Pedo Board II
Nonsurgical closed reduction is preferred, ramus may remodel to form condylar head-like surface in young patients. Rigid or elastic maxillomandibular fixation for 4-6weeks, bite-opening splints, soft diet
what is the tx for condylar fractures?
apexification with MTA followed by RCT
what is the tx option if the pulpotomy fails in teeth with immature root apices?
According to the guidelines, individualized radiographic exam consisting of posterior bitewings with panoramic or posterior bitewings with selected periapical images
what radiographs would you take in a new patient with transitional dentition?
Condylar fractures
what type of fracture has the greatest risk of growth disturbance?
Seen in younger patients. May see bite deviation for unilateral, pain in TMJ area, blunt injury to chin, laceration to chin. Retrognathia and anterior open bite for bilateral subcondylar fracture.
what would alert you to look for subcondylar mandibular fracture? Tx?
Pen V 20-50mg/kg/day Q6H for 1 week; max 3g
what would you prescribe for an avulsion injury for a child younger than 12yo?
teeth with non-restorable crowns, more than 1/3 root resorption, perforation of pulpal floor, infection involving permanent tooth follicle
when is a pulpectomy contraindicated
Can be performed in primary molars with irreversible pulpitis, necrosis, with PAP, resorption without perforation, more than 2/3 root intact. Loss of second primary molar before eruption of first permanent molar can lead to significant space loss. Other option is extraction and distal shoe
when is pulpectomy indicated in primary teeth?
Severe caries, periodontal disease, severe medical conditions such as immunosuppression, severe cardiac conditions - according to IADT; also severe mental disability, seizure disorder
when is replantation of an avulsed tooth not indicated?
Permanent tooth with immature open apices (at least 1.1mm) that is necrotic, no known antibiotic allergy. Patient should be between 7-16yo, in good health. Advantage of revasc is further root development and strengthening of the dentin walls by deposition of hard tissue. o Should only be attempted if tooth is not suitable for RCT, and after apexogenesis, apexification, or partial pulpotomy tx have already been attempted and have a poor prognosis
when would you do revascularization?
Cyclosporine, Nifedipine, Phenytoin (Dilantin). Tacrolimus can substitute cyclosporine. Tegretol can substitute dilantin.
which medications cause gingival enlargement? are there any substitute medications?
Avulsion, extrusive luxation, lateral luxation, alveolar fracture
which permanent teeth injury require immediate tx?
CaOH apexification is more time consuming than creating an apical seal with MTA. CaOH was shown to make the teeth more prone to fracture, whereas MTA strengthens the root. MTA creates a better biologic seal and the root end closure is more predictable.
why is MTA preferred over CaOH for apexification?
MTA forms a hard tissue bridge faster, more predictable pulp barrier and less pulpal irritation than CaOH.
why is MTA preferred to CaOH for DPC and pulpotomy and apexification?
the goal is to maintain pulp vitality and function, at least until complete root development
what is the goal of vital pulp therapy?
38% SDF = 45,500ppm F
38% SDF fluoride amount
Cvek has shown that with traumatic pulp injuries, regardless of the size of the exposure of the amount of time lapsed, pulpal changes are characterized by a proliferative response with inflammation extending only a few millimeters into the pulp.
According to Cvek, what are the pulpal changes resulting from a traumatic pulp exposure?
Entire alveolar process may be mobile and dislocated, may see gingival lacerations. Tooth will be stable within alveolus. Record Pano, PA from different angles. Tx: LA, reposition segment, splint for 4 weeks. Pulp necrosis is frequent finding in teeth associated with alveolar fracture.
Alveolar Process fracture in permanent dentition
Record PA, reposition alveolar segment. Splint to adjacent teeth for 3-4 weeks. Try not to extract teeth in segment because alveolar is critical for development of permanent teeth. If splinting not possible, dietary restrictions will need to be maintained.
Alveolar fracture in primary dentition
LA, RDI, establish working length with paper point method (apex locator unreliable), irrigate with 0.5% CHX, minimal instrumentation due to thin walls, CaOH placed in canals for 2 weeks. Visit 2: irrigate with 0.5% CHX, apical barrier with MTA and moist cotton pellet, IRM for 1 week. Visit 3: verify MTA plug, irrigate with 0.5% CHX, obturate with gutta percha, restore.
Apexification technique
For pt >45kg, Doxycycline 100mg BID day 1, doxycycline 50mg BID day 2-7. pt <45kg: doxycycline 4mg/kg/day BID day 1, 2mg/kg/day BID day 2-7
Avulsion ABX Rx for older than 12yo?
19% formaldehyde, 48.5% cresol, 17.5% glycerin;
Buckley properites
Immediately post-injury there may be paresthesia and no hemorrhage. After eschar sloughs off in 1-3 weeks may have significant bleeding and pain. Commisural splint with acrylic tusks should be delivered within 2 weeks of burn and worn 24hours for 6-8 months to reduce scar contracture. Plastic surgery commisuroplasty can be done 6months post injury
Burn Management
Hold tooth by CROWN, clean with saline. LA, irrigate socket with saline, examine socket reposition any fractures, replant tooth with gentle pressure, suture any lacerations, verify normal position, flexible splint for 2 weeks, systemic ABX. Record PA after replantation to minimize extra-oral time. Initiate RCT within 7-10 days
Closed apex, dry time <60 minutes stored in physiologic storage medium
Record PA in 3 angles, soft tissue radiograph. DPC w/ CaOH for small exposure within hours of injury or CVEK for open apex. for closed apex, RCT is usually tx of choice.
Complicated fracture of permanent tooth
0.05% NaF = 0.022% F = 2200ppm (daily use) indications: ortho appliances, radiation patients, high caries risk patients, poor OH
OTC fluoride mouth rinse
1000ppm = 0.1% F
OTC fluoride toothpaste
Record PA from 3 different angles. If fracture is subosseous, may need ortho extrusion over 4-6 weeks or perio crown lengthening. May also need RCT. Referral to ortho, perio, endo.
Crown root fracture of permanent teeth
Record PA, extract
Crown root fracture of primary teeth
Record PA, reposition tooth and splint for 2 weeks. Teeth with closed apices have lessened likelihood of revascularization, may need RCT. In teeth with open apices PCO is common finding
Extrusive luxation of permanent tooth
Formocresol MOA is tissue fixation. It is bactericidal, persistent chronic inflammation, exfoliation may be accelerated. applied for 5minutes.
Formoresol MOA? properties? how long does it need to be applied?
LA, RDI, remove caries leaving affected dentin on pulpal floor, place CaOH, restore with leak-free seal (SSC for high risk caries)
IPT procedure
all hard bony injuries should be treated first to give the practitioner a good perspective on the true extent of the soft tissue injury. Treating the soft tissue first leads to the potential of tissue re-injury during treatment of tooth displacements.
If the gingival tissue had merely been lacerated and an associated tooth luxation noted, which injury should be treated first?
bilateral periorbital ecchymosis could indicated anterior cranial base fracture (raccoon sign), zygomatic fracture, LeFort fracture
If you see periorbital ecchymosis in a trauma patient, what should you suspect?
traumatic pulp exposure of primary and permanent teeth. <2mm Carious exposure of permanent teeth with reversible pulpitis (esp for immature permanent teeth) where bleeding can be controlled in 1-2minutes
In what clinical scenarios can you do a partial pulpotomy?
Record PA 3 angles. If tooth is not displaced or mobile splint is not needed. For fractures in middle third or mobile, splint for 4 weeks. Fractures in cervical third may need splint up to 4 months. Reposition segment and splint as needed. NO abx.
Intraalveolar Root fracture of permanent tooth
Record 1-2 PA to determine position. Most are displaced labially away from permanent teeth. Majority of teeth re-erupt. PCO is common finding.
Intrusion injury to primary dentition
For open apices and <7mm injury allow for spontaneous re-eruption. If open apices >7mm intrusion, ortho or surgical repositioning. ORTHO REFERRAl/OMFS/ENDO referral. For closed apices <3mm allow for re-eruption for 2-4 weeks. Otherwise, surgical repositioning of ortho will be needed. Closed apices will most likely become necrotic and pulp extirpation should be done within 2-3 weeks. After tooth has been surgically repositioned, place splint for 4-8 weeks.
Intrusive luxation of permanent tooth
If immediate replantation is not possible, place tooth in Hank's balanced Salt solution, cold milk, saline, or saliva to maximize vitality of the root surface cells. For cold milk, tooth should be placed in a cup of milk and the cup should be in a bowl of ice.
List the best storage medium for avulsed teeth to least preferred
MOA is mineralization. PCO common.
MTA MOA? clinical side effects?
MTA pulpotomy can be done in permanent teeth with open apices where extent of pulp inflammation is unknown and continued root development is wanted.
MTA pulpotomy - which clinical scenario would you do this in?
LA, RDI, remove caries, access pulp chamber, remove inflamed pulp tissue up to radicular pulp, irrigate with 2.5% NaOCl, achieve hemostasis with moist cotton pellets, place MTA on radicular pulp stump, GI liner, restore. (moisture from surrounding tissue assists in setting reaction) Recall in 3,6,12 months - assess for continued root development. If it fails, need apexification.
MTA pulpotomy technique
Hold tooth by CROWN, clean with saline. Cover root surface with minocycline or doxycycline before replantation. LA, irrigate socket with saline, examine socket reposition any fractures, replant tooth with gentle pressure, suture any lacerations, verify normal position, flexible splint for 2 weeks, systemic ABX. Record PA after replantation to minimize extra-oral time. For open apices monitor for pulp revasc, if not apexogenesis or apexification may be needed. ENDO referral.
Open apex, dry time <60 minutes stored in physiologic storage medium
LA, RDI, irrigate with CHX. Use diamond bur with copious water to remove 2-3mm of pulp tissue. Do not blow air on pulp because it will cause dessication and tissue damage. Achieve hemostasis with moistened cotton pellet. Apply NaOCl to achieve hemostasis and kill bacteria, place CaOH or MTA, place RMGI, restore with composite.
Partial pulpotomy CVEK procedure
0.5% = 5000ppm G
Prescription toothpaste Prevident
Record PA to confirm avulsion if tooth was not found. R/O aspiration with chest x-ray and medical consult, soft tissue impaction. do NOT replant.
Primary tooth avulsion
record PA, pulpotomy/pulpectomy or extraction
Primary tooth complicated fracture
Most will spontaneously re-erupt within 6 months. Monitor every 2 months. Intrusion and avulsion injuries of primary teeth pose greatest risk to permanent teeth. Most are pushed labially when intruded. May see enamel hypoplasia on permanent teeth.
Primary tooth intrusion management
Record PA, extract coronal fragment if displaced or aspiration risk due to mobility. If not displaced or mobile, monitor.
Primary tooth root fracture
Extraction done only if coronal portion is aspiration risk.
Primary tooth root fracture management
Record PA, smooth rough edges, place GI for insulation if cold sensitive. Restore as needed
Primary tooth uncomplicated fracture
LA, RDI, irrigate with CHX or NaOCl, place CaOH. Restore with composite (etch, bond, etc). Hard tissue healing can be seen 3 months after tx in xray.
Pulp capping procedure
LA, RDI, caries removed, access pulp chamber, use rotary or 21mm K-files up to no.30. Chemical disinfection is more effective in primary teeth - use CHX, NaOCl. Dry canal, RCT is filled with vitapex (CaOH + iodoform). Take post-op x-ray. Restore with SSC
Pulpectomy procedure
LA, RDI, excavate caries, amputate coronal pulp, achieve hemostasis (FC 5min; ferric sulfate 10-15sec; MTA), pack ZOE due to accessory canals in pulpal floor, restore with SSC. Hemostasis is the most important part of a pulpotomy. <50% success rate with inadequate hemostasis.
Pulpotomy technique for primary teeth
LA, RDI, access pulp chamber, irrigate with 5.25% NaOCl and 2% CHX, fill canal with tri-antibiotic paste (copra, mino, metro), place cotton pellet, temporary seal for 2-4 weeks. Visit 2: LA WITHOUT EPI (Carbocaine), RDI, make sure tooth is ASX and no sinus tract, irrigate antibiotic paste with 5.25% NaOCl and saline. Dry canal with paper points. insert sterile endo file past apex to induce bleeding. Stop bleeding 2-3mm below CEJ with moist cotton pellet, allow blood to clot for 15minutes. Place MTA over blood clot, restore.
Revascularization technique
1.1% NaF; 1.1% APF indications: ECC, ortho appliances, reduced salivary flow, radiation, high caries risk, poor OH
Rx fluoride gel for tray or brush on
0.2% NaF weekly use
Rx fluoride rinse
Med hx, tetanus, irrigate area with water/saline/CHX, suture any lacerations, record PAX to confirm correct position, flexible splint for 2 weeks. Systemic ABX. Initiate RCT within 7-10days for closed apices. For open apices monitor for pulp revasc, if not apexogenesis or apexification may be needed. ENDO referral.
Tx for avulsion injury where tooth has already been replanted before coming to dentist?
Record PA in 3 angles to rule out other injuries. Record soft tissue 1/4 exposure if there are lacerations and tooth piece was not found. When possible, re-attach fractured segment. Depending on fracture, smooth surfaces or restore as necessary. Healing depends on any concurrent luxation injuries and dentin seal of restoration. F/U in 3-4 weeks, 6month, 1 year
Uncomplicated fracture of permanent tooth
According to the guidelines, posterior bitewing exam at 6-12month intervals if proximal surfaces cannot be examined visually or with a probe
What is the frequency that radiographs would be taken in patients with clinical caries or at increased risk for caries?
Eliminate the need to extend for prevention and to fill any voids in the surface of the hybrid resin-based composite created during finishing
What is the purpose of sealant placement in a preventive resin restoration?
According to the guidelines, for a new patient in primary dentition you would take individualized radiographs consisting of bitewings, occlusal, and selected periapicals if proximal surfaces cannot be probed or visualized. Without evidence of disease and with open proximal contacts, radiographs may not be required at this time.
What radiographs would you take in a new patient in primary dentition?
According to the guidelines, individualized radiographic exam consisting of posterior bitewings with panoramic or posterior bitewings with selected periapical images. An FMX is preferred if the patient has clinical evidence of generalized dental disease or a hx of extensive dental tx.
What radiographs would you take in a new patient with full adult dentition
Hard tissue healing is the best. Connective tissue healing, interposition of granulation tissue. If pulp necrosis occurs it is usually in the coronal segment. Refer to ENDO. Pulp is extirpated, CaOH for 1 month to disinfect, then tx with MTA for apical barrier and seal with gutta percha.
What types of healing are there in root fractures?
IPT can be done in teeth with caries approximating pulp but have normal asx pulp. The deepest layer of caries is left and covered with biocompatible material to prevent pulp exposure and allow for tertiary dentin deposition and maintain pulp vitality.
When is IPT indicated?
POOR prognosis, expected outcome is ankylosis and resorption. Remove necrotic PDL from tooth. Soak root in 2% NaF for 20 minutes to delay resorption. LA, irrigate socket with saline, examine socket reposition any fractures, replant tooth with gentle pressure, suture any lacerations, verify normal position, flexible splint for 4 weeks, systemic ABX. Initiate RCT within 7-10 days or before replantation. Children under 15yo will probably need decoronation to preserve alveolar bone. ENDO/ORTHO/OMFS/PROSTH referral.
closed/open apex, dry time >60minutes or stored in non-physiologic media like water
Primary and permanent: Record PA, monitor. Gingival sulcular bleeding confirms dx. May have sensitivity to percussion. pulp healing is frequent and long term prognosis is good.
concussion and subluxation injuries
Ferric sulfate is hemostatic, denatures protein, and occludes blood vessels. Application time is 10-15sec. May see self-limiting internal resorption
ferric sulfate MOA? application time? clinical side effects?
5% NaF varnish = 22,500ppmF = 22.5mg/cc indications: moderate-high risk caries
fluoride varnish
0.25g = 0.25mg F; 2-6yo
how much fluoride is a pea size of toothpaste
0.1g = 0.1mg F; less than 2yo
how much fluoride is in a smear of toothpaste?
2% NaF; evidence strongly recommends 4 minutes application. Indicated for school aged children (pre-school children may ingest)
in office fluoride foam tx - what is the concentration and for how many minutes does it need to be applied
No. Current materials have biomechanical properties that can reduce the risk of excessive wear
is the wear of a resin-based composite a significant concern when placing a resin restoration?
Record PA in 3 angles. Tooth may be immobile and have high-pitched metallic sound on percussion because it is locked in bone. Tx: LA, disengage from bony lock, reposition, splint 4 weeks. May need RCT if teeth become necrotic. Depends on open apice vs closed apice. Closed apices revasc likelihood is minimal.
lateral luxation of permanent tooth
The aim of apexification is to allow the formation of an apical barrier in immature teeth in which root growth and development cease due to pulp necrosis. can be done with CaOH or MTA
what is the goal of apexification?
acyclovir is only effective if administered within the first 72 hours of the appearance of the prodrome. In reality, few children will present tot he dentist within this time period and have commonly visited their medical practitioner prior to the dentist. Acylovir should ALWAYS be used when managing children who are immunosuppressed.
should an anti-viral be prescribed for acute herpetic stomatitis?
LeFort II: separates nasomaxillary complex from upper face and skull. Tx is open reduction and internal rigid fixation.
tx?
LeFort III: separates cranium from mid face. May see leakage of CSF - otorrhea, rhinorrhea. Tx is open reduction and internal rigid fixation
tx?
DPC, partial pulpotomy if bleeding can be controlled, cervical pulpotomy when bleeding can be controlled at the entrance of the canal
what are conservative tx options when the pulp is exposed during caries removal?
more than 1/3 root resorption, hx of spontaneous pain, presence of fistual/swelling, necrotic pulp, uncontrolled pulpal hemorrhage, dystrophic calcification, internal resorption
what are contraindications for a pulpotomy?
green-gray discoloration of tooth is sometimes evident after 3-mix antibiotic paste which presents an esthetic problem. Drug tolerance is a potential risk, and as a result the disinfecting action will be impaired. Antibiotic allergy can potentially be life-threatening
what are possible complications of revascularization?
NaOCl, when placed on the exposure site, causes hemostasis, has a beneficial effect of killing bacteria, and does not damage the pulpal cells
what are the advantages of using NaOCl to control pulpal hemorrhage during a pulpotomy procedure?
SDF is indicated in high caries risk patients with anterior/posterior active caries lesion (no pulp exposure), patients with difficulty to accessing dental care, patient with behavior or medical management challenges, difficult to treat cavitated lesions, patient with multiple caries that cannot be treated in 1 visit
what are the indications for SDF according to the guidelines
carious or traumatic pulp exposure with transitory thermal and/or chemical stimulated pain. No percussion sensitivity, intact ligament space, intact furcation bone, normal soft tissue
what are the indications for a pulpotomy?
intrusions are serious injuries with a relatively poor prognosis because of the crushing of the PDL fibers, pulp tissue, and supporting bone. Ankylosis with resulting replacement root resorption is common, as is pulp necrosis and inflammatory root resorption.
what are the most common complications of an intrusion injury?
CaOH and MTA. Both stimulate the healing of the pulp and the formation of a dentin bridge
what are the most commonly used pulp dressing materials in partial pulpotomy, and what are their properties?
CaOH has high pH that causes necrosis and stimulates hard tissue bridge with inclusions. CaOH is also used as interim root canal dressing because it has excellent antibacterial property (7 days), dissolves necrotic pulp remnants, and arrests osteoclastic activity. After it is left in canal for 2 weeks if there are no signs of root resorption, the tooth can be obturated with gutta percha.
what are the properties of CaOH
MTA is mineral trioxide aggregate. It has a high pH and forms a dentin bridge with fewer vascular inclusions than CaOH. Protects against bacterial penetration. Can be used in apexification procedures as well. Takes 4-6hours to set with moisture. Need to seal with moistened cotton pellet and then re-access at 2nd appt.
what are the properties of MTA?
resin-retained bridge, denture, orthodontic space closure, implant later
what are tx options for tooth loss?
Mucosal swelling, sinus tract, increased mobility, pain or sensitivity to percussion. Discoloration of tooth does not indicate extraction.
what clinical signs would indicate extraction of primary tooth following injury?
ecchymosis of floor of mouth, hematoma in buccal vestibule, step deformity, mobility of fracture site, paresthesia in distribution of IAN
what clinical signs would make you suspect a fracture to the body of the mandible?
hx of blow to cheek, periorbital swelling, paresthesia from cranial nerve V.2, limited upward gaze, step deformity, conjunctival hemorrhage, bruising,
what clinical signs would you see in a patient with zygomatic fracture?
Elongation of middle 3rd of face, mobile maxilla, bilateral periorbital ecchymosis, conjunctival hemorrhage. LeFort I separates maxilla from upper face. No fixation tx is done for children under 6yo
what clinical signs would you see in patient with LeFort I fracture? how would you tx this?
caries present on multiple surfaces, incisal edge is involved, extensive cervical decalcification, pulpal therapy is indicated, minor caries but poor OH, inadequate isolation
what indicates use of crowns rather than composite restorations on anterior teeth in children?
inability to isolate the tooth, large multiple surface restorations in posterior primary dentition, high risk patients with multiple caries and/or tooth demineralization, poor oral hygiene, and when maintenance is considered unlikely.
what is a contraindication to placing a resin restoration?
the transplant recipient who is on anti-rejection medication requires only the ROUTINE antibiotic medication to prevent post-op infections. Children who receive a heart transplant are not at risk of developing endocarditis, except if they develop valvulopathy. However, peri-operative and post-operative antibiotics are required to cover the immunosuppressed child from potential infection of tissues involved in the surgery. Amoxicillin is appropriate; it is a broad-spectrum antibiotic which is active against gram-positive facultative oral organisms.
what is the antibiotic of choice when performing any gingival surgery on a child with a heart transplant?
According to the guidelines, for patients in primary and transitional dentition at low caries risk posterior bitewing exam at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe. For adult dentition, posterior bitewing exam at 18-36month interval.
what is the frequency that radiographs would be taken in a patient at low caries risk? primary dentition? mixed? permanent?
