Pediatric
Dentistry – Fall Midterm Exam Review
Pulp Therapy for Primary and Young Permanent Teeth
Management of Traumatic Injuries
Pulp
Therapy for Primary and Young Permanent Teeth
1)
Indicate the
relative value and degree of reliability of the various diagnostic parameters
in primary and young permanent teeth
|
Parameter |
Component |
Value |
|
Radiographic Examination |
Pathologic Bone Resorption |
- May indicate widespread pulpal necrosis and non-vitality of associated tooth - Care should be taken with primary dentition as radiolucencies in bone may be normal and associated with development of tooth |
|
Pathologic Root Resorption |
- Indicates presence of prolonged infection - No pulp therapy here |
|
|
Internal Resorption |
- Indicates advanced degeneration in pulp - Pulp therapy unsuccessful (unable to stop the resorptive process) |
|
|
Calcific Mass/Globules |
- Indicate advanced degeneration of pulp - Also spread of inflammation |
|
|
Soft Tissue Examination |
- Soft boggy tissue - Swollen, inflamed - Exudate accumulation under skin (parulis) - Chronic may show as a fistula - Severe may show as cellulitis |
Pulpal necrosis will often manifest with changes in the soft tissue Any of these situations indicate irreversible state and most likely necrotic |
|
Pain |
Absence of pain |
- Cannot be used as the sole criterion for pulpal necrosis - Many primary pulps degenerate and become necrotic without pain |
|
Presence of pain |
- Can aid in determining pulpal health - Spontaneous/unsolicited toothache is evidence of advanced pulpal degeneration - May also indicate food impaction or excess cement from a recent SSC - Solicited pain (i.e, chewing) indicates lesser degree of inflammation - History of pain indicates extensive pulpal inflammation - Sharp pain may indicate carious exposure of dentinal tubules (brought on by hot/cold/sweet) - Throbbing pain indicates pulpal inflammation, but is not definitive |
|
|
Mobility |
Relates to the degree of resorption of the root whether normal or not |
- Teeth with necrotic or extensively inflamed pulp often exhibit mobility - Not diagnostically valuable alone - May be valuable with radiographic evidence |
|
Percussion |
Better with older children |
- May indicate PDL inflammation - Depends on the reliability of the child’s response - Little diagnostic value in young children |
|
Pulp Tests |
Primary Teeth |
EPT, and Hot/Cold Tests Often unreliable Little or no diagnostic value False positives are common |
|
Permanent Teeth |
Vitalometer à particularly valuable for fully formed tooth, but NOT partially developed Hot/Cold Tests à also valuable |
2)
Suggest the status
of the pulp based on a review of the diagnostic parameters
Use the information in question 1
3)
Given all necessary
diagnostic information in a case study format, recommend appropriate treatment
for the pulp
|
Procedure |
Benefits |
Indications |
Contraindications |
|
Formocresol Pulpotomy |
- Preserves
a functional tooth - Maintain
space in arch - Removes
bacterial contamination - Reduces inflammation
and degeneration of pulp - Places medicament
near normal pulpal tissue |
- In Vital
Primary Teeth - Pulpal exposure during caries removal - History of solicited pain with radiographic deep
carious lesion - Mechanical exposure of a primary tooth |
- Immunocompromised patient - At risk of bacterial sepsis - History of spontaneous pain - Presence of swelling (abscess or parulis) - Excessive bleeding from root canals
(not controlled with cotton pellets in 2-3 minutes) - Pulpal blood that is extremely dark
colored |
|
Pulpectomy |
- Conserves non-vital primary teeth - Maintain space in arch Factors to Consider - General Health of Patient - Tooth involved (primary anterior teeth are good
candidates) - Chronology (critical to preserve primary molar
during period of primary dentition) |
- No vital pulp tissue in canals - Necrotic pulp tissue observed on entering chamber - Radiographic evidence of furcation/perio
involvement - Soft tissue manifestations - Internal resorption - History of spontaneous pain - Presence of swelling (abscess or parulis) - Excessive bleeding from root canals (not
controlled with cotton pellets in 2-3 minutes) - Pulpal blood that is extremely dark
colored |
- Immunocompromised patient - At risk of bacterial sepsis - Radiographic evidence of pathologic root
resorption and/or advanced root resorption |
|
Indirect Pulp Cap Glass ionomer«is used to cover the area left after all caries
removed except that which is directly over the pulp chamber |
- Relatively simple to perform - Carious dentin that has not completely demineralized can remineralize - Seal off bacteria in deep layers of dentin which
become dormant - Does not produce surgical trauma by mechanically
invading the pulp chamber - Dose not introduce dentin chips and bacteria into
the pulp - Produces more reparative dentin than direct pulp caps
or pulpotomies |
- Radiograph shows that a near or probable pulp
exposure exists - No history of prolonged or spontaneous pain - No sensitivity to percussion - No redness or swelling - No mobility - No bone loss - No internal resorption - A definitive, positive response to vitalometer |
- Primary teeth with deep caries |
|
Direct Pulp Cap A minimally exposed pulp is protected with an
antiseptic and sedative agent |
- Allows pulp to recover and maintain its normal
vitality and function |
- Vital pulp - No history of prolonged or spontaneous pain - No sensitivity to percussion - No redness or swelling - No mobility - No bone loss - No internal resorption - Traumatic exposure when treated within a few hours - Pin-point exposures - Pt in good general health - Use in Permanent
Teeth only |
- Primary teeth with carious pulp exposure (high
failure rate near 50%) |
|
Apexogenesis (CaOH Pulpotomy) |
- Pulp may not remain healthy, but it will be strong
enough to undergo RCT - MTA is preferred over CaOH
due to better biocompatibility - Allows apex to mature and dentin walls the thicken - Allows radicular pulp to
remain vital |
- Young vital
permanent teeth with incomplete
apices - Large pulpal exposure during caries removal in
asymptomatic teeth - Traumatic injury with pulpal exposure - No history of prolonged or spontaneous pain - No sensitivity to percussion - No redness or swelling - No mobility, bone loss, or internal resorption |
- Not for primary teeth |
|
Apexification |
- Provides apical stop to facilitate obturation of
canal - MTA is preferred over CaOH |
- Incompletely formed roots of non-vital permanent teeth where a pulpectomy is indicated |
- Not for primary teeth |
§ Primary Teeth § Permanent Teeth
4)
After appropriate
diagnosis with an understanding of benefits, indications and contraindications,
be able to perform the following
|
Procedure («) |
Technique |
|
Formocresol Pulpotomy |
1.
Access pulp
chamber w/ #330 bur 2.
Remove pulp
tissue w/ sharp excavator or slow speed round bur (#4,6,8) 3.
Flush
chamber with water then dry with cotton pellet 4.
Formocresol
moistened cotton pellets are placed to cover the floor of the chamber 5.
Fill pulp
chamber with a thick mix of IRM 6.
Reduce
occlusion and use IRM as temporary |
|
Pulpectomy Complete removal of pulp tissue from a non-vital
primary tooth |
1.
Access pulp
chamber w/ #330 bur 2.
Remove all
necrotic tissue from chamber and canals 3.
Instrument
canals with endo files (30 or 40 for molars, larger
for anteriors) 4.
Dry canals
with paper points, then fill with ZOE 5.
Canals can
be filled using root canal condensers, a Lentulo
spiral, a pressure syringe (Pulpdent), or a Eugoseal syringe (Centrix) 6.
Restoration
of choice is SSC for posteriors |
|
Indirect Pulp Cap Glass ionomer«is used to cover the area left after all caries
removed except that which is directly over the pulp chamber |
1.
Prepare
tooth to ideal 2.
Place a
layer of glass ionomer covering all exposed dentin 3.
IF dentin is
sound, then a restoration can be placed 4.
IF affected
dentin remains, place an IRM temp for 6 months |
|
Direct Pulp Cap A minimally exposed pulp is protected with an
antiseptic and sedative agent |
1.
Prepare
tooth to ideal 2.
IF pulp is
exposed, and criteria are met for Direct Pulp Cap… 3.
Apply MTA
over the exposure 4.
Cover MTA
and remaining deep dentin with glass ionomer (ensure complete seal) 5.
Place
restoration similar to steps 3 and 4 of indirect pulp cap |
|
Apexogenesis (CaOH Pulpotomy) |
1.
Proceed
with steps 1, 2, and 3 of Formocresol Pulpotomy 2.
Place MTA
over amputated stumps 3.
MTA and
surrounding tooth structure is covered with glass ionomer 4.
Final
restoration may be placed, but additional treatment may be needed later 5.
Secure two
radiographs prior to patient dismissal used for future comparison 6.
Recall the
patient in 6 months to check status 7.
Subsequent
recalls will depend on patient’s progress |
|
Apexification |
1.
Pulpectomy 2.
Irrigate
with NaOCl 3.
Dry canals
with paper points 4.
Place
apical MTA plug to create apical stop 5.
Fill with gutta-percha
and monitor for periapical healing 6.
Get a
post-op PA and bitewing 7.
Recall
patient in 6 months |
§ Primary Teeth § Permanent Teeth
Summary of Procedures
|
Procedure |
Primary Teeth |
Permanent Teeth |
|
Indirect Pulp Cap |
ü (glass inomer) |
ü (glass ionomer) |
|
Direct Pulp Cap |
NO |
ü (MTA/glass ionomer) |
|
Formocresol Pulpotomy |
ü (IRM/SSC) |
NO |
|
Formocresol Pulpectomy |
ü (ZOE/IRM/SSC) |
NO |
|
Apexogenesis |
NO |
ü (MTA/glass ionomer) |
|
Apexification |
NO |
ü (MTA/gutta percha) |
5)
Discuss the reaction
of pulpal tissue to formocresol
Formocresol contains formaldehyde and cresol.
Formaldehyde à results in varying degrees of loss of pulp vitality
Forms intra- and inter-molecular bridges between various amino groups
Results in a fixing of the tissue (prevents autolysis)
Cresol
à
expected to cause pulpal necrosis
Disrupts the cell-membrane and denatures proteins
Will provide some bactericidal benefit (“sterilizes”) pulp interface, but also causes some damage
Acts to chemically cauterize area surrounding radicular stumps in pulpotomy
Induces a limited zone of inflammation in the pulp tissue
6)
Understand why it is
not advisable to use direct and indirect pulp caps in the primary dentition
Direct pulp caps are not used in the primary dentition
à because of high failure rate (near 50%)
Indirect pulp caps are not typically used in primary dentition
à because there is usually a small pulpal exposure
à if used, all dentinal tubules must be covered with glass ionomer («)
7)
Discuss the
treatment planning considerations in deciding to perform a complete pulpectomy
on a primary tooth
General Health of the Patient
Immunocompromised or at risk for SBE is not a candidate
Tooth involved
Primary anterior teeth can readily be treated (large canals, easy access)
These become devitalized more often from trauma
Chronology
Critical to preserve primary molar during period of primary dentition (as opposed to mixed)
As primary molars age, there is á deposition of secondary dentin creating irregularities in the canal
8)
Know the appropriate
treatment for emergency pulpal problems
Usually associated with advanced degeneration of pulp
Usually requires pulpectomy, for preservation of tooth
Extraction is an alternative
Antibiotic Therapy for pyogenic infections (fever alone is not an indication for antibiotics)
Amoxicillin 20-40 mg/kg/24hr Q 8h
Clindamycin 10-25 mg/kg/24hr Q 8h (for penicillin sensitivity)
Acetaminophen (or other analgesic may be necessary)
Treatment should never be attempted with systemic antibiotic alone
Extractions are not done in the presence of acute infection
9)
State the
indications for the use of mineral trioxide aggregate, glass ionomer materials,
ZOE and IRM
|
Mineral Trioxide Aggregate (MTA) |
- Powder of hydrophilic particles - Sets in the presence of moisture - Highly biocompatible - Forms a good seal, once set - May have some inductive effect on cementoblasts |
|
- Placed over pulp exposure in direct pulp caps - Also over amputation stumps in apexogenesis - Also an apical plug/stop in Apexification techniques |
|
|
Glass Ionomer Materials |
- Ideal for sealing dentin due to adhesive characteristics - Releases fluoride - Fast setting (light cured) - Micro-mechanical attachment with composite - Somewhat soluble in oral fluids - May wash out over time - Hybrids are much less soluble; retain excellent dentin seal |
|
- Placed over deep portions of moderate/deep carious lesions - Also placed over MTA to prevent microleakage |
|
|
Zinc Oxide & Eugenol (ZOE) |
- An obtundant (sedative) and effective insulator - Forms a good seal to prevent leakage, salivary contamination and pulpal degeneration - Inhibitory of microbial growth (not destructive) - Is hygroscopic (removes moisture) - Non-irritating to the pulp (similar pH) - Eugenol, alone, can be toxic to tissues |
|
- Used to fill root canals of pulpectomized primary teeth - Does not set to hard consistency, so it is highly resorbable - Not a good restorative material |
|
|
Reinforced Zinc Oxide & Eugenol (IRM) |
- May prevent in-growth of bacteria (due to good seal and/or bactericidal properties) |
|
- Used as a temporary restoration for caries control in primary teeth - May be used for direct or indirect pulp caps in permanent teeth - Also used in the pulpotomy procedure in primary teeth |
10) Be familiar with Pacific Pediatric Clinic policies and
procedures («)
relating to pulp therapy and young permanent teeth
Formocresol Pulpotomy, Pulpectomy, Indirect Pulp Cap, Direct Pulp Cap, Apexogenesis, Apexification
Use of glass ionomer
Management of Traumatic Injuries in Pediatric Patients
1)
Describe and understand
the general characteristics of trauma incidents as they relate to patient
dentition
|
Primary Dentition |
Mixed Dentition |
|
- 1.5 – 2 years of age - first steps, á motor coordination - luxation injuries are more common (short clinical crowns, less calcified bone, thin cortical plates) |
- 8 – 11 years of age - sports related, â parental supervision - class II with significant overjet predisposes incisors to traumatic injury - dental fractures are more common (longer clinical crowns, bone more dense, thicker cortical plates) |
Luxation
is just a fancy word for dislocation
2)
Know the components
of thorough trauma assessment and the importance of each
|
History |
* MHx, DHx à need for tetanus and/or antibiotic? * How did the incident occur? * Location of incident (chance of wound contamination) * Time of injury (elapsed time since injury) * Soft tissue management (any fragments?) |
|
Extra-oral Exam |
* Other injuries requiring treatment * Consciousness assessment à
chance of concussion? * Oral Function à a blow to the chin can cause condyle fract. |
|
Intra-oral Exam |
* Assess secondary injuries * Look for debris/fragments in tissue may need to confirm with x-ray |
|
Radiographic Exam |
* Root development of involved teeth * Locate/delineate fracture (x-rays from diff. angles) |
3)
Know the general
principles for treatment of trauma injuries
|
Initial Treatment |
* Calm patient and/or parent * Clean child’s face for clear visualization of injuries * Explain each step to child before you do it * Addressing injury * Select appropriate follow-up treatment protocols |
|
Follow-up Treatment |
* Plan appropriate treatment * Inform patient and parent |
4)
Know the Ellis
classification system of traumatic injuries to the dentition
|
Type of Injury |
Primary Tooth |
Permanent Tooth |
|
Ellis Class I Fracture Enamel only |
Tx: Smooth
rough edges (sensitivity?) Composite Follow-up Prog: Good |
Tx: Smooth rough
edges (sensitivity?) Composite Follow-up Prog: Good |
|
Ellis Class II Fracture Enamel + Dentin |
Tx: Protect
pulp (glass ionomer) Composite (re-attach fragment?) Soft diet Follow-up Prog: Good (best w/ early tx) |
Tx: Protect
pulp (glass ionomer) Composite (re-attach fragment?) Soft diet Follow-up Prog: Good (best w/early tx) |
|
Ellis Class III Fracture Enamel + Dentin + Pulp |
Tx: Pulpotomy
or Pulpectomy Prog: Good if treated quickly and small exposure; Poorer with increasing size of exposure and length of time exposed |
Small Exposure – Recent Tx: Direct
Pulp Cap (MTA) and glass ionomer (bandage) Composite restoration Evaluate root development at follow-up Prog: Guarded Small Exposure – Not Recent Tx: Apexogenesis or Apexification RCT when root complete or closed Prog: Guarded Large Exposure – Recent Tx: [Incomplete Root] Apexogenesis Evaluate root at follow-up RCT when root complete Prog: Guarded Tx: [Complete Root] RCT Prog: Guarded Large Exposure – Not Recent Tx: [Incomplete Root] Apexification Evaluate apical stop at follow-up RCT when apical stop present Prog: Guarded Tx: [Complete Root] RCT Prog: Guarded |
|
Ellis Class IV Fracture Root fracture |
Tx: Extract
coronal fragment, leave apical fragment to resorb Prog: Possible
damage to permanent tooth Apical fragment may become symptomatic |
Tx: Reduce
fracture Non-rigid splint x4 wks (add 2 wks with bone
fracture) Systemic antibiotics Soft diet Monitor coronal fragment (degeneration indicates
pulp removal) Prog: Apical
1/3 à
good Middle 1/3 à fair Coronal 1/3 à poor |
5)
Know the
description, treatment and prognosis for all types of displacement injuries in
both primary and permanent teeth
|
Type of Injury |
Primary Tooth |
Permanent Tooth |
|
Concussion Bumped tooth No mobility No true displacement Percussion sensitive Potential tooth discoloration |
Tx: Soft
diet and observe Prog: Good |
Tx: Soft diet
and observe Prog: Good |
|
Subluxation Mobility No true displacement Percussion sensitive Potential tooth discoloration Potential pathologic resorption |
Tx: Observe Prog: Good |
Tx: Observe Prog: Good |
|
Lateral Luxation Lateral displacement (M-D, B-L) PDL compressed Associated fracture of cortical plate |
Tx: Extract
to avoid permanent tooth damage Evaluate for alveolar plate fracture (BL
displacements) Prog: Possible permanent tooth damage |
Tx: Evaluate
for alveolar plate fracture (B-L displacements) Reposition Non-rigid splint x3-4 wks Soft diet Systemic Antibiotics Prog: Better if
incomplete root PDL resorption common |
|
Intrusion Luxation Apical displacement of tooth |
Tx: Observe Spontaneous re-eruption w/in 3 mos Prog: Primary
tooth may discolor May eventually necrose High risk of permanent tooth damage |
Incomplete Root Tx: Loosen,
wait for re-eruption Ortho extrusion within 3 wks Prog: Possible
revascularization Possible ankylosis/resorption Complete Root Tx: Surgical
repositioning Ortho extrusion within 3 wks RCT Prog: High
risk of ankylosis/resorption Pulpal necrosis common w/out RCT Pathologic root resorption up to 10 yrs later |
|
Extrusion Luxation Coronal displacement w/out complete loss of tooth |
Tx: Extraction Prog: Possible damage to underlying permanent teeth |
Incomplete Root Tx: Reposition Non-rigid splint x2-3 wks Systemic antibiotics Observe Prog: Possible
revascularization Possible ankylosis/resorption Complete Root Tx: Reposition Non-rigid splint x2-3 wks Systemic antibiotics RCT Prog: Good |
|
Avulsion Loss of tooth May have cortical plate fracture(s) |
Tx: Evaluate
for alveolar plate fracture DO NOT re-implant Incisor à no space loss Posterior à space maintenance Prog: Possible damage to permanent tooth |
Tx: Reimplant
ASAP after rinse w/ Hank’s solution or saline DO NOT scrub tooth root Doxycycline if incomplete root Non-rigid splint x7-10 days Tetanus prophylaxis [Incomplete
Root] à x-ray in 2-3 wks remove pulp if resorption noted (MTA fill) [Complete
Root] à remove pulp in 7-10 dys GP fill after 2-4 wks Prog: Guarded (ankylosis and resorption) |
|
Infarction Craze line in enamel w/out loss of tooth structure Visualized during transillum. |
Tx: None Prog: Good |
Tx: None Prog: Good |
6)
Know the description,
treatment and prognosis for all types of dental fracture injuries in both
primary and permanent teeth
See question 4
7)
Be familiar with the
Pacific Pediatric Clinic “Evaluation of Dental Trauma” form
1)
Discuss the
pre-surgical considerations when planning primary tooth extractions
|
Medical History |
Allergies, bleeding problems, cardiac or pulmonary disorders, etc. |
|
Consultations |
Obtain all necessary medical and/or dental consults prior to appointment |
|
Radiographs |
Current; clearly show entire tooth to be extracted and surrounding structures PA is usually required unless bitewing shows complete crown and root |
|
Emergencies |
Anticipate emergencies Tooth aspirations, allergic reactions, etc. |
|
Preparation |
Be well prepared Have all anticipated instruments ready prior to seating the patient |
|
Patient Behavior |
Anticipate any behavior management issues |
2)
Discuss the indications
for extractions in pediatric patients
i. Parulis or fistula formation associated with the tooth
ii. Facial swelling associated with abscessed tooth
3)
Discuss appropriate
local anesthesia techniques in pediatric patients
Profound local anesthesia is essential, and should be confirmed prior to starting extraction
Nitrous oxide/Oxygen analgesia is often useful
See Fall Midterm Review for anesthesia techniques
4)
Know armamentarium
for extraction of maxillary and mandibular primary tooth extractions
5)
Know the extraction
techniques and instrumentation for maxillary primary anterior and posterior
teeth
Maxillary Anterior
a) All maxillary anterior teeth have a conical root shape
b) Epithelial attachment is separated with periosteal elevator or curette
c) No. 1 forceps is seated apical to the height of contour of the crown
d) Free hand fingers are place on the buccal and palatal alveolar bone
e) Slow, constant rotational force is applied
f) Only after tooth is well luxated is an extrusive force applied
g) DO NOT compress alveolus following tooth removal
Maxillary Posterior
a) Epithelial attachment is separated with periosteal elevator or curette
b) Tooth is luxated with a straight elevator à adequate luxation can lessen probability of separated root tips or make removal of root tips easier
c) No. 150S forceps are seated apical to height of contour of the crown
d) Free hand fingers are placed on the buccal and palatal alveolar bone
e) Palatal movement is initiated first, followed by alternate buccal and palatal movements
f) NO rotational forces are applied
g) Only slow, continuous forces are applied to expand the bone and prevent root fracture
h) DO NOT compress alveolus following tooth removal
6)
Know the extraction
techniques and instrumentation for mandibular primary anterior and posterior
teeth
Mandibular Anterior
a) All mandibular anterior teeth have a conical root shape
b) Use free hand to support the mandible, as well as mouth prop (« Molt Prop®) to prevent TMJ injury
c) Epithelial attachment is separated with periosteal elevator or curette
d) No. 1, 44S, or 20 forceps is used to apply rotational forces (crowding may indicate use of buccal and lingual forces prior to rotational forces)
e) Extrusive forces are applied after the tooth is thoroughly luxated
f) Take care not to luxate adjacent teeth
g) DO
NOT compress alveolus following tooth removal
Mandibular Posterior
a) Use free hand to support the mandible, as well as mouth prop (« Molt Prop®) to prevent TMJ injury
b) Epithelial attachment is separated with periosteal elevator or curette
c) Tooth is luxated with a straight elevator
d) No. 151S forceps is used to provide slow, continuous buccal and lingual forces
e) Extrusive forces are applied after the tooth is thoroughly luxated
f) DO NOT compress alveolus following tooth removal
7)
Discuss the avoidance
and management of primary root fractures resulting from extractions
|
Common Etiologies |
s Internal or external root resorption s Ankylosis of tooth being extracted s Failure to adequately elevate before using forceps s Root fracture secondary to trauma |
|
Sequele of Separated Root |
s May become source of post-operative infection (abscess) s May erupt with the permanent tooth as a sequestrum s May resorb normally (most common outcome) |
|
Removal of Separated Root |
s Attempt to remove when clearly visible and accessible |
|
Considerations for Leaving Separated Root |
s After several failed attempts (firmly embedded) s Damage to underlying permanent tooth is likely if removed |
|
Follow-Up for Un-removed Separated Root |
s Post-operative radiograph and clear chart entry s Explanation to parents regarding signs of abscess s Monitor at subsequent patient visits |
8)
Discuss the
prevention of aspiration during primary tooth extraction
Caution patient to avoid swallowing
Gauze screen (“tooth net”) made from unfolded 2x2 gauze placed distal to the tooth being extracted
Upright positioning («NOT used in Pacific Pediatric Clinic)
9)
Discuss the
management of suspected aspiration during primary tooth extraction
|
Fragment Location |
Action Taken |
|
Patient’s Mouth |
Turn patient onto left side and retrieve Aspiration is more likely via right mainstem bronchus in small children |
|
Not Retrieved |
Order a chest film immediately with request to locate foreign object |
|
GI Tract |
Should be expelled with time |
|
Respiratory Tract |
Must be retrieved endoscopically |
10) Discuss post-operative instructions that should be given
to the patient and his/her parent(s)
¨ Have patient bite on gauze for 30 minutes (avoid chewing)
¨ Remind patient (and parent) to avoid lip/cheek biting («Patients get a sticker at Pacific Pediatric Clinic)
¨
Patient is to brush daily
1st day à
rinse mouth to clean
After 1st day à
resume brushing with rinsing
¨ Remind parents that bleeding stimulates saliva, which can give the appearance that bleeding is more copious than it actually is
¨ Written post-operative (home language) instructions are helpful
¨ Give parents a contact number for post-operative questions/emergencies
11) Describe the appropriate post-operative pain management
for pediatric patients
OTC Children’s Tylenol (acetaminophen) is usually adequate
Stronger medications (Tylenol 3, etc.) are not usually necessary
12) Be familiar with Pacific Pediatric Clinic Policies and
Procedures («)
relating to extraction of primary teeth
Sterile surgical gloves
NO upright positioning
Anesthesia sticker to avoid lip/cheek biting
(additional
protocols in Anesthesia portion of Fall Midterm
Review)
Historical Notes:
No laws until 1960s
1962 à Battered Child Syndrome (AAP symposium)
1963 à
First child abuse reporting law enacted in
1974 à Child Abuse Prevention and Treatment Act
1994 à P.A.N.D.A.® Progam
1)
Be able to discuss the
incidence, etiology and types of abuse
|
Incidence of Abuse Statistics are rough approximations at best Many reports go uninvestigated Significant underreporting exists with many reports
labeled “unfounded” |
|
|
National |
>3 million reported cases per year >2000 18,000 now disabled 2nd only to SIDS as the greatest killer ages 1-6 months 2nd only to accidents as the greatest killer ages 1-5 years |
|
|
>500,000 reports annually >5,700 reports
in |
|
Types of Abuse |
|
|
Physical |
Non-accidental injuries inflicted by a caretaker ³ Most common type of child abuse ³ Most easily detected type of child abuse ³ Recognized as one of the major causes of developmental disabilities in children ³ Often arises from an attempt to punish child ³ Can be the result of lashing out at child for unrelated event ³ Trauma to head, neck and associated areas in >50% of physical abuse cases ³ Soft tissue injury (bruises) are most common injury ³ Injuries to upper lip and/or frenum are characteristic of severely abused child ³ 35% of physically abused children returned to parent without intervention are more seriously re-injured ³ 5% of physically abused children returned to parents without intervention are later killed or die as a result of further physical abuse |
|
Sexual |
Any sexual activity with a child under the age of 18 by an adult ³ Probably the most under-diagnosed form of child abuse ³ Majority of victimized children are female ³ Majority of offenders are male ³ Affected child may show age-inappropriate seductive behavior toward adults ³ Young victims may be preoccupied with sexuality of self, parents, or other children |
|
Emotional |
Continual scapegoating and rejection of a child by parents or caretaker ³ Often difficult to detect without long term observation of child and caretaker ³ Parent/caretaker may be psychotic or severely depressed ³ May be perpetrated by teacher or other non-related significant adult |
|
Etiology of Abuse Abuse Incident = Right Parent + Right Child + Right
Day |
|
|
Abuser Right Parent |
³ Can be from any socio-economic strata/cultural/occupational/ethnic group ³ 80% parent, step-parent, or other relative ³ >90% have no psychiatrically diagnosed condition ³ May have had an unhappy childhood ³ May have been abused (abused become abusers is unfounded) ³ Unable to have own needs met ³ Unsupportive, uncommunicative relationships ³ May view child as existing to meet parental needs (unrealistic expectations) ³ Spouse, etc., usually aware of some sort of abuse ³ Substance abuse cited as significant contributing factor ³ Abuse by father nearly equal to abuse by mother |
|
Abusee Right Child |
³ Twice as many females are abused as males ³ Either over 65 years or under 3 years ³ May have disability or be physically impaired ³ May have been unwanted ³ Poor match of parent/child temperaments/personalities ³ Child may remind parent of something/someone they dislike ³ May be at a difficult or demanding age of development |
|
Crisis Right Day |
³ Marital or relationship difficulties ³ Financial problems ³ Additional family stress |
2)
Be aware of the
P.A.N.D.A.® Program for dental professionals
Prevent Abuse and Neglect through Dental Awareness
Established to provide education to dental professionals on how to recognize and report suspected abuse
Promote awareness of child abuse prevention
Sponsored by Delta Dental Plan of California and other professional organizations
3)
Know the recognizable
signs and symptoms of an abused child
|
History |
Carefully/thoroughly recorded Include past MHx, HPInj Parent may be vague or evasive Parent may blame siblings |
Discrepancies between versions of event Discrepancy between version and extent of injury History of repeated suspicious injuries Alleged 3rd party inflicted injury Delay in seeking care |
|
Examination |
Only to extent appropriate Involve second party w/ suspicions, and should
witness exam Ask child for explanation Adequate documentation is essential (photos, x-rays,
models, written description) |
Generally dirty, ill-kept Dressed inappropriately for season to hide injuries Multiple injuries in various stages of healing Bruises in atypical locations (usually bruise at bony prominence, not in soft tissue areas) Scars, welts, electric cord marks, hand or belt marks, burns, human bite marks |
4)
Know the dentist’s
role and responsibilities in recognizing and reporting cases of child abuse
GOAL à assist family in obtaining needed guidance in handling stress appropriately
Dental care providers are required by law to report suspicions
“Social Welfare Services”, “Child Protective Services”, or “Child Abuse” usually have entries in phone book
National Child Abuse Hotline à 1-800-552-7096
Contact local law enforcement in emergency situations
Report must be filed within 36 hours
5)
Know the special
treatment considerations when treating patients that you suspect of being
victims of abuse
GOAL à to treat as definitively as possible on presentation b/c follow-up is unlikely once suspicions are aired
Trauma Isolated to Oral Cavity
Provide definitive treatment à avoid temporary restorations
Discuss treatment/prognosis/follow-up before suspicions of abuse
Discuss suspicions of abuse last
Trauma Beyond Dentist’s Ability to Treat
Perform needed emergency treatment
Refer to appropriate professional
Again, treatment and referrals made before discussion of abuse suspicions
6)
Know the possible sequelae
of reporting child abuse
|
Consequences for Dentist |
Immune from prosecution if report is in good faith (all 50 states) Must have verifiable documentation and be willing to testify Must be notified of outcome by investigating agency |
|
Consequences for Family |
Goal of intervention is to counsel parents Most cases are settled through social service agencies (counseling) Rarely are children removed from home Removed from home if the child is in imminent danger Placement in non-family related foster care is last resort |
7)
Be familiar with
common folk remedies which may be mistaken for child abuse
|
Dry Cupping |
Small amount of alcohol poured in glass, ignited, and glass inverted onto skin Skin is drawn up by suction created by cooling air in glass Well circumscribed round areas of congestion on skin Appearance is similar to bruising Believed therapeutic for aches, pains, and respiratory congestion |
|
Coin Rolling/Rubbing Cao Gio |
Abrasive rubbing of coin edge across oiled skin Adapted from acupuncture Orderly bilateral lines of ecchymosis on skin Believed therapeutic for a number of ailments |
|
Therapeutic Pinching Bat Gio |
Pinching of skin Adapted from acupuncture, acupressure Pinch marks are typically over temples, forehead and neck Believed therapeutic for multiple ailments |
|
Management of Folk Remedies |
Respect families’ cultural beliefs Parents may be reluctant to admit use of folk remedies Parents may claim grandparents provided therapy Parents should be counseled in more appropriate treatment |
1) Your patient Jesse is 5 years old. When you treatment
planned Jesse you noted that the caries in #K likely involved the pulp, yet
there was no furcation involvement and the soft
tissue seemed healthy, thus you planned for a pulpotomy and stainless steel
crown. You have unroofed the pulp chamber in tooth K, removed the coronal
pulp tissue and can see the radicular pulp
stumps. Which of the followoing would indicate
that instead of a pulpotomy you need to consider a pulpectomy for this tooth?
[e]
a. bleeding from the pulp stumps
cannot be controlled with pressure and a dry cotton pellet
b. the raducular
pulp stumps are dry and have a bad odor
c. you note that you have
accidentally perforated the floor of the pulp chamber
d. a and b
e. all of the above
2) Timmy, who is 3 years old, is brought to your office after having fallen off of his older brother's razor scooter. His face is bloody and he has a small laceration to his upper lip. Additionally, one of his central incisors isn't visible clinically - Mom fears that it was knocked out, but she could not find the tooth. You take a modified occlusal radiograph with a #2 film, and it appears that Timmy's central incisor has been completely intruded. You should: [a]
a. observe only
b. attempt to loosen the intruded tooth and watch for re-eruption
c. attempt to loosen and reposition the intruded tooth
d. attempt to loosen, reposition and splint the intruded tooth with a non-rigid splint
e. extract the intruded tooth.
3) Jack, who is 8 years old, falls off of his skateboard and traumatizes his maxillary right central incisor. The tooth has a small class I fracture to the mesio-incisal edge. You wisely take a periapical radiograph and as a result note that the tooth also has a class IV fracture in the apical third of the root. You note slight mobility of the tooth. You should: [a, if primary; c, if permanent]
a. extract the coronal tooth fragment and allow the apical fragment to resorb
b. monitor the tooth's mobility, but delay treatment for now
c. splint the tooth and monitor
d. take away Jack's skateboard
e. c & d
4) Rotational force would be appropriate for extraction of which of the following teeth? [e]
a. #A
b. #F
c. #M
d. #S
e. b and c
5) As a dentist, if you make a report of suspected abuse, in your professional capacity (about one of your patients), you are immune from prosecution as a result of that report. [a]
a. true
b. false
Bart, a 5 year old, presents to the Pacific Pediatric Dentistry Clinic with upper left intraoral pain. Bart points to tooth #I when asked where it hurts. Bart’s medical history is non-contributory and his father reports that he has complained of pain sporadically, but that the current problem has kept him awake for the past two nights. Clinically you see what appears to be a small “pimple” on the buccal mucosa between teeth #’s I and J. Your radiographic exam shows definite furcation involvement of tooth #I, and there in no obvious furcation involvement of #J. Answer the following five questions based on the above scenario.
6) What type of radiograph should you have taken to assess teeth #’s I and J? [d]
a.
Panoramic film
b.
Bitewing film
c.
Maxillary occlusal film
d. Periapical film
e. A and D
7) Which of the following could you use for a definitive vitality test for the potentially involved teeth? [e]
a. electric pulp tester
b. percussion
c. periapical biopsy
d. all of the above
e. none of the above
8) Based on the information you have been given, which of the following is the correct treatment plan for the involved teeth? [b]
a. #I: pulpectomy, #J: pulpotomy
b. #I: pulpectomy, #J: observe
c. #I: extract, #J pulpotomy
d. #I: extract, #J extract
e. #I: extract, #J observe
9) Which injection technique(s) will you use to make sure that Bart is comfortable for treatment of the indicated teeth? [d]
a. Buccal & Palatal Infiltration
b. Inferior Alveolar Block
c. Interdental Infiltration
d. A and C
e. All of the above
10) Assume that tooth #J is salvageable, but tooth #I has to be extracted. What procedure/appliance would you consider to preserve the occlusion? [a]
a. Band and Loop space maintainer
b. Translingual Helix appliance
c. Lower Lingual Holding Arch
d. Distal Shoe
e. Space maintenance is not possible until Bart is older
Suzanne, a 7 year old, presents to the Pacific Pediatric Clinic as a new patient. She has a “back tooth” that feels rough to her tongue, but has not been otherwise symptomatic. You note a large area of cavitation on tooth #30. Your radiographic examination reveals that there is extensive occlusal caries in this tooth which appears to encroach on the pulp. Suzanne has an uncomplicated medical history and has never been examined by a dentist before. Please answer the following five questions based on the above scenario.
11) Suzanne’s mother wants to accompany her to the operatory for examination and treatment. Based on the Pacific Pediatric Clinic policies, this is: [b]
a. no problem because Suzanne is under 8 years
of age
b. against policy because Suzanne should not experience
separation anxiety at her age
c. depends on her behavior in the waiting room
12) Vitality testing of the pulp of #30 is __________________________ . [c]
a. Accurate because the tooth is fully erupted.
b. Accurate because the root apices are closed.
c. Not accurate because the tooth is immature
d. A and B
e. None of the above
13) What size and type film would you use to radiographically assess tooth #30? [d]
a. size 4, bitewing Size 0 à pediatric; PA, BW < 7yrs
b. size 2, periapical Size 1 à adult anterior; PA, BW > 7yrs
c. size 2, bitewing Size 2 à adult posterior; modified anter.
< 7 yrs; PA, BW >7yrs
d. size 1, periapical Size 4 à max/mand occlusals; lateral views of anteriors
e. size 0, bitewing
14) You excavate the caries on tooth #30 and, much to your surprise, there is no pulp exposure, but you are very close to the mesio-buccal pulp horn once all of the carious dentin has been removed. You should: [b]
a. Place a direct pulp cap with glass ionomer
b. Place an indirect pulp cap with glass
ionomer
c. Place an indirect pulp cap with calcium
hydroxide
d. Perform apexogenesis
e. Perform apexification
15) If Suzanne were 12 years old, and you encountered a very small (1 mm or less) pulp exposure when excavating caries, you would: [a]
a. Place a direct pulp cap with glass ionomer
b. Place an indirect pulp cap with glass
ionomer
c. Place an indirect pulp cap with calcium
hydroxide
d. Perform apexogenesis
e. Perform apexification
Joshua, a 3 year old, presents to the Pacific Pediatric Clinic with pain in the lower left quadrant. His medical history is non-contributory. Mother reports that Joshua has complained of pain sporadically, but that the tooth has not kept him awake at night. Clinically the soft tissues show gingivitis but there is no evidence of a parulis or fistulous tract. In the lower left quadrant, tooth #L (perhaps should be K instead) has a large cavitated area with clinically evident caries. Answer the following five questions based on this scenario.
16) What type of radiograph is needed to assess tooth #K? [c]
a.
Maxillary occlusal film
b.
Bitewing film
c. Periapical film
d.
Panoramic film
e.
Based on the symptoms and soft tissue findings, no radiograph is
indicated
17) According to Pacific Pediatric Clinic policy, how many radiographs are you allowed to attempt before getting instructor approval? [a]
a. 0
b. 1
c. 2
d. 3
e. as many as you need for diagnosis
18) Which of the following procedures is indicated for tooth #K? [a, much debate about this one]
a.
Caries control
b.
Direct pulp cap
c.
Indirect pulp cap
d.
Pulpectomy
e. Apexogenesis
19) Assume that tooth #K needs to be extracted, as you discover that it is unrestorable later in your examination. Which forceps should you use for the extraction? [c]
a.
44S
b.
150S
c.
151S
d.
27SS
e. 1
20) Joshua’s mother is so pleased with your treatment of her son that she asks you to talk to her parenting group about early childhood oral care in the hopes of sparing other children the treatment that Joshua needs. The first question that you must answer is “when should a child be seen by a dentist for the first time.” Based on the American Academy of Pediatric Dentistry’s recommendations, you tell them: [c]
a. at
birth
b. at
6 months of age
c. at
1 year of age
d. 3
years of age
e. just before starting school