General Overview Flashcards
% teeth effected in localised perio
<30%
% of teeth effected in generalised perio
30% or more
Stage of periodontitis
The severity of the disease
Grade of periodontitis
Susceptibility of the disease
Stages of periodontitis and their meaning
1 - less than 15% or 2mm bone loss
2 - coronal third bone loss
3 - middle third bone loss
4 - apical third bone loss
Grades of periodontitis and their meaning
Grade A - <0.5
Grade B - 0.5-1.0
Grade C - >1.0
How is periodontitis grade calculated?
% bone loss at worst site/patient age
What does currently stable periodontitis mean?
<10% BOP, no sites of PPD more than 4mm, no BOP at 4mm sites
What does currently in remission periodontitis mean?
BOP 10% or more, no sites more than 4mm PPD, no bleeding at 4mm sites
What does currently unstable periodontitis mean?
BOP at sites of 4mm or sites of more than 4mm PPD
What must be included in diagnostic statement for periodontitis?
Extent, periodontitis, stage, grade, stability, risk factors
BPE and BOP expected for localised gingivitis
0/1/2 with <30% bleeding and no obvious interdental recession
BPE and BOP expected for patient with generalised gingivitis
0/1/2 with >30% BOP and no obvious interdental recession
Clinical gingival health (BPE and BOP)
0/1/2 with no obvious interdental recessions and <10% BOP
Pathway for a code 3 sextant with no obvious interdental recession
Periapical
Periodontal hygiene therapy and review after 3 months with 6ppc of the sextant
Pathway for code 4 BPE
Periapicals or OPT
Full 6ppc
Perio diagnosis
Reversible pulpitis presentation (3)
Discomfort on hot/cold lasting few seconds
No spontaneous pain
No significant radiographic changes in periapical region of suspected tooth
Symptomatic irreversible pulpitis presentation (3)
Not TTP
Pain on hot or cold
Spontaneous pain at random times (lying down, bending over)
Pulp necrosis presentation (4)
Poor oral health
Pt not c/o symptoms
Multiple TTP teeth NOT responding to thermal testing
Symptomatic Apical Periodontitis presentation (3)
Pt complains of pain when biting down
Severe pain on percussion
No radiographic change
Asymptomatic apical periodontitis presentation (2)
Apical radiolucency
No symptoms/pain to percussion or palpation
Chronic apical abscess presentation (2)
Radiolucency suggesting bone resorption
Sinus that intermittently discharges pus through sinus tract
Acute apical abscess presentation
Spontaneous pain, extreme tenderness of tooth to pressure, pus formation, swelling
No radiographic bone loss
Fever, malaise
Lymphadenopathy upon e/o exam
Eruption dates of upper teeth
1 at 7
2 at 8
3 at 11
4/5 at 10
6 at 6
7 at 12
Eruption dates of lower teeth
1 at 6
2 at 7
3 at 9
4/5 at 10
6 at 6
7 at 12
Irrigation protocol for endo treatment
EDTA 17% for one minute
Sodium hypochlorite 3%, 30ml for 10 minutes
Watch winding motion
Back and forth oscillation 30-60 degrees
Light apical pressure
Effective with small K files
Balanced force motion
Rotate file 90 degrees clockwise
Apply apical pressure and rotate the file anticlockwise between 90 and 180 degrees
Appropriate instances to use Hall crown technique (2)
Occlusal caries (cavitated lesion)
Approximal caries
When would you seal caries with fissure sealant?
Occlusal caries - non cavitated lesion
Indications for preformed metal crown (6)
> 2 surfaces affected by caries
High caries risk
Developmental defects
Space maintainer
Poor OH
Excess tooth surface loss
Steps for placing preformed metal crown (7)
Give appropriate LA
Removed caries
Reduce mesial and distal surfaces to width that bur can pass through
Reduce occlusal surface so that straight probe can pass through in occlusion
Select correct size of PMC
Cement using glass ionomer cement
Remove excess cement and floss between the contacts
What is the difference between Hall crown technique and preformed metal crown?
Hall technique seals caries with NO LA, tooth prep or caries removal
PMC uses LA, caries removal and tooth prep of mesial, distal and occlusal surfaces
How many ppm fluoride is in silver diamine fluoride (SDF)
44,800ppmF
When does the apex of a tooth close?
~3 years after eruption
A 10 year old has had a small pulpal exposure of upper canine following trauma less than 24 hours ago. How would you treat this?
Pulp cap
- arrest haemorrhage with pressure (moistened cotton wool with ferric sulphate)
- CaOH placed over exposure
- Cover with GIC
- Definitive restoration
A 12 year old has a large pulpal exposure of upper central incisor following trauma and attends the practice within 2 days. U/E the pulp is partially necrotic, how would you treat this?
Pulpotomy - partial removal of pulp tissue (2-3mm)
Arrest haemorrhaged (moistened cotton wool with ferric sulphate)
Place CaOH over pulp
GIC over CaOH
Definitive restoration
A child attends with a large pulpal exposure in an open apex tooth following trauma. U/E the pulp is non vital, how would you treat this?
Pulpectomy - remove all of the necrotic pulp
If apical constriction larger than 60K file, use mineral trioxide aggregate MTA to provide apical barrier before condensing GP
Place at least 5mm MTA, allow to dry for 10-15min
Obturate with GP system
Properties of CaOH making it good for pulp cap
High alkaline pH which decreases microbial activity
Immediate first aid for avulsed permanent tooth (5)
Store in saliva, or fresh milk
Do not allow to dry out
Wash under cold water for 10s if obvious debris
Handle only crown
Reimplant quickly
Treatment following reimplantation of avulsed permanent tooth
Flexible splint for 2 weeks
Start RCT at 2 weeks
(unless open apex tooth reimplanted within 30-45min)
When is RCT not necessary after avulsion of permanent tooth?
Open apex reimplanted within 30-45min
Splinting time following avulsion or extrusion
2 weeks
Splinting time for a luxation, apical and middle third root fracture or dentoalveolar fracture?
4 weeks
Fluoride concentration in fluoride varnish
22,600ppmF
Indications for pulp treatment in a child (5)
Cooperative
MH makes extraction unsuitable
Missing permanent successor
Necessity to retain tooth (e.g. as space maintainer)
Child under 9 years old
Contraindications for pulp treatment of a child (6)
Poor cooperation
Poor attendance
Cardiac defect
Multiple grossly carious teeth
Advanced root resorption
Severe/recurrent pain or infection
In vital pulpotomy of a child, what materials are used to a) cover root stumps, b) as a core, c) for final restoration
a) reinforced ZOE, CaOH, MTA, biodentine
b) GIC
c) preformed metal crown
How to differentiate between inflamed/uninflamed pulp
Abnormal/normal bleeding
Abnormal - deep crimson, continued bleeding after pressure
Normal - bright red, good haemostasis
For pulpectomy of a primary molar what is used a) to obturate, b) as a core and c) as a final restoration
a) Vitapex (CaOH and iodoform paste) orZOE
b) GIC
c) stainless steel crown
Materials used for fissure sealants (2)
Bis-GMA resin
Glass ionomer cement
How to place a fissure sealant with bis-GMA resin
Moisture control
Clean occlusal surface
Enamel etch (35% phosphoric acid) then wash and dry
Apply bis-GMA to fissure pattern (use microbrush or probe/similar instrument)
Light cure
Check with probe
When should fissure sealants be reviewed clinically?
4-6 months
When should fissure sealants be reviewed radiographically?
High risk - 6 months
Low risk - 12-18 months
How to place a fissure sealant with glass ionomer cement
Dry the tooth
Apply GI, smoothing into fissures with gloved finger
Keep finger over GI until set or cover with petroleum jelly to decrease moisture contamination before GI is set
Indications for glass ionomer fissure sealant
Not possible to get good moisture control (poor cooperation/children with additional needs)
High sensitivity due to developmental or hereditary enamel defects (e.g. amelogenesis imperfecta)
Age of patient suitable for amalgam
15+
When is it appropriate to extract first permanent molars in paediatric patient for orthodontic reasons?
Bifurcation of lower 7s (age 8-10.5)
5s and 8s present and in good position on OPT
Mild buccal crowding
Class 1 incisor relationship
Contraindications for preformed metal crown
Irreversible pulpitis
Periapical pathologies
Insufficient tooth tissue to retain crown
Tomographic slice of interest where structures outside the slice appear faint and out of focus
Focal trough
3 instructions for patient during OPT
Stand still
Tongue to hard palate
Do not talk or swallow
Drugs with suffix -pril (e.g. Lisinopril)
ACE inhibitors
Lower BP
Drugs with suffix -olol (e.g. propanolol)
Beta blockers
Slow heart rate
Drugs with suffix -artan (e.g. Eprosartan)
Angiotensin II blockers/ angiotensin receptor blockers
Reduce BP
Drugs with suffix -pine (e.g. amlodipine)
Calcium channel blockers
Reduce BP
3 drugs known to cause gingival hyperplasia
Calcium channel blockers
Cyclosporine (immunosuppressant)
Phenytoin (anti-epilepsy)
Drugs with the suffix -zide (e.g. chlorothiazide)
Thiazide diuretics
Reduce BP and used to treat heart failure
Drugs with suffix -mide (e.g. furosemide)
Loop diuretics
Reduce BP and used to treat heart failure
Drugs with suffix -statin (e.g simvastatin)
Statins
Lower cholesterol
Which class of drugs should you avoid during antifungal treatment?
Statins
Drugs with the suffix -zole (e.g. clotrimazole)
Antifungals
Main difference between aspirin and clopidogrel
Aspirin causes irreversible change for the life of the platelet
Following an extraction, what is the difference between patient taking an anticoagulant and an antiplatelet?
Patients on antiplatelet will have more immediate bleeding and those on anticoagulant will have an increase in post treatment bleeding
Example of commonly used antiplatelet drug
Aspirin
Clopidogrel
Warfarin method of action
Inhibits vit K synthesis which inhibits production of vit K dependent clotting factors II, VII, IX, X, protein C and protein S
Suitable INR for extraction
2-3.9
Clamp used for molars
A clamp
Clamp used for all teeth other than molars
E clamp
How often should bitewings be taken?
High risk - 6 months
Moderate risk - annually
Low risk - primary 12-18 months, permanent 2 years
OVD definition
Occlusal vertical dimension - superior-inferior relationship between the maxilla and the mandible when the teeth are occluded in maximum intercuspation
RVD definition
Resting vertical dimension - measured at rest where there is no contact between teeth
How is freeway space calculated?
RVD - OVD
Ideal freeway space
2-4mm
What is Willis bite gauge used for?
Recording the vertical dimension in mm between the maxilla and mandible, used with dividers
Function of Foxes occlusal plane
Determine the orientation of the occlusal plane when a record block is in the patients mouth
Reference lines used for anterior and posterior occlusion for Foxes occlusal plane
Post - ala tragus line
Ant - interpupillary line
How long should lab work be disinfected in perform?
10 min
What is the cast composition for a cast made using a primary impression on a stock tray?
50% dental stone, 50% dental plaster (gypsum)
What is the composition of a master cast? (made using a master impression)
100% dental stone
Primary and secondary support for an upper complete denture
Primary - hard palate
Secondary - ridge crest
Primary and secondary support for a lower complete denture
Primary - buccal shelf and retromolar pad
Secondary - ridge crest, genial tubercles
Relief areas for lower complete denture
Lingual ridge incline, mylohyoid ridge
How much spacing in needed in the special tray for alginate?
3mm
What is ICP?
Intercuspal position - when teeth are in maximum intercuspation regardless of condylar position
What is RCP?
Retruded contact position - when the teeth are in occlusion occurring at the most retruded position of the condyles in the joint cavities. This is the most reproducible position
Impairment definition
Loss of psychological, physiological or anatomical structure or function
Disability definition
Lack of ability to perform an activity that is considered normal for a human being
Handicap definition
A disadvantage resulting from an impairment or disability that prevents the fulfilment of a role that is normal for that individual
Contraindications for metronidazole (antibiotic)
Alcohol
Warfarin
Pregnancy
Usual antibiotic for periapical asbcess
Amoxicillin 500mg 3 times daily for 5 days
Antibiotic regime for patient with acute disease including necrotising gingivitis/periodontitis
200mg or 400mg Metronidazole 3x per day for 3 days
Presentation of necrotising gingivitis (6)
Necrosis and ulceration of interdental papilla
Bleeding
Pain
Pseudomembrane formation
Halitosis
Lymphadenopathy
Presentation of necrotising periodontitis (9)
Pain
Bleeding
Necrosis of interdental papilla
Pseudomembrane formation
Halitosis
Lymphadenopathy
Periodontal attachment loss
Bone resorption
Extraoral swelling
Presentation of necrotising stomatitis (2)
Bone resorption
Bone sequestrum
Stages of conventional denture design
1 - Assessment
2 - Primary impressions
3 - Master impressions
4 - Jaw registration
5 - Tooth trial
6 - Denture delivery
7 - Maintenance/review
8 - Aftercare
Stages in replica denture design
1 - Assessment
2 - Replica impressions
3 - Master impressions and occlusion (jaw reg)
4 - Tooth trial
5 - Denture delivery
6 - Maintenance/review
7 - Aftercare
Compressive strength definition
Stress required to cause fracture
Elastic modulus definition
Rigidity of a material, stress required to cause strain (stress/strain ratio)
(strain is change of shape)
Brittleness/ductility definition
Ability to experience dimensional change before fracture
Hardness
Resistance of surface to indentation or abrasion
Tensile strength
Resistance to fracture when pulled
Porcelain characteristics
Rigid, hard, high compressive strength
NOT ductile, low tensile strength
Tensile strength
Resistance of a material to breaking under tension
Creep
Prolonged application of minor stresses (<EL), causing permanent strain
Stressed skin effect
Slight differences in the thermal contraction coefficients lead to compressive forces which aid in bonding. Occurs between porcelain and metal bond
Cobalt chromium alloy characteristics
High melting point, high Young’s Modulus, high tensile strength, high hardness
Low bonding strength, low compressive strength
BSP step 1 of perio treatment
Explain the disease, risk factors and importance of OH
Reduce the risk factors and plaque retentive factors
Carry out OHI and PMPR
BSP step 2 of perio treatment
Reinforce step 1
Subgingival (>4mm) instrumentation
Systemic antimicrobials
Re-evaluate after 3 months
BSP Step 3 for perio treatment
Re-evaluate earlier steps
Manage non-responding sites - for >4mm pockets re-perform subgingival instrumentation
BSP step 4 for perio treatment
Supportive periodontal therapy (SPT)
Reinforce step 1
PMPR
Recall 3-12 months depending on individual
Engaging perio patient plaque and bleeding scores
Plaque 20% or less
Bleeding 30% or less
OR
50% or greater improvement in plaque and bleeding
Non-engaging perio patient plaque and bleeding scores
Plaque >20%
Bleeding >30%
Criteria to check for success of perio treatment
No BoP
No pockets >4mm
No increasing mobility
Plaque scores 20% or less
Functional and comfortable dentition
Which anatomical landmark should the postdam be situated on
Vibrating line
Curve of spee
Antero- posterior curvature of the occlusal plane
Curve of Wilson
Medio-lateral curve of the occlusal plane
What is used to check tooth position on a denture, and what are the geometric guides to tooth position?
Alma gauge
Vertical - 7mm
Horizontal - 5mm to the incisive papilla
Neutral zone (in complete dentures)
Position where the forces between tongue and cheeks or lips are equal
Ideal position of a lower complete denture
What is a wrought alloy?
An alloy that can be manipulated/shaped by cold working
Composition of austenitic stainless steel
Iron 72%
Chromium 18%
Nickel 8%
Titanium 1.7%
Carbon 0.3%
What is an alloy?
Mixture of two metals forming a lattice structure
What is the result of quenching (rapid cooling) austenite?
Martensite
3 phases of steel
Ferrite
Austenite
Cementite
When does steel become stainless?
> 12% chromium
3 dental uses of austenitic stainless steel
Dental equipment and instruments (not cutting edge)
Wires e.g. ortho
Denture bases
Cold working
Work done on a metal/alloy at a low temperature, below recrystallisation temperature
5 differences between self cure and heat cure acrylic
HC higher molecular weight, stronger
HC curing process may cause porosity and contraction
SC higher monomer levels, irritant
SC fits cast better but water absorption in mouth makes it oversized
SC poorer colour stability (tertiary amines susceptible to oxidation)
Initiator in self and heat cure acrylic
Bezoyl peroxide
What type of polymerisation does acrylic undergo?
Free radical polymerisation - chemical union of two molecules to form a large molecule WITHOUT elimination of a smaller molecule
Properties of acrylic
Non toxic
Unaffected by oral fluids
High hardness
Low density
High softening temperature
Dimensionally accurate
Poor mechanical properties
Poor thermal conductivity
Retention definition (pros)
Resistance of a denture to vertical displacement
Definition of stability (pros)
Resistance of a denture to displacement by functional forces in a horizontal direction
4 displacing forces of a denture
Gravity
Muscle activity
Sticky foods
Function
Difference between concussion and subluxation
Concussion - PDL injury where tooth TTP but has not been displaced, no bleeding
Subluxation - PDL injury where tooth is TTP, has increased mobility but has not been displaced, bleeding from the gingival crevice
Difference between lateral luxation, intrusion and extrusion
Lateral luxation - tooth displaced usually lingual or labial direction
Intrusion - tooth usually displaced through the labial bone plate or can impinge on permanent tooth bud
Extrusion - partial displacement of tooth out of its socket
Avulsion
Tooth is completely out of its socket
Information included on a trauma stamp
Mobility
Colour
TTP
Sinus
Percussion note
Radiograph
EPT
ECL
Who should use 1000ppmF toothpaste?
First eruption - 3 years
Who should use 1000-1500ppmF toothpaste?
4-16 years
Who should be prescribed 2800ppmF toothpaste?
High caries risk age 10+
Who should be prescribed 5000ppmF toothpaste?
High caries risk age 16+
How long is the splint time for alveolar fracture?
4 weeks
Possible after effects of trauma to primary teeth
Discolouration
Infection
Delayed exfoliation
What is the splint time for avulsion or extrusion?
2 weeks
How long should intrusion or luxation been splinted?
4 weeks
Enamel hypomineralisation
Qualitative defect of enamel, normal thickness but poorly mineralised, white/yellow defect
Enamel hypoplasia
Quantitative defect of enamel, reduced thickness but normal mineralisation. Yellow/brown defect
What is dilaceration?
Abrupt deviation of the long axis of the crown or root portion of a tooth
Factors affecting trauma injury prognosis
Stage of root development
Type of injury
If PDL damaged
Time between injury and treatment
Infection
How to manage an enamel fracture
Bond fragment to tooth
OR
Smooth sharp edges
Take 2 periapicals to rule out root fracture or luxation
Follow up 6 weeks, 6 months, 1 year
How to manage enamel-dentine fracture
Bond fragment to to tooth with composite bandage (line the restoration if the fracture is close to pulp)
2 periapicals to rule out root fracture or luxation
Sensibility testing and evaluate tooth maturity
Follow up 6 weeks, 6 months, 1 year
Follow up review for a trauma incident
Check radiographs for
- root development (width and length of canal)
- comparison with other side
- inflammatory resorption
- periapical pathology
How to manage enamel dentine pulp fracture - 1mm exposure within past 24 hours
Direct pulp cap
Trauma sticker and radiographic assessment - not TTP and positive sensibility tests
LA and rubber dam
Clean area with water then disinfect with sodium hypochlorite
Apply calcium hydroxide or MTA to pulp exposure
Restore with composite
Review 6 weeks, 6 months, 1 year
How to manage enamel dentine pulp fracture with >1mm exposure, more than 24 hours ago
Partial pulpotomy
Trauma sticker and radiographic assessment
LA and dental dam
Clean area with saline then disinfect area with sodium hypochlorite
Remove 2mm of pulp with high speed round diamond bur
Saline soaked cotton wool pellet over exposure until haemostasis
If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy
Apply Ca OH then GI (or white MTA) then restore with composite
Follow up 6 weeks, 6 months, 1 year
How to treat non vital immature incisor following enamel dentine pulp fracture
Pulpectomy
Extipate pulp and place CaOH for max 4-6 weeks (to avoid problems with CaOH apexification)
MTA plug and heated GP obturation
How to treat crown root fracture with no pulp exposure
Fragment removal and restoration
Fragment removal and gingivectomy indicate in crown root fractures with palatal subgingival extension
Orthodontic extrusion of apical portion
Surgical extrusion
Decoronation - preserve bone for future implant
Extraction
How to treat crown root fracture with pulp exposure
1) preparation
2) temporisation
3) Impressions and occlusal records
4) Cementation
What is an inlay?
Intra coronal restorations fabricated in a lab
Uses of inlays (3)
Occlusal cavities
Occlusal/interproximal cavities
Replace failed direct restorations
Advantages of inlays compared with direct restorations?
Superior materials and margins
Disadvantages of inlays compared with direct restorations
Time and cost
What are onlays?
Extra-coronal restorations fabricated in a lab, similar to an inlay but with cuspal coverage
Uses of onlays (4)
Tooth wear
Increase OVD
Fractured cusps
Restoration of root treated teeth
Replace failed direct restorations
Indications for onlay (6)
Sufficient occlusal tooth substance loss
Buccal and/or palatal/lingual cusps remaining
Remains tooth substance is weakened
Caries
Pre-existing large restoration
MOD with large isthmus
Indications for veneers (7)
Improve aesthetics
Correct peg laterals
Reduce or close proximal spaces and diastemas
Hypoplasia or hypomineralisation
Erosion and abrasion
Fluorosis
Discolouration
Contraindication to veneers
Poor OH
High caries rate
Gingival recession
If extensive prep would be required
Heavy occlusal contacts
Veneer preparation cervical/midfacial/incisal
Cervical - 0.3mm
Midfacial - 0.5mm
Incisal - 1-1.5mm
Class I incisor relationship
Lower incisor edges occlude on the cingulum plateau of the upper incisors
Class II division I incisor relationship
Lower incisor edges occlude behind the cingulum plateau of the upper incisors and the upper incisors are normally proclined
Class II division 2 incisor relationship
The lower incisor edges occlude behind the cingulum plateau of the upper incisors and the upper incisors are retroclined
Class III incisor relationship
Lower incisor edges occlude anterior to the cingulum plateau of the upper incisors
Class I molar relationship
Buccal groove of the mandibular first permanent molar should occlude with the mesio-buccal cusp of the maxillary first molar
Class II molar relationship
Buccal groove of the mandibular first permanent molar occludes posterior to the mesio-buccal cusp of the maxillary first molar
Class III molar relationship
Buccal groove of the mandibular first permanent molar occludes anterior to the mesiobuccal cusp of the first maxillary molar
Canine guidance
Canines cause disengagement of the posterior teeth in the lateral movement of the mandible
What is a group function?
Simultaneous contact of the canine and posterior teeth during lateral mandibular excursions
Indications for restoring a tooth with a crown (4)
To protect weakened tooth structure
To improve or restore aesthetics
For use as a retainer for fixed bridgework
To restore tooth function e.g restore in OVD
When shouldn’t you restore a tooth with a crown? (5)
Active caries and perio
More conservation options available
Lack of tooth tissue for preparation
Unable to provide post and core
Unfavourable occlusion
Electromagnetic spectrum from greatest wavelength to smallest
Radiowaves
Microwaves
Infrared
Visible light
Ultraviolet
Xrays
Gamma rays
What material is the filament in the cathode in an Xray tube?
Tungsten
What is the focussing cup in the cathode of an Xray tube made from?
Molybdenum
Penumbra effect
Blurring of a radiographic image due to focal spot not being a single point but rather a small area
What is the collimator made of and what is it’s purpose?
Lead
Reduce patient radiation dose by approx 50%
Compare continuous vs characteristic radiation
Continuous - produces continuous range of Xray photon energies, maximum photon energy matches peak voltage, bombarding electron interacts with nucleus of target atom
Characteristic - Produces specific energies of Xray photon, characteristic to the element used for the target, photon energies depend on the binding energies of electron shells, bombarding electron interacts with inner shell electrons of target atom
How long to splint a subluxation with excessive mobility?
2 weeks
What is the treatment for an extrusion?
Reposition the tooth by gently pushing it back into the tooth socket under LA
Flexible splint for 2 weeks
Clinical findings of an extrusion (3)
Tooth appears elongated
Tooth mobile
Bleeding from gingival sulcus
Clinical findings of lateral luxation (5)
Tooth appears displaced in socket
Tooth immobile
High ankylotic percussion tone
May be bleeding from gingival sulcus
Root apex may be palpable in sulcus
Treatment for lateral luxation
Reposition under LA
Flexible splint 4 weeks
Monitor
Endodontic evaluation
Likely prognosis of a lateral luxation for an incomplete root formed tooth
Spontaneous revascularisation may occur
If pulp becomes necrotic and signs of inflammatory external resorption, commence endodontic treatment
Likely prognosis of lateral luxation for a complete root formed tooth
Pulp necrosis
- Commence endo treatment and corticosteroid antibiotic or calcium hydroxide as intra-canal medicament to prevent development of inflammatory external resorption
Clinical findings of intrusion (3)
Crown appears shortened
Bleeding from gingivae
High ankylotic percussion note
Treatment for an intrusion for an immature root formation tooth
Spontaneous reposition independent of the degree of intrusion possible
If no re-eruption within 4 weeks, orthodontic repositioning
Monitor pulp condition
Spontaneous pulp revascularisation possible
If pulp becomes necrotic and infected or signs of inflammatory external resorption, commence endo treatment
What is the treatment for intrusion of a mature root formed tooth>
If <3mm spontaneous repositioning may occur. If no re-eruption within 8 weeks, reposition surgically and splint for 4 weeks or reposition orthodontically before ankylosis develops
3mm+ - reposition surgically
In mature teeth, pulp will always become necrotic, start endo at 2 weeks
What emergency advice would you give for an avulsed tooth?
Ensure it is a permanent tooth
Hold by crown
Rinse in cold water, milk or saline if debris
Reimplant immediately if possible
Seek immediate dental care
If reimplantation not possible store in saliva, milk, saline, water DO NOT LET DRY
Treatment for avulsion of a closed root apex tooth
Rinse debris
History and exam with tooth in storage medium (saliva, milk, saline, water)
Reimplant tooth under LA
Splint for 2 weeks
Suture any gingival lacerations
Consider antibiotics, check tetanus status
Provide post-op instructions
Start endo within 2 weeks
Intracanal medicament CaOH up to 1 month or corticosteroid/antibiotic paste for 6 weeks
When would you not reimplant an avulsed tooth?
Immunocompromised patient
Other serious injuries requiring emergency treatment
Very immature apex and time since trauma >90min
Very immature lower incisors in young child finding it difficult to cope
Clinical findings of dento-alveolar fracture
Complete alveolar fracture extending from the buccal to the palatal/lingual bone
Segment mobility and displacement with several teeth moving together
Occlusal disturbance
How to treat dento-alveolar fracture
Reposition any displaced segment
Stabilise by splinting 4 weeks
Suture gingival lacerations if present
Monitor pulp condition of all involved teeth
Splint time for lateral luxation
4 weeks
Possible sequalae of trauma to primary teeth
Discolouration
Infection
Delayed exfoliation
Warfarin mechanism of action
Inhibits synthesis of vitamin K depending clotting factors (2, 7, 9, 10, protein C, protein S)
Dilaceration
Abrupt deviation of the long axis of the crown or root portion of the tooth
After primary impression what is the cast composition?
50% dental stone 50% dental plaster
Indications for veneers
Aesthetic
Peg laterals
Reduce or close proximal spaces and diastemas
Hypoplasia or hypomineralisation
Erosion or abrasion
Fluorosis
Discolouration
How long to splint avulsion or extrusion
2 weeks
When can you seal caries with fissure sealant?
If the caries is occlusal and is a non cavitated lesion
In complete dentures what is the neutral zone?
Position where the forces between the tongue and cheeks or lips are equal, the ideal position for a lower complete denture
What does necrotising stomatitis present with?
Bone denudation
Osteitis and bone sequestrum
Contraindications for preformed metal crown
Irreversible pulpitis
Periapical pathology
Insufficient tooth tissue to retain the crown
What is cold working?
Work done on a metal or alloy at a low temp, lower than recrystallisation temp
Management of orofacial granulomatosis
Oral hygiene support
Symptomatic relief as per oral ulceration
Dietary exclusion (does not cure just reduces orofacial inflammation)
Topical steroids
Topical tacrolimus
Short courses of oral steroids (if severe or unresponsive to topical)
Intralesional corticosteroids
Surgical intervention - unresponsive long standing disfigurement
What viral infections can Coxsackie A Virus cause?
Herpangina - vesicles in tonsillar region
Hand, foot and mouth - ulceration on the gingiva/tongue/cheeks and palate
Maculopapular rash on the hands and feet
Management of these lesions is as with Herpes Simplex virus 1
Ranula
Mucocele in the floor of the mouth
Treatment of necrotising periodontal diseases
Debridement and chlorhexidine mouth rinses 0.2% twice daily
If systemic effects use metronidazole 400mg
Contraindications for fluoride varnish
Hospitalised due to severe asthma
Allergy in the last 12 months
Allergy to sticking plaster
Allergy to colophony
Signs and symptoms of primary herpetic gingivostomatitis
Fluid filled vesicles - rupture to painful ragged ulcers on gingivae, tongue, lips, buccal and palatal mucosa
Sever oedematous marginal gingivitis
Fever
Headache
Malaise
Cervical lymphadenopathy
What is the difference between the stainless steel wire for ortho vs trauma splint
Trauma splint 0.4mm in diameter
Ortho wire 0.7mm diameter
SDCEP plaque scores and their meaning
10 perfectly clean tooth
8 Line or plaque around cervical margin
6 Cervical 1/3rd of crown covered
4 Middle 1/3rd of crown covered
Tests that must be carried out on a type B sterilizer DAILY
Steam penetration test
- Bowie Dick or Helix
How to manage oral ulceration
Nutritional deficiencies
Avoid sharp or spicy food
Prevention of superinfection
Protect healing ulcers
Symptomatic relief
Active ingredient in alkaline peroxides
Sodium perborate
Bohn’s nodules
Gingival cysts filled with keratin that occur in alveolar ridge
How long to splint a mid or apical third root fracture?
4 weeks
How do you respond to someone choking?
ASK - are you choking? Can you cough?
5 back blows followed by 5 abdominal thrusts
At what stages are proteins and prions removed in a washer disinfector cycle?
Pre wash and main wash
How many times should children in Scotland receive fluoride varnish per year?
2 minimum, up to 4
What temperature must types N, B and S sterilisers reach and for what duration?
134-137C for 3 min minimum
Mucocele
Cyst in the mouth due to salivary glands collecting under a mucous membrane
3 medications which cause gingival hyperplasia
Calcium channel blockers (ipine)
Phenytoin
Clyclosporine
Where can tap water be used in the decontamination process?
Mechanical cleaning
Washer disinfector
CANNOT be used for sterilisers or ultrasonic
3 big risks of ortho treatment
Decalcification
Relapse
Root resorption
Annual background radiation dose
2.2mSv
What is external infection related inflammatory root resorption?
Root resorption initiated by PDL damage
Root canal toxins reaching the external root surface causing resorption
The tooth is non-vital
What is external infection related inflammatory root resorption?
Root resorption initiated by PDL damage
Root canal toxins reaching the external root surface causing resorption
The tooth is non-vital
Adults with incapacity act 2000
Protect individuals (age 16+) who lack capacity to make decisions for themselves and to support their families and carers in managing the individuals welfare and financing
Index teeth used in simplified BPE (sBPE)
16 11 26
36 31 46
What does the Equality Act 2010 do?
Legally protects people from discrimination in society
What can you not process in a Type N steriliser?
Wrapped instruments
Channelled or lumened instruments
Treatment for primary herpetic gingivostomatistis
Bed rest
Soft diet
Hydration
Paracetamol
Antimicrobial gel or mouthwash
Topical Acyclovir
Definition of prevalence
Number of disease cases in a population at a given time
Prevalence = number of affected individuals/total number of persons in population
What does angle ANB represent?
Angle that represents the relative anteroposterior position of the maxilla to the mandible
Types of splint
Composite and SS wire
Titanium trauma splint
Acrylic
Orthodontic bracket and wire
How to know whether an individual lacks capacity?
AMCUR
The individual is incapable of acting or making decisions or communicating decisions or understanding decisions or retaining memory of decisions
Minimum age for fluoride varnish
2 years
Epstein pearls
Small cystic lesions found along palatal midline
What is Spaulding classification
Strategy for sterilisation based on the degree of risk involved in their risk
Critical device - penetrates soft tissues (e.g. forceps)
Semi critical device - comes into contact with non-intact skin or mucous membranes (e.g. dental mirror)
Non critical device - only comes into contact with skin and intact mucous membranes (e.g. dental chair)
Load bearing structures of a complete lower denture
Buccal shelf
Residual alveolar ridge
Advice following fluoride varnish
30 mins no food or drinks
4 hours no brushing or hard/sticky foods
When are the only times manual cleaning of instruments should be carried out?
Recommended by the manufacturer’s instructions
No other alternatives
Ultrasonic or WD has failed to remove contamination
Management of TMJDS
Manage stress
Avoid habits such as clenching, grinding, chewing gum, nail biting or leaning on the jaw
A bite raising appliance may be considered if there is nocturnal grinding/clenching
Avoid wide opening
Soft diet
Ibuprofen
Alternate hot and cold packs
Treatment for internal and external related inflammatory root resorption
Endo treatment
CaOH 4-6 weeks
Obturate with GP
Necessary properties of a trauma splint
Flexible and passive
Ease of placement and removal
Facilitate sensibility testing
Allow oral hygiene
Aesthetic
How long to splint lateral luxation
4 weeks
Primary herpetic gingivostomatitis
Acute infectious disease caused by herpes simplex virus I
How would you manage an oroantral communication with the maxillary sinus following extraction of 17?
Inform the patient
If small or sinus intact - encourage clot, suture margins, antibiotic, post-op instructions
If large or lining torn - close with buccal advancement flap, antibiotics and nose blowing instructions
4 main post trauma complications
Pulp necrosis and infection
Pulp canal obliteration
Root resorption
Breakdown of marginal gingiva and bone
Emergency scenario
A - swelling, stridor
B - increased rate, wheeze
C - increased rate, hypotension
D - loss of consciousness
E - rash, swelling
Diagnosis and treatment
Anaphylaxis
Adr 1:1000 0.5mg intramuscular
What type of denture cleaners can be used on metal based dentures?
Alkaline peroxide cleansers such as Steradent max of 15 min
Alkaline hypochlorite cleansers such as Dentural or Milton for 10 min
What are epiludes?
Common solid swelling of the oral mucosa
Benign hyperplastic lesions
3 main types of epiludes
1) fibrous epulis
2) pyogenic granuloma
3) peripheral giant cell granuloma
Steps of disinfection and sterilisation from acquisition to use
Acquisition
Cleaning
Disinfection
Inspection
Packaging
Sterilisation
Transport
Storage
Use
Transport
What should you not clean metal containing dentures with?
Acid cleaners
What type of items can a Type S steriliser process?
Non lumened instrumend or specific kits (does not process wrapped instruments)
What is the first stage of the decontamination cycle?
Washer disinfector
Ramjford’s teeth
16 21 24
36 31 34
Definition of incidence
Number of new cases of a disease developing over a specific period of time in a defined population
Rate = number of new cases of a disease in a period/number of individuals in the population at risk
Two bacteria usually found in necrotic lesions
Fusobacterium
Spirochetes
What effect does lowering kV have on the Xray unit?
Lowering Xray tube potential difference means there are overall lower energy photons produced, increased photoelectric effect interactions and increased contrast between tissues with different Z BUT there is also an increased dose being absorbed by the patient
Fibroepithelial polyp
Firm pink lump thought to be initiated by minor trauma, surgical excision is curative
How long do you splint a cervical third root fracture?
4 months
What is ankylosis related replacement root resorption?
Root resorption due to presence of ankylosis, initiated by severe damage to PDL and cementum
What is internal infection related inflammatory root resorption?
Root resorption due to infected material via non-vital coronal part of canal
What concentration is fluoride varnish?
Sodium fluoride 5%
22,600ppmF
What volume of fluoride should be used for each age group?
P1 (2-5 years) 0.25ml
P2 (5-7 years) 0.4ml
9 protected characteristics from Equality Act 2010
Age
Disability
Gender reassignment
Marriage or civil partnership
Pregnancy and maternity
Race
Religion or belief
Sex
Sexual orientation
What is the Patient Rights Act
Act gives everyone the right to receive healthcare that:
Considers their needs
Considers what would be of most benefit
Encourages them to take part in decisions about their health, and gives them the information to do so
Frankfort horizontal plane
Imaginary horizontal line from the superior aspect of the EAM to the inferior border of the orbital margin
How is ANB calculated?
SNA - SNB
Photoelectric effect
Photon in Xray beam interacts with inner shell electron in subject, resulting in absorption of the photon and creation of a photoelectron
Compton effect
Photon in Xray beam interacts with outer shell electron in subject, resulting in partial absorption and scattering of the photon and creation of a recoil electron
Role of collimation (5)
Lowers surface area irradiated
Lowers volume of irradiated tissue
Lowers number of scattered photons produced in the tissue
Lowers scattered photons interacting with receptor
Lowers loss of contrast on radiographic image (also reduces patient dose and amount of radiation being released into surroundings)
kV in dental radiology according to UK guidance
60-70kV
How to make a critical, semi critical and non critical device suitable for their next use
Critical - clean then sterilise
Semi critical - clean and high level disinfection
Non critical - cleaned and low level disinfection
When to use an ultrasonic bath
Considered back-up method after using washer disinfector
- If WD is out of service and instrument is required
- If WD could not remove certain spots of biological matter
Ultrasonic bath operating temperature
20-30C
Main relief areas of upper complete dentures
Incisive papilla
Palatine raphe
Palatine fovea
Crest of alveolar ridge
Load bearing structures of complete upper denture
Rugae
Posterior palate
Maxillary tuberosity
Main relief areas for a lower completer denture
Genial tubercle
Mandibular torus
Mylohyoid ridge
4 types of factors affecting retention of a denture
Physical - cohesion, adhesion, atmospheric pressure and gravity
Anatomical -undercuts, shape of edentulous area
Physiological - neuromuscular control, quality of saliva
Mechanical - balanced occlusion, contour of polished surfaces
FSD focus to skin distance
> 200mm
Linear no threshold model
Assumes that the damage is linear to radiation dose. It assums that radiation is always harmful with no safety threshold. It estimates the long term damage from radiation
Overview of stages involved in a washer disinfector
1) Flush/prewash - removes gross contamination
2) Main wash - detergent used to more effectively remove biological matter
3) Rinse - removes any remaining residue
4) Thermal disinfection - actively kills microorganisms with the use of heated water
5) Drying - hot air to remove any remaining moisture from the surface of the instruments
Name stages in washer disinfector
Pre wash
Main wash
Rinse
Thermal disinfection
Drying
Temperatures for each stage of washer disinfector
Prewash - <35
Main wash - temp dependent on detergent used
Rinse - <65
Thermal disinfection - 90-95 for minimum of 1min
Drying - generally 100
At what ages should you carry out simplified BPE and which codes should be used?
7-11, codes 0,1,2
12-17, codes 0, 1, 2, 3, 4
Name 4 temporary materials
Polymethylmethacrylate (PMMA)
Polyethylmethacrylate (PEMA)
Bis-acryl composite
Urethanedimethacrylate (UDMA)
Why is there one less stage in production of replica dentures?
For replica dentures, master impressions and jaw reg can be done in the same visit
3 different types of sterliser
Type B
Type N
Type S
Why is a type B steriliser capable of processing wrapped and lumened instruments?
The machine removes all air from the chamber before filling it with steam therefor creating a vacuum.
Type N sterilisers heat the water and as it turns to steam it passively forces the air from the chamber. This can leave pockets of air within the chamber
What is the issue with having air in the chamber of a steriliser?
Pockets of air are always a lower temperature than the steam surrounding it. It can not be heated or maintain temperature in the same way that steam can
Current guidance documents for sterilisation and what standards do they reference?
Guidance SHTM 01 - 01 Part C
Standard - BS EN 285 and BS EN 13060
Triple manoevre
Head tilt, jaw thrust, jaw opening
Normal respiratory rate
12-26 breaths per minute
What is ABCDE in a medical emergency
Airway Breathing Circulation Disability Exposure
How to treat patient presenting as talking, with increased breathing and circulatory rate, alert and awake with pale clammy skin and central chest pain?
Angina
GTN (glyceryl trinitrate) spray 400micrograms sublingually (3 sprays)
Aspirin 300mg crush or chewed if MI
Medical emergency conditions (8)
Anaphylaxis
Angina/MI
Asthma
Cardiac arrest
Choking
Hypoglycaemia
Seizure/fits
Syncope
What would the ABCDE assessment be of someone suffering anaphylaxis, and how would you treat them?
A - swelling, stridor
B - increased rate, wheeze
C - increased rate, hypotension
D - loss of consciousness
E - rash, swelling
Remove trigger if possible, call ambulance, give IM adrenaline 1:1000 0.5mg and high flow oxygen, monitor heart rate and BP, if no response at 5 mins repeat adrenaline and administer IV fluid bolus
ABCDE assessment of someone suffering asthma attack and how would you treat?
A -difficulty completing sentences
B -increased rate with wheeze
C -increased rate
D -alert
E -Tripods
Salbutamol inhaler (blue) 100micrograms per actuation, spacer device where appropriate
ABCDE of someone in cardiac arrest and how to treat?
A - ensure no obstruction
B - stopped, potentially agonal breathing
C - stopped
D - unconscious
E - check for nearby danger
Call for ambulance, help and AED
30 chest compressions/2 rescue breaths START IMMEDIATELY
Continue until AED arrives
If an adult becomes unconscious after choking what is the treatment?
CPR
How to treat a conscious choking adult
If effective cough, encourage cough and monitor
If ineffective cough, 5 back blows, 5 abdominal thrusts
ABCDE hypoglycaemia and how to treat
A - initially talking
B - initially increased rate
C - initially increased rate
D - initially alert
E - irritable, confused, pale
Glucose
Glucagon 1mg IM injection
Seizures/fits ABCDE and how to treat
A - compromised
B - ?
C - ?
D - Unresponsive
E - seizure activity, incontinence
Ensure safe environment, if repeated or prolonged consider Midazolam 10miligrams via buccal mucosa
Syncope ABCDE and how to treat
A - compromised
B - reduced rate
C - reduced rate and pressure
D - Unresponsive
E - pale, clammy
Elevate legs
How to respond to cardiac arrest
DRSABC
100-120 compressions per minute
5-6cm deep
15L 100% oxygen
30 compressions 2 breaths
Place AED ASAP
Shockable cardiac arrest rhythms
Ventricular tachycardia
Ventricular fibrillation
Unshockable cardiac arrest rhythms
Asystole
Pulseless electrical activity
Oral ulceration
Localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue
Causes of oral ulceration (4)
Infection
Immune mediated disorders
Trauma
Vitamin deficiency (iron, b12, folate)
Further investigations for oral ulceration
Diet diary
Full blood count
Haematinics (folate, b12, iron)
Coeliac screen (anti-transglutaminate antibodies)
Clinical features or orofacial granulomatosis (5)
Lip swelling
Full thickness gingival swelling
Perioral erythema
Cobblestone appearance of the buccal mucosa
Angular cheilitis
What investigations should be carried out for orofacial granulomatosis? (8)
Measure growth - paediatric growth charts
Full blood count
Haematinics
Patch testing to ID triggers
Diet diary to ID triggers
Faecal calprotectin
Endoscopy (risky in childhood)
Serum angiotensin converting enzyme (raised in sarcoidosis
What is geographic tongue and how to manage it?
Benign changes in tongue mucosa
Shiny red areas on the tongue with loss of filiform papillae, surrounded with white margins
Bland diet during flare ups
2 variants of mucoceles
Mucous extravasation cyst - normal secretions rupture into adjacent tissue
Mucous retention cyst - secretions retained in an expanded duct
Normal extent of jaw opening
40-50mm
What is TMJ dysfunction syndrome characterised by?
Pain
Masticatory muscle spasm
Limited jaw opening
What is verruca vulgaris and what causes it?
Solitary or multiple intra-oral lesions caused by HPV 2 and 4
What is squamous cell papilloma and what causes it?
Small pedunculated cauliflower like growths
Caused by HPV 6 and 11
2 HPV associated swellings in the mouth
Verruca vulgaris
Squamous cell papilloma
What is the difference between an oroantral communication and an oroantral fistula?
OAC - as soon as you make the communication
OAF - when the communication becomes epitheliazed
When extracting multiple teeth, what order should this be done in and why is that important?
Back to front
- for better vision as blood from extraction sites can obscure vision
- decrease the chance of fracturing the tuberosity
When extracting a lower tooth you fracture the tuberosity. How would you manage this?
Dissect out and close wound or reduce and fixate
Reduction - fingers or forceps
Fixation - orthodontic wire with composite, arch bar, splints
Remember - remove or treat pulp, ensure occlusion free, antibiotic and antiseptics, post-op instructions, remove tooth 8 weeks later
What is the difference between tap water and purified water?
Tap water contains minerals, silicates, organics and metals
What 4 key elements are present in the Sinner circle?
Energy
Chemicals
Time
Temperature
What key element of the Sinner circle is the largest in an ultrasonic?
Energy
What is cancrum oris?
Necrotising and destructive infection of the mouth and face, not strictly periodontal disease
What is the current guidance for washer disinfectors and what standards do they reference?
SHTM 01 - 01 part D
BS EN 15883
Phosphor plate sizes and corresponding radiograph
Size 0 - anterior periapicals
Size 2 - bitewings, posterior periapicals
Size 4 - occlusal
Types of digital Xray receptor and are they single or multiple use?
Phosphor plate, solid state sensor - both multiple use
Is a film Xray receptor single or multiple use?
Single use
What are the types of film Xray receptors?
Direct action film, indirect action film
