extra Flashcards
identify the luxator
A
B is coupland’s elevator
C is right cryer’s elevator
which number of forcept woudl you use to extract 11?
a - 74
b - 101
c - 2
d - 73
C - 2 (upper straight)
upper straight forceps for
maxillary incisors and canines
2
upper universal forceps for
maxillary premolars
76
upper molar forceps for
maxillary first and second molars
94 (right) and 95 (left)
beak to cheek
upper bayonet forceps for
upper third molars
101
lower universal forceps for
mandibular incisors, canines and premolars
74 and 74N (roots)
cowhorn forceps for
mandibular first and second molars
86
squeeze out
lower molar forceps for
mandibular first and second molars
73
extraction movements
buccal expansion - single rooted
figure of 8 - multi rooted
apical pressure for all
demonstarte how you would use a luxator on 26 XLA
Say you would wash your hands
Turn light on
anaesthetise area - 2 buccal infiltrations and 1 palatal
pt head at level of elbow
place finger and thumb of non-dominant hand on either side of the tooth to be extracted
once in PDL, the luxator is worked down the length of the root with rotation and apical pressure
cuts the PDL fibres and expands the socket
restoring 46
please place rubber dam
wash hands, gloves, light on, lower pt
tie floss around the appropriate clamp
place clamp first then rubber dam over with holes punched in (adj for restoration, single tooth for endo)
flick the rubber dam over the wings of the clamp
floss ligatures
wedjets
place the frame - make sure the pt airway not blocked at nose (fold if needed)
demonstrate how to assemble and give an IDB whilst describing the process
check expiry date and batch number
Lidocain not articaine for block - neurotoxic
long needle for block
aim 10mm above the occlual plane
- posterior to internal oblique ridge
- anterior to pterygomandibular raphe
inject syringe from opposite premolars and advance 2.5-3cm
hit bone and withdraw
aspirate
deposite 2/3 cartride and retract whilst depositing to get lingual nerve
impressions remember
adhesive
eval impression - anatomy should be seen
behind for uppers, in front for lower
breather through nose, wiggle toes
lift lip massage to capture anatomy
endo irrigation
choose correct irrigant (sodium hypochlorite),
luer lock syringe,
- side vented,
use index finger to plunge as more sensitive than thumb
describe the appearance
1 ulcer present on the right labial mucosa
inflammatory halo around yellow/grey base
oval in shape and sharply defined
what Qs to ask when taking this pt’s history
about ulcer(s)
- number
- location
- duration
- minor apthous uclers - shorter than major
- more than 3 weeks - refer
- frequency
- size
about them
- diet - low in red meat - possible Fe def
- stress - home, work (predispose ulcers)
- empathetic Qs - affect eating, sleep, morale
- Medical history
- Recurrent aphthous ulcers – crohns, coeliac, Pagets disease, OFG
possible causes of uclers
- stress
- local trauma
- menstruation
- sodium lauryl sulphate
- drugs (NSAID, alendronate and nicorandil)
- smoking
- Crohn’s and coaelic disease
- iron, vit B12 or folate deficiencies
managament apparoaches for ulcers
- Difflam mouthwash (benzydamine)
- topical steroids (hydrocortisone oromucosal tables, betamethasone oral rinses)
- covering agents (lidocaine ointment)
- analgesics
- avoid spicy foods
- SLS free toothpaste - sensodyne pronamel
- refer to GP investifate and tx underlying deficiencies or coextisting patholgy
- refer to oral med if not managed locally or persists >3weeks
56yo pt had severe toothache for 4 weeks from upper right first molar which suddenly stopped
tooth was asymptomatic on the day he attended, he reported ‘part of the tooth came off recently’ whilst he was chewing
pt smokes 20/day and is a nocturnal bruxist
takes warfarin for atrial fibrilation
BPEs
2 2 2
2 2 2
introduce yourself
check ID
check MH and SH - recognise warfarin as bleeding risk
- Medical history
- Diagnoses
- Medications
- say quick look through notes seen have X and on Y is this still correct? Any other medical conditions/seeing doctor for?
social history
- smoking assessment
- alcohol
- work
Pick out main bits
- Tooth
- Pain
- SOCRATES
- How long
- Type
- There right now
- associated factors can be bad taste, foul smell, sinus
56yo pt had severe toothache for 4 weeks from upper right first molar which suddenly stopped
tooth was asymptomatic on the day he attended, he reported ‘part of the tooth came off recently’ whilst he was chewing
pt smokes 20/day and is a nocturnal bruxist
takes warfarin for atrial fibrilation
BPEs
2 2 2
2 2 2
FURTHER SPECIAL INVESTIGATIONS?
- radiographs - OPG, periapicals, occlusals, biteweings
- sensibility testing - ethyl chloride, EPT
- tenderness to percussion - pulpitic or periodntal pain as info on inflmmation of PDL
- mobility - grad I, II, III, - assess # if root invlved or not
probing depth - perio disease, #
tooth sleuth - # cusps
test cavity - last resort if unsure on tooth’s vitality status
how to explain dx to pt
BPE
2 2 2
2 2 2
Large radiolucency – caries
Darkness, shadow that’s the decay/hole in your tooth, gone too far for us to save it as it have reached the nerves inside the tooth
Not sure if be able to restore it as since such a large proportion of it is decayed - empathy
BPE scores – have plaque and calculus in your mouth which can lead to advanced gum disease so need to go through Tx and instructions to help reduce this, smoking will also contribute to this
how to explain tx options to pt
list all tx options - split into immediate (pain relief), medium term, long term
explain risks and benefits of each option
explain it must be holistic decision taking into account the pt concerns, MH. OH, financial cost and biologic cost (price of the teeth/mouth will have to pay if go ceratin option)
56yo pt had severe toothache for 4 weeks from upper right first molar which suddenly stopped
tooth was asymptomatic on the day he attended, he reported ‘part of the tooth came off recently’ whilst he was chewing
pt smokes 20/day and is a nocturnal bruxist
takes warfarin for atrial fibrilation
BPEs
2 2 2
2 2 2
IMMEDIATE MANAGEMENT
- explain INR needs to be checked within 72hrs as pt is high bleeding risk hence unable to extract today
- stabilise teeth with temp filling material/extirpate (if unrestorable then options are: monitor or XLA)
- AAA - advise, analgesia, antibiotics (facial swelling or temp/systemically unwell)
- if XLA then can provide immediate denture if large edentulous space
give cooling period for pt to have time to decide
56yo pt had severe toothache for 4 weeks from upper right first molar which suddenly stopped
tooth was asymptomatic on the day he attended, he reported ‘part of the tooth came off recently’ whilst he was chewing
pt smokes 20/day and is a nocturnal bruxist
takes warfarin for atrial fibrilation
BPEs
2 2 2
2 2 2
MEDIUM TERM MANAGEMENT
- extract tooth under LA with INR checked (may require surgical extraction which involves cutting gum and sutures)
- adv: remove risk fo further pain and infection from tooth
- disadv: will leave gap which may require management
- prevention
- improvement of OHI and diet investigation before any advcanced cons can be given
- smoking cessation
- soft splint for bruxism
- replace denture for a better fitting one if needed whilst waiting for bone levels to stabilise
56yo pt had severe toothache for 4 weeks from upper right first molar which suddenly stopped
tooth was asymptomatic on the day he attended, he reported ‘part of the tooth came off recently’ whilst he was chewing
pt smokes 20/day and is a nocturnal bruxist
takes warfarin for atrial fibrilation
BPEs
2 2 2
2 2 2
LONG TERM MANAGEMENT
leave gap
denture
- can be modified if more teeth lost
- good aesthetics
- removable so pt may not find them natural at beginning (requires habituation)
Bridge
- good aeshetics
- fixed prosthesis
- requires optimum OH
- adjacent tooth may require tooth prep (sound enamel loss, 20% chance of pulp damage) - coventional bridge not resin bonded
- unaesthetic if recession occurs (likely as smokes 20/day)
Implant
- good aeshtetics
- fixed prosthesis
- does not damage adj teeth - low biologic cost
- requires optimum OH
- contraindicated in smokers (higher chance of peri-implantitis)
- expensive - has to be privately funded
amy smith, 7 y.o., female
lives with mum, parents never married and are not together
allergic to penecillin
irregular dental attender, first attended GDP in pain a few months ago
- had a right sided facial swelling, GDP gave her a couse of antibiotics following which it settled
since then has had toothache intermittently from all quadrants of her mouth, kept her awake on a few occassions
taking calpol daily to manage the pain
attending a new pt clinic with her grandma
explain dx to amy and her grandma
introduce yourself
check ID - check who is accompanying her - who have you brought with you today? why? (mum unable due to time, any time suit her better in future)
check MH and SH
briefly repeart what you know of pain history - go over SOCRATES to add stuff
explain multiple carious teeth thta are unrestorable and need extracted
- use pictures, dark areas, Widespread and severe in teeth so likely want to take them out as they’ve been causing her pain for a while and facial swelling
grandma cannot conset so mum or dad will need to attend to sign consent forms
a
my smith, 7 y.o., female
lives with mum, parents never married and are not together
allergic to penecillin
irregular dental attender, first attended GDP in pain a few months ago
had a right sided facial swelling, GDP gave her a couse of antibiotics following which it settled
since then has had toothache intermittently from all quadrants of her mouth, kept her awake on a few occassions
taking calpol daily to manage the pain
attending a new pt clinic with her grandma
explain tx modalities to amy and her grandma
XLA
- quick, removes risk of infection
- multiple carious teeth so would need multiple visits, a lot to manage for someone with no previous experience of dental tx
XLA with IHS (happy air)
- reduces anxiet, some analgesic properties, helps densenstise, can be titrated to response, no recovery period so no time off school needed to recover
- still requires LA, multiple appointments
XGA
- all tx dnone in one go, pt will not remember tx after
- long waiting list, no desensitisation, fasting needed, extreme/radical approach
communication skills
- body language - lean forward, dont cross arms, head tilt and nod
- ask open ended non leading qs
- describe to me the pain
- reapeat a summary of whay they say to check you have gotten the facts correct and show them you are listening
- show empathy
- I’m really sorry, I know you may not want to hear that you need extractions, but it will get you out of pain and help resolve the infections and we can think of a long term option to replace the tooth if you want
- avoid clinical jargon
- ‘chunk nad checl’ - break your information into digestible sections and check if they understand or have any Qs before moving on
- refer them to information sources - leaflets, websites, videos
antiobiotics
1st line
250mg 2 tablets 4xdaily for 5 days Phenoxymethylpenicillin
500mg 1 capsule 3xdaily for 5 days Amoxicillin
400mg 1 capsule 3xdaily for 5 dyas Metronidazole
contraindications for amoxicillin
allergies
contraindications for metronidazole
warfarin
pregnant
no alcohol intake
antibiotics
2nd line
150mg 1 capsule 4xdaily for 5 days Clindamycin
IDB
Left hand feel for coronoid notch of the mandibular ramus with thumb (greatest depression on anterior ramus, in mouth) and use over fingers to support mandible
- 1cm above occlusal plane
Needle entry junction of buccal pad of fat/ pterygomandibular raphe
Syringe lies over contra lateral 5-6
Advanced to bony contact (1cm of needle visible), do not inject onto retract slightly
- If no bony contact reposition syringe mesially
- If bony contact too soon, reposition syringe barrel distally
Aspirate
Inject slowly ¾ cartridge
For lingual anaesthesia withdraw 2-4mm then injection of last 1/4 of solution
for anaesthetising upper tooth for XLA how much LA buccally and palatally
3/4 buccal
1/4 palatal
use handle of mirror on palate to distract
rate of LA deposit
30sec/ml
whole cartridge will take just over 1min
