Notes Flashcards

Question

What are the 9 components of the index of suspicion in paediatrics?

Answer 1

1. Could the injury have been caused accidentally, if so - how? 2. Does explanation of injury fit age and clinical findings? 3. Is explanation consistent with injury, is this within normally acceptable limits of behaviour? 4. If there is delay in seeking advice, are there good reasons for this? 5. General demeanour 6. Nature of the relationship between guardian and child 7. Childs reaction to people 8. Childs reaction to any medical/dental examination 9. Comments by child/guardian that give concern about the upbringing or lifetstyle

Answer 2

Nutrition Warmth, clothing, shelter Hygiene Stimulation and education Affection Failure to thrive Cold injury/sun burn Dental caries/head lice Developmental delay Withdrawn/attention seeking behaviour

Answer 3

1. Pts name, address 2. Date sent, date required, disinfected 1. Please pour up impressions in improved dental stone 2. Please mount casts using facebow and wax bite registration provided to mount on a Denar type II semi-adjustable articulator 3. Please construct conventional (fixed-fixed) bridge with teeth 24+26 as retainers 4. Please provide tooth 25 pontic (modified ridge lap) 5. Teeth 24+26 MCC with buccal shoulder, palatal chamfer 6. Please construct in canine guidance and ensure pontic is free of excursive movements 7. Shade A3 Mr R Jalif Signature Address of practice Phone no.

Answer 4

Site Size and Shape Surface Surrounding tissue Colour Consistency Base Bleeding Functional limitation

Answer 5

Lichen planus is a chronic autoimmune disease that can affect the skin and any lining mucosa. This could be the oral, oesophageal, vaginal mucosa as well as the skin. Reticular Papular Plaque-like Atrophic Erosive - 1-2% chance of becoming malignant Bullous Desquamative Gingivitis Auto-immune, F>M, in most cases will resolve within 2y - Causes Genetics/environment (amalgam, SLS, stress, drugs - B-blockers, NSAIDs, anti-malarials, oral hypoglycaemics)

Answer 6

Site - anywhere - commonly buccal mucosa or lateral tongue Size - any size/shape - striae Surface - roughness of musoca/blister/ulcer Associated - usually bilateral, itchy skin lesion on arm, leg, trunk Surrounding tissue Colour - red/white/both Consistency - homogenous/heterogenous Base Bleeding - no Functional limitation

Answer 7

Most likely spotted oral lesion when doing soft tissue examination Check flexor of wrist, ask about leg, trunk, genitals (more likely to turn malignant) Is the lesion localised and associated with any restorations, if so likely to be lichenoid reaction to amalgam

Answer 8

Ortho or parakeratinized surface Acanthotic or atrophic epithelium Subepithelial band of T Lymphocytes Liquefactive degeneration of basal cells

Answer 9

Photograph asymptomatic/ reticular/non-smoker - no biopsy, reassure that it is self-limiting, not to worry If symptomatic or patient is worried - - Avoid allergens like benzoates - Avoid SLS containing toothpaste - Avoid spicy food - CHX 0.2% can be used - warn pt of risk of staining tongue and teeth - should not be used for longer than 2 weeks - Benzydamine MW (difflam) can be used to help with soreness - 0.15% 300ml 15ml every 1.5h In later stages medicines like corticosteroids can be used too (local - beclomethasone inhaler and systemic - betamethasone tablet) BIOPSY IF PT SMOKER to confirm it is LP and check for dysplasia

Answer 10

So on examination we can see you have these white patches around your mouth. This is what we believe to be a condition called lichen planus (LP), which is a autoimmune chronic inflammation of the skin and in some cases the mouth - it is a very common condition seen in the oral medicine dept. The whiteness arises from extra keratin in your soft tissues, keratin is a protein which is present all around your skin. LP is kind of like an allergic reaction to something and in most cases we don't really know what is causing it, the most common culprits are reactions to medications/amalgam fillings. LP has a small chance to develop into something sinister like a mouth cancer but this is only in 1% of cases. LP is a spectrum disease and can be something as simple as a white patch to a more sinister erosive sore ulcerated area, depending on what area of the spectrum you're on the risk of malignancy may be higher or lower. This is not something we can treat other than managing the symptoms if we do not manage to remove the causative factor.

Answer 11

CN1 (Olfactory) - can patient smell as normal? CN 2, 3, 4, 6 (optical, oculomotor, trochlear, abducens) - test visual acuity and eye movement CN 5 (Trigeminal) - Any abnormal sensations at each branch? Can pt clench jaw? Corneal reflex CN 7 (facial) - facial muscles tests (puff out cheeks, pout, wrinkle forehead, raise eyebrows) CN 8 (Vestibulocochlear) - can pt hear normally? Block one ear and check for differences CN 9, 10 (glossopharyngeal and vagus) - deviation of uvula saying ahh, gag reflex CN 11 (accessory) - can pt shrug their shoulders? CN 12 (hypoglossal) - can patient protrude tongue? deviation on protrusion? asymmetry?

Answer 12

Accept and monitor Intercept with a URA - procline uppers (notice pts age in scenario - this might not be possible) Growth modification - with functional appliance (reverse twin block) or (RME + protraction headgear) - notice pts age in scenario - this might not be possible Camouflage with fixed appliances - accept underlying skeletal A/P discrepancy, move teeth with fixed ortho to hide it Procline uppers and retrocline lowers Risks of ortho - decal, root resorption, relapse, gingival recession This sometimes requires XLA of U5's and L4's Orthognathic surgery with combined orthodontics - to be done once the patients jaws have stopped growing - surgical manipulation of the mandible and/or maxilla to produce optimal aesthetics/function total time = 36 months

Answer 13

Redness and swelling in denture bearing area caused by fungal microorganisms called candida. Common in poor oral hygiene, ill-fitting dentures, older dentures, poor diets, immunocompromised, repeated antibiotics Some symptoms you may have experienced could be redness and swelling of the areas covered by the denture, burning sensation, inflammation of your mucosa, discomfort, bad taste and bad breath

Answer 14

Classification system for denture induced stomatitis Type I - localised inflammation with hyperaemic foci Type II - diffuse inflammation and erythema confined to mucosa contacting denture without hyperplasia Type III - granular inflammation with erythema and papillary hyperplasia

Answer 15

- ask pt about care of denture - cleaning and removal - Prevention - remove at night, steep denture in milton, brushing palate - Advice on cleaning denture - brushing after meals w soft toothbrush and non-abrasive denture cream, soaking in CHX m/w or NaOCL (if acrylic) for 15mins 2x daily - Leave dentures out as much as possible during tx - Consider tissue conditioner for current denture - Consider making new denture (ill-fitting) - Consider underlying deficiency/disease - diabetes/haematinic deficiency - More common in diabetic patients - encourage diabetic control - If local measures fail - Fluconazole 50mg 1 x 7 days (send 7 capsules) - Nystatin 100,000 units/ml - 1ml after food 4x daily for 7 days (send: 30ml) NO AZOLES if WARFARIN/STATIN

Answer 16

Reasoning - Relines - when fitting surface is inadequate but denture otherwise is okay - i.e. occlusal planes, OVD, profile are acceptable but fitting surface underextended, not supportive or retentive - Rebase - when you want to keep the occlusal surface but change fitting and polished surface Method: 1. check all occlusal relationships are acceptable and appropriate 2. remove undercuts from dentures fitting surface using acrylic bur 3. adjust border for under/over extension with green stick 4. apply adhesive to fitting surface of the denture to be refined 5. insert impression material (light body PVS) into the fitting surface and seat the denture 6. functional impression - ask the patient to bite together so the impression is taken in OVD 7. Take a lower impression with denture in-situ 8. Take a bite registration if ICP not obvious 9. When set remove the impression and send the denture to lab for reline "Pls pour impressions in 100% dental stone using impressions provided. Please mount to cast and create a self cure PMMA reline to change the impression surface"

Answer 17

Introduce yourself Take hx: - No. of days symptoms - Does the child have a fever? - Child less active than normal? - Analgesia used? - Did it work? - PHG Signs - lymphadenopathy, malaise, pyrexia, erythematous gingivae, ulceration - PHG symptoms - sore mouth + throat, fever, enlarged lymph nodes, loss of appetite, dehydration

Answer 18

From my clinical findings and from what I can see, I believe that your child has a condition which we call primary herpetic gingivostomatitis. It is a contagious infection which is caused by the herpes simplex virus, the same virus which causes cold sores. It is self-limiting and will disappear within 10-14 days. The blisters do not leave scars. The virus may reactivate in the future and can cause cold sores. Most infections are not clinical.

Answer 19

· Encourage rest · Encourage fluid intake · Pain relief- ibuprofen and paracetamol (helps control fever too)- ask if patient has tried this · Clean teeth with damp cotton wool roll and CHX swab for gums · No AB/AV as they are ineffective- unless severe or immunocompromised - Acyclovir tablets 200mg/oral suspension 200mg per 5 ml, 5 times daily for 5 days (send 25 tablets)- if aged 2 to 17 - Half dose for 6 months to 1 year

Answer 20

If aged 2-17: 200mg/(oral suspension 200mg per 5ml), 5x daily for 5 days (send 25 tablets) If 6m-1y: Half dose

Answer 21

To prevent decay from progressing - more effective than fluoride varnish Reduces dentine hypersensitvity Vaseline on ST, dry teeth, apply for 3 mins

Answer 22

Non-restorable dentine lesions MIH - reduces sensitivity Pre-cooperative Delay sedation/GA Asymptomatic cavitated lesions

Answer 23

Allergy to silver or other heavy metals Painful gums or mouth ulceration Lesions that involve the pulp PA pathology Mucositis/Stomatitis

Answer 24

Permanent discolouration Temporarily stains soft tissues for 1-3 weeks Discolour composite fillings Permanent discolouration of clothes

Answer 25

Brush it off with toothbrush apologise to family - explain what has happened Have emergency kit on standby If reaction - send to a&e If not - watch patient for a few hours in clinic, then send home with the instruction that if the child's condition deteriorates go to A&E Get pt in next day for follow up

Answer 26

Monitoring FV Remove decay and restore Hall technique XLA

Answer 27

SPIKES acronym Setting - sitting down at same lvl as pt, "how have you been since the last time i've seen you" Perceptions - what does the pt understand has happened until now " Are you aware of what we're here to discuss today" Information - inform pt you have the results of the biopsy Ask them if they would like you to go through with them - they will say yes Knowledge - Give them a warning shot - "i wish i had better news" Give them the knowledge of what you know - "the test we have done has shown some abnormalities of the cells" "mrs smith im afraid to say that you have mouth cancer" Let it sink in and let them dictate the pace of the convo Empathy - words to the effect of - "I am deeply sorry to break this to you" - "I understand you must have lots and lots of questions ... do you have anything that comes to mind?" - "Perhaps you would like to bring your husband in with you?" Summarise and close - Repeat the news Summarise what you've told them and the plan for going forwards "The good news in all of this is that we've and will be able to move forward with tx as soon as possible" "I'll be speaking to the surgeons today and they'll be seeing you in the coming week to discuss tx" - Offer them a follow-up appt or phone no. for any questions - Give written material if available

Answer 28

1. Acknowledge the complaint and provide the patient with the practice complaint procedure 2. Inform the dental defence organisation 3. Inform the patient of timescales and stages involved 4. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it - 3 working days maximum but ideally within 24 hours 5. Early resolution 5 working days: For issues that are straightforward and easily resolved, requiring little or no investigation 6. Investigation 20 working days: for issues that have not been resolved at the early resolution stage or that are complex, serious or "high risk" 7. Independent external review ombudsman: For issues that have not been resolved

Answer 29

- Take concerns seriously, answer questions as able: "hello there, what seems to be the problem?" "can i offer some assistance?" - Acknowledge anger "I can see that you're upset and I am sorry you're feeling this way" - this does not accept blame, DO NOT ACCEPT BLAME - Try to offer practical help - offer investigation with receptionist and provide feedback to the patient If you can offer another appointment - "do you still have time for us to see you?" "What would you like us to do, we can work around you" Making an apology - Be honest - Acknowledge the offence - Explain how it happened - we were running over from previous procedure - Express remorse - deep guilt, express it (I am so sorry!) - Ensure amends - "is there anything we can do?" If formal complaint requested, advice on NHS complaints procedure - Then, if required: a local resolution (payout) - If satisfactory: complaint closed - If unsatisfactory - healthcare commission or health service ombudsmen

Answer 30

Type 1DM - normal - 5-7mmol, unconcious <3mmol Assess ABCDE Signs: Pale, shaky, sweaty, clammy, dizzy, hungry, confusion, blurred vision, loss of consciousness You must mention loss of consciousness as it defines different tx If conscious and co-operative - administer oral glucose 10-20g or sugary drink If unconscious/uncooperative - 1mg IM glucagon injection and oral glucose when regain consciousness How does glucagon work? - Increases conc. of glucose in the blood by promoting gluconeogenesis to convert glycogen to glucose After they regain consciousness (15mins - if not 2nd dose) supply oral glucose/sugary drink IM injection and technique: - inject diluting solution in vial with glucagon powder - swirl to mix - dont shake - syringe solution back into syringe - use z-track technique into thigh or bicep - spread skin, advance needle in skin 90 degrees, aspirate, inject 30s, pull out, release tension - say "I would nnormally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time" - Reassess ABCDE - assess effect of medication, more oral glucose required?

Answer 31

Medication - midazolam - a short acting benzodiazepine - enhances the effect of GABA (neurotransmitter) on GABA receptors resulting in neural inhibition Signs: loss of consciousness, uncontrollable spasms, drooling, tonic (falls rigid), clonic (sharp jerky movements), hypotension, hypoxia, loss of airway tone Assess ABCDE Secure airway Administration - Administer 100% O2, 15L/min flow rate - If the fit is repeated or prolonged (>5min) give midazolam 2ml oromucosal solution, 5mg/ml topically into buccal cavity (10mg) - repeat after 5 mins if not worked - If subsided, recover position and check airway - Refer to hospital if - first seizure, seizure is atypical, injury caused or difficult to monitor pt

Answer 32

Introduce yourself and ask the nurse if it is okay to talk = "do you have a minute to talk" Facts - find out the facts of the situation Ask the individual for their account of the situation "So it has come to mt attention that unfortunately there were remarks said publicly about a patient and a talk about posting on social media, I was wondering if you knew anything about this?" - allow nurse to reply "Is it okay if I hear your side of the story" Issue - What is the issue here? Explain the issue to the individual and why it is bad Quote GDC standards - i.e. breach of confidentiality, brings profession into dispute "I know it may have been misjudged, but unfortunately, it is not acceptable to say these things publicly about patients or to post on social media" "As GDC standards state, it is our obligation to have patients best interest and to protect their information. Speaking in the public can breach this confidentiality. The pts are recognisable from the posts and this is not protecting them, for example, if it was someone speaking/posting about your family member, how would you feel?" "It is also not providing the public with confidence in you, us and the profession as a whole. The practice could be in question and the GDC could be informed of this in the future" Option: If involves pt, what options are there to manage this event What is in the pts best interest? "There are a few options to rectify this" - If there is a social media post - delete it and photos immediately Apologise to the patient if still around - if not, the practice can contact pt to ideally attend for a formal apology Now: - What issues do you need to deal with right now? Inform the nurse that this shouldn't happen again Ask/Advise: - Ask the individual if they would be willing to undertake some training or education on this matter "It would be acceptable if we had training on this in the future and have meetings about social media to increase awareness" "Would you be willing to have training on this?" If problem repeats - Get advice from someone more senior (defence union, VT trainer) how to manage this Record: document conversation

Answer 33

Diagnosis - Mrs Smith, you have a very common condition, in fact around 75% of the population get it at one point in their life, it is called temporomandibular disorder also known as TMD or TMJ Explanation "The jaw joint sits in the base of skull and muscles control opening and closing. Now, like any other muscle in the body if they get overworked they can get tired and sore, for example if you climb a mountain you would expect your legs to be sore for a few days" "However, as your jaw joint gets used all day everyday for speaking and eating it doesnt really get a rest, the muscles become inflamed and sore" "The fact that you're sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more" "The clicking by your ear is caused by a small disc that sits between your jaw and skull not moving freely and it becomes trapped in front of the jaw bones and snaps in places" Management - Reassurance - "The way we manage this is very simple" "It involves resting the joints" - Soft foods/cut in small pieces - Chewing on both sides - Avoid chewing gum - Avoid wide opeining - Support jaw on yawning - Avoid grinding during day - Avoid bad habits e.g. biting nails - Analgesia - Heat packs/cold compresses - Make soft splint to aid bruxism Summary - reassurance - common condition with simple conservative management - further options - will review and if pain still evident may require referral with further options of botox and surgery - inform that other symptoms like tongue scalloping and linea alba caused by the clenching and will go away with resoltuion of condition - Any q's?

Answer 34

SPIKES approach - bad news Setting - Sit down at same lvl as pt - Gain rapport - Perception - what does the pt understand has happened until now? "Are you aware of what might be wrong?" - what is pt expecting from appt? - Information - Inform patient that you would like to discuss the prognosis of the tooth - Ask them if they would like to discuss that Knowledge - Give them a warning shot "I wish i had better news" "I'm afraid the news is not good" - pause for a bit - Give them the knowledge of what you know "Your tooth is unrestorable and will be required to be extracted" - big pause - Let it sink in and let them dictate the pace of the conversation from here - they may want to know a lot of info or they may be in shock Empathy - "I am deeply sorry to break this to you and I know this may have come as a shock" Summary and close: - Repeat the news - once again the tooth is unrestorable and will need XLA "We will aim to have this booked in as soon as possible so we can continue with tx" "In the meantime we would not leave you with an empty space so there are immediate options and then more permanent options around 3-6 months down the line when the bone around the socket has stabilised" "The immediate options would include - immediate denture, a bridge using your extracted tooth, direct polycarbonate crown bridge" "More permanent options would be a bridge or a denture, and privately you could consider implant placement" "Any q's?" - we will book you a follow-up appt or you can phone the practice if you have any questions

Answer 35

Problems with denture ○ Impression surface: ■ Cause: poor impression (lack of post dam, poor adhesion to tray), damage to cast ■ Solutions: reline/rebase, remake, add post dam using reline ○ Occlusal surface: ■ Cause: premature occlusal contact, centric occlusion/relation not coincident, high lower occlusal plane restricting the tongue, locked occlusion ■ Solutions: cuspless teeth, selective grinding, re-recording centric occlusion, remake ○ Polished surface: ■ Cause: Overextension, underextended (depth &/or width), not in neutral zone ■ Solutions: remove overextension (esp. lingual lower, use pressure indicating paste, allow fraenal relief and flange), add greenstick to underextension and reline, remake if extensive ● Problems with denture wearer: ○ Poor neuromuscular control e.g. stroke, Parkinson’s ○ Unstable foundations ■ Anterior flabby ridge ● Solution: perforated trays + light bodied PVS impression (Or special tray with surgical window and take a wash and cut it out + light bodied PVS) ■ Atrophic lower ridge: ● Solution: admix technique (3 parts imp compound, 7 greenstick) ■ High fraenal attachments ● Solution: provide relief ■ Palatine tori: ● Solution: relief of area on cast before processing ○ Xerostomia

Answer 36

Anterior flange missing - remove undercuts, build flange w greenstick and reline Rebase if not possible or remake if necessary Midline diastema - if want to keep physical aspects of denture, but change aesthetic onnly - Replica (2 stage putty around denture, vaseline to separate) - Wax replica used for functional impression + jaw registration - Ask lab to close diastema for tooth trial stage Remake if other problems Underextended posteriorly at tuberosities - Reline - if functionally good and only one problem Remake - if everything bad Locked occlusion - no guidance or group function (issue lateral movements)- remake with replica technique and use cuspless teeth Base plate too thin - rebase thicker or rebase using high impact resin Tori - relieve clinically if only problem or ask for tin-foil relief If too thin or other problems - rebase or remake and ensure lab waxes undercuts Tooth position wrong - remake Occlusal table too long - i.e. too many posterior teeth over tuberosities - remove posterior teeth/grind down or remake

Answer 37

Better aesthetics Bonds to tooth Minimal prep required On demand Set Lower thermal conductivity Suppoers remaining tooth structure

Answer 38

Under polymerised base - place increments in smaller than 2mm Polymerisation shrinkage - place composite in small increments (keep c-factor low) Composite insufficiently cured - cure for longer than 30s Moisture sensitive - use dam Post-op sensitivity - use correct technique and bonding Longer placement time Less wear resistance Shorter lifespan

Answer 39

depends on pts OH/diet/parafunction/occlusion/operator skill 5-10 years - 13.7% failure rate at 8 years

Answer 40

BIS-GMA Quartz, silica Silane coupling agent Camphorquinone TEGDMA

Answer 41

Doesn't require undercuts Smooth margins No unsupported enamel No sharp line angles Bevelled cavo-surface margin angles - increases bonding area

Answer 42

Reduce polymerisation contraction stress - place composite in increments in less than 2mm to allow for complete curing, also place increments so they are contacting as little surfaces as possible Place lining material - RMGIC, flowable Check occlusion after completing restoration with articulating paper Use FV - 22600ppmF Use desensitising toothpaste Use water with high speed when preparing - consider excavator for deep caries

Answer 43

Etch 35% conditions dentine (opens tubules, removes smear layer, decalcifies dentine) DBA applied - primer and adhesive Primer (bifunctional) - bonds to dentine with hydrophillic ends and hydrophobic ends are exposed Adhesive - penetrated primed surface by molecular entaglement binding to primer by hydrophobic interactions Composite can bond by hydrophobic interactions

Answer 44

Increases surface energy Removes contaminants Increases surface area by roughening allowing micromechanical interlocking with resin - bond is 20MPA

Answer 45

Durable Shorter placement time Radiopaque Colour contrast Self-hardens at mouth temp Resistant to surface corrosion Good wear resistance Good bulk strength

Answer 46

Potential mercury toxicity Poor aesthetics Does not usually bond to tooth High thermal diffusivity Requires removal of sound tissue during cavity prep Lichenoid reactions - T4 hypersensitivity Tooth discolouration Amalgam tattoos Creep/marginal breakdown

Answer 47

Can last up to 20 years, 5.8% failure rate at 8 years

Answer 48

Undercuts required - retention and resistance form CSMA - 90 degrees for butt joint finish - no bevel Add grooves, isthmus, dove tails for retention Must be at least 2mm deep No unsupported enamel

Answer 49

Silver Tin Mercury Copper Tend to be zinc free now to prevent hydrogen bubble formation

Answer 50

Increases early strength Less creep and corrosion Better marginal integrity

Answer 51

Eliminate bacterial contamination Prevent inhalation of instruments Retract/protect soft tissue Reduced chairside time Increased operator and patient confidence Moisture control

Answer 52

Aim is to remove the nerve of the tooth, disinfect and shape the root canals using files and a mild bleach and then fill with rubber material to render canal inert/stop the infection spreading This usually takes 2 appointments as we would access the nerve chamber, remove the nerve, shape and disinfect in one and place a medicament to resolve your symptoms and then place a temporary filling, we would then get you back in and once you are symptom free and everything is nice and clean we can go in again and fill it and then place a permanent filling or crown. These appointments may last slightly longer than a traditional appointment for a filling and if a crown was required that would itself take a few extra visits. The need for a crown depends on how much viable tooth tissue there is at the end of the procedure. Study by sorenson and martinoff showed long term 94% of molars with crowns or onlays were succesful compared to 56% with fillings Benefits of RCT - removal of infection source - relief of pain - keep tooth/bone - best aestheics - potential abutment tooth Risks of RCT - failure of tx - ledge creation - perforation - pain - apical zipping - instrument separation - hypochlorite incident - tooth or root fracture - requires extensive restoration afterwards - added cost - cost - missed canals if complex anatomy Likelihood of success - up to 90% over 10y w IP - up to 80% over 10y for dead (necrotic) pulp Alternative tx options: - Do nothing and KUO - won't resolve pain + keeps source of infection - XLA We would follow this up via an x-ray in a years time to see whether the lesion has healed and we would assess for up to 4 years

Answer 53

Successful outcomes - no pain, swelling, symptoms - no sinus - no loss of function - normal pdl

Answer 54

Associated w signs and symptoms Lesion has appeared radiographically Pre-existing lesion has increased in size or remained the same Signs of continuining RR

Answer 55

- Leave and monitor - no active tx, but may get infection - including abscess which may flare up later - ReRCT - decreased success, may fail (not guaranteed) - If post-core crown present - removing may cause VRF - More complex if fractured instruments, ledges, blockages, severe curvages so consider referral Periradicular surgery - if re-tx not possible - more difficult to tolerate, invasive, time-consuming, expensive, nerve damage risk, reduced support, scarring XLA - tooth loss, may need replacement with prosthesis, poor aesthetics

Answer 56

Remove GP from coronal 1/3rd - U/S, GG, heat carrier Remove GP from mid 1/3rd - R25 set at 2/3rd EWL, slow pecking motion - clean flutes every 3 pecks Continue until GP removed from the middle third of the canal. If necessary use eucalyptus oil to soften GP. Working length determination with size 10/15 C+/K file Complete apical preparation to CWL with R25/R25 blue. If no apical tugback with K-25 then enlarge apical preparation with R40/R50 or K-files

Answer 57

Pain Swelling Haemorrhage (bleeding - redness) Ecchymosis (bruising) Neurological issues Airway obstruction

Answer 58

Stop Inform pt of what has happened If patient in pain = provide LA block If bleeding - observe haemostasis - saline irrigation Place a steroid containing intracanal medicament i.e. odontopaste - don't use pressure/force Seal cavity Encourage analgesia Consider AB Recommend hot (hematoma) and cold (swelling) compresses Review in 24h

Answer 59

Excessive pressure (>1ml per 15s) Needle locking in canal Loss of WL control Higher NaOCL conc. Larger apical diameter (due to resorption, anomalies, perforation)

Answer 60

Let patient know what you think has happened and apologise Explain that due to cyclic fatigue and tortional stresses on the instrument that the file has become separated Ask if you could take an x-ray (PA) of the tooth to reconfirm suspicion Attempt removal if visible (tweezers or forceps) If you cannot remove - tell pt this will likely require referral to a specialist Options: - Monitor - Bypass - using small K-files, then using ultrasonics - Remove file - Obturate to blockage - Peri-radicular surgery - XLA

Answer 61

Potential perforation achieve haemostasis - saline Apologise to patient and explain that during preparation, filing/drilling has accidentally gone outwith the pulp chamber and root canal system and the long term prognosis of the tooth is affected Repair perforation if accessible with GIC, MTA, or biodentine Otherwise refer for: MTA plug with microscope if close to apex Peri-radicular surgery Or could perform XLA yourself.

Answer 62

Pain hx - SOCRATES Pain to cold+sweet lasting <5 seconds Not spontaneous No radiographic changes Causes - Exposed dentine - Caries - Deep restorations Tx options: - Remove the stimulus e.g. the caries

Answer 63

Pain Hx - SOCRATES Sharp pain on thermal stimulus (hot + cold) Pain lingers for more than 30s after removal of stimulus Referred or spontaneous pain (accentuated by postural changes) OTC analgesics - ineffective No pain to percussion (hasn't reached apical tissues yet) Causes: - Deep caries - Extensive restorations - Fracture involving pulp Tx Options: - RCT - XLA

Answer 64

Pulp is vital but incapable of healing and no clinical symptoms Responds normally to sensibility testing Would see clinical caries/fracture/compromised restoration and prompt X-ray Tx options: - RCT - XLA

Answer 65

Death of pulp Doesn't respond to sensibility testing No symptoms Tx options: - RCT - XLA

Answer 66

Previously initiated - tooth has received partial pulp therapy (extirpation) Previously treated - has been root canal treated or filled with intracanal medicaments (does not respond to testing)

Answer 67

Normal Symptomatic apical periodontitis Asymptomatic apical peridontitis Acute apical abscess Chronic apical abscess Condensing osteitis

Answer 68

Not TTP or TTBP Lamina dura intact - hard bony lining of the alveolus Uniform PDL

Answer 69

TTP, TTBP, Pain on biting (severe indicated degenerating pulp) May be radiographic changes - width of PDL, PAP Tx Options: RCT XLA

Answer 70

Inflammation and destruction of the apical periodontium of pulpal origin. Appears as an apical radiolucency and doesnt present clinical symptoms (no pain on percussion or palpation) Tx options: RCT XLA

Answer 71

Gradual onset Little/no discomfort Intermitted discharge via sinus Radiographic signs of osseous destruction Tx options: RCT XLA

Answer 72

Rapid onset Spontaenous pain Extreme tenderness to pressure Swelling Pus formation Fever, malaise, lymphadenopathy Mat be no radiographic sign of destruction Tx options: RCT XLA Consider AB if immunocompromised, spreading infection or systemic symptoms

Answer 73

Diffuse radiopaque lesions representing localised bony reaction to low grade inflammatory stimulus Tx options: RCT XLA

Answer 74

Law of symmetry (excludes maxillary molars) - 1. Orifices of canals are equidistant from line drawn in mesial-distal direction across pulp floor 2. Orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the centre of pulp floor Law of colour change - colour of pulp chamber floor is always darker than the vertical surrounding dentine walls Law of orifice location - 1. Orifices of the root canals are always located at the junction of the dentine walls and the floor of the pulp chamber 2. Orifices of the root canals are located at the angles of the junction of dentine wall to the pulpal floor 3. Orifices of the root canals are located at the terminus of the root developmental fusion lines

Answer 75

Maintain aesthetics Maintain function - speech and mastication Prevent drifting of teeth Maintaining gingival margin - contour and health Prevent sensitivity Preserve vitality - prevent microleakage Confirm tooth prep Ensure optimum home care/optimum OH Achieve occlusal stability - maintain OVD Isolation for RCT For piloting new occlusions and guidance schemes

Answer 76

Black - household waste - packaging, hand towels Orange - low risk clinical waste - swabs, dressings and other non-sharp clinical waste e.g. dam, micro brush Yellow - high risk clinical waste (not on clinic) - body parts including teeth Red - specialist, hazardous waste - dispose of amalgam in white box with red lid, spill/leak proof (mercury vapour suppressant in lid), amalgam waste, amalgam capsules, amalgam filled teeth Blue - sharps including vials with medication or pharmaceuticals remaining Dispose of sharps in sharps bin (orange stream) - 3As, 2Ns - Always dispose of sharps in sharps box immediately after use - Always keep out of reach of children and non-authorised personnel - Always close sharps box between use temporary closing mechanism - Never retrieve anything from sharps box - Never fill more than 3/4 full

Answer 77

Stop what you're doing Apply appropriate PPE Cover spill with disposable paper towels Apply sodium hypochlorite/sodium dichloroisocyanurate - liquid/powder/granules (10000ppm) Leave for 3-5 mins, use scoop to take up the gross contamination and put into orange waste Clean with water and general purpose neutral detergent disinfectant wipes

Answer 78

Saddles - kennedy classification Support - resistance to occlusal directed load Retention - resistance to lifting away from the tissues Bracing - resistance to horizontal movements achieved by contacting vertical anatomical structures (can be achieved with clasps, plates, major connectors, flanges) Reciprocation - resistance to displacement by active retention forces Connectors Indirect retention - resistance to rotational displacement around the clasp axis Review and simplify

Answer 79

Class I - bilateral free end saddle Class II - unilateral free end saddle Class III - unilateral bounded saddle Class IV - anterior bounded saddle that crosses the midline The most posterior saddle defines the class, additional saddles are modifications - the number of modifications don't include the saddle used to classify the arch

Answer 80

Resistance to occlusally directed load Support classification - craddock - (** preferred) - class 1- tooth-borne - Class 2 - mucosa-borne - Class 3 - mixed (commonly in a lower FES) *Bounded saddles cannot be tooth supported if they are longer than 3 teeth

Answer 81

Rests provide support - these are defined by where they're placed on the teeth Cingulum rests - use: canines and incisors - canines provide best support Incisal rests - use: commonly on lower incisors - poor aesthetics - interfere with occlusion Occlusal rests - use: occlusal surface of molars and premolars - must extend to the midline to prevent tipping and to ensure the load is transferred down long axis of tooth - have to cut rest seat if interfering with occlusion Where should rests be placed? Bounded saddle - immediately next to saddle (unless abutment teeth are heavily tilted) Free end saddle - mesial side of abutment tooth

Answer 82

Resistance to vertical dislodging forces (prevents it falling out) Mechanical - clasps in undercuts Muscular - action of patients muscles Physical - adhesion, cohesion, atmospheric pressure and surface tension Guide planes - limits POI/R - Doesn't deform during insertion and removal - Provides long term retention Clasps - terminal end of clasp sits in undercut types - occlusal - circumferential or ring clasp (posteriors), clasp comes from rest - gingival - commonly used in anterior teeth (5 forward), clasp comes from mesh In Co-Cr RPDs we use 15mm tapering cross sectional diameter clasps which engage a 0.25mm undercut Mesial undercut - self-reciprocating/ring clasp Distal undercut - C-clasp (single clasp with reciprocal arm) - may not need reciprocal arm if base plate provides reciprocation

Answer 83

Resistance to rotational movement around a clasp axis can be provided by connectors, rests, saddle, denture base when planning - look at line between terminal ends of clasps and place indirect retention on the axis 90 degrees to that

Answer 84

Prevents continual horizontal pressure causing tooth movement How many reciprocal arms should there be - ideally 3 arms in a triangle shape

Answer 85

Stress relieving clasp system Used on FES (commonly mandible) Help to eliminate axial torque on abutments - mesial rest - proximal guide plate on or above survey line with undercut below - gingivally approaching I-bar clasp On loading - clasp and plate disengage to prevent pressure Reciprocation is provided via minor connector which connects rest and plate

Answer 86

Rigid part that joins all components Major - connects components on one side of arch to the other Minor - join other components to the major Types of major - Plate - Bar Plate - adv: thinner + can be extended onto tooth surface to provide indirect retention - dis: may have to cover gingival margins, more mucosal coverage Bar - adv: less mucosal coverage and relief of gingival margins - dis: thicker and more edges that can be explored by the tongue Mandibular connector - by default- lingual bar but require 8mm space (4mm for bar, 3mm from gingival margin and 1mm from functional FoM) Avoid horseshoe in upper if FES

Answer 87

Possible causes: - hereditary, keratosis (smoking, traumatic), lichenoid, lupus, pseudomembranous or chronic hyperplastic candidiasis (not in this site), carcinoma/SCC Introduce yourself to patient Discuss your clinical findings - "I have noticed during your clinical examination, that you have a white patch on the floor of the mouth underneath your tongue, are you aware that was there? and if so how long? has it gotten bigger or changed recently? Is it causing you any discomfort or limiting you eating/talking at all?" "The lesion on the FoM has a number of possible causes. Some of these are harmless and benign. However, some causes could be more serious and possibly cancerous so we would want to explore all possibilities." "As the site is a high risk for oral cancer, and you have other risk factors - i.e. your smoking and drinking habits, it would be appropriate to refer you on to have this looked at" "in order to be sure I will make an urgent referral to OM/Maxfax dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is" Inform patient more about biopsy - LA injection around site of sample - Take small amount of tissue to send to lab for analysis - Sutures will be placed to close up wound - Will be sore for about a week - risks: pain, bleeding, bruising, swelling, infection - Sutures will dissolve and come out on their own after 2-4 weeks - Advice will be provided - salt water mouthwashes, softer diet, limit smoking - Review appt will be made to discuss findings Enquire about patient risk factors - Smoking cessation - Reduce alcohol consumption - ideally to 0 Urgent cancer referral guidelines: - persistent unexplained head and neck lumps for >3 weeks - ulceration or unexplained swelling of the oral mucosa for >3 weeks - all red or speckled patches of the oral mucosa persisting for >3 weeks - Persistent hoarseness lasting for >3 weeks (request chest x-ray at same time) - Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks - Persistent pain in the throat lasting for >3 weeks

Answer 88

Urgent cancer referral guidelines: - persistent unexplained head and neck lumps for >3 weeks - ulceration or unexplained swelling of the oral mucosa for >3 weeks - all red or speckled patches of the oral mucosa persisting for >3 weeks - Persistent hoarseness lasting for >3 weeks (request chest x-ray at same time) - Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks - Persistent pain in the throat lasting for >3 weeks

Answer 89

Decal - has the shape of bracket Weakens the enamel to caries, unsightly staining Patient selection - high risk if caries, hx of decal, NCTSL OH - TBI + single tufted brush for brackets Inter-dental brushes and superfloss OHI should include - min 2x daily 2min - dry toothpaste, systematic, modified bass technique - 45 degrees, spit don't rinse - brushing after meals as brackets trap food - disclosing tablets to identify missed areas Diet advice - Limit sugar amount and frequency - Avoid snacks between meals - limit sugar intake to <3x daily - Avoid hard/hot foods, fizzy drinks, sports drinks, sticky sweets, chewing gum - Ideal drinks are water/milk, crackers, cheese, fruit as acceptable snack but be careful of fat in cheese and natural sugar/acid in fruit - Watch out for hidden sugars in foods - Rinse mouth after eating Fluoride use: - toothpaste - duraphat (2800ppm - 5000ppm) 2x daily, ordinary toothpaste at other times Warn re overdose and children Mw - daily 0.05% f mw (225ppm) Use in-between brushing, not after F varnish - PROFLURID (22600ppm) not DURAPHAT - every 4 months This is for prevention - F varnish isnt used for tx of decal as it seals it in Prescriptions: Sodium fluoride toothpaste 0.619% (2800ppm) Send: 75ml Label: brush teeth for 1 minute after meals using 1cm before spitting out, twice daily Sodium Fluoride toothpaste 1.1% (5000ppm) Send: 51g Label: brush teeth for 3 minutes after meal using 2cm, before spitting, 3x daily

Answer 90

Prescriptions: Sodium fluoride toothpaste 0.619% (2800ppm) Send: 75ml Label: brush teeth for 1 minute after meals using 1cm before spitting out, twice daily Sodium Fluoride toothpaste 1.1% (5000ppm) Send: 51g Label: brush teeth for 3 minutes after meal using 2cm, before spitting, 3x daily

Answer 91

Gold standard - cuspal coverage onlay - Gold, composite, porcelain, zirconia - reduces tisk of tooth fracture/catastrophic failure - Less microbial leakage and better seal Full coverage - MCC, GSC, all ceramic, all zirconia - if less tooth structure remains - in order to cover and protect - May require a core build-up - explain to patient that we can use filling material to build up a core which will help retain the crown or "cap" Gold standard is composite core but can also use metal sometimes but isnt as favourable - Sometimes we don't think the core itself will be able to retain the cap and we may need to consider a post, this is a fibre or metal post that sits in the top portion of the root and extends up into the core and helps retain the core which will then help retain the crown. This is often a last resort as it weakens the tooth. - Direct restoration - composite or amalgam - if only occlusal cavity present, not as favourable - more leakage and more likely to fracture, attempt to extend cavity just past the cusps to provide cuspal coverage

Answer 92

Aquacem (GIC) - metal post, MCC, gold restorations, zirconia restorations Panavia (anaerobic cure composite) - adhesive bridges (RBB) Nexus NX3 (dual cure composite) - fibre post, composite/porcelain restorations, veneers

Answer 93

Check on the cast: - Is the restoration as we asked for? - Rocking, M/D contacts, marginal integrity, aesthetics - Check contact points on adjacent teeth on cast to ensure not damaged - can be damaged when prepped tooth is sawn off the cast to invest - Occlusal interference on excursions - Natural teeth contacting (check with shimstock 8μm) Remove crown from cast: - Check if occlusion correct and still the same - Check crown thickness using calipers Crown placed in pt with airway protection - Check all the above - Pt happy with appearance Then cement Post-cementation checks: - Excess cement removed - No space around margins - Interproximal contact point exists and is clear - Occlusion checked with articulating paper (in excursion aswell) - Restoration cleansible - Confirm pt happy with aesthetics and feel

Answer 94

Go through OPT in systematic manner Demographics - Type of X-ray, age, date etc Quality - D/A or A Dentition: Teeth - erupted/unerupted, permanent/primary/mixed, missing/supernumerary, impacted, ectopic Restorations - heavily/moderate/mild restored, overhangs, fractures, poor margins Trauma Disease: Caries - primary/secondary, supra/sub-gingival, PAP Perio - bone levels, localised/generalised, supra-sub gingival calculus Endo - well/poorly compacted, material, mm from apex, separated instruments etc TMJ Other pathology - cysts Diagnosis

Answer 95

● Amoxicillin prescription ○ Metronidazole is the most common antibiotic, but it’s contraindicated due to an alcohol problem. ○ Still get a mark for prescribing metronidazole but have to mention alcoholism on prescription for pharmacist. ● Prescription: ■ Amoxicillin Capsules, 500mg ■ SEND: 9 capsules ■ LABEL: 1 capsule 3 times daily for 3 days ○ Patient’s name - correct place (2 marks) ○ Patient’s address, postcode - in full (2 marks) ○ Patient’s CHI - correct area (2 marks) ○ Number of days treatment - correct number of days - 3 (2 marks) ○ Acceptable drug and formulation - amoxicillin, 500mg capsules (1 mark) ○ Correct drug dose - 500mg (2 marks) ○ Correct frequency - 3x a day (2 marks) ○ Correct duration of treatment - three days (2 marks) ○ Total number of capsules - 9 (2 marks) ○ Prescription signed and dated - correct area (2 marks) ○ Written in indelible ink - pen used (2 marks)

Answer 96

● Big Racks Come Pricey ● Bleeding: ○ If bleeding does occur, arrest with wet gauze using firm pressure for 20 minutes, if unable to arrest, contact the emergency number provided ○ If it doesn’t stop bleeding, phone emergency contact first ○ If continues to bleed/out of hours go to A&E ● Rinsing: ○ Do not rinse the area, for the first 24 hrs ○ After 24hrs you should rinse mouth with warm saline/salt water gently 3-4 times day ● Care: ○ Do not bite lip, cheek or tongue while numb ○ Do not disturb socket with finger, tongue or toothbrush, avoid probing the site ○ Brushing other teeth as normal, avoid that area ○ Inform the patient that they may experience swelling and bruising - should peak at 48hrs, if increasing after this, contact the GDP ○ Avoid hot and hard foods ○ Avoid excessive exercise ○ Eat soft foods on opposite side to extraction for a few days ○ Avoid/Cut down smoking over the next few days/week ○ Avoid alcohol for as long as possible (24 hours) ○ Gentle rinsing after the first day with warm salty water ○ Swelling: peaks at 48 hours, resolves in around 7 days. ■ Can use ice pack today when you go home (5 mins on, 5 minutes off for an hour) ○ If sutures: dissolve on their own in about 2-4 weeks ● Pain : ○ Expect some pain at first ○ Painkillers before analgesia wears off fully ○ Take normal painkillers: Ibuprofen and Paracetamol ○ If pain worsens after 2-3 days return to the practice: possible infection or dry socket ○ Take analgesia as for a headache for 1-3 days after the op and begin before LA wears off ● Provide emergency contact number

Answer 97

ABCDE ● Are you choking? ● 5 back slaps between shoulder blades ● 5 abdominal thrusts between belly button and sternum ● Continually check for object dislodging ● Re-evaluate ABCDE ● BLS if still not resolved ● Call 999 to check for rib fracture

Answer 98

Ask (Smoking history and habits) ○ Do you smoke? ○ What do you smoke? ○ How long have you smoked for? ○ How many cigarettes daily? ○ How quickly do you light up in the morning? ○ Why do you smoke? ○ Does anyone in the family smoke? ○ Do you have any kids in the house? ● Advise (of facts around smoking) ○ Smoking is harmful to general health - cardiovascular and respiratory problems ○ Smoking is detrimental to oral health - risk of tooth loss, reduced ability to heal, staining, periodontal disease, oral cancer ○ Personal: money, bad breath ● Assess (motivation to quit) ○ Are you interested in giving up now? ■ Ask about motivations to quit ○ Have you tried to quit in the past? ■ Why were you not successful? What worked in the past? ● Assist ○ Would you like help from the local stop smoking services ■ Increases quitting likelihood by 4 times ■ Best and evidenced based Tx = NRT - can help in the following ways: ● Champix ● Patches ● Gum ● E-cigs: ○ New to market: don’t fully know side effects ○ Respiratory side effects: fluid in lungs ○ Likely less harmful than tobacco ○ Don't vape around children ○ No long term health data ○ Maintain habit and culture of smoking ● Refer ○ Those interested to local cessation services such as pharmacy, GP and stop smoking services ○ Self referral – Quit Your Way Scotland 0800 848484 or visit www.canstopsmoking.com ○ Run by NHS24 and staffed by trained advisors – talk, refer, offer quit packs ○ Offer written material ○ Arrange follow up ● Actor marks: non judgemental, clear and easy to understand advice, listening, good eye contact, open body language

Answer 99

Diagnosis: Fractured right cheek bone ● E/O exam: ○ Lacerations ○ Nasal bleeding/deviation/patency (by obstructing each nostril) ○ Palpation of zygoma bilaterally (supra/infra-orbital rims, zygomatic arch) from behind ○ Facial asymmetry ○ Limitation of mandibular movement? ○ Examination of sensation of infra-orbital region ■ 3 areas supplied by infraorbital nerve: upper lip, lateral nose, lower eyelid ○ Eye examination ■ Periorbital ecchymosis, subconjunctival haemorrhage ■ Vision assessment – pupillary reaction to light ■ Ask if presence of double vision (diplopia) – (haematoma, muscle/nerve injury) ■ Eyeball mobility assessment – steady pt’s head and ask to follow finger (to 6 points) ● Particularly upwards: either superior rectus nerve supply severed or more commonly the inferior rectus is trapped due to an orbital floor fracture ● I/O features: ○ Tenderness of the zygomatic buttress ○ Bruising/swelling/haematoma ○ Occlusal derangement and step deformities ○ Lacerations (esp. gingivae) ○ Loose or broken teeth ○ Anaesthesia/paraesthesia of teeth in the upper right quadrant + gingivae above incisor/canine ● Further investigations: ○ Radiographs - OM 15/30 or CBCT or CT ● Identification of relevant radiographic findings: ○ Correctly identifies fractures of the right cheek bone, radio-opacity of the sinus. ■ Always compare right side from left ● Further management of the patient: ○ Urgent phone to an OMFS unit or A&E dept for advice and URGENT referral ○ Surgical management: ORIF (if symptomatic e.g. diplopia/asymmetry/enopthalmos) ○ Conservative management if undisplaced, asymptomatic or >1-month-old

Answer 100

● Introduce self & designation (1 mark) ● Gather info about patient's coagulation status: ○ Ask about INR: when it was last done and what the value was (2 marks) ● Ask to see patient’s INR book (1 mark) ● Detailed and valid explanation as to why the tooth cannot be extracted today (4 marks) ○ No jargon! ○ ‘Due to high risk bleeding; which is a result of the warfarin; values above the recommended level for safe extraction’ ● Reference to relevant guidelines (1 mark) ○ SDCEP: INR ideally within 24hrs, 72hrs if stable (stable = INR <4 for last 3mths) ○ Proceed with procedure without interrupting medication IF INR <4 ● Convincing patient and NOT proceeding with extraction (4 marks) ● Deal with patient’s pain (4 marks) ○ Acknowledge the pt is in pain and discuss dealing with the pain ■ analgesia +/- pulp extirpation/sedative dressing ● Ask if the pt understands the explanation and if they have any questions (2 marks) ● Engaging with patient/eye contact/good communication (2 marks) ● Actor marks: communication, empathy, simple language (2 marks)

Answer 101

Introduce self & designation (2 marks) ● Explain that alendronic acid is a bisphosphonate drug (1 mark) ● Explain mode of action of bisphosphonate drugs ○ Bisphosphonates drugs reduce the turnover of bone (1 mark) ○ Bisphosphonates accumulate in sites of high bone turnover = jaw (1 mark) ● Explanation of relevance of bisphosphonates to dentistry ○ There is a risk of poor wound healing following a tooth extraction (1 mark) ○ Need to remove any teeth of poor prognosis prior to beginning drug therapy (1 mark) ○ Important to do everything possible to prevent further tooth loss in the future (1 mark) ○ Reduced turnover of bone and reduced vascularity can lead to death of bone - osteonecrosis (1) ● Specifically name ‘MRONJ’ (1 mark) ● Risk of MRONJ in Osteoporosis - Low risk (1 mark) ● Making clinical diagnosis ○ Chronic periapical periodontitis (1 mark) ○ Gross caries in correct tooth (36) (1 mark) ● Explaining Clinical diagnosis in terms the patient can understand ○ Area of infection associated with left back tooth (36) (1 mark) ○ The tooth is too decayed to have a filling put in it (1 mark) ● Discuss tx options ○ Extraction is only option (1 mark) ○ Tooth is grossly carious beneath the gumline and therefore unrestorable (1 mark) ○ If tooth is kept risk of MRONJ after beginning therapy (1 mark) ● Ask if the pt has any questions (1 mark) ● Actor marks: empathetic/professional approach (2 marks)

Answer 102

Introduce self & designation (1 mark) ● Ask about presenting complaint/reason for attendance (1 mark) ● Ask when pain began/how long pt has had pain (2 marks) ● Ask about changes over time (2 marks) ● Ask about site of pain (2 marks) ● Ask about character of pain now - offer prompt: aching/throbbing etc. (2 marks) ● Ask about stimulants - offer prompt: hot, cold etc. (2 marks) ● Ask about relieving factors - offer prompt: cold, analgesics etc. (2 marks) ● Ask about duration of pain - offer prompt: minutes, longer, constant etc. (2 marks) ● Ask if kept awake (2 marks) ● Provisional diagnosis: Irreversible pulpitis (4 marks) ● Note taking: legible, well ordered, complete (4 marks) ● Actor marks: clear communication, showed empathy (4 marks)

Answer 103

Back cap checked: Gripped and turned anti-clockwise ● Bur security checked: Suitable force applied to remove bur ● Tension applied to handpiece when fitted to coupling: Assesses if handpiece is attached safely ● Bur rotated laterally with fingers: Attempts to spin bur, rolls along finger ● Attempts to move bur laterally: Pushes bur from side to side a few times ● Handpiece sound tested when running: Runs for 5 secs or more, views bur movement

Answer 104

Explain nature of injury in simple terms ○ Enamel dentine pulp fracture or complicated pulp fracture ● Explain treatment : PULPOTOMY (open apex) ○ As this is a large exposure the tx of choice is called a pulpotomy ○ Explain partial removal of pulp ○ Explain that aim is to keep undamaged pulp tissue alive ○ Explain that this is so the tooth stays alive and continues to grow ● Baseline sensibility tests ○ Tests required to see how the nerve in the injured and adjacent teeth respond ○ Tests required as baseline reading for long term monitoring ● LA required ○ Parent informed that LA is required ○ Required to keep patient numb and comfortable ○ Describe that LA involves injection in the gum ● Dental Dam ○ What this is - rubber sheet over tooth acts like mask ○ Why dam is placed - moisture control, protects airway ● Drilling/use of handpiece ○ Drill will be used to remove some pulp tissue ○ Aim is to leave only good tissue ● Dressing ○ Indicate that the tooth will be dressed; Setting CaOH, MTA ● Composite restoration ○ Indicate that a white filling will be placed to regain aesthetics ● Actor marks: Describing tx in an understandable manner, supportive and empathetic regarding injury

Answer 105

Pt details correctly entered on to form ○ Sticker (CHI number, Hosp. Number, Name, Sex, Address, D.O.B) ○ + Hospital department, Date, Time, Consultant, Requested by, Phone no. ● Clinical details entered on to form ○ Pain, swelling etc ○ Other relevant information - MH: nil of note ○ Provisional diagnosis - dentoalveolar abscess ● Specimen details including site ○ Type of sample - pus aspirate ○ Details of site - buccal mucosa of 26 ● Investigation ○ Culture & sensitivity testing: bacterial/fungal ○ PRC and viral load: virus ○ Histopathology: tissue biopsies ● Wearing appropriate PPE when handling specimen ○ Examination gloves worn when handling specimen ● Removal of needle ○ Needle safely removed. (needle removed from syringe with sheath intact) ● Disposal of needle in yellow sharps bin ● Sealing syringe for transport ○ Red cap placed onto syringe hub ● LABEL SYRINGE with pt details & placed in plastic bag attached to request form ○ Fully labelled syringe in sealed bag with red hub cap in place & needle removed

Answer 106

Pre-cementation checks: ○ Is it the restoration as asked for? ○ Check on the cast ■ Rocking, M/D contact points, marginal integrity, aesthetics ■ Check contact points on adjacent teeth on cast to ensure not damaged ● Can be damaged when prepped tooth is sawn off the cast to invest ■ Occlusal interference on excursions ■ No natural teeth contacting (checked with shimstock 8μm) ■ Inadequate reduction DL cusp ○ Remove crown from cast ■ Check if the natural teeth occlude properly now ■ Check if tooth is under-prepped ■ Measure crown thickness using calipers ● Minimum 0.5mm circumferential ● Minimum 1.5mm for functional cusps (1.0mm for non-functional) ● Management ○ Check amount of interference by dropping incisal pin and calculate the difference ■ If do-able to reduce crown without making it too thin then adjust and cement, otherwise... ○ Re-do prep and send back to lab ■ Follow crown prep principles: Ideal taper 6o , retentive grooves/slots, bevel functional cusps, two plane buccal reduction, smooth prep margin at gingival margin ● Avoiding fault in future ○ Measure temp crown thickness before cementing ○ Use sectioned putty index when prepping

Answer 107

Smoker + Alcohol + Acid Erosion/NCTSL + Perio disease + Impacted 8’s. ● Immediate ○ Pain (Pericoronitis? Toothache? Perio abscess? PAP?) ● Initial ○ HPT: ■ Diet advice: including erosion ■ Consider medical referral if GI intrinsic acid ■ Smoking cessation, alcohol advice ■ Supragingival scaling, RSD ○ Removal of non-symptomatic teeth of poor prognosis: Impacted 8’s ■ Inform of risks: pain, swelling, bleeding, bruising, infection, dry socket, IDN damage leading to numbness/altered sensation that can be temporary/permanent ○ NCTSL management ■ Find cause: Diet? Alcohol? Medications? MH? Habit? Parafunction? ● Tx: diet diary, study casts, photos, DBA, GI, composite ■ Fluoride – toothpaste, mouthwash ■ Dietary advice: change habits - don’t swill drink around mouth, use straws, watch ‘healthy eating’ acids (5-a-day), avoid sports gels/drinks - milk/water instead, chew gum, cheese ■ Desensitising agents – stannous fluoride, potassium nitrate - for symptomatic relief ○ Caries management ○ Endodontic treatment: temporary restorations ● Re-evaluation ○ Perio: 6-8 weeks post completion ○ NCTSL (pics, casts) ● Re-constructive ○ Filling spaces: Dentures, Bridgework, Implant? ● Maintenance ○ Perio, NCTSL

Answer 108

Build-up and Diagnosis: ○ ‘Are you aware of what we’re here to discuss today?’ ○ ‘You were here a few weeks ago complaining of painful ulceration...etc and we took some bloods to see if we could identify what is causing your symptoms.’ ○ ‘Would you like for me to talk through our findings?’ ○ ‘Let me start by saying there is nothing sinister going on here…’ ○ ‘But your bloods showed that you have developed a type of anaemia called microcytic anaemia caused by an iron deficiency in your blood’ ● Description of disease: ○ ‘Iron deficiency anaemia is a condition where a lack of iron in the body leads to a reduction in the number of red blood cells.’ ○ ‘Iron is used to produce red blood cells, which help store and carry oxygen in the blood.’ ○ ‘If you have fewer red blood cells than is normal, your organs and tissues won't get as much oxygen as they usually would.’ ○ ‘Many people with iron deficiency anaemia only have a few symptoms.’ ○ ‘Most common symptoms are tiredness and lack of energy (lethargy), shortness of breath, noticeable heartbeats (heart palpitations) and a paler complexion’ ○ ‘In addition, In some cases, including yours, people develop minor ulceration in the mouth’ ● Aetiology: ○ ‘There are many things that can lead to a lack of iron in the body.’ ○ ‘Sometimes it can simply be explained by a lack of iron in the diet.’ ○ ‘However there are other common causes like heavy menstruation (if woman) or bleeding in the stomach and intestines which can be caused by a stomach ulcer or taking NSAIDs.’ (or stomach/bowel cancer but don’t say this) ● Management: ○ ‘Iron deficiency can easily be managed with iron supplements and an increase of iron in the diet.’ ○ ‘This would also resolve the minor ulceration in your mouth which tend to go away in 1-2 weeks without scarring.’ ○ ‘Your GP should be able to prescribe you iron supplements in tablets to be taken twice daily and might chose to investigate you further to determine if there is an underlying condition.’ ○ ‘My advice in the meantime is to try to increase the iron in your diet, avoid spicy foods like curries and if your mouth is very sore (can’t eat etc) I can prescribe a numbing m/w to allow you to be more comfortable’ ■ Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using 15ml every 1.5 hours as required ● Can be diluted 1:1 with water if stinging - Spit out after rinsing - not more >7 days ● Diet advice: ○ Dark-green leafy vegetables, such as watercress and curly kale, iron-fortified cereals or bread, brown rice, pulses and beans, nuts and seeds, meat, fish, tofu, eggs, dried fruit (prunes/raisins) ○ Vit C rich foods/drinks help body absorb Fe ○ Tea, coffee and calcium (found in dairy products like milk) make it harder to absorb iron ■ Only in large quantities ● Summary ○ Reassure patient - common condition ○ Ulcers go away in up to 2 weeks without scarring ○ We know what the cause is and we can manage it ○ Any questions? ● Actor marks communication and simple language

Answer 109

Causes of retained ULA/Unerupted 21 ○ Trauma to A - causing damage to the 1 ■ Complications: Ankylosis, arrested tooth (21) formation, dilaceration, displacement ○ Lack of permanent successor/Hypodontia ○ Ectopic tooth germ ○ Crowding ○ Supernumerary: tuberculate most common ● Signs: ○ Discolouration of A, retained A ○ Radiographic ○ Lateral erupted before central ● Investigations: ○ Radiographic localisation for ortho treatment ■ Another PA or anterior occlusal, or alternatively OPT and occlusal, CBCT for 3D view ● Management: ○ Always palpate: usually U1 is buccal and central (high) ○ Options: ■ Leave and monitor - inform of possible cyst or resorption ■ Extract retained A (leave U1) and space maintenance (warn of cyst formation risk) ■ Surgical removal of both teeth and space maintenance ■ Refer for orthodontic opinion/Tx - Inform of possible ortho tx benefits/risks ■ Auto-transplantation ○ Other options: ■ Extract retained A and hope spontaneous eruption (very unlikely since dilacerated) ■ Expose (closed or open) +/- bonding/traction (won’t work if dilacerated)

Answer 110

Brief history: ○ Take pain history ■ How long for? Any analgesia (calpol)? How much analgesia? - within limits ○ Feeding bottle to bed? ○ What is in the feeding bottle? ● Look at pics carefully to identify pattern of decay ○ Pattern is usually upper incisors, D’s and lower canines (lower incisors protected by tongue) ● Advice: ○ Feeder cup replacing bottle from 6 months ○ No feeding at night (lactose in milk - decreased salivary flow and held in mouth) ○ No on-demand breastfeeding ○ No sweetened milk, soy milk (unless medically advised) ○ Milk and water only between mealtimes ○ Sugarfree variations of drinks/foods/medicine (e.g. sugar-free calpol) ○ Safe snacks include, cheese, breadsticks, fruit, plain crisps ○ Toothbrushing: ■ Assist the child until 7yo ■ Brush in the morning and last thing at night ■ No food/ drink except water after brushing ■ Spit don't rinse ● Management: ○ Extraction of carious teeth under GA: as in pain (discuss GA risk and benefit) ○ GIC remaining teeth and review: if no pain (acclimatisation) ○ Fluoride (supplements + varnish) ● Extra points for empathy

Answer 111

Process ○ Discussion of GA risks/benefits and all other alternative options ○ Referral to hospital for specialist to assess - if any other teeth of poor prognosis they will be added to this plan to avoid future GA ○ GA will involve day in hospital - need to monitor for full recovery ○ Need of chaperone throughout. ● Risks ○ Very common minor risks: ■ Headache, nausea, vomiting, drowsiness ■ Sore throat or sore nose/nose bleed from intubation ○ Risks from treatment: ■ Pain, bleeding, swelling, bruising, infection, loss of space, stitches ○ Rare major risks: ■ Brain damage ■ Death (say as follows): ● 3 in a million. Need a machine to breathe during op and there is a very small risk that you will not be able to breathe independently again on waking - ie never waking again. ○ Upset when coming round - can make underlying anxiety worse ○ Malignant hyperpyrexia (v. rare - important to ask for FH) ● Conditions requiring special care (can be contraindications) ○ Sickle cell disease (or any hypoxia) ○ Diabetes - can’t fast in same way ○ Down’s syndrome ○ Malignant hyperpyrexia ○ CF or Severe asthma ○ Bleeding disorders ○ Cardiac or Renal conditions ○ Epilepsy ○ Long QT syndrome ● Referral ○ 1. Patient name ○ 2. Patient address ○ 3. Patient/Parent contact numbers (landline and mobile) ○ 4. Patient medical history ○ 5. Patient GP details ○ 6. Parental responsibility ○ 7. Justification for GA ○ 8. Proposed treatment plan ○ 9. Previous treatment details ■ Letter must include: ■ Recent radiographs or if not available an explanation of why (e.g. pt uncooperative) ● Assessment appointment: ○ For treatment planning ONLY and plan may change with specialist opinion ○ **Informed consent - MUST be written ○ GA process, side effects and complications ○ Adult escort with no other children ○ Pre-operative fasting ○ Post-operative arrangements ○ Post-operative care and pain control

Answer 112

Explain to pt: pulp exposed and requires pulp cap (explain what is) ○ Likely no actor so no need ○ Address the need: vital therapy and risk of possible death of pulp which requires RCT ● Tooth must be asymptomatic, vital, no history of pulpitis (e.g. prolonged pain, toothache) ○ Pulp exposure must be small and surrounding dentine must be relatively hard - otherwise extripate ● Dam should have been on before the pulp was exposed - saliva contamination must be avoided. ● Haemorrhage from exposed pulp - copious irrigation with sterile saline (arrest bleeding with saline) ● Cavity irrigated with chlorhexidine (0.2%) (Clean with CHX, after bleeding arrested) ● Cavity is blotted dry using sterile cotton wool pledgets. (Do not air dry) ● Exposed pulp covered with hard-setting calcium hydroxide cement (Dycal or Life) ● RMGI lining placed (Vitrebond) and the restoration completed as planned. ● Continuing vitality monitored: if symptomatic RCT required.

Answer 113

Cleanse cavity with 0.2% w/w chlorhexidine. ● Stained firm dentine is left in situ and covered with a setting calcium hydroxide cement (Dycal or Life). ● A stronger lining material is placed (RMGIC – Vitrebond) to protect the Ca(OH)2 and the tooth is restored with a provisional restoration (GI or RMGI). ● The tooth must be vital, asymptomatic and have no history of previous pulpitis. ● The tooth is monitored for 3 months and if vital and asymptomatic, the provisional restoration should be removed, stained dentine carefully excavated and definitive restoration placed. ● If there have been any pulpal symptoms, then RCT should be undertaken.

Answer 114

Ideally prior discussion with patient that if carious pulp exposure then RCT or XLA will be required ○ + Dam has been placed ● Extirpation - Pulpectomy ○ Remove as much pulp tissue as possible with sterile excavator and file/barbed broach ● Odontopaste dressing if tooth vital, Ultracal if non-vital. ○ Odontopaste/Ledermix (antibiotic/steroid agent) as palliative agent in anticipation of RCT/XLA ● Cotton wool roll + GIC restoration

Answer 115

Diagnosis: ○ ‘Mrs Smith, you have a very common condition, in fact around 75% of the population get it at one point in their life. .... It is called temporomandibular disorder, or TMD …’ ● Explanation: ○ ‘The jaw joint sits in base of skull and muscles control opening and closing. Now, like any muscle in the body, if overworked they get tired e.g. if you climb a mountain legs are sore for next few days.’ ○ ‘However, as your jaw joint gets used all day everyday like for speaking and eating it never gets a rest. Muscles become inflamed and sore.’ ○ ‘The fact that you’re sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more’ ○ ‘The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw bones and snaps in place’ ○ Could draw a wee diagram to show disc and explain that when muscles not in harmony the disc is pulled at wrong time to create clicking noise or disc trapped in front of jaw bones crushing the tissue that can cause pain. ● Management: ○ Reassurance! - “The way we manage this is very simple’ ○ ‘It involves resting the joints’ ■ soft foods/cut in small pieces, chewing on both sides, avoid chewy foods/gum, avoid wide opening, avoid stifling yawns, avoid grinding during day, avoid habits (biting nails) ○ Conservative advice including analgesia (paracetamol/ibuprofen) and heat packs. ○ Evidence to show yoga helps and general stress reduction is beneficial. ○ Make splint to break nocturnal habits ● Summary ○ Reassurance - common condition with simple conservative management ○ Important to reduce stress ○ Inform that other symptoms like tongue scalloping and linea alba are caused by the clenching and also go away on management of condition. ○ Ask if any questions ○ Actor marks for communication, simplicity of language and empathy.

Answer 116

Overview of marks: 1. Student listens and is empathetic 2. Asks patient what patient is expecting outlook to be or what they want from appointment 3. Asks permission to continue findings 4. Break news slowly in chunks 5. Avoids jargon, or explains if used 6. Allows patient time to take in information and gives chance to ask questions 7. Repeats the news 8. Summarises what they’ve said 9. Gives patient replacement options 10. Actor asked if they understood, been shown empathy ● Setting: ○ Sitting down at same level as them ○ Try to make them as comfortable as possible ● Perceptions: ○ What does the patient understand has happened up until now? ■ ‘Are you aware of what might be wrong?’ ○ What is patient expecting from appointment? ● Information: ○ Inform patient that you would like to discuss the prognosis of the tooth ○ Ask them if they would like to discuss that...they’ll say yes ● Knowledge ○ Give a warning shot ■ ‘I wish I had better news’ ■ ‘I’m afraid the news are not good’ …. pause for a bit ○ Give them the knowledge of what you know ■ ‘Your tooth is unrestorable and requires to be extracted’ …big pause… ○ Let it sink in and let them dictate the pace of the conversation from here ■ They might want to know loads of info really quickly or they might be in shock ■ Give them chance to ask questions ● Empathy: ○ Words to the effect of ■ ‘I am deeply sorry to break this to you’ ■ ‘I understand this must be hard for you’ ● Summary and close: ○ Repeat the news ○ Summarise what you’ve told them and the plan for going forward ■ ‘We will aim to restore this tooth as soon as possible for you’ ■ Immediate options: ● Immediate denture in the short term then extraction ● Bridge using their own sectioned crown if available ● Direct polycarbonate crown bridge ■ Permanent replacement options: ● Bridge, Denture, Implant (need 3 months for bone around XLA socket to stabilise) ■ Do NOT mention unrealistic interventions - assess by case ○ Ask of any questions they might have ○ Ensure the patient has a clear plan of what will happen next and your roles ○ Offer them a follow-up appointment or phone number for any questions

Answer 117

Anterior flange missing: ○ Remove undercuts, build flange with greenstick and reline ○ Rebase if not possible or remake if necessary ● Midline Diastema: ○ If want to keep physical aspects of denture, but change aesthetic only ■ Replica (2 stage putty around denture, vaseline to separate) ■ Wax replica used for functional impression + jaw registration ■ Ask lab to close diastema for tooth trial stage ○ Remake if other problems ● Underextended posteriorly at tuberosities: ○ Reline: if functionally good and only problem ○ Remake: if everything bad ● Locked occlusion: ○ Remake with replica technique and use cuspless teeth ● Base plate too thin: ○ Rebase thicker or Rebase using high impact resin. Or remake ● Tori: ○ Relieve clinically if only problem or ask for tin-foil relief ○ If too thin or other problems: rebase or remake and ensure lab waxes undercuts ● Tooth position wrong: ○ Remake ● Occlusal table too long - ie too many posterior teeth over the tuberosities: ○ Remove posterior teeth/ grind down - or remake

Answer 118

Problems with denture ○ Impression surface: ■ Cause: poor impression (lack of post dam, poor adhesion to tray), damage to cast ■ Solutions: reline/rebase, remake, add post dam using reline ○ Occlusal surface: ■ Cause: premature occlusal contact, centric occlusion/relation not coincident, high lower occlusal plane restricting the tongue, locked occlusion ■ Solutions: cuspless teeth, selective grinding, re-recording centric occlusion, remake ○ Polished surface: ■ Cause: Overextension, underextended (depth &/or width), not in neutral zone ■ Solutions: remove overextension (esp. lingual lower, use pressure indicating paste, allow fraenal relief and flange), add greenstick to underextension and reline, remake if extensive ● Problems with denture wearer: ○ Poor neuromuscular control e.g. stroke, Parkinson’s ○ Unstable foundations ■ Anterior flabby ridge ● Solution: perforated trays + light bodied PVS impression (Or special tray with surgical window and take a wash and cut it out + light bodied PVS) ■ Atrophic lower ridge: ● Solution: admix technique (3 parts imp compound, 7 greenstick) ■ High fraenal attachments ● Solution: provide relief ■ Palatine tori: ● Solution: relief of area on cast before processing ○ Xerostomia

Answer 119

Diagnosis ○ ‘Mr Smith I’m afraid you’re suffering from a condition called acute necrotising ulcerative gingivitis, or ANUG...’ ○ ‘This is a rare condition presenting as an acute form of gum disease’ ○ ‘This means that the gum disease develops much faster and more severely than normal’ ● Aetiology ○ ‘It can be caused by a variety of reasons but it tends to cluster in people who are stressed, smokers and poorly nourished’ ■ poor OHI, stress, smoking, immunocompromisation, malnourished ○ ‘It can be made worse by high plaque levels due to poor brushing’ ● Symptoms ○ ‘Common symptoms include bleeding/painful gums, painful ulcers, receding gums in between your teeth, bad breath, a metallic taste in your mouth, excess saliva in the mouth and difficulty speaking or swallowing’ ○ ‘The disease can also extend away from the mouth and can cause systemic symptoms like swollen lymph nodes or a high temperature (fever)’ ● Management ○ Reassurance as it can be managed by local measures ■ OHI ■ NsHPT inc RSD (under LA) ■ M/W: CHX 0.2% or hydrogen peroxide, 6% ○ Smoking cessation!! ○ Stress reduction ○ As systemic: lymphadenopathy: ■ Antibiotic prescription - 3 days ● Metronidazole (400mg, Take 1 capsule 3 times per day, for 3 days) ○ No alcohol - vomiting, nausea ● Amoxicillin (500mg, Take 1 capsule 3 times per day for 3 days) - check for allergy ○ Recommend optimal analgesia ○ Advise register with GDP ○ Review within 10 day ○ Referral if no changes on review

Answer 120

● Talk about getting them dentally fit, improving their oral hygiene & looking after their oral health. ○ Chemotherapy puts a toll on the entire body, including the mouth ■ ‘Chemotherapy knocks out your immune system, putting you at risk of getting infections’ ■ ‘We want to limit/reduce/remove sources of potential future infection from your mouth before you start’ ○ GDP attempt to reduce complications in chemotherapy regimen ■ Avoid unscheduled interruption of chemotherapy regimen ■ Remove potential sources of infection ■ Avoid exacerbation of mucositis ■ Minimise effects of vomiting (acid erosion) to dentition ○ Finally, plan prevention and rehabilitation ● Tx to be carried out: ○ Full mouth scaling ○ Remove any dubious prognosis teeth or areas of possible infection ■ Normally XLA need ~10 days to heal ■ Should not be done during chemo due to high risk of infection ■ If done after chemo - again higher risk of infection, slower healing, MRONJ ○ Impression for soft splint ○ Smooth down sharp teeth ● Pre-Treatment Prevention: ○ Oral Hygiene ■ x2 brushing daily at least 2 mins time at a time ■ prescribe 2800ppm duraphat (0.619%) ■ interdental cleaning - specifically instruct how to use ○ Fluoride therapy: ■ fluoride varnish, Duraphat toothpaste, trays to fill at night ○ Diet advice ■ avoid spicy and hot foods, avoid fizzy drink, fruit juices, acidic fruit ○ Smoking and alcohol advise if relevant to SH ● Mid-Treatment Management: ○ Minimal role unless emergency +/- manage pathology ➢ Mucositis ■ Inflammation and ulceration, severe pain requiring analgesia, impact on eating and OH ■ Management: ● General: Avoid smoking, spirits, spicy foods, tea, coffee, non-prescription medicine ● Topical: oral cooling prior therapy – ice, topical lignocaine, saline, sodium bicarbonate, benzydamine hydrochloride, gelclair, caphasol, tea tree oil m/w ➢ Candidosis: Pseudomembranous candidosis (Thrush) - Antifungals ➢ Herpes Simplex reactivation ● Post-treatment Palliative Care: ○ Maintenance of oral and dental health ○ Prevention: diet, OH, fluoride ○ Monitoring: increased frequency check-ups, pros maintenance ➢ Altered taste ➢ Trismus - if radiotherapy was to H&N ➢ Periodontal disease ➢ MRONJ ■ Only if cancer therapy consisted of anti-resorptive or anti- angiogenic drugs ■ Risk = 3% after XLA, = 1% spontaneous ● (compared to 0.1% in non-cancer patients on anti-resorptives/anti-angiogenics) ➢ Dry mouth ■ Decreased salivary flow: 50-60% in first week, further 20% in next 5-6 weeks ■ Change in saliva consistency and character: increased viscosity, decreased pH ■ Change in taste perception ■ Recovery over period of years, will not return to normal ■ Associated problems: dysphagia, dysarthria, dyspepsia, quality of life ■ Increased risk of: caries, perio, candidiasis, sialadenitis, prosthodontics difficulties

Answer 121

Problems ○ Increased OJ (1 mark) ○ Increased OB (1 mark) ○ Peg Lateral (1 mark) ○ Ectopic Canine (4 marks) ● Dental Health Implication ○ Risk of trauma from OJ (1 mark) ○ Risk of trauma from OB (1 mark) ○ Risk of root resorption (1 mark) ○ Risk of cyst formation (1 mark) ● Position determination from radiographs provided - detailed use of parallax and explanation (4 marks) ○ Parallax – OPT and oblique occlusal radiograph views - had to explain how you get your answer ■ Vertical parallax - SLOB ■ Explanation: The tube head shifted up from OPT to oblique occlusal, the canine moved together with the tubehead compared to the incisor. According to SLOB rule, the canine is palatal to the incisor.

Answer 122

Examiner asks: What kind of articulator are these casts mounted on? ○ Average value (1 mark) ■ Also: simple hinge, semi adjustable and fully adjustable ● Upper design (2 marks) & Lower design (2 marks) ○ Design correctly and neatly copied. ○ Rests, major connectors, saddle areas and clasps all drawn correctly onto prescription ● Lab prescription supplied ○ Position of all 8 occlusal rest seats identified (4 marks) ○ 4 I-bars correctly identified (2 marks) ○ 2 occlusally approaching and 2 ring clasps identified (2 marks) ○ Mid palatal strap and lingual bar (2 marks) ● Area providing reciprocation ○ Reciprocation is provided by any part of the denture that is directly opposite a clasp arm. ○ Resist lateral movement of teeth from forces of clasps/retentive component during insertion. ○ Should indicate all 8 areas (2 marks) ● Indicate what bracing is and what parts of denture provide bracing ○ Bracing is the resistance to lateral movements (1 mark) ○ Correctly identify elements that provide resistance to lateral movement (1 mark)

Answer 123

Identify dangers and how to rectify ○ Bracket table: LA needle unsheathed, scalpel, tooth in forceps, endo files ○ Surgery: Sharp box on floor, gloves in sink, blood spillage ● Know waste streams ○ Black: household waste - packaging, hand towels ○ Orange: low risk clinical waste ■ Swabs, dressings and other non-sharp clinical waste e.g. dam, micro brush ○ Yellow: high risk clinical waste (we don't have this on clinic) ■ Body parts including teeth ○ Red: Specialist, hazardous waste ■ Dispose of amalgam in white box with red lid. ■ Spill/leak proof. Mercury vapour suppressant in lid. ■ Amalgam waste, amalgam capsules, amalgam filled teeth ○ Blue: Sharps including vials with medication or pharmaceuticals remaining ○ Dispose of sharps in sharps bin (orange stream): 3As, 2Ns ■ Always dispose of sharps in the sharps box immediately after use ■ Always keep out of reach of children and non-authorised personnel ■ Always close sharps box between use using temporary closing mechanism ■ Never retrieve anything from sharps box ■ Never fill more than ¾ full ● Place sharps box at waist height on a flat surface - sharp box on floor here! ● Blood spillage and how to deal with it ○ Stop what we are doing ○ Apply appropriate PPE ○ Cover spill with disposable paper towels ○ Apply sodium hypochlorite/sodium dichloroisocyanurate – liquid/powder/granules (10,000ppm) ○ Leave for 3-5 minutes, use scoop to take up the gross contamination and put into orange waste ○ Clean with water and general purpose neutral detergent disinfectant wipes

Answer 124

Possible causes of white patch: ○ Hereditary, Keratosis (Smoking, Traumatic), Lichenoid, Lupus, Pseudomembranous or Chronic Hyperplastic Candidiasis (not in this site), Carcinoma/SCC ● Discussing the lesion ○ ‘The lesion on the FOM has a number of possible causes. Some of these are harmless and benign. However, some causes could be more serious and possibly cancerous.’ ○ ‘As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’ ○ ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’ ● Information on what to expect at OM: ○ Biopsy ■ LA injection around the site of the sample ■ Taking a small amount of tissue to send to the lab for analysis ■ Sutures will be placed to close up the wound ○ Post-op advice ■ It will be sore for a week after the procedure, similar to having an ulcer ● Risks: pain, swelling, bleeding, bruising, infection, numbness/altered sensation ■ Sutures will dissolve and come out on their own in around 2-4 weeks ■ Advice will be provided - salt water mouthwashes, softer diet, limit smoking etc ■ Review appointment to be booked to discuss findings ● Management of Risk factors ○ Smoking cessation advice ○ Reduce alcohol consumption ■ Don’t mention 14 units - Consider the lesion as a wake-up call to quit ● Urgent cancer referral guidelines: ○ Persistent unexplained head and neck lumps for >3 weeks ○ Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks ○ All red or speckled patches of the oral mucosa persisting for >3 weeks ○ Persistent hoarseness lasting for >3 weeks (request chest x-ray at the same time) ○ Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks ○ Persistent pain in the throat lasting for >3 weeks

Answer 125

Decal - has the shape of backet ○ Weakens the enamel to caries ○ Unsightly staining ● Pt selection ○ High risk if caries history evidence of decal, NCTSL ● Oral Hygiene ○ Toothbrushing + single tufted TB for brackets ○ Inter-dental brushes and superfloss ○ O.H.I. should include ■ minimum twice per day VERY thoroughly ● Dry toothpaste, methodical: work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 minutes, spit don’t rinse ■ brushing after meals as brackets trap food/plaque ■ disclosing tablets to identify missed areas ● Diet advice ○ Limit sugar amount and frequency ○ Avoid snacks between meals – limit sugar intake to <3 times daily ○ Avoid hard/hot foods, fizzy drinks, sports drinks, sticky sweets, chewing gum ○ Ideal drinks are water or milk, crackers, cheese, fruit is acceptable snack but be careful of fat in cheese and natural sugar/acid in fruit ○ Watch out for hidden sugars in foods such as tomato soup and ketchup. ○ Rinse mouth after eating ● Fluoride ○ Toothpaste ■ Duraphat – 2800 ppm (0.619%) – 5000 ppm (1.2%) ■ Twice daily, ordinary toothpaste at other times ■ Warn re overdose and children ○ Mouthwash ■ Daily 0.05% fluoride mouthwash (225ppm) ■ Use IN-BETWEEN brushing, NOT after ○ F Varnish ■ Proflurid (22600ppm) - not duraphat ■ Every 4 months ● *This is for prevention - F varnish isn't used for tx of decal as it seals it in ● Prescriptions: ○ Sodium Fluoride Toothpaste 0.619% (2800ppm) ■ Send: 75ml ■ Label: brush teeth for 1 minute after meals using 1cm before spitting out, twice daily ○ Sodium Fluoride Toothpaste 1.1% (5000ppm) ■ Send: 51g ■ Label: brush teeth for 3 minute after meal using 2cm, before spitting, 3x daily

Answer 126

Gold standard: Cuspal coverage onlay ○ Gold, composite, porcelain, zirconia ■ Reduces risk of tooth fracture/catastrophic failure ■ Less microbial leakage/better seal ● Full coverage: MCC, GSC, all ceramic, all zirconia ○ If less tooth structure remains - in order to cover and protect ● Direct restoration: composite or amalgam ○ If only occlusal cavity present ○ Not as favourable: more leakage, more likely to fracture ○ Attempt to extend cavity just past the cusps to provide cuspal coverage. ● Core build up if necessary: ○ Gold standard: Composite core ○ Explain to pt the tooth has been hollowed out need to put filling material to fill up the space and retain the crown ○ Nayyar core - not favourable ○ Metal cast post if necessary - not favourable

Answer 127

Caries risk assessment: 7 things ○ clinical evidence, diet, MH, SH, saliva, plaque control, fluoride exposure ● Prevention: 8 things ○ radiographs, diet advice, tooth brushing instruction, strength of fluoride in toothpaste, fluoride supplement, fluoride varnish, fissure sealant, sugar free medicine ● Prevention: High risk ○ Toothbrushing advice: ■ Assist child with brushing until able to brush independently (7yrs) ■ x2 daily with fluoride toothpaste ■ Demonstrate on child 6 monthly, get parent to demonstrate in front of you ■ Methodical approach: ● work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 minutes, spit don’t rinse ○ Diet advice ■ Avoid sugar snacks/drinks ■ Snack on healthier foods: carrot sticks, breadsticks, fruit in moderation ■ Milk and water only (between meals) ■ If nursing bottle: no bottle to bed at night, no soy milk or sweetened milk, no on demand breastfeeding ■ Do not eat or drink after brushing teeth at night ○ Fluoride: ■ Varnish: x4 yearly to children >2yrs (5%, 22600ppm) ■ Toothpaste: x2 daily - 1450 ppm (smear < 3yo pea > 3yo) ● >10yrs: 2800ppm, >16yrs: 5000ppm ● Avoid rinsing mouth, drinking or eating for 30 mins after use ● Advice that this TP is a medicine and should only be used prescribe ■ Mouthwash: x1 daily for >6yo - (0.05%) ● Preferentially at different time from brushing ● Avoid rinsing mouth, drinking or eating for 15 mins after use

Answer 128

When to use each cement: ○ Aquacem (GIC) → Metal post, MCC, Gold restorations, Zirconia restorations ○ Panavia (Anaerobic cure comp) → Adhesive bridge (RBB) ○ Nexus NX3 (Dual cure comp) → Fibre post, Composite/porcelain restorations, Veneers ● Pre-cementation checks ○ Check on the cast ■ Is the restoration as asked for ■ Rocking, M/D contact points, marginal integrity, aesthetics ■ Check contact points on adjacent teeth on cast to ensure not damaged ● Can be damaged when prepped tooth is sawn off the cast to invest ■ Occlusal interference on excursions ■ Natural teeth contacting (check with shimstock 8μm) ○ Remove crown from cast ■ Check if occlusion correct and still the same ■ Check crown thickness using calipers ○ Crown placed in patient with airway protection ■ Check all the above ■ Patient happy with appearance ● Post-cementation checks ○ Excess cement removed ○ No space around margins ○ Interproximal contact point exists and is clear ○ Occlusion checked with articulating paper (in excursion as well) ○ Restoration clensible ○ Confirm patient happy with aesthetics and feel

Answer 129

Fill in details: ○ Patient detail sticker on all three sheets: (Name, Age, CHI, Sex, DOB), Any photos or SH ○ Practitioner details/Practice detail/no ○ Date and time of recording impression, date and time of completed required lab work ○ Plan: stage of Tx (prep or fit), present (work), other lab work ● Instructions ○ Please pour up impressions with 100% improved stone, mount on DENAR II semi-adjustable articulator using facebow/wax bite etc provided. ○ Construct a metal ceramic (NiCr) conventional mesial cantilever bridge to replace tooth XX. Use XX as abutment and XX as pontic. ○ Shade XX. Staining and special effects, Surface features and finish. ○ Ridge-lap pontic (depends on tooth to be replaced) ■ Ridge lap: posteriors, ■ Modified ridge lap: upper anteriors ■ Dome shape: posteriors, lower anteriors ○ Please construct in canine guidance and ensure pontic is free of excursive movements. ○ Please return bridge with cast. ● Signature

Answer 130

Introduce self and designation ● Reassure father everything will be ok ● Knee-to-knee examination ○ Explain to the parent what you intend to do ○ Sit across from the parent with your knees touching theirs ○ Bring your knees together and ask the parent to do the same ○ Ask the parent to sit the child with their legs round the parents waist ○ Lower the child down into your knees and ask the parent to hold the child’s arms ● Trauma stamp: ○ Colour, EPT, EC, TTP/percussive note, mobility, displacement, radiograph, sinus ● Subluxation signs: ○ TTP, mobile, bleeding from gum, no displacement ● Explain nature of injury in simple terms ○ Subluxation of the upper central baby teeth ○ This is an injury to the supporting structures of the tooth ● Explain treatment: JUST OBSERVATION ○ No treatment required ○ Only that can be done today is clean tooth with saline or CHX wipe with gauze due to age. ● Explain home care: ○ Instruct soft food for 1 week ○ Important to keep the area clean and plaque free for good healing ■ OHI - Brush with a soft brush after every meal ■ CHX 0.2% with cotton swab to area x2 per day for 1 week ● Explain possible complications to primary tooth: ○ Pain, swelling, dark discolouration, increased mobility, delayed exfoliation, infection ■ Child may not complain of pain, however, infection may be present and parent should watch for signs of swelling on the gums and bring the child in for treatment. ● Explain possible complications to permanent tooth: ○ Premature or delayed eruption, enamel hypoplasia/ hypomineralization, crown/root dilaceration, failure to erupt, failure to form, odontome formation ● Follow up: 1wk and 6-8wks ● Actor marks for describing tx in an understandable manner, supportive and empathetic regarding injury

Answer 131

Asthma ○ Medication: Salbutamol → Short acting selective beta2-agonist, relaxes smooth muscles in the bronchi causing bronchodilation. ○ Assess ABCDE ○ Signs: airway constriction/bronchoconstriction, fast breathing, wheeze, gasping, clutching chest, blushing, tachycardia - probably regular ○ Call ambulance – location, number, describe Pt condition ○ Administration: ■ Salbutamol inhaler - 100μg per actuation ■ Shake, press, inhale, hold 10 sec asthma attack, COPD, choking, OR ■ 4 actuations in large volume spacer 20 secs inhalation and then put on O2 ● repeat as required ○ Reassess ABCDE ○ Administer 100% oxygen, 15L/min flow rate ● Anaphylaxis ○ Medication: Adrenaline → powerful vasoconstrictor, bronchodilator & increases contractility of myocardium ○ Assess ABCDE ○ Signs: airway constriction/bronchoconstriction, fast irregular breathing, stridor, blushing, tachycardia but weak pulse, urticaria, angioedema. ○ Anaphylactic shock = inability to perfuse organs ○ Secure airway ○ Call ambulance – location, number, describe Pt condition ○ Administration: ■ Adrenaline ½ of a 1ml ampule 1:1000 = 500μg IM injection ● *Aspirate as can generate arrhythmias ● Use Z-track technique to inject into thigh or bicep ○ Spread skin, advance needle in skin 90o , aspirate, inject 30s, pull out, release tension - thigh, hip, deltoid, buttock. ○ Say ‘I would normally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time’ ○ Reassess ABCDE ○ Administer 100% oxygen, 15L/min flow rate ● Differentiator between them - similar symptoms ○ Check medical history or series of events leading to the episode ○ Asthma only has respiratory symptoms and those caused by the hypoxia (e.g. tachycardia) ○ Anaphylaxis is systemic presenting with a weaker pulse, urticaria (hives on skin) and angioedema (swollen face)

Answer 132

‘The treatment is to have the lower L/R third molar removed surgically under local anaesthetic’ ● ‘You will be awake throughout the procedure’ ● ‘You will be numbed up firstly by an injection in the back of your jaw which will numb that side of your jaw all the way down to your chin. You will not be able to feel anything sharp while we take the tooth out but you will still be able to perceive pressure.’ ● ‘The procedure will involve making a cut and raising a bit of your gum, removing bone around the tooth, and possibly sectioning the tooth and removing it piece by piece. This will involve drilling, similar to the one used for fillings. Then we will clean the area with salty water and place some sutures to close up the wound. Once again, you will be numb in the area of treatment during this procedure and will hear sounds of the tooth coming up as well as pressure but no sharpness or pain’ ● Complications: pain, swelling, bleeding, bruising, infection, dry socket (failed clot/exposed bone), jaw stiffness, damage to adjacent tooth ● Also: temporary/permanent numbness, prolonged nerve pain, tingling due to damage to the nerve. ○ ‘This is a sensory nerve and any nerve damage will have no effect on your appearance or the way your mouth or jaw moves. This is something only you will be aware of.’ ○ Risks: 10% temporary, <1% permanent ○ If roots involved with IDN then nerve damage risks increase to 20% temporary and 2% permanent. ○ If IDN involvement: Coronectomy ‘involving the same procedure as above up to the sectioning of the tooth however only the the crown of the tooth is removed leaving the roots in place to avoid risking nerve damage - this cannot be done if the tooth is carious. If the roots become mobile they will have to be removed as well’ ● ‘If you have this procedure performed under local anaesthetic we advise that you refrain from fasting. It is not required to bring someone with you and you will be more than capable of driving yourself home if required however it is advised that you take the rest of the day off from work.’ ● Ask if they have any questions.

Answer 133

Type N – non-vacuum, passive air removal, unwrapped solid products, non-hollow, non-lumened ● Type B – vacuum, active air removal, packaged instruments, lumened, hollow cannulated or porous ● Cycle: ○ Stages: air removal, sterilising, drying, cooling ○ Parameters: 134-137 degrees, 2-2.3bar for a minimum holding time of 3 minutes ○ Type of water used: reverse osmosis/ distilled/ sterile/ de-ionised ● Steriliser tests: ○ Daily: wipe clean, change water, Automatic Control Test (ACT), Steam Penetration Test (Bowie-Dick/Helix) ○ Weekly: ACT, Steam Penetration Test, Vacuum Leak Test, Automatic Air Detector Function Test ○ Quarterly: Validation Report (taking loads of data for effectiveness of steriliser) ○ Yearly: Annual Report – by insurance company for safety (e.g. check pressure release valves) ● Instruments found on top of steriliser ○ Should be set out non-overlapping with hinged instruments open ○ Check for recent print-out from steriliser ○ Check if colour change of packaged instruments ■ Instrument packaging: Brown to Pink ■ Helix/Bowie Dick: Yellow to Blue ○ If unsure, take tray of instruments back to beginning - cleaning in AWD or manual cleaning.

Answer 134

a. Acknowledge the complaint and provide the patient with the practice complaint procedure. b. Inform the dental defence organization if you require advice. c. Inform the patient of timescales and stages involved. d. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3 working days maximum but ideally within 24 hours. e. Early Resolution 5 working days: For issues that are straightforward and easily resolved, requiring little or no investigation. f. Investigation 20 working days: For issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’. g. Independent External Review Ombudsman: For issues that have not been resolved.

Answer 135

LN Palpation: ○ preauricular, parotid, submandibular, submental ○ occipital, posterior auricular, jugulo-digastric, jugulo-omohyoid, deep cervical, supraclavicular ● Take a brief history ○ Noticed lesion? How long for? Painful? Pain/Problems eating or swallowing? Hoarseness of voice? ○ Relevant MH? Smoker? Alcohol? Regular attender? Daily mouthwash use (alcohol)? ● Discussing the lesion ○ ‘The lesion on the FOM has a number of possible causes. Some of these are harmless and benign. However, some causes could be more serious and possibly cancerous.’ ○ ‘As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’ ○ ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’ ● Information on what to expect at OM: ○ Biopsy ■ LA injection around the site of the sample ■ Taking a small amount of tissue to send to the lab for analysis ■ Sutures will be placed to close up the wound ○ Lymph node biopsy - Fine needle aspirate? ○ Post-op advice ■ It will be sore for a week after the procedure, similar to having an ulcer ● Risks: pain, swelling, bleeding, bruising, infection, numbness/altered sensation ■ Sutures will dissolve and come out on their own in around 2-4 weeks ■ Advice will be provided - salt water mouthwashes, softer diet, limit smoking etc ■ Review appointment to be booked to discuss findings ● Management of Risk factors ○ Smoking cessation advice ○ Reduce alcohol consumption ■ Don’t mention 14 units - Consider the lesion as a wake-up call to quit ● Urgent cancer referral guidelines: ○ Persistent unexplained head and neck lumps for >3 weeks ○ Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks ○ All red or speckled patches of the oral mucosa persisting for >3 weeks ○ Persistent hoarseness lasting for >3 weeks (request chest x-ray at the same time) ○ Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks ○ Persistent pain in the throat lasting for >3 weeks

Answer 136

Go through OPT in systematic manner: ● Demographics ○ type of X-ray, age, date etc ● Quality - diagnostically acceptable or not ● Dentition ○ Teeth: erupted/unerupted, permanent/primary/mixed, missing/supernumerary, impacted, ectopic ○ Restorations: heavily/moderate/mild restored, overhangs, fractures, poor margins ○ Trauma ● Disease: ○ Caries: primary/secondary, supra/sub-gingival, periapical pathology ○ Perio: periodontal bone levels, localised/generalised, supra/sub-gingival calculus ○ Endo: well/poorly compacted, material, ?mm from apex/to apex, separated instruments etc ○ TMJ ○ Other pathology: cysts ● Diagnosis IRMER regulations

Answer 137

Explain treatment required ○ Caries management ■ List carious teeth ● Sed/GA referral vs GDP management ■ Start working with least invasive restorations - fissure sealant to then LA procedures ○ Prevention: ■ Assign caries risk ■ 8 things: radiographs, diet advice, tooth-brushing instruction,F toothpaste, F supplements, F varnish, sugar free medicine, fissure sealant ● Mucocele: ○ Leave and review vs referral for surgical removal ○ Explain the procedure: LA around site of swelling, cut in gum and removal in its entirety, sutures ○ Risks: pain, swelling, bleeding, bruising, infection, numbness, sutures ● Hypodontia: ○ Potential problems: space, drifting, overeruption, aesthetics, functional problems ○ Space maintenance: URA ○ Referral to orthodontist at 6-7yrs ○ Tx options in future: ■ Nothing ■ Restorative only: composite, veneers, RBB, RPD ■ Ortho only ■ Restorative + ortho: space closure and reshape teeth to camouflage ● Deal with complaint: ○ ‘I can’t give comment because I don’t know the full story’ ○ ‘I can only offer you this treatment at this present time’ ○ ‘Whatever was offered previously, will not change what treatment is required now’ ○ Tell mum if she is intended to complain, she can go back to the practice, they will have a standard complaint procedure = only if the patient asks (do not offer!) ○ ‘It will be unhelpful for me to be involved in this matter as I don’t know the background behind treatment that was or wasn’t done and would be unfair for me to speculate on it’

Answer 138

Introduce self and designation ● State separated instrument and explain ○ Calmly explain to the patient that there is a file separated in to the canal of the tooth. ○ Explain that thin metal files are used in order clear out the pulp tissue and shape the canal. ○ Sometimes they can separate in tight or curved areas leaving the metal tip lodged in the canal. ● Possible consequences ● Possible treatments ○ Do what you're comfortable with and what you're prepared for based on your illumination, magnification, access to instruments and time. ○ ‘I’ve tried to remove the file and failed and you will arrange a referral to see a specialist.’ ○ Do nothing - dress and monitor. ○ Attempt removal with tweezers if they can see the separated file. ○ Dislodge and remove the broken file with an ultrasonic instrument. ○ Bypass the fragment by watch-winding a small file alongside the instrument and EDTA to soften the dentine. ○ If they remove it: complete RCT as normal. ○ If not possible to bypass or remove the fragment - accept and obturate to file - better outcomes with a protaper file separating at the apex as you're finishing your apical prep (as you know it's clean) ○ Retrograde RCT - apicectomy/peri-radicular surgery ○ XLA as last resort ● Ask if they have any questions ● Check understanding and confirm an option ● Actor marks: professionalism, simple language, enough info provided to gain consent

Answer 139

Component faults: ○ Z-spring encased in acrylic, UR6 adam’s clasp arrowhead fault, UL6 adam’s clasp flyover fault ● Prescription faults: ○ Southend clasp included meaning appliance won’t work, Adam’s clasp on ULC not ULD, FABP instead of PBP. ● How would you rectify these errors? ○ Re-make appliance by taking new impressions ● Activating palatal finger spring: ○ Using spring former pliers – 1-2mm activation ● Fitting a URA ○ Check that the appliance if for the correct patient ○ Check the appliance matches prescription ○ Run finger over all surfaces to check for protruding wires and sharp acrylic ○ Check wirework integrity (if overworked) ○ Fit the appliance ○ Check for any blanching or trauma ○ Check posterior retention ■ Flyovers (first as influence the arrowheads) ■ Arrowheads ○ Check anterior retention ○ Activate appliance - to produce 1mm movement per month: spring formers ○ Demonstrate to patient about insertion and removal ○ Ask patient to demonstrate insertion and removal ○ Review: 4-6 weekly ● Instructions to patient ○ Will feel big and bulky ○ Likely to impinge on speech ■ Start reading a book aloud to prevent this by speeding up adjustment of Teeth ○ May have ‘mild discomfort’ - particularly on teeth being moved - but this is a sign that the appliance is working ○ Initial increase in saliva – 24-48 hours ○ Wear 24 hours/day including meal times ○ Can remove the appliance to clean with a soft brush after each meal or when taking part in active/ contact sport – store in a safe place ○ Avoid hard and sticky foods ○ Be cautious with hot food and drinks as base plate acts as an insulator ○ Non- compliance will lengthen treatment ○ Give an emergency contact number – do not wait till next appt. if there is a problem

Answer 140

1. Black Safety Plus Handle: For LA injection 2. Mouth Mirror: Soft tissue retraction, indirect vision 3. Straight Probe: Test for LA before XLA, test surface 4. Collage Tweezers: Handle cotton pledget (with cross pattern), remove sequestrae 5. Swann Morton Scalpel Handle with no15 Blade: Incision to raise a flap or biopsy 6. ‘S’ Shaped Cheek Retractor: Retract the cheek, retract soft tissue 7. Howarth Periosteal Elevator: Raise mucoperiosteal flaps, flap retraction 8. Howarth Periosteal Elevator: As above 9. Ash Periosteal Elevator: Elevate soft tissue flaps, flap retraction 10. Couplands Osteo Chisel No1: Elevate root and tooth, create space for insertion of forceps 11. Couplands Osteo Chisel No2: As above 12. Couplands Osteo Chisel No3: As above 13. Warwick James Elevator Right: Elevator for removing teeth and roots, especially upper 8s 14. Warwick James Elevator Straight: As above 15. Warwick James Elevator Left: As above 16. Cryers Elevator Right: Elevator used to elevate roots and remove interradicular bone 17. Cryers Elevator Left: As above 18. Curved Mosquito Forceps: Picking up sequestrate or fractured instruments or posts, artery clips 19. Bone Rongeurs: Also known as bone nibblers, used to trim bone, remove spicules and septae 20. Rake Retractor: Flap deflection, scratchin your back 21. Bone File: Smooth down rough bit of bone by pull stroke 22. Victoria Curette: Remove granuloma or cyst from periapical tissue, remove granulation tissue from socket 23. Mitchells’ Osteo Trimmer: Removing sharp bone spicules, exposing canines, apicectomy 24. Straight Spencer Wells Forceps: Picking up teeth, removing sharp bone spicules 25. Alice Tissue Forceps: Used to hold soft tissues, can be used to pick up teeth 26. Kilner Needle Holders: Holding needle for suturing 27. Fickling Forceps: As above forceps 28. Gillies Needle Holders: Holding needle for suturing 29. Gillies Toothed Tissue Forceps: Manipulation of suture 30. Curved Iris Scissors: Cutting suture 31. Lack’s Tongue Depressor: Depressing tongue, retracting tissue 32. Towel Clips: Clipping things on tray table

Answer 141

OFG: Oral granulomatous inflammation causing problems ○ blocks lymphatic channels causing swelling ● Autoimmune – Type IV hypersensitivity to additives ○ (benzoates, cinnamonaldehyde, sorbic acid, chocolate) ● Symptoms: lip swelling/cracked, angular cheilitis, buccal cobblestoning, ulceration, lymphoedema, gingivitis ● History: take full system’s history including info like weight loss and bowel problems ● Diagnosis: Patch testing for 20mins ● Management: dietary avoidance, antibiotics (macrolides), tacrolimus ointment to lip, steroids, azathioprine ● Patient mentions bowel problems = potential for Crohn's ○ Inflammatory disease that can affect ANY part of the GI tract ○ Patchy lesions in colon – causing perforation, stricture, obstruction and increased cancer risk ○ Refer patient to GP to investigate.

Answer 142

Injection in parotid gland → Facial nerve ● Diagnosis: Test branches of facial nerve ● Symptoms: ○ generalized weakness of the ipsilateral side of the face, inability to close the eyelids, obliteration of the nasolabial fold, drooping of the corner of the mouth, deviation of the mouth toward the unaffected side. ● Confirmation: ○ Temporal branch affected - *if stroke patient can still wrinkle forehead* ● Management: ○ Reassurance ○ Cover eye with pad until blink reflex returns - an eye patch should be applied, especially during night time, while artificial tears can be used during the day (+ sunglasses) to prevent exposure keratitis.

Answer 143

Edentulous trays (blue) - shallower ● Primary imp material for lower edentulous: alginate, impression compound ● Stand at 7 o’clock for lower impressions ● Please pour casts in 50/50 dental stone/plaster and construct lower special tray in light cured PMMA with 1-2mm spacer (1mm for PVS, 2mm for alginate)- non-perforated, finger-rests and intra-oral handle. Please return trays with casts

Answer 144

● Staining: ○ Causes: ■ MIH, fluorosis, decal, tetracycline, trauma, dentinogenesis/amelogenesis imperfecta ○ Treatment: ■ Microabrasion: easy to be done, effective, removal of tooth structure, use of acid ■ Vital external bleaching: may not work, gingival irritation, sensitivity, will not bleach restoration, relapse, overbleach ■ Localised composite addition: add bulk to tooth, may not mask totally ■ Comp/porcelain veneer: good aesthetic, tooth prep needed, need to wait until 18 for stable gingival level ■ MCC: destructive ● Missing teeth: ○ Causes: ■ Hypodontia, trauma causing arrested tooth formation, ectopic, dilaceration, supernumerary ○ Treatment: ■ RBB, Essix retainer, RPD, Implant if above 18y/o, Ortho space closure

Answer 145

Faults with metal framework casting ○ These could include: ■ Errors in casting: CoCr bubbles making surface rough - due to air bubbles trapped on wax pattern investing ■ Errors in design: too close to gingival margin, undercuts not blocked out ● Faults with prescription between drawing and writing: ○ Support: rests are missing, no posterior stop (i.e. posterior of free end saddle ends further anteriorly than desirable) ○ Retention: ring clasp around the wrong way (are there ineffective clasps? check the cast for survey lines) ○ Connector: sublingual bar instead of lingual bar on prescription (sublingual bar looks almost identical to lingual bar. The sublingual bar actually lays on the floor of mouth and there is no 1mm from the functional depth as is with the lingual bar. ○ Also check for: indirect retention, appropriate reciprocation for clasps ● No labial relief as asked

Answer 146

All burs given - Remember PPE ● Points for seating position ● Not really marked on pt management - clinicians not really watching whilst you prepare the tooth ● x2 putty index ○ 1 for provisional (do not section) ○ 1 for reduction determination (section along long axis) ● Using a chamfer bur ○ Create 3 notches on buccal surface, each just below 0.5mm in to tooth tissue. Ensure the tooth is cut in two planes as for crown prep ○ Connect the notches with the chamfer bur ● Reduce the incisal edge, ideally around 1mm (0.75-1.5mm) ● Bevel the incisal edge (3 different planes total) ● Use a smooth composite finishing rugby ball bur to finish

Answer 147

Missing teeth - identify the causes ● Gingival margin - from the ACJ, recession ● Probing depths - indicator of tx difficulty ● Loss of attachment - indicator of severity of disease ● Bleeding on probing - indicator of disease activity ● Furcation - involvement indicator of tx difficulty ● Mobility - gives rise to symptom, poorer prognosis ● Reasons for failure ○ Smoking ○ Patient not compliant: OH is poor ○ Inability for patient to practice OH effectively ■ Hard to reach areas - furcations, lone standing teeth ■ Poor manual dexterity - dementia/parkinsons/age ○ Systemic factors: stress, diabetes, pregnancy, malnutrition/poor diet ○ Difficulty accessing for debridement/Inadequate debridement (time constraint, pt cannot tolerate) ○ Iatrogenic factors: overhangs, poor margins

Answer 148

ARR: the difference in risk between the groups ● RR: the ratio of the risk in each group ● NNT: the number of patients you would need to treat to prevent one patient from developing the risk ● 95% CI: 95 times out of 100 the CI will contain the TRUE value in the entire population ○ Can be determined for both ARR and RR ● Null hypothesis (true or rejected) ○ = The intervention works only as well as the control ● FOR ARR – IF CONFIDENCE INTERVAL RANGE OVERLAPS 0 = NULL HYPOTHESIS ○ i.e. if the risk reduction with intervention was 0 then the intervention is the same as the control ● FOR RR – IF CONFIDENCE INTERVAL RANGE OVERLAPS 1 = NULL HYPOTHESIS ○ i.e. if the ratio with of intervention risk over the control risk was 1 then the intervention and control risk are the same ● YOU CAN ALSO COMMENT ON THE BROADNESS OF THE CI RANGE ○ A narrow range means the study is more representative of the true population results compared to a broad range ● What type of study? ○ Randomised controlled trial: prospective ○ Cohort study: prospective ○ Case-control: retrospective ○ Cross-sectional survey: one single point of time ● Criteria for good randomised controlled trial ○ Blinding, inclusion/exclusion criteria, randomisation, control, all subjects accounted for at the end?

Answer 149

Overfilled, underfilled, poorly compacted, accessory canals missed, missed canal, inadequately prepared, extrusion of debris, perforation, RCF of incorrect shape, vertical root fracture, endo file fracture, blockage/ obstruction of canal, poor coronal seal - failed restoration ● Tx options: ○ Leave and monitor: no active tx, but may infection including abscess may flare up later ○ Retreatment: no surgery needed, but chances of success decreased, if post core present, removing may cause vertical root fracture ○ Periradicular surgery: if retreatment not possible, surgery more difficult to tolerate, invasive, time consuming, expensive, nerve damage, reduced support, scarring ○ XLA: tooth loss, need replacement or non-functional and poor aesthetic

Answer 150

History: ○ How dry mouth is affecting the pt? Need water to swallow/ affect speech, uncomfortable? ○ What medications pt is taking (amitriptyline)? Alcohol? Smoking? ○ Medical history - diabetes/epilepsy/anxiety/stroke/sjogren's/CF/HIV ● Usual features/symptoms: ○ Swallowing difficulty, clicking speech, discomfort, altered taste, cervical caries, halitosis, candidiasis ● Management ○ Treat cause: Hydration, Chew gum, Modify drugs, Control diabetes/somatoform disorder, reduce caffeine, Stop smoking/alcohol ○ Prevent diseases: Caries (High F- toothpaste), Candida / Angular cheilitis (CHX) ○ Saliva substitutes: Spray/Lozenges: Saliva Orthana - Stimulants: Pilocarpine ● Contact medical practitioner to query if changing medication is possible

Answer 151

CN 1 (Olfactory) - Can patient smell as normal? ● CN 2, 3, 4, 6 (Optical, Oculomotor, Trochlear, Abducens) - Test visual acuity and eye movement. ● CN 5 (Trigeminal) - Any abnormal sensation at each branch? Can patient clench jaw? Corneal reflex ● CN 7 (Facial) - Facial muscles tests (puff out cheeks, pout, wrinkle forehead, raise eyebrows) ● CN8 (Vestibulocochlear) - Can patient hear normally? Block one ear and check for differences) ● CN 9, 10 (Glossopharyngeal and Vagus) - Deviation of uvula on saying ah, gag reflex ● CN 11 (Accessory) - Can patient shrug their shoulders? ● CN 12 (Hypoglossal) - Can patient protrude tongue? Is there deviation on protrusion? Is there asymmetry?

Answer 152

Normal O2sat = 97-100, Alarm at 90, Hypoxic at 85 ● If dropping: stimulate patient - ask to breathe ● If alarm: ○ supplemental oxygen: nasal cannulation 2L/min ○ reverse with flumazenil (500mg/5ml) ● Contraindications for IV Sedation: ○ severe COPD, hepatic insufficiency, pregnancy and lactation, hypothyroidism, myasthenia gravis ● Contraindications for Inhalation Sedation: ○ common cold, tonsillitis, nasal blockage, severe COPD, MS, pregnancy (1st trimester), claustrophobia (fear of the mask) ● Minimum O2 delivery = 30% (max N2O = 70%)

Answer 153

Procedure (multiple appts) ○ LA - topical gel, CWR, injection + LA risks (perm/temp nerve damage, altered sensations, numbness, lasts for hours, increased HR) - aids pt makes procedure comfortable ○ Rubber dam (nitrile/latex sheet) - isolation, moisture control, airway protection, prevents NaOCL incident - clamp can fracture, mouth open throughout procedure. Test CHX. ○ Radiographs are required pre, during, post tx ○ Access - drills to remove nerve, high/slow speed ○ Files - series of files to clean and shape canal ○ Irrigation - NaOCl (bleach) throughout + EDTA ○ Canal dried with paper points ○ Intracanal medicament - resolves infection/symptoms ○ Obturation - GP root canal filling, coated in sealer, packed with accessory points, burnt off ○ Lining material placed - to seal canal ○ Restoration - temp/permanent, ideally indirect restoration (extra appts + expense) ○ R/V appt needed ● Prognosis ○ Be specific for case - good/poor/limited ○ Orthograde RCT - not guaranteed, but predictable and usually successful ○ - Up to 90% over 10 years for teeth with irreversible pulpitis. ○ - Up to 80% over 10 years for teeth with necrosis. ● Alternatives ○ No treatment ○ Extraction ○ Retrograde RCT ● Risks ○ Instrument separation, failure to negotiate canals to working length, hypochlorite accident, material extrusion, post-op pain, post-op swelling, need for pain control, perforation and root fracture. ○ Failure to resolve symptoms. Expensive. ● Benefits ○ Resolution of infection +/-symptoms, retain tooth, no loss of bone, abutment potential, don’t require replacement for missing tooth, best aesthetics

Answer 154

Extra oral signs: ○ Bruising of face - punch, slap, pinch ○ Bruising of ears - pinch, pull ○ Abrasions and lacerations ○ Burns and bites ○ Neck - choke or cord marks ○ Eye injuries ○ Hair pulling ○ Fractures (nose>mandible>zygoma) ● Intra oral signs ○ Contusions ○ Bruises ○ Abrasions and lacerations ○ Burns ○ Tooth trauma ○ Frenal injuries ● Index of Suspicion ○ Delay in seeking help ○ Story vague, lacking in detail, vary with each telling and person to person ○ Account not compatible with injury ○ Parents mood abnormal. Preoccupied. ○ Parents behaviour gives cause for concern ○ Child’s appearance and interaction with parents is abnormal ○ Child may say something contradictory ○ History of previous injury ○ History of violence within the family ● Taking action ○ Provide any urgent dental treatment ○ Tell parent: unless this will put child at risk. ■ Explain your concerns honestly, inform them of your intention to refer ■ “These types of injuries have to be reported” ○ Seek parents consent to share info ○ Record incident and conversation ○ Refer to social services/police - b be specific about reasons ○ Confirm referral acted upon ○ Arrange dental follow up ○ Be prepared for reporting in case of court ○ Always discuss with colleague

Answer 155

Patient Details ● Practice Details ● Patient Complaint ● Your concerns: Why you are referring? Urgent/ routine? Pt in pain/swelling? ● MH, DH, SH ● Summary of oral health status ● Details of Request: for advice or to see patient ● Enclosing details: radiographs, investigations

Answer 156

● Iatrogenic faults: ○ RCT: fractured file, perforated file, ledging, GP overfill/underfill, extruded sealer, missed canal ○ Restorations: overhangs, fractured, poor margins, post w/o RCT, perforated post ○ External inflammatory/surface/ replacement, internal inflammatory, cervical root resorption? ● Developmental: ○ Cysts: dentigerous, radicular, erupted, keratocyst ○ Unerupted/ectopic/impacted teeth ○ Dentinogenesis Imperfecta (amber radiolucency, bulbus crown, abscess, pulpal obliteration) ○ TMD ● Trauma ○ Bone fracture, Tooth fracture, Displacement

Answer 157

Formulations and max doses: ○ Lidocaine 2% 1:80000 adrenaline: 4.5mg/kg ○ Articaine 4% 1:100000 adrenaline: 5mg/kg ○ Prilocaine 3% w/ 0.03IU/ml felypressin: 6.6mg/kg ● Assembly: ○ Remember to check expiry date and that bung is on the right way round ● Side effects: ○ Allergic reaction (rash, tingling, breathing problems) ○ Seizure, cardiac arrest ○ Nausea, vomiting, dizziness, headache, blurred vision ○ Twitching muscles ○ Nerve damage, continuing numbness, weakness or pins and needles ○ Haematoma ○ Tachycardia ● Checking anaesthesia: ○ Question patient ○ Check by percussion to tooth ○ Probe to gingivae/palate

Answer 158

Equipment: ○ Fox’s Occlusal Plane Guide - Use: to set occlusal plane ○ Willis Gauge - Use: measuring occlusal vertical dimension (OVD, FWS, RVD) ● Lines/Features: ○ High Smile Line ■ Why: Allows waxing of teeth in correct height and alignment (not showing too much gum) ■ How: Getting the patient to smile and marking lip level ○ Centre Line/Midline ■ Why: To orientate central incisors making the block symmetrical ■ How: Using nose septum or using existing lower/upper anteriors ○ Canine Line ■ Why: To set canine position - Also provide size measurements for tooth selection ■ How: Measured using vertical line from inner canthus of the eye ● Reference lines: ○ Used to ensure anterior and posterior occlusal plane is level ■ Ala-Tragus line ■ Interpupillary line

Answer 159

4 criteria!! NEWS assessment (National Early Warning Score) ○ Temperature <36o C or >38o C ○ White Blood Cell count <4 or >11 thousand per mm3 ○ Pulse over 90bpm (tachycardia) ○ Respiratory rate over 20bpm (tachypnoea) ● 2 out of 4 required for definition of sepsis syndrome – Requires URGENT referral ● Always refer URGENTLY if: ○ Spread of infection to pharyngeal or submandibular space ○ Systemic manifestations AND immunocompromised ○ Trouble swallowing or breathing ○ Rapidly progressing infection ● Antibiotics for dental abscess if systemic manifestations OR immunocompromised ○ Always try local measures first - drain by extraction, through canal or by soft tissue incision ○ Amoxicillin: 500mg tablet x3 daily for 5 days ○ Metronidazole: 400mg tablet x3 daily for 5 days

Answer 160

Fungal infection of the cheek side of the mouth ● Potentially malignant, can progress to oral cancer ● Risk factors: OH, steroid inhaler, diet diabetes, deficiency, dry mouth, antibiotic, immunosuppression ● Management: ○ Incisional biopsy - Referral to OM ○ OHI, reduce carbohydrate intake, rinse mouth after inhaler ○ Correct deficiency, control diabetes, stop smoking, correct denture fault ○ Systemic antifungal - review after 7 days ■ Fluconazole 50mg ■ Send: 7 tablets ■ Label: 1 tablet to be taken once per day for 7 days

Answer 161

A – Active component (moves the teeth, 0.5mm) ● R – Retention (holds the brace in, 0.7mm in permanent, 0.6mm in deciduous) ● A – Anchorage (resists unwanted tooth movement) ● B – Baseplate (plus any modifications) ○ Provides anchorage, retention, connector ○ Self-cure PMMA over Heat-cure PMMA ■ Advantages: quicker and easier fabrication - 14mins vs 14hrs ■ Disadvantages: residual monomer can be an irritant ○ Knife edge acrylic ■ Stops the tongue playing with the URA causing ulcers from trauma ● Overbite ○ Please construct a URA to reduce overbite ○ A: ○ R: 16/26 Adams clasps 0.7 H.S.S.W ○ 11/21 Southend clasp 0.7 H.S.S. ○ A: ○ B: Self-cure PMMA / FABP OJ+3mm ● Overjet ○ Please construct a URA to reduce overjet and continue to reduce overbite ○ A: 22,21/11,12 Robert’s retractor 0.5 H.S.S.W + 0.5mm I.D tubing ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 3/3 Mesial stops ○ A: (not ideal – will keep an eye on it) ○ B: Self-cure PMMA / FABP OJ+3mm ● Retracting Canines ○ Please construct a URA to retract canines ○ A: 13/23 Palatal finger spring + Guard 0.5 H.S.S.W ○ R: 16/26 Adams Clasps 0.7 H.S.S.W + 11/21 Southend Clasp 0.7 H.S.S.W ○ A: ○ B: Self-cure PMMA ● Retracting Buccally Placed Canines ○ Please construct a URA to retract buccally placed canines ○ A: 13/23 Buccal canine retractor 0.5 H.S.S.W + 0.5mm I.D. tubing ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 11/21 Southend clasp 0.7mm H.S.S.W ○ A: ○ B: Self-cure PMMA ● Anterior Crossbite ○ Please construct a URA to correct anterior crossbite ○ A: Z-spring 0.5 H.S.S.W ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W ○ A: ○ B: Self-cure PMMA / Posterior Bite Plane ● Posterior Crossbite ○ Please construct a URA to expand the upper arch ○ A: Midline palatal screw ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W ○ A: Reciprocal Anchorage ○ B: Self-cure PMMA / Posterior bite plane

Answer 162

○ Please construct a URA to reduce overbite ○ A: ○ R: 16/26 Adams clasps 0.7 H.S.S.W ○ 11/21 Southend clasp 0.7 H.S.S. ○ A: ○ B: Self-cure PMMA / FABP OJ+3mm

Answer 163

○ Please construct a URA to reduce overjet and continue to reduce overbite ○ A: 22,21/11,12 Robert’s retractor 0.5 H.S.S.W + 0.5mm I.D tubing ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 3/3 Mesial stops ○ A: (not ideal – will keep an eye on it) ○ B: Self-cure PMMA / FABP OJ+3mm

Answer 164

○ Please construct a URA to retract canines ○ A: 13/23 Palatal finger spring + Guard 0.5 H.S.S.W ○ R: 16/26 Adams Clasps 0.7 H.S.S.W + 11/21 Southend Clasp 0.7 H.S.S.W ○ A: ○ B: Self-cure PMMA

Answer 165

○ Please construct a URA to retract buccally placed canines ○ A: 13/23 Buccal canine retractor 0.5 H.S.S.W + 0.5mm I.D. tubing ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 11/21 Southend clasp 0.7mm H.S.S.W ○ A: ○ B: Self-cure PMMA

Answer 166

○ Please construct a URA to correct anterior crossbite ○ A: Z-spring 0.5 H.S.S.W ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W ○ A: ○ B: Self-cure PMMA / Posterior Bite Plane

Answer 167

○ Please construct a URA to expand the upper arch ○ A: Midline palatal screw ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W ○ A: Reciprocal Anchorage ○ B: Self-cure PMMA / Posterior bite plane

Answer 168

Hold by crown not the root Hold under cold running water for 10 seconds to get rid of any evident debris Replace in socket - get child to bite onto tissue (don't do this if its a baby tooth) If not replaced into the socket - store in milk, saliva or saline if available Can also place tooth between cheek and gum depending on age of the child, if very young may become a choke hazard Seek immediate dental advice

Answer 169

Depends on whether it was replanted immediately or <60 mins EAT or >60mins EAT Immediate: - Clean area with saline/CHX - Verify position - clinically and radiographically - Splint teeth 2 weeks - Suture any gingival lacerations - Initiate RCT within 2 weeks - NS CaOH for one month/corticosteroid paste 6 weeks - AB - Check tetanus status >60min EAT - Remove debris with saline - LA - preferably no vasoconstrictor - Irrigate socket with saline - check for any fractures within socket - Replant tooth with digital pressure - verify position clinically and radiographically - Splint for 2 weeks - Start RCT in 2 weeks - NS CaOH for one month/corticosteroid paste for 6 weeks then obturate - AB/Tetanus check >60 mins EAT: - Remove debris and contamination using saline soaked gauze - As before for <60mins EAT Follow up avulsion in closed apex: - 2/52 for splint removal - 4/52, 3/12, 6/12, 1y - Annually for at least 5 years

Answer 170

If replanted immediately - as for closed apex apart from only intervene if revascularisation has not occurred If <60mins EAT - as for closed apex apart from only intervene if revascularisation has not occurred If >60mins EAT - as for <60mins but poorer prognosis

Answer 171

2 PA's to rule out root fracture and luxation ST radiograph Bond fragment/place composite bandage or GIC If within 0.5mm of pulp place CaOH and cover with GIC Sensibility test Evaluate maturity Restore with composite

Answer 172

- Trauma Stamps/radiographs Direct pulp cap: - LA and Dam - Clean with water and then NaOCl - Apply CaOH or MTA to pulp exposure - Restore with composite

Answer 173

CVEK partial pulpotomy - Trauma stamp and radiographs - LA and Dam - Clean area with saline - Remove 2mm of pulp with high-speed round diamond - Place saline covered cotton wool over exposure until haemostasis (if hyperaemic then Full Coronal Pulpotomy) - Apply NSCaOH then GIC or white MTA - Restore with composite

Answer 174

Indications -Good co-op - MH precludes XLA - Missing successor - Space maintainer - Under 9 Contra-indicaitons - Poor co-op - Poor attendance - Cardiac defect - Advanced root resorption - Severe or recurrent pain - Multiple grossly carious teeth

Answer 175

Begin with CVEK partial pulpotomy Assess for haemostasis after application of saline soaked cotton-wool If hyperaemic or necrotic proceed to remove ALL of the coronal pulp Place calcium hydroxide in pulp chamber Seal with GIC lining and quality coronal restoration The aim of pulpotomy is to keep vital tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine

Answer 176

Clinical - pain, sinus, mobility Radiographic - increased radiolucency, external/internal RR, furcation bone loss

Answer 177

When the tooth is non-vital LA/rubber dam Arrest haemorrhage with LA and sterile water Open roof of pulp chamber Use files to remove pulpal tissue from canals to 2mm short of the EWL Irrigate CHX, dry with paper points Place NSCaOH in canal - 4-6wks MTA plug if open apex, fill with heated GP Bonded core, aim to avoid post crown

Answer 178

- Fragment removal and restore - XLA - Decoronation - for future implant to preserve bone - Surgical extrusion - Orthodontic extrusion of apical portion - endo/post crown - Fragment removal and gingivectomy - if palatal subgingival extension

Answer 179

- Temporise with composite for up to 2 weeks - XLA - Decoronation - Surgical extrusion - Orthodontic extrusion of apical extrusion - endo first post crown following - Fragment removal and gingivectomy - if palatal subgingival extension

Answer 180

- Clean with saline/CHX - If undisplaced - monitor - If displaced - reposition under LA - Splint for 4 weeks

Answer 181

- Extirpate to fracture line - Dress with NSCaOH then MTA to fracture line - Obturate to fracture line - or XLA

Answer 182

Calcified tissue healing Connective tissue healing Calcified and connective Osseous healing Non-healing granulation tissue

Answer 183

Concussion - no mobility/displacement/bleeding (pain on percussion) Subluxation - increased mobility/bleeding but no displacement Lateral luxation - displacement other than axially (accompanied by B/L fracture) Intrusion - tooth driven into socket by axial impact/force Extrusion - partial or total separation of PDL resulting in displacement out the socket

Answer 184

Occlusal relief Flexible splint 2 weeks (subluxation only) POI - CHX, soft diet, avoid contact sports Review - trauma stamp, radiographs, sensibility tests (may be a transient lack of sensibility)

Answer 185

Reposition under LA Splint for 2 weeks

Answer 186

● Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it into its original location. ● Stabilize the tooth for 4 weeks using a flexible splint. ● Monitor the pulpal condition. ● If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption: - Incomplete Spontaneous revascularisation may occur If pulp becomes necrotic and signs of inflammatory external resorption commence endo - Complete The pulp will likely become necrotic Commence endo tx Corticosteroid-antibiotic or CaOH as intra-canal medicament to prevent the development of inflammatory external RR Follow up - 2wks, 4wks, 6-8wks, 6 months, 1 year, annual for 5 years

Answer 187

Depends on whether closed or open apex Open apex: - spontaneous repositioning independent on the degree of intrusion - if no re-eruption within 4 weeks - orthodontic repositioning - monitor pulpal condition - spontaneous pulp revascularisation may occur - if pulp becomes necrotic and infected or signs of inflammatory external RR - endo tx ASAP when the position of tooth allows Closed apex: - Up to 3mm - spontaneous (if no eruption within 8 weeks, reposition surgically and splint 4 weeks) - 3-7mm - ortho/surgical - More than 7mm - surgical - Splint 4 weeks - Start endo within 2 weeks or as soon as tooth position allows

Answer 188

Reposition under LA - achieve apical lock Monitor pulpal condition of all teeth involved Flexible splint for 4 weeks Follow up DA fracture 4/52 - splint removal 6-8/52, 4/12, 6/12, 1y Annually for 5 yrs

Answer 189

Soft diet for 7 days - after a few days start to incorporate foods that involve some biting as it stimulates the healing of the PDL Use CHX MW Gentle brushing - avoid brushing that day Avoid contact sports

Answer 190

2 week - subluxation - extrusion - avulsion 4 weeks - lateral luxation - intrusion - apical and middle 3rd root fracture (4 months if coronal) - dentoalveolar fracture

Answer 191

Must be passive measure 0.3mm stainless steel wire against the teeth cut and bend the wire - conforming to curvature of arch etch, wash/dry and prime/bond the avulsed tooth and adjacent teeth Apply composite to the 3 teeth sink the wire into the composite - ensure that both ends of the wire are embedded in the composite add a little bit of composite over the top of the sunked wire, shape the composite and cure remove rough edges of composite and sharp edged of wire with a handpiece

Answer 192

Caused by excess ingestion of fluoride (around 0.1mg of fluoride per kg of BW) during development of teeth (appears as white flecks, mottled appearance, frosty/chalky)

Answer 193

Microabrasion Composite veneer Spot bonding composite Strip crowns

Answer 194

Safely tolerated dose - 1mg/kg Potentially lethal dose - 5mg/kg Certainly lethal dose - 32-64mg/kg

Answer 195

Composite restoration GIC SSC Adhesively retained coping XLA when dental age 8.5-9.5

Answer 196

Acid pumice micro abrasion Resin infiltration External bleaching Localised composite placement Full composite/porcelain veneers

Answer 197

Natural birth? Severe illness in pregnancy? Birth trauma? Pre-term? Prolonged breastfeeding? Childhood medication? Infections - measles, mumps, rubella, chicken pox?

Answer 198

Aged >7 7-11 - only codes 0-2 Probe 16, 11, 26, 36, 31, 46 12-17 - all codes Plaque scores in children: 10/10 - perfectly clean 8/10 - plaque around cervical region 6/10 - cervical third covered 4/10 - middle third covered

Answer 199

Preventive dental team management - raise concerns with parents - offer support - set targets, keep records, monitor progress preventative multi-agency management: - liaise with other professionals - check if child subject to common assessment framework or child protection plan - write letter to health visitor of children who have missed 5 appts and not responded to letter from practice child protection referral - in writing and by phone - observe - record - communicate -refer If child in immediate danger - exclusion order - removal by police or JOP

Answer 200

PPE for patient and team Clean with pumice and water Vaseline on soft tissues Place rubber dam Place sodium bicarbonate guard on gingivae Remove enamel with HCL/pumice slurry with slow speed rubber cup - max is 10x5s appliacations (review shade/shape each time) Apply FV - pro-fluoride Polish with finest sandpaper disc Polish with toothpaste Tell pt to avoid anything highly coloured for 24h

Answer 201

Fluorosis, MIH, AI/DI, tetracycline, trauma

Answer 202

Standardisation of recording of aesthetic procedures (SHADE sheet) Clinical photos Shade Sensibility testing Diagram of defect Radiographs if clinically indicated Pt assessment e.g. VAS etc

Answer 203

When used for the purpose of treating or preventing disease Hypo-mineralisation Fluorosis Trauma

Answer 204

Easily performed Conservative Inexpensive Teeht need minimal subsequent maintenance Fast acting Removes enamel - sensitivity? Teeth may become more susceptible to staining HCL acid compounds are caustic Teeth can appear more yellow as dentine shine through

Answer 205

Brush teeth thoroughly Apply a little gel to tray (half grain of rice) Set over teeth and press down Remove excess Rinse gently, do not swallow Wear overnight (or at least for 2h) Remove, brush and rinse with cold water Sensitive toothpaste may be required Do this for 3-6 weeks and review colour

Answer 206

Adequate root filling No clinical disease/no radiological disease Anterior teeth without large restorations No amalgam intrinsic discolouration No fluorosis or tetracycline discolouration

Answer 207

Remove root filling to level below CEJ Clean out tooth with US Place CWP covered in bleaching agent Place dry CWP on top Seal with GIC/RMGIC Renew within 2 weeks, repeat 6-10 times (if no improvement in 3-4 visits then stop)

Answer 208

Acess cavity of tooth open Consider need for GIC lining Produce custom made mouthguard (cut windows in guard of the teeth you dont want to bleach) Pt applied bleaching agent to back of tooth and tray Pt keeps access cavity clean, replacing gel (10% carbamide peroxide) and removed food debris etc Worn all the time except eating and cleaning - gel changed every 2 hours or so except during the night

Answer 209

NSCaOH 2 weeks, covered in GIC - White GP and composite (allows re-bleaching) - Incrementally cured composite (no re-bleaching) - Crown or veneer if regression GIVE PT TOOTH MOUSE - 2wks

Answer 210

Sensitivity Failure Over-bleaching - white opacities become whiter External cervical resorption Tooth becoming more brittle Damage to ST

Answer 211

Changes the refractive index for diffuse white opacities 1.Rinse and clean teeth 2. Apply icon-etch- rub in (let it sit for 2 mins then rinse off) 3. Apply icon-dry (let it act for 30 sec) 4. Do second etch and repeat with icon-dry (repeat as required) 5. When lesions masked and accessible- apply icon-infiltrate for 3 mins 6. Remove excess and Light cure 40 secs 7. Do second infiltration- accounts for polymerisation shrinkage (leave for 1 min, remove excess and cure) 8. Polish

Answer 212

Before touching patient Before cleaning or aseptic procedure After body fluid exposure risk After touching patient After touching patient surroundings

Answer 213

Social - using plain/antimicrobial soap OR alcohol gel if hands not visibly soiled Hygeinic - used on clinic when seeing pts - using liquid soap AND alcohol hand gel - 6 step technique, then don PPE Surgical - using antiseptic hand cleansers, longer and more thorough hand washing that includes lower arms (hibi scrub often used)

Answer 214

BW's - 2's for adults, 0 for deciduous Anterior PA - 0 Posterior PA - 2 Occlusal - 4

Answer 215

Anterior PA - dot to block Posterior PA's - white dot to incisal edge BW's - dot in the palate Occlusals - dot out of the mouth

Answer 216

Interpupillary parallel to floor Midsaggital plane perpendicular to floor Ala tragus line parallel to floor Maxillary plane parallel to floor Collimator head above bridge of nose Vertical angulation = 60 degrees

Answer 217

FSD = 20cm = 30% dose reduction

Answer 218

FSD = 20cm = 30% reduction Voltage must be between 60-70kV Beam diameter must not exceed 60mm diameter at end of spacer cone - Rectangular collimation must be provided and beam size must not exceed 40x50mm Fastest film availble must be used - F speed or digital Beam aiming devices - dose reduction, improved quality, fewer rejects

Answer 219

Voluntary Informed Not manipulated Not coerced With capacity

Answer 220

The ability to - Act - Make decisions - Communicate decisions in a way that both the dentist and pt understand - Understand decisionns - the tx itself and why it needs to be done, benefits, risks and consequences of no tx - Retain memory of the decision for more than 24h Incapacity = the inability of an individual >16 to opt into a legally binding contract

Answer 221

Welfare guardian - court appoints an individual to consent/make decisions on behalf of a person >16 who has never had capacity Welfare POA - an individual with capacity appoints another individual to consent/make decisions for them once they lose capacity Continuing POA - for financial decisions only cannot make welfare decisions

Answer 222

Adults with incapacity act scotland 2000 Mental capacity act 2005 in england

Answer 223

Benefit Minimum necessary intervention Considers past and present wishes of the pt Consultation of relevant others - close relatives/primary carers/POA or guardians etc Encourage residual capacity - encourage pt to make their own decisions if possible

Answer 224

Welfare POA if there is proof Welfare guardian - proof A healthcare professional under section 47 of the AWI act If no capacity and no proxy - tx can be done if incapacity certificate provided by GP and the AWI principles followed

Answer 225

Atrophy - loss of viable layers Erosion - partial loss in thickness Ulceration - epithelium lost with fibrin exudate on surface Blisters - Collections of fluid in vesicles or bulla Oedema - intra/inter cellular swelling

Answer 226

Symptomatic Abnormal overlying or surrounding mucosa Increasing in size Rubbery consistency Trauma from teeth Unsightly

Answer 227

Areas of tongue lining thin giving migrating red appearance with semi-circular white areas Occurs on dorsum (top) and lateral borders Sensitivity to acidic/spicy foods - nerves and BV's closer to surface Mostly asymptomatic - no tx required If symptomatic - think haemotinic deifciency, parafunction, dysaesthesia

Answer 228

Ulcer with yellow/grey base and erythematous margins

Answer 229

Minor - <1cm, lips, tongue, fom, lasts 10-14 days heals without scarring Major - >1cm, can affect keratinised tissue, can last for up to 3 months, can leave a scar when healed Herpetiform - cluster of ~20 ulcers on NK mucosa, like PHG with no fever, has ability to recur Bechet's - oro-genital ulcers ( 3 episodes mouth ulcers+ genital sores, eye inflammation, skin ulcers, pathergy)

Answer 230

Correct haematinic deficiency - blood tests and diet/supplements Avoid dietary triggers - benzoates Avoid SLS toothpaste If there is a high morbidity/short ulcer free period - betamethasone mw (1 tab in 10ml of water - send 100 tabs, label - use 4x daily, do not swallow, do not eat/drink/rinse) benzydamine MW 0.15%, label - rinse using 15ml every 1.5hrs as required, send 300ml CHX 0.2% - prevent secondary infection§

Answer 231

Treat RAS Colchicine Azathioprine Mycophenolate Infliximab Contact rheumatology

Answer 232

It is an allergic reaction caused by the immune system to an unknown trigger. It can cause painful and widespread ulcers, we also see the skin on the body can be affected by rash and lips can become crusty. These last for about 2-3 months and you may develop or have had flu-like symptoms. You can often get mouth ulcers and if more severe sometimes this can spread to the genitals, eyes oesophagus and airways so it is important that we manage this correctly.

Answer 233

Target lesions - lasting - 2-3 months Flu-like symptoms prior to development of condition Mouth ulcers similar to PHG If severe - involvement of genitals, eyes, oesophagus and airways

Answer 234

Analgesia Encourage hydration Refer for biopsy At OM they may prescribe: Systemic aciclovir Prednisolone - 60mg per day Benzydamine/CHX/Betamethasone Azathioprine if reccurrent AB if triggered by bacterial infection

Answer 235

Benign rare condition affecting the lining of your mouth, it involves spontaneous appearance of blood filled blisters in the mouth which occur rapidly. Unknown cause but often associated with trauma from food or dental tx or prolonged use of steroid inhalers. Blisters burst and leave ulcers that heal without much discomfort. Management: - Drainage of blisters at back of mouth - No tx otherwise - burst on their own - Benzydamine (difflam) if painful/CHX to prevent secondary infection

Answer 236

Uncommon autoimmune condition that causes blistering that affects lining of mouth and gums (or similar surfaces e.g. the nose, genitals eyes etc). Can be associated with scarring and may prompt referral to other specialties.

Answer 237

Bullous - skin Mucous membrane Cicatritial - presence of scarring Symptoms: Blisters in mouth appear red - pain on bursting Ulcers form on bursting of blisters Desquamative gingivitis Sore gritty eyes Skin blisters - trunk, scalp, face, limbs

Answer 238

Pemphigoid - thick-walled blisters - autoantibodies cause separation of epithelium from connective tissue by targeting hemi-desmosomes - linear basement membrane staining on DIF - related to c3, IgG, IgM, IgA Pemphigus - thin-walled blisters - rarely seen intact - Autoantibodies attack desmosomes resulting in intrepithelial bullae - over 50s, females, askenazi jews - basket weave on DIF - associated with c3 and IgG

Answer 239

Rare autoimmune disease that causes blistering or ulceration of mouth, throat, genitals and skin Referral Advise pt to avoid spicy food and benzoates Avoid SLS toothpaste Stop smoking and reduce alcohol intake Use CHX MW Steroids- prednisolone · Benzydamine · Azathioprine · Mycophenolate · Dapsone · Biologics

Answer 240

Test salivary flow rate Check if unstimulated flow is less than 1.5ml in 15 mins

Answer 241

Dehydration Polypharmacy Somatoform disorders Medical conditions - diabetes/epilepsy/sjogrens/stroke/Addisons Management: - Blood tests - U's&E's, glucose, c3's/c4's, autoantibodies, CRP - salivary ultrasound - sialography - eye screening - tear film -Enhanced prevention - CRA, diet advice, F - Sipping water/sugar free gum - Saliva substitutes - sprays lozenges - Pilocarpine (make pt aware can cause sweating and tachycardia) - Contact GP to see if alternative medication can be taken

Answer 242

Difficulty swallowing Clicking speech Discomfort in mouth Altered taste Cervical caries Halitosis Candidiasis Struggles with denture control Food debris in mouth Depapillation and lobulation of tongue Ascending infections of major salivary glands

Answer 243

Drugs - clozapine, haloperidol, anticholinesterases Dementia CJD Stroke Poor swallowing - anxiety, MS, MND, CP Management: - Anti-muscanaric - Botox - Duct repositioning surgery - Biofeedback training

Answer 244

You have a condition which we call sialosis. This is a condition where there is a painless swelling of the salivary glands called the parotid which are on both sides of your face which can appear like mumps but the overlying skin isn't inflamed. You might get some discomfort with this and sometimes it can involve your other salivary glands aswell. It may occur on its own or sometimes it can be associated with other medical conditions but it does not cause any long-term problems. Management: - Blood tests - glucose, LFT, enzymes - Biopsy - If no cause identified - no tx - Surgery - rare

Answer 245

Chronic autoimmune disease which affects salivary and tear glands causing dryness of mouth and eyes. It can also affect the joints. It is far more common in women. Autoimmune disease, but genetics, hormones and environmental triggers may play a part. - dry mouth - issues talking, caries, altered taste - oral thrush - dry, sore, gritty eyes - fatigue - joint ache - swollen salivary glands - parotid and submandibular

Answer 246

Enhanced prevention - diet, OHI, F Salivary subs - lozenges, sprays Pilocarpine Methotrexate and hydroxychloroquine if caught early or joint issues Antifungals if required Dry eye drops or ointments Humidifiers Regular screenings due to increased risk of lymphoma

Answer 247

Uncommon autoimmune condition in which affected pts have persistent swelling in the lips, face or areas within the mouth. It is so named because if a sample of the swollen tissue is examined under a microscope, small collections of inflammatory cells called granulomas are often seen. It can be associated with crohns disease. Angular chelitis Lip fissuring Crusting Redness of peri-orbital tissues Swelling of lips Full thickness gingivitis Swelling of floor of mouth Mucosal tags Cobblestone mucosa

Answer 248

Biopsy Allergy testing Endoscopy - if suspected crohns Exclusion diet - benzoic acid, sorbic acid, cinnamon, E210-219, chocolate Miconazole/hydrocortisone cream for angular chelitis - check for warfarin Tacrolimus ointment 0.03% Prednisolone pulses Azathioprine, mycophenolate, adalimumab

Answer 249

Persistent burning pain or unpleasant sensation often confined to the lips or tongue, or can be more widespread in the mouth. The discomfort is usually present daily and continues throughout the day; often becoming worse in the day. O/E the mouth appears clinically normal. Despite the normal appearance of the mouth the symptoms are very real and can be very distressing, it is associated with neuropathic pain caused by changes in nerves. Symptoms: - Dry mouth - Pain - Numbness - Tingling - Worse when stressed or eating spicy food Management: - Check haematinics - CBT - Benzydamine - Amitrypiline, duloxetine, gabapentin, pregabalin - Stress reduction

Answer 250

Condition that affects trigeminal nerve Sudden attacks of very severe pain on one side of the face Pain is usually sharp, stabbing, or electric shock like, may be triggered by touching the face, shaving, chewing or tooth brushing The painful attacks can last from a fraction of a second to a few mins and can occur several times a day for days weeks or months. Some pts have a dull ache in between episodes. Causes - Idiopathic - Vascular compression - MS - Tumours - Connective tissue disease - AV malformations Investigations - MRI - CN exam - FBC - LFT Tx: - Carbamazepine (side effects: dizziness, drowsiness, memory issues, requires blood monitoring, paraesthesia) 100mg, 2x daily for 10 days send: 20 tablets - oxcarbazepine - lamotrigine - gabapentin - pregabalin - phenytoin - baclofen - LA - if acute in dental setting - Surgery - gamma knife radiosurgery, microvascular decompression, glycerol injections

Answer 251

Hereditary - white sponge naevus, fordyce spots Keratosis (smokers, traumatic) Lichenoid/LP Lupus erythematosus Infection - pseudomembranous or chronic hyperplastic candidiasis Carcinoma/SCC