PEDIATRIC DENTISTRY PEDIATRIC DENTISTRY, Exams of Dentistry

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Paediatric Dentistry

At what stage of foetal development do the primary teeth begin the form? - Begins around 13 weeks of pregnancy What are the eruption times (months of age) of the primary dentition? - 6-12 (A's), 9-15 (B's), 16-22 (C's), 13-19 (D's), 23-33 (E's) What is the mnemonic to remember the eruption time of primary teeth? - Don't have 69ers with those under 16 or you will spend 13 years behind bars. Michael Jordan was the best for 10 years. The range of eruption is 6 months for each tooth except E's which there is a 10 year range. How many months before eruption are crowns completed for primary teeth? - Approximately 6 months At what age are the roots complete in primary teeth? - 3.5 years At what age do the permanent anterior teeth start to develop? - 3-5 months of age for anterior teeth. What are the eruption times for the permanent dentition? - 7, 8, 11, 10, 11, 6, 12 for maxillary teeth Mandibular teeth erupt before maxillary teeth by about 1 year Primary Teeth: Eruption Sequence -

1. Mandibular Centrals
2. Mandibular Laterals
3. Maxillary Centrals
4. Maxillary Lateral
5. Mandibular 1st Molar
6. Maxillary 1st Molar
7. Mandibular Canine
8. Maxillary Canine
9. Mandibular 2nd Molar
10. Maxillary 2nd Molar ABDCE Mandibular primary centrals - 6 months Mandibular primary laterals - 7 months Maxillary primary centrals - 7.5 Months Maxillary primary laterals - 9 months Mandibular D's - 12 Months Maxillary D's - 14 months

Mandibular primary canines - 16 months Maxillary primary canines - 19 months Mandibular 2nd Molar - 20 months Maxillary 2nd Molars - 24 months Canines erupt before what in the primary dentition - They erupt before the 2nd molars, and after the 1st molars Roots of primary teeth are completely formed ____ - one year after eruption Root resorption begins ______ - 1 year after root completion As a general rule, decidious teeth normally erupt from anterior to posterior. The exception is the - canines in each quadrant erupt after the 1st molars What medical history questions should be asked for the paediatric patient? - Pregnancy (eg prematurity) and labour problems Serious illnesses Hospitalisations

Medications Cardiovascular and respiratory system problems Allergies Immunisations What dental history questions should be asked for the paediatric patient? - Any dental treatment before Previous behaviour at dentist Any extractions What extra-oral things should you look for in a paediatric patient? - Size and weight Bruising, finger clubbing, hair Swellings, cleft lip/palate Thumb sucking What teeth should you be checking for the presence of at age 10-11 years? - The canines by palpation What factors should be taken into account when assessing caries risk of a child? - Previous caries experience Current dental status Family history and carer status Attendance pattern Oral hygiene Diet Fluoride exposure Sibling experience Medical history

Social factors (eg recent migration) How often should BWs be taken for high risk kids? - Every 6 months until no new lesions for 12 months How often should BWs be taken for moderate risk kids? - Every 12 months How often should should BWs be taken for low risk kids? - Every 12-24 months What defines a kid with moderate caries risk? - One or two new lesions per year What may limit kids under 6 from brushing their teeth effectively? - Grip strength and dexterity What are the 9 month physical milestones? - Sucking, grasping, kicking Coordinated hands and eyes Interested in moving objects Reaches out to grasp Explores by chewing Pushes up then sits Pulls up to stand What are the 9-18 months milestones? - Crawls well, stands, clumsy walking, climbing Investigates by pushing, pulling, banging

Starts to hold things in thumb and forefinger Practises skills repetitively What are the 18 months - 2.5 year physical milestones? - Toddles and falls frequently Kicks and throws a ball clumsily Learning to use the toilet Holds objects with hands What are the 2.5-3.5 year physical milestones? - Runs and falls frequently Walks up stairs one at a time Moves fingers independently Jumps with both feet Attempts to self dress What are the 3.5-5 year milestones? - Runs smoothly and negotiates curves Stands on one foot and toes Walks up stairs with alternate feet catches balls in arms Threads beads Enjoys arts and craft What are some behavioural methods for removing anxiety in children? - Tell-show-do Playful humour Distraction Positive reinforcement

Modelling Shaping Fading Systematic desensitisation What is the dose of paracetamol for children? - 20mg/kg preoperatively then 15mg/kg every 4 hours Max dose 90mg/kg/day for 2 days then 60mg/kg/day What is the dose of ibuprofen for children? - 5-10mg/kg every 8 hours with a max dose of 2g/day What are the contraindications of using NSAIDs in children? - Bleeding tendencies, renal disease, thrombocytopaenia, asthma What teeth are classically invovled with early childhood caries? - Primary maxillary incisors, later the first primary molars. Canines erupt after the D so aren't affected as often How should parents clean their children's teeth? - Clean the teeth as soon as they erupt but dont use toothpaste until 18 months old. from 18 months to 5 use childrens toothpaste (500ppm). In those over 6 years normal adult toothpaste (1000ppm) can be used. Can flouride varnish be used in children under 10? - Yes Can flouride gel be used in children under 10? - No

When should fissure sealants be placed? - In all permanent molars if moderate to high caries risk. In premolars if high risk. Only deep and retentive fissures in children with low risk. What are the contraindications for pulp therapy in primary teeth? - Congenital cardiac disease due to risk of bacterial endocarditis Immunosuppressed patients Children with poor wound healing eg uncontrolled diabetes Behavioural factors Dental factors (eg exo is ok if within 3 years of exfoliation) What are the indications for pulpotomy in primary teeth? - Asymptomatic or mild transient pain (reversible pulpitis) Carious pulp exposure No radiographic radicular pathology Restorable tooth What pulpotomy medicaments are available? - Ferric sulphate (used in clinic) Formocresol (potential carcinogen) MTA (stimulates dentine bridge formation) Electrocautery Calcium hydroxide What are the contraindications for pulpotomy in primary teeth? - Spontaneous unprovoked pain (irreversible pulpitis) Mobilty, TPP Swelling, sinus

Root resorption/radiolucency What is the procedure for pulpotomy in a primary tooth? - LA and rubber dam Caries removal Removal of roof of pulp chamber Removal of coronal pulp tissue Arrest bleeding at amputation site with ferric sulfate for 15 seconds followed by rinsing and drying Place base of IRM Place GIC core Restore with SCC'Regular radiographic assessment Premature loss of which tooth may result in loss of arch space? - The E's. If these are lost prematurely then the permanent 6's will drift mesially What unilateral space maintainers are available? - Band and loop Crown and loop Distal shoe Removable denture What bilateral space maintainers are available? - Transpalatal arch Nance palatal arch (with acrylic button) Lingual arch (like TPA) How are primary teeth different to permanent teeth? - More bulbous Broad contact points

Thinner enamel and dentine Enamel surface is aprismatic so etching isn't as effective Larger pulp chambers What rubber dam technique is used for children? - Slit dam technique What restorative material would you use for a compliant child in a posterior class II cavity? - CR or compomer When are stainless steel crowns indicated? - Extensive decay Following pulpotomy/pulpectomy Malformed/fractured teeth What are some contraindications for stainless steel crowns? - Teeth nearing exfoliation Caries beneath the level of the alveolar bone What is the desired amount of occlusal reduction for a SCC prep? - 1.5mm occlusal reduction What is the Hall crown technique? - SCC cemented over carious tooth without LA or rubber dam and no caries removal or tooth prep. When may anterior strip crowns be required? What are their success rates? - ECCs or other caries affecting the upper anteriors. 50% success rate. What is alternative restorative treatment? -

A conservative restorative method where traditional procedures aren't possible. Involves using hand instruments for removal of infected dentine and weak enamel. GIC is used as the restorative material. Which direction is the shunt for acyanotic heart defects in children? What may cause this? - Left to right shunt may be caused by ASD, VSD, PDA, coarctation of the aorta, aortic stenosis, What are the oral manifestations of cardiac defects? - Enamel defects, malocclusion, delayed dental development, increased caries risk due to enamel anomalies and sucrose within cardiac medications and high-caloric supplements ipa, intra-oral cyanosis. What may cause cyanotic defects? - Tetralogy of fallot, transpostion of the great vessels, pulmonary atresia When is antibacterial prophylaxis required for children? - When an invasive dental procedure is being undertaken where there is bleeding AND:

1. Previous history of endocarditis or rheumatic heart disease
2. Prosthetic heart valve
3. Cardiac transplant recipients who develop a valvulopathy
4. Unrepaired cyanotic shunts
5. Repaired heart defects using prosthetic materials for at least 6 months after the procedure
6. Repaired defects with residual defects What is the protocol for antibiotic prophylaxis in children? - Amoxicillin 50mg/kg 30-60 minutes prior to procedure OR Cefalexin 50mg/kg (if allergic to penicillin) OR Clindamycin 20mg/kg (if been on Cefalexin long term)

What are the features of Tetralogy of Fallot? -

1. VSD
2. Pulmonary stenosis
3. Overriding aorta
4. RV hypertrophy Why is pulpotomy contraindicated in children with congenital heart defects? - Due to the risk of bacteremia and infective endocarditis How does failure of primary haemostasis (platelet plug) manifest? - Petechiae and purpura or ecchymoses How does failure of secondary haemostasis manifest? - Bleeding in to deep structures such as muscles and joints. How may you screen for vWD? - PFA 100 (platelet function test) What test measures the intrinsic pathway of coagulation? - Activated partial thromboplastin time (APTT) What test measures the extrinsic pathway of coagulation? - Prothrombin time What three broad categories may disorders of haematology be broken into? - Disorder of:
5. Vasculature (eg vit C deficiency)
6. Platelets (eg malignancy, chemo, ideopathic thrombocyopaenic purpura)
7. Coagulation disorders (haemophilia, vWD, vit K deficiency)

What are the dental management principles for children with bleeding disorders? - Atraumatic technique Avoid block injections Use rubber dam to protect tissues Endo is ok Perio requires factor replacement Avoid exo or surgery outside of a hospital Tranexamic acid post surgery 4.8% mouthwash (antifibrinolytic) Avoid NSAIDs What are the oral manifestations of immunodeficiency? - Candida Abscess formation Gingivostomatitis Recurrent herpes Premature exfoliation Delayed wound healing What are the management principles for children with immunodeficiencies? - Meticulous preventive regime Chlorhexidine mouthwash 0.2% BID Prophylactic ABs, antifungal and antivirals during treatment What are the potential oral manifestations of impaired renal function? - Uraemic stomatitis Oral ulceration Intrinsic and extrinsic tooth staining Excessive calculus

Enamel hypoplasia and hypocalcification Delayed dental development Brown tumours (secondary hyperparathryroidism) Poor wound healing Prolonged bleeding (platelet dysfunction) What are the dental management principles for children with renal impairment? - Consultation with renal physician Postpone elective treatment if acute renal conditions Pre-treatment screening for APTT Extraction of pulpally involved teeth May be on long term corticosteroids What are the dental management principles for a patient on dialysis? - Prophylactic ABs to prevent infection of access device Treat the day after dialysis when heparin no longer active Pack sockets with haemostatic agent and sutured closed What drugs should be avoided in children with renal insufficiency? - Paracetamol NSAIDs Penicillin Tetracycline What are the dental implications of liver and biliary disorders? - Coagulation problems Immunocompromise Green intrinsic staining due to hyperbilirubinaemia Developmental defects in teeth

Delayed eruption Gingival hyperplasia Perio What are some examples of liver and biliary disorders in children? - Biliary atresia Alpha 1 anti-trypsin deficiency Hepatitis What are the dental management principles for a patient with liver or biliary dysfunction? - Consultation with gastroenterologist Aggressive management of caries with extraction of suspect teeth Antibiotic prophylaxis as required What are the dental implications for children with type 1 diabetes mellitus? - Perio Xerostomia Intra-oral abscesses Enamel hypocalcification and hypoplasia Increased caries risk Candidal overgrowth What are the dental management principles for a child with type 1 DM? - Have glucose on hand incase of hypo Antibacterial prophylaxis before surgical procedures Take measures to reduce chance of post surgical infection What are the dental implications for children with epilepsy? - Gingival overgrowth

Precipitation of a seizure in the dental chair What are the dental management principles for a child with epilepsy? - Optimal oral hygiene to minimise gingival overgrowth Gingivectomy if permanent dentition Reduce stressful appointments Avoid direct overhead lighting and adrenalin containing LA Have oxygen, phenobarbital and diazepam on hand GA if poor seizure control Use mouth props Early morning appointments Keep sharp instruments away from patient What are the dental implications for children with respiratory disease? - Enamel defects Erosion from acidic precipitate from puffer Exacerbation of acute asthma attack Some bronchodilators and corticosteroid inhalers may cause extrinsic staining Candidiasis due to corticosteroid inhalers Immunocompromised if on high dose corticosteroids What are the dental management principles for a child with respiratory disease? - Rinse mouth following use of puffer Treat in a hospital setting if frequent episodic asthma attacks Avoid adrenalin LA Bring their meds to the appointment Don't treat them if they have URT infection What are the different pulpotomy medicaments? -

Devitalisation (formocresol, electrosurgery) Preservation (ferric sulfate, laser) Regeneration (MTA, calcium hydroxide) What are some differential diagnoses for ulcerative lesions in the mouth of a child? - Primary herpetic gingivostomatitis (HSV-1) Hand foot and mouth (Coxsackie) Herpangina (Coxsackie) Infectious mononucleosis (EBV) Varicella Traumatic (following block injection) Aphthous ulcers What are some differentials for vascular lesions in the mouth of children? - Haemangioma AV malformation Haematoma What are some differentials for an epulis? - Fibrous epulis Pyogenic granuloma Peripheral giant cell granuloma Congenital epulis of newborn What are some causes of gingival overgrowth in children? - Drug induced hyperplasia (phenytoin, cyclosporin, nifedipine, verapamil) What is the probable toxic dose of fluoride for children? - 5mg/kg or 60-100mg in total or half to one tube of 1000ppm toothpaste

What measures should be taken in the case of fluoride toxicity? - Do not induce vomiting due to aspiration and oesophageal burn from hydrofluoric acid Give as much milk as possible or 5% calcium gluconate Admit to hospital and observe What syndrome may present with multiple supernumerary teeth? - Cleidocranial dysplasia What condition may a single median maxillary central incisor associated with? - GH deficiency What are the features of cleidocranial dysplasia? - Short Aplasia of clavicles Frontal bossing Maxillary hypoplasia Supernumary teeth Delayed eruption What syndromes may produce taurodonts? - Ectodermal dysplasia Amelogenesis imperfecta How would you manage a horizontal root fracture in a primary tooth with grade I mobility (patient is one month post congenital heart defect repair)? - If no displacement - soft diet, monitor If displaced - if repaired with prosthesis AB prophylaxis (50mg/kg Amoxicillin) and exo of coronal fragment.

What if this tooth developed a draining sinus? - AB prophylaxis and exo of apical portion, drainage. If soft tissue swelling, fever then amoxicillin (25mg/kg tds 7 days). What problems does trauma to the primary incisors have for the permanent successor? - If under 4 years old: White or yellow-brown discolouration of enamel Enamel hypoplasia Crown dilaceration Odontomal like malformation Eruption disturbances Root abnormalities *What is the fluoride regimen for an 8y.o. with several carious teeth from a non fluoridated area? * - High risk

1. Twice daily toothbrushing with fluoride toothpaste 1000ppm
2. 0.5% neutral NaF mouthwash at a time other than brushing
3. Fluoride varnish 22600ppm to active lesions AND 3 monthly professional APF application 12300ppm. What is the fluoride regimen for moderate caries risk children (1 or 2 lesions per year)? -
   1. Twice daily toothbrushing with 1000ppm fluoride toothpaste
4. 0.05% neutral fluoride mw at a time other than toothbrushing
5. Fluoride varnish 22600ppm to active lesions AND 3 monthly professional APF application 12300ppm. Fluoride for a 2 year old? - Twice daily toothbrushing with 500ppm toothpaste, pea sized amount Supervise brushing For drinking water dissolve one 2.2mg F- tablet in 1L of water.

Avoid bottle feeding at night Substitute bottle for sippy cup