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Question 1

Question 1: Restorative Diagnosis

Possible diagnoses

1. Gingivitis
2. Localised Periodontitis
3. Generalised Periodontitis
4. Dentine Hypersensitivity
5. Lesion of endodontic origin with periodontal involvement
6. Lesion of periodontal origin with endodontic involvement
7. Occlusal trauma
8. Periapical periodontitis
9. Periodontal abscess
10. Reversible pulpitis
11. True combined periodontal-endodontic lesion

For each of the following scenarios select the MOST LIKELY diagnosis from the terms in the table above and answer the supplementary questions.
Each answer may be used once, more than once, or not at all.

1. A patient presents with a 7 mm pocket that is discharging pus, on the mid-buccal aspect of tooth 26. The tooth is non-vital and there is very little pathological periodontal pocketing elsewhere in the patient’s mouth.
   i) What is the most likely diagnosis from the above list?
   (1 mark)

ii) Give TWO anatomical factors that may be responsible for the location of the discharging pocket?
(2 marks)

iii) What treatment would you perform?
(3 marks)
 
Possible diagnoses
1. Gingivitis
2. Localised Periodontitis
3. Generalised Periodontitis
4. Dentine Hypersensitivity
5. Lesion of endodontic origin with periodontal involvement
6. Lesion of periodontal origin with endodontic involvement
7. Occlusal trauma
8. Periapical periodontitis
9. Periodontal abscess
10. Reversible pulpitis
11. True combined periodontal-endodontic lesion

2. A 35-year-old patient presents complaining of mobility of tooth 34, which he feels is becoming worse. On examination, tooth 34 demonstrates Grade II mobility. There is no attachment loss but there is evidence of moderate toothwear affecting a number of teeth, likely attributable to attrition. Radiographic examination reveals generalised widening of the periodontal ligament space of tooth 34 and the tooth responds positively to sensibility testing

i) What is the most likely diagnosis from the above list?
(1 mark)

ii) Describe how would you manage this patient?
(3 marks)

3. A 60-year-old patient presents complaining of generalised bleeding gums. There are CPITN scores of 4 in each sextant, with 78% sites showing bleeding on probing. A panoramic radiograph shows generalised horizontal bone loss, with 50% alveolar bone loss at the worst sites. The medical history is clear and the dentition is only lightly restored.

i) What is the most likely diagnosis from the above list?
(1 mark)

ii) Which Stage AND Grade would you attribute to this case?
(1 mark)

iii) What is the single most important factor to determine from the social history?

(1 mark)

 
Possible diagnoses
1. Gingivitis
2. Localised Periodontitis
3. Generalised Periodontitis
4. Dentine Hypersensitivity
5. Lesion of endodontic origin with periodontal involvement
6. Lesion of periodontal origin with endodontic involvement
7. Occlusal trauma
8. Periapical periodontitis
9. Periodontal abscess
10. Reversible pulpitis
11. True combined periodontal-endodontic lesion

iv) What further investigations would you carry out?
(2 marks)

4. A patient presents complaining of a constant throbbing pain from the right side of her mandible. This has kept her awake at night. On examination, you establish that tooth 46 is grossly carious and is tender to percussion.

i) What is the most likely diagnosis from the above list?
(1 mark)

ii) What further investigations might you perform?
(2 marks)

iii) What are the best treatment options for relief of the patient’s pain?
(2 marks)

Answer 1

1. (i) Lesion of endodontic origin with periodontal involvement
   (ii) Furcal Canal – pathology breaking through into the furcation explaining the mid-buccal aspect. Palatal root stopping pathology from expanding up palatal side, therefore periodontal involvement expresses buccally where it is less inhibited.

(iii) *primary Endodontic Therapy – Root canal and coronal restoration
* Periodontal Therapy within 10 days – supra and sub gingival scaling
* Surgical investigation and treatment – open flap debridement? Emdogain – promotes periodontal fibre regeneration.

2. (i) Occlusion trauma

(ii) *Control plaque induced inflammation – OHI, scale & polish etc
* Correction of occlusal relations
* Splinting

3. (i) Generalised periodontitis.
   (ii) Grade B Stage 3 (severe), unstable
   (iii) Whether or not they are a smoker and if they have just quit.
   (iv) 6Point pocket chart on whole mouth, plaque and gingivitis index
4. (I) Periapical periodontitis
   (ii) Periapical radiograph of tooth, sensibility tests with ethyl chloride and electric pulp test
   (iii) Root canal treatment, extraction

Question 2

Question 6: Study Evaluation

Please read the following reference material, adapted from a research paper

Objective
The purpose of this study was to evaluate the potential benefit of an ultrasonic device in apical surgery on the outcome of treatment.

Study design
Patients were referred for apical surgery on one of their previously endodontically treated teeth. The patients were randomised into two groups. One group was allocated to treatment with an ultrasonic device and the second group allocated to treatment with a bur in an otherwise similar protocol. One year after treatment the results were evaluated using both radiological and clinical criteria by two oral surgeons who were blinded for the therapy.

Results
A total of 399 patients were recruited to the study. One-year follow-up data were obtained from 290 patients (141 bur and 149 ultrasonic). The table presents the overall results

Table: Outcome of Treatment

Failure 	Success 	Total Treatment type			

Bur %(n) 29 (41) 71 (100) 141

Ultrasonic device %(n) 20 (29) 80 (120) 149

Absolute risk difference[95% CI] 9% [-0.8% to 18.9%]

p-value 0.056

1. What is the most appropriate primary study design to “to evaluate the potential benefit of an ultrasonic device in apical surgery on the outcome of treatment”?
   (1 mark)
2. List the FOUR main features of this study design:
   (2 marks)
   It is Randomly allocated
   Patients are unaware of what treatment they are receiving
   Double blind which helps to reduce bias
   Compares one type of treatment to another
3. Choosing ONE of these features, describe how you would implement it in the above study:

(2 marks)

4. In relation to the Absolute risk difference and the 95% Confidence Interval, what conclusion would you draw from the table? Explain your answer.

                           (2 marks)

5. List FOUR patient-related factors which should be considered when interpreting the results:
   (2 marks)
6. Name the standards developed to improve the reporting of randomized controlled trials?
   (1 mark)

End of Question

Answer 2

1. Randomised control trial
2. It is Randomly allocated
   Patients are unaware of what treatment they are receiving
   Double blind which helps to reduce bias
   Compares one type of treatment to another
3. Randomly allocate patients to treatments using a random generator so there is no bias when allocating.
4. The evidence is insufficient because the confidence interval overlaps zero
5. (+/ When was the tooth treated, medical history of the patients should be matched, the tooth should be the same if possible, the initial reason for root treatment should be matched.)
6. (CONSORT)

Question 3

Question 8: Late Erupting

An 8-year-old boy in the mixed dentition attends your surgery complaining that he does not like the look of his front teeth (see photograph above). The deciduous tooth upper incisor became black and firm 3 years ago and fell out recently. He has no relevant medical history.

1. What feature of the patient’s dental history is it important to determine?
   (1 mark)
2. What part of the physical examination is important?
   (1 mark)
3. What radiographic view would be most suitable for this child?
   (1 mark)
4. Given the history, give an account of the sequence of events that have most likely caused non-eruption of upper central incisor?
   (2 marks)
5. Give ONE other possible cause of non-eruption of the upper central incisor in this case?
   (1 mark)
6. What are the principles of the orthodontic management of non-eruption of upper central incisors?
   (4 marks)

End of Question

Answer 3

1. Whether or not there was dental trauma
2. (palpate for presence of other central, count the teeth and assess if they are in chronological accordance to the age of patient and their timing)
3. OPT
4. The primary tooth was traumatised due to dilaceration, which would’ve caused the tooth to go black and also delay the eruption of the 21.
5. (adjacent teeth encroaching on eruption space?)
6. You would expose the un-erupted tooth surgically. If there were any suprenumery teeth present, you would extract them. You would then attach gold chain to the unerupted 21 and bind it to one of the adjacent erupted teeth, this will help pull the 21 one down into the oral cavity. When the patient reaches 9 years old then you can use orthodontics to help, such as fixed appliances.

Question 4

Question 10: Panaromic Radiology

1. Which external reference plane of the patient should you position horizontally when setting up for a panoramic radiograph?
   (1 mark)
2. When you look at the radiograph you have taken, some of the teeth are horizontally distorted. Which positioning error results in the following:
   i) The incisor teeth being horizontally magnified
   ii) The posterior teeth on one side being wider than on the other
3. The patient is unable to remove their earrings with the result that there are ghost images of the earrings. Give THREE important features that apply to all ghost images.
   (3 marks)
4. What panoramic radiograph would you ask to be taken in the following clinical situations:

i) A pre-extraction radiograph for partially erupted 48, when there is no evidence of 38 in the mouth; 48 is to be extracted under local analgesia (1 mark)
ii) For a child patient with caries, who cannot tolerate bitewings

5. The maxillary sinus is depicted in a panoramic radiograph. Which margins or walls are seen in the following locations:

i) Horizontally above the roots of the premolars and molars.
(1 mark)
ii) Vertically above the third molar region.

Answer 4

1. (Frankfort plane)

2(i) (patient is positioned too far from the machine; the x-ray source)

(ii) The patient has moved
3. (They are on the contralateral side to their real position, they are higher up than what they are in reality and they are horizontally magnified)

4(i) (OPT)
(ii) OPT

5 (i) (Inferior border)
(ii) posterior border

Question 5

Question 13: Oral Surgery

You assess that your patient requires removal of teeth 25 and 26 due to caries. The patient has never had teeth taken out before. When discussing their medical history, you elicit they take Warfarin for Atrial Fibrillation.

1. What type of drug is Warfarin AND what is its mechanism of action?
   (2 marks)
2. Which test must be carried out prior to the extractions
   (1 mark)
3. Which guidance document would you refer to for advice on dealing with patients on Warfarin AND within what timeframe should this test be carried out prior to the extractions
   (2 marks)
4. Below what level would it be safe to continue with extractions?
   (1 mark)

You arrange an appointment for treatment and this is carried out uneventfully.
They return the next day complaining they have been bleeding all night.

5. Outline options that you could carry out clinically to deal with this post-operative bleeding.
   (3 marks)
6. If following your interventions, you still could not stop the bleeding – what would you do?
   (1 mark)

End of Question

Answer 5

1. Warfarin is an anticoagulant and inhibits vitamin K
2. INR
3. Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs SDCEP/ 24 hours
4. below 4

5. Get the Pt to bite down on a of damp gauze pack (apply pressure)
Inject LA with adrenaline into the socket, this is a vasoconstrictor (reduce bleeding)
Place gelation(collagen Sponge – Haemostatic packing material) sponge into the socket- this may help form a clot 
Suture Kit – help close wound 

6. (contact emergency services)

Question 6

Question 15: Cerebral Palsy

You are working as a General Dental Practitioner. The dental practice in which you work cannot be accessed from street level as it is situated in a building one level above ground.

A 24-year-old male with cerebral palsy, who uses a wheelchair, arrives with his carer and wishes to gain access to your dental surgery premises.

1. Adjustments can be made to a building to improve access for someone using a wheelchair.

Name TWO adjustments that will allow a person in a wheelchair access to your above ground level dental practice.

(1 mark)

2. Legislation in the U.K. has sought to ensure that all new dental practice premises are built to allow people with an impairment or disability equal access.

Name TWO relevant Acts of Law.

(2 marks)

3. This gentleman could be described as being a person with a disability.

The definition of disability varies between the medical model and the social model. Briefly describe the difference between the two models in their definition of disability.

The medical model is based on what is wrong with the patients, impairments etc. The social model says that society has created these disabilities
(2 marks)

4. The patient is unable to communicate with you verbally. Due to his cerebral palsy he is unable to communicate using sign language or pen and paper.

List TWO other augmentative and alternative communication methods which could be utilised for this gentleman.
(2 marks)

5. Having gained consent from this patient, you are now required to examine him. You are unable to do this safely with him in his current position in his wheelchair. He is unable to weight bear.

Name TWO options that are available to allow for the improved positioning of this gentleman to allow for safe dental examination.
(1 mark)

6. Having positioned the patient correctly, you are now required to access the patient’s mouth.

i) Which particular aspect related to his cerebral palsy may affect the dentist’s access to the mouth?
(1 mark)
Pts with cerebral palsy sometimes have spasms, this may lead to injury if the dentist is inside the pts mouth with instruments

ii) What non-pharmacological adjuncts are available to overcome this and aid the dentist’s access to the mouth?

       Name TWO aids.
								(1 mark)

End of Question

Answer 6

1. Installation of a lift
   Installation of a stair lift (ramp)
2. (Disability Discrimination Act 2004)
   (The Equality Act 2010)
3. Medical says people are disabled because of their impairments and should look to be fixed by treatment

Social disability – refers to societal problems and the way that society is organised and not down to the persons impairment

4. (computers that track eye movement to help form sentences/agree to a gesture that means yes or no and use yes or no questions.)
5. (reclining wheelchair)
   hoist
6. (i) (may be unable to physically open his mouth very far)
   (ii) (plastic mouth openers/tongue depressors)

Question 7

Question 3 - Master Impressions
Master impressions are usually taken at the second clinical visit for a patient requiring complete upper and lower dentures.

1. What is another name given for these master impressions?
   (1 mark)
2. 2. With regard to the physical retention of the dentures, what are TWO important denture design factors?
      (2 marks)
3. List TWO anatomical features that are useful in determining the position of the posterior border of a complete upper denture.
   (2 marks)
4. Give THREE anatomical features that should be recorded in a master impression of the edentulous mandibular arch?
   (3 marks)
5. Give TWO impression materials that can be used to record a master impression of the mandibular arch.
   (2 marks)

Answer 7

1. (definitive impressions)
2. OVD – occlusal vertical dimension – the height of occlusion when teeth are in full intercuspal position
   Whether the Pt has a high smile line
3. (hamular notch and vibrating line)
4. Buccal sulcus – its functional depth
   Retromolar pal
   Mandibular tori
5. Silicone and alginate

Question 8

Question 12: Paeds Behaviour Management

A very anxious 6-year-old child attends your surgery for the first time. The child is not in pain.

Following examination, you note a number of problems. The treatment items you decide on are listed in the table below in the WRONG order.

1. Using the numbers 1 to 8 indicate your sequence of treatment.

Lower primary molar requiring pulp therapy

Occlusal restoration on an upper molar requiring local anaesthesia

Application of fluoride varnish

Extraction of upper primary molar

Small occlusal restoration requiring no local anaesthesia

Oral hygiene instruction and dietary advice

Interproximal restoration on a lower primary molar requiring local anaesthesia

Fissure sealants

									(8 marks)	

2. Name TWO aspects of the child’s behaviour during treatment which would confirm they remain dentally anxious
   (2 marks)

End of Question

Answer 8

1. Lower primary molar requiring pulp therapy 8

Occlusal restoration on an upper molar requiring local anaesthesia 5

Application of fluoride varnish 2

Extraction of upper primary molar 7

Small occlusal restoration requiring no local anaesthesia 4

Oral hygiene instruction and dietary advice 1

Interproximal restoration on a lower primary molar requiring local anaesthesia 6

Fissure sealants 3

2. (hyper vigilant – looking around the room frantically)
   (avoidance behaviour – fierce negotiation)
   (escape from situation)
   (in extreme cases they might bite and become aggressive)

Question 9

Question 19 - Candida

Candidal infection can be associated with morbidity and mortality, especially amongst the elderly and immunocompromised.

1. Name THREE forms of oral candidosis.
   (3 marks)

2.	What class of antifungal agent would you most commonly use to treat patients with recurrent oral candidosis?
(1 mark)

3. What is the mode of action of the antifungal agent you have named as your answer to the question above?
   (2 marks)
   The mode of action of azoles, they bind to the target site of the (p450?) enzymes, therefore inhibiting them. This means the enzyme is now not undertaking the role of helping to make (ergosterol?) which is essential to the fungal cell as it is involved in the structure if the cell membrane and helps with the function of the fungi.
4. Name TWO resistance mechanisms that render Candida species resistant to the class of antifungal agent you have named in Q2 above?
   (2 marks)
5. Name ONE species other than Candida albicans that is intrinsically resistant to the class of antifungal agent named in b) above, and describe ONE way in which this species can be differentiated from Candida albicans?

(2 marks)

Answer 9

1. Erythematous
   Pseudomembranous
   Hyperplastic
2. Azoles
3. The mode of action of azoles, they bind to the target site of the (p450?) enzymes, therefore inhibiting them. This means the enzyme is now not undertaking the role of helping to make (ergosterol?) which is essential to the fungal cell as it is involved in the structure if the cell membrane and helps with the function of the fungi.
4. By altering the target site of the azoles, which prevents binding of the drug and makes it resistant. They also can develop efflux pumps, to pump the drug out of the cell meaning that the drug cannot work reducing concentration of the drug meaning that the candida is resistant.
   (They can become dual resistant
   Candida polymers bind to S.Aureus making it resistant to Vancomycin
   Candida becomes miconazole resistant in return)
5. Candida glabrata is strictly in a yeast formation, albicans is a fungus that switches between hyphae and yeast cell.