Daily exam deck

Question 1

What is the basic investigative process in oral pathology?

Answer 1

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

Question 2

What are the types of differential diagnosis?

Answer 2

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

Question 3

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

Answer 3

Use this scheme

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

DIHDHNI

Question 4

How do we take history about a lesion?

Answer 4

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

Question 5

What is the systematic way to examine a lesion?

Answer 5

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

Question 6

What are some of the terminology in a lesion with elevated morpholoy?

Answer 6

Blisters - Fuild filled masses:

1. Vesicle - upto 0.5cm
2. Bulla - more than 0.5cm
3. Pustule - pus of any size

Non-blisters - not fluid filled elevations

1. Papule - upto 0.5cm
2. Nodule - from 0.5cm to 2 cm
3. Tumour - more than 2 cm
4. Plaque - more than 0.5cm but it is only clightly raised

Question 7

What are some of the terminology of a lesion with depressed or flat morphology?

Answer 7

Depressed:
1. Ulcer (epithelium lost) - if it is yellow tissue more likely to be an ulcer

2. Erosion (epithelium lost)/atrophy - if it is redness tissue more likely to be an erosion/atrophy

Flat:
1. Macule - discoloration (freckel)

2. Patch - big discolouration

Question 8

What kind of structure is this?

Answer 8

A brown macule - a flat discoloration

Site - RHS lower vermilion shifted around 10 mm from the midline of the lips

Size - measure with peiro probe - around 5-10mm

Morphology - flat, round, heart shapped

Colour - brown

Consistency - NOPE IT IS A PHOTO - Texture - maybe rough, defiantly different from the normal lip

Question 9

What kind of structure is this?

Answer 9

It is a white polyp

Site - RHS buccal mucosa adjacanet to the buccal surface of 45

Size - measure with perio probe - around 10-15mm

Morphology - elevated, rounded, sphere like

Colour - white, opaque, with small amounts of pink

Consistency - NOPE IT IS A PHOTO - Texture - rubbery

Question 10

What investigation do we have in oral pathology?

Answer 10

1. Biopsy (taking the whole or some of the tissue) - histopathology (investigative process) and exfoliative cytology
2. Adjunct diagnostic techniques - light-based and vital stains
3. Other techniques - microbiology, biochemistry, serology

Question 11

What are some of the types of biopsy?

Answer 11

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

Question 12

What are the consideration during biopsy?

Answer 12

1. The lesion in question
2. Surrounding anatomy

Question 13

What should you do with some of the lesions that you may encounter to understant if they are vascular?

Answer 13

Use a small, transparent plate and apply pressure - if the lesion stars to blanch, it is most likely to be vascular

Question 14

What are some of the features of pathology that can be observed by a light based system such as Velscope?

Answer 14

In some instances, the pathological tissue may take up the light thus resulting in a shadowing of the structures.

Good adjunct but please do not use this as a basis of diagnosis.

Question 15

What are some common stains in oral pathology?

Answer 15

1. Haematoxylin and eosin
2. Periodic Acid-Shiff - used for fungal infection

Question 16

What is exfoliative cytology?

Answer 16

It is the examination of cells scraped from the surface of the lesion - great for fungal infection - it is quick and easy but may not be used to more complex lesions with pathology below the surface

Question 17

What is fine needle aspiratin used for?

Answer 17

It is mostly used for intraosseous pathology and fluctuant soft tissue pathology and neck masses

Question 18

What is core biopsy used for?

Answer 18

It is used to remove the core of some tissues - it is similar to scalpel biopsy but it has more complication than fine needle biopsy.

Mostly used in biopsy in the abdomen but also can be used on a lymph node

Question 19

What is a smere vs a swab?

Answer 19

Swab - microbial analysis - need to send to a lab for something like PCR

Smere - do a cell analysis - straight under the microscope - think exfoliative cytology

Question 20

What are the two basic types of mucosa present in the mouth?

Answer 20

1. Attached, orthokeratinised mucosa
2. Non-attached, non-keratinised mucosa

Question 21

What are the four layer of the epithelium?

Answer 21

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

E and F and the papillary and reticular layer accordingly

Question 22

What are some the benign lesion of epithelial layer with idiopathic or developmental origin?

Answer 22

1. Leukoedema
2. White Sponge Nevus
3. Epidermolysis Bullosa

Question 23

What is a leukoedema?

Answer 23

It is a common developmental lesion of the oral mucosa. It is a variation of normal mucosa and it is more common in individuals with dark skin. Mainly in buccal mucosa

It can be implicated by the use of tobacco or alcohol.

They are asymptomatic, bilateral, poorly defined and it disappears when the mucosa is stretched or whipped with a gauze. Please consider not to stretched the attached gingiva!

Question 24

What is the histology of leukoedema?

Answer 24

It appears in the supperficial half of the epithelium.

There are large vacuolated cells present with some Pyknotic nuclei.

Epithelial hyperplasia present as well as long elongated rete pegs

Question 25

What is the management of leukoedema?

Answer 25

Unless there are any other worrying signs - no management is needed just monitoring

Question 26

What is the White Sponge Naevus?

Answer 26

It is a rare inherited condition. It is autosomal dominants trait and it is early onset. Majority of cases present with oral lesion, other mucosal surface may be affected.

It is asymptomatic, diffuse, with white thickening and if irregular thickening

Question 27

What is the histology of White Sponge Naevus?

Answer 27

It appears in the superficial layer of the epithelium.

Large vacuolated cells.

Pyknotic nuclei and thickened parakeratin layer

No dysplasia present

Question 28

What is benign migratory glossitis?

Answer 28

It is also known as geographic tongue - it is quite common and the aetiology is well known

It is a result of loss (atrophy) of filiform papillae. Sometimes it can be sore but again not much can be done - if concerning please refer for biopsy

Question 29

What can be commonly seen int eh benign migratory glossitis histologically?

Answer 29

Numerous microabscesses in the surface of epithelium filled with neutrophils and lymphocytes

Question 30

What is hairy tongue (aka coated tongue)?

Answer 30

It is a condition with poorly understood aetiology and a result of increased length of filliform papilla.

May be initiated by heavy smoking, atiobiotics and other.

Usually asymptomatic.

Increased number of chromogenic microorganisms thus a change in colour to usually darker one

Question 31

What do we do in the instance of hariy tongue, migratory glossitis or other benign developmental deviation?

Answer 31

1. Ensure the patient that this is not something pathological
2. Take a smear if needed

Question 32

What is haemangioma?

Answer 32

It is a localised vascular proliferation that may be congenital or arise later in life.

Could be single or multiple and results in soft tissue lesions usually

Question 33

What is the hsitological appearance of haemangioma?

Answer 33

1. Layer of epileium
2. Perforations of endothelial blood vessels and cells - forming capillaries

Question 34

What type of haemangioma is this?

Answer 34

This is capillary haemangioma due to the small capillary vessels presence

Question 35

What type of haemgioma is this?

Answer 35

This is cavernous haemangioma due to larger blood vessels present

Question 36

What is lymphangioma?

Answer 36

It is a type of lesion that is present in tongue swelling. The epithelium lining is very thin with a large, lymph filled vascular spaces

Question 37

What kind of condition is this?

Answer 37

This a lymphagioma of the tongue - due to the pink limp liquid being observed in the hghlighted areas

Question 38

What conditions is this?

Answer 38

This is a caliber persistent labial artery.

It occurs when the inferior alveolar artery maintains it’s size after leaving the mental forament and becomes superficial in the lower lip.

It can present as a nodule. PLEASE PULPATE IT BECAUSE IT WILL PULSE

Question 39

What is this condition?

Answer 39

Oral melanotic macule or focal melanosis or an intraoral freckle

It is a well demarcated, uniform in colour, asymptomatic and has the same consitency as the surrounding mucosa macule.

Histologically it is related to increase melanin deposition.

Sometimes can arise due to medication use specifically oral medications.

Remeber macules DO NOT CHANGE OVER TIME

Question 40

What is this condition?

Answer 40

This iss a mucosal menocytic naevus.

It is a rare oral cavity lesion or patch.

It is bening proliferation of neaevus cells.

The lesion is not neoplastic but is a hamartomatous lesion

Question 41

What is a hamartoma?

Answer 41

It is a tumour-like lesion.

Non-neoplastic proliferation of tissue.

It grows at the same rate as the surrounding tissue

Question 42

What type of naevus is this?

Answer 42

This is a junctional naevus because is confined to the basal layer of the epithelium

Question 43

What type of naevus is this?

Answer 43

This is intraomucosal naevus - because is is not in the epeithelium

Question 44

What condition is this?

Answer 44

This is an amalgam tattoo - it is associated with some of the amalgam being incorporate into the adjcent soft tissue over time. PLEASE LOOK AT AMALGAM NEAR BY.

This lesion can grow but usually at a none alarming rate.

Question 45

What does ectopic mean?

Answer 45

It is a tissues that are in an abnormal sire of position

Question 46

What are Fordyce spots?

Answer 46

They are ectopic sebaceous glands that usually occur on the buccal mucosa - their instance increases with age.

They are slightly elevated yellowish nodules.

It arises due to the arisal of the tissue from the ectoderm during the embrio development

Question 47

What are the histological features of the Fordyce spots?

Answer 47

They are very similar to sebaceous glands

Question 48

What condition is this?

Answer 48

These are lingual tonsils.

This is part of the lymphoid tissue (Welder’s ring) that is used to fight infection.

The lymphoid tissue underneath the folliate papilla goes through lymphoid hyperplasia (growth) and result in an elevation on the postra-lateral tongue surface.

Question 49

What type of nodules are theses?

Answer 49

This is lymphoid hyperplasia

Question 50

What type of tissue is this?

Answer 50

This is lingual thyroid tissue

Question 51

What are the Tori and exostoses?

Answer 51

They are bony protuberances.

Non-neoplastic.

Possibly inherited

Exotoses - multiple or single nodules at the buccal aspect of the alveolar bone

Question 52

What type of cyst is this?

Answer 52

This is a nasopalatine cyst.

It is the most common non-odontogenic oral cyst.

It s asymptomatic unless secondarily inflamed.

Question 53

What type of conditon is this and why?

Answer 53

These are fordyce spots

They are sebatious glands in the oral mucosa.

Do not biopsy and reassure the patient that this is normal.

Pathogenesis: ectoderm refrences

Question 54

What is hyperplasia?

Answer 54

It is an increase in the size of a particular tissue by increase in cell number - it is reversible and stimulus dependent

Question 55

What is hypertrophy?

Answer 55

It is an increase in the size of particular tissue by increase in cell size.

Question 56

What are the two main origins of hyperplastic lesions?

Answer 56

1. Predominantly epithelial in nature
2. Predominantly connective tissue in nature

Question 57

What are the two basic morphological potentials of a lesion?

Answer 57

1. Senssile lesion - broad based lesion
2. Pedunculatedlesion - on a stalk - use a perioprobe to see if a lesion has a neck

Question 58

What are some of the other adjectives that can be used to describe a lesion?

Answer 58

1. Papillary - any small growth projectin into a cavity
2. Verrucous - warty surface appearance (small hyperkeratinised projections)
3. Epulis - lump on the gum non-neoplastic

Question 59

What is fibroepithelial hyperplasia?

Answer 59

It is a growth of fibrous connective tissue underneath an epithelium

Question 60

WHat are the clinical features of fibroepithelial hyperplasia?

Answer 60

It is a exophytic lesion.
Site is a site of trauma

Size is around 1-2mm upto 1cm

Moprphology could be sessile or pedunculated

Colour is similar to normal mucosa but could look inflamed

Consistency could be soft to hard depending on the age of the fibrous tissue

Question 61

What is the aetiology, pathogenesis and treatment of fibroepethilial hyperplasia?

Answer 61

Aetiology: Chronic physical trauma, cheek biting, irritation from broken teeth etc.

Pathogenesis - cellular proliferation and production of cell product - predominantly connective tissue

Treatment: Excision of the tissue and removal of the cause

Question 62

What is papillary hyperplasiaof the palate?

Answer 62

It is a nodular overgowth that is associated with dentures and S.Candida infection.

Associated with nodular hyperplasia in histological samples

Question 63

What is the common histological presentation of the S.Candida infection

Answer 63

It is a presented as a nodule appearance with chronic inflammatory cell infiltrate

Question 64

What condition is this?

Answer 64

This is fibroepithelial polyp. It is a localised fibroepithelial hyperplasia. Can occur anywhere but commonly sites prone to trauma.

It is similar to the colour of the surroinding tissue but may appear a bit more inflammaed.

Question 65

What is the histopathology of fibroepithelial polyp?

Answer 65

It is an overlying epithelium - hyperplastic or atopic or normal. Bulk lesion is made up of densely collagenous fibrous connective tissue.

MAY OCCUR WITH OSSIFICATION

Question 66

What is the aetiology and treatment of fibroepithelial polyp?

Answer 66

Aetiology: chronic physical trauma and inflammation

Treatment: Excision

Question 67

What condition is this?

Answer 67

This is pyogenic granuloma.

It is a localised soft tissue lesion that is common in people who are pregnant due to the hormone imbalance.

Site: Anywhere but classically arises from the interdental papilla

Question 68

What are the clinical features of pyognic granuloma?

Answer 68

Usually sensile

Sudden onset and rapid growth

Bright red and haemorrhagic, ulcerated surface.

Tissue may mature thus becomes fibrosed

Question 69

What is the hsitopathology of Pyogenic granuloma?

Answer 69

Many lesions are made up of exuberant granulation tissue. It is a very vascular lesion with large numbers of thin walled dilated blood vessels lined by endothelial cells

Question 70

What is the treatment for pyogenic granuloma?

Answer 70

Excision and removal of causative factors

Question 71

What are some of the differential diagnosis for pyogenic granuloma?

Answer 71

1. Neoplasm
2. Heamongioma

Question 72

What is peripheral giant cell granuloma?

Answer 72

It is a similar lesion to the pyogenic granuloma but it also involves bone tissue

Question 73

What is the histopathology of the peripheral giant cell granuloma?

Answer 73

It is a well vascularised cellular tissue with mononuclear cells.

If you see multinucleadted diant cells - probs a peripheral giant cell granuloma

Question 74

What is the imortant aspect of the peripheral giant cell granuloma?

Answer 74

It is important to determine that the lesion is not an intra-bony or central lesion which has perforated cortical bone

Question 75

What is ulcerated fibrous epulis with ossification? what are the clinical features?

Answer 75

It is a relatively common oral lesion. Presents as localised lesion of gingiva like fibrous epulis and pyogenic granuloma.

Clinical features:
1. Painless

2. Relatively rapid growth
3. Size usually less than 1 cm
4. Sometimes - surface ulceration

Question 76

What is the histopathology of ulcerated epulis with ossification?

Answer 76

It is a very cellular lesion - well vascularised and collagenous. IT CONTAINS CALCIFICATIONS.

Question 77

What are generalised gingival hyperplastic lesions?

Answer 77

They are lesion that occur due to underlying factors such as plaque or use of certain medications such as hypertension medication (calcium channel blockers) or anti-covulsants or immunosupresants.

Drug Induced Gingival Overgrowth is one of them

Question 78

What is a linea alba?

Answer 78

It is a lesion occurring on the buccal mucosa as a result of a local mechanical trauma

Question 79

What is the clinical presentation of linea alba?

Answer 79

It is usually symptomless and is very very common.

It presents as a white, narrow, linear lesion on the buccal mucosa.

Could be unilateral or bilateral

Question 80

What is the histopathology of linea alba? What is the management of linea alba?

Answer 80

A thichening of the prickle cell layer can be observed. Hyperkeratosis occurs. Nothing cna be done to manage it - just please do not bite your cheek.

Question 81

What is morsicatio buccarum?

Answer 81

It is cheek biting which causes chronic mechanical trauma.

Clinical presentation is a unilateral or bilateral white patch on the buccal mucosa, which is rough and whitenned. Usually symptomless

Question 82

What is the management of cheek biting?

Answer 82

1. Control of habit
2. Might need to treat the underlying stress

Question 83

What is frictional keratosis?

Answer 83

It is similar to the cheek biting and linea alba but usually occurs on commonly traumatised sites such as the lips, lateral border of the tongue, buccal mucosa, edentulous alveolar ridge.

Appears as a poorly demarcated white lesion.

Question 84

What happens histologically in frictional keratosis? What is the management?

Answer 84

Histological features:
1. Hyperkeratosis

2. No dysplastic changes

Management:

1. Identify and try and remove a cause - might be difficult with edentulous patients
2. Always biopsy if in doubt :)

Question 85

What is smoker’s keratosis?

Answer 85

It is a diffused, white, moderately thickened palate that can be sometimes roughened.

It usually involves the entire palate with characteristic, red, minor salivary gland dots.

Associated with tobacco smoking, especially reverse smoking.

Question 86

What is the histopathology of smokers keratosis?

Answer 86

Hyperkeratosis is common. Thickening of stratum spinosum (prickle cell layer)

Question 87

What is the management of smokers keratosis?

Answer 87

1. Smoking cessation
2. The lesion is usually not malignant but close monitoring is idea

Question 88

What condition is this?

Answer 88

This chronic hyperplastic candidiasis.

It is usually a single, fixed, white or mix of white and red patch that syays when whipped.

May occur anywhere but common sites are the tongue and buccal mucosa.

Question 89

What is the histopathological appearance of chronic hyperplastic candidiasis?

Answer 89

Thickening large bulbus epithelial with keratinisation

Question 90

What are the three common oral HPV infections?

Answer 90

1. Squamous papillomas/Oral warts
2. Condyloma accuminatum
3. Focal epithelial hyperpklasia

Question 91

What are histopathological features of the giant cell fibroma? What are the clinical features?

Answer 91

The main difference between giant cell fibroma is the Giant Stellate Cells rather than the osteoclast like cells.

The clinical features are similar: small, raised, pedunculated lesion that is asymptomatic

Question 92

What is the treatment for giant cell fibroma?

Answer 92

usually surgical excision.

The reoccurance of giant cell fibroma is relativley rare

Question 93

What is traumatic neuroma? What are it’s clinical signs?

Answer 93

It is a lesion thatoccurs due to the damage of a nerve trunk following some sort of injury (like surgery or pressure on dentures).

Essenially - the repair of the axon does not go as planned and the lesion if fully comprised of the neural tissue.

Clinical features: small swelling or nodule on mucosa near mental foramen, alveolar ridge, lips or tongue. Pressure on the nodule cuases pain

Question 94

What is histapathology and treatment of traumatic neuroma?

Answer 94

Histopathology: Presents as a mass of irregular bundle situated in variable amount of connective tissue stroma.

Treatment: surgical excision

Question 95

What is this condition?

Answer 95

This is verruciform xanthoma, it is a rare lesion that mimic squamous cell carcinoma.

It is flat, velvety, pebbly.

Question 96

What is the histopathological appearacnce of verruciform xanthoma?

Answer 96

It is usually associated with foamy, lipid filled marophages.

The lesion is bening

Question 97

What are the principles of management of oral ulcers?

Answer 97

1. Detect a lesion
2. Health and lesion histories
3. Examination - identify cause and remove if possible
4. Differential diagnosis
5. Monitor or Investigate - including biopsy/referral for biopsy
6. Follow-up/referral

Question 98

What is an ulcer?

Answer 98

An ulcer is the loss of contnues of epithelial linings and some fo the connective tissue. It is associated with colour yellow.

Question 99

What are the parts of an ulcer?

Answer 99

1. Border
2. Depression

Question 100

What are some of the oral ulcer that require urgent attention and referral?

Answer 100

1. Long-standing ulcers with no obvious cause
2. Indurated (hard) borders - PLEASE PALPATE
3. Deep ulcers with rolled borders
4. Ulcer that is fixed to underlying tissues - usually ulcers are mobile
5. Painless ulcer
6. Ulcers associated with lymphadenopathy - if there is a large swelling - EMERGENCY

Question 101

What are the different sub types of ulcers that can occur?

Answer 101

1. Reactive lesions
2. Developmental
3. Inflammatory/immunologic
4. Infective
5. neoplastic
6. Idiopathic

Question 102

What is a traumatic ulceration?

Answer 102

It is a type of ulceration from mechanical, chemical, thermal and radiation injury.

Please recall the patient in 2 weeks and during the session try to remove the cause.

Question 103

What are the two types of traumatic lesions?

Answer 103

1. Acute traumatic lesions - a lot of pain, surface covered by yellow fibrinous exudate and halo border
2. Chronic traumatic lesions - minimal pain, elevated margins, fibroepithelial hyperplasia, epithelial hyperkeratosis, induration

Question 104

What is a traumatic eosinophilic ulcer?

Answer 104

It is a bening chronic ulcer usually presenting on the tongue.

It is crateriform in shape.

Question 105

What is the histopathological significance of eosinophilic ulcer and why should it worry us?

Answer 105

Eosinophilic ulcers are usually associated with an abnormal presentation of eosinophils thus it is important to send a biopsy sample of the ulcer for histopathological investigation to ensure it is not malignant

Question 106

What is this condition?

Answer 106

This is a minor aphthous ulcer - which one of the most common ulcer of infectious origin.

It usually occurs in non-keratinised mucosa, it is shallow and rounded.

It has erythematous margins and yellowish floor

Question 107

What is this condition?

Answer 107

This is a major Aphthous Ulcer - an uncommon ulcer of infectious origin.

It is usually very large and can involve keratinised mucosa. This need to be reffer for biopsy because this could be a melignancy.

Question 108

What is this condition?

Answer 108

This is Herpetiform aphthous ulvers - it is an uncommon and are very very small.

Named herpetiform due to the resemblance of the ulcers to those of herpetic stomatitis

Question 109

What are the basic management plan for aphthous ulcers?

Answer 109

1. Accurate diagnosis
2. Symptomatic treatment
3. Steroid

Question 110

What are the oral manifestations of Crohn’s disease?

Answer 110

1. Diffuse lip swelling
2. Coble stone thickening of the mucosa
3. Ulcers

Question 111

What is glossitis?

Answer 111

It is the atrophy of the lingual papilla

Question 112

What is periodontitis?

Answer 112

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

Question 113

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

Answer 113

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

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

Question 114

What are the main points of the Specific Plaque hypothesis?

Answer 114

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

Treatment: targeting and elimination of specific microoganisms using antimicrobials

Question 115

What are the main points of the ecological plaque hypothesis?

Answer 115

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

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

Question 116

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

Answer 116

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

Question 117

What is the microbial virulence?

Answer 117

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

Organism need to:

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

Question 118

What is A. Actinomycetemcomitans?

Answer 118

A. Actinomycetemcomitans or AA is a gram negative anaerobe that is associated with localised aggressive periodontitis.
Able to produce high level os leukotoxins thus causes the lysis of PMNs.
It is equiped with adhesis and invasisn which means it can penetrate the tissue and attach to the space it has penetrated

Question 119

What is P.Gingivalis?

Answer 119

P. Gingivalis is a gram negative anaerob that is associated with periodontits (around 79-90% of perio cases will have this bacteria)
Main cause of the inflammation to the tissue - release of endotoxin (name: P.Gingivalis LPS)
Contains invasins, adhesins and also collagenases which degrade connective tissue.

Question 120

What are the main points of the Keystone Pathogen Hypothesis & Polymicrobial synergy and Dysbiosis Model?

Answer 120

1. Keystone pathogens (e.g. P.Gingivalis) trigger inflammation even in low numbers
2. Causes normal microbiome to become dysbiotic
3. Manipulation of native immune responses of host
4. Inflammatory byproducts sustain dysbiotic microbiota

Treatment: host modulation in adjunct to direct antimicrobial measures

Question 121

What are the stages of the IMPEDE model

Answer 121

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

Question 122

What is the consensus on how periodontal destruction actually occur?

Answer 122

It is widely believed that periodontal destruction occurs due to effects of the immune response and not directly due to bacteria. 80 immune response, 20 bacteria.

Question 123

What is the aetiology of periodontitis?

Answer 123

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

Question 124

What are MMPs?

Answer 124

Matrix metalloproteinases (MMPs) are a large family of calcium-dependent zinc-containing endopeptidases, which are responsible for the tissue remodeling and degradation of the extracellular matrix (ECM), including collagens, elastins, gelatin, matrix glycoproteins, and proteoglycan.

They are regulated IL-6 and IL- 8.

They are released by many cells like PMNs.

Question 125

What causes bone resorption?

Answer 125

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

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

Question 126

What is a risk factor?

Answer 126

Health risk factor are attributes, characteristics or exposures that increase the likelihood of a person developing a disease or health disorder.

Question 127

What are some of the pre-disposing factors for periodontitis?

Answer 127

Any factor that result in retention of biofilm or prevents ts removal thus predisposing for disease progression.

E.g.:

Anatomical factors: root proximity, tooth malposition, concavities and furcation

Aquired/Iatrogenic factors: overhangs, open contacts and appliances

All this needs to happen in a susceptible host.

Question 128

What are modifying or systemic factors?

Answer 128

They are factors that modify disease expression and may influence disease progression by altering host’s immune response
e.g. in periodontitis: smoking and diabetes

Question 129

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

Answer 129

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

It increases the risk of periodontitis by 85%!

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

Question 130

What are two useful statistics to give to a smoker patient in order to discourage them from smoking?

Answer 130

1. Regular smokers have around 50% less improvement in clinical parameter after nonsurgical therapy
2. Regular smoker have 2x implant failure rate compared to nonsmokers

Question 131

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

Answer 131

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

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

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

Question 132

What can be seen intraorally in a patient with diabetes and perio?

Answer 132

1. No specific phenotypic features
2. Pronounced clinical and radiographic signs
3. Signs of progression
4. Multiple reoccuring periodontal abscesses
5. Unpredictable responses to therapy
6. Increases risk of future attachment loss

If you suspect undiagnosed or poorly controlled diabetes, refer to GP for further investigations or management

Question 133

What is the relationship between diabetes and periodontitis?

Answer 133

There is a bi-directional relationship between diabetes and periodontitis, meaning improvement in diabetes improve periodontitis but also improvement in periodontitis improve diabetes!

Question 134

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

Answer 134

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

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

Question 135

How do we calculate clinical attachment loss?

Answer 135

Pocket depth + recession or pocket depth - over growth or pocket depth

Question 136

Is periodontal disease rare ?

Answer 136

No - very very common - both gingivitis and perio are pretty common

Question 137

What is prevalence?

Answer 137

It refers to the total number of individuals in a population who have a disease or health condition at a specific period of time, usually expressed as a percentage of the population.

Question 138

What is incidence?

Answer 138

It refers to the number of individuals who develop a specific disease or experience a specific health-related event during particular time period.

Question 139

What have the 70-80s research into Sri Lankan tea labourers showed us?

Answer 139

1. 10-15% resist periodontitis
2. 10-15% have rapid progression
3. 70-80% have moderate progression

Question 140

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

Answer 140

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

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

Question 141

What is one of the findings from studies relating to periodontal health in Australia?

Answer 141

Rates of periodontitis have remained relatively the same yet the tooth retention rate has been improving

Question 142

What levels are we aiming at when we are discussing a plaque index?

Answer 142

We are aming at below 20% as it is essential for stable periodontal and peri-implant health over the long-term.

Question 143

What is the 2017 Periodontits Case definition?

Answer 143

1.Interdental CAL detectable at 2 non adjacent teeth

or

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

AND

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

Question 144

What is one of the findings from studies relating to periodontal health in Australia?

Answer 144

Rates of periodontitis have remained relatively the same yet the tooth retention rate has been improving

Question 145

What levels are we aiming at when we are discussing a plaque index?

Answer 145

We are aming at below 20% as it is essential for stable periodontal and peri-implant health over the long-term.

Question 146

What BOP score are we aiming to achieve?

Answer 146

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

Question 147

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

Answer 147

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

Question 148

What is the second group of systemic disease and conditions that relate periodontitis?

Answer 148

They are some relatively common systemic conditions that have a moderate impact on prevalence / severity of priodontitis.

These diseases usually have an influence on the parthenogenesis of periodontal disease.

Some of these disease and disorders are:
1. Diabetes
2. Obesity
3. Osteoporosis
4. Arthritis - could through are process of inflammatory aggravation called citrulination
5. Stress and depression
6. Hypertension - maybe but probably not - but people with perio are more likely to have hypertension

Question 149

What is the third group of systemic disease and conditions that relate to peridontitis?

Answer 149

They are systemic or local conditions that mimic periodontitis and cause destruction of periodontal attachment. They are independent of plaque induced periodontitis and cause periodontal tissue damage through other mechanisms.

Some of these disease and disorders are:
1. Neoplasm that originate from the gingival and may resemble perio
2. Giant cell granuloma and many other very rare diseases that may mimic symptoms and signs of perio

Question 150

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

Answer 150

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

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

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

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

Question 151

What is the theory of indirect pathway?

Answer 151

It also relates to the periodontal inflamed surface area.

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

Less plausible than the direct pathway.

Question 152

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

Answer 152

AVD is the most common form of death worldwide.

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

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

Question 153

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

Answer 153

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

Question 154

What is the association between periodontitis and diabetes?

Answer 154

Periodontitis and diabetes have a bilateral relationship thus an improvement in one of them may result in improvement of the other

The process of periodontitis affecting diabetes:

1. Periodontal infection causes elevation of serum pro-inflammatory cytokines
2. Systemic inflammation leads to insulin resistance by blocking insulin receptors
3. Bacterial dissemination may alter b cell secretion through b-cell dedifferentiation - also enzymes produced by P.Gingivalis may reduce glucose-induced insulin production
4. There are also some evidence that P.Gingivalis may cause gut dysbiosis but take it with a grain of salt

Question 155

What to do if a patient has uncotrolled diabetes?

Answer 155

You should do non-surgical treatment ad collaborate with GP and inform patient that perio help with diabtes

Question 156

What is prognosis?

Answer 156

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

Prognosis is establish after diagnosis.

Question 157

What s the difference between prognostic factors and risk factors?

Answer 157

Prognostic factors are characteristics that predict the outcome once the disease is present.

Risk factors are characteristics that put an individual at increased risk of developing a disease.

Sometime they are the same but sometimes they are different

Question 158

How can we separate the types of prognosis?

Answer 158

1. Overall prognosis - genetic conditions, patient compliance, age, patient expectation
2. Individual prognosis - local prognostic factors (tooth positions, ppd, furcation etc.) and prosthetic/restorative factors (caries, endodontic status etc.)

Question 159

What is the system of tooth prognosis by Nibali?

Answer 159

It is a very objective system that involves

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

Question 160

When should we extract a tooth?

Answer 160

Only teeth with hopeless prognosis and that are not favourable

Question 161

When would you suggest an immediate extraction?

Answer 161

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

Question 162

What is favourable periodontal disease progression?

Answer 162

It is when the periodontal status of the tooth can be stabilised with comprehensive periodontal treatment and periodontal maintenance. Future loss of periodontal supporting tissue in unlikely.

Question 163

What is questionable periodontal disease progression?

Answer 163

It is when the periodontal status of the tooth is influenced by local and systemic factors that may or may not be able to be controlled. The periodontium can be stabilised.

Question 164

What is unfavourable periodontal disease progression?

Answer 164

It is when the periodontal status of the tooth is influenced by local and/ or systemic factors that cannot be controlled.

Question 165

What is the hopeless periodontal disease progression?

Answer 165

Only extraction may help

Question 166

What are some of the goals of periodontal treatment?

Answer 166

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

Question 167

How can you categories your perio treatment goals?

Answer 167

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

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

Question 168

What are the steps of periodontal treatment for good and fair prognosis teeth?

Answer 168

1. Initial therapy
2. Revaluation or reassessment of prognosis
3. Surgical or maintenance phase

Question 169

What are the steps of periodontal treatment for questionable and unfavourable teeth?

Answer 169

1. Plan potential abutment for rem/fixed prosthesis
2. IF NOT, Initial therapy
3. Revaluation or reassessment of prognosis
4. Surgical (when pocket depth above 6mm) or maintenance phase (if pocket depth are below 6mm after treatment)

Question 170

How to set up a case report for perio?

Answer 170

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

Question 171

How to set up a provisional treatment plan for perio?

Answer 171

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

Question 172

What are acute periodontal conditions?

Answer 172

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

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

Question 173

What happens if a patient shows up to the initial treatment appointment with an active herpes cold sore?

Answer 173

Might need to postpone the treatment as the disease is in it’s most contageous stage - similar to other diseases like COVID 19

Question 174

Would you give antibiotic prophylaxis to patient before root planing?

Answer 174

Yes you would if they have an underlying health condition.

Question 175

What is the objective of the initial phase of therapy?

Answer 175

The objective is to achieve clean and infection free conditions for the oral environment by removal of soft and hard deposits and any retentive points and factors that might propagate them

Question 176

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

Answer 176

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

Question 177

What can you provide for pain management
for perio procedures?

Answer 177

1. LA
2. Topical
3. Mouth rinse using cepacaine

Question 178

What is the relationship between the pocket depth and the average percentage of root surface debrided?

Answer 178

With the increase of pocket depth - the amount of debridement usually goes down even with experienced operators

Question 179

What are some of the difficulties with subgingival root plaining?

Answer 179

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

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

Question 180

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

Answer 180

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

Question 181

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

Answer 181

Repair through long junctional epithelium:

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

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

Question 182

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

Answer 182

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

Question 183

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

Answer 183

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

Question 184

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

Answer 184

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

All defects must undergo non-surgical therapy.

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

Question 185

What are some of the aetiology of furcation involvement?

Answer 185

1. Periodontitis
2. Endodontic infection
3. Iatrogenic - rct perforation
4. Anatomy - like enamel pearls

Question 186

What are some of the anatomy that we must know for furcation involvement?

Answer 186

1. Root fornix - the upper morst area of the furcation close to the crowns
2. Root trunk - the area between the CEJ and the fornix
3. Root divergence - the degree of separation between the roots

Question 187

What is the disadvantage of a short root trunk length for furcation debridement?

Answer 187

A short root trunk length results in earlier furcation exposure but has better accessibility for treatment

Question 188

Why do class 2 and 3 furcations have bad prognosis?

Answer 188

Because of biofilm accumulation and hardness of debridement

Question 189

What are the advantages of access flap debridement?

Answer 189

1. Improved access for professional instrumentation
2. More efficient calculus removal
3. Significant clinical improvements

Question 190

What are other techniques that could be useful in improving the oral hygiene caee for furcations for a patient?

Answer 190

Tunneling technique - surgical exposure of inter-radicular space. Most common complication - root caries.

Root resection - for a patient with RCT and class 3 furcation

Question 191

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

Answer 191

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

Question 192

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

Answer 192

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

BUT when untreated periodontitis is involved:

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

Question 193

What are clinical signs of occlusal trauma?

Answer 193

1. Increased tooth mobility
2. Tooth migration
3. Fremitus positive
4. Wear facets disproportionate to age or diet

Radiographicaly:
1. Widened PDL space
2. Angular bone loss
3. Thickened supporting alveolar bone

Question 194

How should we treat mobile teeth?

Answer 194

1. Treat the cause
   2.Periodontal surgery
   3.Splinting - remember to adjust the occlusion

Question 195

What are the 2 main ways to apply antibiotics for periodontitis?

Answer 195

1. Local - to the site
2. Systemic - through the blood stream

Question 196

What are the disadvantages of supragingival antibiotic application?

Answer 196

It does not create subgingival penetration thus will not greatly affect bacteria which affect periodontal disease.

Question 197

What are the advantages and disadvantages of subgingival antiobitc application?

Answer 197

Advantages
1. high local concentration
2. Fewer side effect
3. Improved compliance

Disadvantages:
1. GCF clearance
2. Reinfection from untreated sites
3. Limited product availability

Question 198

What are the advantages and disadvantages of systemic administration of antibiotics

Answer 198

Advantages:
1. can reach periodontal tissue
2. Easily available

Disadvantages:
1. Variable local concentration
2. Resistance
3. Systemic side effects

Question 199

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

Answer 199

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

Question 200

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

Answer 200

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

Question 201

What is the common combination of anti-biotics used to treat periodontal disease?

Answer 201

Metronidazol & amoxicillin which is known as Winkelhoff cocktail - it is the most researched combination and also does produce clinically significant improvements

Question 202

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

Answer 202

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

Question 203

What patient should get anti-biotic therapy?

Answer 203

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

Question 204

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

Answer 204

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

Question 205

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

Answer 205

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

Question 206

What is supportive periodontal treatment?

Answer 206

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

Question 207

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

Answer 207

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

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

Question 208

What are the steps to a good supportive periodontal treatment session?

Answer 208

1. Patient greeting and interview
2. Review of medicla history
3. Existing factors evaluation and counselling
   4, Clinical examination and re-evaluation: Oral Path, OH status, Perio exam, Caries check, fix-pros check
4. Hygiene
5. Motivation
6. ALWAYS BOOK ANOTHER APPOINTMENT

Question 209

Shouldyou probe all the teeth at SPT session

Answer 209

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

Question 210

What would you mention to a patient who has periodontitis?

Answer 210

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

Question 211

What kind of model of progression is periodontitis believed to be?

Answer 211

Linear destruction model or burst destruction modle.

Phases of remission and exacerbation.

Question 212

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

Answer 212

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

Question 213

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

Answer 213

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

Question 214

What is an endo-perio lesion?

Answer 214

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

Question 215

What is the endo-perio aetiology?

Answer 215

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

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

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

Question 216

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

Answer 216

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

Question 217

What is the treatment of primary endo secondary perio lesion?

Answer 217

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

Question 218

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

Answer 218

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

Question 219

What is the treatment of primary perio secondary endo lesion?

Answer 219

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

or

1. Extraction depending on prognosis

Question 220

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

Answer 220

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

Question 221

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

Answer 221

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

Question 222

What is the treatment of fractures teeth?

Answer 222

1. Do nothing
2. Extraction

Question 223

What is usually associated with hopeless prognosis of EPL?

Answer 223

EPLs that are related to aitriogenic damage.

Question 224

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

Answer 224

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

Question 225

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

Answer 225

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

Grade 2 - wide deep periodontal pocket in 1 tooth surface

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

Question 226

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

Answer 226

Grade 1 - narrow deep periodontal pocket in 1 tooth surface

Grade 2 - wide deep periodontal pocket in 1 tooth surface

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

Question 227

What are the difference between the periodontium in children comparing to adults?

Answer 227

1. Gingival colour more reddish because of the thinness
2. Rounded gingval margins
3. Looser consistency
4. Smoother surface
5. Increase in attached gingiva
6. Sulcus depth shallower
7. Wider PDL space
8. Prominent lamina dura
9. Distance between CEJ to alveolar crest is less

Question 228

What decreases the susceptibility to gingivitis in children?

Answer 228

1. Thicker junctional epithelium
2. T-cell dominated response
3. Few B lymphocytes
4. Less calculus build up thus less niches for bacteria to propagate

Question 229

Why is there around 100% occurrence rate of gingivitis in kids going through puberty?

Answer 229

There is a theory that during puberty when tooth exfoliation occurs, due to some discomfort that may occure during the process - the brushing habit worsen in kids thus resulting in gingivitis.

Also fixed and removable orthodontic appliances contirute to this.

Question 230

What are some of the other systemic factors that may contribute to development of gingivitis in young patients?

Answer 230

1. Smoking
2. Hyperglycemia
3. Nutritional factors
4. Pharmacological factors
5. Sex steroid hormones
6. Hematological factors like leukemia

Question 231

How do we treat primary herpetic gingivostomatitis?

Answer 231

Primary herpetic gingivostomatitis is a disease that occurs after primary infection with herpes simplex virus

Treatment:

10-14 day duration

Control fever, pain and hydration

DO NOT TOUCH THE ULCERS

Question 232

What do we classify any fast-progression periodontitis in young patients?

Answer 232

Grade C and we look at the underlying systemic conditions or genetic factors.

Question 233

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

Answer 233

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

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

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

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

Question 234

What caution should we have in terms of perio and orthodontics?

Answer 234

The actual orthodontic process do not cause attachment loss but:
There needs to be cautious approach for patient with with thin periodontium phenotype as labial orthodontic movement in thin periodontal phenotype may result in bone dehiscence.

And presents of gingival inflammation or trauma may result in CAL.

Question 235

What is pathological tooth migration (PTM)?

Answer 235

In significant periodontitis, the arch integrity may be compromised due to destruction of Sharpay fibres thus resulting in migration of the teeth.

The symptoms may be increase diastemas, drifting of teeth or collapsing of occlusal vertical dimension

Question 236

What is the treatment of pathological tooth migration?

Answer 236

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

Question 237

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

Answer 237

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

Question 238

What is the supracrestal attached tissues?

Answer 238

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

Question 239

What happens when you place the restoration subgingivally inappropriately?

Answer 239

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

Question 240

How do we assess the SAT violations?

Answer 240

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

Question 241

What are the treatments of SAT violations?

Answer 241

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

Question 242

What are the steps to make a gingiva friendly temporary crown?

Answer 242

1. Mark cervical margin and contact point
2. Polish it
3. Consider interdental papilla
4. Polish it

Question 243

How should you design a pontic?

Answer 243

It need to be hygienic in order to be cleaned.

Tell your patient to use super floss to clean under the bridge

Question 245

What is this condition?

Answer 245

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

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

Treatment:

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

Question 246

What is this condition?

Answer 246

This is cancrum oris (noma) - it is a destructive condition involving oral soft tissues and jawbone.

Usually associated with children who are malnourished and have lower immunity due to systemic infections.

Thought to arise from NG

Question 247

What is this condition?

Answer 247

This is actinomyces - an infection characterised by multiple foci of chronic suppuration.

Patient present with firm swelling commonly in the submandibular region with variable pain symptoms.

Treatment: prologned antimicrobial treatment after cultures

Question 248

What are the histological features of Actinomyces?

Answer 248

1. Chronic granulomatous inflammation surrounded by abundant granulation tissue and fibrosis
2. Granules consisting of tangled meshes of organisms may be seen

Question 249

What is syphilis and what are the 2 common types of syphilis?

Answer 249

It is a sexually transmitted disease that is cause by T. Pallidum

Two common types

1. Congenital
2. Aquired

Question 250

What are some of the oral manifestations of congenital syphilis?

Answer 250

1. Notched permanent incisors
2. Hypoplastic first molars
3. Saddle bone deformity

Question 251

What are the lesion of the primary syphilis?

Answer 251

It is a chancre - which occurs at the site of primary inoculation 3-4 weeks after infection.

Lesions are high infectious - be careful!

Heals naturally

Question 252

What are the lesion of the secondary syphilis?

Answer 252

They are usually described as some mucous patch, rash or condyloma lactum.

Usually occur 6-8 weeks after primary stage.

Still infectious - please be careful

Question 253

What are the lesion of the tertiary syphilis?

Answer 253

They are called Gumma - they usually involve the hard palate perfiration or syphilitic glossitis

Question 254

What are the oral manifestation of Tuberculosis?

Answer 254

Mulitlobular ulcerated growth due to immundeficency - histologically it is associated with granuloma inflammation.

Question 255

What are the oral manifestations of Leprosy?

Answer 255

Nodular mucosa lesions are present in 20-60% of the patient

Question 256

What are the aitological factors to Oral Candidosis?

Answer 256

Local factors:
- Poor denture hygiene
-Reduced vertical dimension
-Reduced salivary flow

Systemic factors:
-Extreme of age
-Endocrine disturbances
-Malnutrition
-Antibiotic therapy

Question 257

What are the classifications of oral candidosis?

Answer 257

1. Acute:
   - Atrophic (denture or antiotic-associated)
   - Pseudomembranous condidosis - thrush
2. Chronic
   -Atrophic
   -Hyperpastic
3. Mucocutaneous
   - Usually T cell deficiency

Question 258

What is an Acute Atrophic Candidosis? What is the management?

Answer 258

It is a generalised, red focal area of red/inflamed oralmucosa.

This condition has no other specific symptoms other than pain.

Management:
-Correct diagnosis
-Oral denture hygiene
-Antifungal agents

Question 259

What is the acute pseudomembranous candidosis or thrush?

Answer 259

it is most common type of acute candidiasis.

This is a lesion/lesions that is associated with soft, white/yellow plaque that can be lifted off the mucosa.

These plaques represent inflammatory exudate, dead cells and fungal colonies

Question 260

What is the management of acute pseudomembranous cndidosis?

Answer 260

1. Base your diagnosis on oral features and cytology smear
2. Managment depedns on sverity of symptoms and predisposing factors:

• for simple case - antibiotic therapy, topical antifungal agents and oral hygiene instructions
• for a complex case e.g. patient with immunosuppression - medical consultation and topical/systemic antifungal agents

Question 261

What is chronic atropic candidosis?

Answer 261

Chronic Atrophic Candidosis - is a non-specific red area in the mouth.

Some of the example of it is angular cheilitis

Take a smear.

Question 262

Whatis a Chronic Hyperplastic Candidosis?

Answer 262

It is lesion/lesions that may occur anywere but are common to the tongue and buccal mucosa.

Present as white or mixed white/red patches or plaques on the mucosa.

THIS LESION CAN RESEMBLE OTHER PATHOLOGY - like lichen planus or early squamous cell cercinoma biopsy and re-biopsy after antifungal treatment

Question 263

What can exfoliative cytology be used for?

Answer 263

1. Fungal infections
2. Bacterial infections
3. Viral infections

Question 264

What is one of the treatment of oral candidosis?

Answer 264

Miconazole 2% gel 2.5 mL topically (then swallowed), 4 times daily, after food, for 7 to 14 days; continue treatment for at least 7 days after symptoms resolve

Or Amphotericin B 10 mg lozenge sucked (then swallowed),4 times daily, 7 to 14 days; continue treatment 2 to 3 days after resolved

Question 265

What is a treatment for a patient with angular cheilitis?

Answer 265

Miconazole 2% gel 2.5 mL topically (then swallowed), 4 times daily, after food, for 14 days; continue treatment for at least 14 days after symptoms resolve

or

Chlorimazole 1% cream topically to the angles of the mouth, twice daily for at least 14 days; continue treatment for 14 days after symptoms resolve

Question 266

What are quite common viruses with oral manifestations?

Answer 266

1. Herpes labialis
2. HPV
3. HIV
4. Hep C

Question 267

What is the basic progress of infection and manifestations with a herpes simplex virus?

Answer 267

1. An inividual is seronegative
2. Exposure to the virus occurs
3. Primary disease - Subclinical Gingivostomatitis is considered to be primary disease
4. An inidividual becomes seropositive
5. Reactivation of the diseases (aka Secondary disease) may occur due to stressors - usually results in a cold sore
6. Resolution of the cold sore - return to being seropositive

Question 268

What is gingivostomatitis?

Answer 268

It is a widespread vesicular eruption involving skin, vermillion and mucosa.

It results in painful widespread infection that can be observed in the photo.

It is associated with young children or older adult who are immunocomprimised

Question 269

What is recurrent herpes simlex vitus?

Answer 269

It is a vesicular eruption affecting perioral skin, lips, gignivae and palate - knowns as harpes labialis

Question 270

What are the histological features of herpetic lesions?

Answer 270

1. Intraepitheial vesicle formation - aka acantholysis
2. The vesicles contain inflammatory cells and exudate
3. Destruction of epithelial cells

Question 271

What is the varicells virus?

Answer 271

It is also known as chicken pox!

It is a vesicular infection that migh have some oral mucosal involvement

Question 272

What does the reactivation vericells virus lead to?

Answer 272

It leads to shingles.

Shingles may result in oral manifestations like vesicular lesiosn aorund the oral cavity.

Question 273

What is a dermatome?

Answer 273

A dermatome is an area of sking that is associated with a root of a single neural connection to the spine or orofacial (cranial) nerves

Question 274

What is Oral Hairy Leukoplakia?

Answer 274

It is a oral manifestation that relates to the Epstein Barr Virus and is associated with HIV invection

Question 275

What is this condition?

Extra information: The patient is from Greece?

Answer 275

This a kaposi’s sarcoma - an oral lesion associated with Herpes Virus 8 - it is very aggresive in it’s course

Question 276

What are the two conditions related to Coxsackie virus infections?

Answer 276

1. Hand-foot-and-mouth disease
2. Herpangina

Both are self limiting infections that effect children more than the adults

Question 277

What do you usually associate infections with?

Answer 277

Systemic symptoms such as fever and enlarged tender lymph nodes.

Question 278

What is the difference between true herpes infection ulcer and a herpetiform apthous ulcer?

Answer 278

True herpes infections come with systemic symptoms herpetiform does not

Question 279

What are the most common origins of tumours in the oral cavity?

Answer 279

1. Epithelial - related to the epithelial lining of the oral cavity, salivary gland, oeontogenic epithelium
2. Mesenchymal
3. Haemotlymphoid

Question 280

What is a meaning of tumour?

Answer 280

Tumour - means swelling above the size of 2cm.

Question 281

What is a meaning of a neoplasm?

Answer 281

Neoplasm - is a tumour that does not stop growing

Question 282

What are the terminology of the bening and malignant tumours?

Answer 282

1. Bening tumours have the suffix “…oma”
2. Melignant tumours:
   - Epithelial tumours are “carcinoma”
   - Mesenchymal tumour have a suffic “…sarcoma”

The exeptions are: melanoma and lymphoma which are both malignant

Question 283

What is the orgini of most benign fibromas in the oral cavity?

Answer 283

Most of them arise from fibropepithelials polyps and fibroepithelial hyperplasia

Question 284

What is a solitary fibrous tumour?

Answer 284

The solitary fibrous tumours are benign neoplasms that arise from combination of altering hypocellular and hypercellular areas.

It consists of bands of hyalinised collagen in between spindle shaped cells.

Question 285

What is a myxoma?

Answer 285

It is an uncapsulate lesion with infiltrative growth and stellate and spindle.

Occurs as bubbly in appearance.

Question 286

What is a lipoma?

Answer 286

It is an uncommon lesion in the oral cavity - most commonly filled with adipose tissue (fat cells)

Question 287

What are some muscle tumours?

Answer 287

1. Leiomyoma - smooth muscle, benign neoplasm
2. Leiomyosarcoma - smooth muscle, malignant neoplasm
3. Rhabdomyosarcoma - skeletal muscle, malignant neoplasm

Question 288

Whats is neurilemmoma?

Answer 288

They are benign neoplasm associated with schwann cells.

Could occur as a asymptomatic, submucosal mass

Question 289

What is neurofibroma?

Answer 289

It is usually a multiple lesion - it is asymptomatic and is related to neurofribromatosis

This lesion could turn malignant

Question 290

What is a granular cell tumour?

Answer 290

It is a painless smooth swelling on the tognue related to large granular cells.

Histologically it relates to hyperplasia in an odd way where it looks like it’s invading other tissue

Question 291

What are oral potentially malignant disorders?

Answer 291

It is a clinical presentation that carry a risk of cancer development in the oral cavity whether in a clinically definable precursor lesion or in clincally normal oral mucosa.

Question 292

What are risk factors for cancer?

Answer 292

1. Tobacco
2. Alcohol
3. Betel-quid (tobaco in a different form) - bucal sulcus

Question 293

What is the cinical spectrum of normal mucosa to erythroplkia?

Answer 293

1. Normal mucosa
2. Thin, smooth leukplakia
3. Thick, fissured, leukoplakia
4. Granular, verruciform leukoplakia
5. Red tissue - erytholeukoplakia

Question 294

What is a leukoplakia?

Answer 294

It is a predominantly white plaque of questionable risk having excluded other known diseases or disorders that carry no increased risk of cancer

Question 295

What is proliferative verrucous leukoplakia?

Answer 295

Proliferative verrucous leukoplakia is a progressive, persistent and irreversible disorder characterized by the presence of multiple leukoplakia that frequently become warty.

Question 296

What is eryhtroplakia?

Answer 296

Erythroplakia is a predominantly fiery red patch that cannot be characterized clinically or pathologically as any other definable disease

Question 297

What is lichen planus?

Answer 297

A lichen Planus is a chronic inflammatory disorder of uknown etiology with characteristis relapses and remissions, displaying white reticular lesions, accompanied or not by atrophic, erosive and ulcerative and/or plaque type areas. Lesion are frequently bilaterally symmetrical.

Desquamative gingivitis may be a feature.

Question 298

What condition is this?

Answer 298

This is an oral lichenoid lesion - which is similar to oral lichen planus but is usually around a single site.

Usually associated with medications and go away when medication is stopped

Question 299

What is oral submucous fibrosis?

Answer 299

Oral submucous fibrosis is a chronic, insidious disease that affects the oral mucosa, initially resulting in loss of fibroelasticity of the lamina propria and as the disease advances, results in fibrosis of the lamina propria and the submucosa of the oral cavity along with epithelial atrophy.

Associated with tobaco products that stay in the crevaces of the oral cavity for a long time

Question 300

What is actinic cheilitis?

Answer 300

Actinic cheilitis is a disorder that results form sun damage and affects exposed areas of the lips, most commonly the vermillion border of the lower lip.

Question 301

What is dysplasia?

Answer 301

It is the presence of cells of an abnormal type within a tissue, which may signify a stage preceding the development of cancer.

Question 302

What are some of the architectural changes that occur in dysplasia?

Answer 302

1. Drop shaped rete pegs
2. Irregular eppithelial stratification
3. Loss of polarity in basal cells
4. Increased number of mitotic figures
5. SUPERFICIAL MITOSES

Question 303

What are the cytological changes in dysplasia?

Answer 303

1. Nuclear pleomorphism

2.Cellular pleomorphism

3. Increased nuclear size

Question 304

What are the the different types of dysplasia?

Answer 304

1. Mild (grade I) - dysplasia is in the first third of the pithelium
2. Moderate (grade II) - dysplasia entering the middle third of the epithelium
3. Severe (grade III) - dysplasia near the basal layer

Question 305

What is carcinoma in situ?

Answer 305

It is when dysplasia that has been only registered in one layer of the tissue but is through out the whole layer - the epithelium have not yet created island in the connective tissue below thus the basal layer has not yet been breached

Question 306

How do you manage dysplastic lesions?

Answer 306

1. Observation:
   - Mangaing lifestyle risk factors
   - Regular follow-ups
   -Clinical risk assessment

Excision
- Cold-knife excision
- Cryosurgery
- CO2 laser ablation
- Photodynamic therapy

Question 307

What are risk factors for cancer

Answer 307

1. Tobacco
2. Alcohol
3. Betel-quid (tobaco in a different form) - bucal sulcus
4. Human Papillomavirus (HPV) types 16 and 18
5. Ultraviolet radiation

Question 308

What is the parthenogenesis of cancer?

Answer 308

1. Loss of cell cycle control through loss of apoptosis proteins (p53) and up regulation of proliferation proteins - cell communication occurs
2. Invasion and metastasis - through breach of basement membrane and over expression of oncogenic enzymes - metastasis could be distant

Question 309

What is the clinical presentations of malignant lesions?

Answer 309

RULE acronym:

1. Red/white
   2.Ulcer
   3.Lump

Exceeding 3 weeks in duration

Question 310

What are some of the other presentations of oral cancer coudl arise?

Answer 310

1. Non-healing extraction socket
2. Pigemented lesion (melanoma) with irregular borders

Question 311

What are the common sites for squamous cell carcinoma?

Answer 311

1. Lower lip
2. Tongue

Question 312

What is the pathology of squamous cell carcinomal?

Answer 312

1. Invasion of malignant epithelial
2. Localised tissue destruction like bone erosion - floating tooth on the radiograph (primary intraosennous carcinoma
3. Spread to the lymphatic system
4. Distant metastasis

Question 313

What is the grading of tumours?

Answer 313

It is a process of examining the degree of differentiation of cells

Grade 1 - well differentiated squamous cell carcinoma

Grade 2 - moderately differentiated squamous cell carcinoma

Grade 3 - Poorly differentiated squamous cell carcinoma

Grade 4 - anaplastic - fucked

The greater the grade the worst a prognosis

Question 314

What are the 4 pathways of spread of an oral carcinoma?

Answer 314

1. Direct extension into adjacent tissue
2. Perineural infiltration
3. Vascular invasion
4. Lymphatics

Question 315

What is the staging system used for oral cancers?

Answer 315

Based on TNM system
T is size
N is invasion of surrounding tissue
M is distant malignancies

Minimum is Stage 1: T1N0M0

Max Stage 4 : Any M

Question 316

What is the survival rate of each stage of oral cancer?

Answer 316

Stage 1 and 2 - around 50% over 5 years

Stage 3 - 15-20% over 5 years

Stage 4 - less than 5% over 5 years

Question 317

What is main treatment for patient with oral cancer?

Answer 317

1. Initial diagnosis
2. Definitive treatment
3. Management of complications and monitoring

Question 318

What are the actual treatment options for oral cancer?

Answer 318

1. Surgery
2. Radiotherapy
3. Chemotherapy
4. Combination of treatments above

Question 319

What is the role of a general denstist for a patient with oral cancer?

Answer 319

1. Detection of potentially problematic lesions and referral
2. Management role - for any other oral concern, including complications from treatment of oral cancer
3. Ongoing screening

Question 320

What is the advantage of radiotherapy?

Answer 320

Radiation affect the ability of rapidly dividing cells to replicate, thus a tumour can not grow.

Question 321

What is the disadvantage of radiotherapy?

Answer 321

Radiotherapy may also affect the salivary gland and mucosa - causing it to become atrophied and ulcerated

Question 322

What is the effect of radiotherapy on salivary glands?

Answer 322

1. Loss or atrophy of acini
2. Inflammation
3. FIbrosis
4. Dilation of ducts

Question 323

What is the effect of radiotherapy of the bone tissue?

Answer 323

1. Endarteritis obliterans - destruction of blood vessels thus making the tissue depleted of oxygen and nutrients
2. Osteonecrosis
3. Infection and pain
4. Can be potentially life threatnening

Question 324

What is the common condition that may be caused by radiotherapy?

Answer 324

Radiation mucositis

Question 325

What are the side-effects of chemotherapy on the oral environment?

Answer 325

1. Oral mucositis is common
2. Salivary glands impairment
3. Increase the rate infections and decreased rate of healing due to supressed immunity

Question 326

What is the management of side effects related to chemotherapy?

Answer 326

1. Prevention of oral infections
2. Maintenance of oral hygiene - basic oral care
3. Supportive treatment

Question 327

How do we prevent a patient from having sever cancers?

Answer 327

1. Primary prevention - reducing the risk factors - tobacco control, healthy eating, reduced exposure to sunlight, inherited risks
2. Secondary prevention - early detection

Question 328

What are the 5 categories of most frequent lesions of the oral cavity?

Answer 328

1. Apthous ulcers
2. Herpex simplex lesions
3. Trauma associated lesions
4. Migratory glossitis
5. Candidiasis infection lesions

Question 329

What is oral granulomatosis?

Answer 329

It is a process where multiple granulomas can be seen in the oral cavity.

Associated with:

Crohn’s disease

Leprosie

TB

Question 330

Give 5 differential diagnosis for a white lesion

Answer 330

1. Leukodema
2. Leukoplakia
3. Lichen Planus
4. Frictional keratosis
5. Oral squamous cell carcinoma

Question 331

Give 5 differential diagnosis for red lesions

Answer 331

1. Pyogenic granuloma
2. Haemangioma
3. Peripheral Giant Cell Granuloma
4. Erythroplakia
5. Oral squamous cell carcinoma

Question 332

Give 5 differential diagnosis for a pigmented lesion?

Answer 332

1. Oral melanotic macule
2. Mucosal melanocytic naevus
3. Amalgam tattoo
4. Malignant melanoma
5. Smokers melanosis

Question 333

Give 5 differential diagnosis for a gum lump?

Answer 333

1. Haemangioma

2.Fibroepithelial polyp

3. Pyogenic granuloma
4. Peripheral giant cell granuloma
5. Calcifying fibroblastic granuloma

Question 334

Give 5 differential diagnosis for an ulcer?

Answer 334

1. Herpetiform ampthous ulcer
2. Mild amthous ulcer
3. Major ampthous ulcer
4. Traumatic acute ulcer
5. Traumatic chronic ulcer

Question 335

What lesion is associated with human papilloma virus?

Answer 335

Squamous papilloma.

An asymptomatic, solitary lesion that is associated with cauliflower like apperance

Question 336

What are the histological features of squamous papilloma?

Answer 336

Exaggerated growth of usually parakeratinsed benign squamous epithelium.

Finger-like projections of epithelium with central cres of fibrovascular tissue

Question 337

What is the link between HPV and cancer?

Answer 337

Sometimes HPV can playe a role in oropharyngeal carcinoma - which is a basaloid subtype of squamous cell carcinoma.

Question 338

What is another type of lesion that can be caused by HPV?

Answer 338

Genital warts in the mouth or Oral Condyloma Accuminatum.

It is an infections lesion that can cause transmission through direct contact.

It presents as a broad based pink nodule that grows and coalesce (come as one)

Question 339

What are the two haematolynphoid tumours?

Answer 339

1. Non-Hodgkin lymphoma
2. Hodgkin lymphoma

Question 340

What are the oral manifestation of non-hodgkins lymphoma?

Answer 340

Large ulceration, swelling, pain, paraesthesia and losse teeth
Aetiology is unknowns

Question 341

What is the main feature of oral malignant melanomas?

Answer 341

They have a defused appearance

Question 342

What does lichen planus mean?

Answer 342

Flat fungus - it is originally a tree disorder and IS NOT A FUNGUL INFECTION IN THE MOUTH

Question 343

What are the most common lichen planus lesion appearances

Answer 343

1. Striated lesions
2. Erosive/ulcerative lesions - THESE ARE PAINFUL
3. Atrophic lesion

Question 344

What is lichen planus in oral pathology terms?

Answer 344

Oral lichen planus is a common immune-mediated (NOT AUTOIMMUNE) mucosal disease. It has an incidence of around 2.2%.

It is a chronic disease, often bilaterla and symmetrically distributed.

Common sites: buccal mucosa, dorsal surface of tongue and gingiva.

Could be triggered by medication, dental materials, mints and cinnamon

Question 345

What are clinical features of oral lichen planus?

Answer 345

1. Striae - most common, sharply defined and do not disapear when whiped
2. Atrophic areas - read areas and thin mucosa
3. Erosive areas - shallow area of ulceration
4. White plaque - think about leukoplakia

Question 346

White kind of appearance can the gingiva be if it is affected by lichenoid inflammation?

Answer 346

Desquamative gingivitis appearance - atrophic and “raw”.

Remember that this is not exclusive to lichen planus

Question 347

What are some of the other, extraoral signs of lichen planus?

Answer 347

Cutaneous lesion on the flexour surfaces of the body.

Purple papules, scaly lesions.

Look at patients wrists

Question 348

What is the pathology of lichen planus?

Answer 348

1. Migration of T-lymphocytes into the epithelium
2. Epithelium basal cell layer destruction - the stems cells within the basal cells are lost
3. Epithelium becomes thinner and keratinised
4. Further lymphocytes recruitment forms dense infiltrate below the epithelium
5. Immune reaction leading to keratinocyte destruction

Question 349

What are the option of clinical diagnosis of lichen planus?

Answer 349

1. Very good medical history - all contact reactions, time noticed
2. Histopathology - request histopathology after biopsy
3. Immunofluorescence studies - pathology LAB ONLY - in lichen planus it is deposition of fibrinogen along the basement membrane - it appears shaggy

But the most important part - DISCLUDE ALL OTHER WHITE LESIONS THAT ARE SIMILAR

Question 350

What is immunofluorescence or immunohistochemistry?

Answer 350

It is a test that can be used for autoimmune disease as well immune mediated conditions (such as lichen planus).

For this test - pathology lab needs to pick u the sample on the day or you need to do it asap with prior fixing in paraformaldehyde 4% at room temperature

Question 351

What do we look for in autoimmune diseases?

Answer 351

Auto-antibodies - self anti-bodies that attack self cells.

Question 352

What is the aetiology of lichen planus?

Answer 352

The main factor and process is not known but we have some associations.

Question 353

What are the differential diagnosis for a lesion that is similar lichen planus?

Answer 353

1. Lichen planus
2. Lupus eythematosus
3. Cheek biting/ frictional keratosis
4. Graft versus host disease
5. Candidosis
6. Idiopathic leukoplakia
7. Squamous cell carcinoma
8. Chronic ulcerative stomatitis

Question 354

What are the steps to diagnosis of lichen planus?

Answer 354

1. History of drugs and/or systemic illness
2. Location/pattern of lesions
3. Histopathology and immunofluorescense

Question 355

What is the reported rate of transformation rate of lichen planus into a malignancy?

Answer 355

Around 0.44%.

Question 356

What do you do if you confirm lichen planus?

Answer 356

1. Long term monitoring
2. Reducing factors associated with lichen planus such as tobaco or other
3. Control of symptoms - use CHx and maybe avoid certain foods. Use Corticosteroids, topical injection, antifungal therapy.

Question 357

What are the topical steroid used for lichen planus?

Answer 357

Betamethasome dipropionate 0.05% cream or ointment topically to the lesions, twice daily after meals, until symptoms resolve

Question 358

What is lupus erythematosus?

Answer 358

It is an autoimmune disease.

Two main forms: Systemic lupus erythematosus and discoid (cutaneous) lupus ertyhematosus

Question 359

What can you see histologically around lichen planus?

Answer 359

Melanin continetns - proliferation of melanin around the lichen planus.

This may be also een clinically - post inlammation pigmentation

Question 360

What is aetiology of lupus?

Answer 360

Unclear but it does have auto antibodies circulating and it is genetic in nature

Question 361

What is the common presentation of discoid lupus eythematosus?

Answer 361

They appear disc in shape and similar in appearance to lichenoid lesions but with some epidermal lesions also present in sun exposed areas.

Question 362

What is some of the common aspects of discoid lupus erythematosus lesions orally?

Answer 362

Common in buccal mucosa, gingiva and vermillion.

Plaque or erosions

White keratotic stria

Question 363

What are some of the common aspect of histology of discoid lupus erythematosus lesions?

Answer 363

Similar to lichen planus but the sub-epithelial band is not as uniform than in lichen planus.

Also - lupus band test that is shown in immunoflurescence due to deposition of immunoglobulin and C3 - very very distinct unlike the shagging like in lichen planus

Question 364

What are the clinical features of systemic lupus erytehmatosus?

Answer 364

Butterfly rash in young woman - could be the first sign.

Oral ulcers - pretty common

Question 365

What is the most important difference between discoid and systemic lupus erythematosus?

Answer 365

In discoid lupus erythematosusthere are no major systemic sympotms while the systemic one ususally present with systemic symptoms

Question 366

What is erythema multiforme?

Answer 366

It is a self limiting hypersensitivity reaction which presents itself as recurrent oral ulceration and blistering.

Cell-mediated hypersensitivity reaction - usually trigered by drugs and viruses.

Question 367

What some of the intra-oral and extra-oral manifestations of erythema multiforme?

Answer 367

1. Oral lesions - swollane and crusted lips that are bleeding - widespread erosive lesions and lots of pain
2. Cutaneous lesions - “target lesions”

Question 368

What is the histology of erythema multiforme?

Answer 368

1. Keratosis at the top
2. Apoptosis of basal keratinocytes
3. Intraepithelial vesicle formation
4. Lymphocyte and macrophage perivascular inflitrate in connective tissue

Question 369

What is important to ask a patient that you suspect has erythema multiforme?

Answer 369

Previous virus or drug use history

Question 370

What is Steven Johnson syndrome?

Answer 370

It is a more advanced systemic form of erythema multiforme and it can progress. PLEASE LET THE GP KNOW DUE TO SIGNIFICANT RISK OF DEATH

Question 371

For which drugs could there be a lichenoid drug reaction?

Answer 371

ACE inhibtors, NSAIDS, Tetracyclines and many more

Question 372

What oral lichenoid contact lesions?

Answer 372

They are lichenoid lesions that may occur due to contact with dental materials.

HISTORY and EXAMINATION is essential

Question 373

What do autoantibodies attack?

Answer 373

The usually attack desmosomes that combine cells - and create blister or vesicles

Question 374

What is a vesicle?

Answer 374

It is a blister less than 5mm in diameter

Question 375

What is a bulla?

Answer 375

It is a blister more than 5 mm diameter

Question 376

What is acantholysis?

Answer 376

It is a blister that separates keratinocytes

Question 377

What is pemphigus vulgaris?

Answer 377

Pemphigus is a group of potentially life threatening disease that has an autoimmune basis.

The autoantibodies attack the desmosomes (desmoglein 1 & 3 types) between the cells.

Clinical features - very fragial oral mucosa - think Nikolsky sign and widespread painful erosion.

Very bad because they may cause infection

Question 378

What is mucous membrane pemphigoid?

Answer 378

It is a chronic subepidermal/subepithelial blistering, scarring autoimmune disease with a predilection for stratified squamous mucous membranes and occasionally skin.

This conditions attacks hemidesmosomes - the conectors between the basal epithelium and the connective tissues.

This conditions can result in OCULAR SCARRING - VISION WILL BE AFFECTED.

Question 379

What are the clinical features of pemphigus?

Answer 379

1. Very fragile blistering intraepithelialy
2. Residual erosion
3. Nikolsky sign - rub the tissue and blister signs appears

Question 380

What are some of the other signs of pemphigus extra-oraly?

Answer 380

1. Erisions and crusts on the face
2. Extensive denudation of the entire neck and back
3. Distal onychodystrophy and transverse Beau’s line of the thumb nails
4. DIrect immunofluorescence microscopy of a perilesional biopsy soecimen shows intercellular deposits of IgG in the epidermis - CHICKEN WIRE PATTERN

Question 381

What are some of the histological features of pemphigus?

Answer 381

1. Loss of intercellular adhesion
2. Acantholysis
3. Tzanck cells - detached epithelial cells
4. Intraepithelial blisters

Question 382

What is the management of pemphigus vulgaris?

Answer 382

1. Early diagnosis is important - differentiation from other veisculobullours diseases. Biopsy of perilesional mucosa with immunofluorescence studies -INCISIONAL BIOPSY OF NON-ULCERATED TISSUES
2. Topical steroids in combination with systemic treatments
3. Systemic steroid and immunosuppressive agents

Question 383

What are the clinical features of mucous membrane pemphigoid?

Answer 383

1. More common in females
2. Oral ucosa often first site of involement erosion on non-keratinised mucosa desquamative gignivitis.

Question 384

What is histology pemohigoid?

Answer 384

There is a large loss of attachment and separation of full thickness of pithelium from connective tissue at the basement membrane. With the epithelium forming the rooft of the blister

Question 385

What is the treatment of mucous membrane pemphigoid?

Answer 385

For only oral lesions:
Topical steroid

For widespread lesions:
1. Systemic steroids
2. Immunosuppressive medication

Referral to the specialist

Question 386

What are diagnostic steps of mucous membrane pemphigoid? Why should we refer these patient to a specialist?

Answer 386

Incisional biopsy of non-affected area - looking for gravestone appearance. This occurd due to binding of immunoglobulin to the basement membrane.

Because MUCOUS MEMBRANE PEMPHIGOID MIGHT EFFECT THE EYES.

Question 387

Where are the minor salivary glands?

Answer 387

1. Oral mucosa
2. Pharynx and tonsillar area
3. Larynx, trachea, major bronchi
4. Nasopharynx, nasal cavity and paranasal sinuses

Question 388

What are some reactive salivary gland lesions?

Answer 388

1. Mucoceles:
   - Mucus extravasation mucocoeles
   - Mucus retention cyst
2. Necrotising sialometaplasia
3. Radiation related lesions
4. Salivary gland obstruction

Question 389

What are some infective salivary gland lesions?

Answer 389

1. Mumps
2. Bacterial parotitis

Question 390

What are some of the miscellaneous salivary gland lesions?

Answer 390

1. Age-related changes to the salivary gland
2. Sialadenosis

Question 391

What is mucoele?

Answer 391

It is a clinical term that includes mucus extravasation pehnomenon and mucus retention cyst

Question 392

What are the histological differences between serous and mucus acinii?

Answer 392

Serous - more purple like shown in picture on the left

Mucus - more pale and bubbly like shown on the right

Question 393

What is ranula?

Answer 393

It is a clinical term that includes mucus extravasation phenomenon and mucus retention cyst - however it occurs specifically in the floor of the mouth

Question 394

What are clinical features of mucus extravasation mucocoele?

Answer 394

1. Most common in the lower lip
2. Painless smooth-surfaced mass
3. May have bluish colour
4. consistency - fluid like
5. Associated with trauma
6. NOT A TRUE CYST - granulation tissue capsule

Question 395

What is the most basic explanation of formation of a cyst from a salivary gland?

Answer 395

1. The duct of the salivary gland is damage
2. The saliva in able to float in the surrounding tissue - mucus extravasation
3. Saliva accumulates
4. Inflammatory reaction begins - granulation tissues forms - reactive change to saliva gland occur (acinar atrophy and inflammation)

Question 396

What a cyst?

Answer 396

It is a fluid filled cavity that may or may not be lined an epithelium (true cyst have an epithelium) that is abnormal in nature.

Note - the fluid is not puss -

Question 397

What is a mucous retention cyst?

Answer 397

It is a cyst that occurs during the obstruction of salivary flow

It is less common than extravasation mucocoeles.

The mucosa is intact and the cyst is not surrounded by granulation tissue.

Acinnar inflammation will still occur.

Question 398

What is meal time syndrome?

Answer 398

A sialolith is present in the salivary gland - during meal time salivary flow increases - resulting in a mucus retention cyst - this condition is known as sialadenitis

Question 399

What is the treatment for sialoliths?

Answer 399

Surgical removal of stone with/without gland

Question 400

What is necrotising sialometaplasia?

Answer 400

It is one of the mimics of oral cancer but it is a benign condition which usually affect the palate.

Aetiology - slaivary gland ischaemia due to local trauma - LOCAL ANAESTHETIC - salivary gland inferction characterised by loss of acini and inflammation with ductal mataplasia - cuboidal and columnar epithelium becomes squamous

Question 401

What is the histological appearance of necrotising sialometaplasia?

Answer 401

Squamous metaplasia of ducts mimicking invasive squamous cell carcinoma - but main difference is there no major cellular atypia

Question 402

What is mumps?

Answer 402

It is a disease that mainly affect the parotid gland.

It is caused by a paramyxovirus

Acute onset with pain and bilateral parotid swelling, difficulty swallowing and fever.

Management: rest, lots of fluid, management of pain and antipuruetic

Question 403

What is acute bacterial sialadentitis?

Answer 403

It is bacterial infection of the salivary glands that may be caused by xerostomia or sialoliths.

Might have systemic symptoms

Management: Antimicrobilas and drainage of the puss

Question 404

What is the most common salivary gland to get a sialolith?

Answer 404

Submandibular, because:

1. The duct is bent
2. Gravity - the duct that come out sublingually is affected by it
3. Content is mainly serous

Question 405

What are some of the age related changes of the salivary glands?

Answer 405

1. Acinar atrophy
2. Fibrosis
3. Fatty infiltration
4. Diffuse chronic inflammatory infiltrate

Question 406

Why is there high risk of xerostomia post head and neck radiation therapy?

Answer 406

Patient with head and neck cancer that recieved radiation therapy may have atrophy of acini - thus are unable to produce saliva

Question 407

What is xerostomia?

Answer 407

It is the experience of a patient associated with dry mouht - aka it is a symptom

Question 408

What is salivary gland hypofunction?

Answer 408

It a decreased flow rate of saliva due to a multitude of factors - aka it is sign

Question 409

What are the three main causes of xerostomia?

Answer 409

1. Organic cause - disease
2. Functional cause - dehydration and so on
3. Drugs - like diuretics, SSRIs and other

Question 410

How can you investigate salivary gland disease?

Answer 410

1. Salivary flow test - unstimulated flow of less than 0.1-0.2mL/min , stimulated less than 0.7mL/min
2. Labial salivary gland biopsy - particularly Sjogren’s syndromes
3. Ultrasound
4. Sialogram - injecting contrast medium
5. CT scan - VERY COOL

Question 411

What is the management of a patient with xerostomia?

Answer 411

1. Investigate underlying systemic disease
2. Always get the diagnosis
3. Palliative/symptomatic care and control other diseases and conditions - think mucosal trauma and caries

Question 412

What is Sjogren’s syndrome?

Answer 412

It is an autoimmune diseases that affects the eyes and the salivary glands.

Sometimes it occurs with other diseases like rheumatoid arthritis or other connective tissue disease - known as secondary Sjogren’s syndrome

Question 413

What is important to keep in mind with Sjogren’s syndrome?

Answer 413

They need to be seen by a specialist because there is a chance to develop lymphoma

Question 414

What are the steps to diagnosing Sjogren’s syndrome?

Answer 414

1. Ocular symptoms
2. Oral symptoms
3. Occular signs
4. histopathology - minor salivary glans
5. Salivary gland testing/salivary gland involvement
6. Autoantibodies presence in serum

Question 415

What is the histological features of Sjogren’s syndrome

Answer 415

1. Lymphocytic periductal infiltration of slivary glands
2. Acinar cell destruction
3. Proliferation of ductal elements to form islands of epithelium

Question 416

What is the management of patient with Sjogren’s syndrome?

Answer 416

1. Opthalmological review
2. Palliate dry mouth
3. Prevention and control of caries
4. Dietary advice
5. Management of infection - candidosis
6. Need multidisciplinary management

Question 417

What is associationg between Sjogren’s Syndrome and MALT?

Answer 417

Sjogren’s syndrome may cause B cell lymphomas in mucous associated lymphoid tissue

Question 418

What is Scleroderma?

Answer 418

Scleroderma is a chronic, autoimmune connective tissue disorder that is primarily characterized by thickening and hardening of the skin and other tissue

Question 419

What are some oral manifestations of scleroderma?

Answer 419

1. Widening of periodontal ligament space
2. Tooth resorption
3. Can be concurrent with Sjogren’s syndrome

Question 420

How do you manage scleroderma as a dentist?

Answer 420

1. Oral hygiene
2. Management of concominant conditons

Question 421

What are the steps to describing radiographic lesions?

Answer 421

1. Relative radiodensity - mixed, radioopaque or radiolucent - CONSIDER SOFT TISSUE SHADOWS
2. Site
3. Size
4. Shape
5. Outline or border
6. Effects on adjacent structures

Question 422

How do we describe the size of a boney lesion?

Answer 422

1. Measuring dimension in centimeters
2. Describing boundaries in two dimension - e.g. extending from (blank) to (blank)

Question 423

How do we describe the shape of a boney lesion?

Answer 423

1. Round, oval, kidney like or irregular
2. Unilocular or Multilocular

Question 424

How do we describe a border of a boney lesion?

Answer 424

1. Well or poorly defined
2. Smooth, ragged, corticated or indistinct

Question 425

What are some of the structure a boney lesion can effect?

Answer 425

1. The teeth
2. The bone
3. Displacement or destruction of other structures

Question 426

Where do majority of salivary gland tumour occur?

Answer 426

They are mostly found in the major salivary glands

Question 427

What are some of the general categories of neoplastic lesions that are associated with salivary tissue?

Answer 427

1. Malignant tumours
2. Benign tumours
3. Non-neoplastic epithelial lesions
4. Benign soft tissue lesions
5. Haematolymphoid tumours

Question 428

What are the most common well defined tumour for the upper and lower lips?

Answer 428

Upper - salivary gland neoplasm

Lower - mucococeal

Question 429

What are the main features os benign salivary gland tumours and malignant salivary gland tumours?

Answer 429

Benign (on the left):

1. Slow-growing
2. Soft and rubbery
3. Common in parotid tumours
4. DO not ulcerate
5. No associated nerve signs

Malignant (on the right):

1. Many slow growing
2. Sometimes hard consistency
3. Rare
4. May ulcerate and invade bone

5, May cause cranial nerve palsie

Question 430

What kind of investigation can be used for salivary gland neoplasm?

Answer 430

Fine needle aspiration and cytology, incisional biopsy or excisional biopsy

This leads to processed that are able to tag genes of different tumours:

1. In-situ hybridisation
2. Fluorescent in-situ hybridisation

Question 431

What are adenomas?

Answer 431

It is a type of benign neoplasm

Question 432

What is a pleomorphic adenoma?

Answer 432

It is a type of benign neoplasma that is the most common one - histological presentation are the pleomorphic cells, it comes in blobes and is usually incapsulated.

It is non-ulcerated, slow growing and painless

Question 433

What is a basal cell adenoma?

Answer 433

Basal cell adenoma is a rare benign neoplasm characterised by the basaloid appearance.

It is a slow growing neoplasm.

It is monomorphic - single cell type involved

Question 434

What are the the 2 most common malignant types of salivary gland tumours?

Answer 434

1. Mucoepidermoid carcinoma
2. Adenoid Cystic Carcinoma

Question 435

What is a mucoepidermoid carcinoma?

Answer 435

It is a malignant glandular epithelial neoplasm characterised by mucous, intermediate and epidermoid cells with columnar clear cell and oncocytoid features.

This is the most common malignant salivary neoplasm.

Cystic and solid area mixed in

Question 436

What is adenoid cystic carcinoma?

Answer 436

Adenoid cystic carcinoma is a basaloid tumour consisting of epithelial and myoepithelial cells in variable morphology, It has a relentless clinical course and usually a fatal outcome.

It is slow growing and it may ulcerate or be painful.

Histologically: solid islands, crods, strands of darkly staining epithelial cels in delicate fibrous connective tissue stroma - perineural invasion is common

Question 437

What is the basic histology of the cyst?

Answer 437

1. Lumen on the inside

2/ Epithelial lining surrounding the lumen

3. Capsule around the epithelium and lumen that may be inflamed or may not be inflamed

Question 438

What are key features of jaw cysts?

Answer 438

1. Well-defined raiolucencies with radiopaque borders
2. Apsiration test can confirm fluid contents - if fluid comes out it is probably a cyst
3. Superficial cysts may clinically appear bluish and may be transilluminated
4. Usually asymptomatic

Question 439

Where do most jaw cyst arise from?

Answer 439

1. Reduced enamel epithelium
2. Rests of Serres - remenants of the odontogenic epithelium that are retained in the gingiva
3. Rests of Malassez - remenants of the odontogenic epithelium that are retained in the periodontal ligament

Question 440

What do cysts mimic sometimes on radiographs?

Answer 440

1. Anatomic structures: maxillary sinus and foramina
2. Periapical granulomas
3. Odontogenic tumours - ESPECIALLY AMELOBLASTOMAS
4. Solitary and aneurysmal bone ‘cysts’
5. Giant cell lesions
6. Cherubism

Question 441

What are the three categories of inflammatory jaw cysts?

Answer 441

1. Radicular cyst
2. Residual cyst
3. Inflammatory collateral cyst

Question 442

What is the pathogenesis of radicular cyst?

Answer 442

1. Epithelial lining is derived from remanants of the root sheath
2. Inflammation in the periodontal ligament initiates proliferation of epithelial cells
3. Inflammation usually occurs as a result of pulp necrosis
4. Cyst enlargement occurs as a result of hydrostatic pressure
5. Bone resorption occurs in surrounding area

Question 443

What are the clinical features of radicular cyst?

Answer 443

1. They are asosciated with roots of non-vital tooth
2. Radiographically it presents as a well defined radiolucency
3. Histologically the lumen contains debris

Question 444

What are residual cyst?

Answer 444

Radicular cysts that are “left” within the jawbones after extraction of tooth.

Histologically similar to a radicular cyst but it may have less inflammatory cells

Question 445

What are inflammatory collateral cyst?

Answer 445

It is a buccal or distobuccal aspects of the roots of partially or recently erupted teeth.

It is well defined, corticated radiolucency on the lateral root surface

Histopathology - similar non-keratinised squamous epithelium with fibrous connective tissue capsule

Treatment: curettage of the bony cavity or to extract the tooth

Question 446

What are the common developmental odontogenic cysts?

Answer 446

1. Lateral periodontal cyst
2. Odontogenic keratocyst - second most common
3. Dentigerous cyst - most common one
4. Nasopalatine cyst - not dontogenic tho

Question 447

What word would you use to describe a cyst that is around the coronal part of the tooth?

Answer 447

Peri-coronal radiolucency

Question 448

What is a dentigerous cyst?

Answer 448

It is a developmental odontogenic cyst of the jaws surrounding the crown of an unerupted tooth, the lining attached to the cementoenamel junction

Question 449

What is an eruption cyst?

Answer 449

It is a variant of a dentigerous cyst found in soft tissues overlying an erupting tooth.

Clinical significant sign: presents as a bluish soft tissue swelling of the mucosa

Important: eruption cyst and dentigerous cyst are the same thing - please do not put the in a differential

Treatment: make an incision and make the tooth come through

Question 450

What is an odontogenic keratynocyst?

Answer 450

It is a genetic mutation of PTCH1 gene that activates cell proliferation. It is an aggressive cyst. IT CAN EXPAND THE JAW and IT CAN RE-OCCUR.

It arises from dental lamina and is significant due to active epithelial growth rather than take up of water.

There is a risk of recurrence and occurs in the posterior body and the ramus.

Associated with Gorlin Syndrome or Naevoid Basal Cell Carcinoma Syndrome (same thing).

It could present as a multi-locular appearance

Question 451

What is the lining of odontogenic keratynocyst histologically?

Answer 451

Thing lining of parakeratinised stratified squamous epithelium with palisading hyperchromatic basal cells

Question 452

What naevoid basal cell carcinoma syndrome?

Answer 452

It is a rare autosomal dominant trait.

It is characterised by multiple odontogenic keratocysts, multiple basal cell carcinomas and skeletal anomalies.

Question 453

What is a latral periodontal cyst?

Answer 453

It is a developmental odontogenic cyst lined by non-keratinised epithelium occuring on the lateral aspect or between the roots of erupted teeth

It is uncommon and is treated by enucleation please make sure that the PULP IS VITAL.

Clinical feature: they can be botryoid or come in a bunch

Question 454

What is a gingival cysts?

Answer 454

They are rare, asymptomatic and dome-shaped projection of gingival mucosa that arise from dental lamina.

Question 455

What are calcifying odontogenic cyst?

Answer 455

It is a developmental odontogenuc cyst characterised histologically by ghost cells, which often calcify.

Common in young patients.

Radiographic appearance - most lesion present as well-defined radiolucnecny containing verying amounts of radiopaque material.

Question 456

What are odontogenic tumours?

Answer 456

A diverse group of neoplasms which derive from the epithelium and/or etomesenchyme normally associated with tooth formation.

Therefore all odontogenic tumours arises in the tooth bearing areas of the jawbones

Question 457

What are the benign epithelial odontogenic tumours?

Answer 457

A group of neoplasms cosnisting of proliferating odontogenic epithelium without ectomesenchymal tissue

Question 458

What is ameloblastoma?

Answer 458

Ameloblastoma is a benign but locally infiltrative epithelial odontogenic neoplasm of the jawbones characterised by ameloblas-like cells.

MOST COMMON ODONTOGENIC TUMOUR - most common in the mandible

Question 459

What are clinical features of ameloblastomas?

Answer 459

1. Slow destructive area
2. Expansion rather than perforation
3. Seldom painful
4. Somehow it can mestasise but it is very rare

Radiographically:

1. Typically well defined, multilocla radiolucency
2. FLOATING TOOTH APPEARANCE

Question 460

What is the histology of ameloblastoma?

Answer 460

Core components: Outer layer adjacent to CT resembling pre-ambeloblasts and centra, more loosely organised zone like stellate reticulum cystic breakdown

*there is no mineralised dental tissues or matrices

Question 461

What are the two main histological types ameloblastomas?

Answer 461

1. Folicular - discrete islands of tumour
2. Plaxiform - irregular masses or strands

Question 462

What are the two different types of ameloblastomas depending on cell type?

Answer 462

1. Acanthomatus - folicular and may produce keratin
2. Basal - basal, cuboidal cells present

Question 463

What are the two types of ameloblastomas according to behaviour?

Answer 463

1. Unicystic ameloblastoma
2. Peripheral or multicystic ameloblastoma

Question 464

What is a Unicystic ameloblastoma?

Answer 464

It is an ameloblastoma with a single cystic cavity with wall tissue being the worst clinically.

More likely to be unilocular and may be enucleated

Question 465

What is a
Peripheral or multicystic ameloblastoma?

Answer 465

It is an ameloblastoma with multiple cystic cavity.

It is worst than unicystic ameloblastoma.

This requires excision.

Question 466

What are the treatment for ameloblastoma?

Answer 466

1. Local surgical resection
2. Radio-resistant - because it is a slow growing tumour
3. Good prognosis although regular follow up is essential

Question 467

What is clacifying epithelial odontogenic tumour?

Answer 467

It is also known as Pindborg tumour

It is a bening epithelial odontogenic tumour that secretes amyloid protein and tends to calcify.

Radiographic appearance: Radiopacity inside the radiolucency

Question 468

What is adenomatoid odontogenic tumour?

Answer 468

It is a benign encapsulated epithelial odontogenic tumour that contains rosette or duct-like structure and has an indolent behaviour.

Treatment with enacliation

Question 469

What are odontomas?

Answer 469

Odontomas are mixed odontogenic hamartomas that mature from soft tissues.

IT IS MOST COMMON IN YOUNG PATIENTS.

Two types:
-Complex - irregular mass of calcified material - top image

-Compound - variable number of small tooth-like structues - bottom image

Treatment: Surgical enucleation

Question 470

What is odontogenic myxoma?

Answer 470

It is a benign neoplasm histologically resembling odontogenic extomesenchyme and chracterised by sparse spindle.

Radiographic features: Soap bubble appearance - very multilocular, may be well or poorly defined

Treatment: resection

Question 471

What is cementoblastoma?

Answer 471

It is a distinctive benign tumour that is intimately associated with the roots of the teeth.

It is characterised by formation of calcified cementum like tissue which is deposited directly on tooth root.

Radiographic appearance: well-defined radiopaque mass closely associated with tooth root and often surrounded by radolucent halo.

Treatment: extract tooth and enucleate or locally resect tumour

Question 472

What are fibro-osseous lesions?

Answer 472

They are lesions where bone is replaced by cellular fibrous tissue and is characterised by gradual deposition of woven bone which matures overtime to form lamellar bone.

Diagnosis depends on clinical and radiographic feature of the different lesions

Question 473

What is fibrous dysplasia?

Answer 473

It is a genetically based sporadic disease of bone that may affect single or multiple bones. Fibrou dysplasia occuring in multiple adjacent craniofacial bone is referred to as craniofacila fibrous dysplasia.

Main types: monostotic (single bone) or polyostotic (multiple bones)

Question 474

What are the clinical features of fibrous dysplasia?

Answer 474

Radiological:
Radiolucency or mixed appearance, ill-defined margins and narrowing of the periodontal ligament

Question 475

What is the histology of fibrous dysplasia?

Answer 475

1. Well vascularised fibrous cellular connective tissue
2. Irregular trabeculae of immature woven bone - osteoid bone is the precursur

Question 476

What are the affects of firbous dysplasia on the patient?

Answer 476

Skeletal deformities in the mpatient

Question 477

What is the treatment of fibrous dysplasia?

Answer 477

1. Time the skeletal maturation
2. Orthodontic +/- conservative surgical recontouring
3. May turn into a sarcoma so NO IRRADIATION

Question 478

What is cemento-ossifying fibroma?

Answer 478

It is the bening fibroosseous neoplasms affecting the jaws and craniofacial skeleton

Question 479

What are key features of cemento-ossifying fibroma?

Answer 479

It is rare and ususally occurs in tooth bearing areas of the jaws.

Question 480

What are the clinical features of cemento-ossifying fibroma?

Answer 480

Clinical
1. Painless
2. Slow growing

Radiographic
1. Well demarcated
2. Mixed radiopacity/lucency

Question 481

What is the histopathology of cemento-ossifying fibroma?

Answer 481

1. Well defined, sometimes encapsulated lesion
2. Hypercellular fibrous tissue
3. Variable amounts of calcified tissue

Question 482

What is the treatment of cemento-ossifying fibroma?

Answer 482

Conservative surgical excision.

Juvenile form have a higher tendency to recur

Question 483

What a cemento-ossseous dysplasia?

Answer 483

It is a non-neoplastic fibro-osseous lesion of the tooth bearing regions of the jaws.

It is not common

Question 484

What are the 3 variant of cemento-osseous dysplasia?

Answer 484

1. Periapical cemento-osseous dysplasia - apical areas of mandibular anterior teeth
2. Focal cemento-osseous dysplasia - association with a single tooth
3. Florid cemento-osseous dysplasia - multifocal involvement

Question 485

What are the radiologic features of cemento-osseous dysplasia?

Answer 485

1. Radiolucent and than mixed lesions
2. Well defined
3. Thin radiolucent rim
4. Lesions that are not fused to roots of the teeth

Question 486

What is a simple bone cyst?

Answer 486

It is an intraosseous cavity that is devoid of an epithelial lining and can be empty, blood filled or serous fluid filled.

Also know as a traumatic cyst.

It is pseudo cyst, because it is essentially some blood vessels and inflammed tissues - surgical intervention usually results in positive outcomes.

Question 487

What is a Tori?

Answer 487

It is a non-neoplastic, localised hyperplasia of dense lamellar bone.

Usualy in the palatle midline or mandible.

Question 488

What is a chondrosarcoma?

Answer 488

It is rare malignant bone tumour that produces cartialaginous matrix. THIS IS A TRUE NEOPLASTIC TUMOUR.

Question 489

What is osteosarcoma?

Answer 489

It is a group of malignant bone tumours. Creates bone expansion. Grows fast and could be ulcerated. THIS IS A TRUE NEOPLASTIC TUMOUR.

Question 490

What does osteomayalitis mean?

Answer 490

It means the inflammation has extended into the bone marrow

Question 491

What is alveolar osteitis?

Answer 491

It is a complication of tooth extraction - aka dry socket.

Localised inflammation of the bone, due to lack of blood clot formation or early lysis of clot.

It can progress to osteomayalitis.

Clinical signs: PAIN

Question 492

What is focal sclerosing osteitis?

Answer 492

It is asymptomatic condensation of the bone also known as condensing osteitis.

Maybe included in a differential of cemento-ossifying fibroma.

Question 493

What are the predisposing factors to the oseomyelitis of the jaws?

Answer 493

1. Periapical infection
2. Pericoronitis
3. Compound fractures of the jaw
4. Penetrating injuries
5. Local damage to the jaws
6. Impaired immune function

Question 494

What are the two different types of osteomyelitis?

Answer 494

1. Acute - painful
2. Chronic - not so painful

Question 495

What are the common clinical signs of acute oseomyelitis?

Answer 495

Requires some time to develop rediographically.

Loss of trabeculae, formation of necrotic bone sequestra - radiopaque areas within the jaws.

Question 496

What are histopathological signs of acute osteomlyolitis - particularly dead bone?

Answer 496

A lot of bacterial colonies and empty lacunae.

Question 497

What are the clinical signs of chronic osteomyalitis?

Answer 497

Persisten pain

Draining pass

In the areas of avascular bone

Question 498

What are the radiographical features of chronic osteomyelitis?

Answer 498

Radiolucency with focal areas

Moth eaten appearance

Question 499

What is the management of the chronic osteomyelitis?

Answer 499

1. Aggressive, prolonged antibiotic treatment
2. Removal of the cause
3. Removal of dead bone

Question 500

What is osteoradionecrosis?

Answer 500

It is a form of ostemyalitis. It occurs in patient undergoing radiotherapy or post radiotherapy.

Aetiology: radiotherapy causes endarteritis of vessels - reducing bone vascularity - leading to bone hypoxia.

Remember: only directly irradiated bone is affected.

Question 501

What is the treatment for osteoradionecrosis?

Answer 501

1. Prevention
2. Removal of teeth that are grossly carious
3. Managing sources of infection
4. INTENSE ORAL HYGIENE

Question 502

What is MRONJ?

Answer 502

It is the medication-related osteonecrosis of the jaw.

It is related to antiresorptive, immune modulators or antiangiogenic medications.

Susceptible sites: Exposed bone

Question 503

What does radiopaque border of the lesion signinify?

Answer 503

It means that the lesion is slow progressing

Question 504

What are the most common site of salivary gland tumour? WHat is the most malignant site?

Answer 504

Most common site is related to parotid salivary gland.

Most malignant is sublingual gland.

Question 505

What are the geneneral clinical differences between a bening salivary gland tumour and malignant salivary gland tumour?

Answer 505

Both grow slowly usually

But malignant once are hard, can ulcerte and may cause ner palsie

Question 506

What are some of the common investigation we can use for salivary gland tumour?

Answer 506

1. Excisional biopsy
2. Fine needle aspiration an cytology

Question 507

What is pleomorphic adenoma?

Answer 507

It is a tumour of variable capsulation characterised microscopically by architectural pleomorphism.

It is very common bening neoplasm and occurs mostly in parotid gland. Painless for the patient.

Question 508

What is the histology of pleomorphic adenoma?

Answer 508

The histoloy might be marked variation. Usually involves squamous metaplasia, keratin and sebaceous glands

Question 509

What is the management of pleomorphic adenoma?

Answer 509

Careful excision

Monitoring

Question 510

What is basal cell adenoma?

Answer 510

It is a rare bening neoplasm characterised by basaloid appearance of the tumour cells

Question 511

What are two common carcinomas of the salivary glands?

Answer 511

Mucoepidermoid carcinoma

Adenoid cystic carcinoma

Question 512

What is mucoepidermoid carcinoma?

Answer 512

It is a malignant glandular epithelial neoplasm characterized by mucous, intermediate and epidermoid cells with columnar clear cell and oncocytoid features.

It is most common malignant neoplasm of salivary glands.

Question 513

What is the histology of mucoepidermoid carcinoma?

Answer 513

Usually they are charecterised as low, medium or high grade. the most cystic it is the lower the grade.

Usual suspects - mucous cells and infiltrative appearance

Question 514

What is adenoid cystic carcinoma?

Answer 514

It is a basaloid tumour consisting of epithelial and myopethelial cells in different structural configurations. IT IS USUALLY FATAL

Question 515

What is the histology of adenoid cystic carcinoma?

Answer 515

Solid islands, cords, strands of darkly tained epithelial cells in fibour connective tissues.

Swiss-cheese pattern

Question 516

What are the 4 giant cell lesions of the bone?

Answer 516

1. Central giant cell grnuloma
2. Hyperparathyroidism
3. Aneurysmal bone cyst
4. Cherubism

Question 517

What are the clinical features of central giant cell granuloma?

Answer 517

Most common in anterior mandible

Radiographic appearance:

1. Uniform radiolucency
2. Often multilocular

Question 518

What are the differential diagnosis for central giant cell granuloma?

Answer 518

1. Hyperparathyroidism
2. Cherubism
3. Aneurysmal bone cyst

Question 519

What is the treatment for central giant cell granuloma?

Answer 519

Surgical enucleation.

It has tendency to recur

Question 520

What are the radiographic appearance of hyperparathyroidism?

Answer 520

1. Clear bone resorption and replacement
2. Cystic change within bone - formation of Brown Tumours
3. Pulpal obliteration

Question 521

What is an aneurysmal bone cyst?

Answer 521

It is a bone cyst that may occur due to trauma in molar/ramus lesion and may be painful

Question 522

What are the features of the aneurysmal bone cyst?

Answer 522

Radiographic:
1. Cystic radiolucency, multiloculated

Histologically

1. A lot of multinucleated giant cells and fibrous tissues

Question 523

What is the treatment for aneurysmal bone cysts?

Answer 523

Surgical enucleation

Be careful of acess bleeding

Question 524

What is cherubism?

Answer 524

It is an inherited condition where soft tissue replaces normal bone tissue

Question 525

What are the clinical signs of cherubism?

Answer 525

1. Loosening of teeth
2. Facial swelling
3. Hypodontia
4. Usually occurs in posterior mandible and is bilateral

Question 526

What is the treatment of cherubism?

Answer 526

Cosmetic facial surgery and dental management

Conditions regresses with age

Question 527

Why is open disclosure important?

Answer 527

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

Question 528

What are the elements of open disclosure?

Answer 528

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

Question 529

What is the definition of open disclosure?

Answer 529

Open disclosure is the process of providing an open, consistent approach to communicating with patients/consumers, their family, carer and/or support person following a patient incident. The process includes expressing regret or saying sorry.

Question 530

What are two separate but linked process are initiated in SA dental post patient incident?

Answer 530

1. Open disclosure
2. Incident reporting

Question 531

What are the steps for open disclosure?

Answer 531

1. Acknowledgement of the incident, and offering initiating or signalling the need for open disclosure
2. Preparing for, and engagin in open disclosure discussion, including expressing regret
3. Providing follow up to patient and family/caregiver, including actions taken as a result of the investigation
4. Completing process and maintaining documentation

Question 532

How do we express regret? Give an example.

Answer 532

I am sorry that this has happened to you.

Question 533

Why can be difficult to say sorry at times?

Answer 533

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

Question 534

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

Answer 534

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

Question 535

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

Answer 535

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

Question 536

Can a root caries lesion be restored or remineralised?

Answer 536

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

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

Because root caries restoration have a really poor prognosis

Question 537

What are the basic steps to preventing root caries?

Answer 537

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

Question 538

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

Answer 538

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

Question 539

What determines the effectiveness of silver fluoride?

Answer 539

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

Question 540

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

Answer 540

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

Question 541

What are the basic outcomes of endodontic treatment?

Answer 541

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

Question 542

What is the most common cause of endodontic problems?

Answer 542

1. Caries
2. Trauma
3. Others

Question 543

What is tertiary dentine?

Answer 543

Tertiary dentine represents the more or less irregular dentine formed focally in response to noxious stimuli such as tooth wear, dental caries, cavity preparation and restorative procedures.

It is also known as reactionary dentine or reparative dentine - depending on the type of stimulus.

Question 544

What is reactionary dentine?

Answer 544

Reactionary dentine is defined as a tertiary dntine matrix secreted by surviving postmitotic odontiblast cells in response to an appropriate stimulus, Typically, such a response will be made to milder stimuli and represents up-regulation of the secretoy activity of the existing odontoblat responsible for primary dentine secretion.

Question 545

How can you describe dentine according to Dr. Rossi?

Answer 545

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

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

Question 546

What are the indication of indirect pulp capping?

Answer 546

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

Question 547

What are the three treatments for endodontic problems?

Answer 547

1. Extraction
2. Root canal treatment
3. Vital pulp therapy

Question 548

What are the requirements for successful vital pulp therapy?

Answer 548

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

Question 549

What material is used in vital pulp therapy?

Answer 549

MTA or Calcium Hydroxide but MTA is better

Question 550

What are the three different types of vital pulp therapy?

Answer 550

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

Question 551

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

Answer 551

1, 3, 6 and 12 months

Question 552

What are the steps for direct pulp capping?

Answer 552

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

Question 553

What are indications for partial pulpotomy?

Answer 553

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

Question 554

What are the steps for partial pulpotomy?

Answer 554

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

Question 555

What are the indication for a full pulpotomy?

Answer 555

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

Question 556

What are the steps for a full pulpotomy?

Answer 556

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

Question 558

How to write a diagnosis for endodontic diagnosis?

Answer 558

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

Question 559

What factors should you consider before endodontic treatment?

Answer 559

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

Question 560

What system is used for case selection in endodontics?

Answer 560

American Association of Endodontists Endodontic Case Difficulty Assessment Guidlines

The following considerations are used:

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

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

Question 561

When accessing a tooth - what is a good guide for access cavity location?

Answer 561

A good guide - bitewings!

They will show you that the pulp chamber is situated in the middle thus by drilling in the middle of the tooth - less tooth structure is destroyed comparing to the traditional shape outline method. Remember - long axis of the tooth is an important guide

Remember - traditional shape method does not consider a lot of factors such as the shape of the tooth, caries condition and restorations.

Question 562

What is the objective of initial access?

Answer 562

Just to reach the roof of the pulp chamber.

If you do not sense the “pin drop” of the bur - stop and re-assess - you don’t want a perforation

Question 563

What bur should you do after initial access?

Answer 563

A non end-cutting bur in order to extend the pulp chamber access without removing extra tooth structure from the pulpal floor.

Question 564

How many canal does upper first premolar have?

Answer 564

2 usually

Question 565

How many canals does upper first and second molar have?

Answer 565

Usually 4 - remember MB2

Question 566

What is the purpose of an endoprobe?

Answer 566

Endoprobe is used to assist in identification of root canals

Question 567

What is a good radiographic hint pointing that a lower incisor might have 2 different canals?

Answer 567

If in the radiograph - pulp chamber suddenly thins out or becomes smaller (suddenly) - that means that the tooth might have 2 canals

Question 568

What is the aim of chemo-mechanical debridement?

Answer 568

Aim is to gradually increase the size of the canal to allow for adequate penetration of irrigants/medicaments and to facilitate obturation

Question 569

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

Answer 569

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

Question 570

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

Answer 570

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

Question 571

What are the number on the file represent?

Answer 571

The diameter of the file

Question 572

Why files need to be curved?

Answer 572

Real canals are never straight - a curved file means it follows the natural anatomy of the file.

Question 573

What bur can be used for coronal preparation?

Answer 573

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

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

Question 574

How do you determine root canal lengths?

Answer 574

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

• Estimate working length

3. Use electronic apex locator
4. Confirm with radiograph

• Correct working length established

Question 575

How to use dentaport ZX?

Answer 575

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

Question 576

What is important for file size increase?

Answer 576

1. First - make sure that the smaller file goes to length and is LOOSE - remember circumventional filing (going on all border of the root canal)
2. Irrigate
3. GO to next file

Question 577

What is the master apical file?

Answer 577

It is the largest file that goes to the correct working length

Question 578

Why going above a size 25 may complicate thing during root canal preparation?

Answer 578

Files above size 25 may be too stiff and create iotriogenic errors due to it’s straightness.

Ledges might form or strip perfirations.

Question 579

Why is ledermix bad?

Answer 579

It stains teeth because it is a tetracyclin derivative

Question 580

What is the aim for interim restoration?

Answer 580

1. To prevent bacterial ingress
2. Maintain function of the tooth

Question 581

What material are available for interim restorations?

Answer 581

1. Cavit for initial layer
2. GIC/RMGIC on top

Question 582

What are the reasons for obturation?

Answer 582

1. Remove remaining bacteria
2. Stop nutrients from apical tissues getting into root canal system
3. Stop bacterial from coronal aspect getting into root canal

Question 583

What is the objective of a lateral spreader?

Answer 583

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

Question 584

What is the objective of an endodontic plugger?

Answer 584

It has a stopper to go to appropriate length - it is used to heat the GP point and burn them off

Question 585

What is working length?

Answer 585

It is the distance from a coronal reference point to the point at which canal preparation and obturation should terminate.

Question 586

What are some of the complication could occur if the correct working length is not calculated?

Answer 586

1. Iatrogenic perforation
2. Patency at apical terminus
3. Extrusion of root fillings

Question 587

What are some of the technique that can be used to determine working length?

Answer 587

1. Software
2. Radiographic
3. Electronic
4. Paper point

Question 588

Why is the desired working length is 1-2 mm away from radiographic apex?

Answer 588

Because we looking at a 2D representation of a 3D object and the natural anatomy of the root may have a curvature thus if the working length taken for the entirety of root length - it may create a perforation

Question 589

What is the rule of tube shift in endodontics?

Answer 589

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

Question 590

What are the steps to an initial endodontic procedure?

Answer 590

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

Question 591

What are the steps to root canal obturation?

Answer 591

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

Question 593

What are some of the common consequences of tooth loss?

Answer 593

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

Question 594

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

Answer 594

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

Question 595

What are the aims of a removable dentures?

Answer 595

Restore:

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

Question 596

What are indications for a removable dentures?

Answer 596

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

Question 597

What are contraindications for partial dentures?

Answer 597

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

Question 598

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

Answer 598

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

Question 599

What codes are there for dentures?

Answer 599

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

Question 600

How many appointments do you need for a general denture?

Answer 600

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

Question 601

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

Answer 601

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

Question 602

How do they care for their denture?

Answer 602

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

Question 603

What is the difference between an overlay and overdenture?

Answer 603

Overlay - the denture sits around the tooth

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

Question 604

What are the standard steps for a chrome denture construction?

Answer 604

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

Question 605

What do you do in the consultation appoitmnet?

Answer 605

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

Question 606

What is the purpose of alginate impression?

Answer 606

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

Question 607

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

Answer 607

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

Question 608

What is an occlusal stop?

Answer 608

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

Question 609

What materials could you use for secondary impressions?

Answer 609

1. PVS
2. PE
3. Alginate

Question 610

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

Answer 610

Record centric relation

Question 611

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

Answer 611

As an interim denture or immediate partial denture

Usually 3 appointments:

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

+

Review

(Can’t be chrome or varplast)

Question 612

What is edentulism?

Answer 612

It is the state of being edentulous, without natural teeth

Question 613

What is edentulous?

Answer 613

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

Question 614

What are some of the reasons for tooth loss?

Answer 614

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

Question 615

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

Answer 615

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

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

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

Class IV - A single, bilaterla edentulous crossing mid line

Question 616

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

Answer 616

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

Question 617

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

Answer 617

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

Question 618

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

Answer 618

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

Question 619

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

Answer 619

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

Question 620

What are psychological changes following tooth loss?

Answer 620

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

Question 621

What are current and future treatment options for edentulism?

Answer 621

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

Question 622

What are the standard appointments for a valplast denture contruction?

Answer 622

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

Question 623

What is complete denture retention?

Answer 623

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

Question 624

What is denture stability?

Answer 624

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

Question 625

What is denture support?

Answer 625

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

Question 626

What are some of the important aspect of the denture that promote retention?

Answer 626

1. Proper contour and design of polish surface - harmonising with function of tongue, lips and cheeks
2. Contour and thickness
3. Smoothness

Question 627

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

Answer 627

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

Question 628

What is the neutral zone?

Answer 628

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

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

Question 629

What are some of the physical factors affecting retention?

Answer 629

1. Adhesion
2. Cohesion
3. Surface tension created at the meniscus of the denture border
4. Gravity ( think better for lower and worse for upper)
5. Atmospheric pressure

Question 630

How to maximise denture retention by managing physical factors?

Answer 630

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

Question 631

What are some of the biological factors affecting retention?

Answer 631

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

Question 632

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

Answer 632

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

Question 633

How you tell a contact is high?

Answer 633

A ring shape with hollow middle - means contact is too high.

If it does not follow that round shape - it is not too high

Question 634

What are some of the factors that affect stability?

Answer 634

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

Question 635

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

Answer 635

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

Question 636

What is the primary support areas for the dentures?

Answer 636

Upper - primary support area is the hard palate

Lower - retromolar area and buccal shell

Question 637

What provides retention, stability and support in partial dentures?

Answer 637

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

Question 638

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

Answer 638

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

Question 639

What are the ideal properties for impression materials?

Answer 639

1. Accuracy
2. Elastic recovery
3. Dimensional stability
4. Viscosity that allows a flow into minute details
5. Flexibility
6. Workability
7. Patient comfort

Question 640

What can you use the copper wax for?

Answer 640

You can use copper wax for bite registration

Question 641

What can you use modelling (red) wax for?

Answer 641

Wax rim or was bite registration

Question 642

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

Answer 642

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

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

Question 643

Why to do with alginate impression after you taken them?

Answer 643

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

Question 644

What are the alginates that are available at the ADH?

Answer 644

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

Question 645

What can you use alginate for in rem pros?

Answer 645

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

Question 646

Why don’t we use polysulfieds anymore?

Answer 646

1. Long setting time
2. Smells real bad

Question 647

Where do you use light body and heavy body?

Answer 647

Light body - gingival sulcus

Heavy body - everywhere else and to push the light body

DONT USE WITH LATEX

Question 648

What do we use PVS for in rem pros?

Answer 648

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

Question 649

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

Answer 649

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

Question 650

What are some of the aspects to consider when selecting impression materials?

Answer 650

1. Biocompatibility
2. Accuracy
3. Elastic recovery
4. Hydrophilic or hydrophobic properties
5. Working time and setting time
6. Tear strength
7. Dimensional stability
8. Ease of use and delivery system
9. Cost

Question 651

What are components of the dentures?

Answer 651

1. Denture base
2. Denture teeth

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

Question 652

What materials can be used for a denture base?

Answer 652

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

Question 653

What materials can be used for a denture teeth?

Answer 653

1. Polymethyle methacrylate (PMMA) and it’s modifications - also know as acrylic
2. Formlabs denture resin
3. Sleeve crown (cobalt/chrome)
4. Porcelain teeth

Question 654

What are the disadvantages of porcelain teeth for rem pros?

Answer 654

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

Question 655

What material can you use for denture frame?

Answer 655

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

Question 656

What is the centric relation?

Answer 656

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

Question 657

What is centric occlusion?

Answer 657

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

Question 658

What is posselt’s envelope of motion?

Answer 658

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

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

Question 659

What are clinical applications of centric relationship

Answer 659

When you have a full denture:

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

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

When you have a partial denture:

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

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

Question 660

What is the natural rest position?

Answer 660

It is the occlusal vertical dimension + 2-4 mm

Question 661

What determines the OVD?

Answer 661

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

Question 662

What are the 3 types of occlusion?

Answer 662

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

Question 663

What are the difference between natural and artificial occlusion?

Answer 663

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

Question 664

What is centric postion?

Answer 664

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

Question 665

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

Answer 665

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

Question 666

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

Answer 666

For partial: If anatonical teeth have been severley worn

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

Question 667

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

Answer 667

In a sense - no.

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

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

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

Question 668

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

Answer 668

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

Question 669

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

Answer 669

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

Question 670

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

Answer 670

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

Question 671

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

Answer 671

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

Question 672

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

Answer 672

Counselling & education of an individual in regards to caries.

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

Question 673

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

Answer 673

Universal water fluoridation to prevent caries.

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

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

Question 674

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

Answer 674

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

Question 675

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

Answer 675

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

Question 676

What are the different types of “needs”?

Answer 676

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

Question 677

What are the components of an oral health needs assessment?

Answer 677

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

Question 678

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

Answer 678

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

Question 679

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

Answer 679

The main difference are:

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

Question 680

What are the advantages of high risk approach?

Answer 680

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

Question 681

What are the disadvantages of high risk approach?

Answer 681

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

Question 682

What are the advantages of population approach?

Answer 682

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

Question 683

What are the disadvantages of population approach?

Answer 683

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

Question 684

What are some of the levels of prevention?

Answer 684

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

Question 685

What are some of the example of secondary prevention?

Answer 685

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

Question 686

What are some of the example of primary prevention?

Answer 686

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

Question 687

What are some of the example of tertiary prevention?

Answer 687

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

Question 688

What are the basic principles that evaluate health promotion strategies?

Answer 688

1. Evaluate needs - assessing the need for it and evidence of previous intervention
2. Evaluate the process - is the intevention intervented as reuqired - are the people involved happy
3. Evaluate impact - hort term evaluation of the outcomes
4. Evaluate outcome - long term evaluaton of the outcomes

Question 689

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

Answer 689

Australian Medicines handbook

Question 690

Why do we need to know about drugs?

Answer 690

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

Question 691

What are the four right for drug prescribing?

Answer 691

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

Question 692

What does drug therapy hope to achieve?

Answer 692

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

Question 693

What is a xenobiotic?

Answer 693

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

Question 694

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

Answer 694

Lock & key relationship

Question 695

What is pharmacodynamics?

Answer 695

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

Question 696

What is pharamacokinetics?

Answer 696

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

Question 697

What do we need to remember about drug nomenclature?

Answer 697

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

Question 698

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

Answer 698

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

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

Question 699

What are the two functional types of meidctions?

Answer 699

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

Question 700

Why are pharamacokinetics important?

Answer 700

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

Question 701

What is the important aspects of pharmacokinetics in prescription?

Answer 701

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

Question 702

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

Answer 702

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

Question 703

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

Answer 703

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

Question 704

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

Answer 704

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

Question 705

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

Answer 705

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

Question 706

Why do some medicine should be taken with food?

Answer 706

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

Question 707

Why do some drugs have bioavailability of less than 100%

Answer 707

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

Question 708

What are the steps of drug distribution?

Answer 708

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

Question 709

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

Answer 709

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

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

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

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

Question 710

What determines the dosing regiment?

Answer 710

Pharmacokinetics control the dosage regiment.

Question 711

What is the therapeutic concentration range?

Answer 711

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

Question 712

What is a therapeutic index?

Answer 712

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

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

Example of low therapeutic index - morphine 70:1 index

Example of high therapeutic index - remifantanil 33000:1

Question 713

What are some of the targets for drugs?

Answer 713

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

Question 714

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

Answer 714

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

Question 715

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

Answer 715

Miliseconds

Question 716

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

Answer 716

Nicotinic receptors and ACh receptors.

Benzodiasapine like xanax

Question 717

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

Answer 717

Muscarinic receptors, ACh receptors

Opiod agonists like morphine

Question 718

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

Answer 718

Hours

Question 719

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

Answer 719

Cytokine receptors

Methotrexate

Question 720

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

Answer 720

Oestrogen receptors

Question 721

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

Answer 721

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

Question 722

What is drug elimination?

Answer 722

It is irreversible loss of drug from blood through use of metabolism (drug is converted to another chemical - done by liver) or excretion (loss of the chemically unchanged drug - done by kidneys)

Question 723

What kind of drugs are metabolised by the liver?

Answer 723

Lipid soluble drugs like local anaesthetics

Question 724

What kind of drugs are processed by the kidneys?

Answer 724

Water soluable drugs like anti-biotics

Question 725

What is drug clearance?

Answer 725

It is the measure of rate of elimination. Drugs could be totally cleared or partially cleared

Question 726

What are the steps to drug elimination in the kidneys?

Answer 726

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

Question 727

How does the liver metabolise drugs?

Answer 727

1. Enzymatic conversion of drug to another chemical form in order to make it more water soluble so kineys can excreate them
2. Remember - liver processes most of the medication

Question 728

What are some of consequences of metabolism?

Answer 728

Usually, the metabolites have no pharmacological activity but:

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

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

Question 729

What are 2 phases of metabolism?

Answer 729

Phase I: Oxidation - depends on Cytochrome P450 largley - binds the drugs and important in binding of steroid - essentially all drugs endogenous and exogenous - VERY IMPORTANT

Phase 2: Conjugation - polar chemical group is “added on or transferred” - Enzyme are called transferases

Question 730

What is the metabolic pathway of paracetamol and hepatotoxicity?

Answer 730

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

Now in overdose:

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

Question 731

Why might some people get an overdose with the “therapeutic dose” of paracetamol?

Answer 731

They taking paracetamol from different sources like regular paracetamol + Cough & Cold tablets + nurimol

Question 732

What are the treatments of SAT violations?

Answer 732

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

Question 733

What is this condition?

Answer 733

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

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

Treatment:

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

Question 734

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

Answer 734

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

Question 735

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

Answer 735

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

Question 736

What is bioavailability?

Answer 736

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

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

Good drugs - bioavailabiltiy 100%

Symbol on graphs - F

Question 737

What is the stead-state condition?

Answer 737

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

Question 738

What does clearance rate determines?

Answer 738

It determines the dose rate.

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

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

If clearance is lower than concentration in plasma is higher.

Question 739

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

Answer 739

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

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

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

Question 740

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

Answer 740

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

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

Commonly, renal clearance is down regulated.

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

Question 741

What is drug enzyme induction?

Answer 741

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

E.g. St Johns Wort

Question 742

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

Answer 742

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

Question 743

What is a triple wammy?

Answer 743

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

Process:

1. ACE inhibitors preserve renal function and also cause relaxation of efferent renal arteriole - reducing the GFR
2. NSAID are able to increase the vasoconstriction of the afferent arteriole by inhibiting the production of prostoglandins - a potent afferent arteriole dilator - reducing GFR
3. Dirutetic drive the increase exertion of water through the renal system thus increasing the amount of blood that is carried to the glomerulus through the afferent arteriole - reducing GFR
4. All three factors compound reduce the GFR significantly to cause kidney injury
5. Solution - avoid NSAIDs

Question 744

How to avoid drug interactions?

Answer 744

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

Question 745

What is an adverse drug reaction?

Answer 745

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

This does not include: Overdoes or Error in dosing

Question 746

What is an adverse drug effect?

Answer 746

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

Question 747

What are major types of ADRs?

Answer 747

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

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

Type C - long term affects - tolerance like for caffeine

Type D - delayed effect - thalidomide with babies

Type other - unavoidable toxicity - cancer chemotherapy

Question 748

Who is more at risk of ADRs?

Answer 748

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

Question 749

What are some of the oral reaction to drgus?

Answer 749

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

Question 750

How are drugs discovered?

Answer 750

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

Question 751

What are the steps of pre-clinical drug development?

Answer 751

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

Question 752

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

Answer 752

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

Question 753

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

Answer 753

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

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

Question 754

What are the schedules of drugs?

Answer 754

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

Question 755

Define the following:

Infection

Colonisation

Bacteraemia

Septicaemia

Sepsis

Answer 755

Infection - invasion & multiplication of pathogenic microorganism in body tissue

Colonisation - localised presence of microorganisms

Bacteraemia - presence of viable bacteria in circulation

Septicaemia - systemic infection caused by microorganisms multiplying in circulation

Sepsis - multiple organ involvement from organisms

Question 756

What are antibiotics?

Answer 756

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

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

Question 757

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

Answer 757

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

Question 758

What is important to understand about antibiotics?

Answer 758

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

Antibiotics give immune system more time to mobilise more effectivley

Question 759

How do antibiotics work?

Answer 759

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

Question 760

What are the different efficacy of antibiotics?

Answer 760

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

Question 761

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

Answer 761

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

Question 762

What are some of the resistance pathway for the bacteria?

Answer 762

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

Example: MRSA - multiresistant Staphylococcus aureus

Question 763

What is the “creed” of antibiotic therapy?

Answer 763

In dental clinics - primary removal of infection is essential

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

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

Question 764

What are the principles of antimicrobial selection?

Answer 764

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

Question 765

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

Answer 765

Number of days and numbers of pills

Question 766

What is the difference between the reliever and a preventer?

Answer 766

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

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

Question 767

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

Answer 767

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

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

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

Question 768

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

GABBA receptor

Opiod receptor

Glucocorticoid receptor

Answer 768

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

Question 769

What drug should you not give to pregnant women?

Answer 769

Category C drug like ibuprofen.

Aloso Category D drugs but they are pretty rare!

Question 770

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

Answer 770

SRTART LOW & GO SLOW

BUT DON’T STAY LOW if chronic dosing.

Question 771

What is an example of potentiation effect of medications?

Answer 771

Warfarin and iboprofen/aspirin - increase bleeding significantly

Question 772

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

Answer 772

AUST R listing

Shedule 1 or unscheduled

Question 773

How do antiobitcs have a bacteriostatic effect?

Answer 773

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

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

Question 774

How do antiobtics have a bacteriocidal effect?

Answer 774

By inhibiting cell wall synthesis through rapid depolarization.

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

Question 775

What are the main drivers for ortho treatments?

Answer 775

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

Question 776

What is interceptive orthodontis?

Answer 776

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

Question 777

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

Answer 777

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

Question 778

What is the difference between growth and development?

Answer 778

Growth - is an increase in size

Development - is an increase in complexity

Question 779

What to do if you find growth is abnormal?

Answer 779

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

Question 780

What is a cephalocaudal gradient?

Answer 780

It is a chart of proportional growth.

Structures towards to head grow first

Question 781

What are growth curves?

Answer 781

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

Question 782

What is more useful - developmental or chronological age?

Answer 782

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

Question 783

What are the peaks of growth in people?

Answer 783

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

Question 784

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

Answer 784

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

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

Question 785

What is the use of lateral cephalometry?

Answer 785

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

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

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

Question 786

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

Answer 786

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

Question 787

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

Answer 787

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

Question 788

How does naso-maxillary complex grow?

Answer 788

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

Question 789

How does the mandible grow?

Answer 789

The mandible grows up and back.

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

Cartilaginous growth occurs in the condyle

Question 790

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

Answer 790

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

Question 791

What are the key points to craniofacial growth in orthodontics?

Answer 791

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

Question 792

Which structures make up the cranium?

Answer 792

1. Cranial vault akak calvarium
2. Cranial base

Question 793

What structure make up the face?

Answer 793

1. Naso-maxillary complex
2. Mandible

Question 794

How does the cranium grow?

Answer 794

2 distinct methods of growth:

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

Question 795

From which branchial arch does the mandible originate?

Answer 795

1st Branchial arch.

Question 796

What is an apical base?

Answer 796

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

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

Question 797

What is malocclusion?

Answer 797

It is a failure of the dento alveolar compensatory mechanism.

Question 798

What is crowding and what types of crowding are there?

Answer 798

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

Primary crowding - genetic origin

Secondary crowding - environmental factors such as extraction as a child

Tertiary crowding - occurs in the post adolescent period

Question 799

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

Answer 799

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

Question 800

What is a length of a dental arch?

Answer 800

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

Question 801

What is dental arch circumference?

Answer 801

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

Question 802

What is the inter-canine width?

Answer 802

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

Question 803

What is the inter-molar width?

Answer 803

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

Question 804

What is leeway space?

Answer 804

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

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

Question 805

What is incisor liability?

Answer 805

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

Question 806

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

Answer 806

Space is gained from:

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

Question 807

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

Answer 807

It is a variation of normal dental development

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

Diastema may close after laterla incisors erupt

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

Question 808

What are the factors that facilitate dental arch allignment?

Answer 808

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

Question 809

What are the factors that hamper dental arch alignment?

Answer 809

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