Paeds and Trauma

Question 1

an 8yo child attends with an enamel dentine pulp fracture. You are happy the patient is medically fit with no other injuries.

What two things do you need to know about the injury before you decide whether or not a dirct pulp cap or pulpotomy is the most appropriate treatment?

Answer 1

When did the injury occur? Even if pinpoint exposure, if it had been 24hrs plus, high chance of bacterial ingress

Size of the exposure; more than 1mm pulpotomy is best choice

Question 2

19yo patient attends on Monday morning having sustained trauma to 11, 12 on Saturday. 12 crown missing and sub alveolar fracture. 11 pulpal exposure of 2mm. Both teeth sensitive. Four steps in management of 11?

Answer 2

*Locate the missing fragment of tooth
*Give LA and apply rubber dam
*Pulpotomy; Access pulp chamber, remove coronal pulp, achieve haemostasis with CWP and water/ferric sulphate, place CaOH, seal with GIC, composite bandage
*If unable to achieve haemostasis, pulpectomy.

Question 3

19yo patient attends on Monday morning having sustained trauma to 11, 12 on Saturday. 12 crown missing and sub alveolar fracture. 11 pulpal exposure of 2mm. Both teeth sensitive.
Why would a subalveolar fracture 12 deem the tooth unrestorable?

Answer 3

*Lack of coronal tissue to bond to/support/retain restoration.
*Inability to achieve moisture control
*Inability to take impression for indirect restoration.
*Hard to establish marginal integrity/difficulty cleaning

Question 4

Explain the stages of a pulpotomy for tooth 11

Answer 4

* Apply dental dam

* Remove pulp tissue at 2-3mm radius around the exposed area

* Assess bleeding - if no bleeding, remove more tissue

* Gain heamorrhage control using CWP and saline (NOT ferric sulphate in a permanent tooth as it stains!)

* If hyperaemic, remove more tissue

* Once normal bleeding has stopped, apply non setting calcium hydroxide

* Seal with GI

* Restore with composite restoration

Question 5

Following a pulpotomy, the patient remains asymptomatic and you are now about to take a 6 month post op radiograph. The pulp has remained vital, what favourable sighs would you expect to see on the radiograph?

Answer 5

* Continued root development

* Continued thickening of dentine in the root walls

* No signs of pathology

Question 6

Name 4 fluoride supplements and their doses you would give a patient to prevent decalcification

Answer 6

Toothpaste 1450ppmF 2 x daily

Fluoride varnish 22,600ppmF 4 x yearly

Mouthwash 450ppmF 1 x daily

Fluoride tablets, 1mg 1 x daily

Question 7

Name two methods of preventing decalcifications besides fluoride

Answer 7

OH and diet advice

Fissure sealants

Question 8

5yo Jodie has been brought in by her mothers boyfriend. She has not been sleeping due to pain. Has never been to dentist before. Facial swelling. Boyfriend vague about MH.

What should you establish prior to examination?

Answer 8

Severity of condition. Thorough MH. Consent - record everything that is said and carried out in notes

Question 9

5yo Jodie has been brought in by her mothers boyfriend. She has not been sleeping due to pain. Has never been to dentist before. Facial swelling. Boyfriend vague about MH.

Describe in detail one behavioural management technique to get cooperation

Answer 9

Tell. Show. Do

Explain to Jodie what she can expect. Show her the instruments, 3 in 1, medicaments you plan to use. Demonstrate carrying out exam/treatment, get Jodie to help hold mirror etc

Question 10

5yo Jodie has been brought in by her mothers boyfriend. She has not been sleeping due to pain. Has never been to dentist before. Facial swelling. Boyfriend vague about MH.

Jodie has been uncooperative, what would short term management be?

Answer 10

Drainage

Pain reliefe

ABs (amoxicillin 500mg 3 x daily 5 days)

Tell parent she must be brought back

Question 11

5 year old child brought to practice with pain and swelling by mums bf. Has never attended dentist before. How would you address previous non attendance?

Answer 11

Ensure up to date contact details

Take accurate and detailed notes

Contact mum by phone (or other guardians)

Discuss with mother the necessity of child attending appts

Inform mum of possibility of child protection involvement if non compliant

Set appt over the phone and arrange appropriate escort

Question 12

What evidence based brushing advice would you give for a 5yo to prevent caries?

Answer 12

Brush 2 x daily with fluoried TP 1450ppm

Modified bass technique

Brush 2-5 minutes

Use a pea sized amount of toothpaste

Spit dont rinse

Question 13

What does a BPE score of 3 indicate?

Answer 13

Probing depth of 3.5-5.5mm

Question 14

What teeth should be probed to obtain a BPE score in a 13yo?

Answer 14

Modified BPE until 17yo. Ramjfords teeth. 16, 11, 24, 36, 31, 44

Question 15

What is the normal depth from CEJ to crestal bone?

Answer 15

2mm

Question 16

13yo presents with BPE scores of 3, what medical condition may they have?

Answer 16

Diabetes

Question 17

13yo patient presents with BPE scores of 3. No relavent MH, what could be the cause?

Answer 17

Aggressive periodontitis

Question 18

13yo patient presents with BPE scores of 3s from modified BPE score. What other investigations would you want?

Answer 18

PGI.

6PPC

Radiographs

Diet diary

Question 19

13 yo patient presents with BPE scores of 3s. What is your treatment plan?

Answer 19

Initial non surgical debridement and HPT. Refer to a specialist

Question 20

A patient has fractured 11. What two questions would you want to ask about the traumatised tooth?

Answer 20

When and how did it happen? Can you account for lost fragments?

Question 21

List four things that determine the prognosis of a traumatised tooth.

Answer 21

Type of fracture (complicated/not complicated)

Maturity of tooth

Open or closed apex

Tooth mobility

Vitality of the pulp

Question 22

Following a traumatic tooth injury in a child, what should be discussed with the parents?

Answer 22

Inform them of complications; change in colour, loss of vitality, pain, sinus, infection, damage to adjacent teeth. Inform them of prognosis and treatment options

Question 23

How would you treat and enamel dentine fracture?

Answer 23

Indirect pulp cap, GI or composite restoration

Question 24

Patients parents complain about white/yellow/brown staining on teeth. What 8 questions would you want to ask patients mum?

Answer 24

Pregnancy; any illness, difficulties? Anaemia, gestational diabetes?

Perinatal; normal delivery? Complications? Preterm birth?

Postnatal; prolonged BF, medications, fevers.

Childhood infections; chickenpox, measles, rubella

Question 25

Patients parents complaining of white/yellow/brown spots on childs teeth. List 5 questions to rule out fluorosis.

Answer 25

Excessive use of fluoride toothpaste? Flouride supplements? Fluoridated water? Sibling/parent using high F toothpaste OH regimen

Question 26

List 3 potential future problems due to MIH

Answer 26

Caries susceptibility Difficulty restoring; poor bonding Poor long term prognosis Potential requirement for more complex/extensive/expensive treatment Orthodontic problems

Question 27

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.

Answer 27

History - Full history, Assess if pain/history of pain, Ask the patient about their ortho concerns Caries risk assessment - diet, fluoride exposure, socio-economic, oral hygiene, medication, saliva quality, MH OPT & bitewings - other caries risk, Clinical examination, Special tests: vitality testing, Deal with pain first, Dealing with the caries in the 6’s, GA, sedation, LA (risks, benefits, alternatives), Review developing dentition Prevention regime - 4x fluoride varnish a year, duraphat 2800ppm, OHI, fissure sealants, sugar free medicines Tell the patient and the parents that ortho treatment is not appropriate at the moment Why the patient wants ortho (parent/patient), Inform the patient of the risks, That this could be changed in the future with appropriate oral hygiene care. Ensure that the patient knows that this can be changed, Assess child protection/patient neglect

Question 28

Describe the risk-benefit discussion you would have with the patient and parent regarding ortho treatment with 6s of poor prognosis

Answer 28

Risks of ortho - Root resorption, Relapse, Decalcification, Gingival recession, Other: wear, gingival ulceration, non-completion Risks of extracting 6’s - Mesial tipping of 7’s, Distal migration of 5’s, Extracting at the right time - Bifurcations of the 7’s, 8’s are present Risks of GA - Nausea, drowsiness, vomiting, Slow recovery, Death, Permanent brain injury, Malignant hyperpyrexia

Question 29

7yo with impacted upper 6s, crowded upper 2s. Give 5 possible Tx options for 6s

Answer 29

\* Leave and monitor \* Surgical extraction \* Coronectomy \* ABs and analgesics \* Operculotomy \* XLA Es \* Remove distal aspect of Es \* Ortho appliance to bring 6s into arch \* Ortho seperators

Question 30

What features of the permanent dentition allow for the replacement of primary teeth without crowding?

Answer 30

Growth of maxilla Proclination of permanent teeth Extension of dental arch Presence of space between primary teeth (primate space)

Question 31

What is leeway space and how does it prevent crowding?

Question 32

10yo extrudes 11. What materials/splint would you use? How long would you splint for?

Answer 32

Flexible ss wire splint for 2 weeks Flexible ss wire Acid etch 37% Composite resin Water

Question 33

What 4 tests would you do at a check up following trauma besides a radidograph?

Answer 33

EPT Ethyl chloride TTP Mobility Check for displacement Check for colour change Check for sinus

Question 34

What advice should be given over the phone following avulsion of a permanent incisor?

Answer 34

Reassure the patient Do not handle tooth by the root Do not reimplant if it is a primary tooth Gently rinse under slow running cold water for 10 seconds Reimplant ASAP or store in saliva, milk, saline Come to GDP ASAP

Question 35

Pt attends following trauma. What should you check upon arrival?

Answer 35

How and where did the incident occur? Was consciousness lost? Was there any nausea/vomitting? If yes - A&E! Account for all tooth fragments Check tetanus status

Question 36

What type of splint is advised following avulsion?

Answer 36

EADT \<60mins flexible splint for 2 weeks EADT \>60mins flexible splint for 4 weeks

Question 37

What are some common outcomes following avulsion of a permanent incisor?

Answer 37

Discolouration Mobility Necrosis of the pulp Ankylosis Root resorption

Question 38

What are the clinical signs of osteogenisis imperfecta and dentinogenesis imperfecta?

Answer 38

OI Blue sclera, frequent/multiple fractures DI Loss of enamel. Discolouration. Affects both dentitions. Amber appearance of affected teeth

Question 39

What are the radiographic signs of dentinogenesis imperfecta?

Answer 39

Occult abcsess Bulbos crowns Short and thin roots Teeth erupt with large pulp chambers but obliterated soon after

Question 40

What is the clinical management of dentinogenesis imperfecta?

Answer 40

Prevention Composite veneers Over denture RPD SSC

Question 41

What are the two modes of action of SDF?

Answer 41

1. Promotes arrest and remineralisation of active carious lesions, dentinal caries and teeth with exposed root surfaces causing hypersensitivity. 2. Promotes reduced sensitivity in permanent molar teeth with MIH via occlusion of dentinal tubules.

Question 42

What is the patient selection criteria for SDF?

Answer 42

1. Pericooperative children whose behaviour/medical conditions limit invasive treatment. 2. Need to delay treatment with sedation/GA 3. High caries risk with compromised MH 4. Part of biological caries management plan where carious lesions are also brushed twice daily and diet modifications have been made.

Question 43

What are the contraindications for SDF?

Answer 43

1. Signs/symptoms of pulpal involvement. 2. Radiographic peri-radicular radiolucency 3. Infection/pain from pulpal origin 4. Active ulceration 5. Pregnant/breastfeeding 6. Undergoing thyroid treatment. 7. Non compliance with TB/diet

Question 44

What is SDF?

Answer 44

Silver diamine fluoride. A colourless, odourless solution of silver, fluoride and ammonium ions.

Question 45

What is the concentration of SDF?

Answer 45

38%, 44,800 ppm fluoride ions

Question 46

Give 4 extra oral features of Downs syndrome

Answer 46

Round skull Atlanto-axial instability Oblique palperal fissures Brushfield spots Cataracts Thick fissured dry lips Small midface Thick neck Obesity MH - CLP, CVD, epilepsy, hearing problems

Question 47

Give 4 intra oral features of Downs syndrome

Answer 47

Large fissured tongue/macroglossia Maxillery hyperplasia High arched palate AOB Class III skeletal base CLP Hypodontia Microdontia Increased perio disease due to immunocompromised Spacing

Question 48

Following a root fracture, what types of healing can occur

Answer 48

Calcified tissue union accross fracture line Connective tissue healing Calcified tissue and connective tissue healing

Question 49

Following a root fracture, what is considered non healing?

Answer 49

Granulation tissue

Question 50

How are root fractures managed?

Answer 50

If undisplaced and no mobility - soft diet and monitor If displaced and mobile - reposition under LA and splint

Question 51

How would you manage a patient with a root fracture that has lost vitality?

Answer 51

RCT to fracture line (ns CaOH then MTA or extract

Question 52

What are some signs of fluorosis?

Answer 52

Varies with severity; symmetrical white spots/flecks, brown spots, mottling, pitting Occlusal surfaces of 6s unaffected

Question 53

How can fluorosis be managed?

Answer 53

Accept Microabraision Composite veneers Porcelain veneers (over 18) Bleaching however this may also affect white spots making them more obvious

Question 54

What are the advantages of non vital bleaching?

Answer 54

Easy Conservative Safe No lab involvement

Question 55

What are the disadvantages of non vital bleaching?

Answer 55

External cervical resorption Relapse May fail Over bleaching Crown brittleness

Question 56

Briefly describe the walking bleach technique

Answer 56

Take pretreatment shade Take clinical photo Take radiograph to asses RCT Dental dam Access and remove GP below gingival margin Ensure good coronal seal 10% carbamide peroxide bleach on CWP Cover with dry CWP and seal with GIC Renew every 2 weeks up to 10 times until happy with result/shade Then place temp ns CaOH for 2 weeks to reverse acidity Definitive restoration

Question 57

What is the only splint used for primary teeth?

Answer 57

Flexible for 4 weeks for alveolar bone fracture

Question 58

What is the difference between a flexible and rigid splint?

Answer 58

Flexible 1 tooth either side of trauma Rigid 2 teeth either side of trauma