## Case: Bitewing Radiograph Diagnostic Yield ### Question Have a look at this bitewing radiograph taken in a clinic . The student said they couldn't see any caries and it was fine to bring the child back in for recall in 12 months. What are the main things you should be looking for in a bitewing, and what can you see here? ### Findings and Reasoning * **Radiographic Quality:** This radiograph has a questionable diagnostic yield due to significant proximal overlap and poor positioning that failed to capture the arches well. * **Retake Findings:** A second bitewing was taken on the same patient. With the overlap removed, there is now clear caries extending into the outer third of dentine on the 74 and the outer half of enamel on the 75. * **Clinical Implications:** Because of the pattern of caries in primary teeth, if there are two lesions on one side, there are likely multiple others on the contralateral side. * **Patient Age Assessment:** The first permanent molar is erupted and in occlusion, but root development is only about 2/3 complete. This suggests the child is approximately 7 to 8 years old. * **Conclusion:** Always ensure an ideal record is obtained before making a diagnosis; the initial poor-quality film missed significant pathology. ## Case: Facial Cellulitis and Infected Second Primary Molar ### Question This patient was referred to the emergency department with facial cellulitis . Looking at this radiograph and the intraoral picture, how old is the patient and what is the most obvious finding? ### Findings and Reasoning * **Age Assessment:** The first permanent molar has about one-third root development. Since the crown takes three years to form and eruption occurs at two-thirds root development (around age 6), this child is approximately 5 years old. * **Radiographic Findings:** There is a massive lucency involving the mesial aspect of tooth 85 and a significant furcal radiolucency. * **Etiology:** While it could be a standard proximal caries pattern, the lecturer suspects hyper-mineralized second primary molars as a possible primary cause. * **Clinical Findings:** Intraorally, there is a massive GIC (glass ionomer cement) restoration with a significant margin gap, multiple other carious proximal lesions, and a very obvious dentoalveolar abscess on the buccal . * **Management:** * The GIC restoration was contraindicated and created a "bacterial heaven" underneath. * The first-line treatment is extraction of the tooth (the source of infection). * Because the child presented with systemic signs (facial cellulitis), oral antibiotics were prescribed: Penicillin V (phenoxymethylpenicillin) at 12.5 mg/kg every six hours for five days. * Early intervention (pulpotomy or stainless steel crown) could have saved the tooth, which now results in orthodontic issues like the mesial drift of the 6. ## Case: Inappropriate Sedation and Prescription Errors ### Question A dentist treated a 2-year-old toddler who was in pain and difficult to examine. The dentist prescribed 1mg of Lorazepam for sedation. What was the outcome and what were the findings of the subsequent audit? ### Findings and Reasoning * **Clinical Outcome:** The 2-year-old was overdosed, resulting in central nervous system depression ranging from drowsiness to a coma. * **Errors:** The dentist failed to assess the child based on age and weight, lacked knowledge regarding benzodiazepines, and did not understand the pharmacological risks in pediatric patients. * **Audit Findings:** The dentist had a "formulaic approach," routinely prescribing adult doses for children (e.g., Metronidazole 400mg instead of 200mg; Amoxicillin 500mg instead of 250mg). * **Teaching Point:** Practitioners must know the scope of their practice and the specific pediatric dosages of drugs they prescribe. ## Case: Bitewing Radiograph Diagnostic Yield ### Question Have a look at this bitewing radiograph taken in a clinic  . The student said they couldn't see any caries and it was fine to bring the child back in for recall in 12 months. What are the main things you should be looking for in a bitewing, and what can you see here? ### Findings and Reasoning * **Radiographic Quality:** This radiograph has a questionable diagnostic yield  due to significant proximal overlap and poor positioning that failed to capture the arches well. * **Retake Findings:** A second bitewing was taken on the same patient. With the overlap removed, there is now clear caries extending into the outer third of dentine on the 74 and the outer half of enamel on the  75. * **Clinical Implications:** Because of the pattern of caries in primary teeth, if there are two lesions on one side, there are likely multiple others on the contralateral side. * **Patient Age Assessment:** The first permanent molar is erupted and in occlusion, but root development is only about 2/3 complete. This suggests the child is approximately 7 to 8 years old. * **Conclusion:** Always ensure an ideal record is obtained before making a diagnosis; the initial poor-quality film missed significant pathology. ## Case: Facial Cellulitis and Infected Second Primary Molar ### Question This patient was referred to the emergency department with facial cellulitis  . Looking at this radiograph and the intraoral picture, how old is the patient and what is the most obvious finding? ### Findings and Reasoning * **Age Assessment:** The first permanent molar has about one-third root development. Since the crown takes three years to form and eruption occurs at two-thirds root development (around age 6), this child is approximately 5 years old. * **Radiographic Findings:** There is a massive lucency involving the mesial aspect of tooth  85 and a significant furcal radiolucency. * **Etiology:** While it could be a standard proximal caries pattern, the lecturer suspects hyper-mineralized second primary molars as a possible primary cause. * **Clinical Findings:** Intraorally, there is a massive GIC (glass ionomer cement) restoration with a significant margin gap, multiple other carious proximal lesions, and a very obvious dentoalveolar abscess on the buccal  . * **Management:** * The GIC restoration was contraindicated and created a "bacterial heaven" underneath. * The first-line treatment is extraction of the tooth (the source of infection). * Because the child presented with systemic signs (facial cellulitis), oral antibiotics were prescribed: Penicillin V (phenoxymethylpenicillin) at 12.5 mg/kg every six hours for five days. * Early intervention (pulpotomy or stainless steel crown) could have saved the tooth, which now results in orthodontic issues like the mesial drift of the 6. ## Case: Inappropriate Sedation and Prescription Errors ### Question A dentist treated a 2-year-old toddler who was in pain and difficult to examine. The dentist prescribed 1mg of Lorazepam  for sedation. What was the outcome and what were the findings of the subsequent audit? ### Findings and Reasoning * **Clinical Outcome:** The 2-year-old was overdosed, resulting in central nervous system depression ranging from drowsiness to a coma. * **Errors:** The dentist failed to assess the child based on age and weight, lacked knowledge regarding benzodiazepines, and did not understand the pharmacological risks in pediatric patients. * **Audit Findings:** The dentist had a "formulaic approach," routinely prescribing adult doses for children (e.g., Metronidazole 400mg instead of 200mg; Amoxicillin 500mg instead of 250mg). * **Teaching Point:** Practitioners must know the scope of their practice and the specific pediatric dosages of drugs they prescribe. Case: Bitewing Radiograph Diagnostic Yield A bitewing radiograph showing the crowns and alveolar bone levels of several primary and permanent teeth in a pediatric patient. A bitewing dental radiograph showing several teeth with significant proximal overlap and poor positioning. Side-by-side comparison of two bitewing dental x-rays, showing how a retake with better positioning reveals caries that were previously hidden by proximal overlap. A dental radiograph showing a mix of primary and permanent teeth in a pediatric patient, with a focus on the posterior dentition. A dental radiograph showing the primary and developing permanent teeth of a child, highlighting a significant lucency in the mandibular second primary molar. A clinical intraoral photograph showing a large restoration with a margin gap and a buccal abscess, accompanied by a corresponding dental radiograph. A news article snippet detailing a legal case where a dentist was reprimanded for inappropriately prescribing benzodiazepines to young children. ## Case: Primary Herpetic Gingivostomatitis ### Question A child presents with the clinical features shown in these images (diffuse erythematous gingiva and pinpoint ulcers). What is the likely diagnosis and clinical presentation? ### Findings and Reasoning * **Diagnosis:** Primary Herpetic Gingivostomatitis (the first exposure to HSV). * **Clinical Presentation:** * Systemic signs: Fever, headache, malaise, irritability, and lymphadenopathy. * Oral signs: Fluid-filled vesicles that rupture into solitary or coalesced ulcers with a red halo and yellow-gray slough. * Gingival involvement: Diffuse, shiny, red, and swollen gums that bleed easily upon touch. * **Management:** Primarily symptomatic care (hydration, rest, soft diet). Analgesia via paracetamol (15mg/kg). Topical therapies are risky in infants due to the risk of swallowing/overdose. ## Case: Infectious Mononucleosis (Glandular Fever) ### Question Observe these lesions confined to the posterior oropharynx and the pinpoint blood lesions on the soft palate. What is the diagnosis? ### Findings and Reasoning * **Diagnosis:** Infectious Mononucleosis (caused by Epstein-Barr Virus). * **Clinical Features:** * Systemic: Low-grade fever, malaise, and lymphadenopathy (posterior chain). * Oral: Palatal petechiae (pinpoint blood lesions) on the soft palate and tonsillitis with exudate on hypoplastic pharyngeal tonsils. * **Diagnosis Confirmation:** Monospot test or Paul Bunnell test (detecting antibodies). * **Management:** Symptomatic treatment; fatigue can last for months. ## Case: Herpangina ### Question A child presents with ulcers specifically located in the posterior aspect of the mouth (soft palate/oropharynx). What is the diagnosis and how is it transmitted? ### Findings and Reasoning * **Diagnosis:** Herpangina (Coxsackie group A virus). * **Location:** Unlike HSV, these lesions are much further back in the oropharynx and soft palate. * **Transmission:** Fecal-oral route. * **Clinical Course:** Low-grade fever, sore throat, and vesicles that form ulcers. It is self-limiting. ## Case: Hand, Foot, and Mouth Disease ### Question A child presents with oral ulcers. What other areas should you examine to confirm a diagnosis of Hand, Foot, and Mouth Disease? ### Findings and Reasoning * **Diagnosis:** Hand, Foot, and Mouth Disease (Coxsackie virus). * **Clinical Features:** * Oral: Aphthous-like ulcerations on the buccal mucosa. * Cutaneous: Vesicles on the palms of the hands, soles of the feet, fingers, and toes. * Nails: May show *onychomadesis* (shedding of the nail) or *Beau's lines* (transverse ridging due to arrest of the nail matrix). ## Case: Varicella Zoster (Chickenpox and Shingles) ### Question How does the presentation of Varicella Zoster Virus differ between immunized and non-immunized children, and how does it present in adults? ### Findings and Reasoning * **Non-immunized Children (Chickenpox):** Malaise, fever, and a very itchy (pruritic) vesicular rash. Oral vesicles may rupture into ulcers on the palate and lips. * **Immunized Children:** Often no fever or low-grade fever, a small number of skin lesions, and fewer oral vesicles. * **Adults (Shingles):** A well-demarcated blistering skin rash affecting a specific dermatome (e.g., one side of the face). * **Management:** Symptomatic relief for itching (calamine lotion, antihistamines) and paracetamol for fever. ## Case: Post-Operative Lip Trauma ### Question Look at this large ulceration on the lower lip of a child. If you suspect a viral infection, have you missed a step in the diagnostic sieve? ## Case: Primary Herpetic Gingivostomatitis ### Question A child presents with the clinical features shown in these images (diffuse erythematous gingiva and pinpoint ulcers). What is the likely diagnosis and clinical presentation? ### Findings and Reasoning * **Diagnosis:** Primary Herpetic Gingivostomatitis (the first exposure to HSV). * **Clinical Presentation:** * Systemic signs: Fever, headache, malaise, irritability, and lymphadenopathy. * Oral signs: Fluid-filled vesicles that rupture into solitary or coalesced ulcers with a red halo and yellow-gray slough. * Gingival involvement: Diffuse, shiny, red, and swollen gums that bleed easily upon touch. * **Management:** Primarily symptomatic care (hydration, rest, soft diet). Analgesia via paracetamol (15mg/kg). Topical therapies are risky in infants due to the risk of swallowing/overdose. ## Case: Infectious Mononucleosis (Glandular Fever) ### Question Observe these lesions confined to the posterior oropharynx and the pinpoint blood lesions on the soft palate. What is the diagnosis? ### Findings and Reasoning * **Diagnosis:** Infectious Mononucleosis (caused by Epstein-Barr Virus). * **Clinical Features:** * Systemic: Low-grade fever, malaise, and lymphadenopathy (posterior chain). * Oral: Palatal petechiae (pinpoint blood lesions) on the soft palate and tonsillitis with exudate on hypoplastic pharyngeal tonsils. * **Diagnosis Confirmation:** Monospot test or Paul Bunnell test (detecting antibodies). * **Management:** Symptomatic treatment; fatigue can last for months. ## Case: Herpangina ### Question A child presents with ulcers specifically located in the posterior aspect of the mouth (soft palate/oropharynx). What is the diagnosis and how is it transmitted? ### Findings and Reasoning * **Diagnosis:** Herpangina (Coxsackie group A virus). * **Location:** Unlike HSV, these lesions are much further back in the oropharynx and soft palate. * **Transmission:** Fecal-oral route. * **Clinical Course:** Low-grade fever, sore throat, and vesicles that form ulcers. It is self-limiting. ## Case: Hand, Foot, and Mouth Disease ### Question A child presents with oral ulcers. What other areas should you examine to confirm a diagnosis of Hand, Foot, and Mouth Disease? ### Findings and Reasoning * **Diagnosis:** Hand, Foot, and Mouth Disease (Coxsackie virus). * **Clinical Features:** * Oral: Aphthous-like ulcerations on the buccal mucosa. * Cutaneous: Vesicles on the palms of the hands, soles of the feet, fingers, and toes. * Nails: May show *onychomadesis* (shedding of the nail) or *Beau's lines* (transverse ridging due to arrest of the nail matrix). ## Case: Varicella Zoster (Chickenpox and Shingles) ### Question How does the presentation of Varicella Zoster Virus differ between immunized and non-immunized children, and how does it present in adults? ### Findings and Reasoning * **Non-immunized Children (Chickenpox):** Malaise, fever, and a very itchy (pruritic) vesicular rash. Oral vesicles may rupture into ulcers on the palate and lips. * **Immunized Children:** Often no fever or low-grade fever, a small number of skin lesions, and fewer oral vesicles. * **Adults (Shingles):** A well-demarcated blistering skin rash affecting a specific dermatome (e.g., one side of the face). * **Management:** Symptomatic relief for itching (calamine lotion, antihistamines) and paracetamol for fever. ## Case: Post-Operative Lip Trauma ### Question Look at this large ulceration on the lower lip of a child. If you suspect a viral infection, have you missed a step in the diagnostic sieve? Case: Primary Herpetic Gingivostomatitis ### Findings and Reasoning * **Diagnosis:** Traumatic ulceration. * **Reasoning:** This is not an infection. The history reveals the child bit their lip while it was still numb following an inferior alveolar nerve block. * **Teaching Point:** Always use a systematic approach (history and diagnostic sieve) before jumping to a viral diagnosis. ## Case: Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis ### Question A 13-year-old presents with multiple oral ulcers and is diagnosed with Stevens-Johnson Syndrome (SJS). What is the nature of this condition? ### Findings and Reasoning * **Nature of Condition:** SJS and Toxic Epidermal Necrolysis (TEN) are part of a disease spectrum involving an adverse reaction to medication (e.g., ibuprofen) or occasionally triggered by viral infections. * **Severity:** It is a medical emergency and potentially life-threatening. TEN is the most severe form, where a patient can lose the majority of their skin due to blistering. * **Management Warning:** Do not provide advice on social media for such cases; these require immediate hospitalization and specialist medical care. ### Findings and Reasoning * **Diagnosis:** Traumatic ulceration. * **Reasoning:** This is not an infection. The history reveals the child bit their lip while it was still numb following an inferior alveolar nerve block. * **Teaching Point:** Always use a systematic approach (history and diagnostic sieve) before jumping to a viral diagnosis. ## Case: Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis ### Question A 13-year-old presents with multiple oral ulcers and is diagnosed with Stevens-Johnson Syndrome (SJS). What is the nature of this condition? ### Findings and Reasoning * **Nature of Condition:** SJS and Toxic Epidermal Necrolysis (TEN) are part of a disease spectrum involving an adverse reaction to medication (e.g., ibuprofen) or occasionally triggered by viral infections. * **Severity:** It is a medical emergency and potentially life-threatening. TEN is the most severe form, where a patient can lose the majority of their skin due to blistering. * **Management Warning:** Do not provide advice on social media for such cases; these require immediate hospitalization and specialist medical care. Case: Post-Operative Lip Trauma > Findings and Reasoning