Dental procedures Flashcards
When removing the lower right first premolar how would you position the patient, which forceps and how to remove the tooth?
PPE - mask, visor, apron, wash hands, gloves
Correct forceps
Correct forceps for handedness
Patient - at elbow height
Chair back at least 30-40 degrees
Stood behind the patient, legs back, back straight, leaning in towards patient
Forceps - held from underneath and curve of handle resting in palm of hand
Application of forceps - blades applied buccolingually into gingival crevice, vertically down long axis of tooth
Remove fingers from between handles
Non dominant hand supporting alveolus both buccal and lingually
Rotational movement and deliver buccally
For upper teeth - head at shoulder height
You are expected to perform an extra oral examination
- PPE
- Introduce yourself, explain procedure and gain consent
- Ask if patient has experienced any pain/swelling around the head/neck area
- Visual inspection of the patient - gait, demeanour, colour, symmetry (in front, behind and above), soft tissue lesions - face, vermillion border, perioral tissues
Muscles of mastication - looking for tenderness, size
Insertion and origin of bilateral masseter muscle palpation
Bilateral temporalis origin palpation
Resistance of lateral pterygoid
Lymph nodes - submandibular and submental
Parotid palpation
Cervical lymph nodes around sternocleidomastoid
TMJ - assess opening of the mandible
any deviation on opening and closing of the mandible
TMJ palpation on lateral movement when opening and closing - assess for clicks, crepitus and path of movement
Other features - ears, eyes, neck (scars, swellings)
Give anaesthesia to extract the UL6, assemble and dispose safely. Talk through technique and anatomical landmarks.
PPE
Short needle - blue
Lidocaine 2% 2.2ml - assess cartridge for batch number, date, air bubbles
Assemble needle
Topical LA given - indicate where
Position operator and patient
Buccal infiltration - Unsheathe needle, pull back guard and click, retract tissue with needle
Insert needle into the gingiva down the long axis of the tooth at the height of the mucobuccal fold and insert approx 5mm, aspirate and inject 1ml of solution.
Resheathe with single click
Palatal infiltration
Half way between midline and gingival margin of UL6 LHS palate
Unsheathe, aspirate and inject looking for blanching of tissues
Double click syringe
Remove plunger
Dismantle syringe from handle
Throw cartridge and syringe into sharps
You are required to perform an ID block on a mannequin, perform this procedure on the left hand side of the patient.
PPE
Choose long needle - yellow
Lidocaine
Batch number and expiry, check cartridge for bubbles and cracks explain you would note this
Set up syringe correctly
Use topical correctly so the injection is as comfortable as possible for the patient
Position head for good visualisation plus light
Left hand side landmarks
Coronoid notch
EOR and IOR
Pterygomandibular raphe
1cm above occlusal plane
Technique
Retract soft tissues with finger/mirror
Unsheathe needle
Approach from contralateral premolars
Parallel to the occlusal plane
Insert into tissues lateral to pterygomandibular raphe
Make bony contact and withdraw slightly
Aspirate - checking you are not in a blood vessel
Inject solution slowly to aid patient comfort
Inject 3/4 of cartridge
Continue injecting slowly on retraction of the needle - lingual nerve
Double click and dispose in sharps with cartridge
Tissues anaesthetised
Anatomy explanation
Branch of mandibular nerve which is a branch of the trigeminal nerve
Mandibular foramen
Mandibular teeth on that side, bone, buccal gingiva from premolars to midline and lower lip and chin.
Breaking bad news: You have a patient and you found very advanced periodontal disease, you have radiographs on the screen (bone loss calculus deposits and furcation)
BPE: 444*/434
Explain the diagnosis, not the treatment options
1) Introduce yourself to the patient
Verbal communication
- no jargon
b) give patient the chance to respond to the question and adequate time for thinking
Ensure the patient knows they can ask questions at any time
Get full previous history
Clarify anything that the patient needs further explaining to them and summarise back
Non verbal communication - body language, mirroring, eye contact, tone of voice
Explaining findings of clinical examination and OPT
- BPE - what it means and what different codes mean
Calculus is - hardened plaque
Bone loss
Furcation - bone loss between the roots of your teeth
Radiograph - these are your teeth here is where the bone is we usually want bone to be here etc
Explain where bone level has decreased
Explaining periodontitis
Probe: what do you understand by the term gum disease?
Two forms - gingivitis - reversible and periodontitis
Periodontitis is irreversible and has progressed slowly it cannot be cured but can be controlled and they have an active part in controlling it.
Rate of progression depends on local and systemic risks
In this case - presence of supra and subgingival calculus
Discuss for features mentioned earlier eg pocketing
Check for understanding - repeat information back, explain that future treatment is required and risks of no treatment could be loss of teeth.
We will come up with a treatment plan together that the patient can cope with, I will help and support you through treatment.
Please take a pain history of a patient you have met in ADC.
Introduce yourself to the patient
Consent - Im going to ask you some questions about the pain you have been experiencing is that okay?
To the examiner - I will take a pain history, clinically examine the tooth and undertake special investigations including radiographs
SOCRATES
Site - do you know where the pain is coming from (well or poorly localised)
Onset - spontaneous or stimulated (does anything bring the pain on or does it come by itself)
Character - sharp or dull and throbbing
Radiation - does the pain spread or stay in that area of tooth
Associations - do you feel well in yourself at the moment - temperature, sickness etc
T - how long does it last for? ( seconds minutes hours)
E - what makes it better if anything? What makes it worse if anything?
S - severity - pain on 1-10, is it disturbing sleeping?
DIagnosis - periapical periodontitis - pain on biting
or irreversible pulpitis - worse with hot
So what I understand is (repeats problem)
Ask if the patient is worried or concerned about anything
You meet a patient attending to discuss the options for her symptomatic UR1, history reveals root treated crowned UR1 by GDP, became increasingly symptomatic over the last couple of months. Pain on biting and complains it is difficult to eat and two courses of antibiotics to treat abscesses.
Ask:
Short and snappy SOCRATES
a) two courses of antibiotics
b) RCT
was it done in one session or multiple?
was this carried out under rubber dam? - rubber sheet
was the crown placed after RCT or was RCT carried out through crown?
Radiograph - explain in laymans terms to the patient
Treatment options:
1) Leave and monitor - could get worse, could get better, risk of flaring up again and needing more antibiotics.
2) Re-RCT - need to assess restorability of tooth, will take a couple of sessions as it is a student clinic, needing the tutor to check everything, removing existing rubber filling material placed where the nerve used to be, wait for radiograph then if a new crown is to be made will take a few weeks to be ready and for the preparation also.
Choice between removal of crown and RCT then new crown or RCT through the crown.
RCT steps: removing GP, cleaning and shaping the canals, re GP and new crown with best possible seal at the top.
Putty matrix to provide temp crown before the treatment begins so there is a template for the temp crown.
Orthograde endo retreatment success rate - 62%
Potential to follow up to determine success up to 4 years
3) Extraction of UR1
If patient would not like to come back for multiple appointments can take the tooth out.
Need for immediate replacement - denture to fill the gap or temporary bridge
Long term option - bridge/implant/denture
4) Apicectomy
Last chance before extraction if the Re-RCT fails
Involves cutting the gum will be lifted and bone removed and root tip and infection removed, a filling will be placed at the top of the root and the gum sewed back.
Success rate between 58-96%
Check for understanding and feel free to go away and think about the options and we can come up with a treatment plan for this tooth.
Your patient requires extraction of his symptomatic curved rooted lower left second premolar. Social history reveals he is a smoker, you must gain valid consent for the potential surgical extraction.
1) introduce yourself to the patient
2) social history:
Investigate smoking history
Number per day/history of years of smoking
3) medical history:
Fit and well?
Medications?
4) past dental history
history of previous extractions?
regular attender?
committed to any future tx if necessary?
Ok or anxious of the dentist?
5) consent
a - why does it need to be extracted - use radiographs and symptoms and history given
b - due to the curved roots it may need surgical removal ie cutting and peeling back some of the gum and bone around it if a normal routine extraction does not work. Will be replaced with stitches.
Benefits - relief of pain and infection
Risks - common: pain, bleeding, bruising, swelling, infection
Stitches - resorbable or need to come back and have removed
Dry socket - as you are a smoker you are at increased risk of this. Severe pain 1-2 days post XLA
Pain is extreme - sometimes worse than original toothache
Foul taste
Treated by irrigation with saline and chlorhexidine and dressing with alveogyl
Nerve damage - altered loss of sensation in the lip/chin region from the LL5 to the midline may be permanent or temporary.
Is there anything I can clarify for you? are we okay to proceed?
You meet with a patient with their third episode of pericoronitis of the LR8. The radiograph shows the tooth to be impacted. Explain the available treatment options for the patient and gain informed consent for the surgical extraction.
SH - investigate smoking history - number a day/history of years smoking
MH - generally fit and well? Medications
PDH - history of previous extractions? Regular attender? Pericoronitis history - what treatment was carried out? Okay with the dentist or anxious?
Consent for extraction - clear reasoning, use radiograph and symptoms given
NICE guidelines - 1 severe episode or several episodes
Continuity of antibiotics - may become resistant and not have any effect on the pericoronitis
Method - may need surgical removal - cutting back gum, removing some bone and removing the tooth and stitching the gum back
Benefits - relief of pain and infection
Risks - common - pain, bruising, bleeding, swelling, infection
Limited opening of mouth
Nerve damage - altered or loss of sensation in the teeth on that side as well as the gums from the premolars to the midline
Altered or loss of sensation in the tongue and difficulty speaking, may be temporary or permanent
You are required to take a focused medical history from the mother of 8 year old. She saw a dentist a few years ago. Her MH form shows she has a heart murmur but no other medical conditions. Examination shows distal marginal breakdown of both 75 and 85.
Take a MH and describe the next steps in treatment
Introduce yourself to the patient
What is the condition?
When was it diagnosed?
Who diagnosed it?
Treatment - at the time - hospital admission?
Any long term treatment?
Medications? eg long term warfarin/ anti-coagulants - which? dose? route?
Symptoms - triggers? time span? last symptom? what happens when the symptoms occur?
Who manages the condition? - GP, paediatrician, specialist
Address - so you can get in touch
Lifestyle - what is the effect of this illness on the daily routines of the patient and lifestyle?
Heart murmur - likely cause CHD increased caries risk, anticoagulation risk, increased risk of IE
C/I - pulp therapy
Manifests - increased untreated caries, enamel defects
Treatment options - pulp therapy contraindicated, caution with intraligamentary LA, procedures requiring GA - consult cardiologist and anaesthetist
Beware of anticoagulant therapy
Preference for extraction over pulp therapy in CHD
You meet Oscar and his mother, Oscar is 5 years old and has had caries diagnosed in all primary molar teeth
He is uncooperative and has only let you have a brief look in his mouth, you feel that there is no other option but a GA referral. Give relevant advice regarding the proposed treatment as well as dental health advice.
Why is GA necessary?
- recognition of uncooperative child, with a large number of teeth affected they would get an unacceptable treatment quality without
Explanation of GA in dentistry - not administered by a dentist but a specialist anaesthetist with a team to look after the child but there is a waiting time due to waiting list
MH - update MH, pre op tests and information, risk to patient, precautions
Explanation of GA - given by gas through a mask or IV - anaethesist will choose this
Time - Few mins for simple XLA, 15 mins for multiple and awake once finished
Side effects - common - dizzy and sick for a few hours/ some pain and discomfort/ sore throat
Risks and alternative options - risk of death 3 in 1 million
LA/ sedation/ hypnosis
Consent - once removed these teeth do not return
Treatment will need to be radical due to extent of disease
There may be a waiting list
If ill - contact hospital as might not go ahead
If pain before hand - get in contact as could do antibiotics, access and eugenol/soothing dressing
Dental health advice
Caries - action of acid on the tooth surface, bacteria in plaque react with sugar to produce this acid
Prevention - 1450ppm toothpaste assisted brushing until 7
Fluoride varnish 4x a year
Fissure sealant - all first permanent molars
Diet advice - have sugar with meals, soft drinks with meals
milk and water between meals
Importance of regular reviews - every 3 months
How would you follow up a patient after GA for removal of all primary decayed molar teeth?
How did the procedure go?
Any complications?
No pain or bleeding?
Healing nicely?
Is the child doing OK? - eating and drinking okay? back to his normal self? sleeping okay? behaving okay?
Maintaining good OH
Dental health advice
Caries - action of acid on the tooth surface, bacteria in plaque react with sugar to produce this acid
Prevention - 1450ppm toothpaste assisted brushing until 7
Fluoride varnish 4x a year
Fissure sealant - all first permanent molars
Diet advice - have sugar with meals, soft drinks with meals
milk and water between meals
Importance of regular reviews - every 3 months
Post op denture instuctions for complete complete dentures
Explain todays visit, I’m just going to give you some information and advice, stop me if you have any questions.
Best results achieved with practice and patience
Not unusual to find that new dentures feel large and difficult to control when speaking and eating, may notice an increase of saliva in the mouth. This will disappear and speech will return to normal, may last 3-4 weeks. Eat mainly soft foods for the first dew days.
Cut food into small portions and chew with back teeth on both sides of the mouth at the same time.
For the first week wear it day and night after the first week leave out in a container of water or cleanser as the mouth needs a rest from the dentures to remain healthy.
Cleaning dentures
a) rinse after each meal and brush morning and night using toothbrush soap and water
b) do over a sink filled with water, reduces risk of breakage if dropped
Soaking in Steradent will remove film of plaque not seen by eye (2-3 nights a week)
New dentures can cause areas of soreness and pain
If mild soreness persists - continue to wear the denture, make an appt to come back and see the dentist/student
If soreness and pain is severe - leave the dentures out, make an appt to see the dentist and put them back in the mouth 3-4 hours before the appt so the area can be identified.
Give pt a leaflet and ask if they have any further questions
Post op instructions for extraction of the LR6, fit and well and no medications.
Hot areas and drink - areas that are numb beware of these as the local anaesthetic wears off usually takes between 2-4 hours. Some tingling may be present for a week or two.
Beware of biting during this period and drinking - may drool
If numbness persists for more than a few weeks, contact LDI
Avoid alcohol and vigorous exercise until the next day - may cause bleeding and movement of clot
Does patient smoke - ask for history
Dry socket - little or no blood clot in the tooth socket, bony walls is exposed and becomes inflamed
1) irrigate with CHX or saline, pack with alveogyl, immediate relief, can be repeated
24 hours post op - start salt water rinses 4x a day
Brush teeth as usual but more gently around extraction site
Painkillers - take painkillers as soon as you feel the LA wearing off, if they fail to control the pain contact the hospital via number on sheet.
Antibiotics - only prescribed if infection such as swelling seen or fever or malaiase
Swelling - can take a week to subside
