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BDS3 > Paper 2: CP (Endo, Perio, Cons, Paeds, OS) > Flashcards

Paper 2: CP (Endo, Perio, Cons, Paeds, OS) Flashcards

1
Q

Aetiology of pulpal and periradiuclar disease

A

Bacterial entry towards/into pulp/RC due to

  • caries
  • cracks
  • trauma
  • resorption
  • Perio problems
  • microleakage
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2
Q

Compare the changes in pulp seen as bacteria penetrate and the Tx options

A

Insignificant changes; bacteria within 1.1mm pulp

  • reversible
  • Tx: remove caries, appropriate restoration

Irreversible damage; bacteria within 0.5mm pulp

  • pulp inflamed, areas of necrosis and abscess
  • Tx: RCT (pt compliance?)/XLA
  • eventually -> pulp death + periradiuclar radiolucency
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3
Q

Discuss the distribution of bacteria in the RC

A

More bacterial coronal
- why prep. coronal before apical

Coronal: facultative anaerobes
Apical: obligate anaerobes

Within RC NOT in periapical lesion

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4
Q

What is the periapical lesion?

A

Inflammatory lesion
1st line defence to prevent bacteria entering periapical tissue
If becomes chronic bacteria invade tissues

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5
Q

What is apical periodontitis?

A

Periapical tissue response to bacteria threat from RC

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6
Q

Compare acute and chronic apical periodontitis

A

Acute: acute inflammation @ apex
- possibly due to
— response to irritants in healthy periapical tissue
— infection; may develop into 1ry abscess
— acute exacerbation of chronic apical periodontitis
- PMNs restricted to small area = micro-abscess
— if engulf whole periapical area = dento-alveolar abscess

Chronic Apical Periodontitis

  • inflammation @ apex of non-vital tooth = periapical granuloma
  • granulomatous tissue
  • lymphocytes, macrophages, plasma cells
  • non/epithelialised
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7
Q

Compare periapical true and pocket cyst

A

Periapical true cyst

  • distinct pathological cavity completely enclosed by epithelial lining
  • no communication w/ RC

Periapical pocket cyst

  • apical inflammatory cyst
  • sad-like epithelial lined cavity
  • open to and continuous w/ RC; responds to RCT
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8
Q

Compare microorganisms in 1ry and persistent/2ry infections endodontic infections

A

1ry

  • gram+ and - (prevotella, porphyromonas, fusobacterium)
  • polymicrobial

2ry

  • monoinfection
  • gram+, cocci facultative anaerobes
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9
Q

Discuss yeasts and Enterococcus faecalis in relation to endodontic infection

A

Yeasts; C. Albicans most common

  • found in 1ry and persistent infections
  • RF teeth w/ therapy resistant periapical lesions(retreatment)

Enterococcus faecalis

  • gram+, extra-oral bacteria
  • found in 1ry infection
  • predominant species in RF teeth w/ unsuccessful outcome
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10
Q

Ecology of RC

A 
Warm, moist
Nutritious 
Anaerobic 
Largely protected form host defences 
Bacteria can communicate w/ each other 
Produce virulence factors -> tissue damage
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11
Q

Discuss bacterial survival in RC

A

Planktonic state

  • free floating; not attached to surface
  • single cell or clumped

Biofilms
- community of microorganisms + EC polymer attached to surface
- resist treatment
— exopolysaccharide (bacteria embedded in) resist diffusion antimicrobial
— different cell layers may act as barrier to diffusion
— lay dormant, more resistant to killing
— specific resistance mechanisms

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12
Q

Mechanical methods of diagnosing periapical disease

A 
Palpation: compare contralateral, -ve doesn’t mean no inflammation 
Percussion
Periodontal probing
- narrow pocket
— tooth #
— RC infection draining creating sinus tract 
Tooth slooth 
Transillumination
Dentine sensitivity
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13
Q

Possible differential diagnoses for percussion+

A 
Infected pulp 
O trauma 
Sinusitis 
Cuspal #
PD disease
Apical inflammation
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14
Q

4 soft tissue changes seen in pulpal disease

A

Reversible pulpitis
Irreversible pulpitis
Hyperplastic pulp
Pulp necrosis

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15
Q

Discuss reversible pulpitis

A

Possibly due to

  • caries
  • erosion, attrition, abrasion
  • operative procedure
  • mild trauma
  • scalding

Symptoms

  • transient pain
  • ceases when stimuli removed
  • TTP-

X-ray: normal periradiuclar appearance

Tx

  • cover exposed dentine
  • remove stimulus
  • remove stimulus + dress tooth
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16
Q

Discuss irreversible pulpitis

A 
Due to severe insult on pulp 
Symptoms 
- severe, spontaneous pain
- lingers; min-hr 
- Exacerbated: hot liquids; Relieved: cold
- PDL involved, pain becomes localised

X-ray: normal periradiuclar appearance; late stage PDL widened

Tx: RCT/XLA

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17
Q

Discuss hyperplastic pulp and pulp necrosis

A

Hyperplastic pulp

  • form of irreversible pulpitis called pulp polyp
  • proliferation of chronically inflamed young pulp tissue
  • Tx: RCT/XLA

Pulp necrosis

  • end of irreversible pulpitis
  • Tx: RCT/XLA
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18
Q

Hard tissue changes seen in pulpal disease

A

Pulp calcification

Internal resorption

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19
Q

Discuss pulp calcification

A

Physiological 2ry dentine continually deposited post- tooth eruption and root formation
Deposited on pulp chamber floor and ceiling, not walls
W/ T occludes pulp chamber

3ry dentine deposited in response to stimuli

  • reactionary: mild
  • reparative: string noxious; rapid, irregular, cellular inclusion
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20
Q

Discuss internal resorption

A

Pulp inflammation may result in resorption of dentine by dentinoclasts

Clinically: pink spot
X-ray: punched out lesion continuous w/ rest of pulp cavity

Tx: RCT, XLA (if lesion too advanced)

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21
Q

Compare cracked tooth in non/vital teeth

A 
Vital
- pain
— sharp on biting/release, occasionally from cold
— difficult to localise 
- Ix: tooth slooth, staining, transillumination
- L6-8, esp. 6
- Tx: ortho/Cu band/temp. crown
— progress to cusp coverage restoration

Non-Vital

  • pain: dull ache on biting
  • Ix: TTP, narrow Perio pocket adjacent to #
  • X-ray: halo, J shaped diffuse lesion around root
  • Tx: XLA, consider hemisection
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22
Q

Possible Tx options for reversible pulp damage

A

Indirect pulp capping (stepwise)

  • infected softened dentine removed
  • layer non-infected dentine left over pulp
  • Ca(OH)2 placed, restore
  • 6/12 later remove softened dentine, place Ca(OH)2, restore
Direct pulp capping
- pulp exposed through non-infected dentine
— no recent history spontaneous pain 
- Ca(OH)2/MTA placed
- bacteria tight seal
- 12/12 check X-ray + sensibility
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23
Q

Discuss treatment options when pulp damage is irreversible

A 
Pulp amputation
- remove part of exposed inflamed pulp; remaining pulp tissue preserved 
- superficial damage: partial pulpotomy 
- coronal damage: coronal pulpotomy
-
Pulpectomy 
- total pulp removal followed by RCT
- indicated when
— pulp irreversibly damaged
— pulp cavity req. for retention
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24
Q

Contra/indications for RCT

A

Indications
- functionally and aesthetically important w/ reasonable prognosis
- irreversibly damaged/necrotic pulp
— w/ or w/o clinical/X-ray finding of apical periodontitis
- elective devitalisation
- dubious pulp prognosis prior to preparation

Contraindications 
- can’t be made functional or restored 
- insufficient PD support
- poor prognosis: extensive restoration, vertical #s
- pt
— poor OH; unable to rectify in time
— uncooperative 
— limited opening 
- complex anatomy: dens in dente
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25
Q

General success rates for RCT

A

1ry: 85-95%
Re-RCT: 77-80%

Flare ups: mild discomfort - severe pain + swelling post-treatment

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26
Q

Function of posts in RF teeth

A

Retention

Do not strengthen roots

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27
Q

3 aims of RCT

A

Remove + destroy microorganisms from RC system
Prevent bacterial re-entry from coronal by sealing RC
Allow body to heal

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28
Q

What is importance of the coronal seal of RCT?

A

Aim of RCT is to remove all bacteria from RC system

Important, common cause of failure is coronal leakage thus need to have good seal to prevent bacteria ingress

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29
Q

How to prevent coronal leakage during and after RCT

A 
During
- RD; only TIQ
- remove caries
- interim restoration 
— IRM, GI, Am
— Cu/ortho band; esp. molar as likely to #
After
- coronal aspect RF protected
— 2mm of IRM/Am/comp
— GIC if 3+wks
- sound coronal restoration
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30
Q

Burs req. for RCT

A

Tapered Diamond
Safe Ended Diamond/T
- round ended; won’t over prep/damage
- remove excess around canal orifice
- smooth cavity walls after reaching depth + shape
Goose Neck: long shank, excavate undercuts
LN: v fine

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31
Q

What is the DG16?

A

Instrument used in RCT
Has 16mm shank
Used to explore canal orifice pre-op

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32
Q

Discuss rotary files used in RCT

A

ProTaper SX Shaping File

  • NiTi
  • use: shape coronal 1-2/3
  • shorter (cf other ProTaper); 19mm
  • D0 = 0.19mm; 9 rapidly inc. % tapers
  • diameters ~= GG
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33
Q

3 main hand files used in RCT

A

Hedstrom
Flexofile
K-flex

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34
Q

Standards for SS hand files

A

Lengths: 21/25/31mm
Cutting length: 16mm
Taper: 0.02 (2%)

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35
Q

Define helical angle and pitch (hand files)

A

Helical angle: angle of cutting flutes to long axis of file

Pitch: cutting flutes/mm

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36
Q

Compare Flexofile and K-flex files

A 
Flexofile
- twisted SS
- flexible, non-cutting tip
- 45 degree helical angle
- cross-section changes between sizes
— rectangle; 6-10
— triangle; 15-40
— rectangle; 45+
- rotational + push-pull filing

K-flex

  • twisted SS
  • rigid (cf Flexofile), cutting tip
  • cross-section: diamond, 2 cutting edges
  • rotational + push-pull filing
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37
Q

Discuss Hedstrom files

A

Machined SS
Tapered intersected cones in spiral
Cross-section: speech bubble/elliptical
Push-pull filing only

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38
Q

Principles of safe RC irrigation

A

Never bind: move needle in + out slowly
Side venting needle: prevent pushing through apex
Never inject
Slowly: finger pressure

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39
Q

4 commonly used irrigants for RCT

A

Sodium hypochlorite
Chlorhexidine
EDTA
Aqueous Iodine

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40
Q

Discuss NaOCl

A

Gold standard
Antibacterial
Dissolves organic tissue remnants
Usually used 2.5%: 0.5-5.25%

Accident

  • severe pain
  • swelling
  • extreme blanching
  • bloody exudate

Tx

  • irrigate w/ sterile H2O
  • reassure
  • immediate referral to maxfax
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41
Q

Discuss the other irrigants used in RCT

A

Chlorhexidine

  • 0.2-2%
  • antibacterial
  • doesn’t dissolve organic tissue
  • don’t use w/ NaOCl

EDTA 17%

  • removes smear layer
  • helps in sclerosed roots
  • alternate w/ NaOCl; deeper penetration of antibacterial

Aqueous Iodine

  • use: therapy resistant cases
  • effective against broad spectrum bacteria
  • flush w/ NaOCl remove brown staining
  • possible allergic reaction
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42
Q

In 2 appointment RCT what is the procedure for temporarily sealing RC?

A

Dry canal w/ paper points held in tweezers
Place non-setting Ca(OH)2 in RC
Place cotton pledget or grey cavit G over orifice
IRM/Fuji IX interim dressing
Easily removed 1-2wks later w/ H2O/NaOCl, agitate w/ files

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43
Q

Discuss the movement of hand files in RCT

A

Rotational: watch winding

  • place passively into canal
  • rotate clockwise until lightly engage dentine
  • pullback, rotate anti-clockwise
  • passively into canal again; repeat

Negotiate canals gently
Regularly clean flutes of instruments

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44
Q

Principles of RCT access cavity

A

Remove all pulp chamber contents
SLA to all RCs
Allow inspection of pulp chamber

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45
Q

RCT procedure sequence

A 
Access: SLA, remove pulp chamber
Pre-op X-ray
- estimated WL (whole length - 1mm)
- tip to pulp roof length 
Explore coronal 1-2/3 w/ 10F
Shape coronal 1-2/3 w/ SX
Explore apical 1/3 w/ 10F
Patency
- 10F; 1.5mm>WL (through apical constriction)
Definitive WL X-ray w/ 15F
- 10F doesn’t show on X-ray 
- stopper in reproducible area
- if >3mm from RA; adjust file + retake 
Prepare apical 1/3
- Serial Step Back
- Step Back
Smooth canal circumferentially 
- 20/25F 1mm from WL
Choose master GP: tugback+, to WL
Midfill X-ray: M.GP + 2-3 accessory points 
- M.GP within 1mm RA
- accessory points 1mm back
Complete obturation
Post-op X-ray
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46
Q

Reasons for establishing patency during RCT

A

Prevent blockage of canal
Check for exudate
Aid irrigant apically
Maintain + follow anatomy

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47
Q

Principles of serial step back and step back

A

Serial Step Back

  • getting apical constriction to MAF
  • 15-20-25F @ WL
  • MAF should be 25 or 30F

Step Back

  • after completing serial step back
  • 30F @ 1mm
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48
Q

Why use crown down approach for RCT?

A 
Necrotic bacteria more coronal; removing stops introducing apically
Achieve SLA
- red. curvature
- improve tactile sensation
- greater vol. irrigant
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49
Q

What is the aim of apical preparation in RCT?

A

Get file slight larger than natural RC to WL

  • ensures optimal cleaning
  • provide resistance form to obturate against
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50
Q

Discuss the desired canal taper in RCT

A

Greater canal taper created by using inc. file tip diameters in incremental step back

Standard taper = 5% (0.05mm D inc. every 1mm)

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51
Q

Reason for using intracanal medicaments?

A

During 2 appointment RCT

Eliminate remaining bacteria after canal instrumentation and irrigation

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52
Q

Examples of intracanal medicaments

A 
Non-setting Ca(OH)2
Steroids: ledermix
ABs
Potassium iodide 
Aldehyde:formacresol
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53
Q

Discuss properties of non-setting Ca(OH)2

A

Antibacterial
High pH
Degraded residual organic tissue
BaSO4 can be added to provide radiopacity

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54
Q

Discuss the problem of flare ups post-RCT and Tx options

A

Range from mild discomfort to severe pain and swelling
Occurs in 3-5% pt post-RCT

Tx range

  • painkillers
  • access and irrigation
  • instrumentation and redressing
  • incision and drainage
  • systemic involvement: ABs
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55
Q

Discuss the problems that may arise w/ incorrect instrumentation during RCT

A

Ledges: irregularity in RC impeding access to apex

  • negotiate w/ precurved 10F
  • create good coronal flare during coronal prep

Blockages: packing of dentine tubules w/ debris

  • copious irrigation
  • small file + light picking motion feeling for stickiness

Perforations: iatrogenic creation of communication b/w RC + bone/PDL

  • if enclosed in bone better prognosis cf one in contact w/ OC
  • repair ASAP
  • GIC or MTA

Separated instrument

  • coronal 1/3: remove
  • mid 1/3: more difficult
  • apical 1/3: impossible
  • bypass separated instruments
  • better prognosis if post-shaping + cleaning
56
Q

4 aims of obturation

A

Prevent microorganisms and toxins percolating into peri-radicular tissue
Seal remaining bacteria in unfavourable environment of RC
Prevent percolation of peri-radicular exudate (nutrient) into RC
Prevent reinfection from coronal

57
Q

Requirements for obturation

A

Tooth asymptomatic
Temp. dressing intact
No sinus present
RC dry

58
Q

Ideal properties of RC filling material

A 
Easily introduced into RC
Dimensionally stable
Seal RC; apically, lat., coronally
Impervious to moisture
Nonirritant (peri-radicular tissue)
Nonstaining
Bacteriostatic
Radiopaque
Removable
Long shelf life
Allow good length control
59
Q

Discuss GP and name other RF materials

A

GP

  • most widely used
  • trans-polyisoprene; isomer of natural rubber
  • biocompatible (latex allergy caution)
  • insoluble
  • can’t be heat sterilised
  • degrades in light

Silver points
Acrylic
Pastes

60
Q

Ideal properties of RC sealer

A 
Satisfy req. of RF material
Good adhesion to canal wall
Fine particle size (easy mix) or 2 paste 
Adequate working T
Expand whilst setting
61
Q

Examples of RC sealers

A

ZOE
Setting Ca(OH)2
Resin
GI

62
Q

Obturation techniques

A 
Lat. condensation; cold + warm
Thermo-mechanical compaction 
Vertical condensation
Thermo-plasticised GP
Carrier based
Barrier
63
Q

Cold lateral condensation technique

A 
Finger spreader loose @ WL
M.GP to WL ideally tugback+
- cut tip, try another, change size
- less accurate cf files
Dry canal w/ paper points
Coat M.GP tip w/ sealer, place to WL
Finger spreader 1mm midfill X-ray 
Continue placing accessory GP until canal full
Sear GP off ~1mm below canal orifice -> post-op X-ray
64
Q

Methods to sear GP

A

Heat carrier + Machtou plugger

System B

65
Q

Discuss system B

A 
RC obturator 
Set on touch not continuous 
200 degrees not higher
Use touch coil to activate heated tip
Use for 3s then remove heat
66
Q

Criteria for RCT post-op assessment

A

Length; same as WL
Condensation quality; voids?
Taper; adequate, even throughout

67
Q

Assessing outcome of RCT

A

Tooth function restored w/ no swelling or sinus tract
Pt asymptomatic
X-ray
- normal peri-radicular tissue
- healing (if was peri-apical lesion @ start)
— poor obturation associated w/ 65% non-healing re-RCT cases

68
Q

Rationale for partial pulpotomy

A

Pulp is usually only inflamed to depth of 2mm

  • remove inflamed/necrotic pulp + leave healthy pulp tissue under
  • allows root formation to continue in immature permanent teeth
69
Q

Partial pulpotomy procedure

A

Remove pulp 2mm apical to exposure w/ HS diamond bur
Control haemorrhage; saline soaked cotton pledget
Cover pulp w/ MTA or non-setting Ca(OH)2
Seal w/ GIC, restore (comp)
Re-evaluate 6-8wk, then, 12/12 monitor vitality and root development

70
Q

What is apexification?

A

Method of inducing formation of calcified barrier @ apex of non-vital teeth w/ incomplete root formation

71
Q

Apexification rationale

A

RCT Tx difficult: wide, funnel shaped canals

Ca(OH)2 dressing results in formation cementum-like hard tissue barrier; aids final obturation

72
Q

Apexification procedure

A

Access
Chemo-mechanical cleansing
- moderate lat. pressure + vertical movements on dentinal wall
- chlorhexidine or 0.5% NaOCl
Fill w/ Ca(OH)2 comoressed w/ cotton pledget
- endure contact w/ vital apical tissue
Repeat 3/12 for 18-24/12
- once apical barrier forms complete obturation

73
Q

If after 2 years an apical barrier does not form after apexification what is the Tx?

A

Use MTA to form artificial apical barrier

74
Q

Aim of pulp therapy in deciduous teeth

A

Maintain vitality of teeth + supporting tissue

Maintain dental arch space for permanent teeth

75
Q

Pulp therapy techniques for deciduous teeth

A

Indirect pulp cap; Ca(OH)2
Pulpotomy
Pulpectomy
Indirect pulp cap; success unreliable, not recommended for carious exposure

76
Q

Difference b/w pulpotomy and pulpectomy

A

Pulpotomy

  • only removes inflamed coronal pulp
  • healthy tissue below saved
  • whole coronal or partial

Pulpectomy: total removal of pulp followed by RCT

77
Q

Contra/indications for pulp therapy in deciduous teeth

A 
Indications 
- general
— medical contraindication for XLA (bleeding)
— cooperative pt
— psychologically advantageous 
- dental
— previous Tx experience (LA)
— regular pt
Contraindications
- general
— medical: cardiac lesion, debilitating illness
— uncooperative 
— -ve attitude pt/parent
- dental
— unrestorable
— bone loss
— several teeth w/ pulp involvement
— acute abscess w/ cellulitis 
— close to exfoliation
78
Q

Aim of pulpotomy

A

Remove inflamed coronal pulp
Preserve remaining radicular pulp
Maintain tooth viability

79
Q

Contraindications for pulpotomy

A 
Uncooperative
Bone loss
Resorption
Irreversible pulp damage/pulpitis
Unrestorable
80
Q

Potential pulpotomy materials

A 
Formocresol (no longer recommended)
Ca(OH)2
Ferric sulphate
Gluteraldehyde 
MTA
81
Q

Discuss ferric sulphate use in pulpotomy

A

Fe2SO4 15.5%
- in contact w/ blood forms ferric ion complex
— mechanically seals blood vessels
- no healing
— preserves vital tissues
— conserves radicular pulp w/o reparative dentine formation
- no systemic effects (formocresol)
- clinical, X-ray, histological outcome similar formocresol

82
Q

For deciduous teeth what is the best medicament?

A

Ferric sulphate: 86% 2yr success rate

MTA has better clinical + radiographic outcome but too expensive currently

83
Q

Aim of pulpectomy

A

Remove irreversibly inflamed/necrotic radicular pulp
Clean RC
Obturate RC w/ filling material that resorts @ same rate as 1ry tooth

84
Q

Indications for pulpectomy

A

Cooperative
Irreversible pulpitis: symptoms and/or clinical finding
Non-vital radicular pulp w/ or w/o associated infection

85
Q

Discuss the verbal and non-verbal communication aids in paeds

A 
Verbal
- honesty: tell how it may feel
- empathy, support
- voice control: tone, pitch, speed
- age appropriate 
— simple, soft, non-threatening
— tell what to do and when
Non-Verbal
- body language: open, engaged
- height and position
— eye level
— in front of pt
- pre-appt info
- preparatory video/pictures
- child waiting area: posters @ eye level
86
Q

What are the aims of the parent-child-operator triangle?

A

Build trust in parent and patient
Build compliance
Foster +ve dental attitudes and behaviours

87
Q

Dynamics in the parent-child-operator triangle

A

Parental involvement
- physical support
- discuss + obtain consent: Tx, holding still
Advocate for child
Respect autonomy
- agree stop signal together
- give choice where possible: L or R filling today?

88
Q

Define anxiety and give different types seen in children

A

Anxiety: general feeling of unease; nervousness, uncertainty, worry

Types

  • maternal
  • personality trait: consistent personality attribute
  • state: specific situation
89
Q

Factors affecting anxiety in children

A

Age; pre-cooperative?
Separation anxiety: infancy to 4/5yrs
Coping ability generally inc. w/ age but anxiety may too

Learning disability: low coping ability
Communication disability: selective mutism
Sensory: visual, hearing
Emotional: behavioural

90
Q

9 possible non-pharmacological behaviour management strategies for children

A 
Graded Experience
Acclimatisation 
Tell Show Do
Behaviour Shaping
Modelling 
\+ve/-ve Reinforcement
Distraction 
Desensitisation
91
Q

Discuss graded experience and acclimatisation

A

Graded Experience

  • gradual introduction to dental surgery
  • non-threatening/invasive procedures first

Acclimatisation

  • repeat simple interventions
  • build familiarity
    • new produces 1 at a time
92
Q

Discuss behaviour shaping and modelling

A

Behaviour Shaping

  • hierarchical exposure to dentist
  • reinforce desired behaviour, progress towards
  • feedback: +ve, timely, specific
  • if -ve response; show empathy, return to previous stimulus

Modelling

  • direct observation of pt w/ consent or video demo
  • model is similar age for similar procedure
  • show entering + leaving; emphasise +ve outcome
93
Q

Discuss +ve and -ve reinforcement

A

+ve
- identify desired behaviour + comment on it
- shaping behaviour through appropriately timed feedback
— stickers, colour sheets, bravery certificate, reward chart
- ignore -ve behaviour

  • ve
  • shaping behaviour through removal of stimulus
  • remove parents until demonstrate desired behaviour
94
Q

Discuss distraction and desensitisation

A

Distraction

  • diversionary tactics to dec. perception of unpleasantness
  • visual: video/pics, props
  • auditory: tell story, music
  • motor: hold cotton wool roll, counting

Desensitisation

  • mild exposure to anxiety provoking stimulus until no longer fearful
  • build towards coping w/ procedure
  • 3-in-1 alone, then light press -> full press
95
Q

Distinguish b/w growth and development

A

Growth: anatomical phenomenon; inc. size/no

  • hyperplasia
  • hypertrophy
  • secretion of ECM

Development: physiological phenomenon; inc. complexity

96
Q

Distinguish b/w two types of ossification

A

Intramembranous
- new cells form on periosteum -> secretion of ECM -> mineralisation -> new layer of bone

Endochodrial

  • replacement of cartilage w/ bone
  • begins in and spreads out from 1ry ossification centre
97
Q

What bones make up the cranial vault?

A

Frontal
Parietal
Squamous part of temporal
Occipital

98
Q

What are the bones in the cranial vault separated by?

A

Sutures

At birth these are fontanelles

99
Q

Describe growth of cranial vault

A

Intramemebraneous ossification
- apposition @ sutures and exterior
- resorption @ interior
Growth @ sutures

100
Q

What bones make up the cranial base?

A

Sphenoid
Ethmoid
Petrous part of temporal
Basioccipital

101
Q

Discuss growth of cranial base

A

Endochondrial ossification
- prior to ossification 1ry cartilaginous chondrocranium
Spheno-occipital synchondrosis; affects ant.-post. relation of jaw
Some surface remodelling

102
Q

Discuss growth of maxilla

A

Intramembranous ossification
Growth @ sutures that connect maxilla to cranial base
- craniomaxillary: downward + forward displacement of facial skeleton
- saggital: inc. width of maxilla
Surface remodelling

103
Q

Discuss growth of mandible

A

Intramembranous ossification
Endochondrial @ condyles: elongation in forward + downward direction
Surface remodelling

104
Q

Compare sites of bone deposition and resorption in the mandible

A

Deposition

  • Outer surface of body
  • Post. ramus
  • Chin
  • Condylar cartilage

Resorption

  • ant.-inf. aspect condyle
  • labial roots L incisors
  • ant. border ramus
  • inner aspect mandible
105
Q

Discuss growth rotations of mandible

A

Forward

  • red. lower ant. facial height (short face)
  • inc. overbite
  • space closure difficult

Backward

  • inc. LAFH (long face)
  • red. overbite
  • space closure easier
106
Q

Define conscious sedation

A

SDCEP 2017
Technique in which drug/s produce state of depression of CNS enabling Tx to be carried out but during which verbal contact w/ pt is maintained
Drugs used in dentistry should carry margin of safety wide enough to render loss of consciousness unlikely

107
Q

Aims of sedation for child and dentist

A

Child

  • prevent/red. fear, anxiety, pain
  • facilitate cooperation
  • promote +ve attitude + response to Tx

Dentist

  • facilitate safe provision and completion of quality care by min. disruptive behaviour
  • leave child fir for safe discharge @ end of Tx
108
Q

List agents used for conscious sedation in density

A

Inhalation: nitrous oxide, O2 (1st choice <12yrs)
Oral: benzodiazepines; midazolam
Transmucosal (nasal, sublingual): benzodiazepines
IV: benzodiazepines

109
Q

Discuss ideal properties of sedative agent

A

Comfortable, non-threatening administration
Rapid onset
Predictable anxiolytic and sedative action
Controllable duration
Analgesic
No side effects
Rapid, complete recovery

110
Q

Dis/advantages of NOx

A

Adv

  • colourless, sweet smelling
  • anxiolysis, mild analgesia
  • hypnosis, euphoria
  • non-irritant to mucosa
  • low blood gas solubility; rapid induction + recovery
  • weak: MAC 105%
  • minimal metabolised (<0.01%)
  • haemodynamic stability
  • flexible depth + duration
Disadv
- side effects: nausea, headache, unconsciousness 
- toxicity (long term)
— B12 deficiency, anaemia
— bone marrow suppression 
— inc. risk miscarriage 
- greenhouse gas
- cost
- space for equipment
- req. good rapport
- administration route near operating site
111
Q

Indications for NOx sedation

A 
Dental anxiety 
Long / traumatic procedure
Gag reflex
Medically compromised
- high risk for GA
112
Q

Contraindications for NOx sedation

A 
Pre-cooperative
Language barrier
Refusal 
Nasal obstruction/congestion 
Inc. intracranial pressure 
Respiratory infection
- restricted airflow
- coughing
COPD
- red. ventilation + gaseous exchange

Ear/eye surgery: rapidly fills air-filled cavity -> inc. pressure = pain
Immunocompromised: bone marrow suppression
Multiple sclerosis: exacerbates
Bleomycin chemotherapy
- anti-neoplastic AB used in lymphoma Tx
- risk lung damage -> pulmonary fibrosis

113
Q

Signs and symptoms of conscious sedation

A 
Signs
- slight inc. BP + HR
- peripheral vasodilation
— flushing of extremities, face
- red. muscle tone as anxiety red. 
- normal, smooth respiration

Symptoms

  • lightness of extremities
  • lightheadedness/dizziness
  • wave of warmth
  • tingling in H+F
  • analgesia: numbness mouth, H+F
  • euphoria
114
Q

Signs of over sedation

A 
Persistent mouth closing
Spontaneous mouth breathing 
Red. cooperative
Laughing, crying, giddiness
Feeling of unpleasantness 
Nausea/vomit, headaches
Sluggish/irrational response 
Incoherence
115
Q

Contra/indications for GA

A

Indications

  • pre-cooperative
  • uncooperative (SCD)
  • pain and/or infection can’t be managed by other means
  • severe anxiety: can’t cope under LA/IHS
  • multiple XLA in 2/+ quadrant
  • complex Tx: surgical XLA/drainage, biopsy
  • allergy to LA
Contraindication 
- significant comorbidity 
— complex cardiac problem 
— neuromuscular disorder: muscular dystrophy 
- allergy to GA drugs
116
Q

Discuss the considerations that must be taken when Tx planning for child GA

A

All Tx carried out under 1 GA
Consider MH
Use pre-op X-rays
Restorative Tx considered; SCD, permanent molars
Prevention advice must be given
XLA 6s: seek ortho opinion
Avoid repeat: teeth usually deemed restorable are XLA’d

117
Q

Define periodontitis

A

An infectious disease resulting in inflammation within the supporting tissues of teeth, progressive attachment and bone loss; characterised by pocket formation and/or gingival recession

118
Q

Typical signs of periodontitis

A 
Gingival inflammation 
BOP
PD pocket
CAL
Alveolar bone loss/resorption 
Tooth mobility, teeth drifting
Gingival recession/enlargement 
Tooth loss
119
Q

On IO exam what is important to assess for PD condition?

A 
Soft tissues
OH
Gingival tissues/bio-type
Occlusion 
PD parameters 
Restorative problems + needs
120
Q

What are the gingival bio-types?

A

Thick flat -> thick scalloped -> thin scalloped

121
Q

What are the PD parameters used to assess PD health?

A 
PPD
CAL
Furcation involvement
- Class 1: <3mm
- Class 2: >3mm but not through-through 
- Class 3: through and through 
Tooth Mobility
- Grade 1: <1mm horizontal
- Grade 2: >1/<2mm horizontal 
- Grade 3: >2mm horizontal or vertical 
Recession
Plaque
Bleeding
Suppuration
122
Q

Discuss chronic periodontitis

A 
Most prevalent in adults (can occur in children)
Host factors determine progression 
- usually slow->moderate rate
- periods of rapid destruction can occur
CAL = plaque levels

Systemic factors: DM, HIV
Local factors: tooth, iatrogenic

123
Q

Discuss general features of aggressive periodontitis and compare localised and generalised aggressive periodontitis

A 
General
- healthy 
- familial aggregation 
- rapid rate of progression
— may be self-arresting 
- plaque deposits inconsistent w/ severity 
- neutrophil function abnormalities

Localised

  • early onset
  • 6s and 1s
  • freq. A.a. detection
  • robust serum Ab response

Generalised

  • usually <30y
  • 3 other teeth than 6s/1s
  • freq. A.a. and P.gingivalis detection
  • poor serum Ab response
124
Q

What is considered PD stability?

A

BOP <10%
PPD <4mm
Mobility

125
Q

Differentiate b/w ideal and normal occlusion

A

Ideal: based on morphology of unworn teeth
Normal: minor irregularities in individual teeth but satisfies req. aesthetics + function

126
Q

Discuss dentition at birth

A

Usually no teeth
Dental arches represented by gum pads
- U: wider, longer
Elevated segments = un-erupted teeth

127
Q

Discuss timing of deciduous dentition and features

A

Timing

  • calcification: 4-6/12 +/- 6/12 in utero
  • eruption begins: L1s 6/12
  • established: 2.5y
Features
- incisors spaces
- primate spacing
— 2mm space
— U: M Cs 
— L: D Cs
- flush terminal plane
— long axis Es flat
— guides 6s in
128
Q

Discuss development of permanent incisors

A

Develop P/L to A+Bs
Eruption
- L: 6y
- U: 7y

Inc. width accommodation

  • pre-existing space
  • proclination
  • growth: inc. inter-canine width
129
Q

What is the leeway space?

A

Feature of permanent 3-5s
Different in M-D width of 3, 4, 5s cf c, d, es
- L: 2mm/quadrant
- U: 1mm/quadrant

130
Q

Discuss development of permanent molars

A

6s guided into 1/2 unit class 2 occlusion by flush terminal plane of Es
Once Es exfoliate
- 6s drift ant. closing leeway space
- > space on L = Class 1 occlusion

131
Q

Main non-surgical PD therapy

A 
OHI
Smoking cessation 
Remove plaque retentive factors
XLA hopeless teeth
SP, RSD
Adjunctive therapy if necessary
132
Q

Ideal outcomes of PD Tx

A

Red. PD: 1-2mm
Red. CAL: 0.5-1mm
Red. P+B: <20%

Behavioural change: brush teeth, floss etc
Systemic health
- glycemic control (DM)
- CVD
Improved: long term prognosis + QoL
- bleeding
- halitosis 
- aesthetics
133
Q

What is perio adjunct therapy?

A

Use of medications or devices in addition to nonsurgical PD Tx in order to supplement its efficacy

134
Q

Rationale for use of antimicrobials for PD adjunct therapy

A

Bacterial aetiology of perio
Pathogens can invade tissues not reached w/ SP/RSD
Pathogens can inhabit oral niches not reached w/ SP/RSD

135
Q

Disadvantages to antimicrobial adjunctive perio therapy

A

Plaque 50-300 layers thick, bacteria embedded in glycoside
- survive [AB 500-1000x]> than normally found in circulation
Systemic effects
Microbial resistance

136
Q

Dis/advantages of local AB perio adjunctive therapy

A

Adv

  • high dose directly on site req.
  • red. side effects;
  • assured compliance

Disadv

  • doubtful substantivity
  • AB resistance
137
Q

Important considerations when deciding whether to use antimicrobial perio adjunctive therapy

A

Improved clinical outcome when used w/ NSPT

  • additional CA gain 0.2mm
  • additional PD red. 0.4mm

Most effective in severe cases

May red. cost
Mild adverse effects; mainly gastrointestinal

AB resistance
- use assessed carefully!

BDS3 (4 decks)

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