Dentistry in a Nutshell Flashcards
what things must you talk to the patient about to ensure you are obtaining valid consent (not AMCUR related)
why treatment necessary
what might happen if treatment is not carried out
treatment options - risks and benefits
recommended option
cost
duration
likely prognosis
whether treatment is guaranteed
what tests can you do quickly when the patient comes in with toothache
visual
air from 3 in 1
palpation
probing
percussion
vitality
mobility
tooth sleuth
apart from the usual endodontic diagnoses for pain, what other reasons may a patient have pain
hypersensitivity
dry socket
TMJ pain
oral ulceration
necrotising gingivitis
sinusitis
orthodontic problem
salivary gland infection
ill/loose fitting dentures
what is the immediate management for adults with dental infections
establish drainage
extirpate if endodontically involved
debride pockets if periodontally involved
prescribe antibiotics if indicated
recommend analgesia
consider extraction
what are the indications for antibiotics
limited mouth opening
facial swelling
systemic infection
immunocompromised patient
elevated temperature >38 degrees
when would you refer to maxfax/a&e
difficulty breathing/likely to obstruct airway
involvement of orbital area/closure of eye
difficulty in swallowing/unable to stick tongue out
swelling rapidly increasing in size
evidence of infection in facial spaces (ludwigs angina)
what is the dose of penicillin for dental infections
phenoxymethylpenicillin 250mg
2 tablets 4x daily for 5 days
what is the dose of metronidazole for periodontal abscesses
metronidazole 400mg
1 tablet three times a day for 5 days
what is the dose of metronidazole for pericoronitis and ANUG
metronidazole 400mg
take one tablet three times day for 3 days
when the patient is complaining of post extraction pain what extra oral exam do you do
pyrexia
lymphadenopathy
bruising
trismus
step deformity
when the patient is complaining of post extraction pain what intra oral exam do you do
visual
tactile
inspect socket for healing status
debris
clot
pus
bone sequestra
necrosis
tender/damaged adjacent tooth
what are the differential diagnoses when a patient is complaining of post extraction pain
dry socket
retained root/bone
infection
LA related trauma
haematoma
MRONJ
OAC
ORN
fractured maxillary tuberosity
step deformity
dislocated/fractured mandible
what symptoms may someone have if they have a cracked tooth
pain on biting
localised pain/sensitivity to cold
what are the signs of a cracked tooth
lymphadenopathy
visible fracture
interferences in occlusion
toothwear
heavily restored dentition
swelling
what are the special investigations for a cracked tooth
sensibility testing
radiographs
percussion
tooth sleuth
before deciding that a patient has a cracked tooth, what other diagnoses must you rule out
periodontal and periapical issues
dentine sensitivity
facial pain
apical pathology
high restoration
if a cracked tooth does not extend to the pulp chamber floor how do you manage it
restore with composite/temp crown with occlusal reduction
assess after 2-3 months
if symptomatic after this time then RCT with crown or extract
if a cracked tooth has cracked subgingivally and there is insufficient coronal tissue what is the treatment
extract as this is hopeless
if a tooth is cracked and it extends to the pulp chamber floor and is restorable what is the treatment
RCT and crown
what are the symptoms of pericoronitis
pain on biting
localised pain
pyrexia
may struggle to open mouth wide
what are the signs of pericoronitis
inflamed operculum
signs of trauma
trauma from opposing tooth
swelling
lymphadenopathy
what is the management of pericoronitis
debride around inflamed tooth
irrigate with saline and instruct patient how to perform OH
consider adjusting traumatic occlusion/extracting upper tooth
antibiotics if spreading infection/trismus
review
what are the signs and symptoms of dry socket
pain 24-48 hours post extraction
inflamed non-healing socket
lost blood clot
trapped food debris or bad taste/odour
what are the risk factors for dry socket
smoking
alcohol
immunocompromised
female
oral contraceptive
mandibular
posterior teeth
previous dry socket
poor compliance with post op instructions
traumatic extraction
what is the management of dry socket
curette socket
irrigate with saline and instruct OH
pack the socket with alvogyl (eugenol based dressing)
advise good OH and smoking cessation if available
review after 1 week
if a patient attends with a swelling what do you look for extra orally
site
hard/soft
eye affected
redness
temperature
difficulty breathing
trismus
difficulty swallowing
drainage
lymph nodes examination
if a patient attends with a swelling what do you look for intra orally
associated tooth
hard/soft swelling
mobility
drainage
pocket depth
percussion test
palpation test
sensibility test
fractured tooth/filling
if a patient has a swelling and there is apical pathology on the radiograph what are the differential diagnoses
periapical periodontitis
perio-endo lesion
periodontal abscess
periapical cyst
if a patient has a swelling and there is no apical pathology on the radiograph what are the differential diagnoses
salivary gland obstruction/infection
pericoronitis
fractured jaw
fractured tooth
malignancy
bony diseases
tumour
tori
what are the signs/symptoms of acute apical abscess
localised pain
pain increases on chewing/touching tooth
quick onset of swelling and pain
possible mobility
what is the immediate management of acute apical abscess
establish drainage
analgesia
antimicrobials if indicated
consider relieving occlusion
what is the long term management of acute apical abscess
review
definitive treatment RCT/XLA
what are the signs/symptoms of perio-endo abscess
generalised periodontitis with localised pain
swelling
deep pocketing to root apex
what is the immediate management of perio-endo abscess
debride pockets
irrigate
chemical plaque control
establish drainage
antibiotics
what is the long term management of perio-endo abscess
review OH
decide if the cause is initially perio or endo and treat accordingly
what are the signs/symptoms of salivary gland obstruction/infection
pain in major salivary gland
swelling
history of dehydration
history of xerostomia
what is the immediate management of salivary gland obstruction/infection
analgesia
advise patient to increase fluid intake
use warm compress on gland
massage gland
encourage salivary flow
consult with GMP to consider changing medication
refer to medical centre in severe cases
what is the long term management of salivary gland obstruction/infection
saliva substitutes
high caries risk prevention protocol
what are the signs/symptoms of periodontal abscess
pain/tenderness of gingiva
increased mobility
gingival swelling
suppuration from gingiva
systemic symptoms include pyrexia, lymphadenopathy and malaise
what is the immediate treatment of a periodontal abscess
LA and supra and subgingival debridement of pockets
antibiotics if indicated
consider extraction
what is the long term treatment of a periodontal abscess
review OH
periodontal treatment
consider extraction
what are the signs of a radicular cyst
apical to non-vital tooth
egg shell crackling of bone
treatment of radicular cyst
RCT
XLA
what is the signs of residual cyst
following extraction of tooth with radicular cyst, cyst remains and becomes a residual cyst
treatment of residual cyst
no treatment and monitor
enucleation
signs of dentigerous cyst
cyst that develops around CEJ of teeth and prevents eruption
treatment of dentigerous cyst
surgical removal
uncover tooth
describe a mucocele
fluid filled sack due to trauma of minor salivary gland usually in lower lip
treatment of mucocele
monitor
enucleation
describe a ranula
cyst formed from major salivary gland
treatment of ranula
marsupialisation
treatment of salivary gland stone/obstruction
no treatment
surgical removal
basket retrieval
lithotripsy
what are the special tests in the trauma stamp
sinus
colour
TTP
colour
mobility
electric pulp test
ethyl chloride
percussion note
radiograph
if there is dental trauma with displacement and single tooth mobility what injuries could this be
root fracture and extrusion
if there is dental trauma with displacement but no single tooth mobility what injuries could this be
alveolar fracture
intrusion
lateral luxation
treatment of root fracture
reposition and confirm radiographically
stabilise for 4 weeks with passive and flexible splint
monitor pulp for up to 1 year
treatment of extrusion
reposition and splint for 2 weeks
monitor pulp
treatment of alveolar fracture
reposition and splint for 4 weeks
suture lacerations
monitor pulp status
treatment of intrusion with incomplete root formation
allow for re-eruption without intervention for 4 weeks
if no re-eruption then ortho reposition
monitor pulp
RCT if required
treatment of intrusion with complete root formation
<3mm allow for re-eruption
3-7mm ortho/surgical reposition
>7mm surgical reposition
start RCT at 2 weeks and use corticosteroid paste as intra-canal medicament to prevent external resorption
if a tooth has no displacement but is mobile and is TTP what trauma is this
subluxation
if a tooth has no displacement but is mobile and not TTP what injury could this be
crown fracture if fracture is present
crown-root fracture
if a tooth has no displacement and is not mobile what injury is this
concussion
what is treatment for subluxation
no treatment
monitor pulp for 1 year
what is treatment for enamel fracture
bond fragment or restore
what is treatment for enamel dentine fracture
bond fragment or restore
consider need for pulp cap
what is treatment for enamel dentine pulp fracture
partial pulpotomy/pulp cap followed by restoration
what is treatment for concussion
no treatment
monitor pulp for 1 year
if mobile then splint for 2 weeks
what is treatment for crown-root fracture
if no pulp exposure then stabilise mobile fragment and monitor
if pulp exposure then stabilise or extract fragment, pulpotomy or pulpectomy depending on root maturity. RCT and restore
treatment for avulsion
clean tooth
administer LA
irrigate with saline
reposition socket fracture if present and reimplant tooth
suture any lacerations
radiograph to ensure correct reimplantation
flexible splint for 2 weeks
antibiotics and tetanus booster
RCT after 7-10 days with intracanal medicament
2 week follow up
clinical and radiographic follow up 1 month, 3 months, 6 months, 12 months
post operative advice for avulsion
avoid contact sports
soft diet for 2 weeks
brush teeth after every meal with soft toothbrush
chlorhexidine 0.1% twice a day for 7 days
if an avulsed tooth is immature do you start RCT?
no the aim is to revascularise the pulp
no RCT unless necrotic
emergency management of avulsion
reassure patient
hold by crown DO NOT TOUCH ROOT
clean tooth with milk or saliva
reimplant if possible or store in saliva
treatment for pulp exposure when it is an immature tooth
PARTIAL PULPOTOMY
remove 1-3mm of inflamed coronal pulp or until reaching healthy pulp
control bleeding using CHX or NaOCl
dress with CaOH, biodentine or MTA
RMGIC
restore with bonded restoration
follow up with vitality testing
when are direct pulp caps performed
on immediate pinpoint exposures <1mm
differential diagnoses for extra oral swellings
trauma
dental infection
sialosis
ranula
suppurative/viral sialadenitis
Crohns/OFG
salivary gland tumour
OSCC
pagets
fibrous dysplasia
acromegaly
differential diagnoses for intra oral swellings that are pink
fibroepithelial polyp
drug induced hyperplasia
crohn’s disease
OFG
OSCC
salivary gland tumour
differential diagnoses for intra oral swellings that are red
pyogenic granuloma
giant cell granuloma
denture induced hyperplasia
scurvy
OSCC
differential diagnoses for intra oral swellings that are white
squamous papilloma
OSCC
differential diagnoses for intra oral swellings that are blue
mucoele
ranula
differential diagnoses for intra oral swellings that are yellow
bone exostosis
sialolith
differential diagnoses for localised pigmented lesions
amalgam tattoo
haemangioma
melanotic macula
malignant melanoma
differential diagnoses for widespread pigmented lesions
drug induced pigmentation
addisons disease
sturge weber syndrome
smoking associated pigmentation
differential diagnoses for white patches that are painful
chemical burn
lichen planus
lichenoid reaction
lupus erythematous
differential diagnoses for non painful white patches
white sponge naevus
leukoplakia
candida
OSCC
keratosis
differential diagnoses for painful ulcerative red patches
erosive lichen planus
post radiotherapy mucositis
contact hypersensitivity
differential diagnoses for painful non ulceration red patches
any anaemia
angular cheilitis
acute erythematous candidiasis
geographic tongue
differential diagnoses for painless ulcerative red patches
OSCC
differential diagnoses for painless non ulcerative red patches
erythroplakia
chronic erythematous candidiasis
differential diagnoses for single ulceration
trauma
RAS
behcets
OSCC
syphilis
differential diagnoses for multiple discrete ulcers
ANUG
herpetiform RAS
behcets
differential diagnoses for multiple diffuse ulcers
erosive lichen planus
lichenoid reaction
GVHD
radiotherapy induced mucositis
ORN
differential diagnoses for blistering conditions in children
chickenpox
herpangina
primary herpetic gingivostomatitis
hand foot and mouth
differential diagnoses for blistering conditions in adults
shingles
pemphigoid
pemphigus
erythema multiforme
angina bullosa haemorrhagica
causes of dry mouth
medications
dehydration
drinking and smoking
mouth breathing
anxiety
cancer treatment
health conditions
management of dry mouth
assess to see if lifestyle/medication modifications can be made
drink water, suck ice cubes, sugar free sweets, chewing gum
regular check ups, caries assessment and fluoride application
high strength toothpaste
saliva substitues
medications causing dry mouth
beta blockers
anti-convulsant
analgesics
anti-emetics
parkinsons drugs
diuretics
antidepressants
antihistamines
antipsychotics
anti-manic drugs
management of oral ulceration
make note of appearance
soft diet, avoid spicy foods, avoid SLS, anbesol, CHX
adjust ill fitting dentures/traumatic areas, prescribe
keep ulcer diary and refer for further testing if recurrent
review at 3 weeks
medications causing ulcers
NSAIDs
beta blockers
methotrexate
penicillin
nicorandil
allopurinol
sulfasalazine
gold
anti-convulsants
systemic conditions causing ulceration
herpetic gingivostomatitis
lichen planus
vesiculobullous
hand foot and mouth
haematological malignancy
OSCC
erythema multiforme
haematinic deficiency
inflammatory bowel disease
management of acute pseudomembranous candidiasis (oral thrush)
identify and address underlying causes
improve OH
CHX mouthrinse
miconazole gel/nystatin mouthrinse/fluconazole
management of chronic hyperplastic candidiasis (candidal leukoplakia)
biopsy
check vitamin levels
smoking cessation
2-4 weeks oral fluconazole
management of acute erythematous candidiasis (sore mouth)
spacer device/rinse after inhaler
oral thrush treatment
management of chronic erythematous candidiasis (denture stomatitis)
denture hygiene advice
miconazole gel to fitting surface of denture
refer to GMP if unresolving or make new denture
management of angular cheilitis
correct the cause
topical miconazole
who is ANUG commonly found in
smokers
immunodeficient
stress
poor OH
what bacteria causes ANUG
spirochetes and fusiform
clinical appearance of ANUG
pseudomembranous slough covering ulcerated gingival margin
papillae are punched out
loss of crestal bone
bad breath and metallic taste
advice for ANUG
stop smoking
use soft toothbrush, toothpaste and ID brushes
0.2% chlorhexidine 10ml 2x daily or diluted 6% hydrogen peroxide 3x daily
topical pain relief
treatment for ANUG
advice
LA and debride
advise paracetamol
prescribe antibiotics if required (metronidazole)
review in 1 week
clinical findings of a periodontal abscess
patient has periodontitis
loss of alveolar crest
mobile and TTP in lateral directions
abscess adjacent to periodontal pocket
pus drainage
fever/malaise
tooth is usually vital
treatment of periodontal abscess
LA and debride
antibiotics if required
discuss and make aware of cause
what does NaOCl do
dissolves necrotic and vital organic tissue
antimicrobial
lubricant
what does EDTA do
dissolves smear layer, inorganic tissue
lubricant
chelator
decalcifying agent (for sclerosed canals)
before commencing RCT what do you analyse on the radiograph
root canal anatomy, number, length, curvature and calcifications
what burs are used for access
flat fissure/round bur for initial access
safe ended access bur for widening pulp chamber/removing roof
how do you ensure that hypochlorite is safe
use side venting needle
fill needle up to 3/4
use forefinger to inject
label clearly
ensure the tip does not bind
irrigate using in and out motion
pass behind patient’s head
be mindful of droplets
bend needle
what are the principles of access cavity design
allow removal of entire contents of pulp chamber
allow visualisation of pulp floor and canal orifices
allow direct access to apical 1/3 of canal for instrumentation
allow retention and support of a temporary filling material - good seal
provide reservoir for canal irrigant
be as conservative as possible
is modified step back a hand filing or a rotary technique for canal preparation
hand filing
what are the steps of the modified step back technique
scout canals and coronal pre-flaring with gates gliddens
prepare coronal 2/3 with gates gliddens
establish working length
establish glide path
prepare the canal to 3 sizes larger than first file which binds at the apex
step back using next file size up and 1mm from that length, keep stepping back until you have joined the apical preparation
why would you use a file 3 sizes larger than that which binds at the apex to prepare the canals
remove dead pulp tissue, bacteria and substrates
increase capacity of canals to retain a larger amount of irrigant
prepare canal for adequate obturation
what are the steps of the crown down technique for RCT
scout canals and coronal pre-flaring
prepare coronal 2/3
establish working length
establish glide path
use rotary system to prepare the canal in a brushing motion to working length
what are the advantages of using a coronal preparation technique first in endodontics
improves tactile sensation
prevents pushing bacteria from infected coronal aspect further into the canal reducing the incidence of flare ups
allows more accurate working length determination
how do you manage a hypochlorite accident
stop and inform and reassure patient
irrigate with saline
administer long acting LA and prescribe NSAIDs for pain
cold compresses in initial days and warm compresses later
review after a few days and place temporary seal
clinical photographs for record keeping
if the swelling of the affected side is more than 30% compared to the contralateral side consider referral
what are the steps for obturation via cold lateral compaction
thorough irrigation
select master GP cone and mark working length
coat in sealer
seat in canal and ensure it goes to length
select finger spreader
accessory points
remove GP with super endo alpha at canal orifice
clean access cavity with ultrasonics and cotton pellet
seal root canal filling with core
what are the types of root canal sealer available
resin
GIC
ZOE
calcium hydroxide
bioceramic
how do you manage a ledge in RCT
identify location of ledge with hand file
enlarge canal space to 1mm short of ledge
place shark kink at the end of the hand file
file up and down to smooth the ledge
once a K8 file can glide smoothly move up to 10, 15, 20 etc
continue with preparation as normal
how do you avoid ledges
good cavity access with straight line access to canals
pre curved hand files with lubricant and watch winding motion
never force files
risks of root canal treatment
perforation
instrument separation
continued symptoms
hypochlorite accident
missed canals
trismus
alternative options to RCT
accept and monitor
extraction
surgical RCT
other
how do you manage perforations in house
achieve haemostasis using heat or pressure
plug perforation
allow appropriate setting time
seal with GIC
complete RCT
review at 6 months and then annually
how do you achieve haemostasis and plug perforations in house
haemostasis = 5mins pressure with cotton pellet OR heated instrument to cauterise
plug = use MTA or biodentine for gold standard, can also sue GIC or ZOE
if you are going to refer a perforation, what do you need to do before
cotton wool over the perforation with CaOH and dress with ZOE or GIC
write letter with information on cause and location of perforation
what is the success of perforation repair dependent on and what is the success rate of them
depends on location, size and time
coronal perforations have lower prognosis as can develop perio-endo lesions
smaller perforations and those treated sooner have better success rate
why do perforations normally occur
over instrumentation and poor understanding of anatomy of tooth
why would you re-organise an occlusion
when ICP cannot be established reliably it is re-designed
when would you use a split dam technique
insufficient coronal tooth structure
deep subgingival cavity
tight contacts
indirect cementation
steps of recording a facebow
mould wax around bitefork
place in patient mouth until wax hardens
mark anterior reference point on face - 43mm above distal of 12 incisal edge
assemble transfer jig to earbow and tighten screw securely
re-insert bitefork and tighten earbow
adjust earbow until locating arm is aligned with anterior reference marked on patient face
bitefork and transfer jig sent to lab as one unit
when taking a patient history for tooth wear what things are important to establish
parafunction
diet
gastric issues
morning sickness
lifestyle
recreational drug use
eating disorders
steroid inhalers
medication
habits
what do you assess with extra oral exam for tooth wear
smile line
lip line
RVD, OVD, FWS
phonetics
TMJ
what are the wear indices used
BEWE
Smith and Knight
what special investigations are used for wear
radiographs
articulated study models
sensibility testing
photographs
diagnostic wax ups
what are the types of wear in relation to severity
1 - wear with loss of OVD
2 - wear without loss of OVD with space
3 - wear without loss of OVD and limited space
what is the immediate management of wear
adjust sharp edges
desensitising agent
GIC over exposed dentine
what is prevention advice for wear
modify diet and lifestyle
cease bad habits
promote good oral hygiene
splint
refer to GP for medical problems
apply fluoride
treat dry mouth
what are the absolute contraindications to implants
patient not compliant
ongoing chemotherapy
high dose immunosuppressive therapy
incomplete maxillary/mandibular growth
allergies to implant materials
around the localised site where an implant would be placed, what should we be looking at
distance of bone interproximally between neighbouring teeth
bucco-lingual width of bone
minimal vertical mouth opening
minimal interocclusal distance and soft tissue condition
what are the special investigations for implants
clinical photography
study models
radiographs (PA, OPT, CBCT)
what should be discussed in the consent process of implants
risks v benefits
costs
estimated
number of visits
likely prognosis
importance of maintenance visits
when would you use a facebow when planning for a bridge
when replacing upper canines and multi-unit bridges
how do we ensure a bridge is cleansable
connectors should be at the contact point to allow adequate embrasure space for cleaning
smooth, polished and glazed
how do you prep for anterior adhesive bridge
ensure parallel wall of tooth
no prep needed if 0.7mm of interocclusal space free for retainer
minimal palatal chamfer finish can help with seating and increases resistance form
then take impressions with lightbody on teeth, medium/heavy body or lab putty in tray
what information is included in the lab card for adhesive bridges
shade
pontic design
metal wing coverage
connector level
embrasure space
locating peg
sandblasted metal wings
ask for casts to be articulated to jaw registration provided
what is the average longevity of a conventional bridge
10 years
what is the incidence of devitalisation in a conventional bridge preparation
1 in 5
how do you prep for conventional bridge
outer axial walls have 6-15 degree taper
parallel guideplanes
non functional cusp reduction of 1.5-2mm
functional cusp reduction of 2mm
axial reduction dependant on bridge material
what special investigations are needed for crowns/onlays
radiographs
photographs
impressions for study models
diagnostic wax ups
sensibility testing if needed
what is the risk of devitalisation with crown prep
20-30%
what is the disadvantage of an MCC (porcelain and metal)
metal cervical area can become visible due to gingival recession
what is the advantage and disadvantage of a zirconia crown
adv = good aesthetics
disadv = more abrasive than metal
what are the advantages of a LiDiSi crown
the flexural strength is similar to tooth tissue (much less than MCC though)
good aesthetics
what are the advantages of metal crowns (precious and non-precious)
flexural strength very high
less abrasive
what are the options for crown materials available
porcelain fused to metal (MCC)
zirconia
lithium disilicate
precious metal (gold)
non-precious metal (silver)
what degree of taper should the internal walls of inlay/onlay/crown prep have
4-6 degree
indications for an inlay
occlusal and/or proximal cavities
failed direct restoration replacement
if you are using a ceramic onlay, what should the cusp reduction be
2mm for functional
1.5mm for non-functional
indications for an onlay
cusp fracture
toothwear
caries weakening tooth structure
pre-existing failed restoration with large isthmus
restoration of RCT teeth
axial reduction for MCC crown
buccal = 1.5mm shoulder
porcelain palatal = 1mm chamfer
metal palatal = 1.5mm chamfer
axial reduction for a ceramic crown
1mm rounded chamfer
indications for crown
cusp fracture
toothwear
caries weakening tooth structure
pre-existing failed restoration with large isthmus
restoration of RCT teeth
high aesthetic demand
onlay not possible
steps of a crown preparation
LA
sectional impression for temp construction and separate impression for reduction matrix
occlusal reduction - bevel the functional cusp
axial reduction
interproximal reduction
impressions
temporary construction
what do you do to finish a crown prep
polish proximal boxes and flare edges
prepare rounded shoulder or chamfer margin
round off internal sharp angles
remove any enamel lips
no undercuts
what is deep margin elevation
building up a subgingival proximal box with composite to ensure margins are supragingival before beginning crown preparation
how much space should you have in the interocclusal space of anterior crown prep
2mm
prep dimensions for anterior MCC crown
0.7mm chamfer palatal
0.7mm cingulum reduction
1.5mm labial shoulder
prep dimensions for anterior all ceramic crown
1-1.5mm shoulder/chamfer palatal
1mm cingulum reduction
1-1.5mm shoulder/chamfer labial
steps of temporary crown construction
fill putty index with protemp
allow initial set in mouth and then remove to allow full set out of mouth
use burs and discs to remove excess material
take final impression of crown prep for lab
cement temp crown with temp bond
steps for impression taking for crowns/onlays
syringe light body silicone around prep
take impression with medium/heavy body silicone or lab putty
take opposing arch alginate
take bite registration in ICP
what information do you include on the lab card for crowns/onlays
shade
ask for sandblasting (zirconia/metal) or HF acid treatment (LiDiSi)
ask for casts to be articulated
consequences of poor marginal fit of crown/bridge
plaque retention
secondary caries
localised periodontitis
cement dissolution
poor aesthetics
what causes poor marginal fit of a crown/bridge and how do you fix it
inaccurate impression
poor gingival retraction
inadequate marginal preparation
redefine margins and retake impression and communicate issue to lab
consequences of crown/bridge not seating properly
patient discomfort
plaque retention
secondary caries
localised periodontitis
unnecessary occlusal adjustments
what causes a crown/bridge to not seat properly
inaccurate impression
undercuts in final prep
insufficient taper of axial walls
drifting of adjacent teeth
how do you fix a crown/bridge not seating properly
retake impression
check for undercuts in final preparation
4-6 degree tapered axial walls
ensure good contact points on temporary crown
minimal interproximal reduction with high speed
consequences of occlusal interferences of the crown/bridge
post op pain on biting
occlusal trauma
indirect fracture
opposing tooth cuspal fracture
decementation
bruxism
what would cause occlusal interference with indirects
inaccurate impression
insufficient occlusal reduction
inaccurate bite registration
poor planning and clinical assessment
what can glass ionomer cement
MCC
metal crown
what can RMGI cement and give a brand
MCC
metal crown
brand = RelyX or RIVA luting cement
what can light cured resin cement and give brands
porcelain veneer/inlay/onlay
brand = RelyX
what can dual cured resin cement and give brand
MCC
metal crown
porcelain inlay/onlay
all ceramic crown
brand = nexus/relyX/panavia
what are the ideal endodontic/root factors for post placement
good apical and coronal seal obturated within 2mm of apex, well condensed
no periapical radiolucency
wide width of root
1:1 crown:root ratio
minimal curvature
no resorption
no sinus/abscess/TTP
how many millimetres subcrestal should a post extend
4mm
what are the restorative and occlusal requirements for post
caries free
2mm ferrule minimum around 3/4 of tooth
2mm interocclusal space after core placement
need to have group function
no wear or bruxing habits
what are the periodontal requirements for post
no bleeding pockets >4mm
no pockets >5mm
no pus
BOP <15%
not mobile and no furcations
adv and disadv of direct post
adv = same day placement and lower cost
disadv = less accurate fit, not suitable for wider canals, need ferrule
adv and disadv of indirect post
adv = more accurate fit, wider canals fine, can use when less ferrule remaining
disadv = more than 1 appointment, costly
materials for a post
metal = gold, stainless steel, titanium
ceramic = zirconia, alumina
fibre = glass, quartz, carbon
adv and disadv of metal posts
adv = radiopaque, retrievable, better fit to crown
disadv = poor aesthetics, root fracture, corrosion
adv and disadv of ceramic posts
adv = high flexural strength, greater aesthetics
disadv = difficult retrievability, technique sensitive
adv and disadv of fibre posts
adv = allows light cure, more closely replicates root elasticity
disadv = difficult to retrieve, less radiopaque
adv and disadv of parallel post
adv = less stress on root, greater retention
disadv = less conservative
adv and disadv of tapered post
adv = more conservative
disadv = greater stress on root, less retentive
what is the ideal post
parallel sided
non-threaded
cement retained
what are the risks of post placement
perforation
root fracture
post fracture
infection requiring re-RCT
bruxism, class 2 div 2, deep overbite, edge-edge ALL increases post fracture risk
what are the steps of direct post preparation and cementation
LA and dam
refine crown prep margins
calculate working length and post width required
use gates gliddens to remove 2mm of GP from entrance of canal
prepare post space to correct size for post being used
irrigate with NaOCl
try in post and radiograph to confirm position
cement
build composite core incrementally
remove remaining post coronally once core has been built up
redefine crown margins and do impressions
what are the steps of indirect post preparation
LA and dam
redefine crown prep margins
calculate working length
gates gliddens to remove 2mm of GP from canal entrance
prepare post space to correct post size
irrigate with NaOCl
what are the steps of indirect post impression taking once preparation has already taken place
insert retraction cord
insert impression post and ensure 2mm interocclusal space present
remove retraction cord
light body silicone syringed around post and impression with medium/heavy body
take opposing alginate
bite reg
place temp post inside post prep
build up core
what is on the lab card for cast post
outline only cast post and core are to be constructed
shade
ask for sandblasting of fit surfaces
ask for casts to be articulated
send burn out post corresponding with post preparation drill used to lab
steps of indirect post cementation (cast post)
LA and dam
remove remnant temp cement with ultrasonic scaler
irrigate with NaOCl
try in post and core and take PA radiograph
questions to ask in the denture history
happy with current dentures
how old are current dentures
how many have you had and which were best
what are your main concerns
did your denture fit initially
are you able to eat with dentures in
what are expectations of new dentures
how long do you wear your dentures for
what do you look at in extra oral exam at denture assessment appointment
face structure
centrelines
OVD, RVD
incisal show
lips
aesthetics
occlusal plane
speech
how do you check for retention in complete dentures
push on incisal edges of anterior teeth and check for posterior drop
how do you check for stability in complete dentures
press unilaterally on the posterior teeth and check for a drop on opposite side
how do you check for support in complete dentures
press on occlusal surfaces of teeth and check if denture sinks or if it causes patient discomfort
what do you check for with primary impressions
full coverage of denture bearing areas
no encroachment of impression material on tongue space
presence of rolled borders with no drags
absence of drags, voids and tears
mechanical retention of impression material through tray perforations
what depth of undercut does a 15mm cobalt chrome clasp engage
0.25mm
define retention
resistance to vertical displacement of the denture
define indirect retention
resistance to rotational displacement of the denture
what provides indirect retention
connectors
rest seats
saddles
denture base
how do you decide where indirect retention should be
draw line between most posterior clasp and clasp on opposite side
then draw perpendicular line and place indirect retention component here
how much space does a lingual bar require from floor of mouth to gingival margin
8mm
how short of the sulcus should a special tray be in order to achieve rolled borders
2mm
what do you check when trying in CoCr framework
adaption
presence of sharp edges
are clasps engaging the undercuts
lab induced defects on denture bearing areas
path of insertion
what do you check on partial dentures at the try in stage
adaption
flange extensions
no lab induced defects
balanced occlusion
position of denture teeth bucco-lingually compared to natural teeth
what plane should the posterior occlusal plane be parallel to
ala-tragus line
denture hygiene instructions/denture advice
take denture out at night and leave in bowl of water
clean denture after every meal with warm water and soap and soft brush
retention and general feel improves over time
begin with soft diet
if causes irritation return to previous set but wear 24 hours before so we can see traumatised areas
what is poor retention of complete record blocks caused by
under/overextension
inaccurate fit
incorrect post dam
how much freeway space is desirable
2-4mm
what are the indications for replica dentures
patient requested spare denture set and likes current dentures function and aesthetics
staining of current denture
worn teeth/overclosure
fractured baseplate or denture teeth in an otherwise functional denture
what is the technique for replica dentures
select tray larger than denture
use heavy body putty to take impression of occlusal surface
cut location notches on impression that is set
put more heavy body putty on top of this and then seat an impression tray on top
send away for wax try in
use the fit surface of the wax try in as an impression tray and use light body PVS
risks of immediate denture
suboptimal immediate denture fit as secondary impressions are not routinely taken
denture fit may worsen with time as socket heals and bone remodels
unaesthetic appearance as gingival recession occurs over time
what is the technique for immediate dentures with single tooth
alginates
light body bite registration
shade
send above to lab
proceed with extraction
fit denture
what is the advice given with an immediate denture
wear denture for 24 hours to protect clot formed
remove denture at night and tore in glass of water after initial 24 hours
wash daily
risks of additions to dentures
point of addition slightly weaker and prone to breakage
denture may not fit satisfactorily
unaesthetic appearance possible
limitation
patient will not have their denture for a short period
how do you do impressions for additions to dentures
take impression with denture in situ
indications for overdentures
RCT teeth with wear
bone preservation necessary
over implant abutment
requirements of remaining teeth for overdenture success
satisfactory RCT on retained teeth
adequate interocclusal space
retained tooth periodontally stable
adv and disadv of overdenture
adv = maintains bone around teeth, good transition
disadv = optimal hygiene required
cause and resolution of excessive tooth visible on denture
C = increased OVD, upper anterior teeth set out too far
R = reset all teeth and reduce OVD, reset teeth over ridge
cause and resolution of teeth looking false on denture
C = no gingival contouring, teeth may all appear to have same shape
R = rotate or stagger teeth for natural look, ask lab for anatomical finish
cause and resolution of upper lip too bulky on dentures
C = labial flange too bulky, teeth set too anterior
R = reduce bulk, reset upper anteriors
cause and resolution of upper lip having a sinking appearance with dentures
C = upper anterior teeth are set too far palatally
R = reset teeth anteriorly, add more wax to labial aspect and reset teeth
cause and resolution of having over-closed appearance with dentures
C = reduced OVD
R = remake denture, copy denture with increased vertical dimensions
cause and resolution of having a whistle on S sounds with dentures
C = palate too narrow or space between centrals
R = remove wax from palate, remove acrylic from palate
cause and resolution of lisping sounds on S with denture
C = too much tongue space
R = add more wax or add more acrylic
cause and resolution of muffled F and V sounds with denture
C = incorrect positioning of upper anteriors vertically and horizontally
R = back to try in and reposition teeth
cause and resolution of instability of denture but not when chewing
C = extension issue of flange, post dam issue, xerostomia, flabby ridge
R = adjust extension and post dam, dry mouth treatment, 2 step impression for flabby ridge
cause and resolution of instability of denture when chewing
C = lack of post dam seal, anterior teeth labially, flabby ridge, biting only on anterior teeth, incorrect occlusion
R = new masters, reset teeth, 2 step impressions, repeat jaw reg
cause and resolution of soreness on ridge of denture
C = premature contact, inaccurate denture base, roughness on fit surface
R = new bite registration, reline/rebase, use PIP to identify and adjust
cause and resolution of soreness under lingual flange of denture
C = RVD and OVD dont coincide, overextended lingual flange, molars too distal
R = recheck vertical dimensions, shorten overextended flange, remove last molars
cause and resolution of loose denture
C = extension issues, xerostomia, occlusal errors
R = adjust flange, reline denture, articulate denture and remove interferences
cause and resolution of tight denture
C = denture not relieved in undercut areas causing pain on insertion and removal, clasps too tight
R = check path of insertion and adjust denture, adjust clasps
cause and resolution of burning feeling under denture
C = denture not relieved in undercut areas causing pain on insertion, clasps too tight, high pressure area
R = check path of insertion and adjust denture with acrylic bur, adjust clasps, PIP and adjust
cause and resolution of biting cheek or tongue with denture
C = overclosed, posterior teeth set too lingual or buccal
R = denture needs to go back to try in stage to reset teeth
cause and resolution of denture making patient gag
C = loose denture, patient has strong gag reflex and post dam too far back
R = construct new denture with better retention, CBT for gag reflex or trim post dam
cause and resolution of redness over denture bearing areas or cheeks
C = overclosed, posterior teeth set too lingual or buccal, allergic reaction
R = go back to try in stage and rearticulate and reset teeth, do a patch test
what are the intrinsic causes of discoloured anterior teeth
fluorosis
non-vital
RCT
tetracycline
age
enamel defects
what are the extrinsic causes of discoloured anterior teeth
tea, coffee, alcohol
tobacco
coloured food spices
chlorhexidine
chemo and radiotherapy
what are the treatment options for discoloured anterior teeth
vital bleaching
non-vital bleaching
deep resin infiltration
microabrasion
composite resin bonding
veneers
crown
risks of external vital bleaching
existing restorations not same shade
transient sensitivity
gingival irritation
external cervical resorption
reduced bonding strength of composite
what are the instruction given to patients on how to use whitening trays and gels
clean and dry whitening trays
brush and floss
hydrogen peroxide used for 1-2 hours during day or carbamide peroxide used for 6-8 hours over night
treatment lasts 12-14 days
place a bit of gel at the base of each tooth in the tray
avoid coloured foods, drinks and toothpaste
what is the instructions to lab for bleaching trays
please cast the impressions and construct a gingivally fitted bleaching tray
what is the process for internal non-vital bleaching
PA radiograph
open access cavity and remove 2-3mm of GP below CEJ
place 1mm of GIC over GP
remove stained dentine with round bur
etch with 37% phosphoric acid, wash and dry
place whitening agent into access cavity and cover with cotton pellet
seal access cavity with GIC
repeat at weekly intervals and review after 3 sessions
what are the indications for ICON deep resin infiltration
opaque white spots
fluorosis
MIH
why is initial whitening before icon resin infiltration essential to treatment
changes the refractive index of the white spot to become more similar to enamel
what are the steps for ICON resin infiltration
apply ICON etch (15% hydrochloric acid) for 120seconds
apply ICON drying material (99% ethanol) for 30 seconds
dry and observe, repeat up to 3 times if necessary
apply ICON infiltrant and leave for 3 minutes
light cure for 40 seconds
polish
what does the ICON resin infiltrant do to white spots
alters the refractive index of the opaque white spot such that it becomes similar to that of enamel
advantages of microabrasion
conservative
cheaper
minimal maintenance required
permanent results
quicker results
easy to perform
disadvantages of microabrasion
outcome unpredictable
removes 25-75 microns of enamel per treatment
must be performed chairside
requires PPE
what is the process of microabrasion
pre-op photos
clean the tooth
place rubber dam
place sodium bicarbonate guard around gingival margin
6-10% HCl pumice with a slowly rotating rubber cup on white spot for 5 seconds
wash directly into aspirator
dry tooth and place guard again and repeat maximum of 10 times
fluoride varnish application (profluorid)
polish with fine soflex disc
final polish with prophy paste
avoid coloured foods and drinks that till stain a white t-shirt
review at 4-6 weeks and take photos
what are the reductions required for veneer prep
cervical enamel = 0.3mm
mid-buccal third = 0.5-0.7mm
incisal third = 0.5-0.7mm
incisal edge reduction = 1-1.5mm
what are the steps of veneer preparation
sectional silicone impression
LA and shade
diagnostic wax up to create silicone indices for depth guides
prepare labial surface in 3 planes
consider incisal edge reduction
interproximal reduction
assess preparation from 3 different views
smooth and polish preparation
scan or take silicone impressions
place temporary veneer
how would you go about composite bonding as a temporary trial smile for a patient
take impression of diagnostic wax up and use this as stent
spot etch and wash and dry
load stent with composite and seat and wait for seat
remove stent and excess composite with probe
floss contacts and light cure
review in 2 weeks
diet advice for children
promote balanced diet
milk and water only
reduce sugar to mealtimes only
promote non-cariogenic snacks
no eating or drinking after brushing teeth
be wary of hidden sugars and acid
from what age do you start applying fluoride varnish in practice
3
what is the fluoride application frequency for low and high risk
low = 2x per year
high = 4x per year
what is the fluoride varnish dose for 2-5 years and 6+ years
0.25ml for 2-5 years
0.4ml for 6+ years
instructions to patient after fluoride varnish
avoid eating, drinking or rinsing for 30 minutes
what are the management options for paediatric caries
complete caries removal and restoration
partial caries removal and restoration
no caries removal and restoration
no caries removal and prevention advice
extraction or delay until pain or sepsis
what would partial caries removal and restoration be suitable for
all types of restorable carious lesions as long as good marginal seal
clear superficial caries and from ADJ
when would no caries removal and restoration placement be undertaken
when hall crown used or fissure sealant
how would you perform no caries removal and making the lesion self cleansing
remove undermined enamel and apply fluoride
good for cavitated lesions
steps for fissure sealant
clean teeth
isolate and dry
etch and rinse and dry
fissure sealant application
light cure for 30 seconds
check integrity with probe
steps of vital pulpotomy of a primary molar
assess compliance
LA and dam
remove caries and access pulp chamber
remove roof of pulp chamber
large excavator or slow speed to remove coronal pulp
rinse chamber and apply gentle pressure with ferric sulphate cotton pellet
fill pulp chamber with ZOE/MTA/biodentine
remove dam and select preformed metal crown
when is vital pulpotomy of a primary molar indicated
when vital restorable tooth has:
- large proximal carious lesion
- carious/mechanical exposure of vital coronal pulp tissue
- no radicular pulpitis
- no abscess or when extraction is contraindicated
indications for hall crown
interproximal caries
caries on 2 or more surfaces
pulp treated tooth
contraindications to hall crown
pulpal symptoms or caries close to pulp
patients at risk of infective endocarditis
insufficient tooth remaining to retain crown
method for hall crown
place separators into contact points for 3-5 days
place gauze to protect airway
select appropriate crown size
place GIC into crown
seat crown with finger pressure and child biting
remove excess cement and floss interproximally
reassure that high bite will settle and advise post operative pain relief if needed
parts of the extra oral assessment for orthodontics
AP
vertical LAFH
asymmetry
TMJ
MoM
lymph nodes
salivary glands
soft tissues (lip competence, lip trap, smile line, naso-labial angle)
parts of the intra oral assessment for orthodontics
charting, OH, caries, wear
degree of crowding (mild, moderate, severe)
incisor, molar, canine class
proclination of incisors
overbite
overjet
centrelines
crossbite
risks of orthodontic treatment
relapse
decalcification
root resorption
soft tissue trauma
toothwear
loss of periodontal support
loss of vitality
failed treatment
what is mild crowding
0-4mm
what is moderate crowding
4-8mm
what is severe crowding
8mm+
define class 1 incisors
lower incisal edges occlude with or lie immediately below the cingulum
define class 2 div 1 incisors
lower incisal edges lie posterior to the cingulum plateau of upper incisors, the upper centrals are proclined or of average inclination and there is an increased overjet
define class 2 div 2 incisors
lower incisal edges lie posterior to the cingulum plateau of the upper incisors, the upper central incisors are retroclined, overjet is minimal or may be increased
define class 3 incisors
lower incisor edges lie anterior to the cingulum plateau of the upper central incisors, overjet is usually reduced or reversed
define class 1 molars
mesiobuccal cusp of maxillary first molar aligns with the buccal groove of the mandibular first molar
define class 2 molars
mesiobuccal cusp of maxillary first molar occludes anterior to buccal groove of mandibular first molar
define class 3 molars
mesiobuccal cusp of maxillary first molar occludes posterior to buccal groove of mandibular first molar
define canine class 1
mesial incline of maxillary canine occludes with the distal incline of mandibular canine
define canine class 2
mesial incline of the maxillary canine occludes anterior to distal incline of mandibular canine
define canine class 3
mesial incline of maxillary canine occludes on mandibular first premolar
what are the referral guidelines for non-third molar teeth extractions
unsuccessful initial attempt
abnormal tooth morphology requiring surgical removal
peri-apical radiolucency requiring histological assessment
increased risk of damage to adjacent major anatomical structures
reduced access to treatment site
medically compromised
referral guidelines for third molar extractions
one or more episodes of pericoronitis
unrestorable caries in third molar or impaction causing caries in adjacent second molar
risk of caries in third molar or adjacent tooth
anatomical position of tooth inhibiting proper oral hygiene
periapical pathology
prior to orthognathic surgery
prior to initiating radiotherapy or chemotherapy
referral guidelines for MOS
impacted teeth
OAC/OAF closure
root in maxillary antrum
pre-prosthetic surgery
what is warfarin
vitamin K inhibitor
what is apixaban
factor Xa inhibitor
what is dabigatran
direct thrombin inhibitor
what is rivaroxaban
factor Xa inhibitor
what do you do if patient is on warfarin
check INR 24hrs before
what do you do if patient is on apixaban or dabigatran
miss morning dose
what do you do if patient is on rivaroxaban or edoxaban
delay daily dose till 4 hours post extraction
high risk patients for MRONJ
on oral or IV bisphosphonates for over 5 years
concurrent treatment of systemic glucocorticoids
patient is being treated for cancer
previous MRONJ
recommendations for people on bisphosphonates
assess risk category
avoid extractions
atraumatic extraction technique
liaise with physician
consider referral
consider 8 week review
risks of extraction
pain
swelling
bleeding
bruising
dry socket
jaw stiffness
infection
OAC
root fracture
maxillary tuberosity fracture
altered sensation
damage to adjacent teeth
root displacement into sinus
need for surgical intervention
what are upper straights for
upper incisors and canines
what are upper universals for
upper canines and premolars
what are upper left and right molar forceps for
upper left and right molars
what are upper root forceps for
upper narrow single roots
upper retained roots
what are upper third molar forceps for
upper third molars
what are lower universal forceps for
lower anteriors and premolars
what are cowhorns for
lower 6s
safe dose of lidocaine
4.4mg/kg
safe dose of articaine
7mg/kg
safe dose of prilocaine
6mg/kg
safe dose of mepivicaine
3mg/kg
principles of flap design
gain maximum access with minimum trauma
large flaps heal at the same rate as smaller flaps
broader base to maintain blood supply
cut to bone using a firm continuous incision
avoid sharp angles
either include or exclude papillae entirely
do not crush tissue
keep tissue moist with saline
post operative instructions
be careful because you are still numb
blood stained saliva is normal
wear dentures as normal
call if any issues
dont touch area
avoid hot drinks for rest of day
soft diet for rest of the day
do not smoke or drink alcohol for 24 hours
avoid strenuous activity rest of day
HSMW 4x/day especially after eating starting from tomorrow
damp gauze for bleeding
same painkillers as headache before LA wears off
