Paediatrics Flashcards
1
Q
pharmocological types of behaviour management
A
- local anaesthetic
- pre-medication
- inhalation sedation with nitrous oxide
- intravenous sedation
- general anaesthetic - requires justification
2
Q
paeds behavoiur management
inhalation sedation
A
- nitrous oxide
- will not change a childs wish or want to avoid something
- will allow sufficient decrease in anxiety to increase relaxation and help with ability to tolerat tx
- works well combined with other non-pharmacological techniques
3
Q
paeds behavoiur management
intravenous sedation
A
- with propofol or midazolam
- good options for complex tx in anxious adolescents
- depending on maturity and size - usually over 12s
- works well with other non-pharmacological techniques
4
Q
paeds behavoiur management
levels of cooperation
A
- pre-cooperative
- children who lack cooperative ability
- potentially cooperative
- co-operative
5
Q
paeds behavoiur management
communication
A
- non verbal communication is key
- using their names and repeating can assist in developing rapport
- like to be treated as individuals
- avoid dental jargon
- lowering yourself physically
6
Q
dental axiety/fear/phobia definitions
A
- dental anxiety - reaction to unknown danger - very common when proposed tx never experienced before
- dental fear - reaction to a known denture - involves fight or flight response when confronted with threatening situaiton
- dental phobia - same as dental fear with much stronger response
7
Q
dental fear and anxiety
physiological/cognitive/behavioural reactions
A
- physiological - breathlessness, perspiration, palpations
- cognitive - decreased concentration, hypervigilance, catastrophising
- behavioural - avoidance of tx, escape from situations, aggression
8
Q
paeds behavoiur management
factors affecting anxiety
A
- previous medical/dental/social history
- parental anxiety
- parenting style
- parental presence
- child awareness of dental problem
- behaviour of dental staff
- child temperament
9
Q
paeds behavoiur management
measuring dental fear and anxiety
A
- MCDASf - modified child dental anxiety scale faces
- quick and simple
- questionare with scores 1-5 with corresponding face from least anxious to most anxious
10
Q
inappropriate paeds behavoiur management
A
- negative reinforcement - punishment or chastisement for unideal behaviours
- hand over mouth technique
- selective arental exclusion
- bribery - depends
11
Q
paeds behavoiur management
preparatory info
A
- can also help decrease parental anxiety
- welcome letters
- patient info leaflets
- videos online
- acclimatisation
12
Q
paeds behavoiur management techniques
A
- preparatory info
- voice control
- non-verbal communication
- enhanced control
- tell-show-do
- positive reinforcement
- distraction
- magic
13
Q
paeds behavoiur management
non-verbal communication
A
- happy smiling team
- eye contact
- modelling works best when a child of similar age
- gentle pats
14
Q
paeds behavoiur management
tell-show-do
A
- used to familiarise patients with new procedures
- age appropriate explanation of procedure
- demonstration of procedure
- perform procedure with minimal delay
15
Q
paeds behavoiur management
enhanced control
A
- allows pt a degree of control
- stop, go, rest signals
- this or that
- which tooth do you want to start with
16
Q
paeds behavoiur management
topical anaesthetic
A
- dont hide taste - ask pt what flavour they like and say its a but like that mixed with toothpaste
- dry mucosa, allow adequate time
- warn re temporary numbness of tongue, throat, palate
- usually 5% lidocaine or 18-20% benzocaine
17
Q
paeds non-pharmacological pain management
A
- relaxation techniques
- distraction - counting of fingers, audio and visual, pt fav music or show
- controlled language
- control parental behaviour - parent squeezing leg, high tone of voice
18
Q
paeds when to use articaine
A
- consider as alternative to lidocaine IANB/IDB
- can be considered in young patients for mandibular pulpal anaesthesia
- never use articaine as IDB
19
Q
paeds behavoiur management
chasing technique
A
- topical anaesthetic buccally
- give buccal infiltration
- allow time for papilla to become anaesthetised
- reposition needle perpendicular to papilla and inject into papilla
- check palatal/lingual side of papilla for blanchine
- inject into palatal or lingual blanched mucosa
- chase blanched mucosa until area fully anaesthetised
20
Q
paeds behavoiur management
building a tx plan
A
- stage tx gradually increasing in complexity and challenges unless pt in pain
- exam, acclimatisation, prevention etc
- fissure sealants
- restorative tx with LA upper then lower
- extractions with LA upper then lower or most painful to least painful
21
Q
types of disability
A
- physcial - spina bifida
- medical - cardiac defect
- sensory - deaf, ASD
- mental - learning impairment, AS
22
Q
sensory impairments and their communication aids
A
- visual - braille
- hearing - BSL interpreting service, hearing loops
- ASD - makaton, widget symbols
23
Q
learning disability definition
A
- a state of arrested or incomplete development of mind
- significant impairment of intellectual, adaptive and social functioning
24
Q
learning disability IQ classification
A
- mild 50-70
- moderate 35-49
- severe 20-34
- profound <20
25
autism summary
* neurodevelopmental disorder
* sprectrum disorder
* affects social interaction and communication
* limited and restricted patterns in behaviour
26
autism related conditions
* ADHD
* down syndrome
* dyslexia
* dyspraxia
* epilepsy
* GI issues
* sleep disorder
27
non-verbal communication aids for pt with autism
* makaton
* PECS
* widget symbols
28
autism dental applications
* obtain a profile of likes and dislikes from the parent or schoo;
* send out a social story explaining dental journey using PECS - picture exchange communication system
* be ready and on time
* de-clutter
* consider alternative ways to take examination
29
down syndrome dental feature
* maxillary hypoplasia
* class III occlusion
* macroglossia - enlargement of tongue
* anterior open bite
* hypodontia/microdontia
* predisposition periodontal disease
30
down syndrome associated learning/medical problems
* autism
* cardiac defect
* leukaemia
* epilepsy
* alzheimers/dementia
31
dental examination options for pt with special needs
* knee to knee
* on parents lap
* in wheelchair
* standing up
* open wide disposable mouth rest
32
recommended toothpastes for pt with special needs
* OraNurse toothpaste - contains fluoride, no foaming
* durphate 2800ppmF - for high caries children with special needs, supervised use, 10+
33
pt with special needs
conscious sedation indications
* selection criteria same as non special needs pt
* no-cooperation
* extensive tx
34
pt with special needs
conscious sedation considerations
* avoid inhalation sedation in pt undergoing bleomycin therapy (high O2) and those with musculoskeletal disorders
* joint cases
* medical preassessment
* ASA III and IV will require anaesthetist
* ^^American Society of Anesthesiology Classification A system used by anesthesiologists to stratify severity of patients' underlying disease and potential for suffering complications from general anesthesia
35
special needs pt
general anaesthetic aims
* atraumatic anaesthetic induction - eg oral midazolam
* complete comprehensive dental tx
* eliminate pain and infection
* establish basis for continued preventive care
* short, uncomplicated recovery
36
paediatric pt consent summary
* usually younger children will have consent form signed by parent(s)
* teenagers deemed "gillick" competent may sign consent form
* age 16 + can sign own form unless deemed adult with incapacity - need to ensure appropriate adult with incapacity certificate is available
37
special needs pt key legislation
* AWI sct 2000
* disability discrimination act 1995
* equality act 2010
38
aims of 2021 paeds perio guidelines
* to outline a method for screening under 18s for periodontal disease during routine clinical examination - in order to detect gingivitis or periodontitis at earliest opportunity
* to provide guidance on periodontal management and when it is appropriate to treat in practice or refer
* optimising periodontal outcomes for children and adolescents
39
mnemonic for memorising 2017 perio classification
* Please - periodontal health
* Give - gingivitis biofilm induced
* Gregv- gingivitis non-biofilm induced
* Nine- necrotising periodontal disease
* Percy - periodontitis
* Pigs - periodontitis as manifestation of systemic disease
* Straight - systemic disease affecting periodontal tissues
* Past - periodontal asbcess/perio-endo
* Meal - mucogingival conditions
* Time - traumatic occlusal forces
* Tonight- tooth and prosthesis related factors
40
describe plaque biofilm induced gingivitis
* supragingival plaque accumulates on teeth --> inflammatory cells infiltrate in gingival CT
* junctional epithelium becomes disrupted
* allows apical migration of plaque and increase in gingival sulcus depth - gingival pocket/false pocket
* no periodontal attachment loss
41
most apical extension of junctional epithelium is
* cemento-enamel junction
* CEJ
42
describe periodontitis that is currently stable
* BOP <10%
* PPD <= 4mm
* no BoP at 4mm sites
43
describe periodontitis that is currently in remission
* BOP >= 10%
* PPD <= 4mm
* no BoP at 4mm sites
44
describe periodontitis that is currently unstable
* PPD >= 5mm
* or
* PPD >= 4mm and BoP
45
periodontal health features
specific measurements
* gingival margin above CEJ - no recession
* gingival sulcus 0.5-3mm deep on fully erupted tooth
* in teenagers alveolar crest is situated 0.4-1.9mm apical to CEJ
* <10% bleeding on probing
46
periodontal health reduced periodontium situations
* non-periodontal pt - crown lengthening surgery, recession
* periodontal pt - stable periodontitis
47
non-plaque biofilm induced gingivitis causes
* manifestation of systemic conditions
* genetic/developmental disorders
* traumatic lesions
* infective
* drug induced
48
when to refer non plaque induced gingivitis
* where extent of condition is inconsistent with level of oral hygiene observed
* uneplained gingival enlargement, inflammation, bleeding, tooth mobility
49
periodontitis key features
* apical migration of junctional epithelium beyond CEJ
* loss of attatchment of periodontal tissues to cementum
* transformation of junctional epithelium to pocket epithelium - often thin and ulcerated
* alveolar bone loss
50
dynamic diagnoses of periodontitis
components
1. staging
* bone loss at worst site
* stage I, II, III, Iv
2. grading
* rate of progression - %bone loss/age
* grade A, B, C
3. current periodontal status - stable, in remission, unstable
4. risk assessment - smoking, poorly controlled diabetes
51
paeds perio reminders
* in primary dentition some evidence of bone loss can occur in some children aound primary teeth
* in mixed dentition be aware of false pocketing around erupting permanent dentition
52
gingival overgrowth related to
* systemic and metabolic diseases
* genetic factors - eg hereditary gingival fibromatosis
* local factors
* medication side effects - Ca channel blockers, cyclosporine
* greater incidence seen in puberty
* severity more intense in children than adults with similar amounts of dental plaque
53
gingival overgrowth tx
* rigorous home care
* frequent appointments for PMPR
* +/- surgery - especially with drug induced gingival overgrowth
54
periodontitis as manifestation of systemic disease - paeds
* papillon-lefevre syndrome
* neutropenias
* down syndrome
* LAD
55
simplified basic periodontal examination summary
* in all co-operative children aged 7-18 years old
* siimplified - only 6 teeth
* performed with WHO 621 probe - single black band
56
simplified basic periodontal examination method
* 20-25g force application
* probe inserted parallel to tooth and walked around gingival margin
* on index teeth 16, 11, 26, 36, 31, 46
57
simplified BPE codes
* BPE codes 0-2 ONLY for children 7-11 years old
* all BPE codes 12-17 years
* 0 = healthy
* 1 = bleeding after gentle probing, black band fully visible
* 2 = calculus or plaque retention factor, black band fully visible
* 3 = pocketing 4-5mm, black band partly visible
* 4 = pocketing >=6mm black band disappears
* * = furcation involvement
58
SDCEP plaque score for paeds summary
* assess plaque levels in sextants - worst score in each sextant recorded
* 10/10 = perfectly clean tooth
* 8/10 = line of plaque around cervical margin
* 6/10 = cervical 1/3rd of crown covered
* 4/10 = middle 1/3rd of crown covered
59
pads perio prevention
* hands on demonstration - supervised toothbrushing
* modified bass technique
* consider disclosing tablets
60
treatment and recall period for sBPE (paeds)
* 0 = no perio tx (1 year)
* 1 = OHI (1 year)
* 2 = OHI, supra/sub PMPR, remove plaque retention factors (6 months)
* 3 = OHI, PMRP in pockets, remove plaque retention factors (3 months do 6PPC in affected sextants)
* 4 or * = full 6PPC, consider referal whilst doing initial therapy (code 3) very unusual in children
61
62
Measurements in gingival health
63
trauma to permanent teeth stats
* peak period 7-10 years old
* more common with large overjet - OJ>9mm doubles incidence
* causes - falls, bikes, sport, fights
64
dental trauma
taking a detailed history
* how/when did it happen
* where are the lost teeth/fragments
* any other symptoms
* MH may influence tx options - rheumatic fever, congenital heart defects, immunosuppression
65
crown fracture examination
* EO check for - laceration, haematomas, haemorrhage, mouth opening
* IO - soft tissue, alveolar bone, occlusion, teeth
* rule out facial/jaw #
* check for penetrating wounds/foreign bodies
66
tooth mobility from trauma may indicate
* displacement of tooth
* root fracture
* bone fracture
* tactile test with probe to look for fracture lines or pulpal involvement
67
crown fracture sensibility test
* compare injured tooth with adjacent non-injured tooth
* always test adjacent and opposing teeth in addition to those obviously injured - may have recieved direct or indirect concussive injuries
* continue sensibility testing for at least 2 years after an injury
68
dental trauma
detailed intraoral exam
* sensibility test - thermal or electrical
* percussion - duller note may indicate root #
* occlusion - traumatic occlusion demands urgent tx
* radiographs - intraoral, occlusal, OPT, soft tissue
* classiy the trauma
69
classification of fractures
* enamel fracture
* enamel dentine fracture
* enamel dentine pulp fracture
* uncomplicated root crown fracture - pulp not involved
* complicated root crown fracture - pulp involved
* root fracture - apical, middle or coronal third
70
tooth fracture prognosis depends on
* stage of root development
* classification of injury
* if PDL is damaged too
* time between injury and tx
* presence of infection
71
aims and principles of tooth fracture tx - emergency tx
* retain vitality - protect any exposed dentine with adhesive dentine bandage
* treat exposed pulp tissue
* reduction and immobilisation of displaced teeth
* tetanus prophylaxis
* antibiotics?
72
aims and principles of tooth fracture tx - intermediate tx
* +/- pulp tx
* restoration - minimally invasive acid etch restoration
73
aims and principles of tooth fracture tx - permanent tx
* apexigenesis/apexification
* root filling +/- root extrusion
* gingival and alveolar collar modification if required
* coronal restoration
74
enamel # management/follow up/prognosis
* bond fragment of tooth or grind sharp edges
* take 2 periapical radiographs to rule out tooth fracture or luxation
* follow up 6-8weeks, 6 months and 1 year
* 0% risk of pulp necrosis
75
enamel dentine # management/follow up/prognosis
* either bond fragment to tooth or place composite "bandage" - line restoration if fracture close to pulp
* take 2 periapical radiographs to rule out root fracture or luxation
* radiograph any lip or cheek lacerations to rule out embedded fragment
* sensibility testing and evaluate tooth maturity
* definitive restoration
* follow up 6-8weeks, 6 months and 1 year
* 5% risk of pulp necrosis at 10 years
76
enamel / enamel dentine # follow up
* review 6-8 weeks, 6 months and at one year
* use trauma sticker for clinical review
* check radiographs for - root development, width of canal and length, internal and external inflammatory resorption and periapical pathology
77
enamel dentine pulp # management
* evaluate exposure - size of pulp exposure, time since injury, associated PDL injuries
* choose from 3 options
* 1. pulp cap
* 2. partial pulpotomy
* 3. full coronal pulpotomy
* avoid full extirpation unless tooth is clearly non-vital
78
enamel dentine pulp # management
direct pulp cap tx/follow up
* for tiny exposure 1mm within 24h window
* should be non TTP and positive to sensibility test
* trauma sticker and radiographic assessment
* LA, rubber dam
* clean area with water then disinfect area with sodium hypochlorite
* apply calcium hydroxide (dycal) or MTA white to pulp exposure
* restore tooth with quality composite restoration
* review 6-8weeks, 6 months, 1 year
79
enamel dentine pulp # management
partial pulpotomy tx/follow up
* for larger exposre >1mm or 24+ hours since trauma
* trauma sticker and radiographic assessment
* LA, dam, clean area with saline
* disinfect area with sodium hypochlorite
* remove 2mm of pulp with high speed round diamon bur
* place saline soaked CW pellet over exposure until haemostasis achieved - if no bleeding or cant arrest bleeding proceed with full coronal pulpotomy
* apply CaOH (dycal) or white MTA and then GI
* restore with composite
* follow up 6-8 weeks, 6 months and 1 year - clinical and radiographic review
80
enamel dentine pulp # management
full coronal pulpotomy tx/follow up
* begin with partial pulpotomy
* assess for haemostasis after application of saline soaked cotton wool
* if cannot stop bleeding (hyperaemic) or necrotic proceed to full coronal pulpotomy
* place calcium hydroxide in pulp chamber
* seal with GIC lining and quality coronal restoration
* follow up - 6-8weeks, 6 months and 1 year - clinical and radiographic review
81
enamel dentine pulp # management
aim of pulpotomy
* to keep vital pulp tissue within the canal
* to allow normal root growht (apexogenesis) both in legnth of root and thickness of the dentine
82
enamel dentine pulp # management
if tooth non-vital and immature apex
* full pulpectomy required
* problem - no apical stop to allow obturation with GP
* options:
1. CaOH placed in canal to induce hard tissue barrier to form (apexification)
2. MTA/biodentine placed at apex to create cement barrier
3. regenerative endodontic technique to encourage hard tissue formation at apex
83
enamel dentine pulp # management
non vital tooth with open apex tx steps
* pulpectomy
* rubber dam and access
* haemorrhage control - LA/sterile water
* diagnostic radiograph for WL
* file 2mm short of WL
* dry canal, non setting CaOH in pulp chamber plus cotton wool
* GIC temp on top
* best practice - extirpate pulp and have CaOH no longer 4-6 weeks after identified as non-vital then MTA plug and heated obturation
84
uncomplicated crown root # management
* no pulp exposure
* tx options:
* fragment removal only and restore
* fragment removal and gingivectomy - if palatal subgingival extension
* extraction
* decoronation - preserve bone for future implant
* surgical extrusion
* orthodontic extrusion of apical portion - endo, extrusion, post crown
85
complicated crown root # management
* can be temporised with composite for up to 2 weeks
* fragment removal and gingivectomy - if palatal subgingival extension
* extraction
* decoronation - preserve bone for future implant
* surgical extrusion
* orthodontic extrusion of apical portion - endo, extrusion, post crown
86
87
88
GA agents used
* desflurane
* seroflurane
* isoflurane
* often combines with nitrous oxide
89
what is MCDAS
modified child dental anxiety scale
90
range of techniques for pain control
* behavioural techniques
* local anaesthesia
* conscious sedation
* general aaesthesia
91
indications for the use of GA in children
* the child needs to be fully anaesthetised before dental tx procedures can be attempted
* the surgeon needs the child to be fully anaesthetised before dental tx can be performed
92
general considerations when discussing use of GA with child and carer
* co-operative ability of the child
* percieved anxiety and how child has responded to similar procedures
* degree of surgical trauma anticipated
* complexity of the operative procedure
* medical status of the child
93
circumstances and conditions suitable for GA
* severe pulpitis
* acute soft tissue swelling
* surgical drainage
* single or multiple extractions in a young child unstuitable for conscious sedation
* symptomatic teeth in more than one quadrant
* biopsy
* surigical extractions or exposure
* established allergy to local anaesthesia
94
circumstances and conditions which rarely justify GA and circumstances that override limitations
* carious, asymptomatic teeth with no clinical or radiographical signs of sepsis
* orthodontic extraction of sound permanent premolar teeth in a healthy child
* patient/carer preference except where other techniques have already been tried
* circumstances that override above limitations:
* physical, emotional, learning impairment
* children who have attempted tx under LA/concious sedation and unable to co-operate
* medical problems which are better controlled under use of GA
95
guidelines for the use of GA
explanation of risk
* explain GA carried out by anaesthetic consultant
* procedure will take place in operating theatre
* small but real risk of catastrophe during GA
96
guidelines for the use of GA
tx planning
* all tx required is carried out under a single GA
* radiographs required unless limited diagnostic value
* unrestorable asymptomatic teeth should be removed in addition to those causing pain or sepsis
* most predictably successful restoration provided
* further preventive advice
97
guidelines for the use of GA
consent
* obtained at the time of tx planning and updated on the day of operation
* ensure parents understand whether primary/permanent/both are in tx plan
* interpreting services must be used if parents may not understand nature of proposed tx
* explain that decision about no. fillings/X can sometimes only be made with the child fully anaesthetised
98
guidelines for the use of GA
pre-op assessment advantages
* allowing dentist sufficiet tim to explain tx required and assess parents understanding
* allowing parents and child time to consider tx and ask further Qs
99
guidelines for the use of GA
discharge
* responsibility shared between dentist, anaesthetist and recovery nursing staff
* pt and parents should recieve verbal and written POI
* advice on any expected symptoms in first 24h
* analgesics such as paracetamol recommended first 24-48 hours
* specific OHI after surgery should be given
100
guidelines for the use of GA
clinical effectiveness
* primary tooth restored under GA should be expected to exfoliate naturally without failure
* PMC are most predictable and durable restoration
* pulp therapy with caution under GA due to clinical failure rates unless contra-indications to X
101
guidelines for the use of GA
repeat GA
* undesirable in terms of morbidity, potential mortality, behavioural/emotional effects of pt and cost
* can be due to failures in tx plan or failure of preventive counselling adoption
102
safeguarding children
GDC expectations
* expects all registrants to be aware of the procedures involved in raising concerns about possible abuse or neglect
* have a responsibility to raise concerns
* know who to contact for further advice and how to refer to appropriate authority
103
what is child protection
activity undertaken to protect specific children who are suffering, or at risk of suffering, significant harm
104
GIRFEC key points
* getting it right for every child
* named person for every child as single point of contact - advise & support families and to raise and deal with concerns about a childs wellbeing
* national practice model - wellbeing wheel (SHANARRI), my world triangle, resilience matrix
* single childs plan - planning process for individual children who have wellbeing needs
105
definition of child abuse
* 3 elements must be present
* significant harm to child
* carer has some responsibility for that harm
* significant connection between carers responsibility for child and harm to child
106
CYPA
children and young persons act 1993
107
CYPA and information sharing
* information can be shared when safety is at risk
* or when benefits of sharing info outweight the public or individuals interest in keeping info confidential
* good practice to get consent where possible and safe to do so
* share what you need to and keep a note of what and why you have shared the info
108
what is UNCRC and list of rights
* the UN convention on the rights of the child
* right to respect
* right to information about yourself
* the right to be protected from harm
* the right to have a say in your life
* the right to a good start in life
* the right to be and feel secure
109
child abuse aetiology/contributing factors
* adult - drugs, alcohol, poverty, unemployment, marital stress, mental illness, isolation
* child - crying, soiling, disabililty, unwanted pregnancy, wrong gender
* community/environmental - poor housing conditions, neighbourhood
family violence and dysfunctional family - intergenerational cycle, violence towards pets, poverty
110
parenting capacity
big 3 concerns
* domestic violence
* drug and alcohol misuse
* mental health problems
* cumulative problems increase the likelihood of negative outcome
111
child abuse categories
* physical
* emotional
* neglect
* sexual
112
vulnerable children
* under 5s
* irregular attenders - repetedly DNA, return in pain, exposed to risks of GA
* medical problems and disabilities
113
dental neglect definition
* persistent failure to meet a childs basic oral health needs
* likely to result in serious impairment of a childs oral or general health and development
114
neglect of the childs needs
* nutrition
* warmth, clothing, shelter
* hygiene and health-care
* stimulation and education
* affection
115
effects of neglect
* failure to thrive/short stature
* inappropriate clothing - cold injury sun burn
* ingrained dirt in finger nails, head lice, dental caries
* developmental delay
* withdrawn or attention seeking behaviour
116
indicators of dental neglect
* irregular attendance
* repeated failed appts/late cancellations
* obvious dental disease yet child has not returned for tx
* failure to complete tx
* returning in pain at repeted intervals
* repeated GA for dental extractions
117
managing dental neglect
* guidance - cpdt.org.uk or bda.org/childprotection
* 3 stages
* preventive dental team management
* preventive multi-agency management
* child protection referral
118
managing dental neglect
stage 1
* preventive dental team management
* raise concerns with parents
* offer support
* set targets
* keep records and monitor progress
119
managing dental neglect
stage 2
* preventive multi agency management
* liase with other professionals - school nurse, GP, social worker etc to see if concerns shared
* child may be subject to common assessment framework CAF at this level
* check if child has child protection plan
* agree joint plan of action
* review at agreed intervals
* letter to healthcare visitor if child under 5 who fail appts and fail to respond to letter from GDP
120
managing dental neglect
stage 3
* child protection referral
121
physical abuse Scotland
* already illegal to hit a child with an object or to hit them anywhere on the head
* from NOV 2020 it is illegal to physically punish a child
122
physical child abuse
major clinical features
* skin lesions - bruises, burns, bites, lacerations
* bone fractures
* intracranial lesions
* visceral lesions from blunt trauma
123
physical child abuse
extraoral orofacial signs
* bruising of face
* bruising of eats
* abrasion and lacerations
* burns and bites
* neck - choke or cord marks
* eye injuries
* hair pulling
* fractures - nose > mandible > zygoma
124
physical child abuse
intraoral orofacial signs
* contusions (bruise)
* abrasions and lacerations
* burns
* tooth trauma
* frenal injuries
125
physical child abuse
index of suspicion
* delay in seeking help
* story vauge, lacking in detail
* account not compatible with injury
* parents mood abnormal or gives cause for concern
* childs appearance and interaction with parent abnormal
* history of previous injury
* history of violence within family
126
safeguarding children
how can we help
* share concerns - named person
* know where to go for help and advice
* child protection adviser
* social work/social services
* NSPCC helpline
127
safeguarding children
what happens after I refer
* if child is in immediate danger - child protection order, exclusion order, removal by police or authority of a JP
* otherwise investigation, initial assessment, discussion - decide if child at risk of significant harm
* then joint investigation (scotland) or no further CP action but may get additional support (england/wales/NI/scot)
128
dental trauma epidemiology
* male > female
* maxillary primary incisor teeth most likely affected
* peak incidence 2-4 years of age
* aetiology - falls, bumping into objects, non-accidental
129
classification of injuries
dental hard tissues and pulp
* enamel fracture - uncomplicated crown fracture
* enamel and dentine fracture - uncomplicated
* enamel, dentine and pulp fracture - complicated crown fracture
* crown-root fracture - complicated or uncomplicated
* root fracture
130
classification of injuries
supporting tissues
* concussion
* subluxation
* lateral luxation
* intrusion
* extrusion
* avulsion
* alveolar fracture
131
dental trauma
general patient management stages
1. reassurance
2. history
3. examination
4. diagnosis
5. emergency tx
6. important information
7. further tx and review
132
injury prevalence of primary dentition
* luxation most prevalent 62-69%
* avulsion and ED# 7-13%
* root #2-4%
* crown-root# 2%
133
dental trauma management
reassurance
* decrease pt and pant anxiety
* may still be in shock if injury justy occured
* stay calm
134
dental trauma management
history
* trauma history: when, where, how, any other symptoms or injuries
* MH: bleeding disorders, CVD, allergies, tetanus immunisation status
* DH: previous trauma, tx experience, legal guardian, child attitude
135
dental trauma management
trauma examination
* EO: lacerations, haematoma, mouth opening, CSF, bony step deformities
* IO: soft tissue wounds/foreign bodies, alveolar bone, occlusion, teeth
136
dental trauma management
detailed IO exam trauma stamp
* mobility
* colour
* TTP
* sinus
* percussion note
* radiograph
137
dental trauma management
special investigations
* trauma stamp
* radiographs: periapical, anterior occlusal, panoramic, soft tissue
138
dental trauma management
emergency tx primary tooth
* observation often most appropriate option
* unless risk of aspiration, ingestion or occlusal interference
* tx depends on childs maturity and ability to cope
139
dental trauma management
homecare advice
* analgesia
* soft diet for 10-14 days / normal diet with everything cut small, chew with molars
* brush with soft toothbrush after every meal
* topical chlorhexidine gluconate 0.12% mouthrinse applied topically twice daily for one week
* warn re signs of infection
140
dental trauma management
crown-root#
* remove loose fragments and determine if crown can be restored
* if restorable and no pulp exposed: cover exposed dentine with GIC
* if pulp exposed: pulpotomy or endodontic tx
* if unrestorable: extract loose fragments
141
dental trauma management
root#
* coronal fragment not displaced: no tx
* coronal fragment displaced but not excessively mobile: leave coronal fragment to spontaneously reposition
* coronal fragment displafced, excessively mobile and interfering with occlusion: A extract only loose coronal fragment, B reposition loose fragment +/- splint
142
dental trauma management
avulsion of primary teeth
* radiograph to confirm avulsion
* do not replant
143
dental trauma primary tooth management
concussion/subluxation
* no treatment
* observation
144
dental trauma primary tooth management
lateral luxation
* minimal/no occlusal interference: allow to reposition spontaneously
* severe displacement: extract or reposition +/- splint
145
dental trauma primary tooth management
extrusion
* not interfering with occlusion: spontaneous repositioning
* excessible mobility or extruded >3mm : extract
146
dental trauma primary tooth management
intrusion
* allow to spontaneously reposition
* use either periapical or lateral premaxilla (extra-oral film)
* being able to assess danger to permanent tooth allows better tx re prognosis
* if apical tip of intruded tooth can be seen and tooth appears shorter - apex displaced towards/through labial bone plate
* if apex of tooth cannot be visualised and tooth appears elongated - apex displaced towards permanent tooth germ
147
direct complications of dental trauma to primary tooth
* discolouration
* dicolouration and infection
* delayed exfoliation
148
dental trauma primary tooth management
alveolar fracture
* reposition segment
* stabilise with flexible splint to adjacent uninjured teeth for 4 weeks
* teeth may need to be extracted after alveolar stability has been achieved
149
dental trauma primary tooth
discolouration
* asymptomatic vital or non vital tooth
* mild grey - may maintain vitality#
* opaque/yellow - pulp obliteration
* if no signs of pulp necrosis or infetion - no tx
* review
150
dental trauma primary tooth
discolouration and infection
* symptomatic non vital tooth
* sinus, gingival swelling, abscess
* increased mobility
* radiographic evidence of periapical pathology
* extract or endodontic tx
151
complications of trauma in primary dentition to the permanent successor
* enamel defects
* abnormal crown/root morphology
* delayed eruption
* ectopic tooth position
* arrested development
* complete failure of tooth to form
* odontome formation
152
complications of trauma in primary dentition to the permanent successor
enamel defects
* enamel hypomineralisation - poorly mineralised, no tx or composite masking +/- localised removal or tooth whitening
* enamel hypoplasia - reduced thickness of enamel but normal mineralisation - either no tx or composite masking
153
complications of trauma in primary dentition to the permanent successor
abnormal crown/root morphology
* dilaceration - abrupt deviation of the long axis of the crown or root portion of the tooth
* crown dilaceration management options
- surgical exposure and orthodontic reallignment
- improve aesthetics restoratively
* root dilaceration/angulation/duplication - combined surgical and orthodontic approach
154
complications of trauma in primary dentition to the permanent successor
delayed eruption
* premature loss of primary tooth can delay eruption of around 1 year
* due to thickened mucosa
* radiograph if >6month delay compared to contralateral tooth
* surgical exposre and orthodontic allignment may be required
155
complications of trauma in primary dentition to the permanent successor
ectopic tooth position options
* surgical exposure and orthodontic realignment
* or
* extraction
156
complications of trauma in primary dentition to the permanent successor
arrested development
* options:
* endodontic tx
* extraction
157
complications of trauma in primary dentition to the permanent successor
complete failure of tooth formation/odontome formation
* tooth germ may sequestrate spontaneously
* or may require removal
* odontome formation requires surgical removal
158
paeds oral medicine
oro-facial soft tissue infections
* viral: primary herpes, herpangina, hand foot and mouth, varicella zosterm epstein barr virus, MMR
* bacterial: staphylococcal, streptococcal, syphylis, TB
* fungal: candida
159
paeds oral medicine
oral ulceration definition
* localised defect in surface oral mucosa
* where covering epithelium is destroyed leaving an inflamed area of exposed connective tissue
160
paeds oral medicine
oral ulceration history 10 key facts
1. onset
2. frequency
3. number
4. site
5. size
6. duration
7. exacerbating dietary factors
8. lesions in other areas
9. associated medical problems
10. tx so far: helpful/unhelpful
161
paeds oral medicine
oral ulceration causes
* infection: hand foot and mouth/herpes simplex/ herpes zoster/EBV, bacteria TB/syphylis
* immune mediated disorders: crohns, coeliac, SLE (lupus)
* inherited or acquired immunodeficiency disorders
* anaemia/leukaemia/agranulocytosis
* trauma
* vitamin deficiencies - iron, b12, foate
* recurrent apthous stomatitis
162
paeds oral medicine
recurrent apthous ulceration
appearance and pattern
* most common cause of ulceration in children
* typically round or ovoid in shape with grey or yellow base
* varying degree of perilesional erythema
* 3 patterns:
* minor <10mm
* major >10mm
* herpetiform 1-2mm
163
paeds oral medicine
recurrent apthous ulceration aetiology
* aetiology unclear
* aetiological factors:
* hereditary predisposition
* haematological and deficiency disorders
* GI disease
* minor trauma in susceptible individual
* stress
* allergic disorders
* hormonal disturbance - menstruation
164
paeds oral medicine
recurrent apthous ulceration investigations
* diet diary
* full blood count
* haematinics
* coeliac screen
165
paeds oral medicine
recurrent apthous ulceration management
* manage exacerbating factors - nutritional deficiencies/traumatic factors/avoid sharp or spicy food
* diet analysis may suggest exacerbating food groups
* low ferritin = 3 months of irom supplementation
* low folate/b12/positive coeliac screen = referral to paediatrician for further investigation
* prevention of superinfection - corsodyl 0.2% mouthwash
* protect healing ulcers - gengigel topical gel / gengigel mouthwash (hyaluronate)
* symtomatic relief - LA spray, difflam
166
paeds oral medicine
primary herpetic gingivostomatitis overview
* acute infectious disease caused by herpes simplex virus 1
* primary infection common in children - transmission by droplet formation
* 7 day incubation period
* almost 100% poupulation are carriers
* degree of immunity from circulating maternal antibodies so infection rare in first 12 months
* lasts 14 days and heals with no scarring
* remains dormant in epithelial cells and recurrent disease 50-75%
* triggered by sunlight, stress, other causes of ill health
167
paeds oral medicine
primary herpetic gingivostomatitis signs and symptoms
* fluid filled vesicles which rupture to painful ulcers on gingivae, tongue, lips, BM, PM
* severe oedematous marginal gingivitis
* fever
* headache
* malaise
* cervical lymphadenopathy
168
paeds oral medicine
primary herpetic gingivostomatitis tx
* bed rest
* soft diet/hydration
* paracetamol
* antimicrobial gel/MW
* acyclovir (antiviral med) for immunocompromised children
* most common complication is dehydration
* managed with topical acyclovir cream
169
paeds oral medicine
coxsachie A virus conditions overview
* herpangina: vesicles in tonsillar/pharyngeal region, lasts 7-10 days
* hand foot and mouth: ulceration on the gingivae/tongue/cheeks and palate, rash on hands and feet, lasts 7-10 days
170
paeds oral medicine
orofacial granulomatosis overview
* uncommon chronic inflammatory disorder
* idiopathic or associated with systemic granulomatous conditions (crohsn or sarcoidosis)
* average onset at 11 years
* males> females
* characteristic pathology is non ceacating giant cell granulomas which then results in lymphatic obstruction
* may be predictor for future chrohns disease
* A granuloma is a tiny cluster of white blood cells and other tissue
171
paeds oral medicine
orofacial granulomatosis clinical features
* same features as oral crohns
* lip swelling most common
* full thickness gingival swelling
* swelling of non labial facial tissues
* peri-oral erythema
* cobblestone appearance of buccal mucosa
* linear oral ulcreation
* angular chelitis
172
paeds oral medicine
orofacial granulomatosis diagnoses
* clinical - lip biopsy not essential
* investigations:
* measure growth - paediatric growth charts
* FBC
* haematinics
* patch testing - identify triggers
* diet diary to identify any triggers
* faecal calprotectin
* endoscopy risky in childhoos
* serum angiotensin converting enzyme raised in sarcoidosis
173
paeds oral medicine
orofacial granulomatosis management
* can be difficult
* oral hygiene support
* symptomatic relief as per oral ulceration - LA spray, difflam
* dietary exclusion
* manage nutritional deficiencies which may contribute
* topical steroids
* short courses of oral steroids
* intalesional corticosteroids
* surgical intervention
174
paeds oral medicine
solid swellings
* fibroepithelial polyp
* epulides
* congenital epulis
* HPV associated mucosal swellings
175
paeds oral medicine
solid swellings fibroepithelial polyp
* common
* firm pink lump: pedunculated (stalk) or sessile (fixed/immobile)
* mainly in cheeks along occlusal line, lips or tongue
* once established remains constant size
* thought to be initiated by minor trauma
* surgical excision is curative
176
paeds oral medicine
solid swellings - epulides
* common solid swelling of the oral mucosa
* benign hyperplastic lesions
* 3 main types:
* fibrous epulis
* pyogenic granuloma
* peripheral giant cell granuloma
177
paeds oral medicine
solid swellings - fibrous epulis
* pedunculated or sessile mass
* firm consistency
* similar colour to surrounding gingivae
* inflammatory cell infiltrate and fibrous tissue
178
paeds oral medicine
solid swellings - pyogenic granuloma
* type of epulides
* soft, deep, purple/red swelling
* often ulcerated
* haemorrhage spontaneously or with mild trauma
* vascular proliferation supported by a delicate fibrouos stroma
* probably a reaction to chronic trauma
* tend to recur after removal
179
paeds oral medicine
solid swellings - peripheral giant cell granuloma
* type of epulides
* pedunculated or sessile swelling
* typically dark red and ulcerated
* usually arises inter-proximally and has hour glass shape
* multinucleate giant cells in a vascular stroma
* may recur after surgical excision
* radiographs may reveal superficial erosion of interdental bone
180
paeds oral medicine
solid swellings - congenital epulis
* rare lesion
* occurs in neonates
* most commonly anterior maxilla
* F>M
* granular cells covered with epithelium
* benign
* simple excision curative
181
paeds oral medicine
solid swellings - HPV associated swellings
* veruuca vulgaris: may have skin wart association, solitary or multiple intr-oral lesions,caused by HPV 2 and 4, most commonly on keratinized tissue (gingivae and palate)
* squamous cell papilloma: small pedunculated cauliflower like growths, benign, HPV 6 and 11, vary in colour from pink to whitemsurgical excision tx
182
paeds oral medicine
fluid swellings
* mucoceles
* ranula
* bohns nodules
* epstein pearls
183
paeds oral medicine
fluid swellings - mucoceles
* bluish, soft, transparent cystic swelling
* cann affect minor or major salivary glands
* most = minor SG of lower lip
* most will rupture spontaneously
* surgery only if lesion fixed in size, removal or cyst and adjacent damaged minor salivary gland
* 2 variants: mucous extravasation or retention cyst
184
paeds oral medicine
fluid swellings - ranula
* mucocele in FOM
* can arise from minor salivary glands or ducts of sublingual/submandibular gland
* ultrasound or MRI needed to exclude plunging ranula (extend through FOM to submental or submandibular space)
* occasionally found to be lymphangioma - benign tumour of lymphatics
185
paeds oral medicine
fluid swellings - bohns nodules
* gingival cysts
* remnants of dental lamina
* filled with keratin
* occur on alveolar ridge
* found in neonates (1st 28 days)
* usually disappear in early months of life
186
paeds oral medicine
fluid swellings - epstein pearls
* small cystic lesions
* found along palatal midline
* thought to be trapped epithelium in palatal raphe
* in 80% neonates
* disappear in 1st few weeks
187
paeds oral medicine
TMJDS overview
* temporomandibular joint dysfunction syndrome
* most common condition affecting temporomandibular region
* characterised by pain, masticatory muscle spasm, limited jaw opening
188
paeds oral medicine
TMJDS history
* description of presenting symptoms
* when did discomfort begin
* is pain worse at any time of day
* exacerbating factors
* habits
* stress
189
paeds oral medicine
TMJDS examination
* palpation of MOM at rest and when teeth are clenched - assess tenderness and/or hypertrophy
* palpation of TMJ at rest and when opening/closing - assess tenderness and click/crepitus
* assessment of opening - any deviation of the jaw, extent of opening
* assessment of any dental wear facets
* signs of clenching/grinding: scalloped lateral tongue surface, buccal mucosa ridges
190
paeds oral medicine
TMJDS management
* symptomatic relied: ibuprofenm alternating hot and cold packs
* if measure unsuccessful referral to specialist care indicated
* reduction of exacerbating factors: stress management, avoid clenching, grinding, chewing gum, nail biting
* bite raising appliance may be considered if there is nocturnal grinding/clenching
* allow over worked muscles to rest: avoid wide opening, soft diet which requires little chewing
191
what is the name of the guidance for paeds caries management
* SDCEP
* prevention and management of dental caries in children
192
SDCEP paeds guidelines
overview (flow diagram)
* assessing the child and the family
* defining needs and developing a care plan
* if child in pain manage pain
* caries prevention
* if caries present manage caries
* recall
193
SDCEP paeds guidelines
clinical assessment overview
* assess childs plaque levels and their toothbrushing skills and discuss with child/parent
* assess dentition - visual examination for caries on clean and dry teeth
* consider taking BW to diagnose extent of any caries - assess activity of each carious lesion
* assume all lesions are active unless evidence that they are arrested
* assess risk of lesion causing pain or infection before exfoliation (primary dentition) for tx plan
* discuss findings on the clinical assessment with the child and parent
194
SDCEP paeds guidelines
classification of carious lesions in primary teeth
* categories: occlusal; proximal; anterior; special cases
* caries classified as either initial or advanced
* initial: non cavitation, white spot lesion or dentine shadow or minimal enamel cavitation, radiographically lesion confined to enamel or outer third dentine
* advanced: cavitation or dentine shadow, can have visible dentine, radiographically middle or inner third dentine
195
SDCEP paeds guidelines
classification of carious lesions in primary teeth
special cases
* pulpal involvement: clinical pulpal exposure or no clear separation between carious lesion and dental pulp radiographically
* near to exfoliation: clinically mobile and radiograph shows root resorption
* arrested caries: any tooth with arrested caries where aesthetics is not a priority
* unrestorable: crown destroyed by caries or fractures, or pulp exposed with pulp polyp (pain/infection free)
196
SDCEP paeds guidelines
classification of carious lesions in permanent teeth
* categorised into: occlusal; proximal; anterior; special cases
* either initial, moderate or extensive - anterior is initial or advanced (same as primary classification)
* initial: non cavitated, white spot lesion, stained fissures/discoloured
* moderate: enamel cavitation or dentine shadow, visible dentine, up to middle third dentine
* extensive: cavitation with visible dentine, widespread dentine shadow, inner third dentine
* special cases: pulpal involvement or unrestorable
197
SDCEP paeds guidelines
reversible pulpitis management
* restore
* or place dressing and restore later
198
SDCEP paeds guidelines
irreversible pulpitis management pre-cooperative child
* try to dress with sub-lining of corticosteroid-antibiotic paste
* prescribed pain relief
* primary - refer for tx/X with sedation or GA
* permanent - carry out RCT or X - if child remains uncooperative refer for specialist care
199
SDCEP paeds guidelines
irreversible pulpitis management in cooperatve child
* primary - carry out X or appropriate pulp therapy
* permanent - carry out RCT or X
* if multiple abscessed teeth: in primary dentition refer for X with sedation/GA and in permanent carry out RCT or X (may require specialist care)
200
SDCEP paeds guidelines
oral health promotion advice
* brush twice a day using fluoride toothpaste
* advice amount of toothpaste and fluoride conc appropriate for childs age/caries risk
* supervised brushing until child can brush effectively
* spit dont rinse
* how a healthy diet can prevent caries
* for all children place FS on permanent molars as early as possible after eruption
* for all 2+ apply FV at least 2 x year
201
SDCEP paeds guidelines
toothpaste amount
* <3 years: use a smear
* >3 years: use a pea-sized amount
202
SDCEP paeds guidelines
fluoride amount
* standard prevention: 1000-1500ppmF all ages
* enhanced prevention up to age 10: 1350-1500ppmF
* age 10+ enhanced prevention: consider 2800ppmF
203
SDCEP paeds guidelines
standard orevention for all children
* give toothbrushing advice at least onec a year
* demonstrate brushing on the child annually
* give dietary advice at least once a year
* place sealants in all pits and fissures of peranent molars as soon as possible after eruption
* check existing FS for wear and integrity at every recall visit
* top up worn or damaged sealants
* apply sodium fluoride varnish twice a year age 2+
204
SDCEP paeds guidelines
enhanced prevention for children at increased risk of caries
* at each recall visit give hand on TB instruction
* at each recall visit provide dietary advice
* recommend use of 1350-1500ppmF for up to 10 years and 2800 10+
* consider use of GI as temp sealant on partially erupted 6s and 7s until tooth fully erupted
* FS palatal pits on 12, 22 and occlusal and palatal surfaces of Ds, Es and 7s
* ensure FV applied 4 x year aged 2+
* utilise any community/home support
* in unable to provide FS then ensure FV application is optimal and attempt again if cooperation improves
205
SDCEP paeds guidelines management of caries in permanent teeth if 6s with MIH
* if not severe, not sensitive and do not require restoration - enhanced prevention (FS etc) and monitor
* if small defects that require restoration - adhesive restorative materials
* if molars sensitive use GIC as FS
206
supporting tissue injuries
* concussion
* subluxation
* lateral luxation
* intrusion
* extrusion
* avulsion
* alveolar fracture
207
supporting tissue injuries
important considerations
* impact of injury on:
* surrounding bone
* neurovascular bundle
* root surface
* nature of trauma: separation injury; crushing injury
208
supporting tissue injuries
general points
* remember history
* baseline sensibility tests
* radiographs
* post-trauma homecare instructions
209
supporting tissue injuries
concussion overview/findings/tx/follow up
* injury to tooth supporting structures without abnormal loosening or displacement of tooth
* clinical findings: pain on percussion
* tx: no tx
* follow up clinical and radiographic: 4 weeks and 1 year
210
supporting tissue injuries
subluxation overview/findings/tx/follow-up
* injury to tooth supporting structures with abnormal loosening
* but without tooth displacement
* clinical findings: tender to percussion, increased mobility, bleeding from gingival crevice may be present
* tx: normally no tx, splint if excessive mobility or tenderness when biting
* follow up clinical and radiographic: 2 weeks (including splint removal), 12 weeks, 6 months and 1 year
211
supporting tissue injuries
concussion/subluxation monitoring
* trauma stamp
* sensibility tests: thermal and electrical - false negative result is possible
* radiographs: root development, comparison with contralateral tooth, resorption
212
supporting tissue injuries
extrusion overview/findings/tx/follow-up
* tooth suffers axial displacement partially out of the socket
* findings: tooth appears elongated; usually displaced palatally; tooth mobile; bleeding from gingival sulcus
* tx: resposition under LA by pushing it back into socket; splint
* follow up: 2 weeks (inlcuding splint removal); 4 weeks; 8 weeks; 12 weeks; 6 months; 1 year
* then annually for at least 5 years
213
supporting tissue injuries
lateral luxation overview/findings
* displacement of a tooth in socket in a direction other than axially
* can be accompanied by comminution or fracture of alveolar plate
* clinical findings:
* tooth appears displaced in socket
* tooth immobile
* high ankylotic percussion tone
* may be bleeding from gingival sulcus
* root aex may be palpable in sulcus
214
supporting tissue injuries
lateral luxation tooth prognosis
1. incomplete root formation: spontaneous revascularisation may occur; if pulp becomes necrotic or sign of external resorption - endo tx
2. complete root formation: pulp will likely become necrotic; commence endodontic tx; corticosteroid-antibiotic or CaOH as intra-canal medicament to prevent development of inflammatory external resorption
215
supporting tissue injuries
lateral luxation tx and follow-up
* reposition under LA
* splint
* follow up:
* 2 weeks endo evaluation
* 4 weeks splint moval
* 8 weeks; 12 weeks; 6 months; 1 year
* annually for at least 5 years
216
supporting tissue injuries
intrusion overview/clinical findings
* tooth forced into socket in axial direction and locked into bone
* clinical findings:
* crown appears shortened
* bleeding from gingivae
* ankylotic high, metallic percussion tone
217
supporting tissue injuries
intrusion tx immature root formation
* spontaneous repositioning independent of degree or intrusion
* if no-eruption within 4 weeks - ortho repositioning
* monitor the pulp condition
* spontaneous revascularisation may occur
* if pulp becomes necrotic or infected or signs of inflammatory external resorption start endo tx ASAP when tooth position allows
218
supporting tissue injuries
intrusion tx mature root formation
* <3mm: spontaneous repositioning and if no eruption within 8 weeks reposition surgically and splint (for 4 weeks) or reposition orthodontically before ankylosis develops
* 3-7mm: reposition surgically and splint or orthodontically
* >7mm reposition surgically and spling (4 weeks)
* pulp almost always becomes necrotic
* start endo tx at 2 weeks or as soon as tooth position allows
219
supporting tissue injuries
intrusion follow up
* 2 weeks - start endo tx if tooth pos allows
* 4 weeks -splint removal
* 8 weeks; 12 weeks; 6 months; 1 year
* annually for at least 5 years
220
supporting tissue injuries
avulsion overview/critical factors
* tooth totally displaced from socket
* clinical findings: socket empty or filled with coagulum
* one of the few real emergency situations in dentistry
* critical factors:
* extra alveolar dry time EADT
* extra alveolar time EAT
* storage medium
* management factors: maturity of root, PDL cell condition
221
supporting tissue injuries
avulsion emergency adivice
1. ensure permanent tooth
2. hold by cvrown
3. encourage attempt to place immediately into socket - if dirty rinse with milk, saline or saliva
4. bite on gauze/hankerchief to hold in place
5. seek immediate dental advice
* if replantation not possible store in:
1. milk
2. HBSS (salt solution)
3. saliva
4. saline
5. water
222
supporting tissue injuries
avulsion management closed apex and tooth already replanted
* clean injured area
* verify tooth position and apical status - clinical and radiograph
* place splint
* suture gingival lacerations if present
* consider antibiotics and check tetanus status
* provide post-op instructions
* follow-up
* commence endo tx within 2 weeks using CaOH up to 1 month or carticosteroid-antibiotic paste 6 weeks
223
supporting tissue injuries
avulsion management closed apex EADT<60 mins
* PDL cells may be viable but compromised
* remove debris
* replant tooth under LA
* splint
* suture gingival lacerations if present
* consider antibiotics and check tetanus status
* POI
* follow up
* commence endo tx within 2 weeks using CaOH up to 1 month or carticosteroid-antibiotic paste 6 weeks
224
supporting tissue injuries
avulsion management closed apex EADT>60 mins
* PDL cells likely to be non-viable
* remove debris
* replant tooth under LA
* splint
* suture gingival lacerations if present
* consider antibiotics and check tetanus status
* POI
* follow up
* commence endo tx within 2 weeks using CaOH up to 1 month or carticosteroid-antibiotic paste 6 weeks
225
supporting tissue injuries
avulsion management closed apex follow-up
* 2 weeks - splint removal and have commenced endo by then
* 4 weeks; 12 weeks; 6 months; 1 year
* annually for at least 5 years
226
supporting tissue injuries
avulsion management closed apex if delayed replantatio
* poor long term prognosis - ankylosis related root resorption
* decision to replant almost always correct
* referral to paediatric specialist/inter-disciplinary management
227
supporting tissue injuries
avulsion management open apex if tooth already replanted
* clean injured area
* verify tooth position and apical status - clinical and radiographic
* place splint
* suture gingival lacerations if present
* consider antibiotics and check tetanus status
* POI
* follow up
* endo tx only if definite signs of pulp necrosis and infection of root canal system
228
supporting tissue injuries
avulsion management open apex EAT over and under 60 mins
* EAT<60 mins potential for spontaneous healing
* >60 mins PDL cells likely non viable - likely outcome is ankylosis related root resorption
* management same for both
* remove debris
* replant under LA
* splint
* suture gingival lacerations if present
* consider antibiotics and check tetanus status
* POI and follow up
* endo tx only if definite signs of pulp necrosis and infection of root canal system
229
supporting tissue injuries
avulsion management open apex goal
* revascularisation is goal
* risk of external infection-related root resorption so clone monitoring
* endodontic tx if signs of pulp necrosis and infection
* delayed replantation can result in: akylosis related root resorption
230
supporting tissue injuries
avulsion management open apex follow up
* 2 weeks - splint removal
* 1 week; 2 weeks; 12 weeks; 6 months; 1 year
* annually for at least 5 years
231
supporting tissue injuries
avulsion management
when not to replant
* medical contraindications
* child immunocompromised
* other serious injuries requiring preferential emergency tx
* potential dental contraindications: very immature apex and extended EAT, very immature lower incisorsin young child finding it difficult to cope
232
supporting tissue injuries
dento-alveolar # overview/clinical findings/tx
* fracture of alveolar bone which may ormay not include alveolar socket
* clinical findings: complete alveolar fracture extending buccal-lingual; segment mobility with several teeth moving together; occlusal disturbance; gingival laceration
* tx: reposition any segment; splint; suture gingival lacerations if present; monitor pulp condition of all teeth involved
233
supporting tissue injuries
dento-alveolar # follow-up
* monitor clinically and radiographically
* root development, canal width and length - compare with neighbouring teeth
* 4 weeks (including splint removal)
* 8 weeks, 4 months, 6 months, 1 year
* annually for at least 5 years
234
supporting tissue injuries
types of splint
* chair side: composite and wire; titanium trauma splint; orthodontic brackets and wire; acrylic
* lab made: vacuum formed splint (essex); acrylic
235
supporting tissue injuries
composite and wire splint
* stainless steel wire up to 0.4mm in diameter
* ensure passive
* flexible - include one tooth either side of traumatised tooth/teeth
236
supporting tissue injuries
titanium trauma splint
* rhomboid mesh structure
* 0.2mm thick
* secured to teeth with composite resin
237
supporting tissue injuries
dento-alveolar # advice
* soft diet for 7 days
* avoid contact sport whilst splint in lace
* careful oral hyiene
* with use of chlorhexidine gluconate mouthwash 0.12%
238
supporting tissue injuries
main post-trauma complications
1. pulp necrosis and infection
2. pulp canal obliteration
3. root resorption
4. breakdown of marginal gingiva and bone
239
supporting tissue injuries
external surface resorption
* superfician resorption lacunae - repaired with new cementum
* response to localised injury
* not progressice
240
supporting tissue injuries
external infection related root resorption
* non-vital tooth
* inidiated by PDL damage and propagated by root canal toxins reaching external root surface
* diagnosis: indistinct root surface, root canal tramlines intact
* rapid
* management: remove stimulus, endo tx
* non setting CaOH 4-6 weeks then obturate
241
supporting tissue injuries
ankylosis related root resorption
* initiated by severe damage to PDL and cemenutm
* normal repair does not occur - bone cels faster than PDL fibroblasts
* radiographically shows ragged root outline and no obvious PDL space
* tx: plan loss
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supporting tissue injuries
internal infection related root resorption
* due to progressive pulp necrosis
* radiographically shows symmetrical expansion of root canal walls (ballooning) and tramlines of root canal indistinct, root surface intact
* tx: remove stimulus, endo tx
* non setting CaOH 4-6 weeks then obturate with GP
* if progressive plan for loss
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