taking the fear out of paediatric dentistry: for the dentist…. · stainless steel crowns choice...

Taking the fear out of paediatric

dentistry: for the dentist….

Abigail Moore & Eimear Norton

20th September 2012

What for??

IMPORTANT PART OF INITIAL DIAGNOSIS

• identifies high risk children

• indicates diagnostics needed

• influences treatment plan

• indicates suitable recall interval

• predicts future decay

Oral Health Services Research Centre

http://ohsrc.ucc.ie

Quick Caries Risk Assessment (CRA)Quick Caries Risk Assessment (CRA)

1. Dental history

– Has your child ever had problems with teeth

– Does your child attend a dentist regularly?

– Do parents or siblings have decay problem?

2. Brushing & Fluoride

– How many times a day does your child toothbrush?

– Do they rinse after brushing?

– Do you have fluoride in water/toothpaste?

3. Diet

– How many between meal sugary snacks does your child have a day?

4. Special risk factors

– Any oral appliances worn?

– Do you have a medical card?

– Does your child have any special care or medical needs (meds,

behaviours, saliva)?

Quick Caries Risk Assessment (CRA)HISTORY QUESTIONS

Quick Caries Risk Assessment (CRA)HISTORY QUESTIONS

Oral Health Services Research

Centre http://ohsrc.ucc.ie

1. DECAY– Evidence of Previous Decay

– New caries in last 12 months

– Demineralized areas

2. ORAL HYGIENE– Visible plaque

– Gingivitis

3. ENAMEL DEFECTS – Hypomineralised molars

– Deep fissures

• Supplemental assessment– Radiographs

– Bacterial investigation

Quick Caries Risk Assessment (CRA)CLINICAL EXAMINATION

Quick Caries Risk Assessment (CRA)CLINICAL EXAMINATION

A

CLINICIAN’S

‘HUNCH’ IS

VERY

RELIABLE!

(DISNEY

1992)

A

CLINICIAN’S

‘HUNCH’ IS

VERY

RELIABLE!

(DISNEY

1992)

Oral Health Services Research Centre

http://ohsrc.ucc.ie

• AVOID UNNECESSARY EXPOSURE - ALARA

• INFORMED CONSENT

• INDICATIONS:– Caries

– Trauma

– Disturbances tooth development

– Pathology

• BITEWINGS– Increase no iprox lesions found by x2-8 (Kidd 1990)

– Occlusal caries in dentine – not early (Espelid 1994)

– Detect non-visual lesions

– Diagnosis extent & tx need

– Monitor progression

• TIMING – DEPENDS CRA

• BASELINE: 5 YEAR OLDS: 30% 5 YR OLDS ROI VISUAL CARIES

EAPD Guidelines: Espelid et al. 2003

Radiographs for little people…..Radiographs for little people…..

• BITEWINGS– Increase number interproximal lesions found

by x2-8 (Kidd 1990)

– Occlusal caries in dentine – not early (Espelid 1994)

– Detect non-visual lesions

– Diagnosis extent & treatment need

– Monitor progression

• BASELINE: 5 YEAR OLDS: – 30% 5 YR OLDS ROI VISUAL CARIES

• INTERVAL – DEPENDS CRA


Bitewing Radiographs

Bitewing Radiographs

• UNNECESSARY TO SCREEN FOR JAWBONE LESIONS IN HEALTHY CHILDREN

• INDICATIONS

– If intra oral not showing enough information

– If co-operation does not allow intra-oral

– FAILURE ERUPTION

– SUBMERGENCE MULTIPLE TEETH

– SUPERNUMERARIES/HYPODONTIA

– UNERUPTED CANINES

– SUSPECTED PATHOLOGY

– ORTHODONTIC PLANNING

OPGsOPGs

Baseline

Bitewings

Interval (yrs) Rationale

Age (years) Low risk High Risk

5 3 1 30% 5 year old visual decay

Contacts closed by 3

8-9 3-4 1 FPM’s erupt

Interprox decay distal E, x15 increased risk mesial 6

Adjacent surface x4 chance decay

Progression primary x2 speed adult

Caries free at 8 – likely to stay so until 12

12-16 2 1 1-2 years post eruption PM’s & 7’s- occlusal risk

3-4 years post eruption PM’s & 7’s– iprox risk

20% enamel lesions progress to dentine <1 year, faster

dentine

16+ 3 1 Increased caries rate in teenagers

6 months?? If in dentine then high risk progression so best restore than expose


Nurofen 100mg/5ml

age mls

3-6 months

>5kg only

2.5

6-12 months 2.5

1-3 years 5

4-6 years 7.5

7-9 years 10

10-12 years 15

Calpol 3+

mnths

120mg/5ml

age mls

2-3 months 2.5

3-6 months 2.5

6-24 months 5

2-4 years 7.5

4-6 years 10

Calpol 6+ years 250mg/5ml

age mls

6-8 years 5

8-10 years 7.5

10-12 years 10

12-16 years 10-15

ALTERNATE

NUROFEN & CALPOL

4 HOURLY IN SEVERE

PAIN

ALTERNATE

NUROFEN & CALPOL

4 HOURLY IN SEVERE

PAIN

1st Line Antibiotics1st Line Antibiotics Weight

(age +4) x2

Weight

(age +4) x2

AMOXYCILLIN METRONIDAZOLE

FORMULA

•Amoxycillin trihydrate (broad spectrum

penicillin)

•Amoxil syrup (sugar free)

•125/250mg per 5ml TDS

FORMULA

•Anaerobic infections

•Acute swelling/infection

•Flagyl-S Suspension (Sugar Free)

•200mg/5mls

DOSE:

•8mg/kg

•Double in severe infection

DOSE

•7.5mg/kg

PRECAUTIONS:

•Check history allergies

PRECAUTIONS

•Hepatic impairment

WEIGHT

(AGE +4) X2

WEIGHT

(AGE +4) X2

(BNF May 2012)

Amoxycillin Syrup (sugar free)

250mg per 5mls

100ml bottle

(8mg/kg TDS)1 month –1year62.5mg-125mg TDS

1-5 years

125mg-250mg TDS x 5/7

>5 years250mg-500mg TDS x5/7

(BNF May 2012)

Flagyl Suspension (Sugar Free)200mg per 5mls

100ml bottle

(7.5mg/kgTDS)Acute oral infections (BNF)1-3 years50mg TDS x5/7

3-7 years100mg BD x5/7

7-10 years100mg TDS x 5/7

>10 years

200mg TDS x5/7

(BNF May 2012)

2nd Line Antibiotics2nd Line Antibiotics WEIGHT

(AGE +4) X2

WEIGHT

(AGE +4) X2

AUGMENTIN ERYTHROMYCIN

FORMULA

•Amoxicillin trihydrate/clavulanic acid(K+ salt)

•Organisms resistant to beta lactamase

production

•Augmentin Duo® suspension (sugar free)

•400mg/57mg/5ml

FORMULA

•Erythromycin (macrolide)

•Allergy to penicillin

•Penicillin last 1 month

•Erythroped suspension SF

•125mg/5ml

•Erythroped suspension SF

Forte250mg/5ml

DOSE:

•25/3.6mg/kg/day - 45/6.4mg/kg/day

•2 divided doses

•BD – easier for parents

•Double severe infections

DOSE

•6-7mg/kg QDS

•Double severe infection

PRECAUTIONS:

•Renal impairment

PRECAUTIONS

•Hepatic impairment

(BNF May 2012)

Augmentin Duo® (sugar free)400mg/57mg per 5mls

35 or 70ml bottle

(25/3.6mg/kg/day - 45/6.4mg/kg/day)

<2 years45/6.4mg/kg/day

2-6 years2.5mls BD

7-12 years5mls BD

Adult (>40kg) 10mls BD

(BNF May 2012)

Erythroped suspension SF125mg per 5mlErythroped suspension SF Forte250mg per 5ml100ml bottle

(6-7mg/kd QDS)<2 years125mg QDS

2-8 years250mg QDS

>8 years500mg QDS

(BNF May 2012)

Local AnaesthesiaLocal Anaesthesia

Most difficult procedures in (paediatric) dentistry

prerequisite for dental treatment

Some methods of reducing injection discomfort

1.Behaviour management techniques

2.Surface preparation – topical anaesthesia

3. speed of injection

Areas of most concern:

1.Palatal anaesthesia

2.Inferior dental block

Inferior Dental Block …

Articaine Infiltration

Inferior Dental Block …

Articaine InfiltrationAmide anaesthetic with an ester group

•Increased solubility in fats

•Increased tissue penetration

Superior to lidocaine for infiltration anaesthesia

Robertson et al. 2007

Mandible elimination of need for IDB in children

Daublander JIDA 2011

• Contra-indicated in children less than 4 years

• Reports of prolonged parasthesia following IDB

• Maximum dose – 7mg/kg

half a 2.2ml cartridge per 10 kg

• Primary tooth loses its vertical position

relative to adjacent teeth

• 8-14% of 3-12 yr olds

• Aetiology – imbalance between psychological

resorption & repair

InfraocclusionInfraocclusion

Assessment & diagnosisAssessment & diagnosis

Radiographic

• Loss PDL space of

infraoccluded tooth

• Presence successor

• Angulation successor

• Root dev successor

Clinical

• Mobility

• Percussion tone

• Tipping adjacent teeth

• Overeruption opposing

teeth

Management without successorManagement without successor

ACCEPT & BUILD-UP

• Late infraocclusion with

good root formation (12+)

• Restore occlusal surface

• Composite or onlays

• Maintain occlusal integrity

• Prevent tipping & OE

EXTRACT

• Severe infraocclusion

• To prevent lateral OB

• May avoid future surgical

• Maintain space:prosthesis

• Open or close space

(orthodontic opinion)

Management with successorManagement with successor

– 90% exfoliate if have permanent

successor (typically 6mths late)

(Kurol & Koch 1985)

– Ankylosis likely to be temporary when

permanent successor exist

– Check angulation / stage of root

development of permanent successor

Monitor exfoliation

Regular observation

Failure of eruption of maxillary central

incisor

Failure of eruption of maxillary central

incisor

When to investigate:

– Contralateral incisor erupted 6 mths previously or

lower incisors 1 year

– Deviation from normal sequence of eruption e.g.

lateral incisors erupt prior to the central

http://www.rcseng.ac.uk/fds/publicationshttp://www.rcseng.ac.uk/fds/publications--clinicalclinical--

guidelines/clinical_guidelines/documents/ManMaxIncisors2010.pdfguidelines/clinical_guidelines/documents/ManMaxIncisors2010.pdf

Incidence

•2% incidence in permanent dentition

•1% in primary dentition

Failure of eruption – aetiology Failure of eruption – aetiology

Hereditary factors:

– Supernumerary teeth

– Cleft lip and palate

– Cleidocranial dysostosis

– Odontomes

– Ab. tooth/tissue ratio

– Generalised retarded

eruption

– Ginigival fibromatosis.

Environmental factors:

– Trauma

– Early extraction or loss of

deciduous teeth

– Retained deciduous teeth

– Cystic formation

– Endocrine abnormalities

– Bone disease.

Supernumerary

teeth

Supernumerary

teeth

Management principles:

•Early treatment

– Remove the obstruction (supernumerary)

– Maintain or create space (sectional fixed or URA)

– Allow spontaneous eruption

• 78% within 16/12 (Mitchell 1992)

– If not spontaneous will need gold chain and traction

Molar Incisor HypomineralisationMolar Incisor Hypomineralisation

‘hypomineralisation of systemic origin of 1-4 FPM,

frequently ass. with affected incisors’

Molar expression

�Number molars involved varies from 1-4

�Defect expression varies from molar to molar

�One severe defect in FPM, likely that contralateral tooth is also affected

�Opacities usually limited to incisal or cuspal 1/3

Incisor Expression

�Opacities may be found in upper and sometimes lower incisors

�Risk of defects on upper incisors increases when more FPMs are affected

�Defects of incisors are usually without loss of enamel

Clinical Features/DiagnosisClinical Features/Diagnosis

1. Demarcated Opacity

1. Post Eruptive Breakdown

1. Atypical Restorations

1. Extracted Molars due to MIH

Molars … the options Molars … the options

Amalgam:

least durable; poor retention

inability to protect remaining tooth

GIC/RMGIC:

chemical bond, F release, dentine replacement or

interim restoration, not for stress bearing areas

Composite:

Remove all discoloured defective enamel

Place margins on sound enamel

Choice for molars with limited involvement

Molars … more optionsMolars … more options

Stainless Steel Crowns

Choice for mod-severe PEB

� Control sensitivity

� Prevent further deterioration

� Est interproximal contacts & occlusal relationships

Properly placed SSC can preserve FPM until cast restoration feasible

(Williams et al ‘06)

Cast crowns/ onlays

Rarely indicated in young child

Increased cost, large pulps, short crown

ExtractionExtraction

Severely hypomineralised FPM

Early orthodontic assessment

Some considerations:

•No. & restorability of affected teeth

•Occlusal relationships & buccal crowding

•Condition & presence of unerupted teeth

Timing:

•Dental age – calcification of bifurcation of 7’s

•8.5 yrs – 10.5 yrs

MIH

Incisors

MIH

Incisors

• Aesthetic concern

• PEB unusual

• Full thickness defects

Options:

• Acid-pumice microabrasion: little improvement (unless shallow)

• Bleaching may improve Y/B surface - not underlying opacity

• Direct composite resin: most reliable

– Enamel prep usually required, opaquing shades

Ectopic FPM’sEctopic FPM’s

• Local eruptive disturbance

• 2 - 6 % pop (Bjerklin + Kurol 1981)

• Deviation of normal path - “locked” behind distal aspect of E

Early diagnosis important

Clinical and radiographic findings

Suspect ectopic eruption if:

- asymmetrical eruption (delay > 6mths between 6s)

- overeruption opposing 6

Treatment:

Orthodontic

Separator

Treatment:

Orthodontic

Separator

Impacted Maxillary CaninesImpacted Maxillary Canines

• Normal eruption

– 11-12 years (max 3)

• 2-3% incidence

• 85% Palatal : 15% Buccal

Suspicious of palatal impaction

Suspicious of palatal impaction

Asymmetrical bulge/no bulge > 10 yrs

by 11 most palpable

Delayed eruption >12yrs & contralateral erupted

No mobility C

Mobility, migration, delayed eruption, labial tip or pathology of

lateral incisor

Family hx ectopic canines

Not palpable at 10 years: radiographic exam

Extraction of primary canineExtraction of primary canine

Conditions: Patient should be 10 -13 yrs

Adequate arch space

Little overlap of lateral and canine

Review for 12 months

Conditions: Patient should be 10 -13 yrs

Adequate arch space

Little overlap of lateral and canine

Review for 12 months

Evidence base: Ericson and Kurol 1998

•n= 46 patients 10-13 yrs

•Palatally impacted canine, C extracted

•78% erupted normally

•91% if < ½ lateral root overlapped

•64% if > ½ lateral root overlapped

•50% improvement 6 mths, little change >1 yr

Other options ….Other options ….

Extraction of impacted canine:

Severely displaced, dilacerated, pathology,

2-4 contact

Px not motivated for extended treatment

Leave/no treatment:

if very high, poor prognosis & no pathology

Avoid bone loss, unnecessary sx & ass risks

Patient not motivated

Primary canine good or 2-4 contact

taking the fear out of paediatric dentistry: for the dentist…. · stainless steel crowns choice...

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