1. PAEDS – PBL Group 4

2. Trigger  Trigger 1:  A 7 year old girl is seeking your help because of toothache on her lower right teeth. She came with her mother. According to her mother, at birth she was diagnosed to have “hole on her heart”  Trigger 2:  During history taking, mother claimed that the daughter had: No sleep for the last 3 nights due to pain Been treated by antibiotics and analgesics previously  She went to a dentist and the dentist filled the tooth with ‘temporary’ filling. The mother claimed that the daughter was reasonably cooperative during previous treatment. The mothe wanted you to fix her daughter’s problem

3. History taking  toothache on her lower right teeth  ‘hole on her heart’  No sleep for the last 3 days  Been treated by antibiotics and analgesics  History of pain:  site  onset  characteristics  type of pain  severity  radiation  Alleviating factors  Aggravating factors  recurrence  assoc symptom (swelling, LOA, discharge)  Treatment received: Type of treatment Efficacy of the treatment Chief complaintHx of complaint

4. History taking  hole on heart  tx done surgery (prosthetic heart valve) med (eg. Anticoagulant)  refer guidelines (AHA)  Follow up Frequency & Location  medication  symptom SOB, Cyanosis, Lethargy, Fever, Malaise  IE  Other disease  Blood, Kidney  Allergy Medication, Food, Material  Hx of admission  Cause, when, where & Tx received  Other types of medication  Last visit and tx done (when, where, what)  Temporary filling, reasonably cooperative  Restoration  duration,  History of extraction  Complication (prolong, bleeding, infection)  Plaque control PMHPDH

5. Cardiac conditions associated with highest risk of adverse effect from endocarditis for which prophylaxis with dental procedures is reasonable  Prosthetic cardiac valve or prosthetic material used for cardiac valve repair  Previous IE  Certain specific, serious Congenital Heart Disease (CHD)  Unrepaired cyanotic congenital heart defect with prosthetic heart material or device whether placed by surgery or by catheter intervention, during first 6 month after the procedure.*  Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device(which inhibit endothelialization)  Cardiac transplantation recipients who develop cardiac valvulopathy *Prophylaxis is reasonable because endothelialization of prosthetic material occurs within six months after the procedure.

6. Dental procedure requiring antibiotic prophylaxis All dental procedures involving manipulation of gingival tissue or the apical region of teeth or perforation or oral mucosa including Extraction Routine cleaning Scaling and root planing Periapical root canal treatment Fitting orthodontic bands placing subgingival medications Biopsy Suture removal

7. Situation Agent Regimen—Single Dose(30-60 minutes before procedure) Regimen: Single Dose 30 to 60 minutes before procedure SITUATIONAGENTADULTSCHILDREN ORALamoxicillin2g50mg/kg UNABLE TO TAKE ORALLY Ampicillin OR Cefazolin or ceftriaxone 2g IM or IV 1g IM or IV 50mg/kg IM or IV ALLERGIC TO PENICILLINS OR AMPICILLIN-ORAL Cephalexin* OR Clindamycin OR Azithromycin or clarithromycin 2g 600mg 500mg 50mg/kg 20mg/kg 15mg/kg ALLERGIC TO PENICILLINS OR AMPICILLIN-UNABLE TO TAKE ORALLY Cefazolin or ceftriaxone OR Clindamycin 1g IM or IV 600mg 50mg/kg IM or IV 20mg/kg IM or IV

8. History taking  congenital heart disease  significant hereditary disease  sibling with the same disease  Diet hx  sweet food consumption, bottle feeding (frequency, amount, type)  Habit  thumb sucking  Parafunctional habit Family HistorySocial History

9. Clinical Examination  face, TMJ, lip, mouth opening  lymph node (palpable) + neck  skin (cyanosis)  swelling (fluctuant etc)  site of complaint (85 OL)  presence of temporary restoration (intact)  condition of adjacent structure  presence of sinus tract  TTP, tender to palpation, pocket, mobility, vitality, bleeding  Caries  charting Extraoral examinationIntraoral examination

10. 6 oE opC mE mp6 o E ol(f)E mo Clinical Examination  PE 11, 21  UE 12,22

11. Differential diagnoses  Irreversible pulpitis  Acute periapical abscess  Acute periapical periodontitis  Pulp necrosis

12. Investigations  all developing permanent teeth present except 8’s  all 6’s erupted  all 1’s and lower 2’s erupted  other permanent teeth still not erupt  radiolucency on 55  caries (enamel+dentin+pulp)  radiopaque on 85  restoration (enamel+dentin+pulp)  radiolucency on 26  caries (enamel+dentin)  radiolucency on 16  caries (enamel+dentin)  radiolucency on 46  caries (enamel+dentin)  widening of PDL space dm of 85 OPGPeriapical xray

13. Definitive diagnosis  Irreversible pulpitis

14. Treatment Options  Pulpotomy +/- ssc  Partial pulpotomy +/- ssc  Pulpectomy +/- ssc  Extraction (balancing & compensating)  space maintainer

15. Treatment plan  Emergency  behavior mx (non pharmaco)  prphyab  pulpotomy &ssc  Preventive  OHI  scaling + prophy  diet counseling  FS & PRR  Restorative  restoration of carious tooth  Extraction  nil  Review  fluoride application  Maintenance – r/v