Paediatric Dentistry Manual PDF

**[PAEDS HANDBOOK ]** **[WHAT IS PAEDIATRIC DENTISTRY?]** specialty that involves the practice of oral health care for infants, children and adolescents between birth to the age of sixteen years. **[HISTORY, EXAMINATION AND TREATMENT PLANNING ]** - Establish a good rapport with both the patien...

**[PAEDS HANDBOOK ]** **[WHAT IS PAEDIATRIC DENTISTRY?]** specialty that involves the practice of oral health care for infants, children and adolescents between birth to the age of sixteen years. **[HISTORY, EXAMINATION AND TREATMENT PLANNING ]** - Establish a good rapport with both the patient and any siblings/parent/guardian - Remember to smile and introduce yourself. - Ask the patient who they have brought with them -- avoids mistaking a mother for grandmother etc - Asking patients age is a good ice breaker - The date - The name of the consultant covering the session - Who has attended with the patient? - Why the patient has attended - Confirm medical history **[History ]** - History of pain/facial swelling - whether the patient needed antibiotics - did symptoms interfere with eating/drinking/sleep - Has the patient needed to access any other emergency care? - Also take a history of the patient's previous dental experience. - Do they attend their GDP on a regular basis? - What treatment have they tolerated before? Eg LA, restorations, extraction Mothers are normally good at predicting how their child will react to a treatment **Medical History** follow on Salud, check every visit **[Examination ]** 1. Facial asymmetry 2. Facial swelling 3. Lymphadenopathy 4. Pyrexia 1. Examination of intra-oral soft tissues 2. A full dental charting 3. Simplified BPE as appropriate 4. Orthodontic assessment **[Special tests ]** - **Percussion** -- unreliable in children, light tap with a gloved finger is usually enough - **Sensibility testing** - unreliable in primary teeth, appropriate for permanent teeth - **Radiographs** - **Bitewing radiographs:** shows furcation of primary molars - most likely to see pathology here - **Lateral obliques**: extra oral views for pts who can't tolerate intra oral views - **DPT**: assessment of developing dentition, supernumerary teeth? - **Periapicals**: assessing trauma - **DPT on bitewing setting** caries diagnosis for pt who can't tolerate intraoral, view development - **Upper standard occlusal**: show anterior caries, supernumerary teeth, fractures **[Diagnosis ]** [May include ] 1. **Hard tissue diagnosis** -- "uncomplicated enamel dentine fracture UR1" 2. **Periodontal Ligament diagnosis** -- "Subluxation UR1" 3. **Caries diagnosis** -- " occlusal caries URE extending to inner third of dentine -- pulpally involved"? 4. **Pulpal pathology** -- "non-vital URE" 5. **Gingival pathology** -- "gingivitis" 6. **Tooth surface loss** 7. **Developmental defects** -- "Hypomineralised UR6" 8. **Periodontal pathology secondary to hard tissue or pulp path**o**logy** -- "periapical periodontitis UR5" 9. **Orthodontic diagnosis** -- "Class II division 1 incisor relationship" 10. **Behaviour** -- Frankl Score 11. **Medical diagnosis** **[Treatment planning ]** - Options to be discussed with patient and parent - Modality of treatment will vary depending on - The cooperation of the patient - Medical history - Complexity of care required - Patient/parent choice **Local analgesia** - Topical analgesia and the injection of local analgesia often referred to as "sleepy juice **Inhalation sedation** - Over the age of six years - need to be able to communicate with the dentist for this to be effective - Titrated dose of nitrous oxide/oxygen - Provides sedation and mild analgesia, when children are anxious **Iv sedation** - Using propofol (delivered by an anaesthetist - May be suitable for children over the age of 12 years who are anxious. **General anaesthesia (GA)** - Allows treatment to be completed in one visit - GA should only be considered when all other modalities of delivery are deemed inappropriate. - Associated with risks including a very small (34/million), risk of death. **[Treatment Plan ]** - Should be written in a visit by visit order - Each visit should have a restorative and preventive component - **Prevention component** treating the cause of the disease - **Restorative component** repairing the damage - **Quadrant dentistry** a single quadrant is anaesthetized and all work in that quadrant performed, - Maxillary quadrants are usually treated first as it is easier to achieve LA -- unless mandibular pain present - May alter visit by visit depending on symptoms and patient compliance. **Alternative Options** If patient loses compliance, it is possible to place SSC URD, ULD and LLD using the Hall technique. The patient would then be listed for the extraction of URE, ULE, LLE, LRD and LRE under GA. If patient not cooperative enough to allow any treatment he can be listed for the extraction of all carious primary molars under GA. **[REGULAR DENTAL ASSESSMENTS WITH APPROPRIATE RADIOGRAPHS ]** **[Dental recall intervals]** - Determined for each patient - on basis of disease levels and risk of or from dental disease - NICE guidance states that a recall period of 3, 6, 9 or 12 months, depending on caries risk **At each apt you should:** - The disease risk of the patient should be re-assessed and changed if required - The preventative strategy should be reviewed, and appropriate advice and treatment given - Dietary habits and tooth brushing practice should be reviewed - Any early carious lesions managed with prevention only should be reviewed - Fissure sealants should be examined for wear and leakage. **[Radiographic Recall]** **The Faculty of General Dental Practitioners (FGDP)** sets out guidance for the frequency of bitewing radiographs to diagnose dental caries for both the primary and permanent dentition  **[CONSENT ]** **[Valid Consent]** - according to the Department of Health - Given voluntarily - Person appropriately informed - Person has the capacity to consent to the intervention in question - Be the patient or someone with parental responsibility (PR) for a patient under the age of 18 **[Gillick Competence ]** - Children under 16 - Sufficient understanding and intelligence - Understand fully the proposed intervention You can take their consent without PR as valid as long as they have sufficient understanding and intelligence to fully understand the proposed intervention. If you deem the child not to have this understanding- they are deemed to be a child lacking capacity **PR must be contacted.** **[Young Adults 16-18 ]** - Family Law Reform Act 19693 - Aged 16 or 17 - presumed to be capable of consenting to their own medical treatment inc LA - Given voluntarily by an appropriately informed young person capable of consenting - The refusal of a competent person aged 16--17 may in certain circumstances be overridden - by either a person with parental responsibility or a court **[Parental Responsibility - Who has it? ]** - The child's mother - The child's father, if he was married to the mother at the time of birth - The child's legally appointed guardian - A person in whose favour the court has made a residence order concerning the child - A local authority designated in a care order in respect of the child **[Unmarried Fathers ]** **Before 1 December 2003** - Marry the mother of their child - Obtain a parental responsibility order from the court - Register a parental responsibility agreement with the court or by an application to court **After 1 December 2003** - Register the child's birth jointly with the mother at the time of birth - Re-register the birth if they are the natural father - Marry the mother of their child or obtain a parental responsibility order from the court - Register with the court for parental responsibility Anyone who has parental responsibility given by a court will know and will have the documentation **[Looked after children]** Children\'s Act 1989 under \"General duty of local authority in relation to children looked after by them\" A child is legally defined as 'looked after' by a local authority if he or she - is provided with accommodation for a continuous period for more than 24 hours - is subject to a care order - is subject to a placement order - Care order the local authority will have PR - Placement order the child is placed with prospective adopters which is complex - as they get PR shared with birth parent and local authority as soon as child placed with them - until the adoption paperwork is complete. **[Gaining consent ]** On the paediatric department we routinely gain written consent (Form 2) for - Treatment under general anaesthetic - Treatment under inhalation sedation - Extractions under local anaesthetic **[General Anaesthetic]** There are two waiting lists for general anaesthetic **Exodontia** - This is a waiting list for children requiring extractions only. - If placing on this list put a blue sticker on the front of the children's pathway - Consent must be taken for teeth noticed in mouth to have any decay - plus "any other teeth as necessary (including anterior teeth) to achieve oral health" **Comprehensive Care** - This is a waiting list for both restorative and extraction cases - If placing on this list put a yellow sticker on the front of the children's pathway booklet - Consent needs to be as accurate as possible *Eg: Proposed Treatment: General anaesthetic and local analgesia for the extraction of at least one adult tooth and four primary teeth, restoration of 3 adult teeth and any other restorations and extractions as needed to secure oral health* - Need to consent for radiographs if planning to take these whilst the child is in theatre - Need to consent for extraction of further permanent teeth if restoration is not possible **[BEHAVIOUR MANAGEMENT ]** - Can be challenging for some children - Past experiences my provoke anxiety/ apprehension - May need adjuncts to aid treatment - The way you interact with a child will have significant influence on treatment success - Establish communication, alleviate fear promotes positive attitude toward oral health **[Dental Anxiety ]** - 51% of adults with dental anxiety report this began in childhood - may occur without a specific stimulus - may be a reaction to the unknown - may be the dental environment itself - best to address chid anxiety so it doesn't continue into adulthood **[External Factors to Anxiety ]** - Attitude to dentistry of parents, siblings and peers - Negative portrayals of dentistry in the media - Previous medical or dental experiences - Communication or learning difficulties. Ascertain a child's previous medical and dental experience and how well they coped with these. **[The Waiting Room ]** - The non-clinical environment is a critical aspect of the initial patient - The reception staff should be welcoming, with a calming décor in the waiting room - child-friendly toys and books available distraction and a positive first impression - When calling the patient in, the tone of voice should be welcoming and pleasant. **[The Surgery]** - A bright and friendly environment is available at the University of Manchester Main Clinic. - Themed single surgeries have also been designed for dental sedation. - All members of the dental team must establish a warm and welcoming environment - body language and communication skills are critical - General neatness and apparent cleanliness - Protective equipment -- place on after introducing, explain what it is **[Child Friendly Terms ]** **Childrenese** -- words children can relate to **[Tips and Tricks ]** A dentist with a calm, caring and empathetic approach is much more likely to be successful - Greet the child first and find out what name they like to be called by - Engage with the child by asking who they have brought with them for the appointment - Maintain good eye contact with the child during communication. - Provide clear, direct instructions and avoid open questions. - Question for feeling during procedures: How does that feel? Does that feel ok? - Give feedback about the child's behaviour. - Physical contact can reinforce positive behaviour - placing a hand on shoulder or offering hand to hold after a particularly difficult procedure. **[Things to Avoid ]** - Unsolicited reassurance such as "Don't worry, this isn't going to hurt" or "It's just a small scratch" - Criticising, ridiculing or belittling a patient are highly ineffective. - Non-dental chitchat with another person (dental nurse or parent) **[Frankl's Behaviour Rating Scale ]** - Aid clinicians in determining whether improvements in acclimatisation to the dental setting - Monitoring compliance with individual treatments - Documents the child's cooperation  **[Behaviour Shaping ]** "developing appropriate behaviour by reinforcing successive approximations to the desired behaviour until the desired behaviour is achieved" **[Positive Reinforcement]** - a pattern of behaviour is strengthened in such a way that it increases the probability of that behaviour being displayed again in the future. - Descriptive phrases can emphasise a specific cooperation **[Tell show do]** - **Tell** -- Describe what is to happen - **Show**- Demonstrate the procedure - **Do**- Do it! - De-sensitisation, well-described action and visual tactile demonstrations **[Enhancing Control ]** - provide the child with a stop signal such as raising of the arm - practice this with the child - important the dentist responds promptly when used - (some patients may use as a distraction technique to delay treatment) **[Ask Tell Ask ]** - ask the patient about the proposed treatment - tell them in simple language - ask how they feel about that and whether they would they be able to manage that treatment - then reassess at the end by asking anything else - teaches the patients about the proposed procedure and how this will be achieved **[Distraction ]** - attention drawn to a totally different sensation or action - distraction of attention from stressful thing to something less stressful can be useful - For example, drawing attention to the sensations of lip pulling, etc. during local analgesic - Giving the patient a short break can also be an effective use of distraction. **[Positive Pre-Visit Imagery ]** - For some children, a change to a routine can be extremely distressing - To support these patients' visual aids can be provided such as positive photographs of dentistry - provide children and parents with visual information about what to expect during the dental visit. **[Modelling ]** - children learn about their environment by observing behaviours. - A child would observe the behaviour exhibited by another patient - by observing a behaviour, the likelihood of that observed behaviour being adopted is increased. - familiarise the patient with specific steps involved in the proposed dental treatment. **[Systematic Desensitisation ]** - Allow a patient to gradually come to terms with a particular fear or phobia by repeated contacts. - A hierarchy of fear-producing stimuli is constructed - The patient is exposed to them in an ordered manner starting with the lowest threat. **[Parental Involvement ]** - Parental behaviour and attitudes towards dentistry key effect on a child's behaviour - Parents interrupting flow of communication during treatment distraction and confusion for child - Children are very perceptive to parental non-verbal and verbal anxieties. - Frankl explains the importance of how a passively observing mother can aid a child - provide support as the "silent helper". - Having parents in the surgery can help avoid any misunderstanding if a child becomes upset - helps parents to appreciate how well their child has tolerated treatment/ know limitations Negative Reinforcement Techniques **[Parent in/Parent out ]** - the reinforcement of a behaviour by removing something which is perceived as negative by the patient as soon as positive behaviour is exhibited. For example, if a parent has agreed to leave the surgery due to negative behaviour by the patient, allowing the parent to come back in as soon as the patient shows positive behaviour means that the negative (the parent being outside) is removed, thus reinforcing the positive behaviour. **[Voice Control ]** - deliberate alteration of voice volume, tone and pace to influence child's behaviour. - Useful for the cooperative but inattentive child - inappropriate for young children/ those who have emotional or intellectual impairment - unlikely to be acceptable to most modern parents. **[The Difficult Exam ]** Knee to knee / Lap to lap exam successful technique to aid assessment. **Limited mouth opening? - Bedi Mouth Prop** - used for the administration of medicine BUT - useful aid when held on the finger for a dental exam - can be given to the parent to aid those extra help with tooth brushing. **[Do's and Don'ts ]** - Arrive at the clinic early! -- don't be late! - Be organised -- check your treatment plan beforehand. - Get everything prepared -- necessary equipment and materials - (avoid opening sterile instruments until patient has arrived) - Make a comprehensive treatment plan - Communicate effectively with both children and their parents/accompanying adults. - Focus on success/appropriate behaviour and reinforce - Set clear, easily achievable goals for both the patient and you - try to make each visit a "success". - Don't make promises (or threats) you cannot keep - Make good records to ensure progress is accurately monitored - Do not use put downs/ridicule - Last thing you should record in the notes should be what the plan is for the next **[PREVENTION OF DENTAL CARIES ]** - A multi-factorial disease from the interplay between environmental, behavioural and genetic factors. - every paediatric patient whom you treat on clinic will require some preventive input - input will depend upon the child and their caries risk. - All preventative measures need to be coordinated and supervised by the dental team - Reinforced with good patient and parental motivation. **[Five components involved in the prevention of dental caries]** 1. Plaque control and regular tooth brushing with fluoridated toothpaste 2. Dietary advice 3. Increasing fluoride availability 4. Fissure sealants 5. Regular dental assessments with appropriate radiographs **[Plaque Control and Tooth Brushing ]** - Regular tooth brushing with fluoride toothpaste will reduce both dental caries and periodontal diseases. - Fluoride in the toothpaste prevent, control and arrest caries. - Mechanical removal of plaque reduce the inflammatory response of the periodontal tissues. **The following principles of tooth brushing should be followed:** - Tooth brushing should begin as soon as the [first primary tooth erupts.] - Should occur [last thing at night] and at one other occasion throughout the day - Adult should [supervise] brushing until at least the age of 7 - Toothpaste should be [spat out] following brushing as opposed to rinsing with water - Mouthwashes (included those containing fluoride) should not be used immediately after - The patient's existing method of brushing may need to be modified to maximise plaque removal, - Emphasise the need to [systematically clean] all tooth surfaces. - Brushing is more effective with a toothbrush with a small head and medium textured bristles. - There is evidence to show that [powered brushes] with rotating/ oscillating action can reduce plaque and gingivitis in the short and long term compared to manual toothbrushes. **Concentration and Quantity of Toothpastes** - Children under 3 - toothpaste containing no less than [1,000 parts per million (ppm)] of fluoride. - Children under 3 - use no more than a [smear] of toothpaste - Children aged 3-6 should use a [pea-sized] amount of toothpaste - Family fluoride toothpaste ([1,350-1,500 ppm fluoride]) is indicated for [children age 7+] - Advice must be given about [adult supervision] - For [high-risk] patients' toothpaste with a [higher concentration] of fluoride can be prescribed **Facilitating Tooth brushing** - [Plaque disclosing tablets] and solutions are available. - Children need appropriate [supervision] when using these agents - Disclosing of plaque can be completed in the [clinic or at home]. - Disclosing aims to show patients the plaque present on the teeth in a [visual way] - [Plaque charts] can be used to monitor progress and identify areas where brushing is being missed. - Percentage number of clean surfaces should be recorded - The disclosing agent should firstly be used in clinic to demonstrate it - Petroleum jelly should be applied to the lips prior to use to prevent staining. - The child should try to remove all stained plaque and you should discuss brushing technique. - After 1 week, patient should brush first then disclose to identify areas being missed. - [Timers] can also be used to help the patient brush for the appropriate time. **[Dietary Advice ]** Healthy eating advice promote both good oral and general health. - Amount/ frequency of food/drink containing free sugar/fermentable carbohydrates should be reduced. - Number of times that food or drink containing sugars in one day [should not exceed four. ] - By confining food and drinks which contain sugars to mealtimes will reduce the number of acid attacks - Only [milk and water] should be consumed in between meals. - Drinks containing sugars such as sweetened milk, fruit juices and fizzy drinks increase the risk of caries. - Ensure parents are informed about [hidden sugars in foods.] - Many foods such as crisps, yoghurts and cereals contain added sugar - [Safer snacks] should be encouraged such as [carrot sticks and nuts] - Following tooth brushing at night nothing else should be eaten or drank except for [plain water] - There should be no intake of foods or drinks containing sugars within 1 hour of bedtime - as the [salivary flow], and thus its protective effects are [reduced] - [At 6 months] children should be introduced to drinking from a [free-flow cup] - [From 12 months] drinking from a bottle should be [discouraged]. **Public Health England (2015) advise that the recommended intake of free sugars is no more than** - 19g per day = 5 sugar cubes for 4-6-year olds - 24g per day = 6 sugar cubes for 6-10-year olds - 30g per day = 7 sugar cubes for 11 and over **[Stephans curve ]** - Sugar intake causes a fall in ph. level as oral bacteria convert sugar to acid causing demineralisation - Buffering action of saliva is also reduced. - When sugar intakes are spaced the teeth can remineralise more effective in the presence of fluoride. - Frequent sugar intakes demineralisation occurs more often, limited time for the ph. to rise **[Diet diary ]** - When giving dietary advice it is essential to use a positive approach. - Also focus on how the reduction of sugars will have wider health benefits - Give achievable advice and goals - Diet can be reviewed in the form of a **3- day diet diary** - All food and drinks should be recorded over a 3-days. One day should be a weekend - Diet diary should be reviewed, and advice should be practical and personal - Support given should be constructive - **A recall diet diary** can be completed in surgery - When the patient/ parents/carer recalls food and drink consumed over a 24-hour period. **[Eat well plate]** - Public Health England - Eat at least 5 portions of fruit and vegetables per day - Base your meals on starchy carbohydrates and choose wholegrain options - Ensure that there is some dairy in the diet and choose low sugar and fat options - Eat sources of protein such as meat, beans and fish - The diet should include 2 portions of fish per week with 1 portion being oily fish. - Processed meats should be limited - Choose unsaturated oils and spreads, cutting down on saturated fats - Drink at least 1.2 litres of water per day. - Limit salt/sugar intake. Ideally, max 5% of energy we consume should come from free sugars. **[Increasing Fluoride Availability]** - It is the topical action of fluoride which is essential for caries prevention - Most effective if it is available at multiple times throughout the day. - can be found in fish, vegetables, tea and some natural water supplies - fluoride products available for systemic and topical use for us by patient or given by dentist **The mechanisms of action of fluoride are summarised below**: 1. It has an effect during tooth formation making the enamel crystals larger and more stable. 2. It inhibits plaque bacteria by blocking enzyme enolase during glycolysis. 3. It inhibits demineralisation when in solution. 4. It enhances remineralisation by forming fluorapatite when in solution. 5. It affects pits and fissures -- theyre shallower hence less likely to create stagnation areas. **[Water Fluoridation ]** - [Systemic method of providing fluoride] on a community basis. - Currently in the UK only approximately [10%] of the population benefit from this water supply - Multiple studies carried out across the world showing water fluoridation [decreases caries.] - It's a [cheap and cost-effective method] - Can be considered as an effective method to [reduce social inequalities] in caries level - Can be said to [cause dental fluorosis. ] - Some groups claim that it can [cause health problems. ] - There is further reassurance that [water fluoridation is a safe] and effective public health measure. **[Toothpastes ]** - Fluoride containing toothpastes were first introduced in the early 1970's - Strong evidence shows that toothpastes containing higher concentrations of fluoride are more effective - Consider benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. - A research study has shown that the risk of fluorosis from ingesting too much fluoride is linked much more to the amount of toothpaste that is used, than the concentration. - Brushing by parents/ carers when using toothpastes containing higher levels of fluoride is required. **For patients aged 10 and above**, at a high caries risk, **2,800ppmF toothpaste** can be prescribed. **For patients aged 16 and over** who are at high caries risk **5,000ppmF** **toothpaste** can be prescribed. **[Fluoride Mouth rinses ]** - Can be prescribed for patients 8 years and above who are at a high risk of dental caries. - It should be used daily in addition to tooth brushing. - Rinsing should occur at a different time to brushing to maximise the topical effect. - All orthodontic patients should be using fluoride rinses to minimise the risk of demineralisation. - Children under the age of 8 should not be recommended to use fluoride mouth rinses - because of the increased risk of swallowing the solution. **[Fluoride Varnishes ]** - One of the best options for increasing the availability of levels of fluoride - Varnish can also arrest existing lesions. - Fluoride varnish has a number of practical advantages, it is well accepted and considered to be safe. - Application is simple and trained dental nurses can also place the varnish on prescription. - Gross plaque should first be removed - Teeth should be dried with cotton wool rolls or a triple syringe. - The varnish should be carefully applied with a micro brush to pits, fissures and approximal surfaces - The patient should then avoid food and drinks for 30 minutes - only soft foods should be eaten up to 4 hours after the application. - **Duraphat (5wt% fluoride 22,600ppm fluoride)** is the most widely available fluoride varnish. - Small risk of allergy to colophony history of allergic or asthma, varnish application is contraindicated. **[Fluoride Supplements ]** - Fluoride tablets and drops usually [require good compliance] from families - The fluoride supplement [dose depends on] age of the patient and level of fluoride in water. - There is a [risk of fluorosis] if children under the age of 6 take more than the advised dose. - Therefore, DBOH states that other sources of fluoride may be preferable and should be considered first. - Brushing with a toothpaste containing at least 1,000ppmF or higher is the priority - In addition, a systematic review of fluoride tablets, drops, lozenges and chewing gums concluded that the evidence of the effect of these additional sources of fluoride 'was unclear on deciduous teeth'.  **[SEE PAEDS MANUAL FOR REFERENCES AND COCHRANE REVIEWS...]** **[Fissure sealants ]** - Materials applied to the tooth to obliterate the pits and fissures - Remove the sheltered environment where caries may develop - Sealing occlusal surfaces of permanent molars reduces caries up to 48 months compared to no sealant - Often used as a non-invasive technique to acclimatise patient **2 types** **Resin Materials** - Isolation is critical -- use cotton rolls and suction - Rubber dam? Unlikely with children/ due to tooth erupting **Glass ionomer sealants** - less technique sensitive but poorer retention - indicated If patient is pre-cooperative - if the tooth is partially erupted but high caries risk - can't get good moisture control - should be into all pits and grooves of the tooth, can be buccal and palatal fissures - checked visually for wear and physically with a probe for integrity/ leakage at every recall visit - placed in permanent teeth of patients with a high caries risk inc special needs/ medically compromised **BDA document 2000** - Children and young people with caries in their primary teeth (dmft=2 or more) should have all susceptible sites on permanent teeth sealed. - Children with caries free primary dentition do not need permanent molars sealed routinely in absence of risk factors - Place fissure sealants as soon as teeth have erupted sufficiently for good moisture control. - Where there is caries in one permanent molar, seal all other permanent molars. **[For fissure caries]** Conventional restorations should be placed when there is - Microcavitation - Shadowing visible under the enamel adjacent to the fissure after cleaning and drying the tooth - Dentinal caries clearly visible on a bitewing radiograph. Otherwise place a fissure sealant alone and review the tooth at every recall visit. **Technique for placement of fissure sealants** 1. Clean tooth if obvious debris is present. 2. Isolate tooth with cotton wool rolls, use high volume suction and a dry guard may be beneficial. 3. Apply etch 37% phosphoric acid for 20-30 seconds 4. Wash and dry the surface, maintaining isolation, dry the tooth until there is a frosty appearance. 5. Apply bond using a micro brush, lightly dry with the triple syringe and light cure. 6. Apply resin to the pits and fissures using a spoon excavator. 7. Light cure the resin. 8. Check for adequacy with a probe, if the sealant comes away with probe -- replace! It has been shown that adding a bonding layer may improve the retention of fissure sealants Especially when contaminated with saliva [ ] [ ] **[LOCAL ANALGESIA ]** - Local Analgesia (LA) should be routinely used in all age groups. - Age of the patient should not be a contraindication for its use, even for mandibular blocks. - Full procedure should be explained in simple terms -- sleepy juice - Signal - child can indicate when they feel discomfort can help to enhance control **[Topical/surface analgesia ]** - Topical Analgesia should always be used - most commonly used topical **20% benzocaine** - Other agents Xylonor (5% lidocaine) 1. Apply in small quantity on cotton roll or cotton bed. 2. Ensure that area of application is dry. 3. Apply for at least 3 minutes for best effect. **[Commonly used LA ]** - **Lignocaine 2% with 1:80000 epinephrine** -- most commonly used in dentistry - **Prilocaine 2% with felypressin** 0.54μg/ml - **Articaine 4% with 1:100 000 epinephrine** -- use is being increased -- don't use for ID block -- neurotoxic! **[Technique]** - **Infiltration** -- used for maxillary arch and soft tissue surgery - **Indirect palatal injection** -- through buccal papilla until blanching on palatal **[The Wand Anaesthetic system ]** - A computerised LA system deliver local anaesthetic solution slowly, at a fixed, slow speed. - Made up of a microprocessor control, disposable hand piece and foot control (activation switch). - Thought to provide 'pain free local analgesia to anxious/ needle phobic children **[RESTORATIVE DENTISTRY ]** **The care index** - indication of the restorative activity of dentists in each area. It is the percentage of teeth with decay experience that have been treated by restoration. Other factors deprivation, level of decay and availability of dental services must also be considered. Early involvement of the pulp in primary molars with proximal caries means that many of these teeth will require pulp therapy prior to the placement of a coronal restoration. **Preformed metal crown** is the restoration of choice as tooth becomes brittle -- composite may not last **[Why Save Primary Teeth? ]** 1. Space Maintenance 2. Guidance of eruption 3. Mastication 4. Aesthetics 5. Positive attitude to Dentistry 6. Minimise pain/ Infection 7. Medical **[Acceptable procedures for the pulp endangered by a carious lesion are as follows: ]** 1. Cavity liner/base 2. Indirect pulp therapy 3. Direct pulp capping (Permanent teeth only) 4. Vital pulpotomy (Ferric Sulphate or MTA) 5. Pulpectomy *there is no indication for a "non-vital" pulpotomy in Paeds* *or use of medicaments such as formocresol or cresophene.* **[Equipment ]** **Burs** - Small flat fissure bur cavity prep in posterior teeth - Flame shaped bur and pear-shaped bur prep of conventional crown prep in primary molars. **Handpieces** - paediatric handpieces are preferred. - Air turbine to be used for the preparation of cavities - Slow speed with various sizes of round burs to remove caries. **Cavity preparation** - emphasis should be toward minimal preparation, removing only the affected tooth substance **Quadrant dentistry** - it should be the aim of every student to practice quadrant dentistry. - will enhance behaviour management by reducing treatment time/ repeated local analgesia. **Amalgam** - not used in the department of Paediatric Dentistry **Composite resin** - encouraged to use composite resin for the restoration of occlusal cavities and small class II cavities **Matrix bands** must be well approximated to the tooth **Wedges** are mandatory for the restoration of proximal restorations **Rubber dam** is mandatory for all posterior restorations apart from hall technique crowns **Dry dam** is mandatory for all anterior restoration in the Department of Paediatric Dentistry. **[Moisture Control: Rubber Dam ]** I**ndications** - used to ensure moisture control for fissure sealants, composites and endodontic treatment. - Rubber dam is often described to children as 'raincoat' **Advantages** - Moisture-free operating field - Improves access by retraction of soft tissues including tongue/buccal mucosa - Improves patient comfort. Patients often feel more secure - Improves efficiency of restoring multiple teeth (trough technique) - Reducing the risk of aspiration - Minimise mouth breathing (especially useful when inhalation sedation is used) - Reducing cross-infection by minimising aerosol **Contraindications** - Latex allergy, but latex free is available - LA is mandatory prior to placement of clamp. - Important to choose a correctly-fitting clamp to achieve 4-point contact with the tooth. - Otherwise, the clamp is at risk of "pinging" off mid treatment. - In general, an **fw clamp** - for a permanent molar tooth - **dw clamp** - for a primary molar tooth. **Note that these are not winged clamps.** **[Placement ]** - [Floss] must be placed to prevent the patient swallowing or inhaling it accidently if it "pings" off. - Placed securely on the tooth with 4-point-contact - A hole punch is used to place a [hole in the centre of the dam] -- hole size can be adjusted - [Allows the dam to be used in any of the four quadrants.] - Dam is tucked between teeth or into the gingival crevice to improve isolation -- flat plastic used - Finally, [rubber dam frame] placed -- pulling the dam diagonally to prevent unseating it.  **[Trough technique ]** - Necessary to isolate the entire quadrant - Up to 6 overlapping holes are made in the centre of the dam. - Rubber dam is secured over the clamp and then stretched forward to mesial of primary canine - Secured mesial or distal to primary canine using a wooden wedge, dental floss or a rubber wedget.  - **Anterior teeth** isolated using a dry dam - held in place with loops over the patient's ears. - This is a useful technique for endodontic therapy or anterior restorations. - possible to isolate two quadrants -- usually upper and lower at the same time (**double dam**) -- for GA  **[Minimal cavity preparation]** and [composite restorations] are preferred for the restoration of primary teeth. The remaining susceptible tooth surfaces should be [fissure sealed] at the same time. **[PULP THERAPY]** 2 techniques pulpotomy and pulpectomy **[Pulpotomy ]** - A pulpotomy involves the [removal of coronal pulp] tissue that is inflamed as a result of deep caries - Aims to leave an intact, vital apical pulp upon which a medicament is placed prior to coronal seal. - **Medicaments (ferric sulfate or MTA)** **Indications for a pulpotomy:** 1. Tooth with a deep carious lesion 2. No signs or symptoms of pulp pathology 3. Patient "at risk" from extraction e.g. bleeding disorder 4. Patient "at risk" if GA required for tooth removal e.g. Cystic Fibrosis 5. Minimal number of extensively carious primary molars likely to require pulp therapy (\< 3) 6. Hypodontia of the permanent dentition 7. A regular attender with good compliance and positive parental attitude [Congenital heart defects] - pulpotomy is [contra indicated] - risk of precipitating [bacterial endocarditis]. Extraction is usually the preferred treatment in these cases **[How to carry out a pulpotomy ]** - Administer local analgesia and place a rubber dam. - Remove caries and identify the site of pulp exposure - If there isn't a pulp exposure, access to the pulp chamber is made from the base of the cavity - Remove the roof of the pulp chamber. - When the bur passes through the roof a "dip" is felt. - Once you feel this, don't go deeper - Move bur sideways to remove the remaining roof of the pulp chamber - Remove coronal pulp using a large excavator. - Apply medicament to the pulp chamber -- Ferric Sulphate or MTA - Ferric sulphate is placed on a cotton pledget or burnished onto the pulp using a brush. - Check for haemostasis and fill pulp chamber with zinc oxide eugenol. - If using MTA this will be left in situ to fill the pulp chamber. - Press on the zinc oxide with a damp pledget to ensure it is well condensed into the pulp chamber - Prepare the tooth and restore using a preformed metal crown.  **[Pulpectomy ]** - A pulpectomy is to remove irreversibly inflamed or necrotic radicular pulp tissue - Gently clean canals followed by obturating - Use of a filling material that will resorb at same rate as primary tooth **Indications for a pulpectomy** 1. Tooth shows signs/symptoms of irreversible pulpitis and therefor unsuitable for pulpotomy. 2. Non-vital radicular pulp with/without pathology 3. Compliant patient **[How to Carry Out a Pulpectomy ]** - A periapical radiograph showing all roots and apices is essential prior to beginning pulpectomy. - Administer local analgesia and place a rubber dam. - Remove caries and identify the site of pulp exposure. - If there isn't a pulp exposure, access to the pulp chamber is made from the base of the cavity - Identify root canals and irrigate using normal saline, chlorhexidine or sodium hypochlorite - Estimate working length keeping 2mm short of radiographic apex - Insert up to file size 30 into canals and gently file - Dry using paper points, again keeping 2mm short of radiographic apex - Obturate using pure zinc oxide eugenol/sterile water paste, non-setting calcium hydroxide or Vitapex (calcium hydroxide and iodoform paste) - Restore with SSC. **[Stainless Steel Crown (SSC) ]** - [Preformed metal crowns] [ gold standard] restoration for primary molar teeth - simple to place. - They come in a range of sizes from 2-7 with 2 being the smallest size and 7 the largest. **[Indications for SSC: ]** 1. Restoration of primary molars requiring large, multisurface restorations 2. Restoration of primary molars in children with high caries risk 3. Restoration of teeth after pulp therapy 4. Restoration of teeth with developmental defects DI/AI 5. Abutments for space maintainers 6. Restoration of fractured primary molars 7. Protection of primary molars with non-carious tooth surface loss 8. Restoration of hypomineralised young permanent molars **[Contraindications for SCC: ]** 1. Inability to fit one -- may be due to insufficient coronal tooth remaining, more likely is lack of cooperation 2. If the primary molar is close to exfoliation with more than half the roots resorbed 3. A patient with a known nickel allergy or sensitivity **[Technique for the placement of SSC ]** Appropriate local analgesia should be obtained, and the tooth should be isolated with a rubber dam. Caries removal and pulp therapy should be completed as necessary 1. **Occlusal reduction** - using a rugby ball shaped diamond bur or a diamond wheel. - Follow the occlusal anatomy of the tooth - reduce the crown until it is completely out of occlusion. 2. **Mesial and Distal proximal reduction -- crucial!** - Use a tapered diamond to reduce the mesial and distal surfaces - ensure sufficient clearance for the placement of the SSC. - No gingival step should be left otherwise the crown will not fit properly -- check with probe 3. **Selection of size** - Estimate can be made, press into place from palatal to buccal -- should snap on 4. **Crimp crown margins** - Using adams pliers to ensure a tight fit - Prevents build up of plaque and reduce gingivitis risk 5. **Cementing the crown** - Fill with suitable cement -- usually GI - Seat, apply reasonable pressure until cement has set - Excess can be removed using excavator - Use floss mesially and distally through contact point 6. **Crown in situ** - Blanching of gingiva may be noted -- normal will disappear itself - Bite may feel high -- normal and will adjust itself **[Stainless Steel Crown using the Hall Technique ]** Decay is sealed under preformed metal crowns without LA, prep, or caries removal Clinical trials have shown the Hall technique to be effective and acceptable to most children and parents. **[Indications for a SSC using the Hall technique: ]** 1. Proximal carious lesions in primary molars 2. Class I lesions in primary molars if patient unable to accept conventional restoration **[Contraindications for a SSC using the Hall technique: ]** 1. Signs or symptoms of irreversible pulpitis or sepsis 2. Clinical or radiographic signs of pulpal involvement or pathology 3. Unrestorable crown of tooth 4. Child at risk of bacterial endocarditis **[Technique for the placement of a SSC using the Hall technique ]** 1. **Placement of orthodontic separators** - If there is insufficient space for the seating of a crown - may be placed a week before the fitting of the SSC 2. **Placing the crown** - the patient is not supine as there is a risk of aspiration of the crown. - place some gauze lingual to the tooth being restored to protect the airway 3. **Choosing the size** - size selected usually bigger than with conventional crowns as you will not be preparing - it should feel as if it would seat between the contact points. - Do not seat the crown fully as it will be difficult to take off for cementation. 4. **Cementation** - using a luting cement in the same manner as conventional SSC - Ask the patient to bite the crown on using a cotton roll. **[GENERAL ANAESTHESIA AND CONSCIOUS SEDATION ]** - Pain and anxiety management - Conscious sedation - pharmacological management of patients. - when behaviour management techniques have either failed or have had limited success. - Sedation with nitrous oxide inhalation sedation is the most commonly used technique - can be provided both in the primary care and in hospital. - GA can only be provided in Hospitals in the U.K where critical care facilities is available. **[Conscious Sedation ]** - The use of a drug or drugs produces a state of depression of the central nervous system - But verbal contact with the patient is maintained throughout the period of sedation. - Should carry a margin of safety wide enough to render loss of consciousness unlikely. T**he most commonly used techniques in children are:** - **Inhalation sedation** with [nitrous oxide/oxygen] - **Oral sedation** using [midazolam ] **Other techniques include:** - **Intravenous** using [midazolam or propofol] (in the adolescents) - **Nasal**/**transmucosal** using midazolam **[Inhalation sedation with Nitrous Oxide/Oxygen ]** - The nitrous oxide is titrated to get effective conscious sedation - Requires a cooperative child who will accept a nasal hood - Works well when behaviour management techniques are involved - Onset of sedation can be initiated over 5 minutes - Minimal impairment of protective reflexes - Nitrous Oxide has some mild analgesic property - Nitrous Oxide is administered continuously through a nasal hood (mask) - Useful for anxious but compliant children - Nitrous Oxide is a pollutant and therefore all efforts is made to ensure its used **[Oral Sedation]** - The agent that has been midazolam at 0.3-0.5mg/kg. - Not commonly practiced as it can be unpredictable - Getting access to oral midazolam can be challenging. - Often, it is mixed with juice to mask the taste. - It can be used for young children for simple procedures e.g. single tooth extractions. - It is generally felt the operator/team should be skilled in cannulation in case of over-sedation. **Other features:** - Can be unpredictable - Unable to alter sedation effects - Can take up to 40 minutes to take effect - Duration of effect is around 30 minutes - Recovery is around 30 minutes - Can produce good sedation and amnesic effect **[Intravenous Sedation ]** - Intravenous sedation (IV) for the adolescent patients (12 years onwards) can be effective. - Most commonly used single drug sedation is Midazolam but propofol can also be effectively used. - Propofol is a GA agent require an anaesthetist to provide the sedation. **[Nasal/Transmucosal Sedation ]** - Midazolam nasal spray using Mucosal Atomization Device (MAD) - 0.25 mg/kg is administered - Not commonly used in paediatric dentistry as it can have a profound effect - Can be used in an appropriate environment with anaesthetic support  **[General Anaesthesia ]** Last resort when all other methods have failed - Children should be assessed prior to the GA - Assessment should include radiographs and orthodontic opinion - The treatment plan for the GA should also take into account prevention - Written consent completed by a parent/carer - re-confirmed on the day of the GA. - Information leaflet with fasting instructions and pre/post-operative care is provided - Mostly extractions done, however restorative can be done too [ **DENTAL ANOMALIES** ] **Defects in tooth development** can be hereditary, systemic, traumatic or other local factors. **[Anomalies in tooth number ]** - Alteration in tooth number - Usually occurs during initiation or dental lamina stage of development - Results in extra (hyperdontia) or missing teeth (hypodontia) **[Supernumery teeth ]** - 0.2-0.8% primary teeth - 1.5-3.5% permanent teeth (male: female ratio 2:1) - **Form** - Conical (peg shaped) - Tuberculate - Supplemental - Odontome - **Position** - Mesiodens (in the midline) - Distomolar (distal to the arch) - Paramolar (lingual or buccal to the arch) **[Missing Teeth: Hypodontia ]** **Primary tooth hypodontia:** - 0.1-0.9% Caucasian population - more common in the maxilla - equal between male: female - 30-50% of cases of primary hypodontia will be followed by permanent anomalies **Permanent tooth Hypodontia:** - Prevalence is between 3.5-6.5% (excluding wisdom teeth) - Equal frequency Maxilla: Mandible - Female: Male 4:1 - The type of tooth to be absent varies widely especially between racial groups **Severity of Hypodontia** - Mild \6 absent teeth **[Disorders in shape and size ]** **Macrodont or Megadome** - Larger than normal sized tooth - Megadont often affect maxillary permanent incisors and mandibular second premolars - Prevalence in the UK is approx. 1.1% in the permanent dentition **Microdont** - are teeth which are smaller than normal - More common in females - Not common in the primary teeth - prevalence 0.2-0.5% - Permanent teeth prevalence is 2.5% and generalised microdontia is 0.2% **[Tooth Shape ]** Can originate during the Morphodifferentiation stage of tooth development  **Double teeth: Germination or fused teeth** - Prevalence in primary dentition 0.5-1.6% - Less common in permanent dentition 0.1-0.2% - Male and females equally affected - **Concrescence** - Fusion of two or more teeth by cementum - **Germination** - Occurs when one tooth bud attempt to split into two - Tooth count is normal - There is one main crown with a cleft within the cervical third of the crown - **Fusion** - Arises through union of two normally separated tooth germs - it may be either complete or incomplete - Two canals are usually present - The number of teeth in dentition is normally reduced by one unit **[Accessory Cusp ]** **Dens Invaginatus** - invagination of the epithelium into the dental papilla during development. - This may present as deep cingulum pit especially seen on maxillary lateral incisors. - Dens is more common in the permanent teeth and in females (2:1). **Dens Evaginatus** - More common in premolars - presents as a projection arising from the occlusal surfaces in the central fissure - More common in the Asian population with a prevalence of 1-4% - Projection consists of enamel, dentine and pulp. **Tauradontism** - Describes molar teeth - body of the tooth is enlarged vertically at the expense of the root - Teeth appear as normal and usually detected radiographically **Talon Cusp** - an exaggerated cingulum of the maxillary, usually permanent incisors. **[Disturbances in Eruption ]** Eruption pattern of primary and permanent teeth can vary. Racial variation in eruption dates have been noted. **Premature Eruption** - [Natal teeth] - present at birth - Those that erupt in the first 30 days of birth are called [Neonatal teeth.] - Most commonly affects lower incisors. - Concerns - Feeding difficulties - May be mobile and therefore potential risk to airways **Delayed eruption** - Can occur in both the primary and permanent teeth - [Local causes] of delayed eruption include crowding, supernumeries and impaction - E.g. Ectopic first permanent molars. - Dilaceration can also cause a delay or failure of teeth to erupt - [Systemic causes] include syndromes that are commonly linked to delayed eruption - Down syndrome and turner syndrome - [Nutritional deficiencies], hypothyroidism and hypopituitarism have also been implicated. **Premature exfoliation** - Invariably associated with systemic conditions - Causes can be differentiated into - [Periodontal disease] e.g. leucocyte adhesion defect, papillon-Lefèvre syndrome - [Metabolic conditions] e.g. hypophosphatasia - [Connective tissue disorder] e.g. Ehlers-Danlos syndrome - [Neoplasia] e.g. Langerhans cell histiocytosis - [Self-inflicted trauma ] **Delayed exfoliation** **Infra-Occlusion** - An infraoccluding tooth lies below the occlusal plane as a result of [ankylosis] - Primary tooth remains static while eruption of adjacent teeth continues - May be bilateral or unilateral - May affect both maxilla and mandible - X 10 times more common in the primary dentition - Usually develops during the early mixed dentition - Prevalence 9% and may have a familial link - Can cause a delay in exfoliation of the primary teeth **[Enamel and Dentine defects ]** **[Enamel defects ]** - May present as either hypoplasia, due to defective matrix production (quantitative defect) - or hypomineralisation from imperfect mineralization of the matrix proteins (qualitative defect). - Hypoplastic enamel may appear as grooves or pitting in the enamel - Hypomineralisation may appear as opacities or mottling in the enamel. **Chronological disturbances** - Developmental defects can be acquired or inherited - localised to single tooth or more generalised. - Systemic disturbances may affect ameloblast function - Results in abnormality in secretion of enamel proteins - As well as interrupted calcifications or maturation of enamel. **Fluorosis** - Ranges from very mild white flecking to severe staining (mottling) or hypoplasia - Depends on dosage exposure of fluoride **Molar Incisor Hypomineralisation (MIH)** - Hypomineralisation of systemic origin of 1 to 4 first permanent molars (FPM) and frequently incisors. - Hypomineralisation of 2nd deciduous molars (Deciduous molar hypomineralisation) is an indicator - increased possibility of having hypomineralisation of the first permanent molars (MIH). - **Presentation** - Prevalence 3.6% - 25% - Large, demarcated opacities, whitish-yellow or yellowish-brown in colour - May be associated with post-eruptive breakdown (PEB) - exposed dentine and sensitivity - Incisors less likely to have due to less occlusal force - **Aetiology** - Disturbance during maturation phase of amelogenesis an enamel opacity - Thought to occur between birth and 18 months - Associated with the following: - Asthma - Pneumonia - Otitis media - Antibiotics - Tonsillitis - Dioxins in breast milk - Hypoxia at birth - **Treatment** - [Intensive prevention advice]- de-sensitising toothpaste, fluoride varnish - Poor prognosis molars? - extraction may need to be considered - [Permanent Molars ] - Fissure sealing -- if tooth intact and no sensitivity - Amalgam -- non-adhesive, best avoided - Glass Ionomer cement - interim restoration, poor wear resistance - Composite - good aesthetics/superior wear resistance and adhesion - Stainless steel crowns -- if PEB, cuspal involvement - Cast gold/composite/ceramic onlays - [Incisors ] - Microabrasion in shallow defects - Composite veneers - Porcelain veneers in late adolescence **Amelogenesis Imperfecta (AI)** - Describes a range of inherited enamel defect affecting both dentitions. - Transmission may be autosomal dominant, autosomal recessive or sex-linked. - There are numerous classifications of AI, but it can be described as - [Hypoplastic] - generalised thin enamel which can be rough or smooth or pitted - [Hypomineralisation] - enamel initially normal in form, softer, often discoloured (yellow/brown) - Clinically AI is commonly described as [hypoplastic], [hypomaturation] or [hypocalcified]  - **Management** - Can be complex but the principles are - Intensive preventive advice - Composite resin but bonding can vary depending on nature and extent of defect - Stainless Steel crowns/cast restorations can be use useful on posterior teeth - Advanced restorative work with porcelain in adolescence/adulthood. **[Dentine Defects ]**  **Dentinogenesis Imperfecta** - **Dentinogenesis Imperfecta (DI) Type I** - Seen in patients with osteogenesis imperfecta (OI) type 1. - Discolouration of teeth, - enamel chipping - Extreme attrition of dentine - OI typically associated with bone fragility - Patients have a distinct blue sclera - May have other issues such as hearing loss. - **Dentinogenesis Imperfecta Type II** - All teeth are affected in both the primary and permanent dentition - Teeth have a distinct bluish or brownish colour - Primary teeth can be more severely affected - Enamel chips away easily causing the dentine to wear rapidly - Consequently, infections can readily arise from non-carious teeth - Crowns appear more bulbous radiographically with the roots being short and thin. - The pulp canal can be obliterated - **Management of DI** - Similarly, to AI, there are multiple challenges - Intensive prevention advice - Primary molars - Stainless steel crowns - Permanent molars - Stainless Steel crowns or cast coverage - Permanent incisors - direct or indirect composite veneers. **Dentine Dysplasia type I (radicular dentine dysplasia, rootless teeth)** - Both dentitions affected with discolouration varying from bluish to brownish tinge **Dentine Dysplasia type II (coronal dentine dysplasia)** - Disparity on effects upon the primary and permanent teeth - In the permanent teeth, the colour may be normal but radiographically there is usually a thistle or flame shaped pulp chamber partly occluded by pulp stones R**egional Odontodysplasia** - Often described as 'ghost teeth' - a rare condition characterised by abnormal development of both enamel and dentine - localised or several teeth. - the aetiology is unknown. **[MEDICALLY COMPROMISED CHILDREN ]** **[To treat medically compromised patients safely it is important: ]** 1\. Obtain relevant and thorough medical history -- update each visit 2\. Understand possible implications of the illness on dental treatment 3\. Understand possible implication of the condition on treatment planning 4\. Understand caries risk associated with the medical condition **[Cardiovascular disorders ]** Can be divided into two main groups - [Congenital heart defects (CHD)] (a defect of the heart or great vessels present at birth) - 7-8/1000 live births - [Acyanotic or Cyanotic ] - [Acquired after birth] (e.g. rheumatic fever) **[Classification of CHD]** - **Acyanotic - oxygenated** - Left to Right Shunt - Obstructive lesion - Blood does not bypass lungs - **The most common Acyanotic lesions are:** - Atrial Septal Defect - Ventricular Septal Defect - Patent Ductus Arteriosus - **Cyanotic** -- **deoxygenated -- hypoxemic** - Right to Left shunt - Blood bypasses lungs - Deoxygenated blood in systemic circulation - Cyanosis -- blue lips/skin - Less oxygen - **The most common cyanotic lesions are** - Tetralogy of Fallot - Transposition of the great vessels **[Dental Management ]** - Intensive prevention is imperative - Patients with heart defects required the prescription of antibiotics prior to invasive dental treatment. - Aimed to reduce risk of infective endocarditis (IE). - However, NICE recommended this be stopped. - because no evidence antibiotics prevented IE - Each antibiotic exposure may trigger an anaphylactic reaction. - NICE more recently revised the wording of the guidance to state: ***"Antibiotic prophylaxis against infective endocarditis is not recommended [routinely] for people undergoing dental procedures"*** **[Challenges for the dental team... ]** - L**ack of awareness of parent/carer** - Parents don't have information needed to know how heart defects effect dental health - **INCREASED RISK OF INFECTIVE ENDOCARDITIS** - 38% children under Paediatric Cardiology - 58% evidence of current or previous dental disease - 39% untreated dental caries - Only 79% registered with a dentist - Only 64% of parents aware of link between congenital heart disease and infective endocarditis - **Low priority** - **Low attendance** - **Nutritional issues** - Slower to feed, can take hours to drink a bottle - Feeding slower on something with sugar? Caries risk - **Medication** - Sugary medication such as digoxin - **Increased anxiety** - Paediatric cardiology patients had significantly higher levels of dental anxiety than controls - Due to previous medical experience? - Associated with history of hospital admissions? - Harder for us to treat them **Challenges from the patient/parent...** - Multiple hospital visits -- cardiac surgery - Psychosocial issues - Dental team lacking in confidence -- afraid to do it - Lack of provision of appropriate care -- do we know how to treat them **[Dental Consequences]** Caries risk? -- controversial. Some studies suggest so, some studies suggest not. Enamel defects -- increased due to lack of oxygen? increased risk of bleeding **[Bleeding disorders ]** - Most common bleeding disorders - von Willebrand disease and Haemophilia A. **[Haemophilia ]** - Haemophilia A (factor VIII deficiency) : X linked recessive, 80% - Haemophilia B (Christmas Disease - factor IX deficiency ): 13% also X linked recessive - Factor XI deficiency: Autosomal recessive 6% - 1:10,000 **[Von Willebrand Disease ]** - Most common inherited bleeding disorder - autosomal dominant condition - Affects approximately 1:1000 - characterized by defective platelets that do not adhere to each other and low levels of factor VIII. - Most common symptoms are epistaxis and gingival bleeding. **[Platelet Disorders ]** - Classified as quantitative (low numbers) or qualitative (sufficient numbers but defect of function) - Most common oral symptoms are spontaneous gingival bleeding and bruising. **[Thrombocytopenia ]** - A platelet count \< 150 x 10\^9/L (normal range 150-400 x 10\^9/L - May be idiopathic (of unknown cause) or follow the administration of various drugs. - Platelet count must be at least 80 x 10\^9/L for extractions **[Platelet Function Disorders ]** - May be congenital or acquired and will present with the same symptoms as thrombocytopenia **[Dental Management ]** - Comprehensive bleeding history required prior to deciding on a treatment plan. - If bleeding disorder present, careful liaison with child's paediatric haematologist is required. - Avoid mandibular block injections as they can cause haematoma formation - in pterygomandibular area leading to airway obstruction - Avoid extractions where possible to reduce bleeding risk. - Pulp therapy of restorable carious primary teeth is the treatment of choice - Extractions usually need to be managed in a hospital setting with the haematology team - Direct pressure, placement of surgical and suturing -- when dental extractions completed. **[White Blood Cell Disorders: Leukaemia ]** - Cancer of the blood or bone marrow - Abnormal increase of immature white blood cells - lymphoblasts - Acute lymphoblastic leukaemia (ALL) - most common form of childhood cancer - 75% - May present with oral mucosal/gingival bleeding, pallor, fever, spontaneous bruising and anorexia. - Oral cavity frequently develops complications - direct result of malignancy side effect of medication. - **Treatment** - chemotherapy, radiotherapy, surgery and haematopoietic stem cell transplantation. - **Complications of Chemotherapy** - Oral mucositis - Thrombocytopenia - Anaemia - Viral infections such as herpes simplex - Taste dysfunction - Nausea and vomiting - Radiation damage is site-specific, toxicity is localized to irradiated tissues. - **Complications of Radiotherapy** - Mucositis - Xerostomia due to salivary gland irradiation - Taste dysfunction - Replacement fibrosis of masticatory muscles leading to trismus - Osteoradionecrosis - Dental defects including - Hypodontia/ Microdontia - enamel hypoplasia - arrested root development - premature closure of apices. **[Dental Management ]** - Careful liaison with the child's haematologist/oncologist is necessary to plan treatment - patient may need platelet transfusion and/or antimicrobial prophylaxis prior to treatment - In the ideal situation -- treatment deferred until child is in remission. - Pulp therapy of primary teeth is contraindicated during chemo - risk of infection. **[Paediatric Oncology ]** - **Pre-Treatment** - Dental screening as soon as possible post diagnosis - Prior to chemotherapy starting - Removal of infected teeth - Dressing of other carious teeth - Organise mouth care/ mouthwashes etc - **During Treatment** - Support and encourage maintained mouth care - Help/advise re management of specific oral problems **[Diabetes Mellitus ]** - Type 1/ insulin dependent diabetes mellitus - most common endocrine disorder of childhood - affects approximately 2/1000 children - Peak age of presentation - 5-7 years - symptoms include polyuria, polydipsia and weight loss. - Aim of treatment to maintain blood glucose at a normal level, preventing hypo and hyperglycaemia. - Treatment - administration of insulin as well as dietary control. **[Dental Considerations ]** 1\. Poor control increased caries risk - altered salivary glucose levels 2\. Poor control increased risk of periodontal disease altered response to infection 3\. Increased risk of candida infection 4\. Intensive prevention is a priority 5\. Appts should be made after child has had breakfast and insulin/medication - well controlled 6\. Signs of hypoglycaemia such as sweating, trembling, aggression - should be recognized asap **[Epilepsy]** - A seizure represents the clinical expression of abnormal, excessive, synchronous discharge of neurons, residing primarily in the cerebral cortex. - This abnormal activity is intermittent and self-limiting. - seizures recur over a period of time without obvious precipitants - **Classification** - **Focal onset -- starts in one hemisphere of the brain** - Aware, don't lose consciousness - Impaired awareness - **Generalised -- both sides together** - Motor (tonic clonic) - loss of consciousness, muscle stiffening and jerking movements. - Non-motor (absence seizures) - patient "blanking out" or staring into space for a short time. - Lose consciousness **[Medications]** - **Phenytoin** thrombocytopenia/ /gingival hypertrophy - **Carbamazepine** thrombocytopenia- bleeding problem - **Sodium valproate** caries as its sugary (Epilim) - **Levetiracetam** safe - Optimal oral hygiene - reduce risk of developing gingival enlargement for patients taking phenytoin. - Consider risk of thrombocytopenic bleeding if extracting - Consider a full blood count prior to treatment. - If taking Epilim syrup, discuss sugar-free Epilim solution. - Risk of dental trauma during epileptic seizures esp inc overjet- orthodontic treatment considered - Removable appliances - well retained with clasps to minimize the risk of inhalation during a seizure. - Stressful situations may precipitate a seizure in some patients - Treatment under IS may need to be considered **[Cerebral Palsy ]** - A group of lifelong conditions that affect movement and coordination - Caused by a problem with the brain that occurs before, during or after birth. - Symptoms aren't usually obvious at birth - noticeable during first two or three years of a child's life - **Symptoms of cerebral palsy** - 1\. Delay in reaching milestones -- not sitting by eight months or not walking by 18 months. - 2\. Seeming too stiff or too floppy - 3\. Weak arms or legs - 4\. Jerky or clumsy movements - 5\. Random, uncontrolled movements - 6\. Toe walking - 7\. Swallowing difficulties - 8\. Delayed speech - 9\. Vision problems - 10\. Learning difficulties - **Classifications** - Spastic (70%) -- increased muscle tone - Ataxic (10%) -- problems with balance, movement, gait and coordination - Dyskinetic (10%) -- muscle tone is mixed - Mixed (10%) -- Hemiplegia -- one side of the body is affected - Diplegia -- two limbs affected - Monoplegia -- one limb affected - Quadriplegia -- all four limbs affected - **Dental problems** - Poor OH - mouth breathing and reduced manual dexterity - Tooth wear due to bruxism/gastro-oesophageal reflux - Drooling due to oral muscular hypotonia - Similar caries risk to unaffected children - Increased overjet due to incompetent lips and hypotonia of oral musculature - Tongue thrusting habit - Increased gag reflex -- treat upright - **Medical problems** - Cognitive impairment - Epilepsy 20-40% - Joint contractures - Speech difficulty - Hearing impairment **[Autism Spectrum Disorder ]** - A group of lifelong neuro-developmental disorders - Characterized by severe impairment of social reciprocity, communication and behaviour. - Prevalence is 1:88 and unrelated to race or socioeconomic status. - Range of behaviours - withdrawn, avoiding eye contact, making eye contact, hugging/smiling. - Interaction is usually on the child's own terms and not easily elicited by others. - Intellect ranges from severe learning disability to above average intelligence - **Medical problems** - Iron deficiency anaemia - Epilepsy -- 22x - Abnormal sleeping pattern - Constipation - Macrocephaly - **Dental problems** - Similar caries levels to general population - Poor oral hygiene which is attributed to poor manual dexterity - Increased risk of dental erosion due to bruxism and gastro-oesophageal reflux - Increased risk of dental trauma - difficulty expressing pain - Negative behaviour may be a barrier to accessing dental care - Busy waiting rooms may represent a problem - may not like bright lights, loud noise, dental smells or having their head touched - may communicate via sign language/Makaton rather than verbal language. - **Treatment Tips** - Do not keep them waiting - Ask parents if the patient what the pt is likely to do - Placing a lead apron over the patient during treatment may reassure them of touch. - Routine is important - seeing the same dentist and nurse t will facilitate acclimatization. - OraNurse- flavour free and comes in 1400 ppm fluoride is available online - Patients may open if given a hand mirror - allow the dentist to a brief look intraorally. - may allow a dental examination sitting on a regular chair at a table. **[Down Syndrome ]** - A genetic condition caused by a chromosomal abnormality - trisomy of chromosome 21 - Results in a learning difficulty and a characteristic appearance. - Incidence of 1:700. - **Characteristic appearance** - Small at birth - Hypotonia - Growth defect -- short, broad stature - Brachycephaly (flattened back of skull) - Short arms/legs - Clinodactyly (curved finger most commonly fifth finger) - Slanting eyes - Epicanthic folds - Single palmar crease - "Sandal toe" deformity - Mid face hypoplasia - **Medical problems** - Cardiac defect -- 40% (most commonly AVSD) - Neurological -- atlanto-axial instability (10-15%), ASD (5-7%) and learning disability - Immunology -- impaired cell mediated immunity - infection of skin/GI tract/respiratory tract - Increased risk of leukaemia - Endocrine -- hypothyroidism and decreased growth hormone - Respiratory -- recurrent respiratory tract infection, sleep apnoea and Subglottic stenosis - Obesity - Rheumatology -- arthritis x 6 more common in children with DS - **Dental Problems** - Open mouth posture (due to muscle hypotonia) - Class III malocclusion - Anterior/posterior crossbite - Relative macroglossia - Fissured tongue - Hypodontia - Microdontia - Hypocalcification - Short roots - Taurodontism - Bruxism - Increased risk of periodontal disease - Decreased caries risk - Delayed eruption - Delayed exfoliation - Increased risk of cleft lip/palate **Increased caries risk?** - Higher pH of saliva - Higher bicarbonate levels in saliva - Low streptococcus Mutans levels in saliva - Hypodontia - Microdontia - Spaced dentition - Delayed eruption - Shallow fissures **Increased risk of periodontal disease?** - Impaired cell mediated immunity - Abnormal bactericidal activity of polymorphonuclear leukocytes - Poor manual dexterity - Open mouth posture - Mouth breathing **Management tips-** Tell-show-do, distraction, positive reinforcement, head taping, GA may be needed **[SAFEGUARDING ]** - Range of measures taken to minimize the risks of harm to children. - Non-accidental injury any injuries that are due to abuse **Department of Education and Skills \"Every Child Matters\"** Outcomes for the well-being of children and young people are - Be healthy - Stay safe - Enjoy and achieve - Make a positive contribution - Achieve economic well-being **United Nations Convention on the Rights of the Child** - Article 19- Children should be protected from all forms of physical or mental violence, injury or abuse - Article 24- Children have the right to the enjoyment of the highest attainable standard of health - and to facilities for the treatment of illness and the rehabilitation of health **[Types of abuse ]** - **Physical** - either physical e.g. hitting, shaking, burning, poisoning - if a parent/carer fabricates or induces symptoms of illness in a child - **Emotional** - can include bullying - making the child feel worthless - seeing other abuse - overprotection/preventing social participation - **Sexual** - sexual acts - indecent images - grooming - **Neglect** - failure to meet a child\'s basic physical and psychological needs - including failure to provide food, clothes, shelter, supervision **[Prevalence ]** - High risk children become subject to a child protection plan. - In 2010 there were 35,700 children with a child protection plan in place (3 children per thousand). - Forty-four percent of these were due to neglect. **[Agencies involved in the shared responsibility of child protection ]** 1. Local government children\'s services 2. Health services 3. Education 4. Police and probation 5. Family courts 6. Youth/community workers 7. Sport and leisure 8. Voluntary and private sector organisations 9. Faith communities **[Our role as dentists ]** - Record any noted injuries. The head and neck is a frequent site of injury for physical abuse - Untreated disease can be a sign of neglect - Dentist may be the first health professional to notice signs of neglect or abuse - Dentists often treat families - gain insight to any other issues that may impact on the child **[Signs of abuse ]** - Direct allegation or child says something about injury that gives cause for concern - Worrying child behaviour or child-parent interaction - Delay in seeking medical help - Vague history of accident - History of trauma not matching the presenting injury - Abnormal parent moods or behaviours e.g. Hostility/aggression **[Concerning injuries ]** - Bruising in children/babies who aren\'t able to crawl/walk independently - Bruising on soft tissues such as cheeks and neck, injuries tend to more commonly occur on bony prominences such as forehead and cheekbones - Bruising on the ear caused by pinching or pulling - Patterns of bruising with perhaps similar bruises of various ages - Lacerations on the face without a consistent history - Burns including cigarette burns however beware of medical conditions such as bullous impetigo - Bite marks - Periorbital bruising - Torn labial frenum in a child under 1 yr.- children can tear this easily when learning to walk. **[Signs of emotional abuse ]** - Poor growth - Developmental delay - Education failure - Social immaturity - Lack of social responsiveness - Aggression - Attachment disorders - Indiscriminate friendliness - Challenging behaviour - Attention difficulties **[Signs of neglect]** - Short stature/failure to thrive through poor diet - Ill-fitting clothing - Sunburn - Animal bites - Dirty/smelly or persistent infection with head lice - Missed appointments or immunisations - Withdrawn or attention seeking behaviour **[Signs of Sexual abuse ]** - Intraoral bruising/ulceration - Sexually transmitted disease e.g. Vesicle from gonorrhoea - Disclosure made by child - Pregnancy in a child - Emotional signs e.g. Self-harm/ delayed development/ depression **[Vulnerable groups ]** - **Parent factors** - Young/single parents - Parents with learning difficulties/mental health problems - Substance abuse - **Social Factors** - Poor social environment such as housing, poverty, isolation - Asylum seekers/ refugees - **Child Factors** - younger children experience the most physical abuse and neglect - older children experiencing more sexual abuse - Children with disabilities - Children who are \"looked after\" such as foster or residential care **[What to do if you have concerns ]** 1. Take a thorough history - trauma history, include parent child relationship and child\'s behaviour 2. Avoid asking leading questions, respond calmly and in a non-judgemental manner. 3. If asked to keep a secret explain explain who you may need to share it with and when 4. Discuss case with an experienced colleague. - In the Dental Hospital, this will be either the tutor or the consultant - in practice this may be a dental colleague, social worker or a paediatrician **[Making the referral ]** - Cause for concern for that child? discuss with the family and seek consent to share information. - The only circumstances for when this is not needed is: 1. Discussion may put the child at greater risk/ impede police investigation/social work enquiry 2. When sexual abuse is suspected 3. Where fabricated or induced illness is suspected 4. Where parents are violent or abusive and the discussion may put yourself at risk 5. Where contact to parents isn\'t possible without delaying the referral - Referrals should be made by telephone - direct discussion can be made - followed by a referral in writing within 48 hours. - Record everything in notes!!! **[ORTHODONTIC/ PAEDIATRIC INTERFACE ]** - Paediatric dentists and orthodontists collaborate in treatment planning - Requires good working relationship and communication between them - **multidisciplinary approach** - When theyre located at the same site, communication is much easier and more efficient - many members of a multidisciplinary team may be able to be present at a single appointment. - Enables them to discuss the intricacies of a treatment plan with the patient present. - For general dentists - often need for external referral to an orthodontist in primary or secondary - This process takes time and can delay the commencement of treatment **[Extraction of primary teeth ]** - Prior to forced extraction of a primary tooth, the following recommendations should be considered - **Extraction of primary incisors** - No need to balance or compensate loss of a primary incisor - **Extraction of primary canines and first molars** - Early loss of primary canine in all but spaced dentitions - likely to have effect on centre lines. - The more crowded the dentition, the more the need for balance - Early loss of a primary first molar may necessitate a balancing extraction in a crowded arch. - Compensation is not needed. - In the event that unbalanced extraction of a primary canine or first molar has already occurred, one of three situations will apply - **No centreline shift. Do not balance** - **Centreline shift with complete space closure** - Delay balancing until a full orthodontic assessment is made - **Centreline shift with spacing remaining mesial to the extraction site** - Monitor to determine whether tooth movement is continuing - seek orthodontic advice. - **Extraction of primary second molars** - There is no need to balance the loss of a primary second molar - this will have no appreciable effect on centreline. - However - forward movement and tilting of the adjacent first permanent molar - consideration should be given to fitting a space maintainer **[Prolonged retention of primary teeth ]** - Most common cause of retention is absence of the permanent successor. - MUST refer patient to an orthodontist to determine most suitable treatment options. - May be beneficial to retain this primary tooth into adulthood - Can also be retained from genetic or syndromal factors, trauma, ectopic eruption of the permanent successor, infra-occlusion, ankylosis, crowding or the presence of obstructions such as supernumeraries - General dentists should monitor eruption of the permanent dentition - if a permanent tooth has not erupted within 6 months of the contra-lateral tooth -- radiographs - If over-retained - can cause a deflection in the eruption path of the permanent successor. - Can result in crowding, crossbite and displacement. **[Space Maintainers ]** - Space maintenance - preservation of a space in the primary or permanent dentition. - In the primary dentition - can be used to prevent a malocclusion of the permanent teeth. - In the permanent dentition - preserve space from tooth -- trauma, caries or congenitally missing teeth **[Management ]** - A natural tooth is the best space maintainer - primary molars should be preserved if possible. - Decision to fit a space maintainer must be arrived at by: - balancing occlusal disturbance that may result if one is not used, - AGAINST plaque accumulation and caries risk that the appliance may cause. - Poor oral hygiene is a contraindication **[Space maintenance is most valuable in two situations: ]** - [Loss of a primary first molar where crowding is severe] - i.e. more than 3.5mm (half a unit) per quadrant. - space loss due to drift may be so severe that extraction of 1 premolar may be insufficient to relieve resultant crowding - subsequent orthodontic treatment may then be more difficult - [Loss of a primary second molar, except in spaced arches] - Eg a loop space maintainer was fitted to the LR6 to maintain space from the LRE. **[Types of space maintainer ]**  **[Enforced extraction of poor quality first permanent molars]** - Poor prognosis first molar?- enforced extraction. - vulnerability of first permanent molars to caries in childhood - association with MIH - First permanent extraction can be followed by successful eruption of the second permanent - provides suitable replacement, ultimately third molar eruption completes the molar dentition. - Treatment planning decisions should ideally be made following input from - General dentist, paediatric dentist and the orthodontist - not always be possible **[Balancing and compensating extractions]** Aims to preserve occlusal relationships and arch symmetry within the developing dentition. Factors can influence whether a balancing or compensating extraction is needed: - Which of the first permanent molar/s requires enforced extraction? - The overall condition and long-term prognosis of the remaining first permanent molar/s - The teeth present and developmental status of the dentition (including third molars) - The underlying malocclusion **[Management of the extraction of first permanent molars of poor prognosis ]** - Must consider child's future need/ desire for orthodontic treatment - May not be feasible to seek a specialist orthodontic opinion prior to necessary dental treatment. - In these cases, the dentist should proceed as follows - Under local anaesthetic - If orthodontic advice was not attainable - carry out the enforced extraction - seek advice regarding further elective extractions - Under general anaesthetic - Orthodontic opinion should be sought prior to the GA - Ensure multiple anaesthetics are avoided - Good communication between multidisciplinary team is needed - Patient with high caries risk? May not be suitable for orthodontic treatment **[Non-nutritive Sucking Habits ]** - Sucks on objects such as pacifiers, digits, toys or blankets - Can cause malocclusions if the habit persists - Malocclusion will differ according to type, frequency and duration of the habit - An [anterior open bite] is common - usually symmetrical in dummy suckers, asymmetric in digit suckers - Caused by interference with normal eruption of incisors with excessive eruption of posterior teeth. - [Posterior crossbites] can occur due to lower position of tongue - out of contact with the upper arch. - Can also cause an [increased overjet] - increase risk of trauma to the maxillary incisors - Cessation of these habits can be difficult. - Rewards - Deterrents - application of bitter tasting chemicals to a pacifier or to the digit - Crucial time for elimination is as the permanent incisors erupt. - If the habit persists to this stage, further intervention to aid cessation may be needed. - [Orthodontic intervention] -- palatal arch and palatal crib - [Psychological intervention] -- positive and negative reinforcement **[Ectopic First Permanent Molars ]** - Occurs when the tooth follows an abnormal eruption pathway. - Mesial eruption causes it to contact the distal surface of the second primary molar tooth - Causes resorption of this tooth to varying degrees of severity. - Early treatment is essential to move the ectopically erupting molar away from the tooth it is resorbing. - Allows permanent molar to erupt into a normal position- maintaining a normal arch circumference. - If left untreated, the permanent molar can erupt with [rotation, mesial tipping and poor occlusion.] Usually diagnosed on radiographic examination between 5 and 7 years of age.  **[Causes]** Thought to be multi-factorial Some of the factors that can be involved are - Larger than normal sizes of the primary and secondary dentition - Larger affected first permanent molars and second primary molars - Abnormal crown morphology of the second primary molar - Smaller maxilla - Posterior position of the maxillae in relation to the cranial base - Abnormal eruption angle of the first permanent molar - Delayed calcification of some affected first permanent molars - More common in children with cleft lip and palate and in those with a family history **[Management of the ectopic first permanent molar ]** - **Monitoring** - Spontaneous correction can occur in all degrees of resorption - But more likely in cases with minimal resorption - Requires clinical and radiographic examination after 3-6 months - **Separation** - Suitable if degree of angulation is mild - first permanent molar only impacted against the crown of the second primary molar - The crown of the first permanent molar must be clinically accessible - A brass ligature, spring type wedge, Kesling separator or elastic separator is used - causes disimpaction so that the permanent molar can follow a normal eruption pattern - **Active appliance** - Suitable if crown is not accessible and degree of impaction is more severe - Most consist of a band on the second primary molar with an active arm or spring attached. - Removable appliances - produces a force to distalise the first permanent molar - **Extraction of the second primary molar and appliance therapy** - if second primary molar has a poor prognosis with severe resorption, caries or abscess - The first permanent molar would erupt with mesial tipping - Then a removable or fixed appliance would be used to distalise the first permanent molar **[Impacted Canines ]** - Following the third molar, the maxillary canine is the next most common to be impacted. - Go palatal (92.6% ) more frequent than buccal - Must palpate for unerupted maxillary canines from 8 years of age -- normally palpable at 10-11 - Maxillary canines erupting after 12.3 years in a girl and 13.1 years in a boy are considered late. - Can cause resorption of adjacent incisor roots - **Early identification and treatment is essential.** **[Causes of impacted canines]** The aetiology is unclear, but thought causes: - Family history - Absent, malformed or diminutive lateral incisors - Absence of crowding - Late developing dentitions **[Management of an impacted canine ]** - **Interceptive treatment with extraction of primary** **canine** - Patient 10-13 years, ideally without crowding - Consider the need to retain or create space - If no improvement in the ectopic canine position after 12 months, consider alternatives - **Surgical exposure and orthodontic alignment** - If interceptive extraction of the primary canine is not suitable - fixed orthodontic appliances used so good OHI needed - Ectopic canine must be in a favourable position for orthodontic alignment - **Surgical removal of the palatally ectopic maxillary canine** - Patient is happy with their appearance, or declines orthodontic treatment - Ectopic canine has caused early and asymptomatic resorption of the incisor roots - patient must be happy to have the first premolar replacing the canine - Position - **Transplantation** - Position of the ectopic canine is not favourable for orthodontic movement - Adequate space and sufficient bone for the canine - Canine must be removed with minimal trauma - Canine may need root canal treatment shortly after transplantation - **Leave or observe the canine** - Patient is happy with their dental appearance - No evidence of pathology or root resorption of the neighbouring teeth - Good contact between lateral incisor and first premolar - OR the primary canine should have a good long-term prognosis - Regular clinical and radiographic monitoring of the unerupted canine **[Unerupted maxillary incisors]** - Absence/delayed eruption of a maxillary incisor can be a cause for concern - Missing maxillary incisors are conspicuous and can have an adverse effect on the child's self-esteem - The delayed eruption of a maxillary incisor should be investigated when - Eruption of contralateral tooth that occurred greater than six months previously - Central incisors remain unerupted and the lower incisors have erupted \> one year previously - Deviation from the normal sequence of eruption, e.g. laterals erupting prior to centrals **[Management of the unerupted maxillary incisor]** - **Children up to nine years with incomplete root development of permanent incisor** - Remove obstruction - Do not uncover bone from the unerupted incisor -- maintain the integrity of the follicle. - Create space if required. - Monitor eruption for up to 12 months --many incisors will erupt spontaneously - If exposure is required, then expose minimally to eliminate soft tissue obstruction - If the tooth is still high, expose and bond bracket. - **Children above nine years with complete or nearly complete apex** - Remove obstruction - Create space if required. - The permanent incisor can be monitored for up to 12 months - If the tooth is still unerupted at 12 months expose and bond bracket as required. - **If permanent incisor is impacted** - Expose and bond bracket at first operation. - **Children referred late (over 10 years)** - Remove obstruction, expose and bond bracket at first operation. **[Correction of Crossbites ]** - A condition where one or more teeth are abnormally positioned buccally or lingually - with reference to opposing tooth or teeth in centric occlusion. **[Anterior crossbite]** - When the maxillary anterior teeth are in a palatal position relative to the mandibular anterior teeth - Can be either dental or skeletal in origin. - [Anterior dental crossbites] abnormal axial inclination of the maxillary anterior teeth - [Anterior skeletal crossbites] skeletal problem - mandibular prognathism and midface deficiency.  **[Posterior crossbites]** - when a crossbite involves a premolar, molar or a whole buccal segment. **Posterior crossbites can be further subdivided into:** - Unilateral buccal crossbite with displacement - Unilateral buccal crossbite with no displacement - Bilateral crossbite - Unilateral lingual crossbite - Bilateral lingual crossbite (scissors bite) **[Refer to an orthodontist when:]** - Associated mandibular displacement - Causing hard tissue damage such as attrition - Causing soft tissue damage. - Cause displacing forces apical migration of the gingival attachment - Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments **[Management of anterior and posterior dental crossbites ]** - **Anterior Dental Crossbite** - Involves tipping the affected incisor or incisors labially over the opposing mandibular tooth - Fixed inclined bite planes - Removable appliances with bite plane -