Paeds/Ortho Flashcards

Question

process and risks for GA referral

Answer 1

DWP and paretn of GA risks/benefits and all other alternative options * Referral to hospital for specialist to assess - if any other teeth of poor prognosis * they will be added to this plan to avoid future GA * GA will involve day in hospital - need to monitor for full recovery * Need of chaperone throughout. Very common minor risks: * Headache, nausea, vomiting, drowsiness * Sore throat or sore nose/nose bleed from intubation Risks from treatment: * Pain, bleeding, swelling, bruising, infection, loss of space, stitches Rare major risks: * Brain damage * Death - 3 in a million. Need a machine to breathe during op and there is a * very small risk that you will not be able to breathe independently * again on waking - ie never waking again. * Upset when coming round - can make underlying anxiety worse * Malignant hyperpyrexia (v. rare - important to ask for FH) Conditions requiring special care (can be contraindications) * Sickle cell disease (or any hypoxia) * Diabetes - can’t fast in same way * Down’s syndrome * Malignant hyperpyrexia * CF or Severe asthma * Bleeding disorders * Cardiac or Renal conditions * Epilepsy * Long QT syndrome

Answer 2

1. Patient name 2. Patient address 3. Patient/Parent contact numbers (landline and mobile) 4. Patient medical history 5. Patient GP details 6. Parental responsibility 7. Justification for GA 8. Proposed treatment plan 9. Previous treatment details Letter must include: Recent radiographs or if not available an explanation of why (e.g. pt uncooperative)

Answer 3

Reassure the patient * Fluoride varnish is placed on the tooth and is minimally invasive * Promotes remineralisation (hardening of tooth) and prevents demineralisation (softening of tooth) * It involves dry the teeth and painting a gel on to the tooth Contraindicated in: * Severe uncontrolled asthma (hospitalised in the last 12 months) * Allergy to colophony (sticking plasters) - We can use a colophony free version if needed instructions afterwards * Don’t eat/drink for 1 hour * Soft diet for the rest of the day * No dark coloured foods * Avoid fluoride supplements today Fluoride toxicity: * Very small risk and technically relevant if small child consumes a quantity of toothpaste * 5mg/kg: milk * 5-15mg/kg: ipecac syrup, milk and possible referral * >15mg/kg: hospital referral Patient asks - I’m wondering why my younger child needs fluoride varnish? * Clear justification regarding caries – prevention of tooth decay (fluoride effective), evidence of additional benefit over and above daily tooth brushing * Recommended for all not just those at risk (universal process) * Recommended that children get it atleast 2x a year * Recommendations are evidence based e.g. refer to guidance such as SDCEP, sign etc Patient asks I’ve heard that too much fluoride can be harmful, is that true? * Details know minimal risk with use of fluoride varnish and twice daily use of fluoride toothpaste provided used as recommended * Fluoride varnish quantity carefully controlled * Guidance given regarding toothpaste quantity and Supervised brushing * posible side effects - fluorosis and mottling

Answer 4

Explain nature of injury in simple terms * Enamel dentine pulp fracture or complicated pulp fracture Explain treatment : PULPOTOMY (open apex) * As this is a large exposure the tx of choice is called a pulpotomy * Explain partial removal of pulp * Explain that aim is to keep undamaged pulp tissue alive * Explain that this is so the tooth stays alive and continues to grow Baseline sensibility tests * Tests required to see how the nerve in the injured and adjacent teeth respond * Tests required as baseline reading for long term monitoring LA required * Parent informed that LA is required * Required to keep patient numb and comfortable * Describe that LA involves injection in the gum Dental Dam * What this is - rubber sheet over tooth acts like mask * Why dam is placed - moisture control, protects airway Drilling/use of handpiece * Drill will be used to remove some pulp tissue * Aim is to leave only good tissue Dressing * Indicate that the tooth will be dressed; Setting CaOH, MTA Composite restoration * Indicate that a white filling will be placed to regain aesthetics Actor marks: Describing tx in an understandable manner, supportive and empathetic regarding injury

Answer 5

Introduce self and designation Reassure father everything will be ok Knee-to-knee examination * Explain to the parent what you intend to do * Sit across from the parent with your knees touching theirs * Bring your knees together and ask the parent to do the same * Ask the parent to sit the child with their legs round the parents waist * Lower the child down into your knees and ask the parent to hold the child’s arms

Answer 6

Trauma stamp: * Colour, EPT, EC, TTP/percussive note, mobility, displacement, radiograph, sinus Subluxation signs: * TTP, mobile, bleeding from gum, no displacement Explain nature of injury in simple terms * Subluxation of the upper central baby teeth * This is an injury to the supporting structures of the tooth Explain treatment: JUST OBSERVATION * No treatment required * Only that can be done today is clean tooth with saline or CHX wipe with gauze due to age Explain home care * Instruct soft food for 1 week * Important to keep the area clean and plaque free for good healing * OHI - Brush with a soft brush after every meal * CHX 0.2% with cotton swab to area x2 per day for 1 week Explain possible complications to primary tooth: * Pain, swelling, dark discolouration, increased mobility, delayed exfoliation, * infection * Child may not complain of pain, however, infection may be present and * parent should watch for signs of swelling on the gums and bring the child in for treatment. Explain possible complications to permanent tooth: * Premature or delayed eruption, enamel hypoplasia/ hypomineralization, * crown/root dilaceration, failure to erupt, failure to form, odontome formation Follow up: 1wk and 6-8wks Actor marks for describing tx in an understandable manner, supportive and empathetic regarding injury

Answer 7

Skeletal classification * Class 2 – maxilla more than 2-3mm infringe of mandible; increased OJ; ANB >4o Incisor classification: * Class II div 1 = lower incisor edge lie posterior to the cingulum plateau of the upper central incisors. The upper central incisors are Proclined or of averageinclination and there is an increased OJ Dental factors of class II div 1 malocclusion * Increased OJ – incisors Proclined or average * Variable of OB * Can have good alignment, crowding or spacing in dentition * Habitually parted lips may lead to drying of the gingivae and exacerbation of any pre existing gingivitis Reason for treatment: * Concerns regarding aesthetics * Concerns regarding dental health * Prominent incisors are at risk of trauma especially with incompetent lips * OJ >9mm 2x likely to suffer trauma – IOTN 5A

Answer 8

**1- Accept – leave and monitor** * When there is mildly increased OJ and if patient isn’t concerned * Can give advice and use of mouth guard for trauma protection **2- Attempt growth modification** * Headgear – try and restrain growth of maxilla horizontally and/or vertically * Functional appliance (twin bloc, medium opening activator)– utilise, eliminate or guide the forces of muscle function, tooth eruption and growth to correct the malocclusion. These should be used during growth and coincide with pubertal growth spurt. URA * Limited role unless there is very mild class II, when overjet is due to incisor proclination and favourable OB * Only after specialist assessment Orthognathic surgery * Should be carried out when growth is complete and only when there is severe skeletal A/P discrepancy or vertical direction, * Usually involved mandibular surgery but may include maxilla * Fixed appliances will be required before, during and after surgery.

Answer 9

A – Active component (moves the teeth, 0.5mm) R – Retention (holds the brace in, 0.7mm in permanent, 0.6mm in deciduous) A – Anchorage (resists unwanted tooth movement) B – Baseplate (plus any modifications) * Provides anchorage, retention, connector Self-cure PMMA over Heat-cure PMMA * Advantages: quicker and easier fabrication - 14mins vs 14hrs * Disadvantages: residual monomer can be an irritant

Answer 10

In order to REDUCE an overbite we must make a baseplate modification by using a FLAT ANTERIOR BITE PLANE which is made by taking measurement of OJ + 3mm. We add 3mm to minimise the risk of lowers going behind uppers and prevents the lower teeth retroclining which makes overbite even worse. A FABP creates POSTERIOR OPEN BITE. We then want to start closing the posterior open bite happens as the lower teeth move to occlude with upper teeth and close then open bite - only happens when teeth are erupting and bone and soft tissues are forming (cant be done in adults or will end up with over eruption and roots exposed so teeth become mobile). We then take out the appliance and have a gap that allow us to force the overjet closed Aim: Please construct a URA to reduce OJ 22,21,22,12 and reduce OB (done after 4s extracted and canines moved back) Active components - 22,21,11,12 Robert’s retract 0.5mm HSSW + 0.5mm ID tubing Retention - Posterior retention o 16+26 Adam’s clasps 0.7mm HSSW Stops - 13+ 23 mesial stops 0.7mm HSSW flattened (stops canines relapsing these are passive components) Anchorage - Good and bad moving 4 teeth but all have small roots and moving same direction Base plate - Self cure PMMA with flat anterior bite plane OJ+3mm

Answer 11

Active components - 22,21,11,12 Robert’s retract 0.5mm HSSW + 0.5mm ID tubing Retention - Posterior retention o 16+26 Adam’s clasps 0.7mm HSSW Stops - 13+ 23 mesial stops 0.7mm HSSW flattened (stops canines relapsing these are passive components) Anchorage - Good and bad moving 4 teeth but all have small roots and moving same direction Base plate - Self cure PMMA with flat anterior bite plane OJ+3mm

Answer 12

Aim: please construct a URA to retract 13 + 23 Active components - 13 + 23 palatal finger springs + guards 0.5mm HSSW Retention - Posterior retention o 16 + 26 Adam’s clasp 0.7mm HSSW - Anterior retention o 11 + 21 southend clasp 0.7mm HSSW Anchorage - Good as only moving 2 teeth Base plate - Self cure PMMA

Answer 13

Aim: please construct a URA to retract buccally placed 13 and bring 23 in the line of arch and reduce OB Active components - 13 buccal canine retractor 0.5mm HSSW with 0.5mm ID tubing - 23 palatal finger spring and guard 0.5mm HSSW Retention - Posterior retention o 16+26 Adam’s clasps 0.7mm HSSW - Anterior retention o 11+21 southend clasp 0.7mm HSSW Anchorage - Good only moving 2 teeth Base plate - Self cure PMMA with flat anterior bite plane OJ+3mm

Answer 14

Aim:Please construct URA to correct anterior cross bite Active components - 12 Z spring (or T spring) 0.5mm HSSW Retention - Posterior retention o 16+26 Adam’s clasps 0.7mm HSSW o 14+24 Adam’s clasps 0.7mm HSSW Anchorage - Good only moving 1 tooth Base plate - Self cure PMMA with flat posterior bite plane

Answer 15

Aim: Please construct a URA to expand the upper arch Active components - Midline palatal screw Retention - Posterior retention o 16+26 Adam’s clasps 0.7mm HSSW o 14+24 Adam’s clasps 0.7mm HSSW Anchorage - Good only moving 1 tooth Base plate - Self cure PMMA with flat posterior bite plane

Answer 16

Component faults: * Z-spring encased in acrylic, UR6 adam’s clasp arrowhead fault, UL6 adam’s clasp flyover fault Prescription faults: * Southend clasp included meaning appliance won’t work, Adam’s clasp on ULC not ULD, FABP instead of PBP. How would you rectify these errors? * Re-make appliance by taking new impressions Activating palatal finger spring: * Using spring former pliers – 1-2mm activation Fitting a URA * Check that the appliance if for the correct patient o Check the appliance is asked for * Run finger over all surfaces to check for protruding wires and sharp acrylic * Check wirework integrity (if overworked) * Fit the appliance * Check for any blanching or trauma * Check posterior retention - Flyovers (first as influence the arrowheads);Arrowheads:Activation * Activate to produce 1mm movement per month: spring formers * Demonstrate to patient about insertion and removal * Ask patient to demonstrate insertion and removal * Review: 4-6 weekly Instructions to patient * Will feel big and bulky * Likely to impinge on speech -Start reading a book aloud to prevent this * May have ‘mild discomfort’ - particularly on teeth being moved - but this is a sign that the appliance is working * Initial increase in saliva – 24-48 hours * Wear 24 hours/day including meal times * Can remove the appliance to clean with a soft brush after each meal or when taking part in active/contact sport – store in a safe place * Avoid hard and sticky foods * Be cautious with hot food and drinks as base plate acts as an insulator * Non- compliance will lengthen treatment * Give an emergency contact number – do not wait till next appt. if there is a problem

Answer 17

Decal - has the shape of backet * Weakens the enamel to caries * Unsightly staining Pt selection * High risk if caries history evidence of decal, NCTSL Oral Hygiene * Toothbrushing + single tufted TB for brackets * Inter-dental brushes and superfloss * O.H.I. should include minimum twice per day VERY thoroughly - Dry toothpaste, methodical: work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a * minimum of 2 minutes, spit don’t rinse * brushing after meals as brackets trap food/plaque * disclosing tablets to identify missed areas Diet advice * Limit sugar amount and frequency * Avoid snacks between meals – limit sugar intake to <3 times daily * Avoid hard/hot foods, fizzy drinks, sports drinks, sticky sweets, chewing gum * Ideal drinks are water or milk, crackers, cheese, fruit is acceptable snack but be careful of fat in cheese and natural sugar/acid in fruit * Watch out for hidden sugars in foods such as tomato soup and ketchup. * Rinse mouth after eating Fluoride Toothpaste * Duraphat – 2800 ppm (0.619%) – 5000 ppm (1.2%) * Twice daily, ordinary toothpaste at other times * Warn re overdose and children Mouthwash * Daily 0.05% fluoride mouthwash (225ppm) * Use IN-BETWEEN brushing, NOT after F Varnish * Proflurid (22600ppm) - not duraphat (not for tx of decal as it seals it in), every 4 months

Answer 18

Sodium Fluoride Toothpaste 0.619% (2800ppm) Send: 75ml Label: brush teeth for 1 minute after meals using 1cm before spitting out, twice daily Sodium Fluoride Toothpaste 1.1% (5000ppm) Send: 51g Label: brush teeth for 3 minute after meal using 2cm, before spitting, 3x daily

Answer 19

Problems * Increased OJ (1 mark) * Increased OB (1 mark) * Peg Lateral (1 mark) * Ectopic Canine (4 marks) Dental Health Implication * Risk of trauma from OJ (1 mark) * Risk of trauma from OB (1 mark) * Risk of root resorption (1 mark) * Risk of cyst formation (1 mark) Position determination from radiographs provided - detailed use of parallax and explanation (4 marks) Parallax – OPT and oblique occlusal radiograph views - had to explain how you get your answer * Vertical parallax - SLOB * Explanation: The tube head shifted up from OPT to oblique occlusal, the * canine moved together with the tubehead compared to the incisor. According to SLOB rule, the canine is palatal to the incisor.

Answer 20

Causes of retained ULA/Unerupted 21 * Trauma to A - causing damage to the 1 * Complications: Ankylosis, arrested tooth (21) formation, dilaceration, displacement * Lack of permanent successor/Hypodontia * Ectopic tooth germ * crowding * supernumerary - tuberculate most common signs * Discolouration of A, retained A * Radiographic * Lateral erupted before central investigations * Radiographic localisation for ortho treatment * Another PA or anterior occlusal, or alternatively OPT and occlusal, CBCT for 3D view Management Always palpate: usually U1 is buccal and central (high) Options: * Leave and monitor - inform of possible cyst or resorption * Extract retained A (leave U1) and space maintenance (warn of cyst formation risk) * Surgical removal of both teeth and space maintenance * Refer for orthodontic opinion/Tx - Inform of possible ortho tx benefits/risks * Auto-transplantation Other options: * Extract retained A and hope spontaneous eruption (very unlikely since dilacerated) * Expose (closed or open) +/- bonding/traction (won’t work if dilacerated)

Answer 21

**Accept and Monitor** **Intercept with a URA – procline uppers** notice pt’s age in scenario – this not possible **Growth Modification**: with functional appliance (reverse twin block) or (RME + protraction headgear) notice pt’s age in scenario – this not possible **Camouflage with fixed appliances** * Accept underlying skeletal classification problem, move teeth with fixed ortho to hide it * procline uppers and retrocline lowers * Risks of ortho: decal, root resorption, relapse, gingival recession * Usually together with XLA U5s & L4s (most likely lowers to reduce necessary tipping) **Orthognathic surgery with combined orthodontics** Surgical manipulation of the mandible and/or maxilla to produce optimal aesthetics/function * Multidisciplinary team – careful planning - Orthodontist, maxillofacial surgeon, clinical psychologist etc * Pre-surgical orthodontics – 12-18 months: arch alignment, arch coordination, de-compensation * Post-surgical orthodontics – 12 months TOTAL TIME = 36 months

Answer 22

- mechanical abrasion - crushed/marked - damage - work hardened - fatigue - repeat strain in deep undercut check flyover than arrowheads

Answer 23

amount of toothpaste eaten strength of F in toothpaste weight of child

Answer 24

2yo has 0.25ml 22,600ppmF 5% NaF varnish = 5.65mg

Answer 25

0.5ml 22600ppmF 5%NaF varnish = 11.3mg

Answer 26

give calcium orally and observe

Answer 27

give calcium orally and take to hospital

Answer 28

admit to hospital ASAP for life monitoring and IV calcium gluconate

Answer 29

get their weight and x5 e.g. 20kg child can have 100mg F

Answer 30

carbamide peroxide breaks down into hydrogen peroxide and urea hydrogen peroxide then breaks into free radical which is active oxidising agent which breaks long chanin inorganic chromogenic molecules into shorter chains

Answer 31

time cleanliness concentration temperature

Answer 32

make sure dentally fit - no decay, good perio health record inital shade with shade guide and photos consent - gingival irriation, need to replace restorations, may not work, sensitivity, relapse, compliance dependent

Answer 33

16.7% will break into 5% H2O2

Answer 34

please construct trays for external vital bleaching ensure trays 1mm short of ginigval margin please put bleach wells on labial surface of X

Answer 35

keep bleach in fridge fill wells with 1mm2 (popcorn kernel) of bleach, wear for at least 2hours but ideally overnight

Answer 36

external cervical resorption

Answer 37

remove GP 1mm below ACJ, 1mm RMGIC over GP remove dark dentine, etch enamel 35% phosphoric acid 10% carbamide peroxide

Answer 38

clean tooth througly vaseline to soft tissues rubber dam seal bicarbonate gingival guard wedgets bewtween teeth mix 18% HCl and pumice - apply to teeth, 5secs/tooth wash, repeat up to 10x remove rubber dam polish with F prophy paste apply clear F gel or varnish review after 1 month can be repeated

Answer 39

change refractive index of white area masks white area and makes tooth look like surrounding area

Answer 40

ECl (not on primary tooth) EPT (not on primary tooth) Colour TTP percussive note mobility sinus radiograph displacement (1st visit only) | test tooth nerve, see if any infection underlying

Answer 41

trauma to primary causing damage to permanent - complications: ankylosis; arrested tooth developement (21) formation, dialcareation, displacement lack of permenent successor - hypodontia ectopic tooth germ crowding supernumerary: tuberculate most common

Answer 42

discoloration of A, retained A radiographc lateral erupted before central

Paeds/Ortho Flashcards

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