omfs 2

Question 1

Classification of Local Anesthetics

Answer 1

Route of Administration
Topical
Injectable

Chemical Structure
Esters (e.g., Procaine): Metabolized by plasma pseudocholinesterase; higher allergy risk.
Amides (e.g., Lidocaine, Mepivacaine, Articaine): Metabolized by liver enzymes; lower allergy risk.

Question 2

Lidocaine/Xylocaine
Duration:
Onset:
Dosage:

Mepivacaine
Duration:
Onset:
Dosage:
Availability with VC

Prilocaine (Citanest)
Indications/duration:
Contraindications:

Answer 2

Duration: Medium (1-2 hours)
Onset: 2-3 minutes
Dosage: 4.4 mg/kg, 7 mg/kg with vasoconstrictor (VC); max 500 mg

Mepivacaine
Duration: Medium (2-3 hours)
Onset: Rapid (1.5-2 minutes)
Dosage: 6.6 mg/kg; max 400 mg
Availability: With and without vasoconstrictors

Prilocaine (Citanest)
Indications: Intermediate duration procedures
Contraindications: Methemoglobinemia, anemia, G6PD deficiency

Question 3

Bupivacaine
Duration:
dosage:
Precaution:

Answer 3

Long (4-9 hours)
Dosage: 1.3 mg/kg; max 90 mg
Note: Most cardiotoxic; aspiration necessary before injection
CI in Brugada syndrome is a rare but potentially life-threatening inherited disease that predisposes patients to fatal cardiac arrhythmias

Question 4

5 Indications for Local Anesthetics in Oral Surgery

Answer 4

Achieve profound anesthesia for minor procedures.
Decrease intraoperative and postoperative pain.
Reduce amt of general anesthesia required.
Increase patient cooperation
5. facilitate diagnostic testing.

Question 5

Complications of Local Anesthetics
Systemic Toxicity Signsx 4

Answer 5

Early CNS Signs: Restlessness, confusion, dizziness, tinnitus, possibly seizures.
Progression to CNS Depression: Drowsiness, unconsciousness, respiratory arrest.
CVS Features: Initial hypertension and tachycardia, progressing to hypotension, bradycardia, and potential cardiovascular collapse.

Allergic reaction - skin rash, bronchospasm to severe analyphylaxis

Methemoglobinemia in G6PD/ cardiac and pulmonary diseases–> metabolite of prilocaine [O-toluidine] ->reduces available Hb for 02 -> hypoxia

Mx: continuous infusion of methylene blue or ascorbic acid for 5 minutes to reduce methemoglobin back to Hb

Question 6

Complications of Local Anesthetics
Local Factors x6
Patient Factorsx2

Answer 6

Local Factors
Trismus, hematoma, facial paralysis, paresthesia, needle breakage, failure to achieve anesthesia.

Patient Factors
Trauma (e.g., lip/c cheek biting)-mx POIG, syncope (often psychogenic/fear-induced)

Question 7

Prevention of LA Toxicityx6

Answer 7

1. Calculate correct dosage based on weight.
2. Avoid rapid administration.
3. Avoid intravascular [anatomy] Use aspiration technique before injection.
4. Monitor for slow drug detoxification/elimination.
   5.Avoid repeated injections
5. opt for the lowest effective dose.

Question 8

Management of LA systemic complications and include mx of LA Toxicity

Answer 8

allergic reaction: mild - antihistamine + in comfortable position
Severe cases: -We need to Assess degree of airway obstruction and cardiovascular collapse
–>Stop administration of drug and call for ambulance
P: Position patient supine, raise legs if low BP.-esp if unconscious/convulsing
A: Assess airway, remove debris/suction, pull Md forward, establish airflow with high oxygen 5-6L/min.
B: Breathing;vital signs, pulse rate, BP,RR, temp
C: pulse-adequate circulation
administer IM adrenaline 1:1000 0.5ml stat IV hydrocortisone 200mg stat as needed.
C: Continue monitoring, repeat adrenaline every 5 mins if severe while waiting for ambulance

Seizure Management: If seizures occur, administer a benzodiazepine e.g., diazepam 0.1mg/kg to abort seizure
Seek Medical Help: Depending on the severity, transfer the patient to a hospital for further monitoring and treatment

Systemic Toxicity: LA toxicity can occur due to high blood levels from repeated injections leading to excessive dose or inadvertent intravascular administration. Symptoms may include central nervous system manifestations such as restlessness, excited manner, talkativeness ,confusion, headache, dizziness, tinnitus, and seizures, progress into drowsiness, unconsciousness and resp arrest.

CVs symptom like hypertension + TACHYcardia initially dt DIRECT sympathetic stimulation then hypotension, bradycardia and arrhythmias, unconsciousness, death. Management involves immediate cessation of LA administration, ensuring airway patency, ABC,and providing supportive care.

Reassure patient and call the ambulance
* Give high flow oxygen by face mask
* Sit him upright if breathless, lie him flat if faint, leg slightly raised - Trendelenburg position[ when unconsciousness and hypotension]
* Give GTN tablet under tongue and repeat in 5 minutes
* Give aspirin 300mg if patient not allergic
* Continue monitoring level of consciousness and BP
* Be prepared to initiate CPR if patient loses consciousness

Question 9

mx of Long-Standing Diabetes Mellitus and on Renal Hemodialysis for difficult xn

Answer 9

Preoperative Considerations
MH: Check latest blood glucose levels (ideally <15 mmol/L), HbA1c (ideal <6.5%) glycemic control, and hemodialysis schedule. Comorbidities? - ihd, htn,renal failure
Timing: Schedule dental treatment the day after hemodialysis to minimize bleeding risks dt heparin
Blood Tests: Check aPTT, anti-Xa LMWH levels, and platelet count.
Consultation: Coordinate with the patient’s physician and nephrologist regarding treatment timing and systemic condition management.

Treatment Protocol
Appointment Timing: Short morning appointments to avoid mealtime conflicts.
Antibiotic Prophylaxis: Consider metronidazole for poorly controlled diabetes; otherwise, no antibiotics needed.
Informed Consent: Discuss potential complications like oro-antral communication or root fracture.
Monitor for signs of hypo/hyperglycemia.
Extraction Technique: Use atraumatic methods to reduce risks of oro-antral communication/perf. Consider surgical sectioning if necessary. LA w VC not CI
Local measure- suture+ poig

Postoperative Care
Analgesics: Prefer paracetamol; avoid NSAIDs to reduce renal impact and bleeding risks.
Tranexamic m/w 4x/day 10ml 2/7
Follow-Up: Schedule to monitor healing, considering increased risks of delayed healing and infection.
Special Considerations: High risk of hepatitis B/C due to frequent hemodialysis.

Question 10

manage a 15-year-old boy with facial injuries,

Answer 10

Immediate Management:
ABCs (Airway, Breathing, Circulation):
Ensure airway is clear; have the patient sit upright if conscious.
1. History Taking:
Event Details: Understand the direction and impact of the injury, and check for loss of consciousness./pt or witnesses
Symptoms: Ask about pain, malocclusion, and bleeding.
MH: Check for tetanus immunization status and allergies/ meds/systemic conditions
2. Clinical Examination:
EO Examination:
Inspect and palpate facial structures (scalp, orbits, zygomatic arches, maxilla, mandible).
Check for signs indicating fractures (e.g., bleeding from the ear, difficulty opening mouth). Bleeding from the right ear and LMO could indicatre of a mandibular condyle or temporal bone fracture
Assess for TMJ function, range of motion, and crepitus.
Neurological Assessment:
Evaluate Glasgow Coma Scale (GCS); a score of ≤8 indicates severe injury. e4,v5,m6
Check for e/o soft tissue injuries/contusion/hematoma, rhinorrhea, otorrhea, and signs like Battle’s sign, raccoon eyes-orb rim/zyg # ; FOM Md symp #
Test cranial nerves (CN II/III for visual acuity and pupil light reflex-uneven-intracranial bleed; CN 3/4/6 for eye movement; CN7 for facial expression; CN5 for facial sensation/MoM near the condyle).
Check facial symmetry, step defects, tenderness, numbness.
3. Intraoral Examination:
Look for avulsed teeth/fragments, assess occlusal plane
Check for mobility or misalignment of teeth.
Examine soft tissues for hematomas or mucosal tears.
LF# usually palatal hematoma btw hard and soft palate
Mobility, PPD, G.Bleeding, displacement, P.S.Test, TTP/TOP, occl interference// CRACK teacup sound-LF #
4. Imaging Studies:
Radiographs Needed: Panoramic, PA view, reverse Towne’s view.
Advanced Imaging: Consider CBCT for detailed visualization of mx/md
5.
Bleeding Control:
Manage ear bleeding with sterile dressings; avoid probing the ear.
Fracture Management:
Immobilization [IMF] frgmt with archbar and wires if minimal displacement and able to obtain pre-INJURY occlusion- closed reduction- refer for ORIF if severe.
Soft Tissue Management: LA+ clean [saline, *hydrogen peroxide to remove debris] and suture soft tissue wounds as necessary.
Tooth Avulsion:
Consider chest X-ray if teeth might have been aspirated.
6. Referrals and Supportive Care:
Referrals:
Oral and maxillofacial surgeon for facial injuries.
Otolaryngologist for ear injuries.
Pain Management:
NSAIDs (if no bleeding risks) or tramadol (note: may mask symptoms of increased intracranial pressure).
Other:
Administer tetanus prophylaxis if necessary.
Consider antibiotics and vitamin B complex (Neurobion) for nerve recovery.
POIG- soft diet, avoid sports, ohi , towel massage, ice packs
7. Follow-Up:
Arrange for close monitoring of complications like infection or nerve damage.

Question 11

GCS e,v,m

Answer 11

spontaneously
to sound/speech
to pain
no response E1

place, time, person- ORIENTATED
confused
inappropriate words
incomprehensible sounds
no response V1

OBEYS COMMAND to move
MOVE TO LOCALISED PAIN
flexion to WITHDRAW FROM pain
abn flexion
abn extension
no m/m m1

Question 12

Common Postoperative Complications post surgical removal of teeth x12:

Answer 12

1. Bleeding: reactionary/2ndary
2. Bruising/swelling:collection of blood under skin
3. Trismus (Limited Jaw Opening):
   dt postoperative inflammation/muscle spasms
4. Pain:
   Normal to experience some pain; however, severe or increasing pain might suggest complications such as infection or dry socket.
5. Infection: Symptoms: Increased pain, swelling, redness,+ possible pus formation.
6. Dry Socket (Alveolar Osteitis):
   =blood clot fails to develop/dislodged prematurely. Symptoms: Severe pain, malodor at the extraction site.
7. Delayed Healing:
   Common in complex extractions or if pre-existing conditions like infections or root fractures are present.
8. Nerve Injury:
   Risk of damage to the inferior alveolar nerve, potentially causing temporary or permanent numbness or altered sensation in the lower lip, chin, tongue (affecting taste), and teeth.
9. Injury to Soft Tissues:
   Potential for abrasions to lips, puncture wounds to the tongue, or tears in mucosal flaps.
10. Damage to Adjacent Teeth:
    Particularly second molars at risk if they have caries or large restorations
11. Injury to Osseous Structures:
    Possible fractures to maxillary tuberosity, lingual bone, alveolar process, or mandible.
12. Sinus Communication:
    Risk with upper wisdom teeth extractions when roots are close to the sinus, potentially leading to an oro-antral fistula or displacement of tooth roots into the sinus cavity.

Question 13

Propionic Acid Derivative NSAID- dosage of one example and synergistic effect with pcm

Answer 13

1. Ibuprofen 400mg ibuprofen every 6 hours. First dose taken
   before loss of LA -> by the clock -> PRN
   -If severe pain, take 650-1000mg of paracetamol b/n doses of ibuprofen (synergistic effect)
   -If needed, 60mg codeine [opoid, prodrug of morphine]

2.naproxen

Question 14

Diphenhydramine vs benzyDAMINE

Answer 14

antihistamine vs NSAID - difflam m/w for oral ulcers

Question 15

Types of oral ulcerations in patients undergoing chemo-radiation therapy: 3+1 eg

Answer 15

1. Oral Mucositis: Inflammation and ulceration of mucous membranes due to chemotherapy or radiation [1.a. cytotoxic effects cells]
   1.b. Chemotherapy-induced Ulcers: Caused by systemic effects of chemotherapeutic agents.
   2Neutropenic Ulcers:immunocompromised patients, secondary infection ulcers from opportunistic pathogens (e.g., Candida, herpes simplex virus,)
   3 Traumatic Ulcers: >prone to trauma to fragile mucosa from dental appliances, sharp teeth, or biting.
   4 Aphthous Ulcers: Less common, but can worsen in patients undergoing chemotherapy.

Question 16

6x Causative Factors oral ulcerations in patients undergoing chemo-radiation therapy:

Answer 16

1Direct Toxicity: Chemotherapy and radiation damage rapidly dividing oral mucosal cells.
2Immunosuppression: Treatment-induced immunosuppression raises secondary infection risks.
3 Xerostomia: Radiation ->glands are in the field of radiation, can reduce saliva production, increasing friction and ulcer risk.
4 Malnutrition: Eating difficulties lead to deficiencies that impair healing.
5 Mechanical Trauma: Caused by dental appliances or accidental biting.
6Inflammation: Body’s response to cell damage exacerbates mucosal injury.

Question 17

Management of Oral Ulcerations: 9x

Answer 17

1Preventive Care:
1a Maintain excellent oral hygiene using a soft-bristled toothbrush and non-alcohol mouthwash.
1b Avoid irritants like alcohol, tobacco, and spicy or acidic foods.

2Pain Management:
2a Use topical anesthetics (e.g., benzocaine), systemic analgesics (e.g., paracetamol), and topical analgesics (e.g., benzydamine HCL-DifflamC).
2b Suck on ice chips to alleviate discomfort.
2c Apply mucoadhesive gels to protect ulcerated surfaces and promote healing.

3 Nutritional Support:
Adopt a soft, bland diet and consider nutritional supplements to support healing.
4 Xerostomia Management:
Use saliva substitutes (e.g., OraSeven,LF; LP, GO; Biotene-4hr) and stimulants like pilocarpine/cimeveline. >lubricated
5 Practice parotid gland massage and use xylitol gums to stimulate saliva production.
6 Infection Control:
Employ antifungal/ antiviral, agents as needed to prevent or manage infections.

7iiiAdvanced Therapies:
Consider growth factors, cytokines, and low-level laser therapy to promote mucosal healing.
8Multidisciplinary Approach:
Collaborate with physicians and other healthcare providers to integrate systemic treatments and ensure comprehensive care.

9Regular Monitoring:
Schedule close follow-ups to manage complications and adjust treatment plans as necessary.

Question 18

patient with atrial fibrillation on dabigatran (oral direct thrombin inhibitor). mx
pre op- x3
during -x10

Answer 18

Pre-OP precautions:
1 Consult with the patient’s physician to determine if withheld 1-2days pre-op&24hrs post op necessary?
2. Avoid and GA - may induce dysrrhymthias
3 coagulation test (aPTT) on the day of surgery to verify he has minimal anticoagulant activity [negative predictive value]; if aPTT is high, means pt has high level of Dabigatran in blood and has higher risk of anticoagulant effects=> risk of bleeding.

Treatment Modifications:
1 Keep the dental procedure short,pain free, stress free or hypoxia->risk of arrythmia
2 LA-slowly; atraumatic, profound La
3.Limit the use of adrenaline/lignocaine (1.5-2 capsules max) and avoid bupivacaine.
4. Avoid adrenaline for patients on digoxin or non-selective beta blockers - arrhythmia pt
5. Pretx vital sign, monitor pulse and rhythm
6 local hemostatic agents- SPONGIOSTAN-absorbable gelatin sponge ; surgicel - oxidised regenerated cellulose; bone wax or suturing techniques.;antiFibrinolytic -TRANEXAMIC ACID
7 Be prepared to manage potential bleeding complications.
8Postpone elective procedures if the patient’s atrial fibrillation is not well-controlled or if there is significant risk of thromboembolism.
9 AVOID NSAIDS, AZOLE ANTIFUNGALS, CARBAMAZEPINE - DDI with dabigatran
10. macrolide in arrythmias-Long QT syndrome-life-threatening arrhythmia called torsades de pointes->syncope ->sudden cardiac death

Question 19

Patient with Epilepsy mx:
precaution:-x3
tx modifications:-6x

Answer 19

Precautions:
1. Medication Review: Ensure patient adherence to antiepileptic medications, ideally 2-3 hours before the procedure.
2. Seizure Control: Only treat if seizures are well-controlled; avoid treatment if frequent (more than once per month) or if patient is lethargic, skipped meals, ill, behavioral chges
CAN TX IF >5 yrs seizure free with or w.o meds// 1-2x a year // seizure not involving masticatory system
3.Environmental Factors: Minimize stress/trigger-careful chair light positioning and ensure the presence of a responsible adult.

Treatment Modifications:
1Emergency Readiness: Prepare for potential seizures with necessary medications and equipment - suction +02
2Sedation: manage anxiety if safe.
3 Avoid NSAIDs or aspirin if the patient is on valproic acid[Spontaneous hemorrhage as affect platelet aggreg+petechiae]
3b. avoid erythromycin if on carbamazepine.
4 Mouth props, rubber dam with attached floss
5 Avoid multiple cotton rolls-isolation; Strong suction
6 Restorations-Fixed work over RPD

Question 20

Female Geriatric Patient with Osteoporosis
Precautions:x2
tx mx :

Answer 20

1 Medication Review: Especially if the patient is on bisphosphonates or other anti-resorptive drugs.
Bisphosphonates -low risk if <4yrs with no comorbidities; medium risk if >4 yrs and OR CorticoS/immuSup
- IV 6/12/ YEARLY; HIGH RISK IV AGENT AND MULTIPLE MYELOMA

2 Risk of MRONJ: Consult with a physician about the risk and potentially plan a drug holiday. Oral BPS>3 yrs STOP 3 months resume 6-8 wks AAOMS; <3 yrs-no chgs
3.bone density esp if type 4 and the potential for fracture during the procedure.- refer

Treatment Modifications:
1 Extraction Techniques: Employ atraumatic techniques to reduce the risk of jaw fractures or other complications.
2 Postoperative Care: Provide clear instructions and possibly antibiotics to promote healing and prevent complications[ infection or delayed healing].
3Alternative Treatments: Consider less invasive options like root canal treatment over extractions when feasible.
4. f/up+ f-varnish

Question 21

epileptic drug interactions

Answer 21

avoid NSAIDs /aspirin if the patient is on valproic acid;
avoid erythromycin if on carbamazepine.

Question 22

meds for osteoporosis

Answer 22

Bisphosphonates
o Oral Fosamax (Alendronate)
o I/V Zometa/Reclast(Zoledronate)

• Selective-oestrogen receptor modulator-Raloxifen
• RANKL inhibitors-Denosumab
• Calcitonin
• PTH

Question 23

General Complications Related to General Anesthesia:x6

Answer 23

1iv. Anesthetic Risks:
Allergic reactions, cardiovascular complications (e.g., arrhythmias), respiratory issues, drug interactions.
2. Postoperative Nausea and Vomiting (PONV): Common–> dehydration[severe].
3 Sore Throat:
Due to the endotracheal tube during GA.
4 Airway Complications:
Aspiration, laryngospasm, difficulties with intubation.
5 Thromboembolic Events:
Deep vein thrombosis, pulmonary embolism; higher risk in predisposed patients.
6 Delayed Recovery:
Prolonged drowsiness or disorientation post-GA.

Question 24

A 60-year old Indian retiree
- late afternoon complaining of occasional bleeding gums.
- ex-smoker.
- had a vein taken from
his leg for his heart.
-taking long term steroids for painful joints. During clinical examination while patient was on the dental chair, he became weak, dizzy, with the peripheries turning cold and clammy.
i) Discuss the possible relevant medical problem(s) suspect this patient to be having, that are crucial to your current situation.

Answer 24

presenting with dizziness,weakness and Possible Relevant Medical Problems:
1. CVS: h/o vein harvest for cardiac procedure, stress [clinic] and history as an ex-smoker[ihd], cold clammy hands suggests potential Cardiogenic shock dt heart failure,
tro acute myocardial infarction.

2. Orthostatic Hypotension:
   Symptoms of dizziness and weakness upon sitting up could indicate this condition, possibly due to cardiovascular medication or dehydration.
3. Adrenal Insufficiency (Addisonian Crisis):
   Potential for an Addisonian crisis due to long-term steroid use, characterized by weakness, dizziness, and hypotension.
4. Bleeding Disorders: [Hypovolemic shock- also cold clammy hands]
   Suggested by occasional bleeding gums and potential history of anticoagulant use -> Anemia- chronic blood loss from bleeding gums causing weakness and dizziness.
5. Septic shock-unlikely-warm instead of cold!
   Risk of sepsis, especially with immunosuppression from steroid use, could lead to symptoms observed.
6. Hypoglycemia:
   patient’s age, potential comorbities-dm and potential missed meals, contributing to symptoms like cold, clammy hands and dizziness.
7. Vasovagal Syncope: [not medical prob]
   Situational stressors like the sight of blood or needles->triggered by vagal stimulation-> bradycardia-> hypoTension–>Transient loss of consciousness/faiting dt reduction of blood supply to cerebral tissues.

Question 25

MX of pt weak, dizzy, with the peripheries turning cold and clammy.– Basic life support resuscitation guideline

Answer 25

alert staff to emergency medical services (EMS) immediately due to potential severity.
1) Position: lay pt supine+ elevate legs if no aspiration risk-inc cerebral perfusion
2) Airway and Breathing:
Ensure patent airway, adequate breathing, administer oxygen if available and indicated.
monitor vital signs (RR, temp).
3) Circulation [HR, pulse rate, BP]
Check pulse and BP. Consider IV access for fluid resuscitation if hypotensive.

4)if conscious-Monitor:
Continuously monitor consciousness, pulse, and BP. Provide oxygen at 5-6L/min.
M/H Review:Quickly review patient’s medical history for relevant medications or conditions.
reassurance if conscious, while giving cup of warm Milo/sugary drink

5) if unconscious and no pulse:-CPR
Ensure an automated external defibrillator (AED) is accessible.
adrenal crisis (may require IV hydrocortisone 200mg STAT if confirmed).

Documentation:
Document all observations, actions taken, and patient’s responses.
Reassurance:
Keep the patient calm and reassured throughout the episode.
Follow-Up:
Ensure follow-up for underlying cause, consider liasing with physician and omfs referral.

Question 26

normal respiratory rate is between ….breaths per minute.

normal SpO2 range is …%

patient is conscious, …..them…..as this can also help with oxygenation

Answer 26

12-20 breaths per minute.

94-98%

sit them upright

Question 27

direct and consensual pupillary responses: …and…. pupils may indicate significant intracerebral pathology.

Answer 27

fixed ..dilated

Question 28

epileptic seizure mx

Answer 28

lay pt supine and remove object in mouth
loosen tight clothings
First-line treatment for seizures involves the use of benzodiazepines such as:
IV diazepam 0.1mg/kg to abort seizure/IM midazolam
* Turn victim to recovery position as soon as seizure stops
o Helps open and maintain a clear airway, also avoiding aspiration
Dose reductions are often required for elderly patients.
Failure to respond to first-line treatment requires referral to hospital.

Question 29

CPR- WHAT?
and what is the rate of compression/min and the depth?

Answer 29

CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths.
In adult victims of cardiac arrest, perform chest compressions at a rate of 100 to 120/min and to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than [6 cm]).

Question 30

Dental Clearance Requirements
Pre-Anaesthetic Dental Clearance- purpose, objectives

Answer 30

Purpose: Prevent complications during surgery by Identifying and tx sources of infection; remove loose teeth to prevent aspiration or airway obstruction.

Objectives: Ensure no oral infections that could spread systemically during surgery; ensure a safe airway for intubation and ventilation.

Question 31

Pre-Bone Marrow Transplant Dental Clearance

Purpose:
How?
Objectives:

Answer 31

Purpose: Necessary due to increased risk of oral infections becoming systemic and life-threatening under immunosuppression medication post BM transplant. BM transplant dt M. Myeloma / leukemia pt meaning more susceptible to infections.

How: Eliminate infection sources such as carious lesions or periodontal disease.
Objectives: Reduce risk of post-transplant complications; ensure optimal oral health and patient education on meticulous oral hygiene as pt may need to defer any elective dental tx 6mo-1yr post transplant and only be treated if ANC is SUFFICIENT.

Question 32

Pre-Antiosteoclastic Therapy Dental Clearance

purpose+ onjective

Answer 32

Purpose: Assess dental health due to risks of medication-related osteonecrosis of the jaw (MRONJ) associated with therapies like bisphosphonates/RANKL -or.

Objectives: Address dental issues and Prevent the need for invasive procedures (e.g., extractions) post-medication commencement which pose higher risks of MRONJ; educate on oral hygiene; establish a dental care plan to minimize MRONJ risk.

Question 33

Predisposing Factors of DRY SOCKET 6x

Answer 33

1 Difficult Surgery/ prolonged procedure time.
2 Postoperative Care: Inadequate care like not following post-surgery instructions, vigorous rinsing.
3 Smoking impairs healing and promotes infection.
4 poor OH
5 oral contraceptive
6 Previous occurrence of dry socket

Question 34

Pathophysiology of DRY SOCKET

2 theories

Answer 34

Pathogenesis of dry socket is not completely understood
Failure of blood clot to form or its premature loss at the extraction site, before wound healing occurs. This exposing bone and nerves to oral environ-> inf and pain.

Theories:
Fibrinolytic Theory: Excessive fibrinolytic activity leads to clot disintegration.
Bacterial Theory: Bacterial contamination causes clot breakdown.

Question 35

Management of DRY SOCKET

Answer 35

1Pain Control: Use of analgesics or obtundant dressings.
2Socket Care: Gentle irrigation to remove debris; placement of medicated dressing (e.g., Alvogyl/bipp) to protect the area and promote healing.

3Patient Instructions: Maintain oral hygiene, avoid smoking and using straws.
4Follow-Up: Important for monitoring healing and replacing dressings as needed.

Question 36

diff dry socket with Osteomyelitis- severity, symptom, onset, diagnostic diff, tx

Answer 36

1Condition Severity: Osteomyelitis involves infection and inflammation of bone, potentially with suppuration and pain.

2 Symptoms: Osteomyelitis shows more systemic symptoms like fever and malaise. D.S limited to the alveolar bone at the extraction site, osteomyelitis can involve any of the bones and may spread beyond the initial site and sometime cause swelling.

3 Onset: Dry socket occurs a few days post-extraction, whereas osteomyelitis has a more insidious/gradual onset.

4 Diagnostic difference: Radiographic changes are more apparent in osteomyelitis; dry socket is a clinical diagnosis with typically normal early radiographic appearance.

5. Treatment: More aggressive treatment with antibiotics and possibly surgical debridement.

Question 37

-65-year-old female Malay patient
-white lesion on the ventral surface of the tongue.
- ONLY noticed the lesion 3 months ago.
-wears a lower partial denture.
-Type II Diabetes Mellitus and Ischaemic Heart Disease.
-kidney function is impaired and was told that she may need dialysis in a few months’ time.
-smoking in the past which she claims she has stopped 3 years ago.
a) Discuss the differential diagnosis of this white lesion. =7x

Answer 37

differential Diagnosis of the White Lesion:
1 . Oral Lichen Planus: A chronic inflammatory condition that can present as white, lacy patches on the mucosa, potentially linked to systemic conditions like DM; HTN;SLE GVHD; stress,liver not renal diseases.

2. Candidiasis: Especially in immunocompromised patients, such as those with diabetes, presenting as a white plaque that may be wiped off to reveal a red base.
3. Frictional Keratosis: Chronic irritation from the denture could cause a white callous-like lesion.[MEANS thickened]
4. Squamous Cell Carcinoma: A malignant tumor that can present as a white or red-and-white lesion and should always be considered, especially in patients with a history of smoking.
   5 Nutritional Deficiencies: Deficiencies in iron, folic acid, or vitamin B12 can lead to mucosal changes, including white patches.
   6 Oral Hairy Leukoplakia: Although primarily associated with immunocompromised states such as HIV infection, it could be considered given the patient’s compromised systemic health.
   7 Leukoplakia: A premalignant lesion often associated with tobacco use, which can present as a white patch that cannot be scraped off. Diagnosis by exclusion. Sublingual keratosis is subtype of leukoplakia

Question 38

Treatment Options for the White Lesion: 12x

Answer 38

1. Elimination of Irritants: If the lesion is due to the denture, adjusting or remaking the denture to eliminate irritation may resolve the lesion.
2. Biopsy: Any unexplained white lesion that does not resolve on its own or after the elimination of potential causes should be biopsied to determine its nature.
   3 Monitoring: If HP results are benign; no dysplasia, close follow-up is necessary to monitor the lesion for any changes, especially given the patient’s history of smoking and systemic conditions.
3. OHE
   5 Antifungal Treatment: If candidiasis is suspected or confirmed, topical or systemic antifungal medications would be indicated.
   6 Topical Corticosteroids: For oral lichen planus, topical corticosteroids may be used to reduce inflammation. If Contraindicated for systemic steroids; topical tacrolimus/ topical retinoids

7 Laser Ablation or Cryotherapy: These may be options for lesions that are resistant to other treatments or where malignancy is a concern.
8 Vitamin Supplementation: If the lesion is due to nutritional deficiencies, supplementation may be indicated.
9 Smoking Cessation: Although the patient has quit smoking, reinforcement of the benefits of cessation is important.

10 Surgical Excision: If the lesion is confirmed to be malignant or shows severe dysplasia, surgical excision would be necessary.
11 Management of Systemic Conditions: Optimal control of diabetes and monitoring of renal function are important for overall health and may influence the healing of oral lesions.
12 Regular f/up

Question 39

Factors to Consider When Administering Local Anaesthesia:

Answer 39

1 Patient Medical History: Assess for systemic diseases (e.g., cardiovascular, respiratory, endocrine disorders-DM), allergies, and current medications.
2 Anatomical Considerations: Understand the relevant anatomy for effective administration, including nerve locations and variations- in geriatric and children. Aspiration before injection.

3 Expected Duration of Procedure will influence the choice of anaesthetic and whether additional doses may be required.

4 Pharmacology: Choose the appropriate local anaesthetic agent based on its onset, duration, and potential for toxicity. Consider the patient’s weight for appropriate dose.

5Technique: Select the proper technique (infiltration, block, field block-max teeth) based on the procedure and the area to be anaesthetized.
6 Presence of Infection: Inflamed tissues can alter the pH, affecting the efficacy of the anaesthetic.
7 Patient Factors: Age, weight, anxiety level, and cooperation should be considered to tailor the approach and manage expectations.
8 Clinic Setup: Ensure an aseptic technique to prevent complications.

9 absolute CI for Adrenalinex6
1. <6/12 MI
2. <6 CVAccident
3. <6/12 CABG
4. uncontrolled HTN > 200mg/115mmHg
5. unstAble Angina pectoris
6. uncontrolled thyrotoxicosis
7. Congestive heart failure

Question 40

what is tachyphylaxis

Answer 40

repeated injections of drug- [loss of response dt repeated dose admins]

Question 41

complications of LA and mx
local factors 6x

pt factors-2x

systemic factors 3x

Answer 41

Local Factors
delayed-Trismus/hematoma [dt nick bld vsl], -cold packs/warm towel massage+reassurance
facial paralysis MoFE-symptomatic mx-eye patch + eye drop, dt loss of blinking/corneal reflex; 24-72 hr of symptoms start on acyclovir and oral CCS
paresthesia–neurobion OD 2/52 and referral omfs [delayed presentation]
needle breakage, failure to achieve anesthesia- anatomy well/defer tx.

Patient Factors
=Trauma (e.g., lip/c cheek biting)-mx POIG/orocort E,
=psychogenic/fear-induced to needles- Vasovagal Syncope leading to bradycardia and hypotension.
Management: Position patient supine with legs elevated, ensure airway patency
/recovery is fast

systemic factors: CVS/CNS
allergic reaction: PABA from Ester LA
Symptoms: Skin rashes, bronchospasms, ranging from mild to anaphylaxis.
mx: Discontinue offending agent.
Administer antihistamines for mild reactions.
For severe reactions (e.g., anaphylaxis): STop procedure, alert EMS, Position patient supine-raise legs if low BP,
establish airway, give high-flow oxygen,
administer IM adrenaline 1:1000 0.5ml stat, repeat every 5 minutes, and
give IV hydrocortisone 200mg stat.
Monitor vitals (pulse oximetry, BP).
IV diazepam/ IM midazolam if seizures is noted.

Question 42

Bell palsy , etiology, U/L motor lesion- what is the U/L MNLesion difference?

clinical presentation

Answer 42

Idiopathic peripheral facial CN VII palsy

The most common cause of facial paralysis. Caused by a lower motor neuron lesion.

Upper motor neuron lesion leads to paralysis of the contralateral lower face.
Lower motor neuron lesion results in total ipsilateral facial paralysis.

Unilateral facial sag and forehead weakness (e.g., inability to raise eyebrows, decreased forehead wrinkling).
Hyperacusis and changes in taste can also occur.

Question 43

facial palsy etiology 6x

Answer 43

[1] Idiopathic (most common cause of peripheral facial nerve palsy) known as Bell palsy.

[2] Secondary reasons:-
i. Trauma (e.g., temporal bone fracture)
ii.Tumors (parotid gland tumors, acoustic neuroma)
iii. Infection- Herpes zoster (Ramsay Hunt syndrome)
ivOtitis media
v. Stroke

Question 44

mx of facial palsy

Answer 44

Symptomatic therapy
- Incomplete eye closure: Initiate eye care (e.g., eye drops and eye patch).
-Incomplete mouth closure: Advise freq vaseline application on lips and stay hydrated

Bell palsy is self-limiting, but early treatment is recommended to improve recovery time and prevent incomplete recovery.

Targeted treatment
Oral glucocorticoids:
Start early (i.e., within 48–72 hours of symptom onset) -prednisolone
Antivirals-acyclovir 400 mg orally 5 times daily for 10 days

Follow up with specialist consult if the patient has any of the following:
No signs of improvement in 2–3 weeks

Question 45

Causes of Facial Palsy Not Related to IDN Block 6x

Answer 45

1. Bell’s Palsy: Idiopathic condition where the exact cause is unknown; could be triggered by factors changes in atmospheric pressure (diving/flying).
2. Trauma: Facial nerve damage due to fractures of the temporal bone.
   3.Tumors like parotid gland neoplasms or acoustic neuromas exerting pressure on the facial nerve.
3. Herpes Zoster Oticus : Affects cranial nerves VII and VIII, managed with antivirals; characterized by facial palsy with an ear rash(Ramsay Hunt Syndrome)
4. Otitis Media (Acute and Chronic): Swelling or infection spread that puts pressure on the facial nerve.
   6.Stroke: Can lead to facial palsy due to brain injury affecting the neural pathways.

Question 46

Methemoglobinemia and mx
who affected?

Answer 46

metabolite of prilocaine [O-toluidine]
->reduces available Hb [methemoglobin] for 02 -> hypoxia
Mx: continuous infusion of methylene blue or ascorbic acid for 5 minutes to reduce methemoglobin back to Hb

Methemoglobinemia occurs in G6PD/ cardiac and pulmonary diseases.

Question 47

adjuvant therapies besides LA to pain control? 7x+ 1 [modification to LA technique]

Answer 47

1. Preemptive Analgesics to Reduce postoperative pain, eg NSAIDs or acetaminophen administered before the procedure.
2. Topical Anesthetics-eg Benzocaine applied prior to dental local anesthetic administration.
3. Oral Sedatives: Such as diazepam.
   Inhalation Sedation: Nitrous oxide to reduce anxiety.
   Intravenous Anxiolytics: Midazolam for deeper sedation.
4. General Anesthesia- Indicated for: Extensive procedures/patients who are uncooperative or medically compromised.
5. Acupuncture: More studies needed to fully understand efficacy
6. Psychological Support
   Techniques: Guided imagery, relaxation, deep breathing, and distraction to reduce anxiety and pain perception.
7. Postoperative Care mx: Pain management instructions, including analgesics and cold packs.
   Advice: Recommendations on diet and activity restrictions to aid recovery.

8 Alternative Techniques
Articaine: Used for better diffusion into bone and soft tissue; >effective LA. Synergistic Effect: Often used in conjunction with lidocaine for enhanced efficacy.

Question 48

celecoxib knwn as…
Etoricoxib kwn as…

CI in ..x3

Answer 48

Cerebrex
Arcoxia

Avoid in those at risk of thrombotic events
Avoid in pregnancy, nursing (can go into breast milk)
Avoid in patients taking ACE inhibitors

Question 49

Diagnostic Approach for Acute Maxillary Sinus Infection Post-Extraction inDM pt 7x + 2 extra

Answer 49

1. History of Symptoms (H/O)-Pain and a sensation of weight in the cheek, especially noticeable when bending down.
2. Clinical Examination
   Facial Assessment: Check for swelling or redness of the face and intraoral vestibule.
   Palpation: Assess tenderness in the maxillary sinus area.
3. Nasal Examination-nasal discharge, potentially more pronounced on the affected side.
4. Intraoral Examination
   - extraction site for signs of infection (purulent discharge, malodour, redness, tenderness).
   -Sinus Communication: Perform the Valsalva maneuver or have the patient gently blow their nose with nostrils pinched to check for air/bubbles at the extraction site /misting of a mirror placed at the site.
5. Radiographic Examination
   Imaging: dental panoramic tomogram (DPT) or cone-beam computed tomography (CBCT) to view the maxillary sinus and extraction site for any retained roots or bone fragments.
6. Transillumination to Assess the patency of the sinus by shining a light through it to check for fluid levels or opacification.
7. Vitality Testing-Test adjacent teeth to rule out periapical pathology contributing to sinus symptoms.
8. Laboratory Tests
   Full Blood Count (FBC): Check for signs of infection through changes in neutrophil counts and WBC count, and monitor blood glucose levels.
9. Review of Other Comorbidities/medical conditions, medications, and allergies.

Question 50

Acute Maxillary Sinus Infection Post-Extraction: Management Protocol 9x

Answer 50

1. Initial Findings
   Symptoms: Facial swelling, nasal stuffiness, oroantral communication following tooth extraction.
   Diagnostic Results: Clinical and radiographic evidence of acute maxillary sinus infection.
2. Immediate Management
   Antibiotics: Begin Augmentin and metronidazole to cover both aerobic and anaerobic organisms, considering the patient’s diabetic status.
   Decongestants and Antihistamines: Prescribed to alleviate nasal stuffiness and promote sinus drainage.
3. Supportive Care-Advise against creating negative pressure in the oral cavity (no straw use, no forceful nose blowing/sneeze with mouth closed) for 10-14 days. [<2mm can heal spontaneously]
   Irrigation: Perform frequent gentle irrigation of the fistula to keep the area clean.
4. Temporary Measures
   Fistula Coverage: Construct a temporary appliance to cover the fistula, preventing contamination from food and other oral debris.
5. Surgical Intervention
   Indications: Persistent oroantral communication, evidence of retained dental roots.
   Procedures:
   Surgical closure of the chronic fistula and removal of epithelium from bony walls and any foreign material.
   Possible use of buccal advancement flap or palatal rotation flap with or without alloplastic membrane.
   Caldwell-Luc procedure for diseased tissue removal if conditions persist.
6. Medical Management
   Chronic Conditions: Ensure optimal control of hypertension and diabetes to support healing and infection response.
7. Follow-Up
   Monitoring: Close monitoring of the patient’s response to treatment and healing progress.
   Further Imaging: May be required to assess resolution of the sinus infection.
8. Patient Education
   Complications: Educate on signs of complications such as increasing pain, fever, or spreading infection, and when to seek immediate care.
9. Documentation
   Record Keeping: Document all findings, discussions, and management plans in the patient’s medical/dental record.

Question 51

A 15-year old Chinese male- multiple recurrences of pain and swelling for the past year to multiple areas of his mouth. He has no relevant medical history and appears healthy.
-slight asymmetry to the right part of the face, which has many freckles.
Intra-oral examination reveals mobility to his posterior teeth bilaterally.
Radiographic examination reveals impacted teeth #18, 13, 24, 38, 48 with large radiolucencies around the impacted teeth; the radiolucency around #48 extends to the coronoid process.
-root resorption of #37 and #47.
-thick yellow fluid distal to #47 when you palpate the area but there is no evidence of infection (no enlarged cervical lymph nodes, no erythema and no pain).

mx:-9x

Answer 51

1. Detailed History-comprehensive dental and medical history, including family history.
2. Clinical Documentation
   - Note any facial asymmetry, freckles, and mobility of posterior teeth along with other relevant clinical findings.
3. Radiographic Analysis
   Tools: Utilize radiographs and supplement with CBCT for a detailed assessment of radiolucencies, impacted teeth, and root resorption.
4. FNAC- Aspirate thick yellow fluid to analyze and rule out infection or other pathology.
5. Referral +Multidisciplinary Approach
   Specialists: Refer the patient to an Oral and Maxillofacial Surgeon and a dermatologist for further evaluation and management.
6. Biopsy of the radiolucent areas to provide a definitive diagnosis.
7. Genetic Counseling
   When Suspected: Refer for genetic counseling and testing if a genetic syndrome is suspected.
8. Patient Education
   Communication: Inform the patient and their family about the findings, potential diagnoses, and the need for further investigations and management.
9. Follow-Up to monitor the patient’s condition and response to treatment/ EARLY DETECTion of recurrance

Question 52

Differential Diagnoses for Radiolucencies and Facial Asymmetry

Answer 52

1. Gorlin-Goltz Syndrome (Nevoid Basal Cell Carcinoma Syndrome)
   Indicators: Multiple odontogenic keratocysts, facial asymmetry, skin findings (e.g., freckles).
   Most Plausible Diagnosis: Given the presentation.
2. Ameloblastoma
   Characteristics: Benign, locally aggressive odontogenic tumor.
   Radiographic Signs: Similar to Gorlin-Goltz but typically singular and less likely systemic.
3. Dentigerous Cyst
   Typical Feature: Envelops the crown of an impacted tooth; generally does not cause root resorption/ large radiolucency to coronoid process.
4. Central Giant Cell Granuloma
   Presentation: Benign lesion; causes radiolucencies and root resorption.
5. Odontogenic Myxoma: Rare, presents with multilocular radiolucencies and tooth displacement.

Question 53

Gorlin Syndrome (Nevoid Basal Cell Carcinoma Syndrome)
Key Clinical Features x7

Genetic and Chromosomal Defectx3

Answer 53

1Demographic: Often young patients.
2. Skin: Multiple basal cell carcinomas resembling freckles.
3. Jaw: Presence of odontogenic keratocysts.
4. Hands/Feet: Palmar or plantar pits.
5. Neurological: Calcification of the falx cerebri.
6. Skeletal: Abnormalities like bifid ribs or elevated scapula.
7. Facial Structure: Asymmetry and mandibular prognathism.

Genetic and Chromosomal Defect
1.Condition: Autosomal dominant.
2. Gene Involved: PTCH1 gene on chromosome 9q 22.3.
3. Function: Tumor suppressor gene; mutation leads to syndrome manifestations.

Question 54

A 70-year-old frail, wheel-chair bound Indian lady c/o tongue soreness and general oral pain of 4 months duration.
-multiple periodontally involved teeth and root caries.
i. Atrial fibrillation
ii. Hypertension
iii. Type 2 Diabetes Mellitus
iv. Stroke 9 months ago
v. Osteoporosis
-last few months her mother has been depressed, forgetful and needs help with normal daily activities.
Her medication includes: a beta-blocker (atenolol), an ACE inhibitor (captopril), metformin, anti-thrombotic medications (aspirin and rivaroxaban) and medications for her bone condition (alendronate, calcium and Vitamin D)
a) Discuss how the patient’s medical conditions may have contributed to her oral problems. 6x

Answer 54

Contributions of Medical Conditions to Oral Problems
1. Atrial Fibrillation and Antithrombotic Medications Impact: Increased risk of bleeding, complicating periodontal treatments and other dental procedures.
2. Medication Effects: Beta-blockers and ACE inhibitors for HTN may cause dry mouth (xerostomia), increasing the risk of root caries and periodontal disease.
3. Type 2 Diabetes Mellitus: Greater susceptibility to periodontal disease, xerostomia, burning mouth syndrome, and infections due to altered immune response and impaired wound healing.
4. Stroke: Decreased manual dexterity and potential cognitive impairment, making oral hygiene maintenance challenging.
5. Osteoporosis and Related Medications
Concerns: Medications like Alendronate increase the risk of osteonecrosis of the jaw MRONJ; osteoporosis may worsen periodontal disease due to bone loss.
6. Depression and Cognitive Impairment
Effects on Oral Health: Potential neglect of oral hygiene and decreased ability toreport, manage oral pain and discomfort.

Question 55

Treatment Modifications 8x and Precautions
for
A 70-year-old frail, wheel-chair bound Indian lady c/o tongue soreness and general oral pain of 4 months duration.
-multiple periodontally involved teeth and root caries.
i. Atrial fibrillation
ii. Hypertension
iii. Type 2 Diabetes Mellitus
iv. Stroke 9 months ago
v. Osteoporosis
-last few months her mother has been depressed, forgetful and needs help with normal daily activities.
Her medication includes: a beta-blocker (atenolol), an ACE inhibitor (captopril), metformin, anti-thrombotic medications (aspirin and rivaroxaban) and medications for her bone condition (alendronate, calcium and Vitamin D)

Answer 55

1. Preoperative Assessment: Consultation with the patient’s physician to evaluate medical stability and medication adjustments before dental treatment./ check platelet level on day of exo>4 teeth.
2. Bleeding Risk Management: <2 catridge of LA, Local hemostatic measures (e.g., tranexamic acid mouthwash, suturing techniques); coordinate with physician on antiplatelet+ AOC management.
3. Infection Control: Enhanced aseptic techniques , defer if >10%; 15mmol/L
4. AVOID NSAIDS, AZOLE ANTIFUNGALS, CARBAMAZEPINES FOR RIVAROXABAN/dabigatran
5. Dry Mouth Management
   Solutions: Use saliva substitutes, pilocarpine, xylitol gum, and recommend frequent water intake. F-varnish.
6. Gentle Handling
   Consideration: Minimize discomfort due to the patient’s frailty; use stress reduction techniques and ensure short, efficient appointments.
7. Osteonecrosis Prevention
   Strategies: Avoid bone-impacting procedures when possible; consider conservative approaches. Drug holiday is controversial- depend on duration if >3-4yrs/ IV
8. Stress and Endurance Management
   Techniques: Clear procedure explanations, potential sedation, and keeping appointments short.
9. Supportive Care Involve caregivers in postoperative care; use tools like electronic brushes for easier oral hygiene-stroke. Regular follow-ups to adjust care plans and manage complications.

Question 56

A 22-year-old female Chinese patient comes to your polyclinic with the following main complaint: “My jaw joint has clicking noises on the right side for the past one month”.
a) Do clicking noises warrant any specific dental treatment from you? Rationalize your decision. [25 marks]

Answer 56

TMJ Symptoms Management
1. Evaluation of Clicking Noises
Context: Clicking alone, without pain or functional limitations, typically warrants conservative management and monitoring.
Action: If accompanied by pain or dysfunction, assess further and consider treatment to prevent progression of TMJ disorders.
2. History of Trauma
Importance: Trauma to the chin linked to the onset of clicking suggests a need for a detailed TMJ examination.
Examination Includes:
Palpation of TMJ area.
Assessment of mandibular range of motion.
Observation of jaw functions (any deviations, crepitus, or tenderness).
Additional Checks: Inspect for occlusal discrepancies, step deformities, or fractures.
3. Imaging for TMJ Assessment
Recommended Modalities: MRI for soft tissue, disc position, and integrity.
Bony Structures: Panoramic, reverse Towne’s view, and CT scan for potential fractures or bony changes due to trauma.

Question 57

b) During your history taking and interview, you found that the patient is suffering from mild jaw pain symptoms because her jaw was hit really hard in the chin one month ago.
How will this change your clinical examination and request for imaging modalities if you know no imaging has been done? [25 marks]

Answer 57

2. History of Trauma to the chin linked to the onset of clicking suggests a need for a detailed TMJ examination.
   Examination Includes:
   Palpation of TMJ area.
   Assessment of mandibular range of motion.
   Observation of jaw functions (any deviations, crepitus, or tenderness).
   Additional Checks: Inspect for occlusal discrepancies, step deformities, or fractures.
3. Imaging for TMJ Assessment
   Recommended Modalities: MRI for soft tissue, disc position, and integrity.
   Bony Structures: Panoramic, reverse Towne’s view, and CT scan for potential fractures or bony changes due to trauma.

Question 58

c) After you found that the patient has mild jaw pain, what are the “pain-related” questions that you should ask this patient during history taking which would help in your differential diagnosis? List
Pain-Related History Questions [25 marks] 7x

Answer 58

1. Nature: Describe the pain (aching, throbbing, sharp).
   2 .Timing: When does the pain occur (at rest, during movement, chewing, sleeping at the sides)? Gradual/sudden?
2. Duration: How long does the pain last? Does it resolve on its own?
   4 Triggers: Any exacerbating factorsor
3. alleviating factors?
   6 Associated Symptoms: Any headaches, earaches, or neck pain?
   7 Any medications used and their effectiveness?

Question 59

d) What clinical criteria define or distinguish whether a pain patient is simple or complex? Please list at least five (5) clinical criteria. Also, please state if the above pain patient is simple or complex and justify. [25 marks]

mx:

Answer 59

Criteria for Pain Complexity
1.Duration and frequency of pain episodes.[>3months CHRONIC vs acute]
2. Intensity and nature of the pain (e.g., mild, moderate, severe; constant, intermittent).
3. Presence of associated symptoms such as headaches, earaches, or neck pain.
4. Response to previous treatments or medications.
5. Impact on daily activities and quality of life; LMO

MX: Education and Self-care: Initial approach for simple pain cases.
-Further Interventions: Consider physical therapy/occlusal appliances based on diagnostic results.

Question 60

An adult female presents in your clinic with a chief complaint of difficulty and pain in opening her mouth. Discuss how

a) Duration of onset of chief complaint
influences your differential diagnosis.

Answer 60

1. Duration of Onset
   4x Acute Onset: May suggest trauma, acute infection, recent occlusal changes, or an exacerbation of existing TMJ disorder.

4x Chronic Onset: Could indicate degenerative changes in the TMJ, TMD, arthritic changes, or effects of long-term habits like bruxism or systemic conditions affecting the jaw.

Question 61

An adult female presents in your clinic with a chief complaint of difficulty and pain in opening her mouth. Discuss how

b) Severity of pain on mouth opening
influences your differential diagnosis.

Answer 61

2. Severity of Pain on Mouth Opening

3x Mild Pain: Often related to muscle strain from parafunctional habits, minor soft tissue injuries, or early-stage TMD.

3xSevere Pain: Could be indicative of acute infection, advanced TMD, or neoplastic processes.

Question 62

An adult female presents in your clinic with a chief complaint of difficulty and pain in opening her mouth. Discuss how

c) Presence of tenderness at muscles of mastication on palpation
influences your differential diagnosis.

Answer 62

3. Tenderness at Muscles of Mastication

4x Indications: Suggests a musculoskeletal origin such as myofascial pain syndrome, myositis, muscle overuse, or trauma.

Question 63

An adult female c/o of difficulty and pain in opening her mouth. Discuss how

d) Asymmetry of mandible, with obvious deviation of the chin
influences your differential diagnosis.

Answer 63

4. Asymmetry and Deviation of Chin

3xObservations: may signal a displaced fracture of the mandible, unilateral condylar hyperplasia or hypoplasia, or TMD with possible internal derangement like disc displacement.

Question 64

An adult female presents in your clinic with a chief complaint of difficulty and pain in opening her mouth. Discuss how

e) Taking Fosamax for 2 years
influences your differential diagnosis.

Answer 64

5. Long-term Use of Fosamax
   Effects: Associated with osteonecrosis of the jaw (ONJ), especially after invasive dental procedures. Can contribute to pain and difficulty in mouth opening if ONJ develops. History taking-any recent dental tx

Question 65

An adult female presents in your clinic with a chief complaint of difficulty and pain in opening her mouth. Discuss how

f) Have been chewing Betal nut/quid for the past 15 yearsinfluences your differential diagnosis.

Answer 65

6. Chewing Betel Nut/Quid Habit
   Consequences: Associated with submucous fibrosis leading to trismus + PAIN on mouth opening. Chronic use may cause fibrotic changes in the oral mucosa+ submucosa and increase the risk of oral cancer, potentially involving masticatory muscles or TMJ.

Question 66

history-taking9x, you would perform in order to confirm your clinical diagnosis of a benign odontogenic tumour.

Answer 66

Managing a 47-year-old Chinese male smoker with a buccal swelling in the left mandibular premolar-molar region:

History Taking
1.Onset and Duration: Note when swelling started, changes in size, and outcomes of any previous treatments.
2 .Pain Description: Type (dull, sharp, throbbing), timing (intermittent, constant), onset [gradual/sudden], duration, radiation of pain
3. exacerbating/relieving factors, and medication used.
4. Systemic Symptoms: Fever patterns, weight loss, night sweats.
5. Tobacco Use: no. of packs/ smoking history due to malignancy risk.
6. Dental History: Past dental treatments, perio/endo issues, and oral hygiene practices.
7. Medical History: General health, systemic diseases (e.g., diabetes), medications (e.g., immunosuppressants), allergies.
8. Family and Social History: Family similar issues, lifestyle factors affecting health (alcohol, betel nut chewing, etc.).
9. Nutritional and Social History: Assess for any factors that may impact healing and immune status. [alcohol/betel nut chewing/sunlight exposure/multiple partners]

Question 67

clinical examination, and clinical tests you would perform in order to confirm your clinical diagnosis of a benign odontogenic tumour.

Answer 67

2. Clinical Examination
   Extraoral Examination: Check facial asymmetry, skin changes, lymphadenopathy (size, tenderness, consistency, fixation).
   Intraoral Examination: Assess swelling for size, consistency, borders, color changes, ulceration, and effects on teeth (displacement, mobility).
   Occlusion and Function: Examine bite and jaw function, check for TMJ issues (range of motion, deviation, pain).
3. Clinical Tests
   Palpation: Evaluate if swelling is hard/soft, fixed/mobile, and pain response.
   Percussion: Test teeth in affected area for tenderness or ankylosis.
   Vitality Testing: Conduct tests on adjacent teeth for necrosis or periapical infection.

Question 68

special investigations you would perform in order to confirm your clinical diagnosis of a benign odontogenic tumour.

how to confirm your clinical diagnosis of a benign odontogenic tumour?

Answer 68

Special Investigations:-
Radiographs: Obtain periapical and panoramic images to view lesion extent, effect on bone, and tooth relationship.
CT Scan: Detailed bony architecture and lesion extent.
MRI: Assess soft tissue involvement.
Biopsy: Incisional for larger lesions or excisional for smaller, defined lesions.
Cytology: Consider FNAC to investigate uncertain lesions and rule out malignancy.
Histopathology: Send biopsy for examination to determine tumor nature.
Blood Tests: Complete blood count, ESR, CRP to evaluate general health and infection signs.

Benign Odontogenic Tumor Confirmation: Utilize a thorough evaluation strategy to exclude malignancy, particularly considering the patient’s smoking history and symptoms.

Question 69

Mechanism of Action for Local Anesthetics (LA)

how? what does it do to membrane?

Answer 69

Action Mechanism: Local anesthetics inhibit sodium channels in neuronal cell membranes.
Process: LA drugs diffuse into the nerve, bind to intracellular receptors on sodium channels,
stabilize the membrane, and prevent sodium ion influx necessary for action potentials–> prevents the nerve from transmitting pain signals to the brain, resulting in loss of sensation in the targeted area.

Question 70

a) Discuss the differential diagnosis of the oral mucosal lesions. Write briefly on the treatment options of one of the conditions that you would consider highest in your differential diagnosis list.

A 65-year-old Chinese male seeks treatment for painful, bleeding gums and oral ulcers with red patches involving his tongue and cheek mucosae. This has been present for 3 months. The patient is partially dentate and several of his remaining teeth exhibit recurrent/root caries and chronic periodontitis.
His medical history is significant for:
* Parkinson’s disease
* Asthma
* Hypertension, dyslipidemia
* Ischaemic heart disease – 3 Drug Eluting Stents (DES) placed 6 months ago
* Aortic valve stenosis with mild aortic valve regurgitation
His medications include:
* Aspirin, clopidogrel
* Nifedipine, atenolol, atorvastatin
* Salmeterol / fluticasone inhaler
* Antiparkinsonian drugs; carbidopa-levodopa

Answer 70

1. Oral Lichen Planus
   Chronic inflammation, painful, bleeding gums, ulcerative lesions with Wickham’s striae.
   2.Pemphigus Vulgaris
   Autoimmune, painful oral ulcers, bleeding gums.
2. Mucous Membrane Pemphigoid
   Autoimmune blistering, painful ulcers, red patches.
   4 Candidiasis
   Opportunistic fungal infection, red patches, ulcers,common in immunocompromised pt
   5 Drug-Induced Mucosal Reactions
   Oral ulcers and erythema from medication side effects.
   6 Squamous Cell Carcinoma
   Chronic lesions, induration, fixed lesions; malignancy should be considered, especially with chronicity and patient’s age.
   Management of Oral Lichen Planus
   Topical Treatments: Corticosteroids (first-line), antifungal agents like Nystatin.
   Severe Cases: Systemic corticosteroids, immunosuppressive agents, topical tacrolimus or cyclosporine, PUVA.
   Lifestyle: Good oral hygiene, avoid irritants (spicy foods, tobacco).
   Monitoring: Regular due to a small risk of malignant transformation.

Question 71

mx of oral lichen planus
His medical history is significant for:
* Parkinson’s disease
* Asthma
* Hypertension, dyslipidemia
* Ischaemic heart disease – 3 Drug Eluting Stents (DES) placed 6 months ago
* Aortic valve stenosis with mild aortic valve regurgitation
His medications include:
* Aspirin, clopidogrel
* Nifedipine, atenolol, atorvastatin
* Salmeterol / fluticasone inhaler
* Antiparkinsonian drugs; carbidopa-levodopa

Answer 71

First line
Topical Treatments: Corticosteroids f/by antifungal agents like Nystatin 100,000 U/mL suspension-Swish and spit (or
swallow if esophageal
lesions) for 1–2 min 2-3x/day. Continue until lesions resolved

Severe Cases: Systemic corticosteroids, immunosuppressive agents, topical tacrolimus or cyclosporine, PUVA.

Good oral hygiene, avoid irritants (spicy foods, tobacco) ; SRP with antibiotic prophylaxis
Monitoring: Regular due to a small risk of malignant transformation.

Question 72

mx of oral candidiasis
His medical history is significant for:
* Parkinson’s disease
* Asthma
* Hypertension, dyslipidemia
* Ischaemic heart disease – 3 Drug Eluting Stents (DES) placed 6 months ago
* Aortic valve stenosis with mild aortic valve regurgitation
His medications include:
* Aspirin, clopidogrel
* Nifedipine, atenolol, [atorvastatin-cholesterol mx]
* Salmeterol / fluticasone inhaler
* Antiparkinsonian drugs; carbidopa-levodopa

Answer 72

Topical Antifungals: Nystatin antifungal agents 100,000 U/mL suspension-Swish and spit (or swallow if esophageal lesions) for 1–2 min 2-3x/day. Continue until lesions resolved.
Clotrimazole lozenges- avoid in atorvastatin
Systemic Antifungals: Fluconazole, itraconazole for severe or widespread cases- need to see if can stop meds or change if not risk of muscle pain/rhabydomyolysis.

Combine with topical triamcinolone acetonide (corticosteroid) - beware of CHX interaction -complex formed is ineffective

Systemic: Fluconazole [x warfarin] -risk of bleeding

Question 73

Precautions and Treatment Modifications Under LA pre tx , intra op, post tx

His medical history is significant for:
* Parkinson’s disease
* Asthma
* Hypertension, dyslipidemia
* Ischaemic heart disease – 3 Drug Eluting Stents (DES) placed 6 months ago
* Aortic valve stenosis with mild aortic valve regurgitation
His medications include:
* Aspirin, clopidogrel
* Nifedipine, atenolol, [atorvastatin-cholesterol mx]
* Salmeterol / fluticasone inhaler
* Antiparkinsonian drugs; carbidopa-levodopa

Answer 73

Pre-Treatment Stage
Medical Consultation: Confirm stability of medical conditions; dental treatment planning.
Medication Review: Note antiplatelet and antihypertensive medications; manage bleeding risks.
Informed Consent: Discuss risks, benefits, alternatives.
Preoperative Instructions: Maintain stable medical condition, continue regular medications.

Intra-Operative Stage
Bleeding Management: Minimally invasive techniques, local hemostatic measures.
ABX? presence of aortic valve stenosis and regurgitation, unless the valve has been replaced with a prosthetic valve, does not warrant the use of prophylactic antibiotics according 2007 AHA guidelines
LA Selection: Prefer no VC or lowest epinephrine concentration; consider patient’s cardiac conditions.
Stress Reduction, short, LATE morning as asthmatic pt cortisol level is lower
Monitoring: Continuous monitoring of vital signs.

Postoperative Care
Instructions: Clear postoperative guidelines, signs of complications.
Medication: Prescribe appropriate painkiller -PCM considering patient’s health. No indication for antibiotics unless have systemic symptoms.

Question 74

The intrinsic pathway is activated by …. inside the blood vessel specifically by exposed …. . Factor ….are utilized in intrinsic pathway.

Answer 74

damage….collagen on endothelium+plasma proteins =HMWK/Kallikrein

XII, XI, IX, and VIII

Question 75

Extrinsic pathway is activated by …..causes blood to …..vascular system; involve initiation by Factor…

Answer 75

external trauma that

escape from the

III [TISSUE factor] and interaction with F VII

Question 76

Both pathways converge into the common pathway, leading to the activation of Factor …..and finally formation of a …..

common pathway uses factors ….

Answer 76

X, formation of thrombin

stable fibrin clot

X, V, II-thrombin, I-fibrin, and XIII-fibrin stabilizing factor.

Question 77

Ameloblastoma
Clinical Features3x

Radiographic Appearance 2x

Histologic Appearance 2x

Answer 77

1Presentation: Slow-growing, painless swellings in the jaw, often incidental findings.
2Location: Commonly in the mandible, especially molar and ramus areas.
3 Symptoms: Can cause cortical bone expansion and thinning, facial asymmetry, tooth displacement, occasionally pain or paresthesia.

Distinctive Pattern: Multilocular radiolucencies with “soap bubble” or “honeycomb” appearance.
Other Features: Possible root resorption.

1Common Patterns: Follicular and plexiform.
2 Characteristic: Islands and strands of odontogenic epithelium, peripheral palisading of columnar basal cells, central stellate reticulum-like cells.

Question 78

Odontogenic Keratocyst (OKC)
Clinical Features
Growth Behavior:
Association:
Symptoms:

Radiographic Appearance
Typical Presentation:

Histologic Appearance

Syndrome Association: …

Answer 78

1. Growth Behavior: Aggressive, high recurrence rate post-enucleation.
2. Often associated with impacted teeth and derived from dental lamina
3. Symptoms: Typically asymptomatic until large; may cause cortical expansion, tooth displacement, and pain if infected.

Radiographic Appearance
Typical Presentation: Well-defined radiolucent lesion, often unilocular with a smooth and corticated outline.
-May scallop around tooth roots.

Histologic Appearance
Characteristics: Distinctive thin, uniform parakeratinized epithelium; Corrugated surface, palisading basal cell layer.

Nevoid Basal Cell Carcinoma Syndrome (Gorlin Syndrome)

Question 79

Nevoid Basal Cell Carcinoma Syndrome (Gorlin Syndrome)
Salient Clinical Features
Manifestations: ….7x

Genetic Defect which chromosome??
Pathway Affected: ….

Answer 79

Manifestations: Multiple basal cell carcinomas, bifid ribs, calcification of the falx cerebri, palmar or plantar pits, frontal bossing, and mandibular prognathism, okc.

Genetic Defect
Gene Involved: PTCH1 on chromosome 9q22.3.
Pathway Affected: Hedgehog signaling pathway.

Question 80

Prophylactic Antibiotic Use to prevent infective endocarditis (IE) in high-risk patients such as those with …4x dt Viridans Group Streptococci [VGS]

Answer 80

1. prosthetic heart valves;
   2.history of IE
   3.CHD-Esp those cyanotic chd unrepaired/repaired with with residual shunts or valvular regurgitation
2. valvulopathy in cardiac transplant recipients

Question 81

procedures req ABX PROPHYLAXIS

Answer 81

Manipulation of gingival tissues or periapical regions, or mucosal perforations THAT MAY cause bacteremia.

Question 82

3x dosage for abx prophylaxis adult and c’ren

Answer 82

Dosing for Adults: Amoxicillin 2g or Doxycycline 100mg [>45kg] or Azithromycin 500mg -1 hour before procedure.

C’ren:
Amoxicillin 50mg/kg
Doxycycline 2.2mg/kg [<45kg]
Azithromycin 15mg/kg

Question 83

Use of Antibiotics in Oral Surgery
1Indications
2Duration:

Antibiotic Selection -2

Answer 83

1 Existing Infections: Treat conditions like abscesses, cellulitis, or post-operative infections.
2.Acute onset infections, systemic involvement, osteomyelitis, severe pericoronitis, and those who are medically compromised.

2 Typically 5-7 days to ensure adequate bacterial eradication.

1 Empirical Therapy: Based on suspected organisms, considering patient allergy history and resistance patterns.
2 Cultures: Ideal for tailoring therapy to specific organisms in complex cases.

Question 84

Drug Interactions and Management

Warfarin and Metronidazole:

Answer 84

Interaction: Metronidazole potentiates warfarin effects, increasing bleeding risks.
Management: Monitor INR closely, adjust warfarin dosage as necessary, educate patient on bleeding signs.

Question 85

Drug Interactions and Management
Simvastatin and Fluconazole

Answer 85

Interaction: Fluconazole increases simvastatin levels, raising risks of myopathy and rhabdomyolysis[muscle death].
Management: Consider alternative antifungal or discuss to chg or adjust simvastatin; monitor for muscle pain or weakness.

Question 86

Drug Interactions and Management
Fluoxetine and Ibuprofen:

Answer 86

an SSRI + NSAID
Interaction: Increased risk of gastrointestinal bleeding and potential for serotonin syndrome.
Management: Use gastroprotective agents or alternative pain medications, monitor for gastrointestinal symptoms.

antacids such as Famotidine (20mg BDS 5/7)
Omeprazole PPI (40mg OM 5/7) for patients with gastritis related to NSAIDs

Question 87

5x Problems of Leaving Wisdom Teeth Alone:

Answer 87

1. Decay and Gum Disease: Difficult to clean due to positioning.
2. Cysts/Tumors: Development can lead to jawbone damage and affect surrounding teeth.
   3 Infection- Pericoronitis: Infection of the gum tissue around the tooth crown, causing painful swelling and potentially leading to systemic infections.
   4 Surgical Complexity: Delayed decision to remove can result in more complex, risky surgical procedures due to increased complications over time.
   5 Crowding: Can cause displacement or damage to adjacent teeth.

Question 88

Aetiological factors that contribute to the development of mouth cancer include:

Answer 88

1.Tobacco use, including cigarettes, cigars, pipes, chewing tobacco, and snuff. Reverse smoking 50% on hard palate
2. Heavy alcohol consumption.
3. Betel nuts
4. Human Papillomavirus (HPV) infection, particularly high-risk strains HPV 16, 18 OR /Candida infection/Syphilis/HIV
5. Prolonged sun exposure to the lips without protection.[actinic radiation]
6. Immunodeficiency or immune suppression.
7. Chronic irritation from rough teeth, dentures, or fillings.
8 LOW SES
9 Poor nutrition, especially diets low in fruits and vegetables; high in red meat and processed foods.IRON DEFICIENCY/ VIT A DEFICIENCY
10. Genetic predisposition- HEREDITARY oncogene, p53/ tumor suppressor gene mutation
11. Pre-existing diseases
12. increasing age
13. h/o of PML

Question 89

8x Factors influencing the prognosis for patients with this disease:

Answer 89

1 Location and size of the tumor.
2 Stage of the cancer at diagnosis: earlier detection generally leads to better outcomes- T4-spread to other tissues
3 LN-mobile/fixed LN>6cm
4 Presence of distant metastasis [TMN staging system]
5 Patient’s age, overall health and presence of co-morbidities.
6 Histopathological results- dysplasia
7 Quality and timeliness of medical and surgical intervention.
8 Patient’s adherence to treatment and follow-up care.

Question 90

Role of General Dentist in Mouth Cancer Management
4x
5th tx -pre/during/post
+ 6-9

Answer 90

1 Early Detection-Routine Screenings
2 Education: Inform patients about the risks and signs of oral cancer recurrence, especially high-risk individuals.
3 Prompt Referrals: Send patients for further evaluation if suspicious lesions are detected.
4 Multidisciplinary Approach: Work closely with oncologists and other healthcare providers.

5 Dental Care Throughout Cancer Treatment
Pre-Treatment: Clear any infections and perform necessary dental work (restorations, extractions, periodontal and endodontic treatments) ideally one month prior to cancer treatment to allow healing.
During Treatment: Manage symptoms like mucositis and hyposalivation; focus on maintaining oral health to prevent complications like xerostomia, oral mucositis, and root caries.
Post-Treatment: Continue supportive dental care and monitor for any long-term effects such as osteonecrosis of the jaw (ONJ), particularly in patients who have received radiation doses >60 Grays.
6 Rehabilitation and Support
->Prosthetics: Help fabricate dental prosthetics for patients who have undergone surgical resections.
7 Nutritional Counseling: Assist with challenges like dysphagia and taste loss.
8 Support Services: Offer emotional support and connect patients with support groups to help cope with their condition.
9 Engage in public health initiatives to raise awareness about the importance of early detection and prevention of oral cancer.

Question 91

Pre-Operative Assessment for a 65-Year-Old Patient
Medical History Review
Conditions: Hypertension, dyslipidemia, ischemic heart disease, aortic valve stenosis, Alzheimer’s disease.

Answer 91

1) Check recent cardiovascular interventions; defer treatment if within 6 months or refer. Antibiotic Prophylaxis: Required if prosthetic heart valves are present due to stenosis.
2) Medication Review
Types: Anticoagulants, antiplatelet agents, antihypertensives, cholesterol-lowering drugs, Alzheimer’s medications.
Purpose: Anticipate drug interactions with LA and assess bleeding risks.
3) Consultation with Medical Providers
/ cardiologist and primary care physician for health status and dental treatment clearance.
4) Medication Adjustments: Possible dose adjustments required.
5 ) Vital Signs Monitoring: Ensure blood pressure and heart rate are within safe limits (<180/100mmHg) for dental treatment.
6) Dental Examination
Focus: Assess caries, periodontal disease, prioritize treatment considering patient’s health and cooperation abilities.
7) Cognitive Assessment-Evaluate the patient’s understanding and ability to cooperate during treatment.
8) Treatment Plan Discussion
Informed Consent: Include the patient and caregiver, considering cognitive status.

Question 92

Intra and Post-Operative Precautions with elderly man with Hypertension, dyslipidemia, ischemic heart disease, aortic valve stenosis, Alzheimer’s disease.

Answer 92

Intra-Operative
1 LA Selection: Use anesthetic with minimal VC due to cardiac risks. [<2catridges]
2 Continuous Monitoring: Vital signs must be monitored, specifically ensuring BP <180/100mmHg.
3 Stress Reduction: Implement techniques to maintain a calm environment.
4 Appointment Length: Keep appointments short to minimize stress and fatigue.
5 Bleeding Management: Prepare for potential bleeding due to anticoagulant or antiplatelet use.
6 Post-Operative
Pain Management: Prescribe suitable analgesics, avoiding NSAIDs if on anticoagulants.
7 Postoperative Instructions: Clear guidance for patient and caregiver on care and signs of complications; due to Alzheimer’s impact.
8 Follow-up: Schedule to monitor healing and manage complications.

Question 93

Which antibiotic is best in liver failure?

Answer 93

1 Fluoroquinolones (norfloxacin and ciprofloxacin),
2 third-generation cephalosporins (G3) (ceftriaxone and cefotaxime)
3 trimethoprim–sulfamethoxazole (SXT) are recommended for preventing infections in patients with cirrhosis or liver failure.

Question 94

Which antibiotic is contraindicated in liver failure?

Answer 94

Macrolide , tetracycline and clindamycin ==> hepatoxic

Question 95

1. Patient Awaiting Liver Transplant
   Potential Problems: 3x

mx: preop, during , post-op

Answer 95

1 Increased Bleeding Risk-clotting factors
2 Infection Risk: Elevated due to immunosuppression associated with chronic liver disease-reduction in complement proteins and acute phase proteins needed for Immune system.
3 Drug Metabolism Issues: Altered liver function affects drug metabolism and clearance [Amide LA, metronidazole]

Management Strategies:
1Preoperative Assessment: Collaborate with hepatologist to evaluate liver function and coagulation status PT/aPTT.
2Anesthetic Considerations: Opt for the lowest effective dose[ <2]
3Bleeding Precautions: Check clotting factors and platelets, have blood products ready, use tranexamic acid mouthwash postoperatively. PCC on standby.
4Antibiotics: Use to prevent infections; consider cephalosporin and avoid NSAIDs.

Question 96

2. Patient Undergoing Renal Dialysis
   Potential Problems:–> kidney disease 6x

Answer 96

1. Bleeding risk - depend type of AOCoagulant for dialysis.+platelet is destroyed during hemodialysis.
   2 Nutritional Concerns: Malnutrition and compromised immune state from dietary restrictions.
   3 Hemodynamic Changes: Blood pressure fluctuations due to dialysis;hypotensive*
   4 Infection and Electrolyte Risks: Higher infection risk; dialysis affects potassium [hyperkalemia-> arrhythmia] and calcium levels[hypocalcemia-bone disorder]
2. Anemia: -↓ synthesis of erythropoietin → ↓ stimulation of RBC production → normocytic, normochromic anemia
3. DRUG metabolism and excretion is impaired

Question 97

Patient with Ischemic Heart Disease on Antiplatelet Therapy Potential Problems:

Answer 97

1 Increased Bleeding Risk: From aspirin and clopidogrel.
2 Cardiac Events Risk: Surgery stress may precipitate cardiac events.

Question 98

mx pt with Undergoing Renal Dialysis
4x

Answer 98

Management Strategies:
1Timing of Surgery: Perform surgery on a non-dialysis day, soon after dialysis session.
2 Blood Pressure Monitoring: Monitor closely, especially avoiding measurements on the arm with AV shunt.
3 Bleeding Management: Consult with nephrologist about platelet function, aPTT +INR if on warfarin and possible use of prothrombin complex concentration/desmopressin.
4 Avoid NSAIDS,

Question 99

drugs-directly nephrotoxic

Antibiotics 4x
Analgesic 2x

Answer 99

1 Cephalosporins - Generally, cephalosporins are considered safe for the kidneys, but certain ones can be nephrotoxic in those with renal impairment.
2 Aminoglycosides - nephrotoxic
3 Penicillins - While penicillins are generally safe, high doses or prolonged use can sometimes lead to interstitial nephritis.
4 Tetracyclines- slightly

1 NSAIDs - These are known to be nephrotoxic due to their effect on kidney prostaglandins, which are crucial for maintaining renal blood flow, especially in patients with compromised kidney function.
2 Paracetamol (Acetaminophen) - It’s generally safe in therapeutic doses; however, chronic high doses can indeed be hepatotoxic and potentially nephrotoxic.

Question 100

Management Strategies:
Patient with Ischemic Heart Disease on Antiplatelet Therapy

Answer 100

1 Cardiac Clearance: Obtain clearance and guidance from a cardiologist regarding antiplatelet therapy management. Possible continuation, modification, or temporary cessation as advised.
2 Stress Reduction: Implement stress reduction protocols and consider sedation.
3 Bleeding Control: Use local hemostatic measures and prepare for potential prolonged bleeding.

Question 101

Which of the following is not a high-risk HPV type?
11,16,18,45

Answer 101

over 200 types of HPV, 12 are considered high-risk due to their ability to cause several types of cancer. High-risk HPV types include 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59. Most attributed to HPV-related cancers are HPV-16 and HPV-18.

Low-risk types rarely cause cancer and include both HPV-6 and HPV-11. These types can cause warts on or around the genitals, mouth, and throat.

Question 102

Which oropharyngeal structure(s) do most HPV-positive cancers affect?
a, soft palate and uvula
b. Palatine or lingual tonsils
c. Posterior or lateral pharyngeal walls

Answer 102

HPV-positive cancers predominantly affect the palatine or lingual tonsils. The base of the tongue and tonsillar site tumors show a 62% HPV-positivity rate vs other oropharyngeal sites show a 25% HPV-positivity rate.

may appear with areas of dysplasia, inflammation, or superficial spreading; may appear as exophytic or ulcerative. Can spread across a broad region, including the tonsillar fossa, lateral soft palate, retromolar trigone, and buccal mucosa.

Question 103

Nicotine use is associated with an increased risk of developing necrotizing gingivitis. True or false

Answer 103

TRUE . The risk is related to the amount of nicotine consumed per day. “The influence of smoking on the host immune response has revealed that nicotine impairs neutrophil bactericidal activity against oral pathogens by inhibiting the production of superoxides and hydrogen peroxide, which are responsible for bacterial death.”

Question 104

Oral manifestations of nicotine use include, but are not limited to, an increased risk of developing:

Answer 104

Periodontitis
Leukoplakia
Leukoedema
Necrotizing gingivitis
Oral cancer

Question 105

Alcohol abuse is associated with an increased risk of developing necrotizing gingivitis -true or false?

Answer 105

TRUE. Neglected oral hygiene that may occur due to alcohol abuse may lead to the formation of periodontopathogenic biofilm, which exacerbates the inflammatory response and increases cytokines. Alcohol intake can also cause changes in saliva and decrease salivary flow+ xerostomia, making oral tissues more susceptible to periodontal diseases,gingival recession and caries.

Question 106

The risk of developing osteoradionecrosis after an extraction increases in the years following radiation therapy, peaking in the fifth year. true or false?

Answer 106

The overall risk of developing osteoradionecrosis of the jaw from therapeutic radiation is estimated to be 2%. Certain factors increase this risk, including invasive dental procedures (primarily tooth extraction), tumor location and area of irradiated bone, oral hygiene, periodontal health, smoking and alcohol consumption, and uncontrolled diabetes.

The risk of developing osteoradionecrosis after an extraction is 7%. This risk gradually increases for extractions between the second and fifth years postradiation, reaching a peak risk of 22.6%. After the fifth year postradiation, the risk decreases to 16.7%.

Vindiš, E., et al. Osteonecrosis of the Jaw. Dentistry Journal. 2023; 11(1): 23. https://doi.org/10.3390/dj11010023

Question 107

Both articaine and lidocaine are metabolized primarily in the liver. TRUE or false

Answer 107

false- Most amide anesthetics (except for articaine) are metabolized by the liver by a microsomal enzyme system whereas 90% of articaine is metabolized by esterase in the plasma and excreted via the kidneys. The remaining 10% is metabolized in the liver.
Articaine has a ester side chain allowing it to be quickly metabolized systemically by hydrolysis.

Question 108

examine check lips , tongue using??

Answer 108

Bidigital palpation using the index finger and thumb to press against the tissue is used to palpate the lips, labial and buccal mucosa, and tongue.