CASE pres Flashcards
1
Q
You have measured the BPE- what is this? Discuss the results and how it influences your treatment of the Patient?
A
The BPE score indicates the level of examination & provide basic guidance on TX.
My patient has BPE 4 in all sextants- This means pockets >5.5mm present in all sextants. As well as bleeding on probing/calculus and plaque retentive factors.
Because we had BPEs of 4s we complete a 6 point pocket chart pre and post treatment as per the BSP & SDCEP Guidelines .
2
Q
Discuss your 6 point pocket chart results?
A
Generalised loss of attachment (consistent with radiographs)
Generalised bleeding (Patient a smoker- reduces gingival bleeding)
No furcation involvement/ mobility of teeth.
Largest loss of attachment- 12mm DL to 44.
Largest pocket- 9mm DB to 46.
3
Q
Why did you select OPT radiography and why?
A
The OPT was selected to see the patient’s bone levels.
This was selected over full mouth periapicals as we would need at least 7 more PA (1-8microsv per radiograph) compared to one OPT (4-30Mmicrosv)
These radiation dosages were are according to the international atomic energy agency.
4
Q
What is your periodontal diagnosis and explain why you have selected it.
A
Generalised Stage 4 Grade C periodontitis, currently unstable with risk factor of smoking.
Generalised- >30% bone loss
Unstable- pockets > 4mm with BoP
Periodontitis- inflammation of Soft and hard tissues.
Stage IIII- Greatest bone loss apical third of the root (46 distal)
Grade C- 70%/age = 2.4 which is >1 so rapid progression.
Risk factors- patient smoked 10 a day for 13 years so 6.5 pack years.
5
Q
Why is smoking a risk factor for periodontal disease
A
Smoking alters the balance present in the biofilm of the mouth triggering an immune system attack.
Increased production of inflammatory mediating cytokines- causing tissue breakdown.
There is reduced gingival blood flow- signs & symptoms of gingivitis are supressed.
Impaired white cell function causing impaired wound healing.
6
Q
What are the modified plaque and bleeding scores and when do you complete them?
A
These are scores graded at each appointment using Ramfjord’s 6 teeth (16 21 24 36 41 44)- This pt doesn’t have all of ramfjord’s teeth- we used the 38 instead.
Used to monitor patient engagement.
Plaque score- 2(visible) 1(on probe) 0 (no plaque)- measured buccal/lingual/interproximal. out of 36.
Bleeding score- 1(Bleeding) 0(no bleeding)- measured buccal/ lingual/mesial/ distal out of 24.
For patient enagement- we want a Plaque score <20%. Bleeding score <30% or >50% improvement.
7
Q
Your treatment plan includes a 3 month evaluation. Why is that?
A
3 months gives enough time for healing and decreased pocket depths for:
Oedema to reduce (causing gingival recession)
Increased clinical attachment due to the formation of the junctional epithelium. This increases tissue tone & causes resistance to probing.
8
Q
What are we looking for at the 3 month patient evaluation?
A
SDCEP- pockets <4mm. Plaque score <15%. Bleeding score <10%
BSP-
Stable if <=4mm pockets (no BoP at any 4mm pockets) and <10% BOP
In remission if <=4mm pockets (no BoP at any 4mm pockets) and >10% BoP
Unstable if >=4mm pockets with BoP
9
Q
What are the different results we can see at the Re-evaluation of the patient’s periodontal disease?
A
According to the BSP guidelines:
**Stable periodontitis **
* <=4mm pockets with no BOP at 4mm.
* BoP <10%
Periodontitis in remission
* <=4mm pockets with no BOP at 4mm.
* BoP >10%
**Unstable periodontitis. **
* >4mm pockets with BoP
10
Q
What is the next part of the treatment plan if the patient returns for the 3 month evaluation and has not achieved the SDCEP or BSP stablility?
A
Reinforcing OHI/ risk factor control/ behaviour change.
Targeted PMPR of the unresponding pockets and re-evaluate.(4-5mm)
Any deep pockets >6mm refer for pocket management or regenerative therapy.
11
Q
Hypothetically the patient’s periodontal treatment was successful what does the supportive phase consist of and how do we determine the appointment interval?
A
Reinforce OH/ risk factor control/ behaviour change
Targeted PMPR if the patient returns with any sites with subgingival pockets/ BoP >=4mm.
Only supragingival on sites <4mm without calculus.
According to the BSP
Patients in remission should be recalled every 3 months
Stable patients should be recalled every 6 months.
Consider- evidence based adjunctive effacious toothpaste/ mouthwash to control the gingival inflammation
12
Q
Discuss the patient’s risk of Oral cancer?
A
3/4 of head and neck cancers are due to cigarette use and alcohol .
Normal risk 2.5 per 100,000
Pt 5x more at risk (as they smoke and drink)
13
Q
How does smoking affect a patient’s oral health
A
Smoker’s keratosis
Leukoplakia
Chronic hyperplastic candidasis (promotes candida adhesion)
Lumps (that could be cancerous)
It alters the components in saliva (leading to a drier mouth)
Oral cancer- Cigarette smoke contains carcinogenic chemicals
Increased risk of periodontal disease
Failed dental treatments
Staining of teeth/dental restorations/ dentures
Halitosis
Black hairy tongue (due to the nictoine staining the papillae of the tongue)
14
Q
What is smoker’s keratosis
A
Trauma found where the tobacco is held from thermal gases which causes a white and brown staining on the patient’s palate.
This is due to a thicker keratin layer (white colour) & melanin overproduction.
Malignancy is not common but can be seen.
15
Q
What is leukoplakia and how is it related to smoking?
A
Leukoplakia is an undiagnosed white patch that cannot be scraped off.
It is a potentially malignant lesion that smokers are x6 more likely to have.
16
Q
Your patient attends with a leukoplakia, what do you do?
A
A Leukoplakia is a pottentially malignant lesion- so we biopsy this to exclude carcinoma and assess for candida.
17
Q
How does chronic hyperplastic candidosis cause damage?
A
- Adherence to host cells
- Hydrolytic enzymes
- Candida hyphae invade deeper causing tissue damage & so we can observe epithelial dysplasia (increased malignancy risk)
18
Q
Why are smokers at increased risk of chronic hyperplastic candiosis?
A
Smoking promotes increased keratinisation in the oral epithelium & smoke constituents increase fungal virulence (ability to cause harm )
19
Q
What is chronic hyperplastic candiosis?
A
A candidal infection associated with smoking.
This cannot be scraped off.
We biopsy leukoplakia to test for this.
It is pre-malignant.
20
Q
What are some clinical predictors of oral cancer malignancy?
A
Age (older >younger)
Gender (female > male)
Site (buccal mucosa low risk. Floor of mouth & tongue- high risk)
Clinical- if it is non homogeneous- verrucous/ ulcerated/leukoerythroplakia.
21
Q
You have requested histopathology of your biopsied site. What are we looking for?
A
Changes in the tissue architecture/ cytology.
Can be:
Basal hyperplasia/ Mild/ Moderate/ Severe/ Carcinoma in situ.
22
Q
What is the most common type of oral cancer ?
A
Squamous cell carcinoma
-Verrucous (outward growing)
-Basaloid (associated with HPV)
-Spindle cell (aggressive)
23
Q
Tell us about the patient’s smoking habits
A
He used to smoke 10 cigarettes a day for the past 13 years.
Started when he was 16.
He is currently using a vape to help him quit. Positive- not smoking tobacco. Negative- we don’t know the long term implications.
24
Q
List the 7 red flags for oral cancer.
A
- Ulcer persisting >2 weeks
- Rolled borders with necrotic centre
- Speckled- red and white appearance.
- Cervical lymphadenopathy (enlarged >1cm/ firm/ fixed tethered/ cannot move/ not tender)
- Worsening pain (neuropathic/ paraesthesia/ dysaestheisa)
- Weight loss (i.e. local or systemic effects)
25
The imediate treatment included extraction of the 37. Discuss the special tests used to diagnose this tooth.
What was the diagnosis
The patient was complaining of pain on the LHS
Radiograph- 37distal cavity with radiolucency on the 37 mesial root.
Sensibility testing-
TTP (Inflamation & swelling of the PDL within the bone)
Endo Frost- pain on cold (A delta fibres triggered telling us of pulpal involvement)
Symptomatic Irreversible pulpitis with symptomatic apical periodontitis.
Symptomatic irreversible pulpitis- Pain keeps patient up at night Sharp pain on thermal stimuli.
Symptomatic apical periodontitis- Radiograph shows an apical radiolcuent area. There is a painful response to percussion.
26
Define symptomatic irreversible pulpitis.
Findings indicate the vital inflamed pulp is incapable of healing.
Sharp Pain on thermal stimuli
Pain lasts 30s after stimuli is removed
Patient is kept up at night by pain (increased pressure in the pulp chamber if the patient lies down)
Typically over the counter analgesics are ineffective.
27
Define symptomatic apical periodontitis?
Inflammation- usually of the apical periodontium.
Painful response to biting/percussion/palpitation.
This can be associated with an apical radiolucent area.
28
Discuss all the treatment options considered for the 37?
Accept (but pt in pain )
Pulp extirpate- 38 was mesioangular impacted. Difficulty clamping for dental dam & achieval of moisture control needed to pulp extirpate. It would also be difficult to keep the distal restoration clean due to the impacted 8.
Extract.
29
The immediate treatment included extraction of the 36. Discuss the special tests used to diagnose this tooth.
What was the diagnosis
Clinically- Grossly broken down and carious.
Radiographically- caries MOD and radiolucency around the distal root.
Sensibility testing-
TTP NIL
Endo Frost - NIL.
Diagnosis- Previously treated with asymptomatic apical periodontitis.
Previous RCT.
Asymptomatic apical periodontitis- no clinical symptoms (TTP) but there is an apical radiolucency present on the distal root.
30
What does previously treated mean?
Tooth has been endodontically treated and the canals are obturated. The tooth does not respond to thermal or the EPT.
31
What does asymptomatic apical periodontitis mean?
Inflammation and destruction of the apical periodontium that is of pulpal origin
There are no clinical symptoms but there is an apical radiolucent area.
32
What were the treatment options considered for the 36?
Accept- Not currently causing patient pain. But tooth needs extracted due to gross caries
Extract- Doing this at the same time gives us more space mesially for the 37 extraction.
33
Discuss the extraction technique for extraction of the 36 and 37?
LA
Luxator to cut the PDL
Couplands elevator
Cowhorns for 36. Molar forceps for 37.
Idea- to extract the 36 first to provide space for the 37 extraction.
34
Why is the 48 not restorable.
Radiographically- 48mo gross caries.
Will not be enough tooth tissue left once caries is removed.
48- has moisture control difficulties.
35
Discuss the treatment options for 48
Accept- as not currently causing the patient pain.
Coronectomy- ruled out as likely caries has spread & infected the root.
Extraction- gross caries is at risk of causing the patient pain down the line. Roots are not close to the IADC. Royal college guidelines indicate Asymptomatic but diseased teeth should be extracted. (Not Near the IADN)
36
Discuss the extraction technique for the 48?
LA
Luxator to cut the PDL
Couplands elevator
Cowhorns (as very broken down)
37
Discuss the treatment options for the retained 36 root.
About 8mm in size.
Accept & monitor- with risk of extraction at future date. No current periapical lucency and the patient is not currently in pain.
Extract-
This is a decision the patient made:
He decided at present to retain the root & monitor as symptom & caries free with no PA radiolucency)
But patient was informed of the risks- of infection/ caries and extraction at a later date.
38
What do we inform the patient of to consent to an extraction?
*** Reason for extraction;
**Risks of extraction:
Pain/ Swelling/ Infection/ Bleeding/ Bruising/Dry socket/ Damage to adjacent teeth/ sensitivity/ retained roots/May need further treatment
Upper teeth- maxillary sinus involvement (OAC/OAF/
Lower teeth- IADN. Risk of mandibular fracture lone standing tooth. Risk of extraction becoming surgical.
**Benefits of extraction**
**Other treatment options.** **Risks of not having treatment**.
39
What do we do for after extraction?
Check socket for:
leftover roots
Socket filling up with blood.
Get the patient to bite down on gauze for 10/15 minutes
Provide aftercare instructions.
40
How does the patient smoking affect the extraction
Smokers are at increased risk of dry socket. Smokers who smoke >5 cigarettes within the 1st 24 hours are 3x as likely to have dry socket.
Smoking is causing a reduced blood supply (affecting clotting factors getting to the area)
41
What Diet advice would you give the patient?
Swap out the cans of mango water consumed at breakfast (contain 15 cans of sugar)
Swap the 2 teaspoons of sugar for sweetener.
Avoid drinking sugary drinks such as the can of mango water/ irn bru between meals.
If he is drinking fizzy drinks to try and drink the sugar free alternatives.
Patient also said he comonly drinks Dragon soops- over 50g of sugar per glass.
42
The patient has filled out a diet diary for his caries.
Discuss your findings.
Can of mango water at breakfast- The rubicon can 15g grams of sugar.
Irn Bru- Full fat irn bru 7.5g per glass and 15g per can.
Patient also asked about his alcoholic drinks- commonly drinks Dragon Soops (similar alcoholic drinks have over 50g of sugar per can)
Food- he is not a snacker.
Has 2 sugars with his coffee
43
Compare the endo frost test to the ethyl chloride test?
Ethyl chloride is sprayed on a cotton wool pledget and touched against the tooth.
Chloroethane's low boiling point creates a localised chilling effect.
Endo frost is a propane/ butane/ isobutane gas mixture that produces a colder temperature than ethyl chloride.
44
What is the Endo frost test?
This is a thermal sensibility test .
Endo frost is sprayed on a cotton wool pledget and touched against the tooth.
Endo frost is a propane/ butane/ isobutane gas mixture. This produces a cold temperature -50 degrees
This is testing the A-delta nerve fibes.
If the tooth is still alive, the patient should feel the cold & if the pt has pulpitis. It will be a painful sensation.
45
What is the purpose of the TTP test?
Any inflammation of the PDL and swelling around the root would cause the patient to feel pain and react when you tap the tooth.
It important to tap multiple teeth in a random order.
46
Discuss the treatment options for the 46d?
Radiograph showed secondary caries underneath the amalgam restoration.
Options:
Accept- with risk of caries progression.
Replacement of filling
Amalgam- Less likely to fail/ doens't need moisture control
Composite- aesthetic.
Decision-
Amalgam of 46d due to moisture control difficulties (not enough tooth tissue on the 48 to clamp for dental dam)
Patient wasn't bothered about the aesthetic.
47
You have selected to replace the 46d amalgam restoration with another amalgam restoration. What lining material should be used and why?
Vitrebond which is a RMGIC.
This protects the tooth from the thermal stimuli due to heat being conducted through the metal fillings.
It prevents microleakage.
It also releases fluoride.
48
Why did you not line the 46d amalgam with Dycal?
Dycal is CaOH and this wasn't used due to the difficulties with moisture control.
49
Discuss the treatment options for the 14 23 24?
These buccal abrasion cavities are to be filled.
The gold standard is RMGI due to asthetics and moisture control.
This problem is likely to be due to his toothbrushing habits (no other abrasive habits) and so we would also highlight this when providing him with OHI.
50
Discuss the treatment options for 16md?
Radiographically-
There is secondary caries of the distal amalgam restoration.
There is primary caries of the meisal.
The caries is deep- so there is a risk of pulpal exposure- We discuss this risk of that the decay could be bigger than the radiograph shows which could result in further treatment.
Could be restoration, could require indirect restoration dependent on extent of the carious lesion. (i.e. if cusps are undermined)
51
The patient is experiencing pain in his tooth. What do we expect would make the pain worse?
Cold water- causing a pain that lingers for more than 30s
52
How is the patient trying to quit smoking
The patient is using a vape (an e-cigarette)
53
You have said that the patient drinks 12 units of alcohol a week. How did you find this out?
On further discussion with the patient he informed me he drinks 3 dragon soops on a saturday night.
Dragon soops contain 3.75 units a can so
3.75x3 = 11.25.
54
Describe the sebaceous cyst present on the paient's face .
2cm in diameter
Located on the Left infraorbital medial part of the cheek.
Lump
homogeneous colour
Not tender to palpate.
Pt was complaining that it had grown in size.
According to the notes in 2020 it was only detectable by palpatation. However when he presented in 2023 it was detectable visually
55
The 38 is impacted- describe the impaction of the 38
The 38 is
mesioangularly impacted with a moderate depth.
This means that the 8 is at a mesial angle to the 7.
The moderate depth refers to the corwn of the 8 being related to the crown AND the root of the 7.
56
In future, if the 38 became carious- what other radiographs would we want prior to extraction?
The royal College of surgeons guidance recomends a panoramic radiograph to see the relationship.
If the relationship with the IADC is influencing treatment e.g. tx coronectomy- we can use a CBCT. This could alter treatment if the IADC & the tooth aren't closely related- allowing extraction.
57
What do we look for on a radiograph that indicate there may be a risk of damage to the inferior alveolar nerve.
What is the study that discusses them.
4 root indicators:
Darkened roots
Deflected roots
Narrowed roots
Dark & bifid roots
3 nerve indicators:
Interuption of the lamina dura
Narrowing of the IADC
Diversion & deflection of the IADC
Rood and Shehab 1990.
58
How many roots does the 38 have?
2 roots.
59
How many roots does the 48 have?
2 roots.
60
Is there caries present in the 38?
We did not note anything clinically, then the periapical looks like it could be, however after another check of the occlusal surface- the tooth is clinically sound.
61
The patient has stage IIII grade C periodontal disease. Do you think the patient is motivated enough for the treatment to be successful and why?
Yes- he is attending all of the appointments and is receptive to the advice that has been given to him.
He is also a motivated person shown through his challenge to quit smoking. He was already quitting when I first saw the patient and had decided that vapes would be his preferred choice for quitting.
Patients who are motivated in one part of treatment are more likely to be motivated in another.
62
You have said that at present there is no reconstruction until the periodontal disease is stable.
What if the periodontal disease never becomes stable- Would you consider reconstructing with a denture to replace the missing teeth?
No,
At present the patient is not concerned about the gaps between his teeth aesthetically as they are back teeth.
Functionally there is no need for a denture as on the left side of the patient there is a gap on the upper and the lower. There is only 1 tooth that is out of occlusion which is the 18.
63
What is amalgam?
Give the setting reaction.
A metal alloy filling material containing:
Mercury
Silver
Tin
Copper
Silver and Tin form an intermetallic compound (Ag3Sn) which reacts with Hg to form amalgam.
64
What material did you choose for the buccal abrasion cavities and why?
I used Self Cure Glass ionomer cement.
It has a similar thermal expansion to dentine
Low microleakage
Stable chemical bond.
Does not contract on setting (good for buccal abrasion cavities as we don't want material shrinking in the cavity)
65
You completed the extraction of the 36 and 37 in emergency.
If the extraction became surgical- what flap design would you chose. Justify your answer.
2 sided flap with the relieving incision on the distal (To avoid damaging the Mental nerve)
66
What does an exacerbation of asthma cause?
Narrowingof the lower airway, trapping. air and causing the individual difficulties to exhale.
67
What is asthma?
Asthma is a chronic condition characterised by exacerbations of airway
hypersensitivity, bronchoconstriction, mucus secretion and inflammation of the lower
airways.
Acute exacerbations are frequently caused by respiratory viruses dust/ smoke/ allergies
68
Your patient attends his appointment and starts wheezing. You suspect it may be an asthma attack.
How do you deal with this?
What do you expect to see. :
A- For obstructed airway (ask them to talk)
B- increased breathing. A wheeze due to bronchoconstriction and excess mucous production.
C- increased heart rate
D- Alert
E- get patient into tripoid position
If they cannot complete a sentence- call an ambulance
If mild/moderate- give patient 2 puffs of a salbutamol inhaler (100micrograms per actuation)
If severe- Spacer device - used when patient has lost ability to hold their breath
We use the spacer for 20s- preventing respiratory acidosis (rebreathing their own CO2)
69
How does asthma affect your dental treatment?
Analgesia - avoid aspirin and other NSAIDs (causes bronchospasm)
Sedation- IS not IV for mild or moderate cases in case of patient respiratory failure.
Asthma affects their GA ASA classification
* Mild well controlled asthma ASA II.
* Moderate asthma ASA III
70
How can asthma generally impact his oral health?
Dry mouth (patients are more likely to breathe through their mouth)
Asthmatic patients can have a chronic cough at night (causing reflux of gastric acid and increasing risk of palatal erosion)
71
How does a salbutamol inhaler treat asthma.
Short acting beta 2 adrenergic agonist.
It stimulates beta 2 receptors to cause smooth muscle relaxation.
This is a bronchodilator.
72
How does his Salbutamol inahler affect his dental health ?
Prolonged use of a beta 2 agonist is associated with :
Xerostomia (Diminished salivary production and secretion
Increased caries (associated with diminished salivary production & secretion (beta 2 receptors also located in parotid + other salivary glands)
GORD symptoms- Beta 2 agonist causing smooth muscle relaxation of the lower esophageal spincter.
Erosion- Reflux associated with beta2 agonists.
73
What other ways can asthma be treated?
When would these be used and how can this impact his oral health?
Using low dose corticosteroid inhalers
High dose corticosteroids
Long acting beta 2 agonists
Steroid tablets
A corticosteoid inhaler is selected if a patient is using the b2 agonist more than 3 times a week.
These are selected if the patient's asthma is more severe.
74
If the patients asthma became worse and they started using a corticosteroid inhaler- how would this affect their oral health?
Corticosteroid inhalation causes local immune suppresion .
Increasing risk of infection:
* Pseumomembranous candidasis- White soft plaques/ painful erythematous/ ulcerative surface.
* Increased risk of gingivitis and periodontitis
*Causing Ulcers.
Xerostomia
Cough
Taste disturbance (infection &dry mouth)
Adrenal insufficiency (Inhalation reduces the systemic dose compared to oral corticosteroids but there is still a risk.
Examples: Fluticosone/ beclamethasone
75
What are the symptoms of asthma?
Breathing Difficulties
Wheezing
coughing
Chest tightness
Shortness of breath (Dyspnea)
76
What are some side effects of a salbutamol inhaler
Tremor
Tachycardia
While salbutamol is a beta 2 agonist. it still acts a weak beta 1 agonist.
On overdose the selectivity can be lost (Need to drain 7 devices to overdose)
Causing activation of beta 1 adrenergic receptors in the heart increasing force and rate of contractions.
77
Why is the patient's family history of periodontal disease relevant?
"Family history of periodontal disease or early tooth loss may also be relevant and indicate a patient with a higher risk of susceptibility"
International journal of dentistry- Da silva et al found that polymorphisms associated with interluekin has a significant association with periodontal development
-polymoprhism (variants in the gene)
-Interleukin 1 a proinflammatory mediator whcih stimulates release of enzymes and osteoclasts to cause increased tissue destruction.
78
What is the impact of drinking alcohol on a patient's oral health?
Oral cancer (38x risk when combined with smoking)
Nutritional deficiencies (Oral ulceration/ glossitis/ Angular cheilitis/ Gingivitis)
Dental neglect- drunk people are less likely to look after their oral health (caries/periodontal disease)
Dental erosion- due to alcohol acidity, Vomiting after drinking too much.
Recurrent apthous stomatitis (Nutritional deficiency)
79
How can drinking alcohol affect the dental treatment of a patient?
It affects liver function-
Drug metabolism
-Reduced drug metabolism so affects
LA (articaine- processed in tissues not liver)
Analgesia (Paracetamol. NSAID avoided due to bleeding risk)
Sedatives (avoid IV- Synergistic effect +risk of vomitiing or inhalation of vomiting.)
Antibiotics (Avoid metrondiazole bad reaction with alcohol)
Clotting factors
-Be wary when extracting
-NSAIDs avoided due to bleeding risk in GI
Long term alcohol use can cause- Steatosis-> steatohepatitis-> Cirrhosis
Consent- if patient attends under influence of alcohol .
Post extraction advice- Patient not to drink for 24 hours.
80
What has caused the caries of the 37?
Mesio angular moderate impaction of the 38.
This acts as a plaque trap and prevents patient access for cleaning of the distal of the 37 resulting in caries.
81
Where did you measure the deepest site of bone loss
46 distal
70% bone loss.
82
Is there caries present on the 38?
While the periapical looks like there could be we checked again clinically and the tooth is clinically sound.
This is a tooth that would be monitored.
83
What are the oral implications of vaping?
On a patient using vaping to quit smoking:
They started with an unhealthy situation (smoking impact on their mouth)
So there will be an improvement in oral health compared to smoking (No tobacco effects- tar/ carbon monoxide-carcinogens and oral cancer)
On a patient who wasn't smoking.
Starting in a healthy situation-
*nicotine not a risk factor for periodontal disease*
We don't know the long term impacts
84
What are the likely causes of a buccal cervical abrasion cavity?
These are likely due to forceful toothbrushing.
Toothbrush abrasion commonly presents at the cervical region of canines and premolars like in this patient (14,23,24)
In the patient's dental history he is brushing his teeth for 3 minutes twice a day so the excessive force for the longer period of time could have caused the abrasion of these easier to access teeth. .
85
Can you talk me through how a patient with asthma is treated?
Patients taking a long acting beta 2 agonist also need to take an inhaled corticosteroid (due to the risk of heart disease)
86
So your patient is currently a smoker- Did you any provide smoking cessation & What did you talk to him about?
The patient had already decided to quit smoking prior to attending.
However I encouraged this decision by
highlighting some of the benefits of quitting smoking would have on the patients oral health that he was unaware of.
Such as reducing the patient's risk of:
* Periodontal disease
* Failed dental treatments
* Oral cancer
* Staining of teeth/dental restorations/ dentures
* Halitosis
* Nicotinic stomatitis (smoker's palate)
* Black hairy tongue (due to the nictoine staining the papillae of the tongue)
As well as benefits to the patients overall health:
* Reduced risk of lung and oral cacner
* Improved lung function & decreased coughing + shortness of breath
* Taste and smell sharpening.
I also offered him a referal to recieve specialised help however he said that he was looking into the Easterhouse Smoking clinic himself. (Which offers telephone support at present)
87
How can you continue smoking cessation throughout patient appointments?
Ask the patient how the process of quitting is going.
Encouragement of any progress made.
Also the imporance of encouraging them if they are struggling or take a cigarette
As the average number of times published for a smoker to quit varies significantly-
American Cancer society estimates 8-10 quit attempts. BMJ article from the Ontario Tobacco Research Unit estimates it could be as high as 30 times over a patients life.
Encourgament of the use of E-cigarettes as they have quit smoking tobacco.
88
What is a vape?
Battery powered devices that stimulate the sensation of smoking by heating up a liquid typically containing flavouring additives and nicotine to stimulate the sensation of smoking.
These are not licensed medicines for prescription by the NHS for smoking cessation unlike nicotine patches/tablets/ gum
89
Have you discussed the risk of vaping for the patient?
It still contains nicotine:
Which raises your blood pressure and spikes your adrenaline, which increases your heart rate and the likelihood of having a heart attack.
Side effects of vaping- throat and mouth irritation, headache, cough and feeling sick- according to a cochrane systematic review.
There is not alot of research about vaping at present.
But the european union SCHEER has highlighted concerns regarding:
-Irritable effects on the respiratory system
-effects on the cardiac system.
The CDC has raised concerns about some of the other chemicals contained in vapes (e.g. Cancer causing chemicals/ Flavouring suhc as Diacetyl which is linked to serious lung disease/ heavy metals such as nickel tin or lead/ ultrafine particls that can be inhaled deep into the lungs)
90
What is the recommended weekly alcohol intake?
No more than 14 units of alcohol a week spread evenly over 3 or more days. With several alcohol free days.
91
What is a unit of alcohol?
8g or 10ml of pure alcohol.
(a single shot contains 25ml of spirits)
92
Why do you think his dad lost his teeth quite young?
His dad may have had bad oral hygiene.
There is also a familial link associated with periodontal disease.
"Family history of periodontal disease or early tooth loss may also be relevant and indicate a patient with a higher risk of susceptibility"
93
Did he previously have the sebaceous cyst removed and it has returned? or was it never removed?
He had been referred to the QEUH for removal of the sebaceous cyst. However, did not recieve his appointment.
94
You have mentioned that this patient has gingival recession.
Can you please classify this recession.
Recession type 2- The buccal attachment loss is greater than the inter-proximal attachment loss.
95
After periodontal treatment there is increased sensitivity.
What has caused this and how can you treat it?
Increased gingival recession.
We can use desensitising agents/ fluoride varnish/ dentine bonding agents to decrease oversensitivity.
96
Can you talk me through the classifications of recession?
Type 1- gingival recession with no loss of IP attachment
Type 2- gingival recession where the buccal attachment loss is > than the IP attachment loss
Type 3 - Interproximal attachment loss is greater than buccal attachment loss (there is nothing interproximal left)
97
What percentage of radiographs should be graded as acceptable?
For digital imaging no less than 95% should be graded as acceptable.
98
What are the risks of leaving the root of the 36 in situ?
They could become carious/ infected/ continue to erupt & require removal at a later date.
There is also the risk of cyst formation (Radicular cyst- associated with a non-vital tooth)
99
In future, if the 38 became carious- what problems could we encounter?
How could you overcome this?
The relationship of the 38 with the IADC as seen on the OPT is a concern if this tooth becomes carious.
The roots of the 38 are darkened.&there is loss of the upper lamina dura line of the IADC.
This is a concern as there is a risk of permanent <1% or temporary 10-20% damage to the inferior alveolar dental nerve (Lower lip and chin supply)
Tx options:
Coronectomy (only an option for a patient with minimal or no caries)
100
What is a coronectomy?
An alternative option to surgical removal when there is increased risk of IAN damage with extraction.
When the crown is removed with deliberate retention of the root adjacent to the IAN.
This has a reduced risk of damage to the IAN.
101
What are the risks associated with a coronectomy?
Nerve injury due to trauma from removing the crown (causing roots to press on the nerve)
If the root is mobilised during crown removal (entire tooth must be removed due to the infection risk)
Roots could become infected.
Can get a slow healing/ painful socket
Roots may migrate later and begin to erupt through the mucosa (requiring extraction)
102
How do we complete a coronectomy?
Flap design - 2 sided flap (distal relieivng incision of the 8 and incision around the neck of the 7.
Transect the tooth 3-4mm below the enamel crown.
Pulp is left untreated to heal over
Irrigate the socket with saline
Replace the flap (don't routinely prescribe antibiotics)
Follow up at 1-2 weeks. At 3-6 months then at 1 year.
103
What guidelines do we follow for treatment of 3rd molars
Royal college of surgeons.
104
Why did you sensibility test a tooth that has been root canal treated previously?
I used sensibility testing on the 36 and 37 prior to sending the patient for radiographs.
So I did not know the 36 had been root treated at that point.
105
What is the sebaceous gland?
A holocrine gland found in association with hair follicles.
106
How is a sebaceous cyst formed?
When the opening to a sebaceous gland of the hair follicle becomes blocked.
Sebum is still produced but it cannot escape to the outer skin surface. This produces a pathological cavity containing oil.
These are benign.
107
What is another name for a sebaceous cyst?
Epidermoid cyst
108
What signs of this sebaceous cyst make it less likely to be malignant?
It "started with a tiny spot" in 2019.
It has grown slowly over the past 4 years.
Not causing the patient any pain
One of the signs :
-visibility of a superficial dark spot which represents the obstructed follicle causing the isease.
109
What can often cause a sebaceous cyst?
Acne
Sporadic due to Gardner's syndrome
Sporadic due to Gorlin's syndrome
Patients taking cyclosporine.
110
What is Gardner's syndrome?
An autosomal dominant disease characterised by numerous adenomatous polyps lining the intestinal mucosal surface.
Other extracolonic manifestations including osteomas and epidermoid cysts.
111
What is Gorlin's syndrome?
An autosomal dominant inherited syndrome presenting with:
Palmar and plantar pitting
Multiple basal cell carcinomas
Multiple odontogenic keratocysts.
1 in 560,000 in united kingdom.
112
What is a sebaceous cyst?
A benign capsulated subepidermal nodule filled with dense keratin and often calcifications and cholesterol.
which can contiune to grow in size.
113
How will the sebaceous cyst be managed by Max fax?
They will complete an ultrasound assessment.
To check if it is:
* well defined (easy to draw round)
* smooth margins
* Mobile in surrounding tissues
* no/little internal vascularity (mostly peripheral).
* no cervical lymphadenopathy.
114
Why did you not re-root canal treat the 36? or Root canal treat the 37?
They were grossly carious and unrestorable
36- Gross caries has made it unrestorable due to the loss of the crown- no ferrule present & inability to be adequately isolated.
37- Difficulty to achieve isolation due to the impacted 38. This impacted 38 would also make it difficult if a restoration was placed to keep the margins of the 37 restoration clean.
115
What does the S3 mean in the S3 guideline ?
S3 format is the highest level of guideline production considering both a systematic apprasial of published evidence and clinical experience.
116
What options were discussed to fill the missing spaces?
The patient had not presented with any complaints regarding the missing teeth or I do not have any functional concerns regarding the gap.
This is because there is a gap on the upper and the lower which leaves 1 tooth out of occlusion (the 18)
Therefore, I have decided that any reconstructive treatment will not discussed until the patient's periodontal disease is under control.
117
The pt expresses concerns about the missing space.
What options are available to fill the missing space of the 35/36/37 ?
* Accept space
* Denture
* Implant (dependent on bone levels)
* Bridge- Would be difficult due to mesio-angular impaction of the 38 (Abutment teeth would not be parallel- so bridge would not fit)
118
Your patient has a limited medical history. How did you ensure you had covered everything in the medical history?
What questions did you ask?
I used a systems approach to ensure we had not missed anything. Asking if they had any:
Problems with their:
Heart
Endocrine system (Such as diabetes)
A( bleeding)
Lungs
A (joints)
Bleeding
Liver/ Kidney
E- brain e.g. epilepsy
S- stomach or GI tract.
119
There is a Deep filling with secondary caries on the 17.
How can we avoid exposing the pulp when removing the caries underneath this tooth?
We could consider using :
**Stepwise**-
Avoiding pulp exposure in teeth with deep carious lesions by a two step removal technique.
Stage 1 Selective caries removal & a temporary restoration- inhibitingf urther progression of caries & reactionary dentine to be laid down.
Stage 2- 6-12months later increases the distanc of the pulp from the carious lesion to reduce the chance of pulpal exposure when removing all the caries.
**Selective caries removal-** Removal of sufficient carious tooth tissue to enable an effective marginal seal to be obtained with a bonded adhesive restorative material- inhibiting further progression of residual caries)
120
What are some predisposing factors for dry socket?
* More common in molars
* More common in the mandible
* Smoking due to the reduced blood supply.
* Local anaesthetic with vasoconstrictors
* Excessive mouth rinsing post extraction
* Excessive trauma during the extraction
121
What is dry socket?
A slow healing socket due to partial or full loss of the blood clot.
This is not associate with infection.
Main symptoms of intense pain/ bad smell/ bad taste.
It should start about 3-4 days after extraction and takes 7-14 days to resolve.
122
How can we treat dry socket?
1. Radiograph to ensure that something else isn't causing the pain.
2. Reassure the patient that there is nothing seriously wrong but advise them on analgesia
Then we can:
* LA block & gently irrigate the socket with warm saline- to wash out the food that has gathered.
* Curettage/ debridement- scrape and clean out the socket to encourage bleeding & new clot formation.
* Antiseptic pack to fill up the socket. and stop food and debris getting in.
* Alvogyl- packed in the socket.
* Teach the patient to wash out their own socket.
123
What makes a tooth restorable?
Apical:
Mobility- grade. 1 or less?
No root fractures
B-
Adequate bone levels >50% of bone left
C-
Is there a ferrule?
Is there a favourable occlusion.
Can it be adequately isolated for restoration purposes? (Subgingival caries is more difficult for maintaining moisture control)
No cracks in the tooth.
124
What is a vertical bony defect?
Where the apical end of the pocket is located below the alveolar crest.
125
What is in the code 4 pathway for perio treatment?
If there is a BPE code 4 or obvious evidence of interdental recession.
1. Appropriate radiographic assessment.
2. Full periodontal assessment (6PPC)
3. Is it MI pattern. Localised or Generalised.
4. Stage/Grade/ Status/ risk factor
126
The patient is not registered. What does this suggest?
It suggests that the patient was an irregular attender
He called up his dentist with this initial complaint and was informed that he was no longer registered with the dentist. This is likely to happen to a patient that they do not see regularily.
127
What further advice would you give to the patient regarding his oral hygiene?
Showing him how to brush his teeth less agressively to avoid further abrasion to his teeth.
Ensuring that he is using the right size of interdental brush to adequately clean the spaces (Interdental brushes- bristles engage the teeth without damaging them)
Showing the patient to brush the teeth and gums using the IDB not just the space.
Mouthwash- Advising the patient to use mouthwash at a different time from brushing to avoid washing away the fluoride in his mouth after toothbrushing.
128
What advice would you give the patient about his alcohol intake?
While he is under the weekly recommended alcohol limit (12 rather than 14)
I would advise him that drinking all his units on a saturday would be considered binge drinking and it is advised that the weekly limit of alcohol units should be spread evenly over 3 days with some non-drinking days in between.
129
What are the benefits of retaining roots?
Patient does not need to undergo a surgical extraction to remove the root.
It can maintain alveolar bone for prosthodontic purposes.
130
How would you monitor the 36 retained root?
Clinically- for any symptoms of pain/ infection/ root erupting towards the surface..
Radiographically- Looking for presence of a radiolucency around the root.
131
If the patient had decided he wanted to have the 36 retained root extracted and it became a surgical extraction. What flap would you use ?
2 sided flap with the relieving incision on the distal (To avoid damaging the Mental nerve)
132
What would you tell the patient to reassure them in terms of a surgical extraction ?
The patient will be given local anaesthetic so will feel pressure, not pain.
The gum will be lifted up to help the surgeon see better.
There may be drilling and water from the drill.
Stitches will be used to hold your gum in place after the extraction.
There may be damage to the adjacent teeth.
We would also explain the post-operative complications.
Specialists complete these procedures all the time so are well experienced and have the necessary equipment to deal with it.
133
What is the risk of permanent nerve damage to the Inferior alveolar dental nerve from extraction of a 3rd molar ?
<1%
134
What is the risk of temporary nerve damage to the inferior alveolar dental nerve from extraction of a 3rd molar?
20%
135
How do we consent a patient prior to periodontal disease?
We get the patinet to sign a periodontal consent form as proof that the patient knows what is going on and what they need to do.
The patient needs to know:
-That they have periodontal disease
-That it is not curable
-That it is in their control to make it better.
We need to provide them with the treatment options- Do nothing/Perio tx/ Extraction/ periodontal surgery.
We need to discuss what will happen if they don't control their periodontal disease- Inflammation/ tooth mobility/ tooth loss.
We need to discuss what will happen if they do- less bleeding/ less swelling (black triangles)/ gums going from red to pink/ Gum recession and lengthening of teeth/ Sensitivity- recession exposes more root= more sensitive.
136
What pulpal diagnosis does the pain history suggest?
Irreversible pulpitis-
Pain lasts for hours.
Pain woke them up at night.
Pain was spontaneous (as it woke him up)
Sharp pain due to thermal stimuli.
137
Why might the 16 have fractured?
The 16 was an amalgam restoration.
Over time amalgam can undergo creep- this is when the repeated low force on the material changes it's shape.
This affects the marginal integrity and causes ditched margins. These ditched margins are vulnerable to fracture
138
How did you come to the pulpal and apical diagnoses on the 36 and 37 ?
Using the AAE diagnoses-
139
Do you have any concerns about the Anatomy imaged in the OPT?
No-
Mxillary sinus
Floor of the orbit
Ethmoid sinus
Haller cells (ethmoid air cells)
The reassurance of the anatomy is that the radiolucencies are all symmetrical and they have remained unchanged since the 2017 OPT.
140
Why did you use Endo frost to sensibility test?
To reproduce the symptoms described by the patient & test if the pulp nerve fibres can respond to the stimulus applied to the tooth.
141
Why did you use TTP to sensibility test?
To find out if there is inflammation of the periodontal ligament.
142
Why does the pulp get smaller in older patient?
Secondary dentine is laid down after primary dentine formation is complete.
This means the pulp is further away but reduces the ability for regeneration.
143
How does previous treatment of the tooth affect the pulp?
When we get close to the pulp tertiary dentine is laid down, causing the pulp to shrink back.
Tertiary dentine can be:
Reactionary- in response to a mild stimulus & laid down by primary odontoblasts
Reparative- in response to an intense stimuli that destroys primary odontoblasts and. is laid down by secondary odontoblasts.
144
How does smoking cause oral cancer?
Some of the chemicals in tobacco are carcinogenic meaning they can cause genetic changes in the cells of the mouth leading to the development of oral cancer.
145
After step 3 of S3 guidelines the patient still has pockets >6mm.
What further treatment options could be offered?
Referal for:
Access flap periodontal surgery
Resective periodontal surgery
Regenerative periodontal surgery.
146
What is V/Q mismatch?
When some alveoli have V/Q >1 and some have a V/Q <1 impairing O2 and CO2 trasnfer.
V= ventillation
Q- perfusion.
Ratio of ventilation to blood flow.
147
Discuss the anatomy of the lungs
Conducting zone & respiratory zone.
Conducting= trachea/ bronchi/ non-respiratory brochioles/
Respiratory- respiratory brochioles/ Alveolar duct/ alveolar sac
Alveoli provide elastic recoil for the lungs.
Gas moves over the alveolar wall by diffusion between the alveolar air and pulmonary capillary blood.
148
What investigations are used for asthmatic patients?
Peak expiratory flow rate- How much air the patient can force out in 1 second. (Will be less than normal )
Spirometry- measures flow and capacity
Looks at FEV1 : FVC which is ratio of forced expiratory volume to forced vital capacity. In asthma Ratio <70% and FEV1is improved using bronchodilators.
149
How does a corticosteroid treat asthma?
This is an anti-inflammatory which switches off the inflammatory reaction to cause the bronchi to reduce in size.
150
Discuss the remission of childhood asthma
Often childhood asthma patients can enter remission (Where they do not have any symptoms and have not needed their medication in >2 years.
However Boulet et al found that asymptomatic asthmatics still had a higher elvel of eosinophils and mast cells compared to healthy individuals.
Telling us there is still inflammation & a risk of asthmatic relapse in the future.
Eosinophil (accumulate in site. of infection releasing inflammatory mediators that can cause tissue destruction)
Mast cells( cause smooth muscle constriction)
151
What causes a radicular cyst?
The chronic inflammation at the apex of the tooth due to pulp necrosis of a non vital tooth.
152
What are the radiographic features of a radicular cyst?
Well defined/ round/ oval radiocluency.
Corticated margin continuous with the lamina dura of a non-vital tooth.
153
Describe the formation of calculus deposits.
Calculus is mineralised dental plaque that adheres to the tooth surface.
It is commonly found supragingivally opposite the opening of the major salivary ducts (sublingual)
154
How does the loss of interdental papillae affect the management of this patient?
The type of gingival recession dictates what treatment can be done. Type 2 gingival recession- no treatment .
155
What painkillers did he take and how do they work?
Paracetamol- Paracetamol blocks the positive feedback of hydroperoxide causing the inhibition of COX.
156
What would be your differential diagnosis for the sebaceous cyst if you saw it for the first time ?
Spot
Lipoma
Squamous cell carcinoma
Basal cell carcinoma
Sign of Gardner syndrome.
Another type of cyst.
157
What factors contribute to gingival recession
The decrease in oedema.
Impingement of the supracrestal attachment (by a restoration)
158
How does he have bad perio if he brushes for 3 minutes twice a day and uses interdental brushes every day.
Patient could be overestimating the time
Patient may be brushing but not brushing well or efficienctly.
Using wrong interdental brushes.
159
What tools can be used to assess alcohol intake
Cage - asking yes/no
FAST- grading numbers 0-4.
160
What are the components of GIC
Silica Alumina
calcium fluoride
sodium fluoride
aluminium fluoride
aluminium phosphate
