OSCE STUDY OVERVIEW Flashcards

Question

what aspects make up the caries risk assessment?

Answer 1

- Clinical evidence - Diet - Medical history - Social history - Saliva - Plaque control - Fluoride exposure

Answer 2

- regular radiograph monitoring - diet advice - toothbrushing instruction - high strength F toothpaste - fluoride supplements - fluoride varnish - fissure sealants - sugar free medicine if required

Answer 3

- assist child with brushing until able to brush independently (roughly 7y/o) - 2x daily with fluoride toothpaste - demonstrate on child, get parent to demonstrate - methodical approach

Answer 4

- Check all occlusal relationships acceptable and appropriate - Remove undercuts from denture fitting surface using acrylic bur - Adjust border from over//underextension with greenstick - Apply adhesive and insert imp material (light body PVS) onto fitting surface and seat denture - Ask pt to bite together so imp taken in OVD - Take lower imp with denture in situ - Take a bite reg if OVD not obvious - Send denture for reline

Answer 5

- please pour impression in 100% dental stone using denture impression provided, please create a self-cure PMMA reline to alter impression surface.

Answer 6

- Look and feel from front, above and below - Any lacerations? - Nasal bleeding / deviation / patency (obstruct each nostril) - Facial asymmetry - Limitation of mandibular movement? - Examine sensation of infraorbital region (upper lip, lateral nose, lower eyelid) - Periorbital ecchymosis - Vision assessment - Any diplopia

Answer 7

- Periorbital ecchymosis - Swelling then flattening of face - Lacerations or excoriations - Sub-conjunctival haemorrhage - Numbness - Visual disturbance - Step deformity - Trismus

Answer 8

- Urgent OMFS unit or A+E department

Answer 9

An OAC is an acute communication of the maxillary air sinus with the oral cavity In your case the communication hasn't closed over and instead has healed by epithelialising forming a fistula and a permanent communication of the air sinus and the mouth This is something we want to manage as it makes you more prone to developing sinus infections

Answer 10

- Inform patient and gain consent to monitor, close or refer - Acute [if small <2mm] = encourage clot or suture margins - Acute [if large or lining completely torn] = close with buccal advancement flap - Chronic = excise sinus tract, remove epithelium + buccal advancement flap (or buccal fat pad, palatal flap, bone graft)

Answer 11

- refrain from blowing nose or stifling a sneeze by pinching the nose - steam or menthol inhalations - avoid using straw - refrain from smoking - avoid agitating the area - CHX rinses

Answer 12

‘The jaw joint sits in the base of the skull and muscles control opening and closing. Now, like any muscle in the body, if overworked they get tired, e.g., if you climb a mountain your legs are sore for the next few days’ - ‘However, as your jaw joint gets used all day everyday like for speaking and eating it never gets a rest. The muscles get inflamed and sore’ - ‘The fact that you’re sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more’ - ‘The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw bones and snaps in place’ - Could draw a diagram to show the disc and explain that when muscles are not in harmony, the disc is pulled at the wrong time, to create clicking noise or disc trapped in front of jaw bones crushing the tissue that can cause pain’

Answer 13

- Reassurance- ‘the way we manage this is very simple’ - ‘It involves resting the joints’- soft foods, cut into small pieces, chewing on both sides, avoid chewy food and chewing gum, avoid wide opening, avoid stifling yawns, avoid grinding during the day, avoid habits (biting nails) - Soft diet for 2-4 weeks- soup, yoghurt, stews, casseroles; don’t bite into apples or tear crusty bread, avoid chewy food - ‘The only time your teeth should be touching is when you’re eating’- remind yourself every 30 mins to an hour - Don’t force mouth open and hold it open - Don’t check if it still clicks - Avoid chewing pens, holding things in mouth, don’t rest jaw on hands - Support jaw when yawning - Keep warm in cold weather - Conservative advice including analgesia, (paracetamol / ibuprofen for 14 days) heat packs and massage - Evidence to show yoga helps and general stress reduction is beneficial - Make splint to break nocturnal habits

Answer 14

- Risk of temporary / permanent numbness, prolonged nerve pain, tingling due to damage to the nerve – lip and chin - ‘This is a sensory nerve and any nerve damage will have no effect on your appearance or the way your mouth or jaw moves. This is something only you will be aware of’ - Risks- 10% temporary, <1% permanent (temporary- few weeks to 18 months) - If roots involved with IDN then the nerve damage risk increases to 20% temporary and 2% permanent - If IDN involvement- coronectomy (‘involving the same procedure as above up to the sectioning of the tooth, however, only the crown of the root is removed, leaving the roots in place to avoid risking nerve damage- this cannot be done if the tooth is carious. If the roots become mobile they will have to be removed as well’

Answer 15

- Stimulate patient by asking them to breathe deeply - Supplemental oxygen [nasal cannulation 2L/min] - Reverse sedation with Flumazenil [500 micrograms/5ml]

Answer 16

- Intracranial pathology - Severe COPD - Hepatic insufficiency - Pregnancy and lactation - Hypothyroidism

Answer 17

- Common cold - Tonsillitis / adenoidal enlargement - Nasal blockage - Severe COPD - MS - Pregnancy (1st trimester) - Claustrophobia

Answer 18

- Overfilled - Underfilled - Poorly compacted - Accessory canals missed - Missed canal - Inadequately prepared - Extrusion of debris - Perforation - RCF of incorrect shape - Vertical root fracture - Endo file fracture - Blockage / obstruction of canal - Poor coronal seal - Failed restoration - No penultimate rinse with EDTA - Mixing CHX and NaOCl - Lack of patency

Answer 19

Leave/Monitor = - Risk of infection/abscess/tooth breakdown/catastrophic root fracture Remove crown & remove caries: Restore with new crown if poss = - Adv: removes risk of post removal, removes decay - Dis: not resolving problem of no endo Remove post & core + RCT = - Risk of fracture when removing post/core - RCT involved cleaning out tooth and filling it to prevent infection (multiple appts) XLA - Options for replacement: leave space, restore with brudge, denture, implant

Answer 20

- Procedure requires multiple appts. - Local anaesthetic = topical gel, injection and LA risks (perm/temo nerve damage, altered sensations, numbness, prolonged LA) BUT makes procedure comfortable - Rubber Dam required - Radiographs required pre, during, post tx - Access with drill/bur to reach pulp/nerve - Files used to clean and shape canal - Irrigation with NaOCl (bleach) + EDTA - Canal dried with paper points - Intracanal medicament = resolves inflammation/symptoms - Obturation with GP and accessory points - Lining material placed to seal canal - Restoration = ideally indirect - Rv appt needed.

Answer 21

Case specific based on: - restorability of tooth - initial pulpal and periapical diagnoses - quality of obturation and cleaning out - primary vs re-treatment - operator skill & equipment

Answer 22

- Instrument separation in canal - Failure to negotiate canals to working length - Hypochlorite extrusion/accident - Material extrusion - Post-op pain and swelling - Need for pain control - Perforation - Root fracture - Poor obturation need for re-treatment

Answer 23

- NaOCl - Eucalyptus oil

Answer 24

Anteriors = C or E Premolars = E or EW Molars = A, AW, FW or K

Answer 25

- Choose correct clamp size for tooth - Hole punch in dam (single tooth isolation so one hole) - Opal dam or oroseal for around clamp & dam to improve seal (light cure if opal dam) - Placement of frame on outside of face - Check seal using CHX for disinfecting area, explain pt may smell it but should NOT taste it.

Answer 26

- Overfilled - Underfilled - Short of apex - Poorly compacted - Accessory canals missed - Missed canal - Inadequately prepared - Extrusion of debris - Perforation - Vertical root fracture - Endo file fracture - Blockage/obstruction of canal - Poor coronal seal

Answer 27

Tx Options: - Leave and monitor [may cause pain/infection later] - RCT re-treatment [chances of success decreased, difficulty removing post/core if present] - Periradicular surgery [if re-treatment not possible, more difficult, invasive, time consuming, expensive, nerve damage] - XLA [needs replacement or poor aesthetic/function]

Answer 28

- Introduce self & designation - Calmly explain to pt that there is a file separated into the canal of tooth - These thin metal files are used to clean and shape the canal - Sometimes they can separate in tight/curved areas Solutions: - Do whats best based on illumination/magnification/access to instruments/time - Refer to specialist - Attempt removal with tweezers - Dislodge and remove file with ultrasonic - Bypass the instrument by watchwinding a small file alongside instrument and EDTA to soften dentine - If removed, complete RCT as normal - If not possible to remove, accept and obturate to file - Retrograde RCT (apicectomy/peri-radicular surgery) - XLA last resort

Answer 29

Using Endo-Z bur create a quadrilateral shape access cavity - 3 roots - 94% have 4 canals (MB1, MB2, D, P) - 7% 3 canals (MB, D, P)

Answer 30

Gold Standard = Cuspal coverage (crown/onlay) - Reduced risk of tooth fracture - Less microbial leakage/better seal - Examples include MCC, GSC, all ceramic, zirconia - Core buildup may be necessary (composite gold standard) Direct restoration - Composite or amalgam - Only if occlusal cavity present - Not as favourable, more leakage, more likely to fracture

Answer 31

Tooth must be asymptomatic and vital (no history of pulpitis) and pulp exposure must be small - Arrest any bleeding via copious irrigation with saline - Can irrigate cavity with chlorhexidine 0.2% - Blot cavity dry using cotton wool pledgets - Exposed pulp cobered using hard-setting calcium hydroxide cement (Dycal or Life) - RMGIC lining placed over top (vitrebond) - Complete restoration as planned and monitor tooth

Answer 32

Atypical Odontalgia - Dental pain without detected pathology - Intense unbearable pain for 2/3 weeks usually which settles spontaneously - Typical acute pulpitis symptoms - Treatment = refer to OM, opioid analgesics high intensity/short duration, XLA of tooth if needed Persistent Idiopathic Facial Pain - Pain which poorly fits into standard chronic pain syndromes which often has a high disability level (autonomic component) ○ Management = Refer to OM, believe the patient and do not increase damage, adopt holistic strategy for pain control and quality of life issues

Answer 33

- Alcohol has been found to dehydrate the cell walls enhancing the ability of other toxins such as tobacco carcinogens to penetrate mouth tissues and also nutritional deficiencies associated with heavy drinking can lower the bodies natural ability to use antioxidants to prevent formation of cancers - Drinking alcohol in excess puts you at risk of many cancers including oral, stomach, liver, colon and rectum cancer. - It also causes decay and tooth wear due to the high acidity and sugar levels - It also puts the person at risk of facial and denture injuries if under the influence of heavy alcohol

Answer 34

- No more than 14 units of alc per week - Spread drinking over 3 days or more if you regularly drink >14 units - Try to have at least 2 alc free days - 14 units = 6 pints of beer, 10 small glasses of low strength wine, 14 single 25ml shots

Answer 35

Radiograph shows abscess relating to specific grossly decayed tooth Ask pt symptoms - Swelling/trismus/dysphonia/dysphagia/drooling/inability to stick tongue out/pain - As about temperature, pulse rate, respiratory rate, colour Criteria for SIRS: - Temperature <36 or >38 - WCC <4 or >12x109/L - Heart rate >90/min (tachycardia) - Respiratory rate >20/min (tachypnoea) 2 out of 4 positive sirs = sepsis syndrome and requires urgent referral To OMFS or A&E Always refer if: - Spread of infection to pharyngeal or submandibular space - Systemic manifestations and patient is immunocompromised - Trouble swallowing or breathing – drooling - Rapidly progressing infection

Answer 36

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

Answer 37

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

Answer 38

Dental lichen planus is a chronic condition that affects the inside of your mouth, causing white patches, redness, or sores. It happens because your immune system mistakenly attacks the tissues inside your mouth. Most cases are mild and don’t need treatment, but some people experience discomfort. In rare cases, it can increase the risk of developing oral cancer, so regular check-ups are important Lichen planus has a small chance to develop into something sinister like a mouth cancer in 1% of cases in 10 years in an average case.

Answer 39

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

Answer 40

● Establish what patient knows about the biopsy and possible implications. ● Break the news of diagnosis – ‘epithelial dysplasia which has a potential to be cancerous.’ ● Stress to the patient: ‘This is not cancerous YET but there is evidence of a tissue change.’ ● Ensure they understand: ‘This diagnosis implies there is a HIGHER risk for a transformation to malignancy.’ ● ‘The good news is that the risk can be reduced by removing the factors that can cause cancer’ ● Alcohol advice - mentioning what unit of alcohol is and weekly intake guidelines and dental effects ○ Eye contact, open body language - Actor marks non-judgemental tone and clear advice.

Answer 41

● Discussing the lesion ○ ‘The lesion on the FOM has a number of possible causes. Some of these are harmless and benign. However, some causes could be more serious and possibly cancerous.’ ○ ‘As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’ ○ ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’

Answer 42

● Introduce self & designation (2 marks) ● Explain that alendronic acid is a bisphosphonate drug (1 mark) ● Explain mode of action of bisphosphonate drugs ○ Bisphosphonates drugs reduce the turnover of bone (1 mark) ○ Bisphosphonates accumulate in sites of high bone turnover = jaw (1 mark) ● Explanation of relevance of bisphosphonates to dentistry ○ There is a risk of poor wound healing following a tooth extraction (1 mark) ○ Need to remove any teeth of poor prognosis prior to beginning drug therapy (1 mark) ○ Important to do everything possible to prevent further tooth loss in the future (1 mark) ○ Reduced turnover of bone and reduced vascularity can lead to death of bone - osteonecrosis (1) ● Specifically name ‘MRONJ’ (1 mark) ● Risk of MRONJ in Osteoporosis - Low risk (1 mark)

Answer 43

- Molars - Mandible > maxilla - Smoking due to reduced blood supply - Females > males - Oral contraceptive pill - Excessive trauma during XLA - Excessive mouth rinsing post XLA - Family history

Answer 44

- Reassurance - Optimal analgesia recommendation = ibuprofen 400mg 4x daily (max 2.4g) or paracetamol 1g 4x daily (max 4g) - Avoid smoking - Maintain good OH - Irrigation of socket with saline to flush out debris - Curettage/debridement - Encourage bleeding/new clot formation - Alvogyl (LA and antiseptic/iodine) - Warm salty mouthrinse - Antibiotics ONLY if signs of spreading infection

Answer 45

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

Answer 46

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

Answer 47

○ Soft tissue involvement: simple, compound, comminuted > Fractures involving teeth always expose the periodontium so are always compound > High risk for infection - need for antibiotics ○ Number: single, double, multiple ○ Site: condylar, subcondylar, body, coronoid, angle, ramus, parasymphyseal, symphyseal, alveolar ○ Side: unilateral/bilateral ○ Displacement: displaced, undisplaced ○ Direction: favourable, unfavourable ○ Specific: greenstick (children’s bones bend), pathological

Answer 48

- Pain/tenderness - Lacerations - Bleeding - Swelling - Facial asymmetry - Step deformity - Limitation of movement - Numbness of lower lip/chin

Answer 49

- Lacerations (esp. gingivae) - Bruising/swelling - Occlusal derangement and step deformity - Loose or broken teeth - Anaesthesia or paraesthesia in lower jaw on side of fracture - AOB

Answer 50

- Pull of attached muscles - Angulation and direction of fracture line - Opposing occlusion - Magnitude of force - Mechanism & direction of injury - Soft tissue intact/not intact

Answer 51

○ ‘The jaw joint sits in base of skull and muscles control opening and closing. Now, like any muscle in the body, if overworked they get tired e.g. if you climb a mountain legs are sore for next few days.’ ○ ‘However, as your jaw joint gets used all day everyday like for speaking and eating it never gets a rest. Muscles become inflamed and sore.’ ○ ‘The fact that you’re sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more’ ○ ‘The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw bones and snaps in place’

Answer 52

- Reassurance - Rest the joint - Soft foods/cut into small pieces - Chew on both sides - Avoid chewy foods - Avoid wide opening - Support when yawning - Awareness of grinding - Avoid biting nails/pens - Analgesic advice - Hot/cold compress suggestion - Make soft splint to break nocturnal habits

Answer 53

- Pt details (CHI number, hosp., name, sex, address, D.O.B) - Clinical details of case (pain, HPC, MH) - Provisional diagnosis - Specimen details including site (type of biopsy & details of where taken from)

Answer 54

- fluids from nose - speech changes and nasal voice - difficulty playing wind instruments - problems smoking and using straws - bad taste/odour, halitosis and pus discharge - pain/sinusitis symptoms

Answer 55

- Lacerations - Nasal bleeding/deviation/patency - Step deformity of cheek bone - Facial asymmetry - Numbness of areas supplied by infraorbital nerve (upper lip, lateral nose, lower eyelid) - Periorbital ecchymosis - Subconjunctival haemorrhage - Vision disturbances - Diplopia (double vision) - Eyeball mobility disturbances (ask pt to follow finger)

Answer 56

- Tenderness of zygomatic buttress - Bruising/swelling - Occlusal derangement and step deformities of upper teeth on side of fracture - Lacerations (esp. gingivae) - Loose or broken teeth - Anaesthesia/paraesthesia of teeth in the upper right quadrant + gingivae above incisor/canine

Answer 57

Bleeding into sinus after zygomatic fracture

Answer 58

A: R: 16/26 Adams clasps 0.7 H.S.S.W + 11/21 Southend clasp 0.7 H.S.S. A: B: Self-cure PMMA / FABP OJ+3mm

Answer 59

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

Answer 60

A: 13/23 Palatal finger spring + Guard 0.5 H.S.S.W R: 16/26 Adams Clasps 0.7 H.S.S.W + 11/21 Southend Clasp 0.7 H.S.S.W A: B: Self-cure PMMA

Answer 61

A: 13/23 Buccal canine retractor 0.5 H.S.S.W + 0.5mm I.D. tubing R: 16/26 Adams clasps 0.7 H.S.S.W + 11/21 Southend clasp 0.7mm H.S.S.W A: B: Self-cure PMMA

Answer 62

A: Z-spring 0.5 H.S.S.W R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W A: B: Self-cure PMMA / Posterior Bite Plane

Answer 63

A: Midline palatal screw R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W A: Reciprocal Anchorage B: Self-cure PMMA / Posterior bite plane

Answer 64

- Check that the appliance is for the correct patient - Check the appliance matches prescription - Run finger over all surfaces to check for protruding wires and sharp acrylic - Check wirework integrity (if overworked) Fit the appliance: - Check for any blanching or trauma - Check posterior retention ■ Flyovers (first as influence the arrowheads) ■ Arrowheads * Activation - Activate to produce 1mm movement per month: spring formers - Demonstrate to patient insertion and removal - Ask patient to demonstrate insertion and removal - Review: 4-6 weekly

Answer 65

- Will feel big and bulky - Likely to impinge on speech (start reading a book aloud to prevent this by speeding up adjustment of teeth) - May have ‘mild discomfort’ - particularly on teeth being moved (but this is a sign that the appliance is working) - Initial increase in saliva (24-48 hours) - Wear 24 hours/day including meal times - Can remove the appliance to clean with a soft brush after each meal or when taking part in active/contact sport (store in a safe place) - Avoid hard and sticky foods - Be cautious with hot food and drinks as base plate acts as an insulator - Non-compliance will lengthen treatment - Give an emergency contact number – do not wait till next appt. if there is a problem

Answer 66

Lidocaine 2% 1:80,000adr max dosage = 7mg/kg

Answer 67

Articaine 4% 1:100,000 max dosage = 6mg/kg

Answer 68

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

Answer 69

Asthma: - Wheezing, coughing, difficulty exhaling - No skin swelling but may have colour changes - Response to salbutamol Anaphylaxis: - Fast irregular breathing, stridor - Swelling of throat/lips/tongue, hives, itching, redness - No response to salbutamol

Answer 70

Adrenaline 1⁄2 of a 1ml ampule 1:10000 = 500μg IM injection - *Aspirate as can generate arrhythmias - Use Z-track technique to inject into thigh or bicep ○ Spread skin, advance needle in skin 90o , aspirate, inject 30s, pull out, release tension - thigh, hip, deltoid, buttock. ○ Say ‘I would normally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time’

Answer 71

○ Stop what we are doing ○ Apply appropriate PPE ○ Cover spill with disposable paper towels ○ Apply sodium hypochlorite/sodium dichloroisocyanurate – liquid/powder/granules (10,000ppm) ○ Leave for 3-5 minutes, use scoop to take up the gross contamination and put into orange waste ○ Clean with water and general purpose neutral detergent disinfectant wipes

Answer 72

Signs: - Pale - Shaky - Sweaty/clammy - Dizzy & confused - Blurred vision - Loss of consciousness Medication: - Conscious = oral glucose 10-20g or sugary drink - Unconscious = 1mg IM glucagon injection + oral glucose when awake + oxygen 15L/min

Answer 73

- Feeder cup replacing bottle from 6 months > - No feeding at night (no milk overnight in bottle, decreased salivary flow) - No on-demand breastfeeding - No sweetened milk or soy milk - Milk and water between mealtimes - Sugarfree variations of drinks/food/medicines - Safe snack advice (eg cheese, breadsticks, fruit, plain crisps) - Assist with toothbrushing until 7y/o

Answer 74

- Fluoride supplements and varnish - GIC/fissure seal remaining teeth - XLA of carious teeth under GA/sedation/LA

Answer 75

- Fever - Malaise - Lymphadenopathy - Painful vesicles and ulcers on gingiva, lips, tongue, buccal mucosa & palate - Difficulty eating due to pain and discomfort

Answer 76

- Contagious primary infection caused by herpes simplex virus (1 mark) - Self limiting and will disappear in 7-10 days (1 mark) - High carriage rate in population, common in young children and is usually the first exposure a child has to herpes virus (which is also responsible for cold sores & fever blisters) - Most initial infections are subclinical but can present with blisters on the tongue, cheeks, gums, lips & roof of the mouth. After the blisters pop, ulcers will form. - Other symptoms to watch out for are high fever, difficulty swallowing, drooling and swelling. - Also, because the sores make it difficult to eat & drink, dehydration can occur. - Child may or may not develop cold sores in future

Answer 77

○ Push fluid intake (1 mark) ○ Analgesia to control fever/pain (2 marks) ○ Bed rest, take it easy (1 mark) ○ Clean teeth with damp cotton roll or cotton cloth to rub around gums (1 mark) ○ Can use dilute CHX to swab gums (1 mark)

Answer 78

- Facial bruising (punch, slap, pinch marks) - Bruising of ears - Abrasions and lacerations - Burns and bites - Choke or cord marks - Eye injuries - Hair pulling/bald patches - Fractures

Answer 79

- Contusions - Intraoral bruising - Abrasions and lacerations - Burns - Tooth trauma - Frenal injuries

Answer 80

- Delay in seeking help - Story is vague, lacking in detail, changes with each telling - Account not compatible with injury - Parents mood abnormal - Parents behaviour gives cause for concern - Child's appearance and interaction with parent abnormal - Childs story may contradict - History of previous injury - History of violence

Answer 81

- MIH - Fluorosis - Decalcification - Tetracycline - Trauma - Amelogenesis imperfecta - Dentinogenesis imperfecta

Answer 82

- Hypodontia - Trauma causing arrested tooth formation - Ectopic tooth - Dilaceration - Supernumerary blockage

Answer 83

- Microabrasion - Vital external bleaching - Localised composite addition - Comp/porcelain veneer

Answer 84

- Resin bonded bridge - Essix retainer - RPD - Implant (only if >18y/o) - Orthodontic space closure

Answer 85

- 'I can't give any comment as I don't know the full story' - 'I can only offer the treatment that I have suggested currently' - 'Whatever was offered previously will not change was tx is required now' - Explain to parent that it is within their right to complain but they will have to go back to the previous practise and discuss this with dentist - Practise will have a standard complaint procedure if necessary

Answer 86

- Clinical evidence of decay - Diet - MH - SH - Saliva - Plaque control - Fluoride exposure

Answer 87

- Radiographs at monthly intervals - Diet advice - Toothbrushing instruction - High fluoride toothpaste - Fluoride supplements - Fluoride varnish - Fissure sealants - Sugar free medications

Answer 88

1. Patient name 2. Patient address 3. Patient/Parent contact numbers (landline and mobile) 4. Patient medical history 5. Patient GP details 6. Parental responsibility 7. Justification for GA 8. Proposed treatment plan 9. Previous treatment details ■ Letter must include: ■ Recent radiographs or if not available an explanation of why (e.g. pt uncooperative)

Answer 89

Reassurance - FV is minimally invasive and is painted onto tooth after drying area - Promotes remineralisation (hardening of tooth) and prevents demineralisation (softening) Explanation why: - Clear justification regarding caries - Recommended for all children at least 2x per year - Evidence based recommendation SDCEP Contraindicated in: - Severe asthma pts - Allergy to colophony Instructions - Don't eat/drink for 1 hour - Soft diet for rest of day (no dark coloured food) - Avoid excess fluoride supplements today Fluoride Toxicity - Very small risk - If 5mg/kg --> milk - If 5-15mg/kg --> ipecac syrup, milk and possible referral - If >15mg/kg --> hospital referral

Answer 90

- Rare conditions presenting as an acute form of gum disease that develops faster & more severe than normal - Causes include smoking, stressed and malnourished individuals - Can be made worse by poor OH and high plaque levels - Symptoms = bleeding/painful gums, ulcers, receding gums, bad breath/taste - Managed by plaque removal, CHX mouthwash, OHI, smoking cessation - Antibiotics = Metronidazole 400mg TID 3 days (no alc) - Analgesia

Answer 91

- Young cohort of patients - Usually healthy - Associated with genetic link - Worse in smokers - Rapid disease progression and loss of attachment - Affects 6s and incisors - Pubertal onset typically

Answer 92

- Smoking - Non-compliance from patient - Inability for pt to practise OH effectively (eg hard to reach areas or poor manual dexterity) - Systemic factors: stress, diabetes, pregnancy, malnutrition or poor diet - Difficulty accessing for debridement - Overhangs or poor restoration margins

Answer 93

AVDR Ask = - Ask about abuse in private setting without family members - Non-judgemental language - "everything OK at home? do you feel safe" Validate = - Provide validating messages that remove blame from victim - Show you believe them - Express concern for the patient Document = - Be specific and details - Use patients own words - Name, location, witnesses that the pt mentioned - Describe injuries in detail (take pics if possible) Refer = - To appropriate services - Always offer help

Answer 94

SPIKES Setting Perceptions Information Knowledge Empathy Summary

Answer 95

● Take concerns seriously, answer questions as able: ○ ‘Hello there, what seems to be the problem?’ ○ ‘Can i offer some assistance?’ ● Acknowledge anger ‘I can see that you’re upset and I am sorry that you feel this way.’ ○ This does not accept blame. DO NOT ACCEPT BLAME ● Try to offer practical help: ○ Offer investigation with receptionist and provide feedback to the patient ○ If you can offer another appointment - ‘Do you still have time for us to see you?’ ○ ‘What would like to do, we can work around you?’ ● Making an apology: ○ Be honest ○ Acknowledge the offence ○ Explain how it happened ○ Express remorse: deep guilt, express it! (I am so sorry!) ○ Ensure amends: ‘Is there anything we can do?’ ● If formal complaint requested, advise on NHS complaints procedure ○ Then, if required: a local resolution (payout) ○ If satisfactory: complaint closed ○ If unsatisfactory: healthcare commission or health service ombudsman ● The NHS complaints procedure 1. Acknowledge the complaint and provide the patient with the practice complaint procedure. 2. Inform the dental defence organisation if you require advice. 3. Inform the patient of timescales and stages involved. 4. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3 working days maximum but ideally within 24 hours. 5. Early Resolution 5 working days For issues that are straightforward and easily resolved, requiring little or no investigation. 6. Investigation 20 working days For issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’. 7. Independent External Review Ombudsman For issues that have not been resolved.

Answer 96

● Setting: ○ Sitting down at same level as them ○ Did they bring someone with them? ○ How have they been since you last saw them? ● Perceptions: ○ What does the patient understand has happened up until now? > ‘Are you aware of what we’re here to discuss today?’ > ‘Do you know what the purpose of your biopsy was?’ > ‘Could you explain to me your understanding of things up till now?’ ● Information: ○ Inform patient that you have the results of the biopsy ○ Ask them if they would like you to go through them...they’ll say yes ● Knowledge ○ Give a warning shot > ‘I wish I had better news’ > ‘I’m afraid the news are not good’ .... pause for a bit ○ Give them the knowledge of what you know > ‘The test we have done has shown some abnormalities in the cells’ ...pause… > ‘Mrs Smith I’m afraid to say that you have mouth cancer’ ...then big pause… ○ Let it sink in and let them dictate the pace of the conversation from here > They might want to know loads of info really quickly or they might be in shock > Give them chance to ask questions ● Empathy: ○ Words to the effect of > ‘I am deeply sorry to break this to you’ > ‘I understand you must have lots and lots of questions...do you have anything that comes to mind?’ > ‘Perhaps you would like to bring your husband in with you?’ ● Summary and close: ○ Repeat news ○ Summarise what you’ve told them and the plan for going forward > ‘The good news in all of this is that we’ve acted quickly and will be able to move forward with treatment as soon as possible’ > ‘I’ll be speaking to the surgeons today and they’ll be seeing you in the coming week to discuss treatment’ ○ Offer them a follow-up appointment or phone number for any questions ○ Give written material if available

Answer 97

ASK - Do you smoke? - What do you smoke? - How long for? - How many cigs a day? - Why? ADVISE - Smoking is harmful to general health (CV and resp problems) - Smoking detrimental to oral health (tooth loss, reduced healing ability, staining, perio disease, oral cancer) - Expensive & causes bad breath ASSESS - Are you interested in quitting? - Motivations to quit? - Have you tried in past? - Unsuccessful? Why? ASSIST - Would you like help quitting? - We can refer you to services? - Options: nicotine patches, gum, e-cigs REFER - Refer to local cessation services such as pharmacy, GP and stop smoking groups - 0800848484 - Arrange follow up * Non-judgemental language, clear and understandable advice, good eye contact

Answer 98

STOP and explain to patient that the nurse has injured themself (risks are to nurse NOT pt) Risk of BBV to nurse: - Give examples eg HIV - Estimates of risk (1:3 Hep B, 1:30 Hep C, 1:300 HIV) Explain standard procedure: - Requirement for a source blood sample & clarify this is a UNIVERSAL PROCESS to all pts - Approach this sensitively - Make it clear no pressure on pt Undertake risk questions: - Previous diagnosis of HIV/Hepatitis? - Ever injected drugs? Had sex with a user? - Ever had sex with someone from outside of UK/Europe? - Ever had a blood transfusion done in another country? - Ever had dental treatment in another country? Which one? - Any tattoos by unlicensed people? Gain verbal and written consent

Answer 99

Class I = bilateral free end saddle Class II = unilateral free end saddle Class III = unilateral bounded saddle Class IV = anterior bounded saddle that crosses midline

Answer 100

Class 1 = tooth borne/supported Class 2 = mucosa borne/supported Class 3 = tooth and mucosa borne (eg free end saddle)

Answer 101

Resistance of a denture to occlusally directed load - eg rests

Answer 102

Resistance of a denture to vertical displacement/lifting away from the tissues - eg clasps

Answer 103

CoCr = 0.25mm Gold (Au) = 0.5mm Stainless Steel = 0.75mm

Answer 104

- Anterior palatal strap - Mid-palatal strap - Horseshoe - Full palatal coverage

Answer 105

High Smile Line ■ Why: Allows waxing of teeth in correct height and alignment (not showing too much gum) ■ How: Getting the patient to smile and marking lip level Centre Line/Midline ■ Why: To orientate central incisors making the block symmetrical ■ How: Using nose septum or using existing lower/upper anteriors Canine Line ■ Why: To set canine position & also provide size measurements for tooth selection ■ How: Measured using vertical line from inner canthus of the eye

Answer 106

- Ala-tragus line - Interpupillary line

Answer 107

Faults with metal framework: - Error in casting = CoCr bubbles making surface rough - Error in design = too close to gingival margin, undercuts not blocked out Faults with prescription between drawing and writing: - eg rests missing/clasps on wrong teeth/wrong connector No labial relief Teeth wrong size/shade

Answer 108

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

Answer 109

Any part of denture that is directly opposite a clasp arm Resists lateral movement of teeth from forces of clasps/retentive component

Answer 110

The resistance to lateral movements

Answer 111

- Underextension into sulcus/at tuberosities - Base plate too thick/thin - Tooth position wrong - Denture fractures

Answer 112

Replacement of a denture fitting surface: - Note of caution = reline is satisfactory for a mandibular denture but will increase thickness of maxillary denture (heavier and less retentive) - Use low viscosity light body PVS

Answer 113

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

Answer 114

- thin, under-extended and/or absent flanges - previous repairs - stress concentrators eg midline diastema - poor fit - lack of adequate relief

Answer 115

- Inclusion of a metal plate

Answer 116

Midline fracture: - secure 2 fragments together with sticky wax & additional reinforcement and sent to lab for addition of light cured PMMA Multiple fragments - May not be possible, may have to remake

Answer 117

○ Check all the occlusal relationships are acceptable and appropriate ○ Remove undercuts from dentures fitting surface using acrylic bur ○ Adjust border for under/over extension with green stick ○ Apply adhesive to fitting surface of the denture to be refined ○ Insert impression material (light body PVS) into the fitting surface and seat the denture ○ Functional impression: ask the patient to bite together so the impression is taken in OVD ○ Take a lower impression with denture in situ (gold standard but may not be required) ○ Take a bite registration if OVD is not obvious ○ When set remove the impression and send the denture for reline: ■ Please pour impression in 100% dental stone using denture impression provided. Please mount upper to cast and create a self cure PMMA reline to change the impression surface.

Answer 118

1. Reference points representing the Frankfort plane: a. External auditory meatus (EAM) b. Anterior reference point 43mm from incisal edge of lateral incisor (12/22) marked on patient 2. Attach transfer jig to the bow and tighten score ensuring numbers facing operator 3. Apply bite reg medium (wax/PVS) onto bite form and register maxilla bite 4. Once bite is recorded and accurate attach bite fork to transfer jig through hole next to no.2 on jig 5. Position the bow earbuds into EAM - pull upwards and make sure bow is centred and tighten the screw 6. Slide bow and jig up and down to align with reference point of the infra-orbital foramen on the cheek below then eye and then tighten screw 1 and then 2 7. Unscrew transfer jig from bow and then unscrew bows centre wheel and remove from patients ears 8. Remove from patient's mouth and disinfect for sending to the lab

Answer 119

x2 putty index - 1 for provisional (do not section) - 1 for reduction determination (section along long axis) Using a chamfer bur - Create 3 notches on buccal surface, each just below 0.5mm in to tooth tissue. Ensure the tooth is cut in two planes as for crown prep - Connect the notches with the chamfer bur Reduce the incisal edge, ideally around 1mm (0.75-1.5mm) Bevel the incisal edge (3 different planes total) Use a smooth composite finishing rugby ball bur to finish

Answer 120

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

Answer 121

- Metal post - MCC - Gold restorations - Zirconia

Answer 122

Dual cure composite: - fibre post - composite/porcelain restorations - veneers

Answer 123

Anaerobic Cure Composite: - Adhesive bridge

Answer 124

Check on the cast: - Correct restoration? - Rocking? - Check contact points - Marginal integrity - Are natural teeth still contacting Remove indirect from cast: - Check thickness

Answer 125

- excess cement removed - no space around margins - interprox contact points exists but are clear (can floss) - check occlusion with articulating paper - confirm pt is happy

Answer 126

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

Answer 127

Talk about getting them dentally fit, improving their oral hygiene & looking after their oral health. ○ Chemotherapy puts a toll on the entire body, including the mouth ○ GDP attempt to reduce complications in chemotherapy regime ■ avoid unscheduled interruption of chemotherapy regimen ■ remove potential sources of infection ■ avoid exacerbation of mucositis ○ Finally, plan prevention and rehabilitation

Answer 128

General: - avoid smoking, spirits, spicy foots, tea, coffee Topical: - oral cooling therapy (ice) - topical lignocaine - saline - sodium bicarbonate - benzydamine spray - gelclair

Answer 129

○ Maintenance of oral and dental health ○ Prevention: diet, OH, fluoride ○ Monitoring: increased frequency check-ups, pros maintenance ○ MRONJ risk ○ Altered taste ○ Dry mouth: > Decreased salivary flow: 50-60% in first week, further 20% in next 5-6 weeks > Change in saliva consistency and character: increased viscosity, decreased pH > Change in taste perception > Recovery over period of years, will not return to normal > Associated problems: dysphagia, dysarthria, dyspepsia, quality of life > Increased risk of: caries, perio, candidiasis, sialadenitis, prosthodontics difficulties