients?
Alzheimer's dementia
Epilepsy
Leukaemia
Hearing impairment
Diabetes mellitus.
Intellectual impairment.
Cardiac defects (ventricular septal defect/ Tetralogy of fallot)
Autism
102
How do we manage a ventricular septal defect in a dental setting?(5)
thorough drug history (blood thinners)
Assess risk of infective endocarditis.
(not enough risk for prophylaxis.)
Prior to valve surgery or any other cardiac surgery - patient should be dentally fit (removal of any possible infections)
High risk prevention to maintain good oral hygiene (reduce Infective endocarditis risk)
Treat under sedation (Don't risk GA)
Avoid RCT extract instead?
103
A 10 year old patient presents with an extrusion injury of an upper central incisor. What splint would you use?
2 week flexible splint using composite on either side of the trauma and 0.3mm stainless steel wire
104
Name 4 other ways (other than radiographs) you would use at follow up for an extruded tooth
Colour
Displacement
Mobility
TTP
Sensibility - Electric pulp test and ECT
Tenderness to hot and cold.
105
A 10 year old patient presents with an extrusion injury of an upper central incisor. He has infection related external inflammatory resorption. How do you manage this?
(caused by damage to the PDL from necrotic pulp tissue)
Treatment- RCT
Mechanical debridement & Chemical irrigation then NS caOH for 4-6 weeks before obturation.
106
What factors make up a caries risk assessment?
Every dentist fears people selling sugar mice.
1.Evidence (6s at age 6s/ 3 lesions in 3 years)
2.Diet ( > 3 sugar hits a day)
3.Fluoride use (Do they use fluoride toothpaste)
4.Plaque removal (Do they brush teeth? Do they need help doing so? )
5.Saliva- Low volume? Reduced flow? viscosity? pH?
6. Social history- SIMD
7. Medical history- can cause xerostomia. Sugary medications?
107
What factors make up a caries prevention plan? (8)
Toothbrush instruction
Diet
Sugar free medications
Fluoride varnish
Fissure sealant
fluoride supplement
Strength of fluoride in toothpaste.
Radiographs
108
How often would you take bitewings in a high risk patient?
6 months
109
What toothpaste strength would you advise for a 7 year old?
1450ppm.
110
What fluoride supplement would be indicated with water fluoridation <0.3ppm?
1mg/day fluoride tablets.
111
What is the optimum concentration of fluoride in water?
1ppm.
112
Name 3 sources of fluoride found in food and drink
bony fish, cucumber, tea, beer, oats, coffee, potatoes
113
What are the oral signs of fluorosis?
symmetrical
Diffuse white flecks on the teeth (Brown marks are more severe)
6s are unaffected
114
Give 3 options for treatment of fluorosis
Accept
Microabrasion
Vital bleaching
Porcelain Veneers & crowns (once 18)
115
Patient suffered a lateral luxation 18 months ago. Radiograph showing signs of external inflammatory resorption. Name 8 things you assess in a clinical trauma review
Mobility
TTP
Colour
Ethyl chloride
Electric pulp test
Sinus presence.
Percussion note
Radiograph
116
What is the cause of external inflammatory resorption?
Necrotic pulp tissue and toxins reaching the external root surface via dentinal tubules & damaging the PDL.
117
Patient suffered a lateral luxation 18 months ago. Radiograph showing signs of external inflammatory resorption.What clinical signs may be seen?
Negative sensibility test (pulp is necrotic)
may be TTP,
may be mobile.
Potential sinus
Potential swelling
118
How does external inflammatory resorption present on a radiograph? (3)
The root surfaces are indistinct (- loss of lamina dura/PDL???)
tramlines of the root canal are intact
PA radiolucency
119
Patient suffered a lateral luxation 18 months ago. Radiograph showing signs of external inflammatory resorption. What is your initial management?
Pulp extirpation.
Mechanical debridmenet
Chemical irrigation
NS caOH for 4-6 weeks then obturate.
120
What is the toxic dose of fluoride?
5mg/kg
121
What is your first line of treatment for fluorosis?
Microabrasion – assuming the patient wishes treatment.
122
What are the indications for microabrasion? (5)
- Fluorosis
- Post orthodontic demineralisation
- Demineralisation with staining
- Prior to veneering if there are dark stains present
- trauma
123
What are the advantages of microabrasion? (6)
Easily performed
Conservative
Inexpensive
Teeth need minimal subsequent maintenance
Fast acting
Permanent results
124
What are the disadvantages of microabrasion? (4)
* Removes enamel = Sensitivity/ teeth may be more susceptible to staining
* HCL acid compounds are caustic (requiring protective aparatus for patient/dentist/nurse)
* Prediction of treatment outcome is difficult- treatmetn may appear more yellow (Normal crown colour is shown when white part is removed)
* Must be done in the dental surgery.
125
Describe how we complete microabrasion ?
1. clean teeth with pumice and water
2. Protect the soft tissues with vaseline & a rubber dam.
3. Protect gingivae with sodium bicarbonoate guard.
4. Microabrasion (HCL pumice for 5s, Wash directly into aspirator. Max 10 times for each tooth.
5. Apply fluoride varnish (to remineralise and help with sensitivity)
6. Polish with sandpaper discs
7. Polish with toothpaste
126
How frequently should a high risk 7 year old get bitewings?
6 - 12 months
127
How frequently should a high risk 7 year old get fluoride varnish?
x4 per year
128
High risk 7 year old child.
What common delivery methods of fluoride are suitable?
Toothpaste = 1450ppm (2x daily)
Fluoride mouthwash = 225 ppm (1x daily?)
oral fluoride supplements/tablets = 1mg (1x daily)
FV = 22,600ppm (4x yearly)
129
The high risk 7 year old has recieved bitewings, fluoride varnish, toothpaste. Name some other preventative mangement techniques not mentioned
Dietary advice
OHI
sugar free medication
Fissure sealants.
130
What preventative measures and treatment plan should be used for patients with down syndrome & explain
High risk prevention- (High fluoride toothpaste. Fluoride varnish 4x a year. Fissure sealants- review every 4 month)
Chlorohexidine mouthwash- increased risk of perio disease
Diet advice
Take sugar free mediciations (pts can suffer from other medical conditions)
131
Patient attends after lateral luxation of the tooth 18 months previously.Give 6 things you would find on the trauma stamp
Colour
Mobility
Sinus
Tenderness to percussion
Electric pulp test
Thermal (Ethyl chloride or Gutta percha)
Displacement
Radiographs
132
Patient attends after lateral luxation of the tooth 18 months previously. This is the radiograph. What type of resorption has occured and what is the mechanism for this?
External inflammatory Resorption- Damage to Periodontal ligament. Maintained and propagated by necrotic pulp tissue (and toxins) reaching the external root surface via the dentinal tubules.
133
Patient attends after lateral luxation of the tooth 18 months previously. This is the radiograph.
How do we treat this? (2)
Give an initial/ short term and long term plan for the tooth. (3)
We remove the cause of the inflammation:
* Infective cause (RCT or periradicular surgery)
I think this is external surface resorption as opposed to inflammatory * Pressure cause (Stop ortho treatment or remove impacted tooth)
Initial- symptomatic management = Initiate RCT and leave NS CaoH for 4-6 weeks then obturate.
Short- monitor and review (2 weeks/4 weeks 8 weeks/ 12 weeks. 6 months)
Long- Radiographic review & review yearly for 5 years.
134
How to diagnose hypodontia (2)
Examination
Observe:
* Early on in life
* Delayed or asymmetric eruption
* Retained or infra-occluded deciduous teeth
* Absent deciduous tooth = guaranteed absence of permanent
* Tooth form = tapered and small teeth commonly associated with hypodontia
Radiograph - OPT
135
Paediatric Patient presents with missing anterior teeth. They have been diagnosed with hypodontia. Give 2 treatment options for the missing teeth
Removable prosthesis (denture)
Bridge.
Implants (when they are older)
136
Paediatric Patient presents with missing anterior teeth. They have been diagnosed with hypodontia.
Give 3 members for MDT for hypodontia (3)
GDP
Orthodontist
Restorative dentist
Lab technician
137
Paediatric Patient presents with missing anterior teeth. They have been diagnosed with hypodontia.
Give 3 conditions associated with hypodontia (3)
Ectodermal dysplasia
Cleft palate
Down syndrome
138
Give the percentange incidence of primary and permanent hypodontia?
Primary 0.1-0.9%
Permanent 6%
139
Child comes in with traumatised tooth - 4 signs it is non-accidental injury (4)
Injuries:
patterns of injuries
multiple injuries with various stages of healing
bilateral injuries
injuries to soft tissues i.e cheeks, side of face
Other indications:
Story not match up to injury
Story is vague, lacks detail and keeps changing
Child and parent stories do not match
Delayed presentation
Abnormal interactions between parent and child
History of abuse or violence within the family.
140
Child comes in with traumatised tooth. Give 2 Complications to primary tooth trauma (2)
Loss of vitality
Discolouration
Delayed exfoliation
May require extraction
141
Child comes in with traumatised tooth. Give 4 consequences to the developing permanent tooth.
Can affect-
* Eruption (delayed or ectopic)
* Crown development (crown dilaceration/ Hypomineralisation/ hypoplasia)
* Root development (Root dilaceration/ arrested root development)
* Odontome
* Undeveloped tooth germ
142
Give 3 records you need to take prior to microabrasion
* Shade
* Clinical photographs
* Diagram of defect
* Sensibility test
143
What should you warn the patient of when carrying out microabrasion?
To avoid highly coloured food or drinks for 24 hours.
144
What type of bleach and concentration is commonly used for vital bleaching (2)
10% carbamide peroxide which contains 3.6% hydrogen peroxide and 7% urea.
145
How to work out aetiology of discolouration for upper central (3)
Sensibility testing - vital or non-vital
Trauma history
Assess colour and MH:
Porphyria = red primary teeth
CF = grey
Thalassaemia and sickle cell = blue, green, brown
Hyperbilirubinemia = green teeth
146
Patient has attended with a discoloured upper central incisor. Outline and explain 2 treatment options
| 2020 Q3
Microabrasion (Hydrogen chloride pumice 5s application up to 10 times)
External vital tooth whitening (10% carbamide peroxide at home with a mouthgaurd or 10-38% in the chair.)
Indirect restoration (crown / veneer) - if pt not complaining of symptoms- this is not the first treatment choice.
147
What are the reasons for a child to be anxious before visiting the dentist?
* Attitude and previous experience of family and friends.
* pain/discomfort expectation, Previous negative experinece
148
How may anxiety be measured in in children?
MCDAS- modified child dental anxiety scale - 1 to 5 with faces representing each number.
A score >27/40 or 5/5 on any treatment indicates DFA.
149
Give 8 behavioural management technique
Tell, show, do = Provide an age appropriate explanation, demonstrate aspects of the procedure in a non-threatening manner, initiate treatment with minimal delay
Positive reinforcement = uses presentation of a stimulus to increase the liklihood of the behaviour being repeated (reinforces good behaviour)
Systematic desensitisation = Exposure therapy, gradually introduce potentially anxiety provoking stimuli from least to most
Relaxation = the space exercise and progressive muscle relaxation
Role modelling = have the patient watch a child of similar age undergo the same procedure with ease
Voice control = use of controlled alterations to the pace, tone, volume of the voice to direct childs behaviour
Acclimatisation = gradual, planned, sequential introduction of the clinial environment, staff, instruments etc
Distraction = diverts the child attention away from anxiety provoking stimuli
150
A 6 year old patient attends with pain in LRQ with grossly carious 85 and a buccal swelling. He has haemophilia A. What is your likely diagnosis?
periapical abscess due to gross caries
151
A 6 year old patient attends with pain in LRQ with grossly carious 85 and a buccal swelling. . He has haemophilia A.
What is the treatment of choice for this patient?
We will need to contact haemophihlia centre for blood results before treating.
We want to avoid an extraction if possible.
So Caries excavation and a sedative dressing.
Deal with the pulp- Pulpotomy/ Pulpectomy as atraumatically as possible.
Refer to a specialist clinic (haemophilia clinic) for extraction. (will need coagulation factor (8 or 9) replacement or the use of tranexamic acid.
152
A 6 year old patient attends with pain in LRQ with grossly carious 85 and a buccal swelling.He has haemophilia A. List the 8 stage sin this treatment.
Pulpotomy/pulpectomy atraumatically as possible (remove caries with a hand instrument)
Possible antibiotics if you have to refer.
LA- Can only use buccal infiltrations.
Place dental dam.
Remove caries as atraumatically as possible (hand instrument)
Remove coronal part of the pulp with a sterile excavator (2mm) & arrest the haemorrhage by packing a cotton pledget with ferric sulphate into the pulp chamber & leaving for 20s.
Check bleeding of stumps
Bright red & good haemostasis- normal bleeding- Dress pulp with Ca(OH)2 Place a GIC core and restore.
Deep crimson & continued bleeding- Try ferric sulphate again. If not stopped Pulpectomy
If There is an infection (antibiotics)
If extracting:
Mild or carrier = boost factor 8 levels using DDAVP & for very mild patients a Tranexamic acid down
Moderate/severe = Factor 8 replacement
For the LA- use buccal infiltration.
Observe to ensure haemostasis
- observe mild & carriers- 3 hrs
- observe Moderate and severe- overnight
153
Name 2 local haemostatic agents
- LA + vaso e.g. lignocaine with adrenaline
- Surgicel (oxidised regenerated cellulose)
- Collagen sponge
- Sutures
- Damp gauze and firm/even pressure
- Fibrin foam
- Kaltostat sodium alginate & calcium alginate
dressing.
154
Regarding autism, what is the triad of impairment?
Social Impairment in:
1. Interaction - cant read social cues, problem forming relationships
2. Communication - literal understanding of language
3.Imagination - rigid and unflexible ways of thinking
155
What other features does autism have?
ADHD
Dyslexia
Dyspraxia
Learning difficulties
sleeping disorder
Epilepsy
* Patients don't like change (repeat limited behaviours and resist change)
* Have difficulties with communication and language
* Have difficulties forming relationships with other people
-One doc answer ->
hypersensitivity, hyposensitivity, obsessive, learning difficulties, epilepsy, tubular sclerosis.
| ** See other answers
156
How do we manage a child with autism in a dental setting?
Pre treatment
* Ask the parent to complete the ASD questionaire (Special interests/ how they communicate/ any previouslypossible dental treatment)
* Send a social story to help the child prepare.
* Send out a plastic mirror.
Treatment
* Be on time
* Multiple shorter visits to familiarise yourself
* Keep all appointments same time/ day/ dentist
* Speak literally
* Diet advice - pt willneed to be weined off think about difficulties with change)
* OHI-
* Topical fluoride every 3-4 months
* GIC fissure sealant - cover with oronurse so they can't taste the salt and vinegar
* Wait until child is more familiar before restorations
* Give a preformed metal crown home before to familiarise.
Environment- Quiet surgery. No radio. No interuptions.
157
What are the indications for fissure sealants? (4)
Standard prevention in all permanent molars after eruption.
High caries risk (all molars/ premolars/ palatal pit of upper laterals)
Children with disabilities/Learning difficulties /Medically compromised - all teeth sealed
Patients with caries in 1 permanent molar should have all 4 molars sealed
Patients with occlusal caries in 1st permanent molars should have 2nd permanent molars sealed on eruption.
158
Give 2 materials used for Fissure sealant
BisGMA resin-
GIC- if good moisture control cannot be achieved or sensitive teeth.
159
Briefly describe the technique for placing fissure sealants
1. Isolate the tooth with a cotton wool roll .
2. etch with 37% orthophosphori caicd.
3. Wash and dry to leave a chalky white surface.
4. Change cotton wool rolls.
5. Apply BIS GMA resin to the depths of the dry fissure pattern
6. Light. cure/
6. Check for air bubbles/flash/ adhesion/excess/ opalescence at the tooth interface
7. Review every 4-6 months
160
What are the 4 types of cerebral palsy?
1. Spastic 2. Ataxic 3. Athetoid 4. Mixed
161
How are the 4 types of cerebral palsy further classified
Hemiplegia- one side of the body is paralysed.
diplegia- symmetric affecting arms or legs
paraplegia- Paralysis of lower limbs
quadriplegia- all limbs paralysed.
162
What is cystic fibrosis?
A recessive disorder where there is an inherited defect on the CFTR gene on chromosome 7 which affects the chloride channels. This causes the production of sticky mucous on any surface where mucous is secreted.
163
What are the general signs and symptoms of cystic fibrosis ? (8)
Troublesome cough - trying to get rid of the mucous
Repeated chest infections
Poor weight gain
liver dysfunction
Reduced fertility.
Diarrhoea - Mucous blocks pancreatic secretions = no digestive enzymes produced to digest fat.
Diabetic symptoms: Mucous blocking pancreatic secretions = no insulin.
Osteoporosis: lack of nutrient absorption
164
What are the dental considerations to CF
?
* Thickened saliva (so lower plaque & gingival disease - less caries)
* Higher calculus level
* Enamel defects
* delayed eruption
* GA risk
* Sedation is contraindicated due to the respiratory failure.
* Patient shave a higher sugar intake so OH is crucial)
If they have liver problems we need to manage them aswell.
165
Child attends with a discoloured tooth.
What questions would you ask to find out more about the previous trauma?
When did the Trauma happen to the tooth?
How did it happen?
Were any parts of the tooth lost (If so where are they)
Did the patient suffer any other symptoms or injuries from the trauma?
When did the discolouration occur?
166
A child attends with a discoloured tooth.
What diagnostic tests check for the vitality of the tooth?
Electric pulp test
Ethyl chloride test
167
A child attends with a discoloured tooth-
How do we treat a tooth that has suffered from a subluxation injury? (4)
Subluxation - Traumatic injury to the PDL with increased mobility.
Clean area with saline, CHX
2 week flexible splint if patient wishes (for comfort but not necessary)
Advise - Soft food diet for 1 week and OH with a soft brush and CHX.
Follow up: 2 weeks, Follow up 12 weeks. 6 months. 1 year.
168
Child attends with ectopic canine. At what age should you be able to palpated the canines in the buccal sulcus?
Maxillary canines should be palpable between ages 9-11.
169
There is a suspicion of child abuse with your child. What 4 things make you suspect a non accidental injury?
Injuries in the triangle of safety (Ears/side of face/ Neck/ top of shoulders)
Bilateral injuries
Patterns of injuries
Injuries at varying stages of healing
The delay in seeking help
The story is vague & not compatable with the injury .
Patient has history of previous injuries.
Child's appearance and interaction with the parent is abnormal.
170
What are 4 general extra oral features of Down syndrome children?
Broad flat face
Flat back of head
Epicanthic eye fold
Slanting eyes
Short nose.
Neck instability.
171
What are 6 intra oral features of Down syndrome children?
large fissured tongue/macroglossia,
Maxillary hypoplasia,
High arched palate,
AOB,
class III,
CLP,
hypodontia,
microdontia,
increased periodontal disease due to immunocompromised,
spacing
172
Your patient has down syndrome.How would you alter the prevenative plan for these patients?
Fluoride varnish 226000 ppm 4x yearly.
Stronger toothpaste strength (2800ppm 7-15. 5000ppm 16+)
Fissure sealants- all teeth.
Radigraphs- every 6-12 months.
Fluoride supplementation (mouthwash)
Diet advice
Sugar free medications .
173
The patient has attended with lateral luxation 18 months ago. What is lateral luxation?
Displacement of the tooth other than axially/to the side (Not up and down).
This is accompanied by fracture of either the labial or palatal/ lingual bone.
The PDL has been torn on one side and Crushed by the tooth on the other.
174
The patient has attended with lateral luxation 18 months ago.How long are lateral luxation injuries splinted for?
Patient wears a flexible splint for 4 weeks.
175
The patient has attended with lateral luxation 18 months ago. What kind of root resorption can occur with lateral luxation trauma?
External inflammatory resorption
176
What is the cause of root resorption? (All 4 types)
External surface - in response to localised injury damaging the PDL .
External inflammatory - Damage to the PDL maintained and propagated by necrotic pulp tissue reaching the surface via dentinal tubules.
Internal inflammatory - initiated by non-vitality.
Ankylosed related replacement root resorption-Initiated by severe damage to the PDL.
177
How does external inflammatory resorption appear clinically
Negative response to sensibility testing
Negative response to EPT
Pain on percussion
Maybe mobile
sinus
178
What toothpaste strengths are used in children?
Normal risk :<3 years (smear of 1000-1500ppm)
>3 years pea sized amount 1,350-1500ppm
High risk:
<10 1500ppm
>10 2800ppm
>16 5000ppm
179
What is the time interval between fluoride vanrishes?
Every 6 months (twice yearlY) if normal caries risk.
Every 3 months (4 times yearly) If high risk.
180
How does fluoride work? (5)
The fluoride ions replace the OH- ions in hydroxyapatite within the tooth to produce fluoroapetite which is less susceptible to demineralisation.
Slows down the development of decay by stopping demineralisaton of dentine.
Makes enamel more resistant to attack from plaque bacteria.
Speeds up remineralisation
Can stop bacterial metabolism at high concentrations as it inhibits bacterial pathways which leads to less acid production.
181
A 10-year-old boy presents to your reactive after having fallen and banged his upper front tooth. On examination you diagnose a subluxation injury
- Give 3 diagnostic features of a subluxation injury
TTP & increased mobility
Gingival bleeding
No displacement of the tooth.
182
A 10-year-old boy presents to your reactive after having fallen and banged his upper front tooth. On examination you diagnose a subluxation injury
When would you review a subluxation patient
Dental trauma IADT guidelines:
2 weeks. 12 weeks. 6 months. 1 year
new guidance: 2 weeks, 4 weeks, 3 months, 6 months, yearly 5 years and beyond
(unsure what this one is)
183
A 10-year-old boy presents to your reactive after having fallen and banged his upper front tooth. On examination you diagnose a subluxation injury.
He is coming back for review .
Give 2 features you would be asessing radiographically
Root development - length of roots, width of root walls
PA pathology
Any root resorption - tram lines intact, shortening of the roots, PDL uniform?
184
A 10-year-old boy presents to your reactive after having fallen and banged his upper front tooth. On examination you diagnose a subluxation injury.
How would internal inflammatory root resorption present both clinically, radiographically, what would it indicate about this tooth, what medicament would you place to halt the resorption?
**Clinical presentation **
Positive sensibility test (EPT/Ethyl chloride)
Pink colour-
Often asymptomatic
Acute pulpitis (active stage) Periapical periodontitis (Necrosis)
Sinus tract may be present in late stage.
**radiographic presentation **
Root surface is intact.
Tramlines of the root canal are indistinct
Internal ballooning of the canal
**Indicates**:
This is initiated by non-vitality. The infected material propagates resorption.
**To halt the resorption **
1.Pulp extirpation
2.Mechanical debridement
3.Chemical irrigation
4.Non setting CaOH for 4-6 weeks then obturate.
185
Patient is 10/11 years old and they had extrusion of their 11s.
What is extrusion?
A tooth injury where there is partial or total separation of the PDL (tearing injury) which causes displacement out of the socket.
186
A patient presents with dentinogenesis imperfecta.
Compare the clinical presentation of dentinogenesis imperfecta and osteogenesis imperfecta.
Dentinogenesis imperfecta
Bulbous crown
Loss of enamel (In type 1)
Discolouration Amber appearance of affected teeth due to dentine.
Both primary and permanent dentition are affected.
Multiple periapical abscess due to pulpla strangulation/occult abscesses
Osteogenesis Imperfecta
Blue sclera
lots of bone fractures.
187
Compare the pulpotomy technique used for a primary incisor and a primary molar?
For bleeding control-
We use ferric sulphate for a molar. We would not use ferric sulphate for an incisor as it stains the tooth.
For the restoration-
Incisor- needs to be more aesthetic so a composite or MCC.
Molar- restoration can be SSC.
188
When is a full coronal pulpotomy used, what does it follow on from and what treatment can be used afterwards?
Used after a partial pulpotomy (pulp tissue is removed until we reach healthy pulp)
IF you still have infection
Pulp isn't bleeding= necrotic
Pulp doesn't stop bleeding= hyperaemic
You remove all the coronal pulp & place calcium hydroxide in the pulp chamber.
If this still doesn't help we can do a pulpectomy then prepare the canals & obturate with GP
189
What are the indications for a pulpectomy
Exposure of non bleeding or severely hyperaemic pulp
Irreversible pulpitis
Clinical/ radiographical signs of periapical periodontitis or acute abscesses.
190
Tooth 11 has a traumatic exposure.
What 2 factors would influence your choice of treatment .
Size of exposure
Time since exposure
Associated PDL injuries
191
Tooth 11 has had a traumatic pulpal exposure.
Discuss the treatment options for this tooth.
Apply LA
Isolate tooth with rubber dam
Clean the exposed area with saline
Disinfect with sodium hypochlorite.
<1mm < 24 hours = direct pulp cap
- trauma stamp
- place calcium hydroxide
- Seal exposed resin with GIC or composite resin.
- place composite restoration
>1mm or > 24 hours;
Partial pulpotomy- removal of the necrotic pulp (removed to a depth of 3mm and 2-3mm around the exposed area.)
Full coronal pulpotomy (if the tooth doesn't bleed or doesn't stop bleeding after partial pulpotomy)
Pulpectomy- removal of the whole pulp/ instrumented/ filled with NS CaOh & restored)
192
A Child attends your practice & you are concerned about child abuse. What oro-facial injuries are suspicious?
** Extra-oral:**
Bruising of face – punch, slap, pinch
Bruising of ears – pinch and pulling
Abrasions and lacerations
Burns and bites
Neck marks – choking or cord marks
Fractures – nose>mandible>zygoma
**Major clinical lesions:
**
Skin lesions – bruises, burns, bites, lacerations
Bone lesions – fractures
Intracranial lesions – from shaking
Viscera lesions – blunt trauma to abdomen
** Intra-Oral:**
Contusions
Bruises
Abrasions and lacerations
Burns
Tooth trauma
Frenal injuries
193
Your patient has attended with an avulsed tooth. What medical history questions are important?
Any congenital cardiac defects
Rheumatic fever
immunosuppressed
Any medications
Has the patient had their tetanus immunisation
Where are all the fragments of the tooth (we want to know if anything has been inhaled, swallowed, embedded)
Any other more serious injuries or LOC
194
Why does a coronal 1/3 fracture have the poorest prognosis (3)
There is little PDL support to keep the crown in position during function
It is difficult to stabilise
It is close to the gingival margin causing an increased risk of bacterial invasion.
195
How can anxiety manifest?
Physiological and somatic sensations
* Breathlessness
* Perspiration
* Palpitations
* Feeling of unease
Cognitive changes:
* Interference in concentration
* Hypervigilance (trying to figure out what is going on)
* Inability to remember certain events.
* Imagining the worst that could happen.
Behavioural reactions:
* Avoidance- postponing appointment/constantly speaking at you/closing their mouth
* Running away
* Anxiety may manifest as aggressive behaviour (we need to discuss the child’s feelings towards the dentist)
Signs of DFA in children:
* Asking questions to time delay
* School age children-Complain of stomach aches and Ask to go to the toilet frequently
* Older children- complain of headaches/ dizziness. May fidget or stutter. “Can’t be bothered”
196
You have decided to provide a pulpotomy for tooth 11. You have anaesthetised the patient who is now comfortable.
Explain the stages of the procedure you now carry out. (8)
1. Provide LA
2. Apply rubber dam
3. Remove pulp tissue at a 2-3mm radius around the exposed area.
4. Assess bleeding; (if no bleeding or hyperaemic remove full coronal tissue)
5. Gain haemorrhage control using a saline soaked cotton wool ball.
6. Once normal bleeding has stopped - apply NS CaOH.
7. Seal in with GI
8. Restore tooth with an acid etched composite tip.
197
The patient remains asymptomatic and you are now about to take a 6 month post op radiograph of tooth 11. The pulp has remained vital- what favourable signs would you expect to see on the radiograph? (2)
Continued root development - increased length, continued thickening of dentine in the root wall
No apical pathology.
