OSCE DOC - Restorative Flashcards
Patient has toothache. Unrestorable 26 requiring extraction. However pt is taking warafin. How would you approach this patient intially, what information should you gather before discussing any treatment?
- Introduce myself to the patient.
- Ask about the patients INR. When they last recorded it and what the value was.
- Ask to see their INR book
Patient has toothache. Unrestorable 26 requiring extraction. However pt is taking warafin and there INR is 5.5. What would you do?
- Explain to the patient that their INR is too high today for us to safely take out their tooth due to the high bleeding risk.
- Expalint the SDCEP guidlines state that the patient INR must be below 4 and taken within 24hrs of appointment if unstable. (72hrs if the patient is stable. A stable pt is a patient with <4 INR for 3 months)
- Explain that once their INR reduces they an extract the tooth
Patient has toothache. Unrestorable 26 requiring extraction. However pt is taking warafin and INR is too high to xla. However, the patient is still in pain so how would you treat them today to help with this?
- Acknowledge the patient is in pain and discuss dealing with the pain
- Analgesics +/- pulp extripation with sedative dressing.
- If extremely urgent then refer to secondary care.
- Ask the patient if they understand and what tx option they would like to go for and rebook extraction for a future date when INR will be within safe limits.
- Ask if they have any questions
What does the INR value have to be below and when must it have been recorded in a stable patient taking warafrin?
According to SDCEP a stable patient must have an INR value of <4 within 72hrs of the xla appointment. (a stable patient is someone with over 3months of INR scores <4. Unstable patients must have their INR recorded within 24hrs.)
Patient is taking alendronic acid. Discuss with the patient the risks associated with this.
- Alendronic acid is a bisphosphonate which reduces bone turnover
- Bisphosphonates accumulate in areas of high bone turnover. AKA the jaw.
- This can cause MRONJ
- There is then a risk of poor wound healing following the extraction. Reduced bone turnover and vascularity can lead to death of bone - osteonecrosis.
What are some signs and symptoms of MRONJ that a patient might present with?
- Delayed healing
- Pain
- Soft tissue infection
- Swelling
- Numbness
- Paraesthesia
- Exposed bone inside or outside the mouth
- Also could be asymptomatic
What is the risk of MRONJ in osteoporosis patients?
Low risk (0-10 cases per 10,000)
How long must a patient be taking bisphosphonates before they become high risk of MRONJ?
More than 5 years
What else makes a patient high risk of MRONJ?
- Previous diagnosis
- anti-resorptive or anti-angiogenic drugs for the
management of cancer? - Bisphosphonates for longer than 5 years
- Patient on bisphosphates for any length of time but also takes systemic glucocorticoid?
What advice can you give patients that are high risk of MRONJ?
- improve their oral hygiene,
- reduce sugary
snacks and drinks, - limit alcohol intake,
- stop smoking.
How long does the bone need to not be healed for before you diagnose MRONJ? and what do you do after this?
If the extraction socket is not healed at 8 weeks and you suspect that the patient has
MRONJ, refer to an oral surgery/special care dentistry specialist as per local protocols.
Treatment Planning (12 mins)- 36 marks
This patient has presented to your practice for the first time, complaining of bleeding gums when he brushes his teeth. This has been a problem for several years. He is also aware that his teeth are getting shorter, but he is not unduly concerned by his appearance.
HE HAS NO OTHER SYMPTOMS.
He is 36-years of age, works as a bricklayer and has no relevant medical history. He smokes 20 cigarettes per day and drinks approximately 12 units of alcohol per week. He drinks 1 litre of fizzy juice each day. He has considered stopping smoking.
He last visited a dentist about 2 years ago. He brushes his teeth once per day but uses no means of interdental cleaning. He is not aware of grinding or clenching his teeth.
Look at the clinical photographs, radiographs and study casts provided.
You should spend 3-4 mins looking at the photos, radiographs and models, and then explain to the patient your findings, diagnosis and proposed management (7-8 mins). Remember, once in the station, you have 11 mins in total.
Recommendations for management should focus on the patient’s principal complaint but you should give brief advice concerning other important needs you identify.
Immediate
Pain (Pericoronitis? Toothache? Perio abscess? PAP?)
Initial
HPT
- OHI, PGI (HGDM), (6ppc depending on BPE), supragingival scaling and RSD with or without LA as needed
- Diet advice (including erosion)- diet diary
- Consider medical referral if GI intrinsic acid
- Smoking cessation, alcohol advice
Impacted 8s
- Assess prognosis- is it causing problems with other teeth? Is there pain? Is there a risk of caries, perio, cyst, tumour, resorption in the 7 or 8? Proximity to IAN? Has there been recurrent infection?
- Extract or monitor
- 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, habits, parafunction and treat with diet diary, study casts, photos, DBA, GI, composite, no splint for erosion!
- Fluoride- toothpaste, mouthwash
- Dietary advice- change habits- don’t swirl drink around mouth, use straws, watch ‘healthy eating’ acids (5/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 (12 weeks after treatment)
NCTSL (photos, study models)
Re-constructive
Filling spaces- dentures, bridgework, implant, ortho?
If NCTSL not progressing, but patient not happy, can proceed with restorations
Maintenance
Perio, NCTSL
Monitor impacted 8s if they were not extracted
Bridge Prescription (6 mins)
For conventional cantilever bridge
Include how you would fill out the sheet and sent it off to the lab.
Fill in details
Patient detail sticker on all three sheets (name, age, CHI, sex, DOB), any photos or SH
Practitioner details / practice details / no.
Date and time of recording impression, date and time of completed required lab work
Plan- stage of treatment (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, can be cleansed if designed carefully
- modified ridge lap- upper anteriors, lingual surface cut away, problems with food packing
- dome- lower incisor, premolar or upper molars, acceptable if occlusal 2/3 of buccal surface visible, poor aesthetics if gingival 1/3 of tooth visible
- ovate
- wash through- no contact with soft tissue, consider in lower molar area
Please construct in canine guidance and ensure pontic is free of excursive movements
Please return bridge with cast
Signature
Radiographic Reporting OPT (6 mins)
Discuss with clinician what you can see.
Go through OPT in a systemic manner
Demographics:
Type of X-ray
Age, date, etc.
Quality:
Grade A/N - Just diagnostically acceptable or diagnostically not acceptable now
Dentition:
Teeth- erupted / unerupted, permanent / primary, missing / supernumerary, impacted, ectopic
Restorations- heavily / moderately / mildly restored, overhangs, fractures, poor margins. Comment on any RCT.
Trauma
Disease: ABC (apices, bone loss, caries)
Caries- primary / secondary, supra / subgingival, 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
Post and Core Crown (6 mins)
Patient already has post core crown on tooth, but no endo treatment has been done. Lingual caries but no pain. Patient wants no treatment.
Explain options, explain advantages and disadvantages of each.
- Introduce self and designation
- Address patient by name
i) Leave / monitor:
Advantages- may stay asymptomatic but unable to tell for how long
Disadvantages- risk of infection / abscess / tooth breakdown / catastrophic root fracture / pain / eventual loss of tooth / decay goes below bone level so unrestorable
ii) Remove crown and remove caries
Restore with new crown if restorable
Advantages- removes risk of post removal, potentially lessens the likelihood of pain and infection occurring
Disadvantages- not actually resolving the problem of no endo treatment (risk of periapical infection), crown may not be able to come off without the post being removed, tooth might be deemed unrestorable after removal of caries
iii) Remove post core and replace and RCT
Risk of removing post and core- root fracture, core / post fracture- which could result in it being unrestorable or needing further treatment with endo specialist which could include surgery / extraction
iv) RCT- involves cleaning out the tooth and filling it to prevent infection- needs a series of appointments.
Risks of endo
Many appts- at least 2 for endo, then at least 2 for crown
v) XLA
1 appt
But without a tooth
Explain risk of tooth being unrestorable requiring XLA
Options for replacement:
Leave space
Restore with bridge
Restore with denture
Restore with single tooth implant
- Once discessed tx options, confirm patient decision
- Ask if they have any questions
- Re confirm
Actor marks
If there are photos / radiographs- use them as part of the discussion
Dental Dam Placement for 35MOD (12 mins)
Explain how you would place dam for this restoration.
Select correct clamp- clamp chart provided
Suggested clamps
- anteriors- C or E
- premolars- E or EW
- molars- A, AW, FW or K
- use floss around clamp
Can use nurse for assistance
Place dam over 36-34- due to contacts
Hole punch into dam (largest single hole for endo; 3 teeth for restorative) – place wedges if required for more than single tooth dam
Use wedget and floss ligature
Opal dam or oroseal for around clamp and dam – light cure
Placement of frame on outside of face
Check seal using CHX for disinfecting the area.
Marks for correct clamp, correct number holes, ligature, wedgets, frame on outside of dam, efficiency, cutting ligature
Veneer Prep- 11 (12 mins)
All burs given
Describe how you would carry out a veneer prep on 11 in practice.
- Remember PPE
Not really marked on patient management- clinicians not really watching you whilst you prepare the tooth - 2x putty indices
- 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 2 planes as for crown prep
- Correct the notches with the chamfer bur - Chamfer margin finishes cervically or just above gingival margin
- Reduce the incisal edge
- Ideally around 1mm (0.75-1.5mm)
- Bevel incisal edge (3 planes total) - Finish
- Smooth composite finishing rugby ball bur
