Taking the fear out of paediatric dentistry: for the dentist. Abigail Moore & Eimear Norton 20 th September 2012

Transcription

1 Taking the fear out of paediatric dentistry: for the dentist. Abigail Moore & Eimear Norton 20 th September 2012

2 Quick Caries Risk Assessment (CRA) 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

3 Quick Caries Risk Assessment (CRA) HISTORY QUESTIONS 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)? Oral Health Services Research Centre

4 Quick Caries Risk Assessment (CRA) CLINICAL EXAMINATION 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 A CLINICIAN S HUNCH IS VERY RELIABLE! (DISNEY 1992) Supplemental assessment Radiographs Bacterial investigation Oral Health Services Research Centre

5 Radiographs for little people.. 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

6 Bitewing Radiographs 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 EAPD Guidelines: Espelid et al. 2003

7 OPGs 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

8 Baseline Bitewings Interval (yrs) Age (years) Low risk High Risk Rationale % 5 year old visual decay Contacts closed by 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 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 Increased caries rate in teenagers 6 months?? If in dentine then high risk progression so best restore than expose EAPD Guidelines: Espelid et al. 2003

9 Calpol mg/5ml mnths age mls 2-3 months months months years years 10 Calpol 6+ years 250mg/5ml age mls 6-8 years years years years Nurofen age 3-6 months >5kg only 100mg/5ml mls months years years years years 15 ALTERNATE NUROFEN & CALPOL 4 HOURLY IN SEVERE PAIN

10 1st Line Antibiotics Weight WEIGHT (age (AGE +4) x2 X2 AMOXYCILLIN FORMULA Amoxycillin trihydrate (broad spectrum penicillin) Amoxil syrup (sugar free) 125/250mg per 5ml TDS DOSE: 8mg/kg Double in severe infection METRONIDAZOLE FORMULA Anaerobic infections Acute swelling/infection Flagyl-S Suspension (Sugar Free) 200mg/5mls DOSE 7.5mg/kg PRECAUTIONS: Check history allergies PRECAUTIONS Hepatic impairment (BNF May 2012)

11 Amoxycillin Syrup (sugar free) 250mg per 5mls 100ml bottle (8mg/kg TDS) 1 month 1year 62.5mg-125mg TDS 1-5 years 125mg-250mg TDS x 5/7 >5 years 250mg-500mg TDS x5/7 (BNF May 2012)

12 Flagyl Suspension (Sugar Free) 200mg per 5mls 100ml bottle (7.5mg/kgTDS) Acute oral infections (BNF) 1-3 years 50mg TDS x5/7 3-7 years 100mg BD x5/ years 100mg TDS x 5/7 >10 years 200mg TDS x5/7 (BNF May 2012)

13 2 nd Line Antibiotics WEIGHT (AGE +4) X2 AUGMENTIN FORMULA Amoxicillin trihydrate/clavulanic acid(k + salt) Organisms resistant to beta lactamase production Augmentin Duo suspension (sugar free) 400mg/57mg/5ml DOSE: 25/3.6mg/kg/day -45/6.4mg/kg/day 2 divided doses BD easier for parents Double severe infections PRECAUTIONS: Renal impairment ERYTHROMYCIN FORMULA Erythromycin (macrolide) Allergy to penicillin Penicillin last 1 month Erythroped suspension SF 125mg/5ml Erythroped suspension SF Forte250mg/5ml DOSE 6-7mg/kg QDS Double severe infection PRECAUTIONS Hepatic impairment (BNF May 2012)

14 Augmentin Duo (sugar free) 400mg/57mg per 5mls 35 or 70ml bottle (25/3.6mg/kg/day - 45/6.4mg/kg/day) <2 years 45/6.4mg/kg/day 2-6 years 2.5mls BD 7-12 years 5mls BD Adult (>40kg) 10mls BD (BNF May 2012)

15 Erythroped suspension SF 125mg per 5ml Erythroped suspension SF Forte 250mg per 5ml 100ml bottle (6-7mg/kd QDS) <2 years 125mg QDS 2-8 years 250mg QDS >8 years 500mg QDS (BNF May 2012)

16 Local 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

17 Inferior Dental Block Articaine Infiltration Amide anaesthetic with an ester group Increased solubility in fats Increased tissue penetration Superior to lidocaine for infiltration anaesthesia Robertson et al 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

18 Infraocclusion Primary tooth loses its vertical position relative to adjacent teeth 8-14% of 3-12 yr olds Aetiology imbalance between psychological resorption & repair

19 Assessment & diagnosis Mobility Clinical Percussion tone Tipping adjacent teeth Overeruption opposing teeth Radiographic Loss PDL space of infraoccluded tooth Presence successor Angulation successor Root dev successor

20 Management without successor EXTRACT ACCEPT & BUILD-UP Severe infraocclusion To prevent lateral OB May avoid future surgical Maintain space:prosthesis Open or close space (orthodontic opinion) Late infraocclusion with good root formation (12+) Restore occlusal surface Composite or onlays Maintain occlusal integrity Prevent tipping & OE

21 Management with successor Monitor exfoliation Regular observation 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

22 Failure of eruption of maxillary central Incidence 2% incidence in permanent dentition 1% in primary dentition When to investigate: incisor 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 clinical- guidelines/clinical_guidelines/documents/manmaxincisors2010.pdf

23 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.

24 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

25 Molar 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

26 Clinical Features/Diagnosis 1. Demarcated Opacity 1. Post Eruptive Breakdown 1. Atypical Restorations 1. Extracted Molars due to MIH

27 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

28 Molars 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

29 Extraction 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

30 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

31 Ectopic 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

32 Treatment: Orthodontic Separator

33 Impacted Maxillary Canines Normal eruption years (max 3) 2-3% incidence 85% Palatal : 15% Buccal

34 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

35 Extraction of primary canine Conditions: Patient should be yrs Adequate arch space Little overlap of lateral and canine Review for 12 months Evidence base: Ericson and Kurol 1998 n= 46 patients yrs Palatally impacted canine, C extracted 78% erupted normally 91% if < ½lateral root overlapped 64% if > ½lateral root overlapped 50% improvement 6 mths, little change >1 yr

36 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