Paeds Op tech revision Flashcards
(89 cards)
1
Q
goal for child’s oral health
A
reach adulthood with intact permanent dentition
2
Q
operative differences between children & adults
A
- maturity/behaviour
- Constant change - mouth size etc
- Developing dentition
- Operator access - little mouths
- Tooth size & shape
- Preventive care
- Choice of restoration
3
Q
example questions for taking a pain history from a child
A
- Where is the pain
- What does the tooth feel like
- Does anything make it better or worse
- How long has it be painful for
- Kept awake/off school
- Relieved with analgesics/antibiotics - calpol
4
Q
paediatric sequence of treatment planning & restorations
A
- Prevention
- Fissure sealants
- Preventive restorations
- Simple fillings eg. shallow cervical cavities
- Fillings requiring LA but not into pulp (in co-operative children)
- Pulpotomies (upper arch first)
5
Q
when to use LA on children?
A
- Minimal cavities With hand excavation or limited caries removal with slow speed may not require LA
All others DO need LA
-Use Topical!!
6
Q
when do you not use LA on paediatric restorations?
A
Minimal cavities With hand excavation or limited caries removal with slow speed may not require LA
7
Q
what LAs should be used on children?
A
topical
Lignocaine max dose is 4.4mg/kg. (A 10th of a cartridge per kg). A 2.2ml cartridge of 2% lignocaine has 44 mg of active agent.
- Max number of cartridges for 20kg 3-5 y/o =
- Limit for 20 kg child is 88 mg = 2 cartridges
Prilocaine 3% (with Felypressin) max dose is 6 mg/kg. (Just less than a 10th of a cartridge per kg). A 2.2ml cartridge has 66 mg.
- Max number of cartridges for 20kg 3-5 y/o =
- Limit for 20 kg child is 120 mg = 1.8 cartridges
8
Q
what is lignocaine max dose?
A
4.4mg/kg
9
Q
what is prilocaine max dose?
A
6mg/kg
10
Q
occlusal cavity design in primary molars
A
no greater than 1.5 mm deep and must include all pits and fissures
- but preserve transverse ridges unless undermined by caries
In upper 5’s - banana shape (distal) and kidney bean (mesial)
In lower 4’s and 5’s = straightened out S
11
Q
upper 5s occlusal cavity shape
A
banana shape (distal) and kidney bean (mesial)
12
Q
lower 4s and 5s occlusal cavity shape
A
straightened out S
13
Q
cavity design for interproximal cavity in primary molars
A
- Isthmus should be ½ to ⅓ of the width of the occlusal surface
- Axial wall follows contour of tooth
- Rounded line angles
- Marginal ridge almost removed - then sink the box an create an axial wall and a gingival floor
14
Q
what is box prep?
A
- Axial walls follow contour of the tooth
- Rounded line angles
- No occlusal extension
15
Q
what burs should be used in primary molar cavity prep?
A
- Occlusal - round bur for plunge cut or/then fissure bur
- Interproximal - fissure bur
- Box - fissure bur
16
Q
7 restorative materials used in paeds
A
- Fissure sealants
- Temporary & intermediate dressings (e.g. ZOE)
- Glass ionomer
- RMGI
- Compomer (cross between composite and GI)
- Composite
- Preformed metal crowns - best material for primary molars
17
Q
what 3 factors help determine restorative material and LA usage in children?
A
- Caries extent
- Longevity of tooth
- Co-operation of child
18
Q
advantage of preformed metal crowns
A
have lower replacement and failure rate than amalgam restorations
19
Q
amalgam Vs compomer Vs GIC
A
amalgam and compomer have similar failure rates over 3 years
amalgam and compomer last longer than GIC
20
Q
which is more successful RMGIC or GIC?
A
RMGIC
21
Q
the Hall technique
A
a novel method of managing carious primary molars by cementing preformed metal crowns (also known as stainless steel crowns) over them without local anaesthesia, caries removal or tooth preparation of any kind.
22
Q
how do you treat cervical caries in children?
A
- hand excavate caries or use a slow speed handpiece with a round bur
- wash & isolate (preferably with rubber dam)
- either glass ionomer cement covered with vaseline or compomer
23
Q
how do you treat inter-proximal caries in children?
A
- hand excavate or use a slow-speed round bur
- wash & isolate (preferably with rubber dam)
- place an acetate strip into interproximal area and restore with compomer / composite (strip crown)
24
Q
what are some key instruments in paeds op tech?
A
- Tapered diamond separating bur
- Preformed metal crowns
- GI luting cement
- Crown crimping pliers
- Curved crown scissors
25
how to select crown to use?
- Measure mesio-distal width of crown or space with dividers
- Trial and errors
- Impression and crown prep on model
26
how to carry out marginal ridge reduction?
- Start from occlusal portion of marginal ridge
- Break contact area and produce knife edge finish mesially and distally
- ensure no ledges as they will prevent crown from seating
27
how much should the occlusal surface be reduced by (if needed)?
1-2mm
28
should the buccal and lingual surfaces be reduced?
only to remove any sharp angles caused by occlusal or interproximal caries
29
how should the crown fit?
snap fit
number towards the buccal
30
3 potential problems when placing crown in child
- rocking
- canting to one side
- loss of space (extensive caries)
31
what is rocking due to crown?
- Cervical margin > 1 mm beyond max curvature
- Difficult to contour margins sufficiently to contact tooth throughout
- Open margins and an unstable crown will result
SOLUTION = adjust tooth prep
32
what is canting to one side due to crown placement?
- Uneven reduction of occlusal surface
SOLUTION = round occluso-buccal line angle
33
what is ideal situation to reduced loss of space in crown placement?
rectangular shape and not square shape
34
5 things to remember for of the Hall technique
- Separators can be used if contact areas are a problem
- Use GIC
- Ideally fit should be subgingival or at least below the margins of any cavitation
(Gingiva may blanche but will turn back to normal)
- There should be NO clinical or radiographic signs of pulpal involvement
- Tooth should have sufficient sound tissue left to retain the crown
35
what are Separators used in the Hall technique?
- Two lengths of dental floss should be threaded through the separator.
- Stretch tight and “floss” through contact point.
- See patient 3-5 days later for removal of separator (if not already fallen out).
36
the Hall technique Procedure
- Dry the crown
- Fill crown with GILC - ensure crown is well filled and there are no air bubbles
- Place crown over tooth and partially seat until crown engages with the contact points
- Remove the finger and encourage child to bite into place or fully seat crown with firm finger pressure alone
- Extruded cement will need to be removed from margins asap
- Ask child to bite firmly on the crown for 2-3 mins
(Prevent crown from springing back a short way and sucking back the cement from the cement from the margins and potentially reducing effective seal)
reassure child and parent
37
why might the child and parent need reassured after crown placement in the Hall technique?
- Preformed metal Crown is supposed to be tight and gum will adjust
- Child will get used to the feeling in 24hrs
- Occlusion tends to adjust to give even contacts bilaterally within a few weeks
38
minor failures which can occur in paeds op tech
- new/secondary caries
- filling/crown worn, lost or requiring other intervention
- restoration lost but tooth restorable
- reversible pulpitis treated without requiring pulpotomy or extraction
39
major failures which can occur in paeds op tech?
- irreversible pulpitis
- abscess requiring pulpotomy or extraction
- interradicular radiolucency
- filling lost and tooth unrestorable
40
what do space maintainers do?
maintain the space for permanent teeth
41
disadvantages of unplanned primary tooth extractions
- Loss of space causing increased risk of malocclusion (A malocclusion is a misalignment or incorrect relation between the teeth of the two dental arches when they approach each other as the jaws close.)
- Decreasing masticatory function
- Impeded speech development
- Psychological disturbance
- Trauma from anaesthesia/surgery
42
indications in children for pulp treatment
- Good cooperation
- Medical history precludes extraction
- Missing permanent successor
- Overriding necessity to preserve the tooth (Space maintainer)
- Child under 9 years of age - no point as adult teeth will be in soon
43
contra-indications against for pulp treatment
- Poor cooperation
- Poor dental attendance
- Cardiac defect
- Multiple grossly carious teeth - will fail
- Advanced tooth resorption
- severe/recurrent pain or infection
44
pulp capping on vital tooth success rate
poor
45
pulpotomy on vital tooth success rate
85-100% over 3-5 years
46
pulpectomy on non-vital tooth success rate
90%
47
pulpotomy is needed when there is a....
carious or traumatic exposure of pulp
48
what does pulpotomy do?
the radicular pulp is preserved and the bleeding controlled
49
what must you use when carrying out a pulpotomy?
- rubber dam
| - LA
50
process of pulpotomy
- remove caries prior to access
- remove entire roof of pulp chamber
- remove coronal pulp with sterile excavator or slow speed large round steel bur
- place cotton pledget with ferric sulphate for 20 secs (to reduce bleeding)
- place ZOE in the pulp chamber and restore using a preformed metal crown
Access, Amputation, pulp stump evaluation, restoration
51
what does normal bleeding indicate?
non-inflammed pulp
- bright red
good haemostasis
52
what does abnormal bleeding indicate?
inflamed pulp
- deep crimson
continued bleeding after pressure
53
when would you carry out a pulpectomy?
non-vital or hyperaemic pulp
| irreversible pulpitis
54
signs and symptoms indicating requires a pulpectomy
- bleeding
- pulp necrosis & furcation involvement
- irreversible pulpitis
- Periapical periodontitis
- Chronic sinus
NOTE : severe infection with facial swelling = extraction
55
what is the aim of a primary molar pulpectomy?
prevent/control infection by extirpation (removal) of radicular pulp followed by cleaning and obturation (blocking) of canals
56
what is the patient indications needed for a primary molar pulpectomy?
excellent patient co-op
57
what do you need to work out prior to carrying out a pulpectomy?
Estimated working length (EWL) -would usually do radiographically
- Take 2 mm off as to not go straight through apex
58
procedure for a primary molar pulpectomy
- open roof of pulp chamber
- remove contents of pulp chamber
- use files to remove pulpal tissue from canals to 2mm short of EWL
- Irrigate with chlorhexidine and dry with paper points
- obturate canals with Vitapex® which is a - seal with thick mix of ZOE/GI and restore with a preformed metal crown.
- Post treatment radiograph in clinical setting.
59
potential complications of a primary molar pulpectomy
- Early resorption leading to early exfoliation
| - Over preparation
60
what are the follow ups required for a pulpotomy and pulpectomy?
Clinical -R/V 6 monthly
- Failures (Pathological mobility; fistula/chronic sinus; Pain)
Radiographic - R/V 12 - 18 monthly
Failures (Increased radiolucency; external/internal resorption; Furcation bone loss)
61
what percentage of children suffer trauma to their teeth and why?
- At age of learning to walk
| - Between 8-12 - most active - sports etc
62
how to manage a fractured incisor? (3)
```
Enamel fracture (E#)
- Selective grinding, acid etched tip (AET)
```
Enamel and dentine (ED#)
- AET, reattach crown fragment
```
Pulpal exposure (EDP#)
- Pulp capping, pulpotomy - partial/total, pulpectomy
```
63
what needs to happen if there is a crown fracture?
first aid/emergency treatment
- History
- Examination
- Cover over exposed dentine (compomer or composite ‘bandage’) - what we did in practical
- DEFINITIVE WOULD BE ACID-ETCH COMPOSITE TIP
64
what is the prognosis process for a pulpal exposure in children?
- Associated PDL injury
- Extent of exposed dentine
- Age of patient (Open apex = under 10 - better blood supply; Closed apex = over 10)
* when there is no luxation (displacement) the prognosis is better*
- Bacterial ingress causes pulp death
65
2 treatment options for vital immature (open apex) tooth with pulp exposed
Pulp cap = small exposure, less than 24hrs
- Apply Ca(OH)2 direct to exposure site
Pulpotomy = larger exposure, more than 24hrs
- Maintains the vitality of the remaining
- Root formation can continue
66
4 treatment options for non-vital immature pulp exposed tooth
Pulpectomy
- remove all necrotic pulp
Apical barrier formation
- Mineral trioxide aggregate (MTA) used to provide apical barrier against which to condense root canal filling (gutta percha)
Apexification
- Calcium hydroxide placed in root canal to induce apical barrier
- Average time 9 months (checked every 3 months)
- Outdated
MTA
- 5 mm of MTA should be placed at the apical end of the root
- Placement can be aided by use of microscope
- Placement is carried out by using obtura probes, disposable MTA carriers or experimentally using a venflon
- wait at least 24 hrs to harden the obturate with a heated GP (gutta percha) system
67
3 treatment options for mature tooth (closed apex) with pulp exposed
Pulp-cap
- Small exposure, less than 24 hrs old
Pulpotomy
- Large exposure, >24 hrs old, necrotic pulp
Pulpectomy
- Large exposure, >24 hrs old, necrotic pulp
- Then do conventional RCT
68
what are the uses of calcium hydroxide?
- Used to induce a calcific barrier following pulpotomy procedures
- Induces barrier formation at apex of non-vital immature permanent incisors (apexification)
- Useful for decreasing microbial load in non-vital mature permanent teeth
- Use not being advocated to 4-6 weeks due to the fact that it makes dentine brittle
69
2 ways to manage an avulsed tooth
- first aid
| - splinting
70
first aid management of an avulsed tooth
- Maybe by teachers, youth group leaders etc
- Place tooth back in place (clean if needed under cold water for no more than 10 seconds) and get child to bite on a bit of tissue - go to dentist straight away
- If not comfortable with that
- Store in cold milk or saliva - go to dentist straight away
DO NOT HANDLE BY THE ROOT
71
splinting management of an avulsed tooth
Flexible 2 weeks
- avulsions
Flexible 4 weeks
- luxations (moved tooth but still in socket)
- Apical and middle 3rd root fractures (up to 4 months)
Rigid 4 weeks
- Dento-alveolar fractures
Composite & wire work best
Can use also
- Acrylic & wire (Bulky)
- Vacuum formed splints
- “Gumshield’ splints
- Ortho brackets and wire (must be passive, if
72
when flexible 2 week splint with a single tooth lost how many teeth are required?
One tooth - must have a tooth at either side (Therefore 3 TEETH TOTAL)
73
when flexible 2 week splint with a two tooth lost how many teeth are required?
two teeth - must have a tooth either side of splinted (therefore 4 TEETH TOTAL
74
spinting process
- Cut and bend 0.6mm (thickness) stainless steel wire.
- Apply composite resin to traumatised tooth and those adjacent.
- Sink the contoured, passive wire into the composite.
- Shape and cure composite.
- Smooth rough composite and wire ends.
75
fissure sealant is
A protective plastic coating used to seal fissures and pits to prevent food and bacteria getting caught in them and causing decay
76
fissures are prone to decay because
- Less protected by fluoride than interproximal or smooth surfaces
- Not possible to clean the base of fissures with a toothbrush
77
what materials are mainly used in fissure seals?
- Mostly bis-GMA resin applied following acid etch of the fissure pattern
Occasionally GIC
78
indications for a fissure sealant placement
- Children deemed at being high risk of caries should have their permanent molars and premolars sealed on eruption
- Medically compromised children, learning difficulties or physically/mentally handicapped
- Recent SIGN 138 - all first perm molars in children
79
what factors contribute to tooth selection in fissure sealant placement?
Greatest benefit on occlusal surfaces on permanent molar teeth
Should also seal cingulum pits of upper incisors, buccal pits of lower molars and palatal pits of upper molars
Sealing of primary molars may be advised in high risk children
- A child with caries in one first perm molar should have the other 3 sealed immediately
Occlusal caries in First Permant Molar’s (6) indicates that second permanent molars must be seals on eruption
80
fissure sealant procedure
Isolation - single tooth dental dam
- Can use dry guards or cotton wool
Have nurse help with retraction and aspiration
Work with efficient speed to decrease risk of moisture breach
Etch enamel and wash after 20 seconds
- Check enamel chalky
- Any etched enamel not covered with sealant will remineralise in 24 hrs
Add the resin to the depths of the dry fissure pattern (micro brush)
Ensure that material is in base of fissure.
Avoid overfilling as will decrease long term retention.
Excess can be removed with a dry microbrush.
- Should be “spidery” and not “swimming pools”!
Light cure
81
what and how to check after fissure sealant placement?
Used sharp probe and attempt to dislodge
- Check for air blows
- Check no material has flown interproximally - is so remove with floss or probe
- Check there is no excess material distal to the tooth in soft tissues
82
when and how to review fissure seals?
Review every 4-6 months
Review radiographically as per the patients caries risk assessment. (High risk every 6 months, low risk every 12-18 months)
83
indications for GI fissure sealant
Where good moisture control can’t be achieved
- High risk children with partially erupted molars
- Special needs children
- Poorly cooperating children
Where there is a high degree of sensitivity due to developmental or hereditary enamel defects (amelogenesis imperfecta)
- Useful as fluoride releasing but poorly retained and regular reapplication
84
procedure for placing a GI fissure sealant
- Attempt to dry tooth with air or cotton wool.
- Apply GI from applicator.
- Smooth into fissures using gloved finger or thumb.
- Keep finger over GI until set or place vaseline to decrease moisture contamination until set.
85
stained fissures defintion
A fissure that is discoloured, brown or black. Also included are fissures where there is an area of white or opaque enamel i.e. its normal translucency is lost but it has no evidence of surface breakdown (cavitation).
86
how to diagnosis of a stained fissure
- Visual (dry tooth)
- probe/explorer
- Bitewing radiographs
- Electronic
- Fibre optic transillumination
- CO2 laser
- Air abrasion
GREATER ACCURACY WHEN 2 OR 3 METHODS ARE USED TOGETHER
87
treatment of a stained fissure
- If investigation reveals that caries does not enter the dentine, provide a fissure sealant and monitor.
- In some cases where diagnosis is inconclusive it is prudent to clean the stained fissure with a small slow speed bur- if only hard material is encountered then fissure seal.
When diagnostic methods have established that a stained fissure is a carious lesion into dentine, restorative treatment is indicated.
- If the lesion remains small a preventive resin restoration (PRR) or sealant restoration (SR) can be provided- this is where the defect is filled with a small amount of composite then sealed over the top with a fissure sealant.
- If the defect is found to be large then a conventional composite or amalgam restoration will be required.
88
how to treat a carious stained fissure
When diagnostic methods have established that a stained fissure is a carious lesion into dentine, restorative treatment is indicated.
- If the lesion remains small a preventive resin restoration (PRR) or sealant restoration (SR) can be provided- this is where the defect is filled with a small amount of composite then sealed over the top with a fissure sealant.
- If the defect is found to be large then a conventional composite or amalgam restoration will be required.
89
management of virgin caries in first permeant molars
- Maximise prevention
- Always prioritise FPM’s in any mixed dentition treatment plan (i.e. restore 6’s prior to dealing with lesions in primary molars)
- Caries most commonly affects the pits and fissures of the FPM’s but may also develop interproximally below the contact point
- When caries in the FPM’s is extensive always consider the long term prognosis
- Remember that the pulp is much more likely to be exposed on caries removal due to its size (may wish to consider stepwise caries removal in order to induce calcific barrier formation over the pulp)
