Notes Flashcards
What is the first line antibiotic for dental abscesses?
According to SDCEP drug prescribing guidelines it is a 5 day regimen of either:
Phenoxymethypenicillin tablets, 250mg
Send: 40 tablets
Label: 2 tablets four times daily for five days
Amoxicillin 500mg
Send: 15 tablets
Label: 1 tablet 3 times daily for five days
If pt is allergic to penicillin - metronidazole (avoid w alcohol)
What antibiotics would you provide for a patient with spreading infection from a dental abscess and an allergy to penicillin?
SDCEP - June 21 update
Metronidazole - 400mg
Send: 15 tablets
Label: 1 tablet three times daily
What antibiotics would you provide for a patient with spreading infection from a dental abscess who has an allergy to penicillin and is on warfarin?
Clindamycin capsules, 150mg
Send: 20 capsules
Label: 1 capsule four times daily swallowed with water for five days
During an IV sedation assessment, what important things should you explain to the patient after introducing yourself.
Take hx - establish nature of fear/phobia/anxiety (cant do IV sedation for people with needle phobia)
Explain to pt:
- Need an escort
- No alcohol before
- No responsibilities or work the following day
- No driving for 12 hours
What medications would you be looking for in a MH during a sedation assessment?
Drug interactions - alcohol, opioids, erythromycin, antidepressants, antipsychotics, antihistamines, recreational drugs
What are the ASA classifications?
ASA Class I - Normal healthy pts
ASA Class II - Mild systemic disease, BP <160/95
ASA Class III - Severe systemic disease
ASA Class IV - Incapacitating disease which is a constant threat to life
ASA Class V - Moribund pt not expected to live >24h
What are the indications for IV sedation?
MH aggravated by stress - ischaemic heart disease, hypertension, asthma, IBS, epilepsy
Handicap/parkinsons/learning difficulties
Phobia/gagging/fainting
Especially long/unpleasant procedure
What are contraindications for IV sedation?
COPD
Hepatic insufficiency (midazolam is metabolised in the liver)
Pregnancy
Severe special needs
What drugs are used in IV sedation?
Midazolam - 5mg/ml
Reversal agent:
Flumazenil - 200 microgram
What are the indications for inhalation sedation?
Anxiety
Needle fear
Gagging
Traumatic tx
MH that increases stress
Unaccompanied adults needing sedation
What are contra-indications for inhalation sedation?
Common cold
Enlarged tonsils/adenoids
Severe COPD
1st Trimester pregnancy
Limited understanding
What are the pre-op instructions for IS?
Light meal pre-appt
Routine medication should be taken
Children accompanied by adult
Adults need accompanied at 1st appt only
No alcohol
Sensible clothing
Arrange childcare post appt
Plan to remain in clinic 30mins post appt
What categories are involved in a caries risk assessment in paediatric dentistry?
- MH
- SH
- Fluoride use
- Saliva
- Diet
- Clinical evidence
- Plaque control
What are some reasons for delayed eruption of a permanent tooth?
Abnormal development position
Supernumerary tooth
Displacement of permanent teeth due to trauma to primary tooth causing ankylosis
Dilaceration
Impaction
Eruption cysts
Early loss of primary teeth
What are signs of a supernumerary tooth?
Delayed eruption
Midline discrepancy
Midline diastema
Crowding of permanent teeth
Displacement of permanent teeth
Rotation of permanent teeth
What OHI advice would you give to a parent?
Standard prevention, 1x yearly
Brush as soon as 1st primary tooth erupts
x2 daily, 2 minutes, morning + last thing before bed - no food or drink (except water) afterwards
Spit out toothpaste, don’t rinse - removes action of fluoride
Assist child until 7 years old, supervise after until child is confident
Use correct amount of fluoride for childs age:
<3 - smear, >3 - pea
Age <3
LR = 1000ppm
HR = 1350-1500ppm
Age 3-9
LR = 1350-1500ppm
HR = 1350-1500ppm
Age >10
LR = 1350-1500ppm
HR - 2800ppm (>16 - 5000ppm)
If a child is at high risk of caries what actions can you take?
Enhanced fluoride toothpaste
- >3 - pea 1450ppm
- >10 - Rx duraphat 2800ppm
Standard prevention advice every recall (3 months)
3 min hands on TBI - annual
Plaque disclosing tablets
TB charts
Free TB/Toothpaste
Floss DE6’s x2 weekly
What is considered an overdose of fluoride when ingested? What is management?
It depends on how much fluoride was ingested and the weight of the child
(average tube toothpaste - 90g)
5mg/kg - Give milk orally and observe for a few hours
5-15mg/kg - Give milk, calcium lactate/calcium gluconate and admit to hospital
> 15mg/kg - Give calcium gluconate, urgent referral to hospital for cardiac monitoring and IV calcium gluconate
What diet advice would you give to a parent?
Standard prevention - 1x yearly
- Sugar - reduce frequency to no more than 4x daily
- Hidden sugars - fruit juice, sweetened milk, soya milk
- Acid - limit fizzy drinks to meal times
- Sugar free snacks - cheese, breadsticks , carrots
- Water only between meals and in bedtime bottle
Enhanced:
- standard prevention at 3 month recall
- Diet diary - 2 days during week and 1 weekend, add timings of meals/snacks and accurate measurements
- Action planning
What are the elements of standard prevention in paeds?
OHI
Diet advice/diary
Fluoride varnish
Fluoride toothpaste
Fluoride supplements
Fissure sealants
Radiographs
Sugar-free medicine
How can fluoride be used in prevention for paediatrics?
Standard prevention:
>2y - NaF varnish (22600ppm) 2x yearly
2-5 - 0.25ml
>6 - 0.4ml
Enhanced - Additional 2x yearly so 4 in total unless they have received care from childsmile
0.5ml of duraphat contains 11.3mg of fluoride/0.25ml of duraphat contains 5.65mg of fluoride
· Safely tolerated dose is 1mg per kg, average 3 year old weighs 15-20kg
Fluoride Varnish Contraindications
· Allergies- colophony (Elastoplast)
· Ulcerative gingivitis
· Severe asthma (hospitalised or oral steroids)
· severe allergie
FV aftercare advice:
· Avoid eating or drinking for at least an hour
· Eat soft food all day
· Avoid brushing that night only - brush as normal from tomorrow morning (high risk as normal)
· avoid fluoride supplements for 2 days
> 7 - NaF mouthwash
When would you take radiographs for kids?
BW’s from age 4
standard - every 2 years
high risk - every 6-12 months
When would you use fissure sealants?
Place in all pits+fissures of permanent teeth if child is high risk from CRA
Standard - L6 buccal pits, U6 palatal pits
Pre-cooperative child - GI as temp sealant on PE 6/7s
Check existing fissures - may need to be topped up
What are the 5 options for caries management in primary dentition?
- Complete caries removal + rest
- Partial caries removal + rest
- No caries removal, seal
- No caries removal, prevention, make self cleansing
- XLA
What are the 9 components of the index of suspicion in paediatrics?
- Could the injury have been caused accidentally, if so - how?
- Does explanation of injury fit age and clinical findings?
- Is explanation consistent with injury, is this within normally acceptable limits of behaviour?
- If there is delay in seeking advice, are there good reasons for this?
- General demeanour
- Nature of the relationship between guardian and child
- Childs reaction to people
- Childs reaction to any medical/dental examination
- Comments by child/guardian that give concern about the upbringing or lifetstyle
What are 10 neglect markers in paediatrics?
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
Write a prescription for a conventional fixed-fixed bridge replacing tooth 25.
- Pts name, address
- Date sent, date required, disinfected
- Please pour up impressions in improved dental stone
- Please mount casts using facebow and wax bite registration provided to mount on a Denar type II semi-adjustable articulator
- Please construct conventional (fixed-fixed) bridge with teeth 24+26 as retainers
- Please provide tooth 25 pontic (modified ridge lap)
- Teeth 24+26 MCC with buccal shoulder, palatal chamfer
- Please construct in canine guidance and ensure pontic is free of excursive movements
- Shade A3
Mr R Jalif
Signature
Address of practice
Phone no.
You are conducting an intra-oral examination and you spot a lesion on the RHS buccal mucosa, how would you describe this?
Site
Size and Shape
Surface
Surrounding tissue
Colour
Consistency
Base
Bleeding
Functional limitation
What is Lichen Planus and what are the 7 types?
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)
Describe a lichen planus lesion for your notes.
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
What else extraorally should you examine when looking for LP?
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
What histopathological features are shown in LP?
Ortho or parakeratinized surface
Acanthotic or atrophic epithelium
Subepithelial band of T Lymphocytes
Liquefactive degeneration of basal cells
What special investigations are required for LP and what is the treatment?
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
Explain what Lichen Planus is to a patient.
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.
What are the cranial nerve tests?
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?
What are the tx options for a 20y/o male with a class III malocclusion?
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
How would you explain denture induced stomatitis to a patient?
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
What is newton’s classification?
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
what is the management of denture induced stomatitis?
- 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
Why and how would you carry out a reline for a complete denture?
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”
What hx would you take from a patient who brings her child to the clinic and they aren’t feeling well - pics provided of small vesicles in labial mucosa and tongue.
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
You have diagnosed a child with primary herpetic gingivostomatitis, explain this in laymans terms to the parent.
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.
How do you treat PHG?
· 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
What is the prescription for acyclovir for PHG?
If aged 2-17:
200mg/(oral suspension
200mg per 5ml), 5x daily for 5 days (send 25 tablets)
If 6m-1y:
Half dose
Why is SDF used?
To prevent decay from progressing - more effective than fluoride varnish
Reduces dentine hypersensitvity
Vaseline on ST, dry teeth, apply for 3 mins
What are the indications for SDF?
Non-restorable dentine lesions
MIH - reduces sensitivity
Pre-cooperative
Delay sedation/GA
Asymptomatic cavitated lesions
What are contraindications for SDF?
Allergy to silver or other heavy metals
Painful gums or mouth ulceration
Lesions that involve the pulp
PA pathology
Mucositis/Stomatitis
What are the disadvantages of SDF?
Permanent discolouration
Temporarily stains soft tissues for 1-3 weeks
Discolour composite fillings
Permanent discolouration of clothes
What are the steps if you give FV to an allergic child?
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
What alternatives are there to SDF?
Monitoring
FV
Remove decay and restore
Hall technique
XLA
Break bad news of a SCC to a patient.
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
What is the NHS complaints procedure?
- Acknowledge the complaint and provide the patient with the practice complaint procedure
- Inform the dental defence organisation
- Inform the patient of timescales and stages involved
- 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
- Early resolution 5 working days: For issues that are straightforward and easily resolved, requiring little or no investigation
- Investigation 20 working days: for issues that have not been resolved at the early resolution stage or that are complex, serious or “high risk”
- Independent external review ombudsman: For issues that have not been resolved
Patient was annoyed that they had to wait an hour and receptionist was rude. How would you deal with this situation?
- 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
Medical emergency - explain hypoglycaemia to a nurse and management.
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?
What is the management of a epileptic fit?
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
You overhear a nurse bad-mouthing a pt to a colleague in a public area, they refer to them in a derogatory manner and joke about posting this on social media. Pt and family are easily identifiable from info heard, discuss this issue with your nurse
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
A 27-year old teacher presents with a bunch of E/O and I/O signs of TMD. Click on both sides, sore
muscles, sore in morning, tongue scalloping and cheek biting (linea alba). Please discuss the diagnosis
with the patient, and conservative management for this condition. You do not need to obtain further
information from the patient.
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?
A 28-year old female patient who works in television has had an accident in which she injured her face.
There are no other injuries and you have completed the examination as well as taken a radiograph. You
have diagnosed the tooth as having a vertical root fracture and is unrestorable.
Explain your findings to the patient and how you would treat them.
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
What are common denture faults?
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
C/C denture provided, please identify 6 faults with this denture and how to rectify.
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
What are the advantages of composite?
Better aesthetics
Bonds to tooth
Minimal prep required
On demand Set
Lower thermal conductivity
Suppoers remaining tooth structure
What are the disadvantages of composite?
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
What is the failure rate of composite?
depends on pts OH/diet/parafunction/occlusion/operator skill
5-10 years - 13.7% failure rate at 8 years
What are the constituents of composite?
BIS-GMA
Quartz, silica
Silane coupling agent
Camphorquinone
TEGDMA
What are the requirements of a composite cavity?
Doesn’t require undercuts
Smooth margins
No unsupported enamel
No sharp line angles
Bevelled cavo-surface margin angles - increases bonding area
How can you avoid sensitivity following composite placement?
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
How does composite bond to dentine?
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
What is the purpose of etching enamel as well as dentine?
Increases surface energy
Removes contaminants
Increases surface area by roughening allowing micromechanical interlocking with resin - bond is 20MPA
What are the advantages of amalgam?
Durable
Shorter placement time
Radiopaque
Colour contrast
Self-hardens at mouth temp
Resistant to surface corrosion
Good wear resistance
Good bulk strength
What are the disadvantages of amalgam?
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
What are the failure rates of amalgam restorations?
Can last up to 20 years, 5.8% failure rate at 8 years
What are the requirements of an amalgam cavity prep?
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
What are components of amalgam?
Silver
Tin
Mercury
Copper
Tend to be zinc free now to prevent hydrogen bubble formation
What does copper in amalgam do?
Increases early strength
Less creep and corrosion
Better marginal integrity
What is the purpose of dental dam?
Eliminate bacterial contamination
Prevent inhalation of instruments
Retract/protect soft tissue
Reduced chairside time
Increased operator and patient confidence
Moisture control
Describe an RCT to a pt
(remember - explanation, procedure, benefits, risks, tx options, follow-up, succesful outcomes)
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
What are succesful outcomes of a RCT?
Successful outcomes
- no pain, swelling, symptoms
- no sinus
- no loss of function
- normal pdl
What are unsuccesful outcomes of RCT?
Associated w signs and symptoms
Lesion has appeared radiographically
Pre-existing lesion has increased in size or remained the same
Signs of continuining RR
What are the tx options following RCT?
- 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
What are the steps involved in re-rct?
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
What are symptoms of a NAOCL extrusion?
Pain
Swelling
Haemorrhage (bleeding - redness)
Ecchymosis (bruising)
Neurological issues
Airway obstruction
How do you manage a hypochlorite extrusion?
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
Risk factors for NaOCL extrusion?
Excessive pressure (>1ml per 15s)
Needle locking in canal
Loss of WL control
Higher NaOCL conc.
Larger apical diameter (due to resorption, anomalies, perforation)
You were instrumenting a canal and you notice your file is shorter than normal on reconfirming length, what would you do?
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
You are instrumenting a canal when you spot sudden bleeding and the patient is in pain, what do you suspect has happened and what would you do?
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.
How would you diagnose reversible pulpitis, causes and management?
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
How would you diagnose symptomatic irreversible pulpitis?
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
How would you diagnose asymptomatic irreversible pulpitis?
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
How would you diagnose pulp necrosis?
Death of pulp
Doesn’t respond to sensibility testing
No symptoms
Tx options:
- RCT
- XLA
Other than normal pulp, RP and IP what pulpal diagnoses are there?
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)
What periapical diagnoses are there?
Normal
Symptomatic apical periodontitis
Asymptomatic apical peridontitis
Acute apical abscess
Chronic apical abscess
Condensing osteitis
What are the signs of normal periapical tissues?
Not TTP or TTBP
Lamina dura intact - hard bony lining of the alveolus
Uniform PDL
What are the signs of symptomatic apical periodontitis?
TTP, TTBP, Pain on biting (severe indicated degenerating pulp)
May be radiographic changes - width of PDL, PAP
Tx Options:
RCT
XLA
How would you diagnose asymptomatic apical periodontitis?
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
How would you diagnose a chronic apical abscess?
Gradual onset
Little/no discomfort
Intermitted discharge via sinus
Radiographic signs of osseous destruction
Tx options:
RCT
XLA
How would you diagnose an acute apical abscess?
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
How would you diagnose condensing osteitis?
Diffuse radiopaque lesions representing localised bony reaction to low grade inflammatory stimulus
Tx options:
RCT
XLA
When making your access cavity what 3 laws should you follow?
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
What are the functions of provisional restorations?
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
What are the 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 (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
How do you deal with a blood spillage?
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
What is the system of design for RPD?
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
What are the kennedy classifications?
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
What is RPD support defined as and whats the classification for it?
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
What provides support for an RPD?
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
What is retention for an RPD and how do we achieve it?
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
What in indirect retention for an RPD and what can provide it?
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
What is reciprocation in terms of RPD?
Prevents continual horizontal pressure causing tooth movement
How many reciprocal arms should there be - ideally 3 arms in a triangle shape
What is an RPI?
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
What is the purpose of a connector in an RPD? what are the types and advantages/disadvantages?
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
You have found a white patch on the floor of the mouth, what are the possible causes? discuss the need for a biopsy and possibility of oral cancer. Discuss patient risk factors (smoking and alcohol)
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
What are the urgent cancer referral guidelines?
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
Patient attends concerned about spots underneath his ortho brackets, wants you to go over advice on how to avoid decalcification.
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
Write a prescription for duraphat toothpaste(s).
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
You have decided a tooth needs a RCT - you have already explained and consented for an RCT, talk to the patient regarding restorative options post RCT.
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
When would you use each cement for indirect restorations?
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
What are the pre and post cementation checks for indirect restorations?
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
You are presented with an OPT - how would you systematically report your findings to an examiner.
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
Patient has severe pericoronitis, is feeling unwell and has pus suppurating from the site.
You have irrigated but feel antibiotics are required to treat the patient. Note the patient is an alcoholic.
You are provided with all the details and a prescription pad to write a prescription.
● 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)
XLA post op-instructions.
● 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
An adult appears to be choking - how do you deal with the emergency?
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
Give smoking cessation advice.
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
State the fracture type most likely from the photo available and clinical history. (right orbitozygomatic fracture)
Perform an E/O exam (on a
mannequin) to assess this patient for the facial fracture.
Suggest further investigation for this fracture type,
what you can see on the investigation, and further management if you had this patient present to you in a
standard dental surgery
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
Discuss with a patient that their 26 is unrestorable and likely requires XLA - MH: warfarin
● 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)
What are the risks of MRONJ?
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)
Take hx and diagnose irreversible pulpitis
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)
What are the handpiece safety checks?
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
Paeds Trauma - 11 EDP# immature apex - 8 yr old - Outline procedure to parent of anxious child
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
Pus apirate and completion of path form for a 26 dentoalveolar abcess.
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
Crown Critique - Gold crown fitted onto mounted casts (6 mins)
Use articulating paper, shimstock and calipers to assess crown
Make decision to redo prep and send back to lab
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
Treatment Planning - Examination of information, Diagnosis and Tx planning (12 mins)
35-year old male - C/O BOP on brushing and shortened clinical crowns. Smokes 20 cigarettes daily, drinks
25 units alcohol weekly and 1-litre full fat fizzy juice daily.
Casts provided: show lower crowding.
Photos provided: show erosive wear, gingival erythema.
Full mouth PA views on viewer: impacted lower 8, mild bone loss upper anterior teeth.
Spend 3-4 minutes looking at these, then diagnose the conditions present and outline your treatment plan.
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
Recurrent Aphthous Stomatitis - Recurrent Minor Ulcers (6 mins)
27-year old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history
provided etc). Using this information and the available lab results (Patient has low iron and folate). Discuss
the lab findings, the diagnosis and management options for this condition with the patient. You do not
need to gain any more information from the patient.
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
Ortho - Retained ULA + Unerupted UL1 (6 mins)
Photos of discoloured 61 and labial/buccal segments of an 8 year old. PA of a dilacerated floating 21 that
could be anything. Please identify the problem present for this patient and discuss its further
investigation/management with your examiner.
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)
Concerned mother with 2 year old in pain. Take a brief pain history then photo of decayed 52-62 (upper
incisors) provided. Explain diagnosis to parent, prevention and management options (GA)
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
how do you consent a patient for a GA and then how do you refer?
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
Direct Pulp Cap: assume dam placed, tooth with cavity close to pulp (12 mins)
Assuming dental dam has been applied, please place a direct pulp cap on an exposed 36 following a pulpal
exposure on the mesial axial wall.
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.
How would you place an indirect pulp cap?
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.
What would you do in the case of a carious pulp exposure?
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
A 27-year old teacher presents with a bunch of E/O and I/O signs of TMD. Click on both sides, sore
muscles, sore in morning, tongue scalloping and cheek biting (linea alba). Please discuss the diagnosis
with the patient, and conservative management for this condition. You do not need to obtain further
information from the patient.
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.
Breaking Bad News - Unrestorable 11 requiring XLA - SPIKES (6 mins)
A 28-year old female patient who works in television has had an accident in which she injured her face.
There are no other injuries and you have completed the examination as well as taken a radiograph. You
have diagnosed the tooth as having a vertical root fracture and is unrestorable.
Explain your findings to the patient and how you would treat them.
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
What are common complete denture faults?
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
What are some general denture faults with the denture itself and with the wearer?
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
30 yrs pt not registered with GDP, CO of signs of ANUG. Smoke 20 cigarettes daily - otherwise fit and well.
Has cervical lymphadenopathy. Discuss diagnosis with pt, and proposed management. No need to obtain
more information from the pt.
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
50-year old patient about to begin chemotherapy for breast cancer. No idea of need to go to a dentist for
assessment but oncologist sent her to you as her GDP. Explain the relevance of dental health for cancer
treatment, diagnose a condition of a tooth (gross caries/apical periodontitis from radiographs) and your
proposed management. Talk through side effects of treatment and how you can help to manage these.)
● 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
O/E - Ectopic canine, OJ, OB, Peg lateral, what are the problems, dental implications and how would you determine position from a radiograph? (6 mins)
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.
Previous station on Denture design - Articulator Identification, Reciprocation, Bracing
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)
Cleanliness Champions/Cross-infection (6 mins)
What is wrong with this bay? identify dangers + how to rectify.
Know waste streams - disposal of amalgam and sharps. Cleaning up blood spillage
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
Discuss need for biopsy + possibility of oral cancer. Discuss pt risk factors (smoking + alcohol)
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
Ortho - Decalcification (6 mins)
Patient wants you to go back over advice on how to avoid decal. Diet advice. Tooth brushing instruction.
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
Endo Restoration Options - Molar tooth - Explain to patient
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
Paeds – Caries - Risk assessment and management (6 mins)
Diagnose Caries on Bitewings, Explain prevention and TB advice to mum
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
Identify types of crowns/bridges on casts - Cements used to bond each (6 mins)
GSC, MCC, Porcelain crown, Porcelain veneer, Adhesive Cantilever bridge
Pre + Post cementation checks
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
Bridge prescription for conventional cantilever (6 mins)
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
Paeds Trauma - Subluxation - 18-month old knee to knee (12 mins)
Fake child (doll) who fell down, knee to knee exam, subluxation of upper centrals, explain management to
father, possible consequences to permanent.
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
Medical Emergency – Explain asthma & anaphylaxis drugs to nurse (12 mins)
New nurse asks what do I do if pt has an asthma attack and how can you identify it. How to treat it and use
a spacer. What do I do if it turns to anaphylaxis and how will I know it is anaphylaxis. What do you know
about adrenaline and how to I use it.
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)
Surgical removal of 8 - Discuss surgical procedure, go through complications for consent (12 mins)
‘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.
Decon - Sterilisers (6 mins)
Difference between type N and type B, Cycle, Type of water used, Tests for sterilisers
Instruments on top of steriliser - how do you know if sterilised - what do you do?
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.
What is the NHS complaints procedure?
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.
Lymph node exam - Cancer Suspicion - Urgent referral (6 mins)
Extraoral exam checking for swollen lymph nodes and you should be able to name the different ones. You
get given a picture of a lesion (probably FOM) and you need to take brief history from actor and tell them it
could be sinister. Need to console patient and tell them they’ll be referred urgently and what happens next.
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
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
Treatment Planning for Child - Parent considering complaint (12 mins)
Mucocele, Caries, PA pathology, Hypodontia
Parent considering taking legal action as previous dentist never took radiographs or advised on treatment
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’
Endo file separation during RCT. You temporise tooth and explain what happened. Discuss options.
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
Ortho - URA: Faults, activation, delivery checks and care instructions (6 mins)
Required to fit upper removable appliance to a 9-year old. Examine the prescription and the appliance, look
for defects and answer the examiners question. Asked about FABP, show how to make adjustments to
adams clasps and activate palatal finger spring. Prior checks before delivery and care instructions.
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
Name all the oral surgery equipment you can and what they are used for (32 items - 32 marks)
- Black Safety Plus Handle: For LA injection
- Mouth Mirror: Soft tissue retraction, indirect vision
- Straight Probe: Test for LA before XLA, test surface
- Collage Tweezers: Handle cotton pledget (with cross pattern), remove sequestrae
- Swann Morton Scalpel Handle with no15 Blade: Incision to raise a flap or biopsy
- ‘S’ Shaped Cheek Retractor: Retract the cheek, retract soft tissue
- Howarth Periosteal Elevator: Raise mucoperiosteal flaps, flap retraction
- Howarth Periosteal Elevator: As above
- Ash Periosteal Elevator: Elevate soft tissue flaps, flap retraction
- Couplands Osteo Chisel No1: Elevate root and tooth, create space for insertion of forceps
- Couplands Osteo Chisel No2: As above
- Couplands Osteo Chisel No3: As above
- Warwick James Elevator Right: Elevator for removing teeth and roots, especially upper 8s
- Warwick James Elevator Straight: As above
- Warwick James Elevator Left: As above
- Cryers Elevator Right: Elevator used to elevate roots and remove interradicular bone
- Cryers Elevator Left: As above
- Curved Mosquito Forceps: Picking up sequestrate or fractured instruments or posts, artery clips
- Bone Rongeurs: Also known as bone nibblers, used to trim bone, remove spicules and septae
- Rake Retractor: Flap deflection, scratchin your back
- Bone File: Smooth down rough bit of bone by pull stroke
- Victoria Curette: Remove granuloma or cyst from periapical tissue, remove granulation tissue from socket
- Mitchells’ Osteo Trimmer: Removing sharp bone spicules, exposing canines, apicectomy
- Straight Spencer Wells Forceps: Picking up teeth, removing sharp bone spicules
- Alice Tissue Forceps: Used to hold soft tissues, can be used to pick up teeth
- Kilner Needle Holders: Holding needle for suturing
- Fickling Forceps: As above forceps
- Gillies Needle Holders: Holding needle for suturing
- Gillies Toothed Tissue Forceps: Manipulation of suture
- Curved Iris Scissors: Cutting suture
- Lack’s Tongue Depressor: Depressing tongue, retracting tissue
- Towel Clips: Clipping things on tray table
History of patient given - swollen lips all his life. Chat through history, ask and ascertain local and
systemic signs. Chat about how you would manage it going forward.
Asked patient about any bowel problems he said yes, informed of potential Crohn’s.
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.
Facial Palsy - Given IDN - Identify and manage (6 mins)
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.
Complete Dentures - Primary Impressions and Lab Card (6 mins)
Select tray for edentulous lower primary impression. Select handle and place in correct place.
What position would you stand in, what material would you use. Write this stage on lab card.
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
Paeds - Deal with parent and child with staining or missing teeth? Can’t remember was shown X-rays,
given clinical info and had to reassure parent. (12 mins)
● 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
CoCr Partial Denture trial on cast - Check metal framework against prescription and find faults (6 mins)
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
How do you carry out a Veneer Prep - 11 (12 mins)
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
Perio - Comparing Pre and Post-treatment pocket charts (12 mins)
Indicate where healing has occurred, where it hasn’t. Reasons for failure.
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
PMHP - Statistics (6 mins)
Gleam MW (new) vs Leading brand mw. Null hypothesis, 95% confidence, Risk Ratio of 1.39
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?
Failed RCT - Causes and Options (6 mins)
Patient has failed root treatment. Explain why it might have failed. What options are available?
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
Dry Mouth - History Taking - Amitriptyline, take a hx, what are signs/symptoms and how is it managed? (6 mins)
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
Cranial nerve tests?
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?
IV Sedation (6 mins)
O2 dissociation curve, Max N2O%, Alarms - what to do if it goes off, Contraindications
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%)
Endo - RCT Risks VS Benefits - Explanation of RCT
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
Non-accidental Trauma - Signs - Taking action
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
Write a referral letter to OS department for the extraction of a lower 8
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
Look at an OPT and choose 10 iatrogenic/developmental faults in the dentition
● 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
Local Anaesthetic - Common Formulations and Doses - Assembly - Side Effects - Anaesthesia check
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
Complete Denture Jaw Registration - Equipment - Lines/Features - Reference Lines
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
Sepsis Syndrome – SIRS – Systemic Inflammatory Immune Syndrome criteria? + management?
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
Candidal Leukoplakia (Chronic Hyperplastic Candidosis) - Advice and Management
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
URA Design
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
Write a URA px to reduce 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
Write a URA px to reduce 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
Write a URA px to retract 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
Write a URA px to retract 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
Write a URA px to correct 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
Write a URA px to expand the upper arch
○ 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
What advice would you give for an avulsed tooth?
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
What is the tx for an avulsed tooth with a closed apex?
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
How does treatment of an avulsed tooth with an open apex differ from one with a closed apex?
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
What is the management option for an ED fracture?
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
What is the management of a <1mm/<24h pulp exposure - non TTP/+ve to sensibility testing
- 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
What is the management of >1mm/>24h pulp exposure which is non TTP/+ve sensibility
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
What are indications and contra-indications for pulpotomy?
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
When is a full coronal pulpotomy used?
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
What are signs of failure of full coronal pulpotomy?
Clinical - pain, sinus, mobility
Radiographic - increased radiolucency, external/internal RR, furcation bone loss
When would you carry out a pulpectomy and how?
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
What is the management of a crown-root fracture with no pulp exposure?
- 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
What is the management of crown-root fractures with pulp exposure?
- 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
What is the management of a vital root fracture?
- Clean with saline/CHX
- If undisplaced - monitor
- If displaced - reposition under LA
- Splint for 4 weeks
What is the management of a Non-vital root fracture?
- Extirpate to fracture line
- Dress with NSCaOH then MTA to fracture line
- Obturate to fracture line
- or XLA
What are the types of healing that can occur after root fracture?
Calcified tissue healing
Connective tissue healing
Calcified and connective
Osseous healing
Non-healing granulation tissue
What are the PDL injuries that can occur from trauma?
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
What is the management of concussions and subluxation injuries?
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)
What is the management for extrusion?
Reposition under LA
Splint for 2 weeks
What is the management for lateral luxation injuries?
● 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
What is the management of intrusion injuries?
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
What is the tx for dento-alveolar fracture?
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
What advice would you give following trauma?
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
When is a 2 week splint indicated and when is a 4 week splint indicated?
2 week
- subluxation
- extrusion
- avulsion
4 weeks
- lateral luxation
- intrusion
- apical and middle 3rd root fracture (4 months if coronal)
- dentoalveolar fracture
How do you place a flexible splint?
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
What causes fluorosis?
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)
What is the tx for fluorosis?
Microabrasion
Composite veneer
Spot bonding composite
Strip crowns
What is the potentially lethal dose of fluoride ingestion?
Safely tolerated dose - 1mg/kg
Potentially lethal dose - 5mg/kg
Certainly lethal dose - 32-64mg/kg
What are tx options for MIH on molars?
Composite restoration
GIC
SSC
Adhesively retained coping
XLA when dental age 8.5-9.5
What are tx options for MIH on incisors?
Acid pumice micro abrasion
Resin infiltration
External bleaching
Localised composite placement
Full composite/porcelain veneers
What questions should you ask if you suspect MIH?
Natural birth?
Severe illness in pregnancy?
Birth trauma?
Pre-term?
Prolonged breastfeeding?
Childhood medication?
Infections - measles, mumps, rubella, chicken pox?
When would you carry out a BPE on a child?
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
How do you manage abuse for paeds pt?
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
What are the steps in microabrasion?
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
What can be the causes of staining on teeth in paeds?
Fluorosis, MIH, AI/DI, tetracycline, trauma
What pre-operative records would you take for stained teeth?
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
When is bleaching allowed in children?
When used for the purpose of treating or preventing disease
Hypo-mineralisation
Fluorosis
Trauma
What are some advantages and disadvantages of microabrasion?
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
What are instructions for night guard bleaching?
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
What are the requirements for non-vital bleaching?
Adequate root filling
No clinical disease/no radiological disease
Anterior teeth without large restorations
No amalgam intrinsic discolouration
No fluorosis or tetracycline discolouration
What are the steps in walking bleach?
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)
What are the steps of the inside-outside technique?
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
What are the steps following NV bleaching?
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
What are the risks involved with bleaching?
Sensitivity
Failure
Over-bleaching - white opacities become whiter
External cervical resorption
Tooth becoming more brittle
Damage to ST
How does ICON work? and steps?
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
What are the 5 instances for handwashing?
Before touching patient
Before cleaning or aseptic procedure
After body fluid exposure risk
After touching patient
After touching patient surroundings
What are the types of handwashing?
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)
What film sizes should be used when for x-ray?
BW’s - 2’s for adults, 0 for deciduous
Anterior PA - 0
Posterior PA - 2
Occlusal - 4
Where do the dots face on film when taking each type of radiograph?
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
When doing an occlusal radiograph how would you position the pt?
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
What is the FSD for dental x-rays and what does this achieve?
FSD = 20cm = 30% dose reduction
What are the harm reducing steps taken in an x-ray?
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
What does consent need to be?
Voluntary
Informed
Not manipulated
Not coerced
With capacity
What is the capacity criteria?
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
What guardians are there?
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
What acts are relevant to capacity?
Adults with incapacity act scotland 2000
Mental capacity act 2005 in england
What are the principles of the AWI?
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
If a pt has no capacity, who can consent for them?
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
What are different mucosal reactions?
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
When would you refer a swelling to OM?
Symptomatic
Abnormal overlying or surrounding mucosa
Increasing in size
Rubbery consistency
Trauma from teeth
Unsightly
What is geographic tongue?
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
What is the appearance of RAS?
Ulcer with yellow/grey base and erythematous margins
What types of RAS are there?
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)
What is the tx for RAS?
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§
What is the management for behcets?
Treat RAS
Colchicine
Azathioprine
Mycophenolate
Infliximab
Contact rheumatology
Describe erythema multiforme to a patient.
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.
What are the signs and symptoms of EM?
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
What is the management of EM?
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
What is angina bullous haemorrhagica? management?
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
How would you describe pemphigoid?
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.
What are the types of pemphigoid and what are symptoms?
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
What are the histological features of pemphigoid and pemphigus vulgaris?
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
What is pemphigus vulgaris? management?
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
How would dry mouth (hyposalivation) be diagnosed?
Test salivary flow rate
Check if unstimulated flow is less than 1.5ml in 15 mins
What can cause and what is the management of hyposalivation?
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
What symptoms may a pt complain of with dry mouth?
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
What are the causes of hyper salivation and how is it managed?
Drugs - clozapine, haloperidol, anticholinesterases
Dementia
CJD
Stroke
Poor swallowing - anxiety, MS, MND, CP
Management:
- Anti-muscanaric
- Botox
- Duct repositioning surgery
- Biofeedback training
Describe sialosis to a patient
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
What is sjogrens disease? symptoms?
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
Managment of sjogrens?
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
What is OFG and symptoms?
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
How do you diagnose OFG and management?
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
What is burning mouth syndrome and symptoms? management?
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
What is trigeminal neuralgia? Symptoms and management?
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
What could be all differential diagnoses of a white patch?
Hereditary - white sponge naevus, fordyce spots
Keratosis (smokers, traumatic)
Lichenoid/LP
Lupus erythematosus
Infection - pseudomembranous or chronic hyperplastic candidiasis
Carcinoma/SCC
