Pulp Therapy/Orofacial Trauma Flashcards
(184 cards)
1
Q
Dentin-Pulp Complex
A
- Pulp originates from mesenchymal tissue
- Odontoblasts synthesize dentin organic matrix and line the edge of the pulp space
- Cytoplasmic processes extend into dentin tubules
- Orbans (1980) stated that “The pulp lives for the dentin and the dentin lives by the grace of the pulp.”
2
Q
Dentin components
A
- Inorganic - hydroxyapatite
- Organic - mostly type I collagen but odontoblasts also secrete type V collagen, dentin sialoprotein and phosphophoryn, acid phosphatase and alkaline phosphatase
3
Q
Dentin types
A
- Primary - tubular dentin formed before eruption; includes mantle dentin
- Secondary - regular, circumferential dentin formed after tooth eruption; tubules are continuous with primary dentin
- Tertiary - in response to irritation
4
Q
Primary dentin vs secondary dentin
A
- Bulk of dentin formed during primary dentinogenesis
* Secondary dentin forms at a slower rate over the life of the tooth
5
Q
Tertiary dentin
A
• Forms in response to irritation:
- Previously called irregular, irritation, reparative and/or replacement dentin
- Reactionary dentin - formed by original odontoblasts; continuous with secondary dentin
- Reparative dentin - original odontoblasts died, dentin formed by new odontoblast-like cells; not continuous with secondary dentin
6
Q
Dentin-pulp reaction to damage
A
• When there is damage to dentin-pulp complex due to disease, trauma, operative, odontoblasts react to defend the pulp • Stimulated to create tertiary dentin - Appears sclerotic histologically - Decreased dentin permeability - Depends on extent of injury
7
Q
Mild insult consequence
A
Odontoblasts usually survive and secrete reactionary dentin in response to injury
8
Q
Severe insult consequence
A
May cause death of odontoblasts
- May lead to generation of new odontoblast-like cells and secretion of reparative dentin matrix
• Tubular structure discontinuity and reduced permeability
9
Q
Molecular basis for odontoblast stimulation
A
- TGF-b (transforming growth factor beta) is sequestered in dentin matrix during tooth development
- TGF-b may be released when caries or acid etchant causes dissolution of matrix
- Growth factors interact with pulp to cause proliferation and differentiation of mesenchymal cells to form reparative dentin
10
Q
Odontoblast stimulation by calcium hydroxide
A
Calcium hydroxide has a similar effect – high pH causes slight demineralization and releases TGF-b leading to reparative dentin and apexification
11
Q
Example of mild insult
A
- Cavity preparation (no pulp exposure)
* Caries lesion in dentin
12
Q
Example of severe insult
A
- Chronic pulpal inflammation due to deep caries
- Dry cutting
- Endotoxins from bacteria in deep caries lesions
- Mechanical exposure of pulp
- Presence of bacteria increases extent of pulpal inflammation
13
Q
Importance of seal on restorations
A
• Importance of a good seal on restorations to minimize microleakage and bacterial invasion
14
Q
What is RDT?
A
Remaining dentin thickness
15
Q
Values for remaining dentin thickness
A
- Bacteria in cavities with RDT < 0.25 mm results in more severe pulp inflammation than when RDT is greater
- Best to have > 0.50 mm
- When RDT is > 0.5 mm diffusion of irritants is delayed – odontoblasts secrete reactionary dentin - increases distance between pulp and restorative material
- When RDT is < 0.5 mm, reduction in odontoblasts – differentiation of odontoblast-like cells - secretion of reparative dentin - decreased permeability - protective barrier
16
Q
Pulp cells
A
• Fibroblasts are most frequent cell type
- Capable of generating odontoblast-like cells
- Many are undifferentiated (stem cells)
• Macrophages - involved in signaling pathways, activated by inflammation
• Dendritic cells - induce T-cell dependent immunity
• T-lymphocyte
• Mast cells - rare in normal pulp, common in chronically inflamed pulp
17
Q
Structural proteins of pulp
A
• Collagen - type I and III are main subtypes
- Comprises 26-32% of dry weight in premolars and molars
• Elastin - found in walls of arterioles
18
Q
Cells in dental pulp
A
- Fibroblasts
- Odontoblasts
- Histiocytes
- Macrophages
- Granulocytes
- Mast cells
- Plasma cells
19
Q
Neuropeptides
A
• Calcitonin gene-related peptide (CGRP) is most common
- Important in induction of neurogenic inflammation
• Substance P
• Neuropeptide Y
• Neurokinin A
• Vasoactive intestinal peptide (VIP)
20
Q
Drug to regrow teeth?
A
• Tideglusib stimulates stem cells in the pulp of teeth.
• Functions as a Gycogen Synthase Kinase (GSK-3) enzyme antagonist
- GSK-3 is involved in dentin degradation
• From the lab of Paul Sharpe in the UK
21
Q
Types of pain
A
• Spontaneous, nocturnal, constant
- Irreversible
• Thermal, chemical, intermittent
- Reversible
22
Q
Subjective findings
A
- Young children are not good historians
- May not report pain
- May report pain when no evidence of disease
23
Q
Objective findings
A
- Extraoral
- Intraoral
- Radiographically
- Percussion
- Palpating
- Cold testing
24
Q
Nerve fibers in pulp
A
• Myelinated — A fibers
- A-beta and A-delta (90%) both innervate dentinal tubules and are stimulated by fluid movement in the tubules
- Increase in number over time; relatively few at time of eruption - may be why EPT is unreliable in young teeth
• Unmyelinated — C-fibers
- 3 to 8 times more frequent than A-delta fibers in pulp
25
Nerve fiber: A-fibers
Myelinated nerves that conduct rapid and sharp pain sensations:
• Mainly A-delta type
• Located in periphery of pulp
• In close association with odontoblasts; extend fibers to many dentinal tubules
26
Nerve fibers: C-fibers
Thinner, non-myelinated nerves involved in dull aching pain:
| • Typically terminate in pulp tissue proper either as free nerve endings or as branches around blood vessels
27
Nerve plexus of Raschkow
* Myelinated nerve fibers located in cell rich zone
* Monitors painful sensations
* Mediates inflammatory events and tissue repair
28
Electric pulp testing
* Stimulates sensory A fibers
* C fibers do not respond
* On anterior teeth, incisal edge has lowest response threshold
* Generally not reliable in young children
29
Cold testing
* Excites intradental A fibers
* C fibers not usually activated unless stimulus causes injury to pulp
* No evidence that cold testing injures pulp
30
Hydrodynamic theory
* Fluid movement in dentinal tubules is translated into electric signals in axons that innervate dentinal tubules
* Increased pressure = increased nerve impulses from the pulp
* Outward fluid movements produce stronger nerve response than inward movement
* Primarily A fibers that are stimulated
31
Pulpitis pain
* Most likely due to C fiber activity resulting from pulpal tissue injury
* Prolonged or spontaneous pain indicates irreversible pulpitis
32
Prescribing radiographs recommendation: New Patient being evaluated for oral diseases
* Child with primary dentition (prior to eruption of first permanent tooth): individualized radiographic exam consisting of selected periapical/occlusal views and/or posterior bite wings if proximal surfaces cannot be visualized or probed. Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time.
* Child with transitional dentition (after eruption of first permanent tooth): individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images.
* Adolescent with permanent dentition (prior to eruption of third molars) + Adult, dentate, or partially edentulous: Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images. A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment.
33
Prescribing radiographs recommendations: Recall patient* with clinical caries or at increased risk for caries**
* Child with primary dentition (prior to eruption of first permanent tooth) + child with transitional dentition (after eruption of first permanent tooth) + adolescent with permanent dentition (prior to eruption of third molars): posterior bitewings exam at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe.
* Adult, dentate or partially edentulous: Posterior bitewing exam at 6-18 month intervals
34
Prescribing radiographs recommendations: Recall patient* with no clinical caries and not at increased risk for caries**
* Child with primary dentition + child with transitional dentition: posterior bitewing exam at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe
* Adolescent with permanent dentition: posterior bitewing exam at 18-36 month intervals
* Adult, dentate, or partially edentulous: posterior bitewing exam at 24-36 month intervals.
35
Prescribing radiographs recommendations: patient (new and recall) for monitoring of dentofacial growth and development, and/or assessment of dental/skeletal relationships
* Child with primary dentition + child with transitional dentition: clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development or assessment of dental and skeletal relationships
* Adolescent with permanent dentition: clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development, or assessment of dental and skeletal relationships. Panoramic or periapical exam to assess developing third molars.
* Adult, dentate or partially edentulous: Usually not indicated for monitoring of growth and development. Clinical judgement as to the need for and type of radiographic image for evaluation of dental and skeletal relationships.
36
Prescribing radiographs recommendations: patient with other circumstances including, not not limited to proposed or existing implants, other dental and craniofacial pathoses, restorative/endodontic needs, treated periodontal disease and caries remineralization
For all categories: clinical judgement as to need for and type of radiographic images for evaluation and/or monitoring in these conditions.
37
Accessory canals
* Luglie PF et al. 2012. Found that 77% of the samples (both maxillary and mandibular primary molars) had one or more extra foramina near the furcation.
* May not be primary cause of infection transmission.
38
Radiolucent lesions
* Periapical radiolucencies can only be seen radiographically after cortical bone at the apex is destroyed and the infection has spread into cancellous bone.
* Lamina dura is cortical bone
39
Furcation radiolucency
* Furcation radiolucency in primary molars is a sign of pulp necrosis
* Recommended extraction when furcation lesion is present following pulpotomy
40
Myers study on furcation radiolucency
Myers et al (1987) is one of the few studies describing histopathology of furcation lesions in primary teeth:
- Granulomatous inflammation present in majority of specimens
- Chronic proliferating inflammation also seen
- Epithelium present in some specimens suggest cystic potential
Myers DR et al (1988) found greater percentage of specimens with granuloma + epithelium or furcation cyst than were found in the untreated teeth in previous study
41
Vital pulp therapy — primary teeth
* Indirect pulp cap
* Direct pulp cap
* Pulpotomy
42
Indirect pulp cap
• Partial caries removal decreased risk of pulp exposure by 98%; 3 studies with 24 month follow-up showed 94.4% success
• Independent of medicaments used
- Compared calcium hydroxide to bonding agent liners
• Most important factors for success:
- Accurate diagnosis of vitality
- Well sealed restoration - composite or SSC
43
Partial caries removal
```
Goal is to remove soft carious dentin and leave firm or leathery dentin over pulp.
• Slow speed with large round bur
• Hand excavation
• Chemomechanical - Carisolv
• Margins must be free of caries
```
44
Carisolv
• Carisolv is a gel based chemico-mechanical caries removal system:
- Consists of 0.95% sodium hypochlorite solution and a gel containing three amino acids (glutamic acid, Leucine, Lysine), sodium chloride, Na-CMC (carboxymethylcellulos)
• Sodium hydroxide provides a pH of 11 and purified water acts as a vehicle
• May lead to excess caries removal if IPT is the goal
• Not routinely taught in dental schools
45
Liners under restorations
• Ideal liner: (1) the ability of the material to kill bacteria, (2) induce mineralization, and (3) establish a tight bacterial seal
• Most common liners: CaOH, Glass ionomer, MTA
• Multisubstrate bonding ability - bonding to dentin and to composite restoration is a plus
- RMGI, dentin bonding agents, etc.
46
MTA facts
* Mineral trioxide aggregate
* Main soluble component is CaOH
* Alkaline pH contributes to antibacterial activity
* Hard-setting — minimizes microleakage
* Biocompatible — minimal inflammation
* Stimulates reparative dentin formation
* Induces dentin bridge formation
47
Calcium hydroxide [Ca(OH)2]
* Alkaline pH leads to antibacterial activity
* Causes superficial necrosis of pulp
* Stimulates reparative dentin
* Water soluble, so may not create good seal
48
Resin modified glass ionomer (RMGI)
* Initial pH is 4.0-5.5
* Demineralizes dentin
* May release bioactive materials in dentin matrix
* Irritating to pulp
49
Direct pulp cap
* Small mechanical or traumatic exposure
* Healthy pulp
* Goal: preserve vitality
* Tertiary dentin
* No harm to successors
* Continued root formation for permanent teeth
50
Recommendations for direct pulp cap
* Not recommended for carious exposure in primary teeth
* Hemostasis is important
* Success rate up to 80-90% when bleeding well controlled
* Ca(OH)2 or MTA in direct contact with pulp
51
Pulpotomy indications
* Carious exposure in vital primary tooth
| * Restorable tooth
52
Pulpotomy contraindications
* Fistula or swelling
* Necrotic pulp
* Uncontrolled hemorrhage
* Radiolucent lesion
* Pathologically resorption
* Dystrophin calcification
* More than 1/3 root resorption
53
Pulp medications
* Fixatives: FMC, glutaraldehyde
* Mineralization/bacteriostatic: Ca(OH)2, iodoform
* Palliative sealers: ZOE
* Obturators: MTA
* Coagulants: Ferric sulfate
* Antibiotics/antimicrobial: NaOCl, erythromycin, 3X antibiotic
54
Composition of Formocresol
* Formula: 19% formaldehyde, 35% cresol in 15% glycerin and water
* Bactericidal
* Mutagenic and carcinogenic potential - humoral and cell mediated response
* No dentin bridging
55
Mechanism of formocresol
Fixation followed by degeneration
• Acidophilic zone of fixation
• Pale staining zone of atrophy - fewer cells & fibers
• Broad zone of inflammatory cells extend apically
56
Formocresol and cancer
• Systemic distribution of radio-isotope-labeled formaldehyde has been demonstrated following formocresol pulpotomy in dogs and rhesus monkeys (found in bone, urine, liver, kidney, lungs, skeletal muscle and cerebrospinal fluid within minutes of the pulpotomy)
• Mutagenicity in peripheral blood lymphocyte cultures following formocresol pulpotomy as been found
• A correlation between formocresol pulpotomies in primary teeth and enamel defects in the permanent successor has been suggested
• In June 2004 - The International Agency for Research on Cancer (IARC) classified formaldehyde as carcinogenic to human beings
• Work group of experts determined there is:
- sufficient evidence that formaldehyde causes nasopharyngeal cancer in humans
- limited evidence for cancer of the nasal cavity and paranassal sinuses
- strong but not sufficient evidence for a causal association between leukemia and occupational exposure to formaldehyde
57
Percentage of formaldehyde in Buckley’s Formocresol
Buckley’s Formocresol contains 19% formaldehyde in its full strength
58
AAPD guideline on vital pulp therapies in primary teeth with deep caries lesions
* Panel recommends use of MTA and formocresol - strong recommendations, moderate-quality evidence
* Success rates in multiple clinical trials between 77-91%
* Review of available data, FMC is unlikely to be genotoxic, immunotoxic, or carcinogenic when used judiciously for pulpotomies
59
Glutaraldehyde
```
• A dialdehyde compound
• Large molecule - does not penetrate into periapical tissues
• Mild fixative
• Antibacterial:
- Requires pH between 7.5 and 8.5
- Short shelf life
• Concentration 2-5%
• Overall success lower than FMC or FS
• Low antigenicity and low toxicity
• Lloyd et al recommended concentration of 2% with exposure time of 10 min
• AAPD guidelines — not evaluated
```
60
Ferric sulfate
• Iron (III) sulfate
• Agglutination agent
- Acidic pH (<1.0)
- Produces hemostasis
• Forms a protein complex and concludes capillaries
• Antibacterial against numerous oral bacteria
• Must have healthy radicular pulp to obtain hemostasis
• Concern related to iron and risk of mycobacterium infection due to waterline contamination
• Lower success rate than FMC or MTA
• Studies have demonstrated internal resorption ***
• AAPD guidelines - conditional recommendation with low evidence
61
Ferric sulfate and mycobacterium
* Nontuberculosis mycobacterial infection linked to pulpotomy procedures and possible dental waterline contamination reported in California and Georgia
* ADA News September 21, 2016
* MMWR report stated the outbreak was caused by contaminated water used during pulpotomies. Improper treatment of waterlines.
62
Sodium hypochlorite
* Generally used at 5% concentration
* Anti-microbial
* Biocompatible, non-irritating to pulp
* Surface effects, minimal penetration
* Similar success to FC at 12 months
* AAPD Guidelines - Conditional recommendation with very low evidence
63
Calcium hydroxide
* AAPD guidelines - not recommended for vital tooth pulpotomies in primary teeth
* Very high pH
* Thought to initiate inflammatory cascade***
* Low success rate due to internal resorption***
64
Mineral trioxide aggregate composition
* Tricalcium silicate, dicalcium silicate, tricalcium aluminate, gypsum, tetracalcium aluminoferrite and bismuth oxide
* Hydrophilic particles set in presence of moisture
* High biocompatibility
* pH 12.5 after setting - reaction product is CaOH2
* Compressive strength similar to IRM
* Better seal than amalgam
* May turn tooth gray over time
65
Mineral trioxide aggregate mechanism
* Provides a biologically active substrate for cell attachment
* Stimulates reparative dentin
* Minimal pulp necrosis and inflammation
* Forms dentin bridge more quickly than Ca(OH)2
* AAPD guideline - strong recommendation with moderate evidence
66
Calcium silicate
* Contains tricalcium silicate, dicalcium silicate, calcium carbonate, oxide filler, iron oxide shade, and zirconium oxide
* Creates dentin bridge
* Bioactive properties
* Alkaline pH
* Setting time 9-12 minutes — enhanced by calcium carbonate and calcium chloride
* Less evidence than MTA
* Creates a good seal — prevents microleakage
* Induction of reparative dentin
* AAPD guidelines — conditional recommendation, very low evidence
**Less discoloration
67
Non-vital pulp therapy for primary teeth
```
Pulpectomies indications:
• Necrotic/irreversible inflammation
- Spontaneous pain
- Pain on stimulation that lingers
- Draining fistula
• Abscesses (in limited instances)
```
68
Primary maxillary molar anatomy
* 3 roots is most common; may have 2 or 3 roots
* 1/3 of maxillary first molars have fusion of palatal and distobuccal roots
* 2nd maxillary molars have 3 canals (70%) or 4 canals (30%)
69
Primary mandibular molar anatomy
• 1st molars have 2 roots with 3 (80%) or 4 (20%) canals
- Mesial roots with 2 canals
- Distal root with 1 or 2 canals
• 2nd molars have 2 roots and 4 canals
70
Pulpectomy
* Radiographic findings documented
* Clinical findings documented
* Eliminate infection via adequate canal de ride net, irrigation, and filling material
* Maintain tooth until normal exfoliation
71
Pulpectomy indications
* Irreversible pulpitis or necrosis
* No root resorption
* Restorable tooth
72
Pulpectomy contraindications
* Non-restorable
* Perforation of pulpal floor
* Extreme tooth mobility
* Radiolucency involving permanent tooth follicle
* Children with medical compromise
* May be more “heroic” for 2nd primary molar prior to eruption of permanent molar
73
Zinc oxide and eugenol
* Most widely used for pulpectomy
* Biocompatibility
* Antibacterial
* Resorts more slowly than deciduous roots
* Resists resorption if extruded beyond apex
74
Iodoform pastes
* Vitapex: 30% calcium hydroxide; 40.4% iodoform; 22% silicone oil
* Kri paste: iodoform, camphor, parachlorophenol, and menthol
* Magisto paste: same as Kri paste plus zinc oxide, thymol, lanolin, and calcium hydroxide
* Antibacterial
* Resorts faster than primary tooth roots
**Antimicrobial component
75
Medicaments success rates — primary teeth
* ZOE: 65-100%; average 83%
* Vitapex: 90-100%
* CaOH2: 60%
* KRI paste: 84%
* ZOE + iodoform: 93-100%
76
Lesion sterilization and tissue repair (LSTR)
* Goal is to sterilize lesion and avoid instrumentation of canal
* Ciprofloxacin, metronidazole, minocycline (1:3:3)
77
Does caries in primary teeth predict enamel defects?
• Originally described by Turner in 1906
• Broadbent et al, 2005
- Study limited to incisors
- Permanent tooth with a carious predecessor had 2.3 times the odds of having a demarcated opacity compared with a permanent tooth with a sound predecessor
- Thought to be related to periapical infection
78
Primary incisor pulp therapy
• Previous studies suggested that pulpectomies were more successful than pulpotomies
• Howley et al, 2011 compared FMC pulpotomy to Vitapex pulpectomy
- Randomized, controlled trial
- No significant difference found between the two treatments
• Radiographic success: FMC 89%, Vitapex 73%
• AAPD guidelines: did not separate out tooth type
- Guidelines should be applied to all primary teeth equally based on clinical and radiographic findings
79
Treatment for immature teeth with vital pulp without pulp exposure
```
• Incomplete apical closure.
• Indirect pulp treatment is indicated.
- Medicaments:
• MTA
• Ca(OH)2
• Glass ionomer
• Restored with material to eliminate microleakage
```
80
Treatment for immature teeth with carious or traumatic pulp exposure
• Direct pulp cap if small exposure
- Using biocompatible material with a good seal that promotes pulp repair and dentin bridge
• MTA or Ca(OH)2 most commonly used but MTA preferred due to hard setting ability, better seal and biologically active substrate
• MTA shows signs of reparative dentin after 3 weeks
* If esthetics is a concern, CaOH2 may be preferred over MTA due to dark staining (even white version)
* Calcium silicate materials (like Biodentine) may also be a good alternative
- Faster setting
- No tooth discoloration
- More clinical trials needed
81
Indication for pulpotomy on immature permanent teeth
* Pulp exposure due to caries or trauma
* Hemorrhage is controlled with pressure
* Tooth is vital
* No spontaneous pain or evidence of necrosis
* No radiographic evidence of periapical lesion
82
Permanent tooth pulpotomy
* Goal is to maintain canal vitality and complete root apex formation
* Similar to DPC except entire coronal pulp tissue removed
* Calcium hydroxide or MTA then well sealed restoration
83
Nonvital permanent teeth treatment
• Apexification - goal is to induce root development by forming a calcific barrier
- Ca(OH)2 applied over a year or more to stimulate hard tissue barrier
- MTA to create an apical plug (shorter term option)
- Pulp revascularization
84
Ca(OH)2 Apexification
* Predictable - forms barrier 74-100% of time
* Requires multiple visits
* Barrier is somewhat porous
* Most severe complication is cervical root fracture when dentin is exposed to calcium hydroxide long term
85
MTA apexification
* Procedure done in one visit
* Creates a strong seal and is radiopaque
* If procedure fails, may require apical surgery
* Minimal risk of root fracture
86
Requirement for pulpal revascularization
• Disinfection of the canal
• Creation of a scaffold for new tissue to grow on
• Stem cells
• Signaling molecules
• Good seal of coronal access
• Necrotic immature permanent teeth:
- With or without apical pathos is
- Restorable crown without need for a post
• Bleeding into root canal brings undifferentiated mesenchymal stem cells into the root canal space
• Requires at least 1.1 mm open apex
• Patient between 7-16 years in good health
• Disinfection with either antibiotic paste or calcium hydroxide
• Create a seal over blood clot and restore
87
Pulpal revascularization - visit 1
* Remove necrotic pulp and disinfect root canal
* Irrigate gently with NaOCl - stay 3mm from apex
* No mechanical de ride meant
* Rinse with saline and dry with paper points
* Place medicaments: Ca(OH)2 or triple antibiotic paste
* Seal with temporary restorative material
88
Pulpal revascularization - visit 2
* Irrigate with EDTA - may help adhesion of new cells; releases growth factors that can promote osteoblast-like cells
* Over instrument the canal to draw blood into canal space to provide scaffold and to provide source of stem cells
* Place MTA or Biodentine over blood clot as a barrier
* Place final restoration
89
Bone healing
* Bone deposition in periapical area is not very evident radiographically until sufficient thickness of bone is present
* Periapical bone regeneration usually occurs at a rate of 1.2 mm per month
* Continuous bone deposition increases the bone density along the periapical area resulting in a diminished periapical lesion size after about one year
90
Who is at risk for orofacial trauma?
• Among 5 year old children, 1/3 have had trauma to primary teeth.
- Most common is luxation
- Most occur at 18-30 month of age
• Among 12 year olds, 20-30% have had dental injuries
- Most common is uncomplicated crown fracture
- Peak incidence at 9-10 years
91
Epidemiology of tooth trauma
* 71% of trauma cases involve the maxillary central incisors
| * Males > females (2:1) with a notable increase in trauma seen in boys 7-10 years of age
92
Where does trauma occur?
* Falls: school 30.3%, home 66.7%, other 36.8%
* Sports: school 24.2%, home 2.8%, other 15.8%
* Violence: school 30.3%, home 5.6%, other 2.6%
* Bicycle: school 3%, other 18.4%
* Games: school 12.1%, home 2.8%, other 21.1%
* Sharp object: home 22.2%, other 5.3%
93
Sports related dental injuries
* Assessed dental injuries in high school athletes over a 5 year period
* Rate of injury was 0.9 per 100,000 exposures
* Highest rate for girls was field hockey (3.9) and for boys was basketball (2.6)
* For 72% of injuries, not wearing a mouthguard
94
ADHD and dental trauma
• Herguner et al, 2015
- Compared children with and without traumatic dental injury (TDI)
- Children with TDI had significantly higher hyperactivity scores than control group
• Sabuncuoglu and Irmak, 2017
- In a review of literature from the past 10 years, concluded that ADHD is a risk factor for TDIs
95
Overjet and trauma
```
• 0-3mm:
- No injury: 74.3%
- Mild: 16.8%
- Moderate to severe: 8.9%
• 4-6mm:
- No injury: 66.1%
- Mild: 15.1%
- Moderate to severe: 18.9%
• >6mm:
- No injury: 51.4%
- Mild: 16.7%
- Moderate to severe: 31.9%
```
96
Meta-analysis of TDI and overjet
54 studies of traumatic dental injuries world wide:
- Primary and permanent incisors with overjet threshold between 3-6 mm
- Concluded that odds ratio of TDI due to large overjet was 21% with over 235 million cases over a 24 year period
97
Trauma prevention
* At home - child proof household
* Sports - helmets, face masks, mouth guards
* Bicycle - helmets
* ADHD - medication?
* Excessive overjet - early ortho intervention
98
Types of mouthguards
* Custom (type I) - impression, vacuum formed; better retention and protection
* Mouth-formed (type II) - boil and bite; formed in the mouth after heating
* Stock (type III) - ready made
99
Mouthguard characteristics
• Proper fit is important for protection as well as comfort
• At least 3mm thick to provide cushion and distribute shock from impact
• Price varies considerably
- Custom may be between $60-$285 (up to $800)
- Mouth formed and/or stock between $8 to $25
100
Mouthguard materials
* Poly (vinyl acetate-ethylene) copolymer clear thermoplastic
* Polyurethane
* Laminated thermoplastic
* Polyolefin
101
Do mouthguards reduce TDI?
Systemic review and meta-analysis:
• 14 studies met inclusion criteria
• Found an association between use of mouthguard and prevention of dental trauma
• In two meta-analyses, athletes who wore a mouthguard were 82% and 93% less likely to suffer injury compared to those not wearing a mouthguard
102
Mouthguards and concussions
No significant difference was observed in reduction of impact force to the head with or without wearing a mouthguard
103
“Game On” Mouthguard
* First mouthguard to receive ADA seal of approval
* Heated in microwave
* Comes in youth and adult sizes
* Made out of polymer Vistamaxx
* “LockDown Fit” technology
* Mouth-formed type
104
Sports requiring mouthguards
* Field hockey
* Football
* Ice hockey
* Lacrosse - men and women
* Wrestling if wearing orthodontic appliances
* High school and NCAA have similar requirements
105
TDI incidence by sport *** (test question note)
* National high school sports-related injury surveillance study
* Total of 222 injuries
* 72% of injuries, no mouthguard worn
* Sport (number of injuries/mouthguard worn):
* Boy’s basketball: 53/N
* Boy’s football: 26/Y
* Boy’s baseball: 23/N
* Girl’s field hockey: 22/Y
* Boy’s wrestling: 20/Y
* Boy’s soccer: 19/N
* Girl’s basketball: 16/N
* Girl’s softball: 12/N
* Girl’s soccer: 9/N
* Boy’s lacrosse: 6/Y
* Girl’s lacrosse: 4/Y
106
Neurological symptoms after trauma
* Headache that is worse over time
* Nausea/vomiting
* Irritability
* Ataxia
* Blurred vision/unequal pupils
* Confusion
* Changes in breathing pattern
* Slurred speech
* Fluid leakage from ears and/or nose
107
Modified Glasgow Coma Scale **
* Eye opening
* Verbal response
* Best motor response
* Perfect score is 15; lower score, more severe injury
108
Refer patient to hospital and/or ER
* Loss of consciousness
* Neck and head pain
* Numbness anywhere on body
* Amnesia of traumatic episode
* Nausea and vomiting
* Drowsiness
* Blurred vision
Advise parents to continue assessment of these signs and symptoms in the next 48 hours
109
Tests of cranial nerve function ***
Nerve/function/how to test
* Olfactory (1): olfaction/with an odorous substance
* Optic (2): vision/vision chart
* Oculumotor (3): most eye muscles/“follow the moving finger”
* Trochlear (4): superior oblique/look down at the nose
* Trigeminal (5): facial sensation, muscles of mastication/touch the face, clench the teeth
* Abducens (6): lateral rectus/look to the side
* Facial (7): facial expression, taste/smile, raise the eyebrows; sugar or salt
* Vestibulocochlear (8): hearing, balance/ a tuning fork, look for vertigo
* Glosopharyngeal (9): pharynx sensation/gag reflex
* Vagus (10): muscles of larynx and pharynx, parasympathetic/check for hoarseness, open wide and say “AH”
* Accessory (11): trapezius and sternocleidomastoid/test shoulder raise or turning the head
* Hypoglossal (12): tongue muscles/stick out the tongue
110
Rapid neurological exam
* Extraocular movements intact
* PERRLA - Pupils Equal Round, Reactive to Light and Accomodation
* Facial - close eyes, smile, frown
111
Trauma statistics
```
• Fractures - most common is mandibular (74%)
- Twice as common in boys
• Most common midface fracture is nasal
• Subcondylar/condylar fractures
- Injury to chin
- Deviated bite
```
112
Complications with condylar fracture
* Ankylosis
* Asymmetry
* Malocclusion
* TMJ dysfunction
113
Extraoral clues
* Chin laceration - rule out condylar fracture
* Battles sign - mastoid hematoma, rule out posterior cranial fracture
* Raccoon sign - orbital hematoma, rule out anterior cranial bone fracture
* Facial asymmetry
* Change in occlusion - inability to close
114
Intraoral clinical examination
```
• Alveolar ridges and bone structures
• Arch continuity
• Deviation on opening
• Teeth:
- Displacement: measure and record
- Fractures: describe extent
- Mobility: note, classify and record
- Missing teeth: note and record
- Pulp exposures: note and record
- Occlusion: important in detecting posterior fractures and jaw/alveolar fractures, also some displacement
```
115
Radiographs
* Follow guidelines
* Reproducible periapicals; may need multiple
* Panoramic when indicated
* Soft tissue to identify foreign body (1/4 exposure)
* Verify presence/absence of tooth and tooth parts
116
Radiographic exam
* Evaluate proximity of crown fracture to pulp
* Diagnosis of periodontal injury
* Assess for root fracture
* Assess apical maturity
* Locate intruded teeth
117
Pulp vitality testing
* Not reliable at the time of trauma
* Positive responsiveness to thermal/electric pulp testing increased over time following concussion injury
* Young children may not be able to respond accurately
118
Concussion assessment
* Seizure
* Headache
* Loss of consciousness
* Vomiting/nausea
* Skull fracture
* Drowsiness
* Amnesia
* Focal neurological signs
119
Avulsion primary teeth
* Radiograph to ensure missing tooth is not intruded
* Do not re-implant***
* No concern with space loss if primary canines are present
* If primary tooth is lost prematurely, permanent teeth may be delayed in eruption by 1 to 2 years due to fibrotic scar tissue in eruption path
* Confirm age of patient before making promises over the phone
120
Intrusive luxation primary teeth
* Most common in maxillary primary incisors
* One of the most dangerous injuries to the developing tooth bud
* Tooth may become discolored
* Management: allow to re-erupt
* Radiographs: occlusal and lateral anterior
* Allow to re-erupt (2 to 6 months) unless displaced toward permanent tooth bud — then extract
121
When to extract intruded primary tooth
* There are signs of swelling, spontaneous bleeding, abscess and fever
* Primary root tip is displaced toward permanent tooth bud — 90% are pushed labially
* It does not re-erupt at all in approximately 6 months
122
Primary tooth lateral luxation
• Luxation: tooth is displaced laterally — usually toward palate
- Radiograph
- Reposition if occlusal interference
- Extract if apex is displaced into permanent tooth bud
123
When to extract for primary dentition lateral luxation
• Extraction indicated if:
- Unable to reposition
- Occlusal interference
- Tooth is close to exfoliation
- Tooth is displaced labially and interfering with permanent tooth bud
124
Primary dentition extrusive luxation
• Vertical displacement of tooth out of socket
• May be very mobile
• If minor (< 3mm), reposition in socket
• If severe (>3mm), extract
• Likely to become discolored
- Yellow discoloration indicates pulp obliteration; good prognosis
- Does not always mean it is necrotic
125
What do guidelines say about extrusive luxation?
When there is more severe occlusal interference the tooth can be gently REPOSITIONED by combined labial and palatal pressure after the use of local anesthesia
126
Prognosis - extrusive luxation
* Pulp canal obliteration: 38%
* Tooth loss: 20%
* Pulp necrosis: 17%
* Inflammatory root resorption: 6%
127
Classification of injuries to the dentition (fractures)
• Crown fractures:
- Uncomplicated = enamel or enamel/dentin
- Complicated = enamel/dentin/pulp
- Crown/root fracture with or without pulp exposure
• Root fractures
128
Primary dentition - crown fracture with pulp exposure
```
• Unusual in primary dentition
• Radiograph
- Evaluate root development
- Evidence of root fracture?
• Pulpotomy with Ca(OH)2 GI and composite OR extraction
```
129
Partial pulpotomy (Cvek)
* Removes inflamed pulp
* Preserved pulp
* Increases healing potential
* Goalis to avoid need for RCT
130
Primary dentition - crown/root fracture
• With or without pulp exposure
- Remove fragment and restore
- Extract tooth if pulp exposure
• Radiograph to assess location of fracture
• If minimally displaced, may reposition and monitor
• If displaced and mobile, coronal fragment should be extracted, then monitor retained root tip
• Extract if signs of necrosis
131
Prognosis of primary dentition root fractures
* Apical 1/3: most maintain vitality and are minimally mobile
* Middle or cervical 1/3: poor prognosis - extract - gentle attempt to dislodge apical fragment. Don’t disrupt permanent tooth bud.
* Tooth loss: 72%
* Pulp necrosis: 9%
* Pulp canal obliteration: 9%
132
Primary dentition alveolar fracture
* Entire segment is mobile
* May have occlusal interference
* Reposition and splint segment
* May require general anesthesia
* Stabilize for 4 weeks
* Monitor teeth in area of fracture
* No occlusal interference
* Watch for signs of apical periodontitis
* May disrupt permanent tooth development
133
Primary dentition alveolar fracture prognosis
* Pulp canal obliteration: 39%
* Tooth loss: 23%
* Pulp necrosis: 15%
* Inflammatory root resorption: 12%
134
Complications of trauma
* Color changes
* Pulp canal obliteration
* Pulp necrosis
* Ankylosis
* Resorption
* Enamel hypoplasia of permanent successor
* Delayed eruption of permanent tooth
135
Study regarding complications of trauma
• Study of sequelae to permanent teeth from primary tooth trauma
• 29% of teeth in trauma group demonstrated sequelae
- Enamel discoloration most common defect
- Intrusion most common injury causing defect
- Injury at 1 year most common caused sequelae
• In control group, 7% had enamel defects
• Calcific metamorphosis: no treatment needed
• Pulpal necrosis & abscess: extraction (more often) or pulpectomy
136
Discolored primary incisors
To evaluate late complications of asymptomatic traumatized primary incisors with dark coronal discoloration:
• 97 teeth with follow-up between 12-75 months
• In 52% the color faded or became yellowish and in 48% it remained dark
• >50% of the primary incisors that retain their dark coronal discoloration remain clinically asymptomatic till the eruption of the permanent successor
137
Complications of primary tooth trauma
```
• Permanent tooth malformation:
- Hypomineralization
- Hypoplasia
- Dilaceration
- Severe malformation
- Arrest of development
• Document information provided to parent
```
* Color change - 53%
* Pulp necrosis - 25%
* Pulp canal obliteration - 36%
* Gingival retraction - 6%
* Disturbances in physiologic resorption - 4%
* Premature tooth loss - 46%
* Ankylosis
* Ectopic eruption
138
Systemic review on the complications of trauma
* Found that injury to primary incisors frequently resulted in developmental disorders in permanent incisors
* Younger age at time of the injury and more severe trauma caused more significant permanent tooth injury
139
What affects prognosis of permanent tooth trauma
* Timely treatment
* Appropriate treatment
* Patient/parent compliance
* Appropriate follow-up
* Prevention of subsequent trauma
140
Timing of care and outcomes
* Complications included pulpitis, pulp necrosis, internal resorption or extraction due to pulpal or periodontal complication
* Unfavorable outcomes associated with delayed tx, stage of root development, and need for repositioning with splint
141
Avulsion permanent teeth
```
• Avulsed teeth comprise 1 to 16% of all traumatic injuries to the permanent dentition
• Long-term success in avulsion depends on many factors:
- Time out of socket
- Handling of PDL cells
- Use of biologic storage medium
- Maintenance of PDL cell vitality
- Type and time of splinting
- Timing for RCT
```
142
Key questions for permanent tooth avulsion ***
```
1) Extra-oral dry time
• Immediate replantation
• Less than 60 min
• More than 60 min
2) Open or closed apex
```
143
Preserving the periodontal ligament attachment apparatus
Biological considerations:
• Avulsion severs pulp’s neurovascular supply
• PDL cells are cut off from their blood supply and begin to suffer ischemia
• Aggravated by drying, exposure to bacteria or chemical irritants
144
Periodontal ligament cells
* Survival almost guaranteed if replanted within 5 min
* Reasonably good prognosis if 15-20 min delay
* If longer, need to be in physiologic transport medium
145
Top 6 transport media choices ***
* Tooth’s own socket is the very best transport medium
* Hank’s Balanced Salt Solution - cell culture medium
* Cold milk - most likely to be available
* Saliva
* Isotonic saline
* Cold contact lens solution
146
Effect of storage media on PDL cell apoptosis
• Apoptosis = programmed cell death
• Study compared milk, HBSS, Gatorade and contact lens solution
- Gatorade and contact lens solution had greatest apoptosis
- Cells treated in solutions on ice: less apoptosis
147
Contraindications to replantation
* Severe cardiac disease
* Seizure disorder
* Severe mental disability
* Compromised healing
* Poor alveolar support
148
The use of adjunctive systemic antibiotics in avulsion cases
* Hammarstrom et al (1986) found that systemic antibiotics (Pen VK) given at time of replantation were effective in preventing bacterial invasion of necrotic pulp, thus reducing inflammatory root resorption.
* There have been questions about this due to limited evidence, however, still recommended in the guidelines.
* Tetracycline (Doxycycline) has been found to be even more effective in reducing inflammatory root resorption when compared to Pen VK
* Tetracycline has been shown to possess not only anti-microbial properties, but is also anti-resorptive
149
Tetracycline (doxycycline)
• IADT guidelines: tetracycline for children > 12 years
• For attends not susceptible to tetracycline staining:
- RX: Doxycycline 4.4 mg/kg/day q12h on day one, then 2.2-4.4 mg/kg/day for seven days
150
Pen VK
• For patients susceptible to tetracycline staining:
- RX: Pen VK 500 mg QID or child equivalent dose for seven days (50 mg/kg/day divided q 6-8 hours)
• Clindamycin for Penicillin allergic < 12 years
151
Consequences of avulsion
* Possible revascularization for open apex
* Pulp necrosis
* Pulpal obliteration
* Ankylosis
* Inflammatory root resorption
152
Topical antibiotics, open apex, < 60 min extra-oral dry time
•The use of topical antibiotics to treat open apex avulsed teeth with extra-oral dry time < 60 minutes:
- Cvek et al (1990) showed that pulp revascularization is highly dependent on presence/absence of bacteria in the pulp lumen
- Cvek et al (1990) and Yanpiset & Trope (2000) demonstrated that teeth with open apex soaked in Doxycycline solution have a greater pulpal revascularization rate (double revascularization rate)
- Ritter et al (2004) reported that topical treatment of immature avulsed dog teeth with Minocycline (Arestin) improved pulp revascularization (91%) when compared with doxycycline solution (73%) and saline (33%)
- Minocycline Hydrochloride Microspheres (ArestinTM, OraPharma Inc.) $500 for 24 dosages; shelf life: 2 years
153
Enhancing revascularization after avulsion — mechanism
The use of topical antibiotics to treat open apex avulsed teeth with extra-oral dry time < 60 minutes:
• Hypothesis:
- Antimicrobial effect —> Tetracycline kills bacteria on the root surface, and most importantly at the pulpal lumen
- Tetracycline inhibits osteoclast function
• Doxycycline solution: 1 mg Doxycycline/20 mL saline
154
Intrusive luxation sequelae
Tsilingardis et al (2016):
• Fewer complications for immature teeth with mild intrusion and treatment by spontaneous re-eruption
• 75% of mature teeth with intrusion between 3-7mm developed pulp necrosis
• Important to monitor carefully
155
Treatment for permanent tooth intrusion
* Less than 7mm with immature root development: spontaneous eruption
* Less than 3mm with mature root development: spontaneous
* 3-7 mm or greater with mature root development: surgical or orthodontic
156
Lateral luxation permanent teeth
* Open apex: monitor for continued root formation as a sign of revascularization
* Closed apex: monitor for signs of discoloration, lack of pulp response, indicating pulp necrosis
* Luxation injury with concomitant uncomplicated fracture significantly increases risk for pulp necrosis
157
Root fracture permanent teeth
• Splint up to 4 months for root fracture in cervical third
• Location of fracture will affect prognosis
- Apical 1/3 = best
- Cervical 1/3 = worst
• Monitor pulpal status for 1 year
• If pulp necrosis, initiate RCT of coronal fragment
158
Splinting for traumatic injuries
Primary/Permanent
* Concussion/subluxation: none/none or 2 weeks
* Intrusion: none for both
* Extrusion: none/2 weeks
* Lateral luxation: None or 2 weeks/4 weeks
* Alveolar fracture: 3-4 weeks/4 weeks
* Avulsion (<60 min): not applicable/2 weeks
* Avulsion (>60 min): not applicable/4 weeks
* Root fracture: none/4 weeks
* Root fracture — cervical third: none/4 months
159
Uncomplicated fracture prognosis
• Wang et al (2014):
- 603 teeth with or without luxation
- Measured pulp necrosis over 6 months
- Increased risk for necrosis with complete root formation and luxation injury
- Pulp necrosis most likely to occur in first 3 months
160
Complicated crown fracture permanent teeth
* Open apex: preserve pulp vitality by pulp capping or partial pulpotomy
* Same treatment for young patients with closed apex
* Calcium hydroxide or MTA (white) are suitable materials for such procedures
* In older patients, RCT can be the choice, but pulp capping or partial pulpotomy may also be selected
161
How does Ca(OH)2 work?
* High pH (12.5) causes necrosis and stimulates hard tissue bridge
* Antibacterial
* May reduce fracture resistance
* Hard tissue bridge may contain vascular inclusions and can be an entry point for bacteria
162
How does MTA work?
* High pH causes coagulation necrosis
* Forms a zone of reparative dentinogenesis
* Dentin bridge forms more quickly with fewer vascular inclusions
* MTA forms a physical bond to dentin that helps decrease bacterial infiltrations
163
What is ankylosis?
* The PDL is fibrous connective tissue that is positioned between cementum and alveolar bone
* It helps dissipate pressure during mastication
* In healthy teeth, release cytokines and growth factors that block osteogenesis within the periodontium
* Ankylosis occurs when damage to cells disrupt normal activity resulting in growth of bone across the ligament space
164
Diagnosis of ankylosis
• More pronounced in growing child
• Tooth appears to be in infraocclusion
• Diagnosis is through clinical assessment
- Position of tooth relative to others
- High pitched sound during percussion
- Radiographs provide limited value
165
Evaluation of infraposition
* Minimal: less than 1/8 crown height
* Moderate: >= 1/8 but < 1/4 crown height
* Severe: >= 1/4 but < 1/2 crown height
* Extreme: >= 1/2 crown height
166
Factors affecting rate of infraposition
* High risk of severe infraocclusion if diagnosed before growth spurt
* Progression varies on an individual bases depending on vertical growth
167
Decoronation
* Malmgren et al suggested decoronation in 1984 as an alternative treatment to extraction of ankylosed teeth which attempts to preserve its surrounding alveolar bone
* Recommended when infraocclusion score reaches moderate level
* Procedure involves gingival mucoperiosteal flap elevation, subcrestal removal of the tooth crown leaving the root in its alveolus to be replaced by bone through replacement resorption
* Ultimate goal is to maintain the alveolar bone ridge width, height, and continuity, and facilitate future rehabilitation with minimal, if at all, ridge augmentation procedures.
168
Consequence of preservation of decoronation roots
Preservation of decoronation roots in the alveolar process not only helps (1) maintain existing bone volume (buccopalatal width of the alveolar ridge) but also (2) enables vertical bone growth which can be observed coronary to the decoronation root
169
Monitoring pulpal vitality
• Laser doppler flowmetry
- Vascular supply is superior to innervation in assessing pulp vitality
- LDF measures pulpal blood flow to assess revascularization
- LDF more reliable in children
- Limitations: interference from blood flow in adjacent tissues, stained teeth, mineralized chambers, cost
170
Pulp canal obliteration
* Color change alone is not a predictor of necrosis
* Total PCO more likely to have necrosis
* Endo indicated if: PA lesion, pain to percussion, negative EPT
171
Oral electrical burns
* Due to biting on electrical cord
* Consult/coordinate with plastic surgeon
* Expect sloughing of eschar in 7-10 days
* Appliance needed to minimize wound contracture
* Fixed commissary appliance delivered 10-14 days after surgery
* Appliance worn for 6-12 months
172
Iagtrogenic injuries in dental office
* Phenol
* Sodium hypochlorite
* Acrylic resin
* Eugenol
* Phosphoric acid etchant
173
What is child abuse and neglect?
Any act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.
174
What is dental neglect?
The willful failure of a parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.
175
Child abuse and dental trauma
Fischer-Owens et al (2017) Pediatrics
• More than half of child abuse cases involve craniofacial, head, face, and neck injuries
- Lacerations to mucosa, tongue, gingiva
- Fractured, displaced, avulsed teeth
- Facial bone or jaw fractures
• Document findings, report injuries if concerning
176
Epidemiology of child abuse and dental trauma
National statistics:
• 50% of victims are under 7 years
• Children who died from maltreatment - 74% were under 3 years
• All races, ethnicities and socioeconomic groups
- 44% Caucasian
- 22% Hispanic
- 21% African-American
177
Who are the perpetrators?
```
• Mostly parents - 91%
- Women 54%, men 46%
• 40-60% were abused as children
• Isolated, young, single parents
• Poverty
• Depression
• Substance abuse
• Unwanted parenthood
```
178
Profile of abused
* Low birth weight
* Physical disability
* Mental disability
* Hyperactivity or aggressively
* One of many siblings
* Age 2-4
* Lives in household with unrelated adults
179
Child abuse findings
• Head and face are most common locations for bruising in abused children
• Bruises are rare in pre-ambulatory children
- “those who don’t cruise, rarely bruise:
• Bruises to torso, ears, and neck in children under 4 are suggestive of abuse
- “TEN 4” mnemonic
• Know how to report issues in your state
180
Does injury match description?
* Where is most common injury from a fall?
* Was injury witnessed?
* Conflicting accounts
181
Sexual abuse
* AAP clinical report: “The evaluation of children in the primary care setting when sexual abuse is suspected”
* In 2006 study, 1.8 children per 1000 were victims of sexual abuse
* More than half of abused children don’t disclose this until they are adults
182
Human trafficking
• Estimated that > 100,000 children are victims of prostitution in the US each year
- Average age is 12; may be as young as 6
- 25% may still be seen by health care professionals
- Both boys and girls are victims of trafficking
183
Münchausen syndrome by proxy ***
* Names for the fictional Baron von Munchausen who performed fanciful and imagined exploits in book by Rudolf Erich Raspe
* Also known as medical child abuse
* Parent fabricates illness of child
* There is no typical presentation of this condition
184
Profile of Muchausen syndrome by proxy
* Usually females (97%) and usually the mother (95%)
* Average age at time child presents: 27 years
* Most are in healthcare related field
* Perpetrator with history of child maltreatment
* Psychological dx: personality disorder, depression, and factitious disorder toward self
