1 Flashcards
Montgomery consent
states that you must ASK the patient what they’d like to know about the procedure (aswell as informing them)
3 patients that are high risk for life-threatening complications of IE
-previous IE infection
-Any prosthetic valve placement
-Congenital Heart Disease (Cyanotic or Repaired prosthetically)
*treat (for invasive procedures) in consultation with their cardiologist
There is always the Tx option of
Doing nothing
Patients may not know exactly what is wrong with thier heart. What do you do if its an invasive procedure?
Consult their cardiologist
The ‘vast majority’ of dental patients at an increased risk of IE
Have dental treatment routinely performed (no AB, no changes)
Stents and pacemakers are not at increased risk
Of IE
Make sure that infection (in those with increased IE risk) is assessed and treated promptly.
To reduce IE risk
If a patient opts for AB prophylaxis, it IS appropriate to include their cardiologist in the consultation. They may provide insight that would sway the patient against their opinion with your discussion alone
But they can’t force you to prescribe
You can refer to another dentist or arrange consultation with cardiologist
‘Invasive’ is anything that
goes farther than supra-gingival scaling (step 1 okay, step 2>4 is NOT)
IE. Clamps, endo, XLA, matrix bands, retraction cord are all invasive.
LA and BPE is not invasive BUT 6PPC is
☆’Invasive’ basically means you need to have a AB prophylaxis chat - with those special 3 sub-group patients listed above. BUT its advised you should never NOT have dental tx as a result of being at ‘higher risk of IE’.
You’ll have the IE discussion…
at the first examination, when the patient joins the practice OR
immedietely after they are diagnosed/have the heart operation
Penicillin allergy?
Do NOT prescribe amoxycillin.
At greater risk of hypersensitivity reaction to amoxycillin.
Risk of AB prophylaxis? Ie. Why not?
You can get CDI (clostridium difficile infection) which CAN, in some cases be fatal
CDI is more common in those that have taken broad-spectrum antibiotics (basically the two are corolated. So it’s like this.Taken AB? You’re now in the at risk group of getting a CDI)
^Especially catious in vulnerable groups. They’re at highest risk of fatal complications (esp. Gastric disease/meds patients)
^No data on how many more CDI infections happen as a result of AB prophylaxis. Sorry cuz.
When do you prescribe AB for prophylaxis (invasive procedure)
AB are prescribed at the appointment before (unless you have them in the practice)
When take AB prior to invasive Tx
AB’s are instructed to be take 60 minutes before the (invasive) procedure
Ideally in practice, but if no hx of prior complications to AB, can take at home
Patient had an AB for an infection in the last 6 weeks
Give them one from a different class of drugs
First line AB for IE prophylaxis
3g amoxycillin 60 mins before (1 sachet)
*known to interact with warfarin, monitor INR
AB prophylaxis if allergic to penicillin
600mg Clindamycin 60 mins before (2 capsules)
*take with water
*do not prescribe to those ‘diahrreal states’
Explain IE to a patient. Why AB prophylaxis is an option. How this relates to dental treatment.
IE is an infection (of the lining of the heart)
This affects 1:10,000/year approx (standard)
BUT
Because they’re at an increased risk, their odds would be less than that. How much is unclear. But that’s the choice they have to make.
We would always recommend to follow through with dental tx.
The infection is due to bacteria entering the bloodstream.
Invasive dental procedures put the patient at higher risk of this happening, and thus a higher risk of a IE.
An IE can happen anytime though. Flossing, brushing and chewing can also can an IE
It’s all a case of how likely will it be to happen. That’s the magic question that we can’t anwser. We can only inform the patient that this is their risk and their odds are worse than the average person.
It is unclear if AB Prophylaxis even prevents IE
It is clear there are side effects to AB prophylaxis
These side effects; nausea, diarrhea, anaphylaxis, colitis-infection must all be communicated to the patient for them to have informed consent
*If a patient begins to experience flu-like symptoms following the invasive procedure (at higher risk of IE) get them to contact their GMP immedietely
Record discussion with patient in notes
Patient is on a doac.
FOR ALL PATIENTS:
Apixaban treat early in day, limit initial area, consider staging
Dabigatran suture/packing recommended
Rivaroxaban LOW : don’t interrupt medication
Edoxaban HIGH : Skip/delay morning dose (advise when)
Warfarin patient needs an extraction
Warfarin FOR ALL PATIENTS: Check INR <4 (<24hrs) (<72hrs*)
Acenocoumarol : Consider staging Tx
Phenindione : Suture/packing recommended
: Delay/ Refer if urgent Tx (>4 INR)
:Proceed as normal for low risk
Patient presents with a ‘parin’
Dalteparin FOR ALL PATIENTS: Check low or high dose
Enoxaparin : Consider staging Tx
Tinzaparin : Suture/packing recommended
: If high, ask their clinician
Aspirin
Aspirin (alone, low risk, local haemostatic measures)
Clopidogrel
Clopidogrel FOR ALL PATIENTS: Expect greater bleeding
Antiplatelet
Dipyridamole : Limit initial Tx area (definitely)
Prasugrel : Suture/packing recommended
Ticagrelor
Anticoagulant/antiplatelet combination
Ask prescribing clinician
For all these patients:
-treat early in day (and week)
-Give pre-op and post-op instructions
-Treat atraumatically
-Establish haemostasis before discharging
-Take extra care and attention to avoid complications with patients that live far from emergency care
*Metal heart valve, coronary stent or episode of deep vein thrombosis <3 months?
Do NOT stop medication
HIGH RISK BLEEDING PROCEDURES:
HIGH RISK BLEEDING PROCEDURES:
More than 3 XLA
Complex XLA
Any flap raising procedure
Biopsy
Gingival recontouring
3 risk categories; examples of each
3 categories (unlikely, low risk, high risk)
Unlikely: supragingival stuff/BPE/LA
Low: 1-3 XLA, Subgingival stuff/6PPC/incision&drainage/RSD/retraction cord for indirects
High: More than 3 XLA
Complex XLA
Any flap raising procedure
Biopsy
Gingival recontouring
High risk procedures, doac regime
(High risk procedures)
Apixaban MISS MORNING DOSE / EVENING DOSE AS NORMAL
Dabigatran
Rivaroxaban DELAY DOSE UNTIL 4HRS AFTER HAEMOSTASIS
Edoxaban TAKE AS NORMAL (ONE EVENING DOSE)
At risk patients and prescribing rules
DRUG PRESCRIBING FOR DENTISTRY
Elderly, Pregnant, immunocompromised, renal or hepatic impairment, nursing mother?
DOUBLE CHECK BEFORE PRESCRIBING MEDICATION
Contraindicated: under no circumstances prescribe
Caution: prescribe if no safer alternative found, consider reduced dose
Most odontogenic pain can be sufficiently relieved with
Ibuprofen and paracetamol
Dental abcess/infection
400mg/3x daily/x5 days (15 tabs) METRONIDAZOLE (/Penicillin allergy)
*interacts with warfarin/alcohol
*DO NOT PRESCRIBE alongside these drugs
Hypoglycaemia
1mg intramuscular (if unconscious/unresponsive)
ANUG/ANUP drug prescription
ANUG/ANUP:
400mg/3x daily/x3 days (9 tabs) METRONIDAZOLE
Sinusitis prescription
PHENOXYMETHYLPENICILLIN (PEN V)
250mg(x2)/4x daily/x5 days (40 tabs)
Paracetamol or Ibuprofen or both? Who gets what?
90% of people get both (4×1g, 4x400mg)
Ibuprofen prescribing
Asthma, elderly, Hepatic impairment, Renal impairment, pregnant, breast-feeding, heart disease, heart failure or hypertension, GI bleeding/issues, Anticoagulant/bleeding issues
ALL CAUTION/CONTRAINDICATED W/ IBUPROFEN!!!!!!!
Ibuprofen is trickier (Consult the SDCEP for all above groups)
*Aspirin interacts with Ibuprofen ^
Avoid prescribing Ibuprofen if already on existing NSAID
Paracetamol prescribing
Paracetamol is safe for 98% of patients
(Severe alcohol, renal or hepatic issues, Paracetamol hypersensitivity are the only 4 groups of patients you’re cautioned with)
3rd molar pain
-Socrates
-Previous Tx (if any), antibiotics
-Hx of facial swelling?
-Attended hospital for pain?
3rd molar assessment
-eruption status
-impacted or not (horizontal, mesio-angular, disto-angular, vertical)
-caries
-check the opposing tooth, traumatic or not (upper arch)
-mouth can open more than 3 fingers width: can have surgery (anything less, generally no)
-mild, mod or severe impaction
-check no. Of roots
-check proximity to IAN
(Darker on x-ray=air) I.e less density
-CBCT
Clinical review vs. Active surveillance
- a.s. is bringing the patient in specifically for an x-ray/ look for an existing issue whereas a review is just a check up, routine
Patients that can’t have coronectomy
Diabetes/cancer/chemo patients (contraindicated for coronectomy)
Patient with MRONJ can be an indication for
Coronectomy: raise a flap first
If roots aren’t moving, you close everything up (suture)
If roots are moving, you CANT leave them in-situ
3 sided flap best for 3rd molars
Envelope flap for root left near crestal bone
2 sided flap for root lower down/ harder access
- carious 8 (coronectomy contraindication)
-impacted (because something is stopping it coming through)
Tx options:
-Surgical removal
-Do nothing
OPT (could be)
-Mandibular fracture (‘crunch’ from Hx, tetanus)
Needs a fracture radiograph (PA mandible: posterior to anterior x-ray)
Pulp extirpation
Pulp exirpation: First stage in an RCT (to save the tooth) to avoid extraction
K-files (10,15,20,25)
Endo Burrs (white plastic box)
Chlorohexidine
Leadermix/ NSCaOH (same thing)
Calcium hydroxite (irrigation)
Cotton pellets (to put one in chamber)
Close with GIC/RMGIC
-doesn’t matter with moisture control/blood because its temporary)
When describing bone levels on a radiographic report:
1.Mild, moderate or severe
2.Localised or Generalised
3.Horizontal or angular
Single tufted toothbrush good for
gingival hyperplasia/ getting down into the pocket (deep) and removing the plaque/ good for posterior teeth
Cavitron
Cavitron:
Supra
-interproximal/ general (small head)
-beaverhead (gross caries/ general)
Slimline
- anterior pockets (< or equal to 5mm)
-posterior, furcations, interproximal
(Left or right - SIDE of the tooth)
So use the right one on the buccal of Q3, lingual of Q4
Or the left on the buccal of Q4, lingual of Q3 (unsure for upper but check orientation against tooth. Should be curved away from the tooth into the furcation)
Separator
Separators
-Let patient know it’s normal for the separator to be uncomfortable/ feel pressure but it’ll get better in one or two days
-5-7 days of separator before crown
PMC application
(hall technique)
-place with GI
-Write tooth and Size of Crown in notes
SDF - VCG
-warn of staining and possibility of pain still present due to caries depth (VCG)
SDF placement
-Vaseline on lips and soft tissues
-SDF applied for 2 minutes
-Dried with cotton wool
Bridge success
Quality of bonding surface, bonding procedure
Retainer, pontic design
Occlusal management
Improving bridge retention
rest seats, grooves, notches, locating margins, larger surface bonding area, sandblasting fitting surface of wing
Problems associated with TMD
tmd, mobility, tooth fractures/+ restorations, nctsl - attrition, chewing
UOM and OPT
Vertical parallax
Opt first, then UOM (tube moves UP from a horizontal position - OPT)
If it moves up - palatal
If it moves down - buccal
Ie. If it moves WITH the xray > palatal
Moves away from the xray > buccal
Work out which way the tube is moving - then decide does it move with or not
X2 periapical
Horizontal parallax
Ghost image is
Artifact (of the xray)
Patient positining, earrings,
ANUG presentation, risk factors and tx
1 Acute Necrotising Ulcerative Gingivitis
- red inflamed papilla, grey slough that wipes off
-painful, bleeding gums
- Hx (stress, smoking, age, diet), radiographs
- stress, poor diet
-age
-metronidazole 400mg, 3x daily, 3 days (3 days important), chx mouthwash, ibuprofen/ paracetamol
Picture of a chemical burn
Chemical burn with phosphoric acid (cervical margin 22)
Due to extensive acid etch
No treatment
Don’t brush area for a few days, let it heal
Prescribe CHX
Surgically you would repair it (future)
Primary herpatic gingivostomatitis
3.primary herpatic gingivostomatitis
Highly infectious
PPE very important
Herpes simplex 1 (sometimes 2)
Tongue, lips, cheek, everywhere
High fever
Prescribe tablets (aciclovir) (5 tabs/ 5x daily) < high fever indicates prescription
Patient wants an implant to fill the space. Adjacent tooth is grade 1 mobile with a 5mm pocket
You can’t place implants where adjacent teeth have deep pockets/ mobility. Stabilise the perio first
Leukemia presents with bad perio
Urgent! Referral to gp
Analgesics (very painful)
Regular fluids
Internal resorption looks like
Internal parallel lines disrupted = internal resorption
External replacement resorption
ERR - Classic change in pitch of tooth on percussion (like the tooth absorbs the sound, dull sounding - cause - No pdl (bone on root)
ERR - Endo has no + effect on tooth/Prognosis
A.k.a ankylosis
External cervical resorption
ECR looks like an apple core out of the tooth (radiographically)
Has a portal of entry
Pink spot + Bleeding common
ECR - CBCT Is very helpful
Poor Prognosis for ECT means extraction/ prosthesis replacement
Xerostomia and bonding
Harder for gi to stick in acidic environments (comp too) Ie. Xerostomia patients
5 cysts
Radicular cyst is most common (non-vital teeth only)
Dentigerous cyst 2nd most common
Keratocyst 3rd most common (like cream cheese coming out)
Lateral periodontal cyst 4th most common (on side of tooth, vital tooth)
Nasopalatine cyst
Cyst definition
Equal to or 1cm> : is called a cyst
Apical granuloma (anything less than a cm)
Ameloblastoma
Ameloblastoma, most common tumour of the jaw (odontogenic tumour)
(Radiolucency in the mandible, 1cm around the lesion has to be removed too - segmental resection
Marsupilisation
Periradicular surgery
Aim of periradicular surgery
Achieve apical seal, remove existing infection
Indications: failed endo: apical cyst, lateral perforation, underfilled, overfilled, root dilaceration, broken instrument
Apicectomy
Removing 3mm of the apex with a fissure burr (apicectomy)
Clear out apical gp then place your apical seal with retrograde root filler (mineral trixoide aggregate/ zinc Oxide eugenol)
Using ultrasonic to clean out old apical gp
(Distal/mesial reliving incision) Ash to raise flap and Mitchell’s to identify apex
Causes of failure of periradicular surgery
Causes of failure (periradicular surgery)
Inadequate seal, too little apex removed, presence of lateral canals, displacement of seal, removed too much apex, poor healing response, poor perio status of the tooth (not enough support)
Pockets after the 3 rounds of pmpr
Anything 6 or above mm pockets, go surgical tx (after adequate PMPR)
Home measures (brushing) can help pockets UP TO 4mm 5 and above need a dentist to help improve the pockets. Thats why these are the numbers periodontists are obsessed with
Perio team members
Dental hygienist, therapist, oral health educator, gdp
What’s on a prescription to a dental hygienist
Specific patient problems
What la they need (specify) if any
Treatment required
If a 6ppc has been carried out or not (need one for definitive perio diagnosis)
Necessary recall period
Referring a patient to a perio specialist
BPE scores should be included in the referral (to give an idea)
Tx carried out
Mx hx
GDP details
Patient details
Smoking history
Diagnosis and classification
Justification for referral
Relevant radiographs
Prognosis of teeth
McGowan
Glication numbers
(hba1c) <48 good > 48 bad (look it up)
Endo re-tx failure, why?
Endo re-tx failures are because the bugs go out of the tooth and attack the bone/pdl/external root surface. Creating a chronic Inflammation response
Crown on a RCT tooth. Do you re-tx?
Guidance: Yes if poor rct radiographically, No if it looks good
End of day. Patient decides. They foot the cost and the risk
What does a coronal seal do
To prevent microorganisms entering the tooth
Cuspal coverage, why?
Protect the tooth from fracture. Or at least give it the best chance
Fibre Post cement
Relyx
GI cement or COMP resin cement in poor moisture conditions for crown/bridge cementation
GI cement
Instruments on the bracket table
• Mirrors: Viewing intra-orally, soft tissue retraction & protection
• Probes (No 6 is straight) Caries protection, point focus, surface testing, retraction
• CPITN Probe – For BPE. One black band 3.5mm-5.5mm with ball end 0.5mm wide
• PCP-12 Probe – For periodontal pocket chart. Two black bands 12mm 9mm 6mm 3mm
• Tweezers – For handling small objects. Surgical locking tweezers. College tweezers.
• Excavators (spoon or round excavator) - Caries excavation, material removal & manipulation, shaping & contouring restorations. Come in 3 different sizes
• Plastics & Flat plastics - Manipulation of shapeable filling material: Composite or GI
• Condensor – Condensing amalgam, manipulate comp. Standard plugger & lustra amalgam
• Carvers – Carving amalgam, shaping composite
• Chisels – Finishing cavo-surface margin angles. Removal of unsupported enamel prisms. Blacks, Gingival Margin Trimmers & Blacks 84 (straight)
• Burnishers – Finishing amalgam restorations/manipulating composite
• Applicators – Placement of lining material: Thymozin instruments
• Spatulas, Matric retainers, amalgam carriers & composite guns
Terms to describe a cavity
Cavo-surface margins: Approx 90.
Line angles: 2 points
Point Angles: 3 points
Occlusal/Pulpal Floor
Gingival floor
Pulpal Axial Wall
Buccal/Lingual Axial Wall
Interproximal box
Isthmus
Scalers
6) Scaling
• Mini-sickle – Two cutting surfaces on each blade for embrasure surfaces supra-gingivally. Triangular in cross section
• Columbia Universal Curette – Two cutting surfaces on each blade. Sub gingival & root planing anywhere in mouth. Limited access to deep pockets. Rounded in X-section
• Gracey Grey - Single cutting edge on each blade. Deep sub-ging scaling of anterior teeth
• Gracey Green – Single cutting edge. Deep sub-ging scaling of buccal/lingual surfaces of posterior
• Gracey Orange – Single cutting edge. Deep sub-gingival scaling of mesial surfaces of posterior teeth
• Gracey Blue – Single cutting edge. Deep sub-gingival scaling of distal surfaces of posteriors
• Hoe Scaler Yellow – Gross supra & sub-gingival scaling (root surface debridement) on buccal & lingual surfaces
• How scaler Red – Gross supra & sub-gingival scaling (root surface debridement) on mesial & distal surfaces
o Principles for using Gracey Curettes
1. Determine LARGER, OUTER cutting edge before beginning
2. After visual inspection, confirm the correct cutting edge by adapting it to the tooth with the TERMINAL SHANK PARALLEL to the surface to be scaled.
Only the back (flat, shiny face) of the instrument can be seen from above if the correct edge has been selected
3. Lower shank is parallel to tooth
4. Use fulcrum & finger rest
5. Vertical & diagonal cutting strokes may be made
Syringe assembly
• Before beginning, check patients medical history & check injection site
1. Tear back sterile seal of cartridge, check sell by date & insert gold end into syringe
2. Grip & retract plunger handle to cover silicone washer. Roll plunger onto cartridge
3. Slide protective sheath back towards handle until it CLICKS. Make sure there is no gap and plunger is locked to syringe handle
4. Remove needle cap & discard it. Needle is ready for use
5. Passive aspiration & Active aspiration
6. To change cartridge, slide sheath up to 1st holding position, remove & change
7. When used lock needle in 2nd holding position of-Do not try unlock when like this
8. Fully retract & peel plunger - autoclave. Needle in sharps box & cartridge in glass box
Primary eruption dates
• All deciduous teeth should have erupted by 2 ½ years (Start at 4-6mths lower central)
• All permanent teeth should have erupted by 12 years (Start at 6yrs First molar)
• For every 6 months of life, approximately 4 teeth will erupt
• A, B, D, C, E (First molar before canine)
o Lower Central (81 & 71) 4-6 months
o Lateral Incisor 7-9 months
o 1st Molar 12-14 months
o Canine 16-18 months
o 2nd Molar 20-24 months
• Primary teeth: All lowers develop before uppers except 5s
o Upper: 1st molar then front to back EXCEPT 3s: 6, 1, 2, 4, 5, 3, 7, 8
o Lower: 1st molar then front to back: 6, 1, 2, 3, 4, 5, 6, 7, 8
7years 8 11 10 10 6 12
1upper 2 3 4 5 6 7
1lower 2 3 4 5 6 7
6years 7 9 10 10 6 12
• From eruption date, it will take about 3 years for root to complete apexogenesis
• Primary anteriors are smaller in both crown & root proportions
• Primary molars are wider mesio-distally
• Primary molar crowns are more bulbous
• Primary teeth are usually whiter in colour
Primary tooth morphology
- Upper right 1st:
• 2 buccal roots;1 lingual. Mesio-buccal root is wider cervically than disto-buccal root is
• Tubercle of Zuckerkandl on mesio-buccal cusp
• 4 cusps. Large mesio-buccal & diminutive disto-buccal. Mirrored lingually - Lower right 1st:
• Prominent tubercle (Tubercle of Zuckerkandl on mesio buccal cusp)
• 4 cusps. Mesio cusps larger than distal.
• Buccal cusps are seen to lean lingually - Upper right 2nd:
• Replica of permanent first maxillary
• 2 buccal roots;1 lingual. Transverse ridge
• Cusp of Carabelli often seen on lingual surface of mesio-lingual cusp - Lower right 2nd: 3 cusps like permanent first
• Similar to mandibular permanent first molar
• 5 cusps: Three buccal & two lingual
• Buccal cusps have a lingual lean
Splinting a tooth
11) Splint
• Wash under water 10s by holding crown & reimplant or store in a cup if patients saliva/saline
• Flexible splint for 2 weeks for avulsion. One abutment tooth either side. Must be passive.
1. Cut & bend 0.6mm stainless steel wire. Measure length using a piece of floss, and bend using Adams pliers
2. Acid etch 10s on middle of tooth, apply prime & bond
3. Apply composite to traumatised tooth and those adjacent, avoiding contact areas
4. Sink the contoured, passive wire into the composite
5. Shape & cure composite. Add thin covering to top of wire
6. Smooth rough composite and wire ends
Surveying a cast
• Survey: Determines guide planes and marks survey lines for fabrication of RPD
• Line on a cast represents the largest concavity of tooth in relation to planned path of insertion
• Guide planes: Two or more parallel tooth surfaces which determine the path of insertion (and withdrawal of an RPD)
• Path of insertion: Path followed by denture from first contact with teeth/tissue until it fully seats
• Path of withdrawal: Opposite to the path of insertion
• Path of displacement: Any path by which denture can be displaced
• Common path of displacement: Taken at 90o to the occlusal plane (horizontal)
• Survey: Carried out to eliminate undercut areas that would prevent the denture from being inserted/removed. Or for undercuts that can be utilised by clasps
• Tool of surveyor: Chuck holds it. Analysing rod, graphite markers, 3 undercut gauges, wax knife
• Sequence:
1. Position cast onto surveyor table & orientate to common path of displacement
2. Tripod cast as common path of displacement
3. ‘Eyeball’ abutment teeth & associated soft tissue with analysing rod
4. Mark upper & lower survey lines on abutment teeth & associated soft tissue with graphite marker
5. Select undercut gauge and clearly identify undercuts which cannot be seen for mechanical retention
• Tripoding records the common path of displacement and insertion & withdrawal
• Table can be tilted to:
o Provide retention (using guide surfaces of teeth)
o Improve appearance (close unsightly gaps)
o Eliminate interference (undercuts present satisfactory path of insertion)
• Survey line indicates the extent of the undercut: below line must be used or blocked out
• The path of insertion can be altered so it is different from the common path of displacement
o Aesthetics
o Retention
o Interference
13) RPD Design
• Support rests: Occlusal, cingulum, ring, incisal, ledge,
• Retention: Occlusally or gingivally approaching (ring)
Reciprocation or bracing (arm or plate)
• Connector plate/bar: Major connector – Open/closed design
Maxilla: anterior, mid palatal, posterior, ring connector
Mandible: Lingual bar–needs 8mm, lingual plate, Kennedy bar, sub-lingual plate
• Minor connector: Joins component to major connector
• Acrylic retention: Mesh, bar, post
• Finishing lines: Bounded or free end saddle
RPD prescription
• Instructions:
o What does the dental technician need to know?
o What do you want the technician to do?
• 1st visit:
o Selection of stock trays &alginate primary impressions taken
o Disinfect & sealed clear bag with gauze
• Instructions 1st clinical
o Please pour up primary impressions in dental stone
o Please make special trays (1-2mm spacer) with working handle.
o Do we need articulated study casts?
• Before 2nd: Survey to path of insertion to decide undercuts. RPD Design
• 2nd visit
o Secondary impressions with special trays
o Send design
• Instructions 2nd clinical
o Please pour up working impression (Master) and construct working duplicate
o Construct wax occlusal rims. Indicate whether these need to be wax or resin
• 3rd Visit: Jaw registration
o Patients without occlusal contacts and stops to indicate correct ICP
o Patients with occlusal contacts in the ICP
• Instructions 3rd clinical
o Please articulate casts to registration provided
o Please set up teeth for wax trial or construct metal framework for metal wax trial
o Tooth selection: Material, Mould, Shade
• Instructions 4th clinical
o Please flask pack and finish (CoCr) or please process in acrylic resin
Hand washing
• Social hand wash: 6 steps at 5 moments:
o Before touching a patient
o Before a clean/aseptic procedure
o After bodily fluid exposure risk
o After touching the patient
o After touching patient surroundings
o Use liquid antimicrobial soap, with hot water
o Or washing with alcohol gel when hands are not visibly soiled
• Hygienic hand hygiene consists: When hands are visibly soiled.
o 6 steps before all aseptic procedures on the ward
o Wash with an antiseptic scrub (chlorohexidine), hot water and soap and then an alcohol based gel.
• Surgical: For before invasive procedures
o Use surgical scrub
What patients are at risk of MRONJ
Patients taking Anti angiogenic and anti resorptive drugs; biphosphonates, RANKL inhibitors, anti-angiogenic
Trauma stamp (9)
Sinus
Color
Mobility
Tender to percussion
Tender to palpation
Percussion note
Ethyl chloride
Electric pulp test
Radiograph
Significant findings on trauma review
Continuation of root formation
Loss of pulp vitality
Breakdown of the periodontal ligament
Resorption (+ type)
Fracture healing (+type)
5yr resorption rate on trauma review
Open is always better Prognosis than closed apex
Intrusion 67 / 100
Avulsion frequent
Low incidence of resorption
Concussion
Subluxation
Extrusion
Lateral luxation (3/38)
Resorption types
External surface
External inflammatory
Internal inflammatory
Replacement resorption - ankylosis
External surface resorption
Damage to the pdl that subsequently heals
Common aetiology; excessive orthodontic forces
External inflammatory resorption
Moth eaten appearance
Diagnosis indicated by; tramlines of root canal intact, indistinct root surfaces
Due to PDL damage initially, but then propagated by necrotic pulp tissue
A progressive form of resorption
External and Internal inflammatory resorption treatment
Pulp extirpation
Mechanical debridement
Chemical irrigation
Ns CaOH for 4-6 weeks
Obturate
Ie. Remove propagating stimulus
Internal inflammatory resorption
Internal ‘ballooning’ of canals
Initiated by non-vital pulp
Progressive
Diagnosed by; root surface intact, root canal tramlines indistinct
Tx is the same as external inflammatory resorption
Replacement resorption- ankylosis
Propagated by severe damage to PDL
Healing does not occur
Bone fuses directly to dentine
Progressive; tooth gradually resorbed as its now part of bone remodelling
Diagnosed by; loss of lamina dura and loss of pdl
Treatment: nil
Ragged root outline
Pulp canal obliteration
Response of a vital pulp
Progressive hard tissue formation within pulp cavity
Gradual narrowing of pulp chamber and pulp canal - total or partial obliteration
Treatment: conservative as only 1% give rise to periapical pathology
Types of root fracture healing
Calcified tissue
Granulation tissue - non healing
*detected as black mass around fracture line
Osseous tissue
Connective tissue
Mix of connective and osseous tissue
Endo design objectives
Create a continuously tapering funnel shape
Maintain apical foramen in original position
Keep apical opening as small as possible
Advantage of k files
Flexible so can be used in curved canals
