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Dentistry in a Nutshell > case pres > Flashcards

case pres Flashcards

1
Q

measured bpe
what is this & discuss results

A

BPE is a screening tool NOT a diagnostic tool; helps give a guide for tx
pt had bpe of 3 in all sextants measured
‘walk’ the probe around all of the teeth using enough pressure that will blanch a finger nail ~ 15-20g
WHO 0.5mm diameter ball ended probe

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2
Q

bpe of 3

A

black band partially visible
probing depths of at least 4mm present (3.5-5.5)
calculus / overhangs / plaque / BoP

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3
Q

how do you carry out mpbs

A

ramfjords teeth
16 21 24
36 41 44
using a WHO probe (ball end 0.5mm diameter)
teeth used in this case was
18 21 24
36 41 44
used to monitor pt engagement

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4
Q

why OPT & PAs

A

pt initially came in to emergency clinic where PA of 35 36 37 was taken to assess 36
pt refused xla on emergency clinic of 36 due to dental anxiety
struggled with gag reflex when taking PA so decided at r/v that an opt supplemented with PAs of 11 and 21 (due superimposition of cervical spine) would be better for this patient

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5
Q

OPT v PA

A

would need at least 7 or more PAs to get a full mouth of PAs which is 4 microsv per radiograph whereas one OPT is 20 microsv
radiation doses according to international atomic energy agency

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6
Q

what regulations do we follow regarding radiation dosage

A

IRMER17 & IRR17 in UK
IRR17 - deals with occupational exposures & exposures of general public. annual dose limits are specified
IRMER17 - deals with medical exposure of patients. roles inc referrer / practitioner / operator / employer (dentist can be all of these)

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7
Q

what is ICRP and what do they say regarding radiographs

A

international commission on radiological protection
3 basic principles
1. justified - must do more good than harm
2. optimised - should use as little radiation as is practicable (ALARP)
3. limited - individual dose limits are used to ensure no one has unacceptable dose

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8
Q

periodontal diagnosis and why

A

generalised periodontitis stage 3 grade c currently unstable with risk factor of ex smoker
generalised - >30% bone loss
stage 3 - interproximal bone loss mid 1/3 of root
grade c - % bone loss divided by pt age which in this case is 60/54 which is >1 so rapid progression
currently unstable - pockets greater than or equal to 4mm & BoP
(NOTE - typo in poster; remember to say this)
risk factors - ex smoker (smoked 10 a day for 15 years so 7.5 pack years) & currently socially smokes cannabis

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9
Q

what is periodontal disease

A

Periodontal diseases (gingivitis and periodontitis) are a group of inflammatory conditions that affect the
hard and soft supporting tissues of the teeth and can lead to poor aesthetics, tooth loss, loss of function and reduced quality of life. A plaque biofilm is essential for development.
Damage from periodontal disease causes irreversible bone loss which manifests as clinical loss of attachment

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10
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 attack
increased production of inflammatory mediating cytokines causes tissue breakdown
there is reduced gingival blood flow - signs & symptoms are suppressed
impaired white cell function causes impaired wound healing

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11
Q

what defines an engaging patient

A

improvement in OH; greater than or equal to 50% improvement in plaque & bleeding scores OR
plaque levels less than or equal to 20% & bleeding levels less than or equal to 30%
OR
pt has met targets outlined in their personal self care plan as determined by their health care practitioner

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12
Q

why re evaluate 3mths after BSP step 2

A

3 mths gives enough time for healing & decreased pocket depths for:
- oedema to reduce (causing gingival recession)
- increased clinical attachment due to formation of junctional epithelium
this increases tissue tone & causes resistance to probing

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13
Q

what constitutes periodontal health

A

<10% BoP
pocket depth less than or equal to 4mm
no BoP at 4mm sites
note - this can be adjusted to the patient i.e. pt may have PPD of 5-6mm in absence of BoP which may not represent active disease

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14
Q

what is stability and how do we measure it

A

stability is a reflection of the current level of disease activity
assessing stability relies on measuring extent of BoP and level of PPD across dentition

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15
Q

what are the different results we can see at the 3mth re evaluation mark

A
  1. stable - BoP <10% / PDD <4mm / no BoP at 4mm sites
  2. in remission - BoP >10% / PPD <4mm / no BoP at 4mm sites
  3. unstable - PPD >5mm / PPD >4mm & BoP
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16
Q

according to BSP what does a code 3 mean

A

initial perio therapy and r/v in 3mths with localised 6PPC in involved sextants
- if no pockets greater than or equal to 4mm & no radiographic evidence of bone loss due to periodontitis then continue with code 0/1/2 pathway
- if pockets > than or equal to 4mm remain and / or radiographic evidence of bone loss due to periodontitis then continue with code 4 pathway

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17
Q

what is bsp step 1

A

building foundations for optimal treatment outcomes
- explain disease, risk factors & tx alternatives, risks & benefits inc no tx
- explain importance of OHI, encourage & support behaviour change for OH improvement
- reduce risk factors inc removal of plaque retentive features, smoking cessation, diabetes control interventions
- provide tailored OH inc ID cleaning, tp & MW, PMPR inc supra and sub gingival scaling of clinical crown

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18
Q

what is bsp step 2

A

if pt engaging with step 1 then can progress to step 2
engagement assessed via MPBs
- reinforce OH / risk factor control / behaviour change
- subgingival instrumentation (hand or powered) either alone or in combination

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19
Q

what happens after 3mth evaluation according to bsp

A

if unstable go to step 3 which is re performing subgingival PMPR for moderate pockets of 4-5mm & considering alternative causes / referral for deep residual pocketing of >6mm

if stable go to step 4 which is maintenance; supportive perio care encouraged as well as regular targeted PMPR (time frame decided with what pt needs dictate)

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20
Q

what is sciatica

A

sciatic nerve which runs from lower back to feet is irritated or compressed
nerve starts in lower back and runs down back of each leg
usually clears up in 12wks but can recur; influenced by poor sleep, stress & emotional wellbeing
issues with dental tx with regards to time in chair & getting into chair

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21
Q

pt manages sciatica flare ups with tramadol what is this

A

opioid painkiller
used to tx moderate to severe pain (often prescribed if weaker painkillers no longer work and you have long term pain)
pt taking standard tablets that contain 50mg
taking as and when required
can have withdrawal effects (dose should be gradually reduced) - agitation / anxious / shaking / sweating

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22
Q

tramadol mechanism of action

A

centrally acting synthetic opioid analgesic & SNRI (serotonin / norepinephrine reuptake inhibitor) it:
1. is an agonist of the opioid receptor (release of nociceptive neurotransmitters i.e. GABA / substance P / noradrenaline / acetylcholine is inhibited as decreases intracellular cAMP which modulates the release of nociceptive neurotransmitters)
2. inhibits serotonin reuptake
these pathways are complementary & synergistic; improving ability to modulate the perception of & response to pain
+ enantiomer inhibits serotonin reuptake & - enantiomer inhibits norepinephrine reuptake enhancing inhibitory effects on pain transmission in spinal cord
-> closes voltage gated calcium channels & opens calcium dependent potassium channels resulting in hyperpolarisation & a reduction in neuronal excitability

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23
Q

side effects of tramadol

A

dry mouth !!!!
arrythmia
respiratory depression
confusion
withdrawal

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24
Q

caution when prescribing tramadol

A

opioids co prescribed with benzodiazepines & benzodiazepine drugs can produce additive CNS depressant effects thereby increasing risk of sedation, respiratory depression, come & death

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25
Q

risk factors for candida

A

long term corticosteroid use
immunosuppressive drugs
broad spectrum ABs
diabetes
nutrition
dialysis
smoking
denture wearing
anaemia
steroid inhaler use

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26
Q

pseudomembranous candidiasis

A

white pronounced plaques
wiped away easily to leave bleeding erythematous surface

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27
Q

other types of candida

A

erythematous - red & angry; either atrophic from HIV or denture stomatitis
hyperplastic - white patches, less pronounced & plaque like than pseudomembranous, can’t be wiped off, associated with candidal leukoplakia which can be pre malignant
angular cheilitis - seen at commissures & angles of mouth

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28
Q

systemic candida tx

A

azoles - i.e. fluconazole / miconazole gel. inhibit ergosterol synthesis (fungistatic). c.glabrata resistant. avoid in warfarin / statins.

polyenes - i.e. nystatin. binds directly to ergosterol on cell membranes causing pores to open & cell contents to be lost (fungicidal).

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29
Q

nystatin prescription sdcep

A

nystatin oral suspension
100,000 units / ml
send 30ml
1ml after food 4x daily for 7 days

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30
Q

why was pt given nystatin

A

pt request no tablets as doesn’t like taking tablets

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31
Q

issue with chronic candida

A

yeasts in candida can metabolise simple sugars to alcohol & CO2 gas
acetaldehyde produced from subsequent alcoholic breakdown is a carcinogen (cancer causing chemical)

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32
Q

virulence factors of candida

A

phospholipase - degrades lipids, aids host cell penetration
haemolysin - degrades RBCs, facilitates hyphal invasion
proteinase - degrades protein, aids adhesion to epithelial cells
alters target site to prevent azoles from binding
changing cell membrane composition to prevent insertion of polyene

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33
Q

pt doesn’t have any of usual risk factors for candida what has caused this

A

pt not seen dentist in 10yrs & only quit smoking 1yr prior
could have had candida for a long time and not realised

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34
Q

perio guidelines followed

A

SDCEP
BSP
S3 guidelines - S3 format is the highest level of guideline production considering both a systematic appraisal of published evidence & clinical experience

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35
Q

to ensure you have covered everything in medical history

A

a systems enquiry
HEALABLES
H - heart
E - endocrine
A - a musculoskeletal
L - lungs
A - a joint issue
B - bleeding
L - liver / kidney
E - brain e.g. FFS / epilepsy
S - stomach / GI

36
Q

benefits of keeping retained roots

A

no need to undergo surgical xla to remove
can maintain alveolar bone for prosthodontic purposes

37
Q

how to consent pt prior to perio disease

A
  • signed perio consent form is proof pt knows what is going on & what they need to do
  • pt must know; they have perio, it is not curable, it is in their control to make it better
  • need to provide them with tx options; do nothing / perio tx / xla / perio surgery
  • need to discuss what will happen if perio not controlled i.e. inflammation / tooth mobility / tooth loss
  • need to discuss what will happen if they do control it i.e. less bleeding / less swelling so formation of black triangles / gums going from red to pink / gum recession & lengthening of teeth / sensitivity (recession exposes more root so more sensitive)
38
Q

symptomatic irreversible pulpitis

A

subjective & objective findings that vital inflamed pulp is incapable of healing & RCT indicated
sharp pain upon thermal stimulus
lingering pain (often 30secs or longer following stimulus removal)
spontaneity (unprovoked pain)
referred pain
pain may be accentuated by postural changes such as lying down or bending over
OTC analgesics typically ineffective
common aetiologies inc deep caries, extensive restorations, fractures exposing pulp tissues
can be difficult to diagnose as inflammation has not yet reached the PA tissues thus resulting in no pain or discomfort to percussion

39
Q

symptomatic apical periodontitis

A

represents inflammation usually of apical periodontium producing clinical symptoms involving a painful response to biting and / or percussion or palpation
may or may not be accompanied by radiographic changes i.e. depending on stage of disease there may be normal width of the pdl or there may be PA radiolucency
severe pain to percussion and / or palpation is highly indicative of a degenerating pulp & RCT is needed

40
Q

why was 36 xla * come back to this question*

A

severe caries
unrestorable
unable to gain adequate moisture control to place suitable restoration
caries nearly subcrestal ?
unable to place adequate dam so cannot carry out rct

41
Q

what is grade I mobility

A

increased mobility of the crown of the tooth to at the most 1mm in a horizontal direction

42
Q

attritive wear

A

physiological wear of teeth due to tooth to tooth contact

43
Q

signs of attritive wear

A

polished facet
flattening of cusps
shortened clinical crown
restorations show same wear as tooth substance
can see present in pt on lower anterior 3-3; note this could also be due to MCC opposing these teeth
pt identified parafunctional habits - grinds teeth at night

44
Q

smith & knight

A

tooth wear index
pt scored 2
surface - incisal
criteria - loss of enamel exposing dentine for less than 1/3 of surface
loss of enamel just exposing dentine
defect <1mm deep

45
Q

why remove crowns

A

unaesthetic
poor margins

46
Q

how to remove crowns

A

drill off using tungsten carbide / diamond bur

47
Q

options for 11 & discussion with pt

A
  1. no tx, not causing any pain, PA radiolucency present but no symptoms; might require treatment in the future
  2. replace 21 and not 11 but this will leave uneven looking crowns
  3. can replace but may make it worse, depends on quality of tooth structure remaining underneath crowns, may need RCT but no clear canal visible may not be possible would require referral to specialist with microscope equipment. Possible sensitivity following this & will not last forever.
48
Q

why MCC crowns

A
  • cheaper
  • functional
  • less tooth tissue removal required
  • not as good aesthetics
  • can see metal collar
  • metal shine through
  • less destructive than all ceramic
49
Q

why not all ceramic crowns

A

definitely more aesthetic but more expensive and require increased removal of healthy tissue so increased chance of pulp exposure upon prep
emax less prep but all ceramic more prep

50
Q

dimensions for emax / mcc

A

emax 2mm all the way round ?
mcc - 1.3mm labial should and 0.5mm palatal chamfer ?

51
Q

why not place bridge for missing gaps

A

18 and 48 are in occlusion
replacing 47 with nothing above it is pointless; would be for aesthetic rather than functional purposes
same with the 37 as nothing in upper arch opposing this
mesially tilted so difficult to get parallel prep for conventional cantilever

52
Q

why soft splint

A

protect remaining tooth structure
identify where parafunction is worst
cheap & easily constructed prior to more definitive hard splint following restorative tx

53
Q

tmd

A

symptom complex of multifactorial aetiology which almost certainly represents a psychological response to stress that becomes chronic through increasing muscle tension affecting MoM namely masseter, lateral pterygoid, temporalis. muscle hyperactivity can release lactic acid & other components that can cause pain

54
Q

effect of cannabis on dental tx / teeth

A
  1. xerostomia - decreased saliva production
  2. increased risk of perio - contains toxins & carcinogens that can irritate gum tissue leading to increased inflammation
  3. tooth discolouration - adheres to enamel leading to yellow / brown staining
  4. oral cancer risk - not as high as tobacco. long term exposure increases risk of OC
  5. healing - may impair ability to heal due to reducing blood flow to surgical site & interfering with body’s natural healing process
55
Q

discussion with pt re prosthetic tx

A

Long term stability of crowns due to lack of posterior support, lot of weight on the front so contributing to attrition of lower anteriors due to parafunction
denture would help relieve this pressure
provide more function

56
Q

calculus

A
57
Q

why restore in composite over amalgam

A

more aesthetic
bonds to tooth

58
Q

constituents of composite

A
59
Q

what is addiction

A

chronic, primary, neurobiological condition influenced by genetic, psychosocial & environmental factors

60
Q

effects of cannabis

A

euphoria
slowed thinking & reaction time
confusion
impaired balance & coordination
cough
respiratory infection
increased HR
anxiety
addiction

61
Q

risk factors for substance abuse

A

social deprivation
poor housing
adverse childhood experiences
poor role models
low educational aspiration
lack of opportunities
high unemployment

62
Q

cannabis & LA

A
  1. potency alteration - cannabis can alter perception of pain & alter sensitivity to pain so could influence effectiveness of LA
  2. metabolic interactions - can impact metabolism & clearance of LA from body altering duration of action or potency
  3. cardiovascular effects - with adrenaline can prolong acute tachycardia (HR >100bpm)
  4. CNS depression - both cannabis & LA depress CNS leading to sedation / drowsiness so combination can increase effect risking excessive sedation / respiratory depression if high doses are used
  5. individual variability - some people may experience heightened sensitivity to pain or altered anaesthesia
63
Q

how does LA work

A

reversibly binds to sodium channels preventing the entry of sodium into the cells thereby inhibiting the propagation of nerve impulses
consequently nociceptive impulses associated with painful stimuli do not reach the brain and pt does not perceive pain
note - lidocaine fully metabolised in liver

64
Q

mx of attrition in this pt

A

prevention & monitoring
this is tx
pts usually in this phase for 6mths
advice re TMD & provision of splint

65
Q

cannabis facts

A

most abused drug in UK with 18.7% of adults aged 16-59yrs reporting having used it in previous yr
THC is 1 of 66 cannabinoids within cannabis & is most associated with hallucinogenic / psychoactive effects
THC reacts with 2 main receptors: CB1 (mainly found in brain) and CB2 (mainly found in immune cells and GI tract)
most common route of admin is smoking through which 50% of THC is inhaled
high often felt within mins and lasts 2-3hrs
THC accumulates in adipose tissue & slowly released back into the body
total elimination can take up to 30 days

66
Q

further dental health impact following cannabis use

A
  • poor OH & perio
  • reduced salivary flow
  • appetite enhancing nature of drug
  • LA containing adrenaline may prolong tachycardia following acute dose of cannabis
  • chronic use results in increased risk of oral leukoplakia / OSCC / candidiasis / oral infections
  • cannabis may compound effects of anaesthetic agents thus increasing arterial pressure & HR to possibly life threatening levels
  • pts should be advised not to use cannabis for at least 72hrs before tx under conscious sedation in order to reduce the likelihood of drug interactions & unpredictable sedation quality
67
Q

options for LA without adrenaline

A

prilocaine & mepivicaine
have weak vasodilation properties. both are short acting anaesthetics & good options for children, elderly & pts with contraindications to adrenaline

68
Q

why is adrenaline added to LA

A

to act as a vasoconstrictor and delay drug absorption which prolongs duration of LA and reduces toxicity risk

69
Q

LA preparation

A

LA base
reducing agent (sodium metabisulfide)
preservatives
fungicide
+/- vasoconstrictor

70
Q

adrenaline v felypressin

A

felypressin = less effective vasoconstrictor but is an alternative for hypertensive pts or those wanting adrenaline free LA
f - acts on ADH receptors
a - acts on adrenoreceptors

71
Q

prilocaine & mepivicaine

A

prilocaine (citanest) 3% HCl w felypressin (pulp infil = 30-45mins, pulp block = 60mins, soft tissue = 3-6hrs) max dose = 8 cartridges (8mg/kg)
mepivicaine 3% HCl plain (pulp infil = 20mins, pulpal block = 40mins, soft tissue = 2hrs) , max dose = 6 cartridges (3mg/kg)

72
Q

aims of TMD tx

A
  1. control immediate pain
  2. lower psychological stress
  3. eliminate TMJ damage
73
Q

possible tx for TMD pts

A

rest
heat
analgesics
injections
CBT
hypnosis
psychiatric tx
rest
masticate bilaterally
avoid trauma
splint

74
Q

use of splint

A

increase vertical dimension, may reduce joint loading, eliminate faulty occlusal interferences, provide cognitive awareness of damaging oral habits

75
Q

reasons for parafunction in this patient

A

STRESS - due to caffeine intake, cannabis intake etc

76
Q

why is this patient at high risk for candida

A

dry mouth
can use gel / spray / pastilles to help salivary flow

77
Q

benefits of this pt receiving a denture

A
78
Q

what kind of denture would you start with and why

A

acrylic - cheaper, better transitional denture, would aim for upper and then discuss provision of lower
ask at each appointment highlight positives of getting denture but ensure it is something that pt wants; let pt come to you and ask you for denture
would then transition to a chrome denture
and then discuss provision of lower RPD if that was something pt was interested in

79
Q

why leave RR

A

preserve bone height for future implant placement
near vital structures i.e. IAN
present for no of yrs with absence of PA pathology
can be left & monitored to ensure caries free / no PA pathology

80
Q

reasons why these RR were extracted

A

infection risk
sitting in soft tissue so straightforward low risk procedure

81
Q

pros / cons acrylic denture

A

cheap
non toxic / non irritant
bulkier
less heat transfer
quicker to make
easier to add to
(can add stainless steel clasps to acrylic denture)

82
Q

pros / cons CoCr denture

A

stronger
thinner
more expensive
more difficult to add to
takes longer to make

83
Q

3 methods of testing for candida

A
  1. swab / oral rinse for culture
  2. biopsy for hp using PAS stain
  3. smear for microscopy
84
Q

why does dry mouth impact tx

A

less saliva
saliva is antibacterial, acts as a buffer, aids digestion

85
Q

sclerosed canal

A

calcified deposits within canal
2ndary dentine gets laid down an calcified blocking canal system
can be idiopathic, age related, trauma related

86
Q

healthy gingiva

A

pink knife edge, no erythema, stippled, no BoP

87
Q

how many units in 4 glasses of wine

A

9.6

Dentistry in a Nutshell (30 decks)

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