Download PAEDODONTICS AND ORTHODONTICS

PAEDODONTICS AND ORTHODONTICS
1. Slide herpetic stomatitis
Most common cause of severe oral ulceration in children. Cause by herpes
simplex virus. Primary infection usually after 6 months of age (eruption of
primary incisors). 2-3 days incubation, prodromal 48 hours (irritability, pyrexia,
malaise, peak incidence 14 months. Stomatitis, gingival tissues red and
oedematous. Intraepithelial vesicles that rapidly break down to painful ulcers, self
limiting ulcers, heal within 10 days. Symptomatic care, oral fluids, analgesics
(paracetamol 15mg/kg 4 hourly), clorhexidine 0.2% mouthwash or swabbed over
the affected areas, acyclovir oral suspension for severe cases or immunosupressed
patients in the first 72 hours.
2. Slide: correlate cephalometric drawing with malocclusion type I, II divison 1
and 2, or III.
Skeletal class I: maxilla and mandible are in a normal relationship (orthognatic).
Skeletal class II: the mandible appears small relative to the maxilla (retrognative).
Skeletal class III: the mandible appears larger than the maxilla (prognatic).
3. Design removable appliance for correction of cross-bite 11 or 12, describing
each component.
These appliances (Hawley) should be used only to correct cross-bites of dental origin.
Components: Acrylic base plate or body, retentive components (Adams clasps on the
first permanent molars, ball retainers between the primary molars and labial bow),
active components (posterior bite planes to open the bite and allow free labial
movement of anterior teeth, a Z-spring palatal to the malposed tooth).
The spring is activated 2 mm, review in 4 weeks.
4. Factors that may influence correction of dental cross bite upper incisor
Overbite: increase overbite helps retain the incisors in positive overjet once the
appliance is removed (incline plane)
Origin of crossbite.
Adequate space to move the teeth.
Cooperation of patient with removable appliances.
5. A couple of slides showing a patient same MIC and CR with one upper incisor
in cross-bite. Choose the correct alternative: this cross bite is skeletal,
functional, simple or not possible to determine from the information given.
I think is simple due to ectopic eruption of one incisor.
3 Types of anterior crossbite: *Ectopic incisors: an incisor may erupt ectopically
either in the maxilla or labially in the mandible to a crossbite relationship, in child
with balanced skeletal relationship; *Skeletal class III malocclusion: incisors
positioned correctly within the alveolar ridges, they are in negative overjet on
closing into centric occlusion with no deviation of mandibular closure; *Pseudo
class III malocclusion: mandible goes in a protrusive bite and thus crossbite of
incisors avoiding traumatic occlusion with lingual position of one or more
maxillary incisors.
6. What is the objective of an orthodontic appliance in a finger sucker child?
Break the habit, habit remainder.
Hawley appliance with a palatal bar may be fitted as a habit reminder.
A fixed appliance consisting on bands on the first molars and an anterior tongue crib
will ensure compliance, as the child cannot remove it.
7. Primary canine with internal resorption, pink crown .X ray coronal RL in
dentin. Identify the condition (trauma, infection). Tto: pulpectomy, extraction
8. Analysis of cephalogram. Cephalometric traces of malocclusions, describe
what type is each one. Type of face, dolico, mesio, braquio. We had to
recognise that the patient was dolicofacial and had an open bite. SNA 81 +/- 3,
SNB 79 +/- 3, ANB 3 +/- 2, 1 to max 109 degrees +/- 6,1 to mand 93 +/-6,
interincisal angle 135….
9. How many mg are there in a cartridge of lignocaine 2%?
2.2 ml=44 mg, 1.8 ml=36 mg.
10. Slide colgate 0.76% with MFP (sodium monofluoride) is for:
adults/children/1000 ppm/etc. Conventional tooth paste contain 1000-1100
ppm of fluoride, Added as sodium fluoride: sodium monfluorophosphate or
stannous fluoride. A 1000 ppm toothpaste contains 1 mg F/g toothpaste. A 400
ppm toothpaste contains 0.4 mg F/g toothpaste
Picture of a junior colgate toothpaste, multiple choice to pick for what kind of
patient is this (children and adolescents) and describe the concentration of
fluoride: Low fluoride toothpastes are available for children, 250, 400 or 500 ppm.
Parents should use low fluoride toothpastes for infants and young children, before
eruption of central incisors, living in optimally fluoridated areas. The age of
initiation of toothpaste use should be delayed to approximately two years of age.
11. What is the use of water fluoridation and their quantity, why
Fluoride is added to water to increase the concentration from 0.1-0.4 ppm to 1
ppm = 1mg/L (level recommended for optimal dental health benefits.. Reduces
prevalence of caries 20-40%, Benefits adults as well as children, less root surface
caries. Water fluoridation is the preferred source considering cost effectiveness
and wide spread community exposure.
Toxic dose: 5 mg F/kg
12. When a child should stop taking F tablets.
Fluoride supplements are intended for use only in areas where is little or no
fluoride in the drinking water. Use 2 tablets of 0.25 for 0.50 mg daily dose; 2
tablets of 0.50 mg for 1.0 mg daily dose. The predominant effect of fluoride is
topical rather than systemic. Mild fluorosis will occur with ingestion of 2 mg or
more of fluoride per day.
If they are using it correctly and dissolving the tablet in water and drinking it
throughout the day there is no upper age limit; as people can be susceptible to
decay at any age. That’s is the reason why water fluoridation work so well.
Tablets should be given until 16 years of age because wisdom teeth are still
forming (crowns complete).
13. Mistakes in pulpotomy
Miss any remanent. Symptomatic tooth, pain, swelling increased, mobility, poor
coronal seal, fistulae, radiographic signs. Placement of Calcium hydroxide over a
blood clot, not over vital tissue.
14. Difference between pulpal floor in primary teeth and permanent teeth
Floor of pulp chamber is thin and accessory canals in the interradicular area.
15. Diference between primary and permanent teeth
The enamel and dentine are thinner than in the permanent tooth. The pulp chamber is
larger, extended pulp horns. Longer roots, Root canals with irregular and ribbon-like
in shape. Narrower occlusal table (greater convergence of the buccal and lingual
walls), broad contact points, bulbous crown. Inclination of enamel prisms (in cervical
are inclined in an occlusal direction, not need to bevel the gingival floor of a proximal
box), cervical constriction, alveolar bone more permeable (LA possible infiltrative in
mandibular molars), Thin pulpal floor and accessory canals in the interradicular area.
16. Family brings a child after 2 days of trauma. What do you do?
Depending on the trauma, examine extraoral wounds, ask questions, palpate facial
skeleton, injuries to oral mucosa or gingivae, palpation of alveolus, displacement of
teeth, abnormalities in occlusion, extend of tooth fracture, pulp exposure, colour
changes, mobility of teeth, reaction to pulp sensibility tests and percussion, check
immunization (tetanus booster?), antibiotics if significant injuries, x rays, soft diet,
advice to the parents of possible sequelae, such as necrosis, individualized follow up.
17. While working on child refuse to do F sealant. Afraid. What went wrong?
The approach, improper. Pain. Fear of unknown.
18. Why are sweet or sugar containing foods bad for the teeth?
They are cariogenic, demineralised tooth structure. Sugar containing foods are
metabolised by bacteria in the mouth, resulting in acid on the tooth surface (sugar
feeds bacteria). The acid reduces calcium, phosphates and carbonates from the
tooth enamel into the plaque an d saliva surrounding the tooth
19. Are all sweet foods equally harmful to the teeth? Are sweets snacking harmful
for the teeth? yes
The higher the content the worse, even though frequency of intake is more
important over quantity.
20. My children insist on having snacks. If I should not give biscuits, cakes and
the like, what else could I give?
Low the content of sugar in food, give teeth a rest for at least 2 hours after every
meal and snacks to allow acid levels to drop and become neutral and remineralize
the teeth. Limited sweets to meal times.
21. Would it be better if I stopped my children from having snacks altogether?
Popcorn, cheese on crackers, fruits and vegetables are good snacks.
22. If I do not add sugar, how can I expect my child to drink his milk? Don’t all
children prefer sweetened food and drinks?
23. What about older children and adults who have already developed a taste for
sweets? Start reducing slowly. Educate them and change habits.
24. Is it true that the use of a pacifier (comforter) or nursing bottle is bad for my
child’s teeth?
Yes, it is one of the causes of early childhood caries or rampant caries. Prevalence
ranges from 2.5%-15%. Rampant caries affects maxillary anterior teeth, later lesions
on posterior teeth, maxillary and mandibular primary molars. Canines are affected
less than first molars because of late eruption, mandibular anterior teeth are
unaffected (salivary flow and position of tongue).
Caries is due to exposure to carcinogenic substrate for long periods. The teat of a
feeding bottle is held next to the palatal surfaces of the upper anterior teeth for up to 8
hours, there is low salivary rate at night and reduced buffering.
Management: cessation of the habit can be done by removing sugar, dietary advice,
fluoride application, and restoration of teeth with GIC, composite resin-strip crowns
and/or stainless steel crowns. If extraction is required, loss of anterior teeth will not
result in space loss if the canines have erupted. If posterior teeth need to be extracted,
the parents should be advice of possible space loss and space maintainer. For small
children GA often required.
25. So what advice can you give me about reducing the effect of what my family
eats on dental decay?
Many foods labelled “no added sugar” have high level of natural sugars.
26. Dx of mesiodens (in an OPG) and treatment
Supernumenary teeth in the midline of the maxilla. Diagnosed by failed or ectopic
eruption of permanent tooth, routine radiographs (occlusal radiographs give the
clearest view for localization and to assist in determine the optimal surgical
approach, as part of a syndrome (cleidocranial dysplasia). Management is
extraction; some require surgical removal as early as possible to allow eruption of
the permanent tooth. During surgical removal care must be taken to avoid
disturbing the development permanent teeth. Inverted supernumeraries placed in
the apical region of permanent incisors, may be left until the apices of incisors
have formed to minimize the risk of damage.
27. Complications during an alveolar inferior block? Cause of a swelling in the
cheek after an alveolar inferior block? Causes of management of an hematoma
*Traumatic lesion, lip biting. *Haematoma in patients with coagulations disorders.
Haematoma is a rare swelling of the tissues on the medial side of the mandibular
ramus after deposition of anaesthetics. Manage by pressure and cold (ice) to the area
for a minimum of 3-5 min. *Trismus, muscle soreness or limited movement.
*Transient facial paralysis, produced by deposition of local anaesthetics into the body
of the parotid gland, irritability to close lower eyelid and drooping of the upper lip on
the affected side.
28. Slide adult down patient with congenital heart anomaly and suspected
penicillin allergy, before exo, give amoxi/clinda??? Clinda
29. Would you consider GA in a mild mental disable patient, reasons, future
problems this patient may have, long term management.
A disabled person is someone with a physical or mental impairment which has a
substantial and long term adverse effect on his ability to carry out normal day to day
activities. Usually have increased periodontal problems, poor plaque control,
malocclusion, self inflicted traumatic injuries and tooth grinding.
GA in restorative care it might be kinder, as long as there are not medical
contraindications. Sedation is an alternative. Encourage brushing teeth, electric
toothbrush may be helpful. If unable, carer should do it and should be trained to do it.
Diet modification, regular professional cleaning, chlorhexidine as chemical control of
plaque may be helpful.
30. Indications for pulpectomy and pulpotomy in children
Pulpotomy: when the pulp is reversibly and minimally inflamed, where the
marginal ridge is already destroyed in first primary molars, where radiographic
evidence of caries extends more than two thirds in depth through the dentine, if
there any doubt as to wether or not pulp has been exposed (mechanical or
carious).
Pulpectomy: evidence of pulpal necrosis, hyperaemic pulp (persistent bleeding
during a pulpotomy procedure), evidence of furcation or periapical involvement
on radiographs, spontaneous pain (unstimulated pain), buccal or extraoral swelling
and increase mobility.
31. Slides:
 Lost of space due to proximal caries leading to loss of contact.
 What type of appliance could you use for space maintenance of a
deciduous loss prematurely: Hawley appliances (removable), Band and
loop in unilateral loss, Nance appliance or lingual arch if the loss is
bilateral, Distal shoe if the first permanent molar is not yet erupted,
risk of infection.
 Submerged permanent teeth (tooth): ankilosed , the tooth remains
stationary while the alveolar bone grows around it and adjacent teeth
erupt. Should be retained as long as they maintain arch length or as
long as they don’t prevent the eruption of the sucedaneous teeth.
 Traumatic intruded young permanent tooth: one of the worst injuries,
damage to the supporting estructures and neurovascular bundle. Early
reposition to avoid ankylosis, minimize pressure to the periodontal
ligament and allow access to the palatal surface to extirpate the pulp
within 14 days. Partially intruded immature teeth, leave to reerupt with
regular monitoring.
 Open bite, causes: can occur in class I,II, or III malocclusions, either
skeletal: vertical greater than horizontal growth; or environmental:
habits, tongue thrust; or a combination.
32. Discuss, describe this conditions. Write down what you would say, 5 min each
topic. State what it is e.g. a mesiodens is a supernumerary tooth.
Incidence of the condition/lesion?
Cause (if known)
Macroscopic appearance of the lesion (if appropriate)
Microscopic appearance (if appropriate)
Clinical signs and symptoms
Management of the condition
Prognosis/ expected outcome of the case (if appropriate)
 Nursing bottle, caries affecting the upper anterior of a 3 year old. Q 26.

A pulpal abscess presenting a pimple above a discoloured temporary upper
central incisor in a 5 year old child:
Cause by trauma, caries, spread of an acute odontogenic infection. A large
collection of pus cannot be drained through a primary tooth and extraction is
indicated. Pulp therapy is unlikely to be successful.

A teenager presenting with a large extraoral swelling from a broken down 25.
The patient is feeling unwell with trismus, raised temperature, foetid breath,
loss of appetite and sleep.
Due to caries or trauma and spread of infection to the facial tissues. Antibiotics
are necessary when systemic involvement. Restore 25, RCT or if apex open treat
canal with ledermix and CAOH. When proper apical seat and symptoms subside
restore.

A pulpal abscess presenting as a diffuse (localised) swelling in the buccal
sulcus of an 8 year old. Adjacent to the swelling is a temporary first molar
which recently has a pulpotomy performed on it. What would you do?
Extraction.

There are multiple small vesicles over the tongue, gingivae and buccal mucosa
in the mouth of a 2 year old child. The child has been unwell for the past three
days with a slight temperature, lack of appetite, poor sleeping pattern and is
pale in colour. Q1.

A 10 year old child presents with 4 severely hypoplastic first permanent molar
teeth. He has a history of severe ear infections in his first 12 months
Enamel hypoplasia is caused by failure of the apposition and protein matrix formation
or an alteration in the mineralization of the matrix leading to a bulk loss. Management
by restoration with composite resin, SSc, GI temporarily, onlays, crowns, venners.

Ankylosis of a temporary first mandibular molar tooth in a 14 year old patient.
He has a damaged heart valve from an early attack of rheumatic fever.
Might be cause by failure of formation of first premolar, arrested tooth
development.

A case of moderately severe fluorosis on all upper incisor teeth in a 12 year
old. This patient lives in the country and drinks only tank water.
A disturbance of tooth formation caused by fluoride being present in the tissue fluids
over a prolonged period during tooth development (birth-6 years of aye).
Cause by the additive effects of fluoride supplements, fluoride in the individual’s diet
(baby foods and beverages), fluoride toothpastes (0.12-0.38 mg ingested per
brushing), topical application during enamel formation (18-36 months). Dental
fluorosis is a qualitive defect of enamel (hypomineralization), resulting from increase
of fluoride concentration during enamel formation. Threshold dose 0.1 mg/kg.
Manage by surface remineralisation, microabrasion or restorative replacement of the
affected discoloured enamel.

An 8 year old patient presents following a fall from a skateboard. The crowns
of both permanent upper central teeth are fractured and show bleeding from
the pulp. There is a slight amount of soft tissue bleeding around the teeth. The
child is not experiencing severe pain but both he and his parents are very
distressed
The time elapsed since the injury and the stage of root development will influence
treatment. If the tooth is treated within hours conservative management is
appropriate, otherwise pulp amputation is required. The aim is to preserve the
vitality of the pulp tissue and to encourage the formation of a dentine bridge over
the defect.
If incomplete root apex or mature with vital pulp perform a pulpotomy
(apexogenesis), removal of the contaminated pulp tissue with a clean, round, high
speed diamond bur, using saline or water irrigation; a non setting CaOH or
ledermix cement dressing is placed onto the uncontaminated vital tissue, then GIC
and restoration with composite resin. Review in 3-6 monthly, pulp vitality test and
x rays. Success rate 80-96%.
If incomplete root apex with necrotic pulp: the aim is to use calcium hydroxide
therapy to create an apical hard tissue barrier (apexification) against which the
root canal filling can be placed, up to 18 months, changing CaOh every 2-3
months.
OPG: overall picture of the developing dentition and jaws. 7 years will
demonstrate presence or absence of all permanent teeth, except 8s.
Lateral cephalogram: useful to asses skeletal discrepancy, baseline to monitor
future growth.
Mixed dentition analysis to determine the space available in the arch for
permanent successors to erupt. Arch length + mesiodistal widths of mandibular
permanent incisors. Unerupted teeth are measured using radiographs (HixonOldfather method), or prediction formulas (Tanaka and Johnston).
Space maintainers: Hawley appliance (removable), Band and loop in cases of
unilateral loss, Nance appliance or lingual arch if the loss is bilateral, distal shoe if
first permanent molar is not yet erupted.
Premature loss of a primary canine, extract contra lateral, fixed lingual arch tp
support the incisors.
Serial extraction: arch deficiency of > 4 mm. Purpose is to encourage early
eruption of first premolars, ahead of canines. The premolars are then removed,
allowing room for canines to erupt spontaneously, years of supervision. Remove
canines first at age 8.5- 9.5 years to allow alignment of incisors, then removed
first molars about a year later to allow eruption of premolars, then space
maintainer. Extract 4s as 3s are erupting.