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Case Pres Flashcards

1
Q

how are you addressing the presenting complaint

A

Broken filling : in immediate stage of tx plan

Loose denture - replacing heavily restored 16 and 27 to incorporate denture design to improve denture retention however discussed with the patient that this will extend the time she is to wear her current denture and she was okay with it, advised fixodent in the meantime, ensure clasps are engaging

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2
Q

what is hypothyroidism

A

Thyroid doesnt produce enough hormones for the bodys needs, these hormones are needed to regulate the metabolism, energy porduction and growth

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3
Q

primary causes of hypothyroidism

A

hashimotos
idiopathic atrophy
FH
hyperthyroidism tx
iodine deficiency
drugs
congenital

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4
Q

secondary causes of hypothyroidism

A

hypothalamus
pituitary

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5
Q

signs and symptoms of hypothyroidism

A

goitre
weight gain
bradycardia
slow memory
confusion
delayed reflexes
dry coarse skin

tired
depression
cold intolerance
weight gain
hoarse voice
puffed face
angina
slow memory

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6
Q

primary hypothyroidism bloods

A

raised TSH
low T4

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7
Q

dental implications of hypothyroidism

A

recognise - goitre and cancer
avoid sedatives
delayed eruption / wound healing
enlarged tongue
avoid treatment in untreated severe cases as there is a risk of myxodema coma
change to taste sensitivity

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8
Q

dose of levothyroxine

A

1.6mcg per kg a day increased in 25mcgs

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9
Q

MOA of levothyroxine

A

replacement therapy of T4 - binds to the thyroid hormone receptors and regulates T4 levels

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10
Q

caution groups for levothyroxine

A

cardiovascular disease
thyrotoxicosis

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11
Q

side effects of levothyroxine

A

angina
anxiety
arthralgia
diarrhoea

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12
Q

dental implications of levothyroxine

A

dry mouth
difficulty swallowing/breathing
fainting
swelling of lips/throat/tongue
jaw/neck pain

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13
Q

what is depression

A

A mental health disorder characterised by persistent feelings of sadness, hopelessness and a loss in interest/pleasure in activities
Change in sleep pattern/appetite/ weight/ fatigue or loss of energy
Thoughts of death or suicide

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14
Q

dental implications of depression

A

○ Low motivation for OH
○ Bad diet high in sugar
○ Grazing as unoccupied
○ Concurrent eating disorder
○ Missed appts
○ Dry mouth from meds
Linked to stress - bruxism

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15
Q

caution groups for citalopram

A

prolonged QT interval
poorly controlled epilepsy

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16
Q

dental implications/ side effects of citalopram

A

dry mouth
drowsy
anxiety
increased risk of bleeding
confusion
hypersalivation

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17
Q

citalopram dose

A

20mg up to 40mg

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18
Q

what is osteoarthritis

A

A degenerative joint disease in weight bearing joints or joints which have been subject to damage - cartilage repair dysfunction

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19
Q

signs and symtpoms of osteoarthritis

A

jaw stiffness in the morning
difficulty moving from inactive to active position
joint swelling and deformity
pain worse w activity

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20
Q

dental implications of osteoarthritis

A

chronic NSAID use - bleeding and ulcers
TMJ involvment impairing dental access
reduced dexterity for OH

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21
Q

why is osteoarthritis untreated

A

nothing prevents it - cant alter progression

manage pain, increase muscle strength, loose weight, walking aid, prosthetic joint replacement

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22
Q

what is GORD
how is stomach acid produced

A
  • Stomach acid production : acetylcholine + gastrin + histamine trigger parietal cells in stomach
    • Heart burn
    • Usually after excessive food or drink
    • Causes :
      ○ Defective lower oseophageal sphincter
      ○ Impaired lower clearing
      • Impaired gastric emptying
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23
Q

how does GORD cause malignancy

A

barretts oesophagus - metaplasia - turns to gastric mucosa which can produce acid due to chronic irritation from acid

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24
Q

signs of GORD

A

epigastric burning worse on lying down / bending
GI bleeding
severe pain

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25
Q
A
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26
Q

tx of GORD

A

stop smoking
loose weight
avoid triggering activity
drugs

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27
Q

dental implications of GORD

A

○ Link to toothwear - erosion
§ More posteriorly
§ As acid from the stomach renters the mouth
§ Dentine hypersensitivity
§ Tooth discolouration
○ Dry mouth - side effect of meds, due to changes in saliva production due to acid exposure
○ Oral ulcers
○ Hallitosis
○ Perio
Cancer risk

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28
Q

MOA of lansoprazole (PPI)

A

inhibits secretion of gastric acid from proton pumps in the parietal cell of the stomach lining

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29
Q

side effects of lansoprazole

A

constipation
diarrhoea
abdominal pain
nausea
vit b12 deficiency overtime

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30
Q

dose of lansoprazole

A

15-30mg a day in the morning

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31
Q

dental implications of lansoprazole

A

dry mouth
vit b12 deficiency
increased risk of fractures
dry throat

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32
Q

reasons she could have dry mouth

A

polypharmacy
drugs
GORD
age related acinar tissue loss

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33
Q

role of saliva

A

lubricating
digestion
buffering
antibac
wound healing
taste perception

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34
Q

ulcer questions to ask

A

where
size and shape
blister or ulcer
how long for
recurrent - same site
painful

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35
Q

ulcer examination

A

margins
base
surrounding
systemic

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36
Q

what is her BEWE

A

6 low risk

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37
Q

explain BEWE

A

score each sextant

1 - no erosive wear
2 - initial loss of surface texture
3 - distinct defect - hard tisse loss <50%
4 - >50%

0-2 no risk
3-8 low
9-13 med
14+ high

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38
Q

explain the smith and knight scores

A

0 - no loss of surface enamel characteristics
1 - loss
2 - B L O loss, dentine exposure <1/3
3 - B L O >1/3
4 - complete enamel loss, pulp exposure

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39
Q

why not re RCT

A

cause symptoms
not improve
fracture file

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40
Q

how to reRCT

A

handfiles + solvent + reciproc
refer to endo specialist - microsurgery / guided endo access

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41
Q

why are the RCT suboptimal

A

not to apex

16 - M root curved distally
47 - m root GP close to perforating

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42
Q

why are the canals sclerosed

A

deposition of calcified tissue into the canals due to chronic irritation to the pulp or chronic pulpitis
deposition of secondary dentine which becomes calcified
dystrophic calcification - deposition of calcium salts in tissues undergoing necrosis / degeneration
age related

43
Q

why are the RG DA

A

so the half and half image is not diagnostically acceptable but together they are as i am able to place a crown on the tooth based off the information and it is not worth exposing pt to further radiation for this clinical question
IRMER ALARP

44
Q

normal wear per annum

A

20-38um

44
Q

tailored OHI

A

fixodent
diet advice - acids
ETB
1450ppmf TP
dry mouth
denture hygiene
wait 30min before brushing
resize brushes

44
Q

how to correct the RG error

A

staff training on proper storage and handling of receptors

quality assurance - checking receptors every 3m for image quality, uniformity and the receptor

45
Q

why not XLA 15

A

been there a long time without symptoms
preserve bone height
max sinus

46
Q

surgical XLA of 15 RR

A

check if any debris comes out with it
post op PA
if radiolucency still present arrange further investigation or refer for secondary opinion

47
Q

why restore with crowns

A
  • Cuspal coverage for the RCT teeth - prevent catastrophic fracture, maintain coronal seal, prevent microbial ingress
    • Able to incorporate denture design for the uppers
    • Substantial tissue lost
    • Replace failing direct restoration 47,48
    • Replace weakened tooth structure
    • Improve / restore aesthetics
    • Restore function
    • Lack of caries / periodontal disease
    • Good bone support
      Favourable occlusion
48
Q

MCC preparation

A

1.3mm NW / 1.8MM W
1.3mm shoulder buccal
0.5mm chamfer palatal

49
Q

metal crown preparation

A

0.5mm NW, chamfer
1.5mm W

50
Q

metal crown cement

A

GI - aquacem
resin based luting cement with metal bonding agent MDP - PANAVIA

51
Q

MCC cement

A

aquacem

52
Q

why chose MCC for lowers

A

moisture control as saliva pools in this area
less preparation than all ceramic
aesthetics better than metal

53
Q

why chose metal for uppers to incorporate denture design

A

as placing rest seats in porcelain is more likely to cause shear fracture than in metal
optimal junction w CoCr clasp
least preparation
not in aesthetic zone however can offer buccal porcelain
strong
less abrasive than porcelain

54
Q

core material options and reasoning

A

composite - best as bonds to tooth but requires moisture control

amalgam - requires retention, poor aesthetics and core cannot be prepared same visit

GI - expands with water

55
Q

if posts were to be used in the molars which root

A

upper palatal
lower distal

56
Q

options for restoring 47

A

do nothing

XLA - fucntional tooth, good perio condition, minimal caries, asymp

his tooth is RCT so direct is not the best option as we want cuspal coverage to prevent fracture and maintain coronal seal

direct - AMA, comp
indirect - onlay, crown / metal, MCC, all ceramic

due to hard moisture control for cementation, not being in a highly aesthetically demanding zone and having enough clearance for the preparation of an MCC we chose MCC

reRCT or accept

57
Q

risks of accepting RCTs

A

become symptomatic

58
Q

options for restoring 48

A

do nothing

XLA

direct - AMA, comp

indirect - onlay, crown / metal, MCC, all ceramic

direct is an option for this tooth as it is not RCT however the direct restoration was failing and there was substantial tissue loss rendering an indirect the best choice

another option for this tooth was XLA as it is functionless however it is asymp, healthy, restorable, avoids XLA complication such as proximity to IAN/infection and is of psychological benefit

due to hard moisture control for cementation, not being in a highly aesthetically demanding zone and having enough clearance for the preparation of an MCC we chose MCC

59
Q

options for 16

A

do nothing - asymp, no disease and functioning restoration

XLA and complete denture

replace with indirect and incorporate denture design as heavily restored and new denture required and also it is RCT so this gives cuspal coverage

reRCT or accept

60
Q

function of cuspal coverage for RCT teeth

A

prevents fracture
coronal seal to prevent microbial ingress

61
Q

options for 27

A

do nothing - asymp, no disease and functioning restoration

XLA and complete denture

replace with indirect and incorporate denture design as heavily restored

62
Q

assessing suitability for indirect after restoration removal

A

amount / quality of remaining tooth structure - ferrule, where would margins be placed
dam
bone levels

63
Q

denture design incorporation into indirects

A

0.25mm buccal undercut suitable for CoCr clasp
rest seat
no palatal undercut to allow POI
guide planes increase the SA in contact w denture saddle and increase retention
must place rest seats into metal as placing in ceramic will lead to shear fractures

64
Q

why cocr not acrylic for denture

A
  • Thinner so less bulky in mouth
  • Thermal conductivity
  • Stronger and she have opposing natural lower teeth which could cause flex in acrylic and risk breaking her denture and this pt has a history of breaking her upper denture in the past
  • Craddock 3 not 2 which acrylic would be meaning uses the teeth and ST for better retention and stability
  • Retention as can use CoCr clasps
    • Easier to keep clean as CoCr isn’t porous like acrylic
  • Can still add to this should she lose her teeth as it extends onto the palatal of the molars
  • less periodontally destructive

is heavier/expensive tho and acrylic would be the more conventional option

65
Q

hypothyroidism and depression

A

hypothyroidism is a natural cause of depression

66
Q

properties of low gold alloy

A

biocompatible
ductile
corrosion resistance
aesthetics

67
Q

how is an MCC formed

A

porcelain adhesion to metal by ceramic melting and wetting surface metal in a vaccum
requires high melting metal with thermal properties matching porcelain

68
Q

when to use MCC

A

insufficient occlusal space
high fucntional load
aesthetics

69
Q

relevance of hayfever (allergic rhinitis)

A

sinus problem could present as an ill defined toothache in maxilla
antihistamines have a synergistic effect with sedation
antihistamines reduce salivary flow
dry mouth due to nasal congestion causing mouth breathing
allergy to dental products

70
Q

process of incorporating indirects into denture design

A

surveyed study casts first and denture design

crown preparation
master imp of denture bearing area and crown prep at same time
temp
try in crown and denture
temp
only cement crown when denture ready to be fitted - must seat denture immediately after cementation

71
Q

why craddock 3

A

bounded saddle longer than 3 teeth
free end saddle
palate

72
Q

where to place rest for free ended saddle

A

mesially

73
Q

retention

A

resistance of a denture to lifting away from the tissues

74
Q

support

A

resistance of a denture to occlusally directed load

75
Q

what is erosion

A

loss of tooth structure by acids and not involving bacterial fermentation

76
Q

what is attrition

A

wear of tooth against tooth

77
Q

presentation of erosion

A

glassy appearance
translucency
dentine sensitivity
unstained when active and stained unactive
bilateral concave lesions without chalky appearance of bacterial and acid decalcification
preferential wear of dentine leads to cupping
restorations unaffected

78
Q

aetiology of erosion and causative factors

A

chemical dissolution of tooth structure
extrinsic - frequent consumption of acid
instrinsic - regurgitation of gastric acid

79
Q

presentation of attrition

A

shortened crown height
flat incisal edge
wear facets on teeth in guidance - canines and premolars
limited to contacting surfaces of teeth
restorations wear too

80
Q

prevention and monitoring of toothwear

A

study casts to compare

advice - don’t swill drinks, straw to back of mouth, avoid acid last thing at night, dont brush immediately after acid instead rinse with water

fluoride

DBA

Splint

control gastric acid

treat dry mouth

81
Q

review of toothwear in evaluation stage

A

pt expectations
rate of wear - will it compromise the longevity of the tooth
sensitvity

active treatment when wear leading to further complications, aesthetics beyond pt acceptability, leaving it might cause more complex treatments to be required

82
Q

occlusal exam?

A

could have used a facebow or wax blocks however we were conforming to the occlusion

lab were given study casts

83
Q

sensibility testing - was it required

A

I sensibility tested these teeth as this is my case presentation exam however upon reflection I might not have needed to do this due to there being no apical areas and her age as it likely would not have impacted my treatment plan

84
Q

which teeth were sensibility tested

A

48 and 27

85
Q

why do 1 yearly rv

A

non smoker / drinker
low caries rate
no periodontal disease

86
Q

why use metal crowns for denture abutments

A

thinner
stronger
better junction with CoCr claps

87
Q

why did I use SDR not amalgam for NAYAAR cores

A

aesthetics
flow and adaptability to cavity walls ensuring complete coverage and sealing of structure
minimally invasive as doesn’t require retentive preparation
deep curing depth
biocompatibility

88
Q

why no lower denture

A

pt doesn’t want one
copes fine wihtout
lower dentures are less well tolerated
adequate lower teeth left

89
Q

how should the guide plane be set

A

to match the POI of anterior undercut

90
Q

what is a milled crown and how is it prepared

A

mill cuts out for a solid block of material based on specifications from a digital impression of prepared tooth

scanned image of cast
articulated
select crown margin
adjust crown margin
select crown type and place on model
adjust size and shape of crown
save file
send to milling machine and crown in 30-40mins

91
Q

nayaar core

A

utilises canal orafices and pulp chamber to retain restoration

92
Q

reasons for fracture of amalgam filling in 47

A

undermined by secondary caries
cyclic loading - constant pressure from chewing
overloading - bruxism
inadequate condensation
creep - gradual deformation under constant stress

93
Q

dry mouth management

A

local measures - frequent sips of water, suck on ice/sugar free pastilles, sugar free chewing gum

topical fluroide

artificial gel, spray or pastilles

94
Q

impact of dry mouth on dental treatment

A

the buffering and antibac role of saliva is lost therefore more prone to caries / periodontal disease

the lubricating role of saliva is lost therefore denture retention would be reduced - which could help to explain her loose denture

proteins and enzymes in saliva help with digestion also so that could be impaired

reduced wound healing / taste

95
Q

difference between caries and erosion

A

erosion is the chemical dissolution of tooth structure due to acid not involving bacteria whereas caries is when bacteria in dental plaque produce acids that lower the pH leading to demineralisation in localised areas

96
Q

why is her denture loose

A

she had abutment teeth removed during covid, they were added back onto the denture by her GDP previously but she says it has been loose since
the ridge will also have resorbed and changed

97
Q

guidelines for reRCT

A

ESE

98
Q

head and neck cancer - recognition and referral guidleines

A

NICE

99
Q

why clinical gingival health

A

as worst BPE was 2 and she had <10% BOP

100
Q

how does calculus form

A

accumulation and mineralisation of plaque (due to minerals calcium and phosphate in saliva)

101
Q
A

Case Pres (1 decks)

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