All year revision

Question 1

Why is open disclosure important?

Answer 1

1. Patient has a right to be informed of what is happening to them
2. To minimise harm to the patient
3. We have a duty of care to the paitnet
4. To maintain trust in the dentist-patient relationship
5. To gian informed consent for any further treatment related to the incident
6. To prevent a recurrence of the incident to others
7. To possibly avoid formal complaint

Question 2

What are the elements of open disclosure?

Answer 2

1. An apology or expression of regret
2. A factual explanation of what happened
3. An opportunity for the patient to relate their experience
4. An explanation of the steps being taken to manage the event and prevent recurrence
5. Appropriate documentation of the process

Question 3

How do we express regret? Give an example.

Answer 3

I am sorry that this has happened to you.

Question 4

Why can be difficult to say sorry at times in the context of open disclousure?

Answer 4

1. Innate fight or flight response
2. Vulnerability aspect
3. Fear
4. Self-image issues
5. Worry that patient might still file a complaint
6. Lack of confidence

Question 5

What are some of the risk factors for root caries and why?

Answer 5

1. Root surface exposure - cementum and dentine are less minirelised thus begin to demineralise at a higher salivary pH comparing to enamel
2. Very poor saliva quality and/or quantity - REALLY IMPORTANT FACTOR
3. Wearing of partial dentures
4. Other factors are similar to normal caries factors

Question 6

What are some of the key questions we should ask a patient who we think has root caries?

Answer 6

1. What is going on? - Diagnosis + evaluation of specific risk factors
2. Evaluation of disease state - understanding of remin/demin balance
3. Impact and implications of disease
4. Risk and benefit analysis
5. What are the patient expectations?
6. What is the plan for monitoring and ongoing care?

Question 7

Can a root caries lesion be restored or remineralised?

Answer 7

In all situations, try to avoid operative interventions before prevention has been given a chance to work

1. Address risk factors
2. Apply needed chemicals for remin
3. Consider silver fluoride
4. Restorative work might be needed in some cases

Because root caries restoration have a really poor prognosis

Question 8

What are the basic steps to preventing root caries?

Answer 8

1. Identifying cariogenic biofilm with tri-plaque disclosing gel
2. Disrupt the biofilm mechanically
3. Disrupt the biofilm chemically - high strngth fluoride or chlorexedine
4. Evaluate saliva - replace the building blocks of tooth structure - MORE FLUORIDE
5. Raise the pH

Question 9

What are some of the silver fluoride products available in Australia?

Answer 9

1. Creighton Dental CSDS silver fluoride
2. SDI Riva Star
3. SDI Riva Star Aqua (ammonia free - thus does not irritate soft tissue as much)

Question 10

What determines the effectiveness of silver fluoride?

Answer 10

1. Site consideration - type of lesion and size
2. Material selection - concentration
3. Control of caries risk factors
4. Monitoring and reapplication

Question 11

What are the key considerations to understand when restoring a root caries lesion?

Answer 11

1. Size and type of lesions
2. Extent and rate of caries activity
3. Physical and mental condition of the patient
4. Aesthetic requirements

Question 12

What are the basic outcomes of endodontic treatment?

Answer 12

1. Maintain the health of all or part of the dental pulp
2. Preserve the normal periradicular tissues
3. Restore the periradicular tissues health

Question 13

How can you describe dentine according to Dr. Rossi?

Answer 13

Dentine is like Swiss cheese - it is pour-us - the closer you are to the pulp the bigger the holes.

The permeability properties of dentine regulate the rate of diffusion of irritants that initiate pulpal inflammation.

Question 14

What are the indication of indirect pulp capping?

Answer 14

1. Deep lesions likely to result in pulp exposure
2. No history of subjective pretreatment symptoms such as spontaneous pain or provoked pulpal pain
3. Pulp should test vital
4. Pre-treatment radiographs should exclude apical pathosis

Question 15

What are the requirements for successful vital pulp therapy?

Answer 15

1. Pulp is not inflamed
2. Haemorrhage is controlled
3. Non-toxic caping material is applied
4. Good seal provided by capping material and restoration to prevent influx of bacteria - MOST CRITICAL FACTOR

Question 16

What material is used in vital pulp therapy?

Answer 16

MTA or Calcium Hydroxide but MTA is better

Question 17

What are the three different types of vital pulp therapy?

Answer 17

1. Direct pulp capping - no pulp is removed as pulp is not inflamed during mechanical pulp exposure
2. Partial pulpotomy - a little pulp removal to stop the bleeding in inflamed pulps
3. Full pulpotomy - removal of the entire pulp in the pulp chamber

Question 18

How often do you wanna recall your patient after vital pulp therapy?

Answer 18

1, 3, 6 and 12 months

Question 19

What are the steps for direct pulp capping?

Answer 19

1. Consent, LA and appropriate rubber dam isolation
2. Tooth disinfection with CHx post removal of all caries
3. Control of haemorrhage from the pulp
4. Application of calcium hydroxide liner or MTA
5. Tooth restoration
6. Recall every pattern: 1, 3, 6 and 12 months

Question 20

What are indications for partial pulpotomy?

Answer 20

1. Traumatic exposure
2. In immature permanent tooth or mature permanent tooth with simple restoration needs
3. Patient who can not affor root canal therapy

Question 21

What are the steps for partial pulpotomy?

Answer 21

1. Consent, LA, Appropriate rubber dam
2. Disinfect the tooth after caries removal with CHx
3. Remove 1-2mm of superficial pulp tissue
4. If extensive bleeding observed , extend the preparation apically
5. Use preassure yo facilitate haemostasis
6. Calcium hydroxide liner or MTA use
7. Restore tooth
8. Recall every pattern: 1, 3, 6 and 12 months

Question 22

What are the indication for a full pulpotomy?

Answer 22

1. Traumatic exposure
2. In immature permanent tooth or mature permanent tooth with simple restoration needs
3. Extensive pulpal inflammation or small coronal pulp
4. Patient who can not afford root canal therapy

Question 23

What are the steps for a full pulpotomy?

Answer 23

1. Consent, LA, Appropriate rubber dam
2. Disinfect the tooth after caries removal with CHx
3. Remove entire mass of coronal pulp tissue to level of canal
4. If extensive bleeding observed , extend the preparation apically
5. Use preassure yo facilitate haemostasis
6. Calcium hydroxide liner or MTA use
7. Restore tooth
8. Recall every pattern: 1, 3, 6 and 12 months

Question 24

How to write a diagnosis for endodontic diagnosis?

Answer 24

1. Pulpal and root canal condition - aka irreversible pulpitis, necrotic pulp, reversible pulpitis
2. Periapical status - clear periapical radiolucency with a corresponding draining sinus or no periapical radiolucency

Question 25

What factors should you consider before endodontic treatment?

Answer 25

1. Strategic value of the tooth
2. Periodontic factors
3. Patient factors - MHx, age, compliance
4. Restorability options - consider oral hygine - and consider teeth that are not restorable

Question 26

What system is used for case selection in endodontics?

Answer 26

American Association of Endodontists Endodontic Case Difficulty Assessment Guidlines

The following considerations are used:

1. Patient considerations
2. Diagnostic & treatment considerations
3. Other considerations

Tally the numbers:
1. Easy - less than 20
2. Moderate - 20-40
3. Hard (refer) - above 40

Question 27

What is the purpose of an endoprobe?

Answer 27

Endoprobe is used to assist in identification of root canals

Question 28

What are the types of irrigants used in chemo-mechanical debridement?

Answer 28

1. EDTAC - 15% commonly used as a removal of smear later and to increase permeability of dentinal tubules
2. Sodium hypochlorite - 1% commonly used, dissolves organic matter - DANGEROUS

Question 29

What is a good way to ensure you dont push sodium hypochloride through the root apex?

Answer 29

Bend the needle but not at the hub and measure it - so it is far from the apex!!!!

Question 30

What bur can be used for coronal preparation?

Answer 30

Gates-Glidden burs - they are used coronaly in order to make the canal access easier

You distinguish them by number of slots - 2 slots is size 2, 3 slots is size 3

Question 31

How do you determine root canal lengths?

Answer 31

1. Know average lengths
2. Measure from pre-operative radiographs

• Estimate working length

3. Use electronic apex locator
4. Confirm with radiograph

• Correct working length established

Question 32

How to use dentaport ZX?

Answer 32

1. Moisture in canals but not too much
2. Attach the lip clip
3. Attach the file clip
4. Advanced the file until the read is “Past apex” withc careful watch-winding movement
5. Come back to “Apex” reading
6. Measure the file

Question 33

What is the objective of a lateral spreader?

Answer 33

To condense the master GP and create space for accessory GPs - it has one end unlike endo probe

Question 34

What is the rule of tube shift in endodontics?

Answer 34

SLOB - (Same lingual opposite buccal) - usually the tube shift goes lingual

Question 35

What are the steps to an initial endodontic procedure?

Answer 35

1. Consent, LA, rubber dam isolation
2. Removal of caries and access to the pulp
3. Idenitifcation of the appropriate access using radiographs
4. Identification of canals using endo probe
5. Using a small size file a few milimeters into a precieved canal in order to confirm that it is actually a canal
6. Irrigation with a bent needle for safety
7. Flaring of the coronal protion of each canal using Gate-Glidden burs
8. Irrigation
9. Estimationg of working length of each canal.
10. Determination pf correct working length with appropriate file, raiographs and apex locators
11. Apical preperation of each canal. Pre-curved files, watch-winding technique performing circumferential filing
12. Recapitulate with a size 10 file between each file and irrigate well between each file
13. Work up until file 25 -take radiograph to check the master apical file is at an appropriate length
14. • irrigate and try master gutta percha of the the biggest size possible
15. Place medicaments with lentulo spiral
16. Resore with cavit and GIC

Question 36

What are the steps to root canal obturation?

Answer 36

1. Consent, LA, Rubber dam isolation
2. Re-access tooth and remove caivt safeyl
3. Irrigate
4. Check master apical file goes to correct working length
5. Select master GP largest size that goes to correct working length
6. Take radiograph to confirm
7. Dry canals with paper points
8. Place the sealer with lentulo spiral
9. Coat master GP with sealer and place into the canal
10. Use lateral spreader to condense the master GP
11. Place accessory GP into space create
12. Continue with lateral spreader until the space is filled
13. heat the end of the endodontic pluger and burn off GP points
14. FInal level of root-fillin should bet at or below CEJ
15. Clean pulp chamber and reestore.

Question 37

What are some of the common consequences of tooth loss?

Answer 37

1. Bone resorption - can lead to high frenum/muscle attachment
2. Overreruption of opposing tooth
3. Medially/distally drifting/tilting of adjacent tooth/teeth
4. Occlusal disharmony affecting function
5. Change in speech and aesthetic
6. General affects on general health as well as quality of lfie

Question 38

What are some of the way we can classified removable dentures?

Answer 38

1. Based on location of missing teeth - partial vs comlete
2. Based on materials - acrylic, valplast, crhome
3. Based on support - tissue or tooth or combined
4. Construction methods - immediate vs conventional

Question 39

What are the aims of a removable dentures?

Answer 39

Restore:

1. Aesthetics
2. Function
3. Speech
4. Preserving remaining soft and hard tissues

Question 40

What are indications for a removable dentures?

Answer 40

1. Replacing single or multiple missing teeth
2. Temporary space maintenance in congenital missing teeth
3. Obturation of hard palate after removal or oral cancer

Question 41

What are contraindications for partial dentures?

Answer 41

1. Lack of suitable abutmnet teeth
2. Rampant caries
3. Severe periodontal diseases
4. Poor oral hygiene
5. Patients who cannot tolerate dentures
6. Patient who recently received head and neck radiation treatment

Question 42

What should we consider before making a denture for a patient?

Answer 42

1. Patient oral hygiene
2. Existing oral health conditions: caries, perio, pathologies, salivary flow and quality
3. GIngivae and abutment tooth/teeth
4. Gagging issues patient might have
5. Patient’s perception

Question 43

What codes are there for dentures?

Answer 43

1. Codes starting with 7
2. Denture reline
3. Denture repair

Question 44

How many appointments do you need for a general denture?

Answer 44

1. Denture consult + primary impressions
2. Secondary impressions
3. Bite registration + shade mould selection
4. Denture try on
5. Denture insert
6. Review denture

Question 45

What will the patient feel when they get a new denture?

Answer 45

1. Excessive saliva
2. Change in speech
3. Feeling of bulkiness
4. Food might get stuck under denture
5. Denture moves to some extend
6. Remove denture to clean
7. Might have a sore spot or ulcer
8. Might have a high spot

Question 46

How do they care for their denture?

Answer 46

1. Remove dentures and clean after meals
2. Brush dentures as brushing your teeth
3. Brush and remove dentures at night and keep in denture container

Question 47

What is the difference between an overlay and overdenture?

Answer 47

Overlay - the denture sits around the tooth

Overdenture - the chrome part of the denture sits on top of teeth

Question 48

What are the standard steps for a chrome denture construction?

Answer 48

1. Denture consult + primary impressions
2. Secondary impressions
3. Frame try in + bite registration + shade mould selection
4. Trial denture - aka wax
5. Denture insert
6. Review denture

Question 49

What do you do in the consultation appoitmnet?

Answer 49

1. Take all histories
2. Do a specialised limited exam - extra oral exam, intraoral exam, occlucal exam
3. Take alginate impressions

Question 50

What is the purpose of alginate impression?

Answer 50

To make a study cast and fabrication of a special trays - preforated (for secondary alginate) vs non perforated (for rubber based material)

Question 51

What do you write in a lab prescription after completing primary impression with alginate?

Answer 51

1. Please pour up alginate impressions for study models
2. Please construct a CCA special tray for upper or lower arch

Question 52

What is an occlusal stop?

Answer 52

It stops the tray from touching the teeth. Similarly - the gingival stopper will stop at the gingival thus making your impression better

Question 53

What materials could you use for secondary impressions?

Answer 53

1. PVS
2. PE
3. Alginate

Question 54

What to do if the patient has no teeth and you still need a bite registration?

Answer 54

Record centric relation

Question 55

What are the indications for temporary denture? How many appointment does a construction require?

Answer 55

As an interim denture or immediate partial denture

Usually 3 appointments:

1. Denture consult, alginate impression + shade selection
2. denture try in
3. Denture insert (after extractions)

+

Review

(Can’t be chrome or varplast)

Question 56

What is edentulism?

Answer 56

It is the state of being edentulous, without natural teeth

Question 57

What is edentulous?

Answer 57

It means “without teeth”. It could be partial or complete

Question 58

What are some of the reasons for tooth loss?

Answer 58

1. Decay and periodontal disease
2. Trauma
3. Orthodontic extractions
4. Congenital missing teeth
5. Impacted teeth
6. Pathologies
7. Radiation therapy to treat head and neck cancers

Question 59

What are the Kennedy’s classifications of partial edentulous arch?

Answer 59

Class I - bilaterla edentulous areas located posterior to the remaining natural teeth

Class II - A unilateral edentulous area located posterior to the remaning natural teeth

Class III - A unilateral edentulous area with natural teeth remaining both anterior and posteror

Class IV - A single, bilaterla edentulous crossing mid line

Question 60

What are the 3 main categories of changes following tooth loss?

Answer 60

1. Morphological changes - extra and intra oral changes
2. Neuromuscular changes
3. Functional changes

Question 61

What are some of the extra oral changes that occur due to tooth loss?

Answer 61

1. FLat philtrum and deep nasolabial grooves
2. Hollow cheeks
3. Decreased columella-philtrum angle
4. Narrowing of the lips
5. Decrease face height
6. Commissures drop
7. Lost support for facial muscle
8. Reduced facial height

Question 62

What are some of the intra-oral changes that occur due to tooth loss?

Answer 62

1. High frenal attachment due to bone loss
2. Bone resorption
3. Traumatised neuromascular structure under denture
4. Atrophic mucosa - can cause pain due to proximity of the denture to the nerves
5. Class III skeleton relationship will develop eventually
6. Decrease in occlusal vertical dimension

Question 63

What are some of the occlucal changes that occurs due to tooth loss?

Answer 63

1. Occlusal disturbances
2. Lost of occlusal vertical dimension
3. Increase in parafunctional habits

Question 64

What are psychological changes following tooth loss?

Answer 64

1. Emotional effects of tooth loss
2. May increase stress levels
3. Social-disability

Question 65

What are current and future treatment options for edentulism?

Answer 65

1. Prevention of edentulism - MAIN STRATEGY - think about biopsychosocial approach
2. Monitor alveolar ridge resorption
3. Monitor oral mucosa health and screening oral mucosa lesions
4. Rem. Pros.
5. Consider implant retained overdenture or implat supported overdenture where appropriate

Question 66

What are the standard appointments for a valplast denture contruction?

Answer 66

1. Consult, alginate impressions, bite reg, shade selection adn mould
2. Dentur try in
3. Denture insert
4. Review

Question 67

What is complete denture retention?

Answer 67

Complete denture retention is the resistance to displacement of the denture base away from the ridge. It provides psychologic comfort to the patient.

Question 68

What is denture stability?

Answer 68

Stability is the resistance to horizontal and rotational forces. Stability has been cited as the most significant property in providing for physiologic comfort.

Question 69

What is denture support?

Answer 69

Support is the resistance to vertical movement of the denture base towards the ridge.

Question 70

What are some of the aspect that de-promote denture retention?

Answer 70

1. Overextension of denture base
2. Overcontour of polished surface

Question 71

What is the neutral zone?

Answer 71

It is a virtual potential denture space with a dynamic equilibrium forces of the tongue, cheeks and lips.

If denture seats in a neutral zone - denture is more retentive.

Question 72

How to maximise denture retention by managing physical factors?

Answer 72

Good primary and secondary impressions - good accuracy, tissue contact and adequate periphery seal - remember special tray needs to have near perfect coverage and cover all hard tissues such as the tuberosities

Question 73

What are some of the biological factors affecting retention?

Answer 73

1. Height of bone ridge
2. Shape and width of bone
3. Muscle attachment
4. Neuromuscular control - muscle movement diseases such as Huntington’s disease may cause some problems

Question 74

What are some of the other method of providing retention for complete denture?

Answer 74

1. Adequare extension and shape of the falanges of the denture
2. Adequare saliva to provide adhesion, cohesion and surface tension - water can be used before insert
3. Mechanical - overdentures using implants or root stumps

Question 75

What are some of the factors that affect stability?

Answer 75

1. Firm keratinised tissue
2. Ridge height
3. Ridge contour
4. Ridge stability
5. Intimate base adaptation
6. Adequate extension
7. Occlusal harmony
8. Neuromuscular control

Question 76

What is the primary support areas for the dentures?

Answer 76

Upper - primary support area is the hard palate

Lower - retromolar area and buccal shell

Question 77

What provides retention, stability and support in partial dentures?

Answer 77

1. Clasp units
2. Major connectors
3. Intra/extra coronal attachments
4. Implant locator attachment
5. Locator attachment on root
6. Survey crown

Question 78

What are some of the other methods of achieving retention acrylic dentures?

Answer 78

1. Clasps
2. Acrylic dental papilla - soft tissue support

Question 79

How do we provide better stability and support to a denture?

Answer 79

1. Maximise denture base extension
2. Bilateral balance of occlusion
3. Consider mono-occlusion

Question 80

When would you use Zinc Oxide Eugenol (ZOE) in rem pros?

Answer 80

Only use in edentulous patient because it is very very very rigid.

Please apply vasaline to patient face because it may burn the patient

Question 81

Why to do with alginate impression after you taken them?

Answer 81

After taking the impressions make sure you wrap it in a damp towel!

Question 82

What are the alginates that are available at the ADH?

Answer 82

1. Halas Alginate - very dimensional stable
2. Kromopan Alginate - EXTREMLY DIMENSIONALLY STABLE WOW

Question 83

What can you use alginate for in rem pros?

Answer 83

1. Primary impression
2. Secondary impression - for mobile teeth
3. Valplast denture impressions
4. Obturator of cleft palate

Question 84

Where do you use light body and heavy body?

Answer 84

Light body - gingival sulcus

Heavy body - everywhere else and to push the light body

DONT USE WITH LATEX

Question 85

What do we use PVS for in rem pros?

Answer 85

1. Seondary impressions for all impression
2. Wash impressions for reline
3. Impressions for obturators for cleft palate

Question 86

What are some of the applications for Coe-soft and Coe-comfort in rem pros?

Answer 86

1. Impressions for reline
2. Impression for obturators of cleft palate
3. Functional/neautral zone impressions
4. Temporary reline
5. Tissue condition impression

Question 87

What are components of the dentures?

Answer 87

1. Denture base
2. Denture teeth

Denture connectors:
3. Major connect
4. Minor connector
5. Clasp unit

Question 88

What materials can be used for a denture base?

Answer 88

1. Polymethyle methacrylate (PMMA) and it’s modifications- also know as acrylic
2. Rubber reinforced Lucitone 199 - a type of acrylic that is specifically used at ADH
3. Polyamides like Valplast - good for aesthetics for short saddles
4. Formlabs denture resin

Question 89

What are the disadvantages of porcelain teeth for rem pros?

Answer 89

1. They can not be adjusted or need glaze after occlusal adjustment
2. They cause significant wear to opposing teeth
3. They are quite brittle and easy crack or chip

Question 90

What material can you use for denture frame?

Answer 90

1. Cobalt chrome - Remanium+ is used at ADH
2. Titanium - for patient alergic to cobal chrome or other materials
3. HPPE frame

Question 91

What is the centric relation?

Answer 91

It is the retruted contact position. It is the maxillo-mandibular relationship independent of tooth contact. This CAN BE RECORDED IN EDENTULOUS PATIENT. You can ensure that the patient is in centric relation by asking them to go through repeated movement of protrusion and retrusion in order to arrive at the centric relation.

Question 92

What is centric occlusion?

Answer 92

It is the intercuspation position. It is the occlusion of opposing teeth when the mandible is in centric relation. This may or may not coincide with maximum intercuspal position

Question 93

What is posselt’s envelope of motion?

Answer 93

The posselt’s envelope of motion looks at the following aspects of incisor potion through the movement of the mandible?

1. Intercuspal position (ICP) aka cnetric occlusion
2. Retruted contact position (RCP) aka centric relation
3. Edge-to-edge articulation (E)
4. Maximal opening without condylar translation of the condyle (rotation only)(R)
5. Maximal mandibular opening with translation of condyle (T)
6. Protrusion (Pr)

Question 94

What are clinical applications of centric relationship

Answer 94

When you have a full denture:

During bite registration you need to take an impression of the centric relation

While in try in and insert you need to assess the centric occlusion

When you have a partial denture:

During bite registration you need to take an impression of the centric occlusion

While in try in and insert you need to look at centric occlusion or maximal intercuspal position

Question 95

What is the natural rest position?

Answer 95

It is the occlusal vertical dimension + 2-4 mm

Question 96

What determines the OVD?

Answer 96

OVD is determined by the contact between natural teeth. If there is no natural teeth - please estimate OVD by subtracting from natural resting position

Question 97

What are the 3 types of occlusion?

Answer 97

1. Balanced occlusion - the best type of occlusion - when is a balanced intercuspal position on anterior and posterior teeth - best of denture stability and create pressure to retain the bridge.
2. Monoplane occlusion
3. Lingualised occlusion - the elimination of buccal cusp contact - may be used if the patient has a modified occlusion due to skeletal and other reasons

Question 98

What are the difference between natural and artificial occlusion?

Answer 98

1. Natural teeth retained by periodontal tissue - denture teeth are not
2. Natural teeth move independently - denture teeth move as a unit
3. Malocclusion in natural dentition may not cause any symptoms for yeras - in denture teeth there will be an immediate response
4. In natural teeth, second molar is one of the power points of mastication - in denture teeth this may cause a shifting of the denture base
5. Bilateral balance during excusrion is rare in natural teeth - in dentured teeth it is required for stabilisation of denture base
6. Proprioceptors guide neuromuscular control during function, meaning mandible return to centric occlusion - if any interference occurs in dentured teeth, denture base shift and may be dislodged

Question 99

What is centric postion?

Answer 99

It is position of the mandible when the jaws are in centric relation

Question 100

What is the clinical significance of curve of Spee and Curve of Wilson in dentures?

Answer 100

1. Curve of Spee os designed to permite protrusive disocclusion of the posterior teeth by combination of anterior and condylar guidance
2. Curve of Wilson permits lateral mandibular excursion free from posterior interference

Question 101

When would you select no-anotomical teeth for a denture?

Answer 101

For partial: If anatonical teeth have been severley worn

For full: If the alveolar ridges are poor and there is uncoordinated jaw movements

Question 102

What can compromise competent lip seal?

Answer 102

1. Excessive occlusal vertical dimension
2. Excessive overjet or proclination of upper anterior teeth
3. Excessive upper incisal length

Question 103

Can you state that “caries is a multifactoria disease”?

Answer 103

In a sense - no.

Because caries is primarily driven by free sugars - remove the sugars and there will be no caries.

But only because there other modifying factors - we claim that caries is a multi-factorial disease.

This is an argument made by Aubrey Sheiham, a dential rsearch of University College London

Question 104

What is the potential issues with increasing the oral health workforce in order to improve overall oral health in global population?

Answer 104

1. Logistic challenge with the geographical distribution of dental practitioners
2. Dentist-to-population ratios are only a crude measure of oral health-care service availability, and are not correlated to disease prevalence
3. Individual actions in clinical settings are unlikely to prevent future disease

Question 105

What is the potential issues with increasing awareness about oral health-related behaviours in the population to improve overall oral health in global population?

Answer 105

1. If this worked (alone) and actually changed behaviours, we would have different figures by now
2. Dental education campaigns, when not articulated with other actions may not be effective overall and may also increase inequalitie

Question 106

Why behavioral interventions that do not take into account the social determinants of health are unlikely to work?

Answer 106

1. Since patterning of health behaviours reflects underlying inequalities in material and social resources, it is unlikely that the growing inequality in health behaviours can be addressed without tackling these social factors
2. The likelihood of adhering to health-related behaviours following universal education campaigns is also shaped by the social determinants of health

Question 107

Please describe the health impact pyramid from least population impact to most population impact.

Answer 107

1. Counseling & Education
2. Clinical interventions
3. Long-lasting protection interventions
4. Changing the context, so the defaul choice is healthy
5. Socioeconomic factors

Question 108

What is an example of increased indivdual effort and low population impact activity?

Answer 108

Counselling & education of an individual in regards to caries.

It result in the ost benefit to the individual but the efforts by the individuals must be high, it is more suseptible to socio-economic difference and has minimal impact on overall population.

Question 109

What is an example of low level individual effort and high impact on population?

Answer 109

Universal water fluoridation to prevent caries.

This is an example where an individual needs to put low effort, yet statistically we have evidence of high impact on populations.

These universal adjustments also help to deal with socio-economic inequalities as we can regulate the aount of fluoridation depending on the gneral community need.

Question 110

What are some of the pre-requisites for health according to the Ottawa Charter?

Answer 110

1. Peace
2. Shelter
3. Education
4. Food
5. Income
6. A stable exosystem
7. Sustainable resources
8. Social justice and equity

Question 111

What are some of the action areas of health promotion according to Ottawa charter?

Answer 111

1. Build healthy public policy - think sugar tax
2. Create supportive environments - think ban of sugary foods in schools
3. Strengthen community action - support your local dental programs such as the indigenous oral health unit
4. Develop personal skills - raising awareness with patients
5. Reorient health services - focus on both high risk and popuation approach

Question 112

What are the different types of “needs”?

Answer 112

1. Normative need - expert opinion on needs of an individual
2. Perceived need - based on the individual’s perception
3. Expressed need - defined based on people’s use of service
4. Comparative need - when different types of need are interpreted considering other populations’ standards

Question 113

What are the components of an oral health needs assessment?

Answer 113

1. Systematic approach
2. Normative/ preceived/ expressed needs addressed
3. Likelihood of engaging in interventions
4. Workforce and skills requirement
5. Effectiveness of interventions

Question 114

What are three aspect of pubic health that helps us to view it?

Answer 114

1. Disease prevention - action to reduce or eliminate or reduce the onset, causes, complications or recurrence of disease
2. Health protection - crafting a safe environment
3. Health promotion - process of enabling people to increase control over and to improve their health

Question 115

What is the main difference between high risk approach vs the population approach?

Answer 115

The main difference are:

• Exposures with high individual risk can have a small impact on population risk if the exposure is rare (aka people with sever conditions are very rare - thus intervention is not as widespread)
• Exposures with low individual risk can have a big impact on population health if exposure is widespread (aka people with not so severe conditions are common - thus intervention is more widespread)

Question 116

What are the advantages of high risk approach?

Answer 116

1. Beneficial for the individuals
2. Important in addressing inequalities

Question 117

What are the disadvantages of high risk approach?

Answer 117

1. Does not change population levels of disease
2. Issues in identifying who is at risk
3. Does not change the drivers in the population

Question 118

What are the advantages of population approach?

Answer 118

1. Tries to remove the reason why the disease is common
2. Almost everyone benefits
3. May have a large impact at a population level

Question 119

What are the disadvantages of population approach?

Answer 119

1. May not address health inequalities
2. Does not represent a large benefit to the individual

Question 120

What are some of the levels of prevention?

Answer 120

1. Primary prevention
2. Secondary prevention
3. Tertiary prevention

Question 121

What are some of the example of secondary prevention?

Answer 121

Secondary prevention occurs to treat asymptomatic disease - example: small restorations

Question 122

What are some of the example of primary prevention?

Answer 122

Primary prevention occurs to stop the disease - example: water fluoridation

Question 123

What are some of the example of tertiary prevention?

Answer 123

Tertiary prevention occurs in established diseases or established disease with complications - example: full mouth rehabilitation

Question 124

What are the basic principles that guide health promotion strategies?

Answer 124

1. Using evidence to guide our decisions about interventions
2. Consistently evaluating the effectiveness of interventions in terms of their impact

Question 125

What is a good book to have for reference for pahrmacology?

Answer 125

Australian Medicines handbook

Question 126

Why do we need to know about drugs?

Answer 126

1. We prescribe them
2. For the one we dont prescribe - patient may want to have info about them or drugs they are taking may affect your approach to their dental treatment

Question 127

What are the four right for drug prescribing?

Answer 127

1. Right drug
2. Right dose
3. Right frequency
4. Right duration and deprescribing

Question 128

What does drug therapy hope to achieve?

Answer 128

1. Prevent diseases
2. Cure a disease
3. Decrease mortality
4. Decrease sickness
5. Decrease symptoms of illness

Question 129

What is a xenobiotic?

Answer 129

It is a substance that is not synthesized in the body but must be introduced into the body from outside.

Question 130

How would you try to explain the relationships between substrates and their target molecules/active sites?

Answer 130

Lock & key relationship

Question 131

What is pharmacodynamics?

Answer 131

It is the effect of drug on bod. Like paracetamol relieves pain and is antipyretic (lower body temp)

Question 132

What is pharamacokinetics?

Answer 132

Effects of body on the drug. Like absorption and distribution and elimination. It looks at the how it is done and the rate at which it is done

Question 133

What do we need to remember about drug nomenclature?

Answer 133

Always use the GENERIC NAME. Because that way when prescription is getting fulfilled - it is not dependent on the supply of a certain brand name.

Question 134

What are the potential clinical consequences of this difference in inhibition for a patient requiring 3rd molar extraction?

Answer 134

Due to affect on platelets by aspirin, by irreversible inhibition of platelets, there needs to be extra caution in planing and use of extra tools such as mucoperiosteal flap use due to increase risk of inability to achieve adequate haemostasis.

Please ensure use of local haemostatic measures and remember that temporary interruption is not required.

Question 135

What are the two functional types of meidctions?

Answer 135

1. Agonists - drugs that elicit response
2. Antagonist - drugs that bind but do not elicit response - essentially just occupy the space on the receptor by being competetive

Question 136

Why are pharamacokinetics important?

Answer 136

1. Adverse harmful effect to a medicine in people oftent due to altered pharmacokinetics - e.g. kidney disease
2. Patient does not get better or gets worse on a medicine often due to altered pharamacokinetics 0 e.g due to genetic factor or taking other medicines

Question 137

What is the important aspects of pharmacokinetics in prescription?

Answer 137

Same does does not suit all patient. There is a difference in doses due to age, weight, pregnancy, environment, diet and use of other medications.

Question 138

Your prescribe the antibiotic metronidazole 200 mg twice a day for a spreading odontogenic infection and it has no effect. WHat could be a pharmacokinetic reason?

Answer 138

1. Not dosing properly
2. The drug is broken down too fast and it can not reach appropriate blood levels
3. The drug is not being absorbed properly due to nausea and vomiting

Question 139

Your prescribe the antibiotic metronidazole 200 mg twice a day for a spreading odontogenic infection and it has no effect. What could be a pharamacodynamic reason?

Answer 139

1. Metronidozale can not affect the bacteria that is responsible for the odontogenic infection
2. Bacterial resistance

Question 140

What are some of the ways we can introduce the drug to the organism?

Answer 140

1. Enteral - through the intestine - oral, sublingual and rectal
2. Parentral - everything else due to them being sensative to gastric juices or we need a quick effect - injections basically - intravenous, intramuscular or subcutaneous
3. Other routes - inhalation, tranasal, topical, transdermal patches and other other like eyes, nose, ears drops

Question 141

What are some of the factors that effect the gastrointestinal absorption?

Answer 141

1. Blood flow
2. Surface area of the intestines - remember stomach does not matter intestine is due to increased surface area of the intestine - microvilli and villi.
3. Gastric emptying - e.g. codeine slows down the emptying of the stomach thus may increase the time that the drug may take to the site of absorption - water pormmotes stomach emptying 200ML OF WATER IS GOOD

Question 142

Why do some medicine should be taken with food?

Answer 142

1. To reduce side effects
2. To reduce side-effects of stomach upset
3. To treat heartburn/indigestion
4. To ensure the medicine is absorbed into the blood stream: like very water soluble drugs
5. To help process the meal - like for diabetes medication

Question 143

Why do some drugs have bioavailability of less than 100%

Answer 143

1. Insufficient time for absorption
2. Decomposition in gut lumen
3. Liver and first pass effect - portal vein passes through the liver thus the drug might be over processed there and it does not really reach systemic circulation

Question 144

What are the steps of drug distribution?

Answer 144

1. Initially drug enters the blood stream and makes it to the capillaries around the organ tissue in the body
2. Capillary endothelium is very “leaky” which means certain molecules can pass through. Exception: blood-brain barrier which is actually less permeable
3. Drugs need to be lipid soluble to defuse into the target cell if not they can interact with receptors on the cell membrane

Question 145

Whatis the interaction between cliclosporin and Saint John’s wort?

Answer 145

Ciclosporin is an immunosupresant that is able to aid in organ transplants.

St John’s Wort is a over the counter herb that cna aid in depression.

St John’s Wort is able to trigger an increase production of an enzyme that metabolises ciclosporin.

Thus decreasing long term plasma concentration leading to transplant organ rejetion by the body.

Question 146

What determines the osing regiment?

Answer 146

Pharmacokinetics control the dosage regiment.

Question 147

What is the theraoetuic concentration range?

Answer 147

It is when the optimal concentration is reached, meaning the concentration of a medication is not too low to be ineffective and not too high to cause toxicity.

Question 148

What is a therapeutic index?

Answer 148

The ratio of the dose that produces toxicity to the dose that produces a clinically desired or effective response.

Essentially drugs with a large therapeutic index are more safe and harder to get an overdose on.

Example of low therapeutic index - morphine 70:1 index

Example of high therapeutic index - remifantanil 33000:1

Question 149

What are some of the targets for drugs?

Answer 149

1. Non-specific targets
2. Proteins - the most common
3. RNA/DNA
4. Lipid cell membranes

Question 150

What are some of the receptors that are targeted by medications?

Answer 150

1. Ligand-gated ion channels (ionotropic receptors
2. G-protein-coupled receptors (metabotropic)
3. Kinase-linked receptors
4. Nuclear receptors

Question 151

How long does it take for ligand-gates ion channels to respond?

Answer 151

Miliseconds

Question 152

What are some of the examples of ligand-gated ions channels? What are some of the drugs that bind to them?

Answer 152

Nicotinic receptors and ACh receptors.

Benzodiasapine like xanax

Question 153

What are some of the examples of G-protein-coupied receptors (metabotropic)? What are some of the drugs that bind to them?

Answer 153

Muscarinic receptors, ACh receptors

Opiod agonists like morphine

Question 154

How long does it take for Kinase-linked receptors to respond?

Answer 154

Hours

Question 155

What are some of the examples of Kinase-linked receptors? What are some of the drugs that bind to them?

Answer 155

Cytokine receptors

Methotrexate

Question 156

What are some of the examples of Nuclear receptors? What are some of the drugs that bind to them?

Answer 156

Oestrogen receptors

Question 157

What are the two drugs of asthma therapy? How do they work?

Answer 157

1. Relievers - bind to G protein-coupled receptors for relaxation
2. Preventers - bind to nucleus to alter ntranscription of inflammatory mediators

Question 158

What are the steps to drug elimination in the kidneys?

Answer 158

1. Afferent arteriole caries the blood to the glomerulus - drugs are than filtered as plasma water
2. The plasma enters into the proximal tubules in which the drug is secreted via active pumps that pup the drug into the kidney lumen
3. Lumen moves through the proximal tubule into the dital tubules and collecting duct where some rebasorption could occur but most emportantly water is removed and lipid soluble drugs will be diffused back into the blood stream - thus they need to metabolised by the liver

Question 159

What are some of consequences of metabolism?

Answer 159

Usually, the metabolites have no pharmacological activity but:

1. Some may act as parent drgus
2. Some may be antagonistic - causing convulsions or nauses/vomiting

Concept - active metabolites is clinically important for elderly and patients with renal disease - because some patient may not be able to excrete the metabolite at the same rate thus the metabolite may have a toxic effect.

Question 160

What is the metabolic pathway of paracetamol and hepatotoxicity?

Answer 160

1. Paracetamol enters the liver where 55% of it is turned into water soluble Paracetamol Glucuronide, 40% of it is turned into water soluble Paracetamol Sulphate and 5% is turned into Reactive Electrophilic metabolite
2. This reactive electophilic metabolite than can turne into paracetamol glutathione and be excreted in the kidneys or it may bind with metabolite-proteins and cause hepatic cell death

Now in overdose:

1. There is not enough sulphate to turn paracetamol into paracetamol sulphate so more paracetamol is trned into a reactive electrophilic metabolite thus increasing binding to metabolit-protein and cause more heaptic cell death
2. The way to help a patient in this situation - measure blood and introduce a N-acetylcysteine (NAC) which will hel with conversion thus stop metabiolite-protein bindings

Question 161

What is the basic investigative process in oral pathology?

Answer 161

1. Presentation of chief concers
2. Information collection - medical history, patietn history, clinical examiantion and special tests
3. Information collation
4. Development of a differential diagnosis - list most likely diagnoses and do specific test to eliminate potential diagnoses
5. Arrive to definitive diagnosis and commence treatment

Question 162

What are the types of differential diagnosis?

Answer 162

1. Clinical differential diagnosis
2. Radiographic differential diagnosis
3. Provisional/working/tentative diagnosis
4. Histological differential diagnosis
5. Definitive diagnosis

Question 163

What is the step by step process to understand the arisal of a certain oral lesion?

Answer 163

Use this scheme

1. Developmental origin
2. Inflammatory origin
3. Hyperplastic origin
4. Degenerative origin
5. Hormonal origin
6. Neoplastic origin
7. Idiopathic origin

DIHDHNI

Question 164

How do we take history about a lesion?

Answer 164

1. Duration when the patient first started seeing the lesion
2. Variations in site and character of the lesion
3. Symptoms - related to the lesion and any systemic symptoms
4. Onset - any associated hsitorical events related to the lesion

Question 165

What is the systematic way to examine a lesion?

Answer 165

1. Site - using anatomical terminology
2. Size - measure with a probe
3. Morphology - elevated, flat or depressed
4. Colour - compare to adjacent normal tissue
5. Consistency - how it feels (ONLY CLINICAL DO NOT SAY THIS IN EXAM), texture - how the surface looks like (PHOTOS ARE APPROPRIATE :))

Question 166

What are some of the types of biopsy?

Answer 166

1. Scalpel biopsy - incisional or exitional - most common procedure
2. Fine needle aspiration
3. Core biopsy
4. Exfoliative cytology - taking the gunk and spreading it over a film

Question 167

What are the four layer of the epithelium?

Answer 167

1. stratum basale (D)
2. stratum spinosum (C)
3. stratum granulosum (B)
4. stratum corneum (A)

E and F and the papillary and reticular layer accordingly

Question 168

What is periodontitis?

Answer 168

Periodontists is a multi factorial, inflammatory diseases associated with dysbiotic microbial dental biofilms and characterised by non-reversible progressive periodontal tissue destruction. It manifests through: CAL, radiographically assessed alveolar bone loss, presence of periodontal pocketing, gingival bleeding and leads eventually to tooth loss.

Question 169

What are the main points of the old, Non-specific Plaque Hypothesis?

Answer 169

1. All plaque bacteria are equally pathogenic
2. Quantity of plaque determines the pathogenicity
3. Host has threshold capacity to detoxify bacterial products
4. Disease develops if threshold is surpassed

Treatment: non-specific mechanical removal of total amount of plaque

Question 170

What are the main points of the Specific Plaque hypothesis?

Answer 170

1. Due to advancement of microbiological technologies, specific bacteria that are believed to be pathological to the periodontium were isolated
2. Not all plaque is equally pathogenic
3. Presence and increase of specific microorganism causes more destruction

Treatment: targeting and elimination of specific microoganisms using antimicrobials

Question 171

What are the main points of the ecological plaque hypothesis?

Answer 171

1. Disease is the result of an imbalance in the total micro-flora due to ecological stress
2. Quantitative plaque increase changes local micro-environment promoting the growth of specific pathogens, qualitative shift
3. Ecological factors such as the presence of nutrients and essential cofactors, pH and redox potential

Treatment: prevention of dental caries, modification of micro-environment to prevent nourishment of pathogens

Question 172

Explain, briefly, the Yellow, orange and red groups that were suggest by Dr. Socranky research of 1998. Please include the names of at least 3 different bacteria in all of the groups.

Answer 172

1. The yellow, orange and red groups are suggested groups of bacteria that are associated with periodontal health and pathology
2. Yellow group - include: S. Mitis, S. Oralis and S, Snagius - are early coloniser groups that are related to healthy periodontium
3. Orange group - include: P.Intermedia, P.Nigrescens and F. Nucleatum - are late coloniser that are believed to be an intermediate step and are able to facilitate red group (the most pathogenic group) in binding in the periodontal pocket
4. Red group - include: P. Gingivalis, T.Forsythia, T. Denticola - believed to be the most pathogenic group

Question 173

What is the microbial virulence?

Answer 173

Virulence is defined as the degree of pathogenicity of the ability of the organism to cause disease measured in experimental procedures.

Organism need to:

1. Attach and colonise
2. Multiply and gain access to appropriate nutrition
3. Evade host defences
4. Propagate

Question 174

What are the stages of the IMPEDE model

Answer 174

Stage 0 - gingival and periodontal health
Stage 1 - gingival inflammation
Stage 2 - Polymicobial emergence
Stage 3 - Inflammation - mediated dysbiosis - initial perio
Stage 4 - Late stage periodontitis

Question 175

What is the aetiology of periodontitis?

Answer 175

1. Predominance of PMNs in pocket epithelium/activation in connective tissue
2. Elevated activity of macrophages
3. Plasma cells dominate the infiltrate
4. Increase of pro-inflammatory cytokine production (like IL-6 and IL-8 and more)
5. This results in disturbed tissue homeostasis leading to destruction of collagen, connective tissue matrix and bone
6. This results in true pocket development from the junction epithelium

Question 176

What causes bone resorption?

Answer 176

1. RANKL - produced by osteocytes in large quantities, due to stimulation of pro-inflammatory cytokines like IL-6 and IL-8, able to activate osteo clasts - bone resorbing cells
2. RANK - receptor on osteocalst - binding site of RANKL
3. OPG - scavenger receptor that prevents RANKL binding thus preventing bone resorption

RANKL:OPG ratio: relative amount regulate the bone turn over

Question 177

How does smoking increases the risk of periodontitis and by how much on average does it increase the instance of periodontitis according to latest studies?

Answer 177

The mechanisms:
1. Chronic reduction in blood flow and vascularity
2. Increase the prevelance of potential periodontal pathogens in the sulcus
3. Shift in neutrophil function towards destructive activities
4. Shift to a dysbiotic, pathogen enriched microbiome
5. Affects PMNs making them more aggrevated
6. Increase the number of aggravated T cells that produce inflammatory cytokines

It increases the risk of periodontitis by 85%!

Smoking cessation has beneficial effect on therapy outcomes and disease progression - this should be attempted for patient with nicotine dependence/

Question 178

How does diabetes increases the risk of periodontitis and by how much on average does it increase the instance of periodontitis according to latest studies?

Answer 178

1. No solid evidence of causal relationship between poorly controlled diabetes and periodontal microbial dysbiosis in humans, but there some evidence in vitro thus it is biologically plausible
2. Osteogenesis reduction due to apoptosis of osteoblasts and PDL fibroblasts
3. Increase in RANKL expression and OPG expression is decreases
4. Increase in collagenase activity

It increases the risk of periodontitis by 3x to 4x!

Multidisciplinary control and treatment of diabetes is ESSENTIAL to treatment of periodontitis.

Question 179

How do you write a diagnostic statement for periodontist modified by diabetes?

Answer 179

1. Type of periodontal disease
2. Disease extent
3. Stage
4. Grade
5. Current disease status
6. Risk factor profile

E.g.
Periodontitis: generalized (65%), Stage III (CAL <10 mm), Grade C (HbA1c 8.9%), currently unstable (PPD <8mm, BOP 45%).
Risk factors: uncontrolled diabetes (HbA1c 8.9%), smoking 20 cig/day, high strss levels (change in work)

Question 180

How can you link back the instances of severe periodontitis with the current classification standards?

Answer 180

It was discovered, that on avergaere, people with sever cases of periodontists have attachment loss of around 0.45mm per annum.

Thus in the new classification, Grade C (fast progressing) is considered to be when an individual has a rate of progression of more than 2mm per 5 years (5 x 0.45)

Question 181

What is the 2017 Periodontits Case definition?

Answer 181

1.Interdental CAL detectable at 2 non adjacent teeth

or

2. Buccal or oral CAL above or equal to 3mm with pocketing equal or more than 3mm at 2 or more teeth

AND

OBSERVED CAL CANNOT BE ASCRIBED TO NON-PERIODONTITIS CAUSES: SUCH AS VERTICAL ROOT FRACTURE/S

Question 182

What BOP score are we aiming to achieve?

Answer 182

BOP score of less or equal to 20% because that is associated with significantly lower risk of CAL progression and want the score to decrease continuously and keep stable.

Question 183

What the Community Periodontal Index of Treatment Needs codes and what treatment do they need?

Answer 183

Code 0 - healthy - treatment: home care
Code 1 - bleeding on probing but no attachment loss - treatment: oral hygiene instructions
Code 2 - calculus present + BOP - treatment: calculus removal and scaling + OHI
Code 3 - pockets of below 5 mm - treatment: calculus removal and scaling + OHI
Code 4 - pockets of above 6 mm - treatment: complex therapy + calculus removal and scaling + OHI

Question 184

What is the theory of “direct pathway” that connects periodontal health with systemic health?

Answer 184

It believed that due to increased number of bacteria and smaller barrier to penetrate (ulcerated epithelial pocket lining).
1. The ulcerated periodontal pocket liing acts as a gate for viable bacteria, bacterial toxins/componetns
2. It results in frequent transient bacteremia
3. And could result in substantial systemic inflammatory response

This pathway also goes via other organs and systems like during swallowing or inhalation.

Important to understand that systemic bacteraemia as a result of periodontal infection is rare.

There is actually a way you can calculate periodontal inflamed surface area thus it is important to reduce that area with treatment.

Question 185

What is the theory of indirect pathway?

Answer 185

It also relates to the periodontal inflamed surface area.

It is a theory that states that affects on the systemic health from periodontal disease result due to pro-inflammatory mediators that are involved in periodontitis.

Less plausible than the direct pathway.

Question 186

What is the association between periodontitis and atherosclerotic coronary vascular disease?

Answer 186

AVD is the most common form of death worldwide.

It is a result of vascular inflammation and subintimal lipid accumulation which could result in build up of atheroma, stenosis of the valves, rupture of blood vessels and thrombosis.

There is some evidence to suggest there is association between the A.a. bacteria and P. Gingivalis being recovered from human atheromas. Thus an increase in those bacteria may result in increases risk of atheromas. These bacteria may effect the endothelia walls, immune function, impact macrophage function through different mechanisms.

Question 187

What are some of the steps that need to be taken for a patient with AVD as soon as they have been diagnosed with the condition?

Answer 187

1. Periodontal health needs to be assesed
2. A treatment plan with focus on prevention should be constructed
3. Combination of at home and in chair procedures must be performed to maintain good periodontal health thus reduce the risk of AVD worsening

Question 188

What is prognosis?

Answer 188

A prognosis s a prediction of the probable course duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of is factors for the disease.

Prognosis is establish after diagnosis.

Question 189

What is the system of tooth prognosis by Nibali?

Answer 189

It is a very objective system that involves

1. Bone loss
2. Furcation and modbility
3. PAI score

Question 190

When would you suggest an immediate extraction?

Answer 190

1. Due to pain
2. Due to acute abscesses
3. If patient request due to other treatment like ortho

Question 191

What are some of the goals of periodontal treatment?

Answer 191

1. Absence of pain
2. Reduction and elimination of infections and inflammation
3. Cessation of attachment loss and gain of attachment
4. Restoration of physiologic bone and gingival contour to aid plaque control
5. Satisfactory function and aesthetic for the individual

Question 192

How can you categories your perio treatment goals?

Answer 192

1. Immediate goals
2. Intermediate goals
3. Long term goals

Remember - patient must know that periodontal treatment is not a one off - it is continuous

Question 193

How to set up a case report for perio?

Answer 193

1. Reason for referral
2. CC
3. MHx
4. DHx
5. Family Hx
6. Diagnosis
7. Oral hygiene
8. Establishing goals and motivation
9. Prognosis
10. Treatment plan
    11 Treatment

Question 194

How to set up a provisional treatment plan for perio?

Answer 194

1. Emergency phase - e.g. exo
2. Systemic phase - e.g. control systemic diseases
3. Initial phase - e.g. testing and debridement
4. Surgical phase - regenerative surgery
5. Restorative phase - temporary crowns
6. Maintenance phase - depending on risk close recall or normal recall

Question 195

What are acute periodontal conditions?

Answer 195

They are conditions that are:
1. Rapid in development
2. Cause pain/discomfort
3. Rapid tissue destruction
4. Usually a result of infection

e.g. hepatic gingival stomtitis, necrotising gingivitis/periodontitis

Question 196

Would you give antibiotic prophylaxis to patient before root planing?

Answer 196

Yes you would if they have an underlying health condition.

Question 197

What are the steps to the initial phase of treatment for Stage I-III of periodontitis?

Answer 197

1. Patient self care and removal of biofilm by patient with - behavioral modification, mechanical (like brushing and using of inderdental brushes or other methods) and chemical (mouthrinse and oral irrigation)
2. Supragingival scaling and reduce predisposing factors such as bad restorations - the evidence suggest that are not preffered way i.e 1 quadrant per session or half the mouth per session

Question 198

What are some of the difficulties with subgingival root plaining?

Answer 198

1. Macromorphology of the roots - e.g. the mesial forcation of the upper sixes is quite deep and hard to get
2. Micromorphology of the cellular cementum
3. Irregular of the base of the pocket

Even with these problems, subgingival debridement seen to be incredibly useful in causing a reduction in bacteria levels and pathogenic bacteria like P.Gingivalis reduces

Question 199

What are some of the factors that may impact outcome of non-surgical periodontal therapy?

Answer 199

1. Smoking
2. Number of roots on the tooth
3. Plaque levels

Question 200

What is one of the ways periodontal pocket repairs after the subgingival debridement?

Answer 200

Repair through long junctional epithelium:

It is a restoration of the continuity in the wound or defect area, without regeneration of the originally intact tissues from and function for example long junctional epithelial attachment with new collagen fibers parallel to it. Thus the periodontal pocket closes up.

Some of the tissue may actually reattach but it important for those tissues to not be infected.

Question 201

What are some of the side effects of non-surgical therapy

Answer 201

1. Reduction in gingival tissue due to reduced oedema - increase in th black triangle between teeth
2. Increase in dentine hypersensativity due to damaged cementum that covers dentinal tubules
3. OH may causes reduction in dentine like making those wedge like

Question 202

What are some of the complexity factors could occur in the periodontium?

Answer 202

1. Pocket depth and type (supraboney or infraboney)
2. Vertical bone loss
3. Furcation ivolvment
4. Ridge defects
5. Masticatory dysfunction

Question 203

What are some of the common boney defects and how would you describe them?

Answer 203

1. 3 Wall defect - balcony-like defect
2. 2 wall defect - 2 roots of adjacent teeth are connected ( a little bit) or where is 2 walls of the defect
3. 1 wall defect - might manifest itself as a v shape with a single wall

All defects must undergo non-surgical therapy.

The defects can be accessed using horizontal strokes, mini-currettes or special ultrasonic scalers.

Question 204

What occurs in the primary occlusal trauma and how does it affect the periodontal health?

Answer 204

1. There is excessive occlusal force
2. This results in acute inflammation and compression
3. This lead to bone resoprtion and widening of the PDL with no clinical attachment loss
4. When occlusal forces removed - PDL goes to normal

Question 205

What occurs in the secondary occlusal trauma and how does it affect the periodontal health?

Answer 205

1. Excessive occlusal force applies to healthy teeth, healthy gingiva on a reduced periodontium
2. SImilar addaption and widening of the PDL with no clinical attachment loss
3. When forces removed some bone apposition might occur

BUT when untreated periodontitis is involved:

1. The occlusal forces may cause damage to the connective tissue supporting the teeth
2. When occlusal trauma remove attachment is lost

Question 206

What is the recomendation in terms of use of oral antiseptics in conjunction with periodontal treatment?

Answer 206

They may be considered, in some cases, as adjuncts to mechanical debridement - cases like patient who cant perform proper mechnanical plaque control post surgery or necrotising periodontal disease or people with saviour arthritis

Question 207

What are some of the challenges faced with use of antibiotic therapy on periodontal bacteria?

Answer 207

1. There are thousands different types of periodontal bacteria present - hard to choose one antibiotic
2. The bacteria reside within a biofilm thus they are harder to reach - THUS BIOFILM NEEDS TO BE REMOVED AND ANTIBIOTICS ADMINISTERED 24 HOURS POST DEBRIDEMENT

Question 208

What are the recommendations of anti-biotic prescription for periodontal disease in Australia?

Answer 208

Amoxicillin 500 mg orally, 8-hourly for 7 days PLUS Metronidazole 400 mg orally, 12-hourly for 7 days

Question 209

What patient should get anti-biotic therapy?

Answer 209

1. Young patient
2. Generalised severe periodontitis patient
3. Patients with systemic diseases
4. Rapidly progressing form
5. Refractory/therapy-resistant forms of periodontitis

Question 210

When should you recall the patient after completion of the innital phase of dembridment and provision of at home OHI?

Answer 210

After around 12 weeks in order to give the periodontium the chance to heal

Question 211

What should you do after the patient has come back after the 12 weeks?

Answer 211

1. Review MHx and risk factors
2. Assess the OH performance
3. Periodontal examination
4. Re-evaluation - caries check, restorative and implant status
5. Supportive periodontal therapy session - the aim of therapy is to have pocket of no more than 4 mm
6. The third step can be taken aswell after another reassessment - this involves teeth that did not respond to therapy well and may need to address those remaining point of biofilm accumulation
7. If the pocket are more than 6mm, surgeyr may be needed

Question 212

What is supportive periodontal treatment?

Answer 212

It is treatment that plans to maintain already achieved goals with improvement of periodontal health. Patient should come back for assessment every 3-12 months depending on their risk profile )high risk - come every 3 months, low risk - every 12 months)

Question 213

How can we evaluate risk of periodontal disease progression in the patient?

Answer 213

There dirrent matrix you can use to determine the recall frequency - a common one is the PRA (periodontal risk assessment) and it can be accessed online.

Preio-tools.com seems like the website to go to to find different matrix that may assist you.

Question 214

Shouldyou probe all the teeth at SPT session

Answer 214

YES of course you should to understand the health of pockets - but you can choose not to do a brand new perio chart unless you find some findings

Question 215

What would you mention to a patient who has periodontitis?

Answer 215

1. Periodontitis - a disease that destroys the bone underneath the tooth
2. Usually occurs from bacteria aggrevating the gums
3. Aggrevating the gums leads to inflammatory condition - gingivitis
4. When gingivitis is present with some underlying risk factors such as smoking, diabetes or immunuesupressed organism - periodontitis is caused
5. Periodontitis is caused by the immune system trying to fight off the bacteria in the plaque - but not bring very mindful of the surrounding tissue
6. Unfortunatley periodontitis is irreverisble - but if proper treatment - it can be slowed down or even arrested - thus we need to collaborate on this issure

Question 216

What are some of communication pathways between the pulp and periodontium?

Answer 216

1. Apical foremen
2. Dentinal tubules
3. Accessory canals
4. Lateral canals

Question 217

What is the primary aetiology factors of endo-perio lesions?

Answer 217

1. Endo or perio infection
2. Trauma an/or iatriogenic trauma - like perforation during root canal treatment or root fracture or crack post RCT or root resorption

Question 218

What is an endo-perio lesion?

Answer 218

An EPL (endo-perio lesion) is a pathological communication between the pulpal and periodontal tissues at a given tooth accompanied by a deep periodontal pocket and altered pulp sensitivity test that may occur in (symptomatic) acute or chronic (asymptomatic) form.

Question 219

What is the endo-perio aetiology?

Answer 219

1. Primary endo infection - carious lesions affect the pulp and secondarily affect the periodontium

• Inflamed pulp exerts little or no effect on the periodontium
• Necrotic pulp cause bone resorption
• Sinus tract drain through PDL into gingival sulcus
• Isolated periodontal defect

2. Primary perio - periodontal disease introduces bacteria through different channels of communication in

Question 220

What are some of the diagnostic hints that might lead us to see that the lesion is a primary endo secondary perio lesion?

Answer 220

1. Pulp test negative
2. Compromised coronal integrity
3. Isolated deep narrow peridontal pocket - might need to use a guttapercha and take a PA

Question 221

What is the treatment of primary endo secondary perio lesion?

Answer 221

1. RCT
2. No immediate scaling and root instrumentation - please await healing first - 3-6 months should be enough for healing and reassessment

Question 222

What are some of the diagnostic hints that might lead us to see that the lesion is a primary perio secondary endo lesion?

Answer 222

1. Sever periodontitis
2. Pathological changes occur in pulp
3. Retrograde pulpitis - acute pain for long duration
4. Pulp test incoclusive
5. Coronal integrity intact
6. Deep periodontal pockets around the tooth

Question 223

What is the treatment of primary perio secondary endo lesion?

Answer 223

1. Scaling and root instrumentation needs to be done together with the root canal treatment

or

1. Extraction depending on prognosis

Question 224

What is the diagnostic clues of a combination endo-perio lesion?

Answer 224

1. Pup test is negative
2. Deep peridotnal pockets on multiple sites

Question 225

What is the treatment for a combination endo-perio lesion?

Answer 225

1. Scaling and root instrumentation needs to be done together with the root canal treatment
2. Possible resective surgery

Question 226

How to write a diagnostic statement for a endo-perio lesion?

Answer 226

1. Write that it is a endo perio lesiom
2. Root damage extent
3. Perio status of the patient
4. Grade of the problem

Question 227

What are the classifications of periodontal pockets associated with an endo-perio lesion associated with periodontitis patients?

Answer 227

Grade 1 - narrow and deep periodontal pocket in 1 tooth surface

Grade 2 - wide deep periodontal pocket in 1 tooth surface

Grade 3 - wide deep periodontal pocket in more than 1 tooth surface

Question 228

What are the classifications of periodontal pockets associated with an endo-perio lesion associated with non-periodontitis patients?

Answer 228

Grade 1 - narrow deep periodontal pocket in 1 tooth surface

Grade 2 - wide deep periodontal pocket in 1 tooth surface

Grade 3 - deep periodontal pockets in more than 1 tooth surface

Question 229

What is the BPE and how do we use it for paediatric patients?

Answer 229

BPE stands for basic periodontal examination and we use it as a code system similar to PSI!

Children with codes 0,1,2 should just have routine exams

While children with codes 3 & 4 should be undergoing consistent periodontal care to improve their condition

Note that some times Code 3 in a mixed dentition could be just erupting teeth so please be considerate.

Question 230

What is the treatment of pathological tooth migration?

Answer 230

1. Periodontal therapy - treating of Stage 4 perio is successful
2. During ortho therapy - after periodontal stabilityis achieved - patient periodontal status needs to be closely managed by a periodontist - maintenance and interruption of ortho treatment is possible
3. Life long orthodontic and periodontic care needs to be provided for the patient

Question 231

What kind of instrument could you use of disturbing the biofilm in a patient with orthodontic appliances?

Answer 231

1. Airflow instrument
2. Different ultrasonic scalers
3. Hand instruments - use appropriate size because it is generally difficult to debride

Question 232

What is the supracrestal attached tissues?

Answer 232

It is the combination of junctional epithelium width and connective tissue attachment width

Question 233

What happens when you place the restoration subgingivally inappropriately?

Answer 233

It results in violation of supracrestal attached tissues resulting in chronic inflammation and bone loss because the body ants to maint that SAT at around 2mm

Question 234

How do we assess the SAT violations?

Answer 234

1. Radiographic findings
2. Clinical assessment - beeding on probing int he area, clinical attachment loss and pocket formation - debridement does not help the lesion
3. Bone sounding - pass through the attached tissues witha
   sterile probe should be around 3mm from gingival margin - if the margin of the restoration and the alveolar crest have a distance of less than 2mm it is considered as a SAT violation - note that this is a guide, healthy alveolar crest could be upto 3mm below CEJ

Question 235

What are the treatments of SAT violations?

Answer 235

1. Consider restoring appropriately - please do not damage the tissues, remove the cement properly
2. Re-establish SAT width by surgical crown lengthening or orthodontic extrusion

Question 236

What is this condition?

Answer 236

This is necrotising gingivitis. It is usualy caused by a presence of an opportunistic bacteria and an underlying stress factor.

Clinical features: necrosis of the papilla, sudden onset, ulcer covered by greyish pseudomembrane from surrounding mucosa

Treatment:

1. OHI
2. Debridement
3. CHx
4. Metronidozole 400mg 6 hourly for 5-7 days

Question 237

What are the four concepts we need to understand in pharmakokinectics?

Answer 237

1. Clearance
2. Half life
3. Volume of distribution
4. Bioavailability

Question 238

What does the shape of the curve of plasma concentration over time depend on?

Answer 238

1. Dose
2. Route of administration
3. Single dose versus chronic dose
4. Patients’ elimination and distribution rates

Question 239

What is bioavailability?

Answer 239

It is how much of the drug enters the blood stream and how much can actually be used.

Usually calculated by finding the difference of plasma concentration betwene oral ingestion and with use of IV

Good drugs - bioavailabiltiy 100%

Symbol on graphs - F

Question 240

What is the stead-state condition?

Answer 240

When we can achieve the balance between the rate of elimination and plasma concentration

Question 241

What does clearance rate determines?

Answer 241

It determines the dose rate.

It is important to know that clearance is an independent pharamakokinetic parameter.

If clearance is higher than concentration in the plasma should be higher.

If clearance is lower than concentration in plasma is higher.

Question 242

How do we know that we are at the steady state?

Answer 242

Half-life - time for blood concentration/amount of drug in body in half.

Half-life is very useful because it tells us when we are in the steady state. E.g. if half-life 97% is achieved in 5 doses - means it takes 5 half-lifes to get to the steady state.

It will also take 5 half-lifes to clear the drug.

Question 243

What are some of the important aspects of Drug-Drug interactions?

Answer 243

Pharamacokinetic:
Interacting drug alters the plasma concentrations of index drug.

Usually also alters the hepatic clearance, could up or down shift it.

Commonly, renal clearance is down regulated.

Pharamacodynamically - some drugs may make the reaction to other drugs more potent

Question 244

What is drug enzyme induction?

Answer 244

When a drug stimulates gene transcritption that makes of a certain enzyme in general resulting in need in higher dose.

E.g. St Johns Wort

Question 245

A patient is taking some wafarin 3 mg daily and felodipine. They have candidiasis infection. You start them on fluconaole 100mg daily. Their candidiasis infection clears up but they starting to experience major gingival bleeding and bruising. Why?

Answer 245

1. Fluconazole is an aenzyme inhibitor which prevents warfarin to be metabolised
2. Thus decreasing the clearance of warfarin and increasing plasma concentration
3. Increased plasma concentration results in toxicity which leads to increase in bleeding and bruising

Question 246

What is a triple wammy?

Answer 246

It is a pharmacodynamic problem which occurs with use of ACE inhibitor, diuretic and NSAID and can result in Acute Kidney Injury (AKI)

Process:

1. ACE inhibitors preserve renal function and also cause constriction of efferent renal arteriole
2. NSAID are able to increase the vasoconstriction of the afferent arteriole by inhibiting the production of prostoglandins - a potent afferent arteriole dilator
3. Dirutetic drive the increase exertion of water through the renal system thus increasing the amount of blood that is carried to the glomerulus through the afferent arteriole
4. All three factors compound and increase the pressure within the nephron in their own way and increase the risk of acute kidney injury due to increase pressure tearing the nephron
5. Solution - avoid NSAIDs

Question 247

How to avoid drug interactions?

Answer 247

1. Thorough history
2. Check the list with the datatbases
3. Remember of the over-the-counter and herbals

Question 248

What is an adverse drug reaction?

Answer 248

Any response to a drug which is unintended, harmful and which occurs at a dose usually given to humans for management of disease.

This does not include: Overdoes or Error in dosing

Question 249

What is an adverse drug effect?

Answer 249

An injury resulting from medical intervention related to a drug - includes wrong dose or device malfunction

Question 250

What are major types of ADRs?

Answer 250

Type A - Exaggerated response to medication even tho the dose is normal - it is usually predictable with dose decrease should fix it

Type B - BIZARRE effect - not predictable - high risk of death - need to stop the drug - ALWAYS ASK THE PATIENT IF THEY ARE ALLERGIC BEFORE ANY PRESCRIPTION ESPECIALLY WITH ANTI-BIOTICS

Type C - long term affects - tolerance like for caffeine

Type D - delayed effect - thalidomide with babies

Type other - unavoidable toxicity - cancer chemotherapy

Question 251

Who is more at risk of ADRs?

Answer 251

1. Elderly
2. Infats and children
3. Women
4. People with history of multiple allergies
5. People with other diseases
6. Certain ethnicity and pharmacogenetics

Question 252

What are some of the oral reaction to drgus?

Answer 252

1. Local reaction such as chemical irritation or suppression of oral flora
2. Systemic reaction like from bone marrow depressor or immune suppressors
3. Stevens-Johnson syndrome - lots of ulcers - could be caused by ibuprofen
4. Lichen planus - can be caused by allopurinol
5. Gingival bleeding - SSRIs
6. Xerostomia - polypharmacy

Question 253

How are drugs discovered?

Answer 253

1. Purification from natural sources through tradition medicine and chance observation - aspirin
2. Screening of biological sources such as soil, microbes or marine organisms
3. Chemical modification of active and known drugs
4. Rational Drug Design depending on the disease - custom designs by manipulation or proteins etc - SSRIs
5. Pure chance (Srendipity) - Aspartame
6. New Indications from clinical observation
7. Recombinant proteins - using bacteria to make endogenous proteins

Question 254

What are the steps of pre-clinical drug development?

Answer 254

1. Laboratory tests in vitro - through use of high throughput screening
2. Whole animal testing
3. Phase I trials - is it immediatley safe?
4. Phase II trials - trials in the target illness - can it work?
5. Phase III trials - large scale clinical trials - is it effective?

Question 255

What are the steps of approval of a drug in Australia?

Answer 255

1. Aims - to protect public from drugs that are: unsafe, ineffective and poor quality
2. Process - TGA is presented data
3. Evaluation of quality, safety and efficacy
4. Registration
5. Movement to the market

Question 256

What are the two types of products that are listed on the website of TGA known as the ARTG?

Answer 256

AUST L - listed produucts with little side effects - like sports supplements

AUST R - registered products with side effects - think all other proper medicines

Question 257

What are the schedules of drugs?

Answer 257

1. Schedule 1 - unscheduled drugs - paracetamol
2. Schedule 2 - Pharmacies only - Telfast
3. Schedule 3 - Pharmacist Only medicines - Morning-after pill
4. Schedule 4 - Prescription only - Antibiotics
5. Skip all other schedules
6. Schedule 8 - Drugs of addiction dependence - Morphine

Question 258

Define the following:

Infection

Colonisation

Bacteraemia

Septicaemia

Sepsis

Answer 258

Infection - invasion & multiplication of pathogenic microorganism in body tissue

Colonisation - localised presence of microorganisms

Bacteraemia - presence of viable bacteria in circulation

Septicaemia - systemic infection caused by microorganisms multiplying in circulation

Sepsis - multiple organ involvement from organisms

Question 259

What are antibiotics?

Answer 259

They are drugs that stop the spread and multiplication of bacteria in the body that are causing harm.

They come under general term of anti-infectives and antimicrobials.

Question 260

What some of the other anti-infective and anti-microbials?

Answer 260

1. Antibacterials - bacteria
2. Antivirals - viruses
3. Antifungals - fungal infections
4. Antimycobacterials - for TB
5. Antiprotozals - malaria medication
6. Anthelminitics - againts worms

Question 261

What is important to understand about antibiotics?

Answer 261

Antibiotics do not cure infections - our immune system does. Antibiotics just needed for their bactericidal or bacteriostatic functions.

Antibiotics give immune system more time to mobilise more effectivley

Question 262

How do antibiotics work?

Answer 262

1. Inhibit metabolism of a bacteria (folic acid blockage) - trimethoprim - bacteriostatic effect
2. Inhibit cell wall synthesis - penicillins - bacteriocidal effect
3. Disrupt cell membrane - both bacteriostatic abd bacteriocidal
4. Inhibit protein synthesis - metronidazole inhibits DNA synthesis

Question 263

What are the different efficacy of antibiotics?

Answer 263

1. Narrow spectrum - a few species - benzylpenicillin
2. Moderate spectrum - several species - amoxicillin
3. Broad spctrum - many species - tetracyclines

Question 264

What are the 2 concepts that determine anti-biotic efficacy?

Answer 264

1. Time-dependent killing - time in the blood where drug is above MIC - MIC can change with resistence - penicillins
2. Concentration-dependent killing - the higher the peak concentration the more it will kill - prologned duration of killing - aminoglycosides

Question 265

What are some of the resistance pathway for the bacteria?

Answer 265

1. Bacteria produce enzymes that inactivate the drug
2. Bacteria changes drug binding site
3. Drug is pumped out of microbe
4. Microbe makes alternative enzyme bypass pathway

Example: MRSA - multiresistant Staphylococcus aureus

Question 266

What is the “creed” of antibiotic therapy?

Answer 266

M - microbiology guides therapy
I - indications should be evidence-based
N - narrowest spectrum required
D - dosage appropriate to the site & typ of infection

M - minimise duration of therapy
E - ensure monotherapy in most situations

Question 267

What are the principles of antimicrobial selection?

Answer 267

1. Use narrowest antibiotic to treat disease
2. Use the safest
3. Avoid topical administration of a drug used systemically
4. Don’t use combinations
5. Don’t give prophylactically
6. After considering all theses factors - choose lowest coast

Question 268

What should the dentist put on the prescription sheet to make sure that pharmacist does not dispense too many antibiotic capsules?

Answer 268

Number of days and numbers of pills

Question 269

What is the difference between the reliever and a dialator?

Answer 269

Preventer is taken before to lower the chance or severity of asthma through different vasodialating effect. Usually a low dose of corticosteroids

Reliever - is usually just use for quick relaxation of smooth muscles.

Question 270

Neostigmine is a competitive inhibitor of cholinesterase. Why is it useful in the treatment of Myasthenia Gravis?

Answer 270

Myasthenia Gravis is a auto-immune disease that affect acetylecholine receptors on skeletal muscles - thus affecting the contraction of said muscles. It is an inhibitor.

Neostigmine inhibits the enzyme acetylcholine esterase which breakswdown acetylcholine thus increasin it’s number in synaptic cleft.

this results in improvemenet in the condition due to greater numbers of acetylecholine.

Question 271

Rank the following in terms of speed of onset action when an agonist occupis the receptor?

GABBA receptor

Opiod receptor

Glucocorticoid receptor

Answer 271

1. GABBA receptor - inhibitory receptor in the nerve - very quick because it is an ion channel
2. Opiod receptor - G protein-coupled receptors - moderatley quick
3. Glucocoricoid receptor - nuclear receptor superfamily of transcription factors - very slow

Question 272

What drug should you not give to pregnant women?

Answer 272

Category C drug like ibuprofen.

Aloso Category D drugs but they are pretty rare!

Question 273

What is a good principal of drug dosing for older patients?

Answer 273

SRTART LOW & GO SLOW

BUT DON’T STAY LOW if chronic dosing.

Question 274

What is an example of potentiation effect of medications?

Answer 274

Warfarin and iboprofen/aspirin - increase bleeding significantly

Question 275

If a mouthrinse claims that is is for treatment of “gingivitis” but you can buy it at Woolworths, what type of listing is it and what type of schedule is it?

Answer 275

AUST R listing

Shedule 1 or unscheduled

Question 276

How do antiobitcs have a bacteriostatic effect?

Answer 276

Sulfanilamide antibiotics have a bacteriostatic effect by targeting synthesis of folica acid - an important component of bacterial RNA and DNA

Sulfanilamide can completitivley inhibit enzymes that are used in production of folic acids, thus slotwing the synthesis thus slowing growth of bacteria due to reduced production of plasmids (circular DNA in bacteria).

Question 277

How do antiobtics have a bacteriocidal effect?

Answer 277

By inhibiting cell wall synthesis through rapid depolarization.

Beta-lactam - like amoxycillin - able to bind to bacterial cell walls causing repid depolirasation resulting in loss of membrane potential leading to inhibition of protein synthesis and destruction of DNA.

Question 278

What are the main drivers for ortho treatments?

Answer 278

1. Aesthetics
2. Functional reasons: increased overjet, crossbites
3. Societal and cultural pressures

Question 279

What is interceptive orthodontis?

Answer 279

Interceptive orthodontics or primary orthodontics is an approach that uses phased treatments to manipulate growth, and particularly common growth patterns and correct developmental occlusion problems.

Question 280

What should a graduate dentist be able to do in terms of orthodontics?

Answer 280

1. Distinguish abnormal development and growth from that which is normal
2. Perform an orthodontic examination and explain the diagnosis, then devise treatment options, detailing the benefits and risks of each
3. Commence, monitor and complete interceptive orthodontic treatment in a patient

Question 281

What is the difference between growth and development?

Answer 281

Growth - is an increase in size

Development - is an increase in complexity

Question 282

What to do if you find growth is abnormal?

Answer 282

1. Establish possible aetiological factors
2. Seek assessments
3. Understand suitable options for intervention

Question 283

What is a cephalocaudal gradient?

Answer 283

It is a chart of proportional growth.

Structures towards to head grow first

Question 284

What are growth curves?

Answer 284

Scammon’s curves They are graphs that represent that different tissues grow at different rates

Question 285

What is more useful - developmental or chronological age?

Answer 285

Developmental. It is more useful to know stage of growth, rather than age, that specific growth occurs for orhtodontics.

Question 286

What are the peaks of growth in people?

Answer 286

1. Childhood peak at about 5 years
2. Juvenile peaks at about 7 and years old
3. Adolescent peak at about 11-13 years for females and 13-15 years in males

Question 287

When do you want to catach potential orthodontic case for interceptive treatment?

Answer 287

Class II treatment are most effective when you detect that the patient cephalogram is at CS 1 or 2 and you able to utilise maximum mandibular growth.

Class III treatment is most eefective when it is broken down itno two distinct stage: Maxillary expansion before maximum mandibular growth AND mandibular manipulation during pre-pubertal/pubertal stages.

Question 288

What is the use of lateral cephalometry?

Answer 288

Lateral cephalometry standardised, reproducible radiograph used primarily for orthodontic diagnosis and treatment planning.

It is used to compare jaw growth over time thus is a good guide in orthodontic treatment.

It is able to assist with cervical vertebrae maturation which is a type of biological indicator of skeletal maturity. The vertebrae C2-C4 is assessed.

Question 289

What type of growth is responsible for ossification of the cranial vault?

Answer 289

Intramembranouse ossification - which is a direct transition of the mesenchymal tissue into bone due to osteoblasts deposition. This usually occurs in non-load bearing areas csuch as the cranial vault, maxilla and mandible (body)

Question 290

What type of growth is responsible for ossification of the cranial base?

Answer 290

Endochondral ossification - where bone develops from carilagious precursor. It is usually occuring in load bearing areas like cranial base, long bone and mandibular condyle.

Question 291

How does naso-maxillary complex grow?

Answer 291

It grows downwards & forwards in relation of the cranial base.

Question 292

How does the mandible grow?

Answer 292

The mandible grows up and back.

It occurs via the bone remodelling via subperiosteal resorption & deposition.

Cartilaginous growth occurs in the condyle

Question 293

Why is bone resorption in certain areas of the mandible essetial?

Answer 293

Bone resorption creates space for the eruption of teeth that don’t have of decidious pre-cursor - thus lower the probability of impacted molars (think surgical extraction or third molars)

Question 294

What are the key points to craniofacial growth in orthodontics?

Answer 294

1. Much of the vertical face height increase due to tooth eruption + alveolar bone production
2. Mx & Md + dentitions desplaced down and forward relative to the cranial base
3. Individuals experience differing amounts and direction of facial growth
4. Around adolescence, slight differential growth of Md relative to Mx - meaning mandible tries to catch up
5. Facial growth dependent on idividual growth patterns
6. Factors infleuncing growth & development: genetics, SES, neural control, exercise, neural control, hormones and more.

Question 295

Which structures make up the cranium?

Answer 295

1. Cranial vault akak calvarium
2. Cranial base

Question 296

What structure make up the face?

Answer 296

1. Naso-maxillary complex
2. Mandible

Question 297

How does the cranium grow?

Answer 297

2 distinct methods of growth:

1. Intramembrenous ossification - provides gross growth
2. Ectocranial resorption and remodeling - localised growth - the inner cortical plate resops and the outder cortical plate experiences deposition due to local growth of brain - think about all the cruves and bumb the brain has

Question 298

From which branchial arch does the mandible originate?

Answer 298

1st Branchial arch.

Question 299

What is an apical base?

Answer 299

It is the junction of alveolar & basal bones of the maxillary & mandible in the region of the apices of the teeth.

It is important for dento-alveolar compesation - which means that tooth eruption and alveolus dvelopment compensate for apical base dimension - making the teeth look “out of place slightly”

Question 300

What is malocclusion?

Answer 300

It is a failure of the dento alveolar compensatory mechanism.

Question 301

What is crowding and what types of crowding are there?

Answer 301

Crowding - the discrepancy between tooth size & jaw size that results in the misalignment teeth.

Primary crowding - genetic origin

Secondary crowding - environmental factors such as extraction as a child

Tertiary crowding - occurs in the post adolescent period

Question 302

At 10 years old - what sould you do to the patient in order to recognise appropriate tooth growth and positioning?

Answer 302

Palpate around the areas that are distal and lingual of the primary canines in order to feel the permanent canines - because they are the most impacted teeth besides third molars.

Question 303

What is a length of a dental arch?

Answer 303

It is the approximate distance from central incisors to most distal point of 2nd primary molars

Question 304

What is dental arch circumference?

Answer 304

Distance measured round the arch from the mesial contact of first primary molar to the mesial contact of the other first primary molar

Question 305

What is the inter-canine width?

Answer 305

The horizontal distance between cusp tips of the upper and lower canines

Question 306

What is the inter-molar width?

Answer 306

The horizontal distance between the righ and left central fossae of the upper and lower first primary molars

Question 307

What is leeway space?

Answer 307

It is the difference between the combined mesio-distal width of the permanent canine & premolars and the width of the corresponding precursors.

This space is eventually lost as mesial drift of first primary molars occurs following eruption of permanent canine & pre-molars

Question 308

What is incisor liability?

Answer 308

It is the difference between the total mesio-distal dimensions of the decidous and permanents incisors

Question 309

How do permanent incisors have enough space to fit in the arch during eruption?

Answer 309

Space is gained from:

1. Residual spacing between deciduous incisors
2. Permanent incisors erupt into more labial position and occupy a great arch perimetes
3. Deciduous canines move distally as incisors erupt
4. Transvers increase in intercanine arch width

Question 310

WHat is a physiological explanation of a common upper midline spacing aka “ugly duckling gap?

Answer 310

It is a variation of normal dental development

It arises as the effcts of:
- incisor apicies initially close together as incisors erupt
- lateral pressure from erupting laters and canines

Diastema may close after laterla incisors erupt

Diastema may persist if:
- deciduous canines have been lost
- upper incisors are flared labially

Question 311

What are the factors that facilitate dental arch allignment?

Answer 311

1. Use of interdental, primate and leeway spaces
2. Increased inter-canine width; mainly due to transverse growth
3. Proclined eruption of permanent incisors, forming a wider arch & increases dental arch length
4. Appositional growth of alveolar processes in 3 planes
5. Appropriate size of apical base and teeth

Question 312

What are the factors that hamper dental arch alignment?

Answer 312

1. Lack of interdental, primate and leeway spaces
2. Reduction in dental arch length after permanent incisors erupt
3. Dento-alveolar disproportion (mismatch between tooth & jaw size)
4. Early loss of primary teeth
5. Soft tissue issues - low frenal attachment resulting in midline diastema
6. Oral habits such is sucking on a pacifier or suck on a thumb

Question 313

Why are 5th and 7th generation of adhesive system kinda mid?

Answer 313

1. Because they are known to leave moisture bubles at the surface as well as water tress that impare bonding
2. Because there is an issue with the acid that is used with self etching. Essentially a special compound is used to neutraulise the acid over time so that self etching does not continue to destroy tooth structure - but unfortunaley that compound affect may be delayed thus the created resin tags are not formed properly - this reduced their effectiveness thus making the restoration last less time :(

Question 314

How would you explain to the patient the CR survival?

Answer 314

An average composite may last around 3-8 years but only if it is maintained. Give car analogy.

Question 315

How do we treat hypersensitivity?

Answer 315

1. Block dentinal tubules - using restorations or protective coverings
2. Block nerve activity - stanous fluoride and potassium nitrate
3. Remove the cause - erosion and toothbrushing technique change

Question 316

How do we manage dentine hypersensitivity?

Answer 316

1. Occlude dentinal tubules to reduce impact of stimuli on fluid movement - can be done through chemical occlusion (fluorides) or physical occlusion (sealed resorations)
2. Reduce sensitivity of nerves - using potassium nitrate

Question 317

How to write a pulpal diagnosis?

Answer 317

1. PULPAL diagnosis - pulpitis, necrosis or absent pulp
2. PERIAPICAL DIAGNOSIS - Symptomatic/Asymptomatic Periodontitis/Abscess
3. CAUSATIVE AGENT -caries, trauma, idiopathic

Please refer to the radiograph if you looking at one

Question 318

How to write a treatment plan?

Answer 318

1.Completion of all histories and exams
2. Taking consent for additional testing - TRI-PLAQUE GEL
3. Diagnosis, presentation of treatment plan and consent
4. Chief Concern
5. Preventative care
6. In chair treatment
7. Close date recall
8. Transition to regular recall

Question 319

What are the steps to occlusal analysis?

Answer 319

1.Teeth present/missing
2.Morphology of teeth
3.Wear - mild, moderate, sever
4.Crowding,spacingrotations
5.Axail inclanations
6.Shape of dental arch
7.Cruve of spee and wilsons curve
8.Angle molar classification/canine classification
9.Overbite (%) / overjet (mm)
10.Mediolateral

Question 320

Why is the pharyngeal phase is troubled for infants with cleft lip and palate?

Answer 320

Infants with cleft lip and palate may have trouble with the sealing of the nasal cavity as well as creating vaccum for sucking

Question 321

What are the steps to performing bisected angle?

Answer 321

1. Informed consent
2. Sit the patient up right or on a slight angle - situated the tube next to the patients side where the taking of the x-ray will take place - check the settings on the x-ray machine
3. Grab a standart size film
4. Situated the film dot to slot - black to beam
5. Situated the film parallel to the palatal/lingual surface of tooth being imaged
6. Ask your patient to gently hold the film with their thumb - make sure the patient does not bend the film
7. Horizontal beam angulation - align the beam at the right angle to the tooth of interest - similarly to a bitewing - unless 14
8. Vertical beam angulation - assess the angulation of long axis of the tooth and angulation of detector - mentally bisect the angle created between the tooth & detector
9. Vertical beam adjusted so central ray is at 90 degrees to bisecting line
10. Technique is the same for all teeth in mouth

Question 322

What are the steps of ribbond application?

Answer 322

1. Measure the teeth and cut the Ribbond - could be done by making a pattern closely adapting a piece of tinfoil or dental floss around teeth
2. Prepare lingual surfaces and labial interproximals for bonding - etch bond cure
3. Wet the ribbond with resin
4. Apply a thin layer of flowable resin the to the lingual and interproximal surfaces
5. Adapt the ribbond around the ressin filled surfaces including interproximal contacts
6. Remove excess composite
7. Cure the first layer
8. Cover the ribbond splint with a flowable
9. Light cure the covering layer of composite
10. BE VERY CAREFUL WHEN POLISHING

Question 323

What are the steps to TMJ examination?

Answer 323

History taking:
- History of pain or discomfort and general health
- Causative factors – trauma or everyday activity
- Social history

Extra-oral examination
- Symmetry of the facial features
- Signs of vertical dimension loss
- Palpation of masticatory muscles

Palpation and TMJ opening
- Palpation of the TMJ on opening checking for crepitus or clicking
- Assess the range of motion on opening
- Assess the amount of opening - use fingers

Intra-oral examination
- Occlusal analysis

Question 324

What are some of the common TMD disorders dental school wants to focus on?

Answer 324

1. Myofacila pain
2. TMJ hypertranslation
3. Inflammed TMJ
4. TMJ Internal derangement

Question 325

When do you do hot therapy and when do you do hot therapy?

Answer 325

Use cold therapy during initial injury - in order to reduce the symptoms of inflammation.

Use hot therapy if you experience muscle stifness.

Question 326

What are the four stages of mastication?

Answer 326

1. Oral preparatory stage
2. Oral propulsive phase
3. Pharyngeal phase
4. Oesophageal phase

Question 327

What happens during oral preparatory phase?

Answer 327

1. Food enters oral cavity
2. Voluntary mastication and bolus formations

Question 328

What happens during oral propulsive phase?

Answer 328

Tongue elevated and propels bolus to pharynx

Question 329

What happens during pharyngeal phase?

Answer 329

1. Machanoreceptos in the pharynx detect the bolus
2. Soft palate elevates to seal nasopharynx
3. Larynx and hyoid bone move anteriorly and superiorly
4. True and folse vocal cord adduct
5. Epiglotis moves posteriorly and inferiorly
6. Respiration stops
7. Pharyngeal wave occurs
8. Upper oesophageal sphincter relaxes and opens

Question 330

What occurs during oesophegeal phase?

Answer 330

1. Bolus passes to oesophagus
2. Oesophagus contracts sequentially and involuntaraly
3. Lower oesophageal sphincter relaxes
4. Bolus reaches stomach

Question 331

What is the pathway of the jaw closing reflex?

Answer 331

1. Muscle spindles within the muscle of mastication detect stretch
2. Through the first order neuron, which passes through the foramen ovale, trigeminal ganglion into the trigeminal tract nucleus
3. Synapses occurs and through the interneuron, the action potential is propagated to wht trigeminal motor nucleus
4. Synapses occurs in the trigeminal motor nucleus to the muscle of mastication (for example the masseter) in order to generate an appropriate response and maintaining the mandible in anappropriate position during running fo rexample

Question 332

What is the purpose of the jaw closing reflex?

Answer 332

1. To test patients status of the trigeminal nerve
2. To keep the madnible in an appropriate position

Question 333

How does GC Tooth Mousse help with dentinal hypersensativity?

Answer 333

Fluoride usually reacts with calcium in the saliva to form CaF2 which sits on the surface of the tooth and releases fluoride ions as it dissolves over time “slow release device”.

Can occlude dentinal tubules.

Question 334

How does Colgate Neutrafluor 5000 Plus Toothpaste help with dentinal hypersensativity?

Answer 334

Fluoride is able to create lobules and aid in occlusion of dentinal tubules.

Question 335

How does stanous fluoride (SnF) help with dentinal hypersensativity?

Answer 335

1. Precipitation of metal ions on physically occlude dentinal tubule, relieving sensitivity
2. Precipitate is also acid resistant and can act as a barrier against future erosive lesions to an extent

Question 336

How does MI varnish help with dentinal hypersensativity?

Answer 336

1. MI Varnish contains NaF and CPP-ACP dispersed in rosin and ethanol solution
2. When applied, it adheres to the tooth surface and seals exposed dentine tubules
3. Contact with saliva sets the varnish and starts the slow dissolution process, driving the release of fluoride and CPP-ACP
4. Fluoride ions that are released bind with calcium ions in pellicle and plaque to form globules of calcium fluoride.
5. These globules deposit on the tooth surface, providing additional blockage of exposed dentine tubules, enhanced acid resistance and promote calcium and phosphate enriched saliva

Question 337

How to involve the patient? Or what are the ways to involve a patient?

Answer 337

1. Assess patient preferences for shared decision-making.
2. Educate patients about all possible treatment options and how they fit into a patient’s current health status.
3. Discuss patient values and health-related goals.
4. Come to a treatment decision with the patient.

Question 338

What are the 5 pro-inflammatory actions that is caused by smoking?

Answer 338

It induces:

1. Advanced glycation end products
2. Monocyte and marcophage activation
3. Alteration responsiveness to acute pathogens
4. Inflammatory mediator release
5. Th2, and Th17 - type inflammation

Question 339

What are the 5 suppressive effects of cigarette smoke on immunity?

Answer 339

Decreases:

1. Immunity to infections
2. Innate defenses againts pathogens
3. Adaptive immune cell activation
4. Function of natural killer cells
5. Phagocytic uptake of bacteria and apoptotic cells

Question 340

What are the considerations for a patient undergoing dialysis and taking medication?

Answer 340

1. Consultation with nephrologist
2. Platelet dysfunction and anaemia resulting in bleeding tendency should be discussed
3. Heparin anticoagulation can be given to patient who is on haemodialysis - thus maybe try to do a procedure on another day
4. Avoid compression on the arm with the vascular access
5. Do not presribe some drugs - check with MIMS or consult with the renal specialist
6. Look out for renal osteodystrophy - there is weaker bone with those patients so extra care need to be taken care when performing surgery

Question 341

What are the 4 effect of smoking on the oral cavity?

Answer 341

1. Xerostomia
2. Increase is dysbiosis of biofilm
3. Heat damage to the cells
4. Increase in extrinsice staining

Question 342

What type of receptors are PMRs?

Answer 342

They are ruffini-type endings

Question 343

During implant placement - how does some sensation occur?

Answer 343

Due to osseoperception - a type of mechanoreception in the absence of a functional periodontal mechanoreceptive input

Question 344

What are the 4 locations where osseoperception may occur?

Answer 344

1. TMJ receptros
2. Receptors in the muscles
3. Mucosal receptors
4. Periosteal mechanoreceptors

Question 345

What muscles cause referred pain in the ears?

Answer 345

Masseter and lateral pterygoid

Question 346

What location can temporalis cause referred pain in?

Answer 346

Anterior temporalis:
1. Anterior maxillary teeth

2. Eye brows

Posterior temporalis:
1. Posterior molar teeth

2. Just posterior of the temporal muscle

Question 347

What are the 8 aspects of patient centered care?

Answer 347

1. Respect for the patient’s values, preferences, and expressed needs;
2. Information and education;
3. Access to care;
4. Emotional support to relieve fear and anxiety;
5. Involvement of family and friends;
6. continuity and secure transition between health care settings;
7. physical comfort;
8. coordination of care.

Question 348

How do bulk composites cure?

Answer 348

They cure by the use of a photo-initiator (light cure) but they can be cured deeper due to

1. A more translucent material
2. Filling that is more efficient in a present of a photo-initiator

Question 349

What structure is under number 1?

Answer 349

LHS inferior border of the orbit

Question 350

What structure in under number 2?

Answer 350

LHS Condyle

Question 351

What is structure under number 3?

Answer 351

Superimposed over the sinus, malar process

Question 352

What is structure under number 4?

Answer 352

Pterygo-maxillary fissure

Question 353

What is the structure number 5?

Answer 353

Condesnsing osteotitis around the 35

Question 354

What structure is under number 6?

Answer 354

Zygomatic arch

Question 355

What structure in under number 7?

Answer 355

Ear lobe

Question 356

What is structure under number 8?

Answer 356

LHS Inferior Alveolar Nerve Canal

Question 357

What is structure under number 9?

Answer 357

Central Hyoid bone

Question 358

What is the structure number 10?

Answer 358

RHS Styloid Process

Question 359

What structure is under number 11?

Answer 359

RHS Maxillary Sinus

Question 360

What structure in under number 12?

Answer 360

RHS Zygomatic Arch

Question 361

What is structure under number 13?

Answer 361

Primary image of RHS hard palate

Question 362

What is structure under number 14?

Answer 362

Secondary image of RHS palate

Question 363

What is the structure number 15a?

Answer 363

LHS External Acoustic Meatus

Question 364

What structure is under number 15b?

Answer 364

Genial tubuciles

Question 365

What structure in under number 16?

Answer 365

Mandibular notch/oro-pheryngeal space

Question 366

What is structure under number 17?

Answer 366

Nasal septum

Question 367

What is structure under number 18?

Answer 367

Infra-orbital fissure

Question 368

What is structure under number 19?

Answer 368

Nasal cavity/sinus

Question 369

What is structure under number 20?

Answer 369

RHS Maxillary tuberosity

Question 370

What are some of the common errors with bisected angle?

Answer 370

1. Elongation - vertical beam angulation is too shallow
2. Foreshortening - vertical beam angulation too steep
3. Vertical detertor postion - not the entire tooth structure present
4. Contact point of two adjacent teeth
5. Cone cutting

Question 371

What are some of the options to achieve anaesthesia in the mandible?

Answer 371

1. IANB
2. Gal-gates technique
3. Mentla nerve block
4. Supraperiosteal infiltration

Question 372

What are the steps to management of an oral lesion?

Answer 372

1. Take full patient history
2. Thourguh exam including palpations, stretchung and whipping - checking for symmetry
3. Risk factor modification
4. Accurate clinical diagnosis
5. SYmptom relief
6. Reviews/follow up

Question 373

What are the six features are wrong with this OPG and what are the error on effect on final image?

Answer 373

1. Unnecessary artefacts i.e. the glasses - Results in unnecessary object being presented on the DPR, the glasses
2. Patient positioned forward - Anterior teeth blury and too small - spine sen on the film
3. Failure to position the tongue against the palate - large, dark, shadow over the maxillary teeth between palate and dorsum of tongue
4. Head is tilted to the side in the horizontal direction - condyles are not equal in height, nasal structure is distorted
5. Head is turned to one side - seems like the RHS was closer to the detector than LHS - resulting in LHS ramus appearing larger
6. Exposure factors have not been selected properly - the image appears to be blur overall
7. Chin down - the V shape - joker brain
8. Chin up - fraun

Question 374

What are the standard precautions?

Answer 374

1. Hand hygine, as consistent with the 5 moments for hand hygiene
2. The use of appropriate personal protective equipment
3. The safe use and disposal of sharps
4. Routine environment cleaning
5. Reprocessing of reusable medical equipment and instruments
6. Respiratory hygiene and cough etiquette
7. Aseptic technique (the dirty and clena areas)
8. Waste management

Question 375

What are the 5 moments for Hand Hygiene?

Answer 375

1. Before touching a patient
2. Before a procedure
3. After a procedure or body fluid exposure risk
4. After touching a patient
5. After touching a patient’s surrounding

Question 376

How does fluoride affect PEP-PTS system?

Answer 376

It inhibitis enolase - an enzyme which is use if break down of carbohydrates

Question 377

There i s a pleomorphic nuclei with prominent intercellular bridges, keratin pearls in lamina propria. What is the most likely diagnosis?

Answer 377

SCC

Question 378

Which factor decreases densty in bitewings?

Answer 378

Decrease in kVp

Question 379

In cancer treatment, what do analogs inhibit the production of?

Answer 379

Folate and pyrim

Question 380

What is the most common recepto in the oral cavity?

Answer 380

Merkel’s disk for fine discrimination for light touch

Question 381

What do you do with an angry patient?

Answer 381

1. Aknowledge frustrations
2. Say sorry
3. Provide opportunity to ask question and relate their experiences
4. Discuss the potential consequences of the injury
5. Discuss the steps that are taken to prevent that injury from reoccuring

Question 382

What are the requirements for writing a prescription?

Answer 382

1. Patient name
2. Our name and adress of practice
3. Generic drug name
4. Form of the drug aka tablet or capsule
5. Strength
6. Quantity
7. Dose & frequency of administration
8. Our signature
9. Date

Question 383

What are the difference between the atrophic oral lichen planus and biofilm induced gingivitis?

Answer 383

1. Red buccal gingiva
2. Pain on brushing
3. Eating certain foods
4. Condition does not resolve post debridement

Question 384

What are the treatment for disquamative gingivitis?

Answer 384

1. Topical steroid - 0.05% betamethasone diproponate 2x daily for about 7-14 days - continue for 7 days after smptom subside
2. Rinses with 0.2% CHx muhtrinse for 2 weeks seperate to the betamethasone and tooth brushing
3. Avoid spicy foods
4. Brush with soft brissle tooth brush

Question 385

What are the steps for critique of a bitewing?

Answer 385

1. Exposure settings- contrast and density
2. Orientation of detector- dot to distal
3. Horizontal detector placement
4. Vertical detector placement
5. Horizontal beam angulation
6. Vertical beam angulation
7. Central beam position
8. Collimator alignment
9. Sharpness of image
   Overall diagnostic quality

Question 386

How would you restore 15 distal?

Answer 386

Direct bond approach: etch-37 % orthophosphoric acid+ primer+ adhesive + CR
20% polyacrylic acid for 10secs,RMGIC base/liner+ CR

Sectional matrix+ clamp + wedge + ball burnisher/flat plastic

Tofflemire matrix +retainer+ wedge + ball burnisher/flat plastic

LC
Floss (+/- polishing strip if required)