Past Papers Flashcards
Cheek bone fracture
Diagnosis: right cheek bone fracture
E/O exam:
Palpation of zygoma
Examination of eye
Examination of sensation of infra-orbital area
I/O features:
Tenderness of the buttress of the zygoma bone
Bruising, swelling, haematoma
Occlusal derangement
Anaesthesia/paraesthesia of teeth ULQ
Radiographs: Occipito-mental views or CBCT or CT
Radiograph identification: fracture of the cheek bone, radio-opacity of the sinus
Management:
Urgent OMFS phone referral
(A&E also acceptable)
Surgical management:
ORIF - Open reduction Internal Fixation
Unrestorable 26 but patient is on warfarin
Ask about the patients coagulation status:
When was INR last done and what was it’s value
Ask to see patients INR book
Explain why tooth cannot be extracted today (without jargon) because there is a high bleeding risk and the INR values are above what guidelines suggest are recommended values for safe extractions
Refer to SDCEP guidelines: ideally measured in last 24hrs, if not, last 72 if stable (INR <4 for last 3 months)
Do not extract the tooth
Deal with pain: analgesia +/- pulp extirpation + sedative dressing
Ask if patient understands and have any questions
BBV sharps injury
● Explain nature of injury sustained by dental nurse to pt
○ Risks are to nurse & not pt
● Explanation of risks from BB to dental nurse
○ Risks of transmission of a BBV (giving examples e.g. HIV) to the dental nurse,
including estimate of risk (low) based on the type of injury, explained in detail
● Explanation of standard procedure for managing sharps injuries which is applied to all
patients
○ Explanation of requirement for a source blood sample and clarity that this is a
universal process applied to ALL patients
● Explanation that there is no pressure on the pt to comply with the request to provide a blood
sample for source pt testing
○ Approach the request for a blood sample from the pt sensitively and professionally,
making it clear that there is no pressure on the pt to agree
● Undertake review of medical history
○ Covered all issues relating to BBV risk
● Consent:
○ Establishes pt understands options/gives opportunities to ask questions
○ Confirms patient’s decision
8yr old (clinical picture) EDP fracture
EDP# - 8 yr old
● Explain nature of injury
○ Enamel dentine pulp fracture or complicated pulp fracture
○ Simple explanation parent can understand
● Explain treatment : PULPOTOMY (open apex)
○ As this is a large exposure the tx of choice is called a pulpotomy
○ Explain partial removal of pulp
○ Explain that aim is to keep undamaged pulp tissue alive
○ Explain that this is so the tooth stays alive and continues to grow
● Baseline sensibility tests
○ Tests required to see how the nerve in the injured and adjacent teeth respond
○ This is with a view to long term monitoring
● LA required
○ Parent informed that LA is required
○ Why LA is required
○ That LA involves injection in the gum
● Dental Dam
○ What this is - latex/nitrile sheet acts like mask
○ Why dam is placed - moisture control, protects airway
○ All explained in language the parent understands
● Drilling/use of handpiece
○ Drill will be used to remove some pulp tissue
○ Aim is to leave only good tissue
● Dressing
○ Indicate that the tooth will be dressed; non-setting CaOH
● Composite restoration
○ Indicate that a white filling will be placed to regain aesthetics
● Actor marks
○ Described tx in an understandable manner, they were supportive and empathetic
regarding Molly’s injury
Pain history
● Introduction
● Ask about presenting complaint/reason for attendance
● Ask when pain began/how long pt has had pain
● Ask about site of pain
● Ask about character of pain now - aching/throbbing etc.
● Ask about stimulants - hot, cold etc.
● Ask about relieving factors - cold, analgesics etc.
● Ask about duration of pain - minutes, longer, constant etc.
● Ask if pt kept awake
● Provisional diagnosis: Irreversible pulpitis
● Note taking: legible, well ordered, complete
● Actor marks: clear communication, showed empathy
26 dentoalveolar abcess pus aspirate and pathology form
● Pt details correctly entered on to form
○ Sticker (CHI number, Hosp. Number, Name, Sex, Address, D.O.B), Hospital,
department, Date, Time, Consultant, Requested by, Phone no.
● Clinical details entered on to form
○ Pain & swelling, maxilla and provisional diagnosis - dentoalveolar abscess
● Specimen details including site
○ Pus aspirate & details of site - buccal mucosa of 26
● Investigation
○ Culture & sensitivity testing
● Wearing appropriate PPE when handling specimen
○ Examination gloves worn when handling specimen
● Removal of needle
○ Needle safely removed. (safe removal - needle removed from syringe with sheath
intact)
● Disposal of needle in yellow sharps bin
● Sealing syringe for transport
○ Red cap placed onto syringe hub
● Syringe with hub cap is labelled with pt details & placed in plastic bag attached to request
form
○ Fully labelled syringe in sealed bag with red hub cap in place & needle removed
Biphosphonates, alendronic acid
● Name & Designation
● Explain that alendronic acid is a bisphosphonate drug
● Explain mode of action of bisphosphonate drugs
○ Bisphosphonates drugs reduce the turnover of bone
○ Bisphosphonates accumulate in sites of high bone turnover = jaw
● Explanation of relevance of bisphosphonates to dentistry
○ There is a risk of poor wound healing following a tooth extraction
○ Need to remove any teeth of poor prognosis prior to beginning drug therapy
○ Important to do everything possible to prevent further tooth loss in the future
○ Reduced turnover of bone and reduced vascularity can lead to death of bone -
osteonecrosis
● Specifically name BRONJ (MRONJ)
● Risk of BRONJ (MRONJ) in Osteoporosis
○ Low risk
● Making clinical diagnosis
○ Chronic periapical periodontitis
○ Gross caries in correct totoh (36)
● Explaining Clinical diagnosis in terms the patient can understand
○ Area of infection associated with left back tooth (36)
○ The tooth is too decayed to have a filling put in it
● Discuss tx options
○ Extraction is only option
○ Tooth is grossly carious beneath the gumline and therefore unrestorable
○ If tooth is kept risk of MRONJ after beginning therapy
● Ask if the pt has any questions
● Empathetic/professional approach
Actor station. Pt’s 2 year old child about to have fluoride varnish placed – discuss with the patient
their concerns – patient asks why needs fluoride varnish, fluoride toxicity, and also asks oral hygiene
instructions
Reassure the patient: fluoride varnish is placed on the tooth and is minimally invasive. It
involves dry the teeth and painting a gel on to the tooth
● Contraindicated in: severe uncontrolled asthma (hospitalised in the last 12 months) or allergy
to colophony (sticking plasters)
● We can use a colophony free version if needed
● Fluoride varnish; promotes remineralisation (hardening of tooth) and prevents
demineralisation (softening of tooth). Prevents acid production
● Instructions afterwards
○ Don’t eat/drink for 1 hour
○ Soft diet for the rest of the day
■ No dark coloured foods
○ Avoid fluoride supplements today
● Fluoride toxicity:
○ 5mg/kg: milk
○ 5-15mg/kg: ipecac syrup, milk and possible referral
○ >15mg/kg: hospital referral
Breaking bad news: SCC
○ Setting:
■ Private room, 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
○ 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:
■ 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
Denture induced stomatitis
● Professional introduction: Full name & designation
● Acknowledges diabetic history & asks about control
● Ask is denture worn at night?
● Ask about denture hygiene
● Explanation of clinical findings (implying correct diagnosis) - clear with no jargon
● Advise leaving denture out at night
● Advise denture hygiene - brushing and soaking
● Palate brushing
● Would check fit or provide new denture
● Checks understanding
● Examiner asks “what antimicrobial agent would you prescribe to treat this condition?”
○ None or Chlorhexidine
● Actor marks: Communication - understood everything
A 50-year-old male patient attended for HPT with the hygienist 3 months ago. Their 35 is
tender, has a swelling around the tooth and has 8mm pocket on the distal aspect as well as
suppuration. The patient is systemically well and has a normal body temperature.
Provide your diagnosis to the patient and discuss how you would like to investigate the matter
further. Indicate to the examiner when you wish to receive the results of the special
investigations
Ask for: otherwise you won’t get it
○ PA radiograph (2 marks)
○ Sensibility testing (2 marks
EPT 35 & 36 respond positively
PA radiograph shows periodontal/periapical pathology
● Swelling (2 marks)
● Pocket with pus (2 marks)
● Bone loss from radiograph (2 marks)
● Diagnosis- Periodontal abscess (2 marks)
● Treatment
○ Irrigate through pocket (2 marks)
○ Debridement (2 marks)
○ Hot salty mouthwash (2 marks)
● No antibiotics, since it’s a localised infection (2 marks)
● Actor- Empathy (1 mark), Communication (1 mark), Understanding (1 mark)
OAF
How to diagnose oro-antral communication?
○ Radiographic position of roots in relation to antrum
○ Bone at trifurcation of roots
○ Bubbling of blood
○ Nose holding test
○ Good light and suction
● Chronic OAF, patients may complain of:
○ Fluids from nose
○ Speech and singing of nasal quality
○ Problems playing wind instruments
○ Problems smoking or using the straw
○ Bad taste/odour, halitosis, pus discharge
○ Pain/sinusitis type symptom
● Management of oro-antral communication:
○ Inform patient
○ If small or sinus intact – encourage clot, suture margins, antibiotics, post-op
instructions
○ If large or lining torn – close with buccal advancement flap, antibiotics and nose
blowing instructions
● Post-operative instructions for OAC :-
○ Refrain from blowing nose or stifling a sneeze by pinching the nose
○ Steam or menthol inhalations
○ Avoid using a straw
○ Refrain from smoking
● Antibiotics
○ Amoxicillin, 500mg, send - 21 capsules, label take 1 capsule 3 times daily - 7 days
○ Doxycycline 100mg, send - 8 capsules, label take 1 capsule daily (take 2 on day 1)
for 7 days
Primary herpatic gingivostomatitis
● Introduction and designation
● Ask history: how long? Fever? Analgesia? No. of days symptoms? Child pyrexic? Less active
than normal? Have analgesics been used? Were they helpful?
○ Signs: lymphadenopathy, malaise, pyrexia, erythematous gingivae, ulceration
○ Symptoms: sore mouth and throat, fever, enlarged lymph nodes
● Diagnosis: primary herpetic gingivostomatitis, primary infection caused by herpes simplex
virus, high carriage rate in population, common, most infection are subclinical but can present
like this florid infection, self limiting can will disappear in 7-10 days, child may or may not
develop cold sores in future
● Management: fluids, analgesia for pain & fever, clean teeth with cotton roll, bed rest, aciclovir
is not recommended, nutritious/good diet, tell parents since pt (sam) has had problems for 3
days and otherwise fit & healthy -> antiviral med. Is not indicated. Can use dilute CHX to
swab gums.
● Can also use chx, hydrogen peroxide 6%, benzydamine/difflam
● Prescription (if necessary - ie severe or immunocompromised): NB if under 2ys half dose
(100mg)
Aciclovir 200mg tablets - 5 day regime
Send: 25 tablets
Label: take 1 tablet 5 times daily
● Refer immunocompromised patients to hospital
Reline complete denture
● Reasoning:
○ Relines done when fitting surface inadequate but denture otherwise okay
■ ie occlusal planes, OVD, profile are acceptable
■ Fitting surface not supportive, stable or retentive; underextended
○ Rebase: when you want to keep occlusal surface, but change fitting and polished
surface (i.e. buccal etc)
● Method:
○ Remove undercuts from dentures fitting surface using acrylic bur
○ If underextended: add greenstick to bring flange to appropriate extension
○ Take functional impression with light-body PVS using denture as tray
■ Functional = get them to bite down as the PVS sets
○ Please pour up impression in 100% dental stone using reline impression with denture
provided. Please mount upper to cast and create a self cure PMMA reline to change
the impression surface.
Identify faults on denture, how would you fix each individual problem? cu is fractured continually
due to functional issues
● Anterior flange missing
○ Remove undercuts, build flange with greenstick and reline
● Midline Diastema - midline diastema is fracture prone
○ If want to keep aspects of denture, but change aesthetic only
○ Remake: Replica (2 stage putty around denture, vaseline to separate, rubber banded
together)
○ Wax replica used for functional impression + registration
○ Ask lab to close diastema for tooth trial stage
● Underextended posteriorly at tuberosities
○ Reline: if functionally good and only problem
○ Remake: if everything bad
● Locked occlusion
○ remake/replica with cuspless teeth
● Base plate too thin: fracture prone
○ Rebase, Remake
● Tori
○ Relieve clinically if only problem or ask for tin foil relief
○ If too thin or other problems: remake and ensure lab waxes undercuts
● Tooth position wrong
○ Remake
● Too long occlusal table (too many posterior teeth over the tuberosities)
○ Remake
○ Or remove posterior teeth/ grind down
Set teeth (4 upper anterior teeth) for tooth trial
● Tooth trial: Check denture extension, support, retention (trial denture will be looser than the
actual one), stability, occlusion (balanced occlusion and articulation), speech, aesthetics
(tooth mould, shade, gingivae position). Mark post dam on cast.
Gold crown fitted onto cast
You had to assess with casts mounted on the articulator, using articulating paper, shimstock and
calipers whether you happily cement crown and reduce to gain balanced occlusion
Make decision to redo prep and send back to lab
● Pre-cementation checks
○ Is it the restoration as asked for?
○ Check on the cast
■ Rocking, M/D contact points, marginal integrity, aesthetics
■ Check contact points on adjacent teeth on cast to ensure not damaged
■ Occlusal interference on excursions
■ No natural teeth contacting (checked with shimstock 8μm)
■ Inadequate reduction DL cusp
○ Remove crown from cast
■ Check if the natural teeth occlude properly now
■ Check if tooth is under-prepped
■ Measure crown thickness using calipers
● Minimum 0.5mm circumferential
● Minimum 1.5mm for functional cusps (1.0mm for non-functional)
● Avoiding fault in future
○ Measure temp crown thickness before cementing
○ Use sectioned putty index when prepping
● Management
○ Check amount of interference by dropping incisal pin and calculate the difference
■ If do-able to reduce crown without making it too thin then adjust and cement,
otherwise…
○ Re-do prep and send back to lab
Cast and OPG given, need to exam, diagnose and tx plan
● (Possibly: perio, caries, smoker, alcohol, NCTSL, impacted 8)
● Treatment Planning
○ Immediate
■ Pain (Pericoronitis? Toothache? Perio abscess? PAP?)
○ Initial
■ HPT:
● Diet advice: including erosion
● Consider medical referral if GI intrinsic acid
● Smoking cessation, alcohol advice
● Supragingival scaling, RSD
■ Removal of non symptomatic teeth of poor prognosis: Impacted 8’s
● Inform of risks: pain, swelling, bleeding, bruising, infection, dry
socket, IDN numbness
■ NCTSL management
● Find cause: Diet? Alcohol? Medications? MH? Habit? Parafunction?
● Advice: Diet advice, Fluoride (TP/MW), Desensitising
● Tx: Diet diary, study casts, photos, DBA, GI, composite
■ Caries management
■ Endodontic treatment: temporary restorations
○ Re-evaluation
■ Perio: 6-8 weeks post completion
■ NCTSL (pics, casts)
○ Re-constructive
■ Filling spaces: Dentures, Bridgework, implant?
■ Fixed pros otherwise
○ Maintenance
■ Perio, NCTSL
Medical emergency - hypoglycaemia
Drug correct, action (detailed), description of emergency (signs/symptoms)
Medication: Glucagon > increases the concentration of glucose in the blood by
promoting gluconeogenesis and glycogenolysis to convert glycogen to glucose.
○ Type 1 Diabetic - Hypoglycaemic coma – normal = 5-7mmol, unconscious <3mmol
○ Signs: Pale, shaky, sweaty, clammy, dizzy, hungry, confusion, blurred vision, loss of
consciousness > they must mention loss of consciousness as it defines Tx:
○ If conscious and cooperative > administer oral glucose 10-20g or sugary drink
○ If unconscious/uncooperative > 1mg IM glucagon injection and oral glucose when
regain consciousness.
○ IM injection and technique
■ Inject diluting solution in vial with glucagon powder
■ Swirl to mix - don’t shake (will foam up)
■ Syringe solution back into syringe
■ 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.
● In OSCE: “I would normally prepare needle/change needle, remove
clothing, alcohol wipe skin, but not going to as life threatening +
saves time
○ Reassess – ABCDE – assess effect of medication, oral glucose?
○ Call ambulance – location, number, describe Pt condition
Epilepsy mx emergency
● Epilepsy
○ Medication: Midazolam: a short-acting benzodiazepine > enhances the effect of
the neurotransmitter GABA on the GABA receptors resulting in neural inhibition
○ Signs: loss of consciousness, uncontrollable muscle spasms, drooling, tonic (falls
rigid), clonic (sharp jerky movements), hypotension, hypoxia, loss of airway tone
○ Management
■ Assess the patient
■ Do not try to restrain convulsive movements.
■ Ensure the patient is not at risk from injury.
■ Secure airway
■ Administer 100% oxygen, 15L/min flow rate
■ If the fit is repeated or prolonged (>5min): give Midazolam 2ml oromucosal
solution, 5mg/ml topically into buccal cavity (10mg) - repeat after 5 minutes if
not worked
● Check expiry date and the form of midazolam is compatible with
buccal administration, choose appropriate dosage of midazolam by
age (different tubes of midazolam with different dosage available)
■ If subsided: recovery position and check airway
■ Refer to hospital if: first seizure, seizure is atypical, injury was caused or
difficult to monitor patient
Aggressive perio
Patient generally fit and well
● Associated with a familial history of aggressive periodontitis
● Rapid loss of attachment not proportional to plaque levels
● Other:
○ A severe condition usually found in younger patients
○ Severe degree of destruction of the connective tissue attachment and bone,
considering the age of the patient
○ Genetic predisposition, but factors that make it worse: poor OH, smoking
● Pattern
○ Localised if 6s and incisors (and <2 other teeth) on young patient
○ Generalised if 3 teeth other than 6s/1s/2s on older patient (~30 yrs old)
● What to tell patients
1. Convincing evidence of a genetic predisposition to periodontitis, in particular the
aggressive forms
2. Other risk factors such as smoking and OH have an impact
3. It is important to screen and monitor siblings and children of patients with severe
periodontitis since they may have a greater risk of develop the disease
- Be careful as patient can feel hopeless and give up - emphasise it’s STILL
TREATABLE
● Treatment:
○ Meticulous self-care
○ Professional instrumentation (non-surgical & surgical if necessary)
■ 6PPC, NSHPT, plaque retentive factors
○ 2 week course of daily CHX m/w & CHX spray
○ Do not routinely use systemic antibiotics. May be appropriate as an adjunct from
specialist = not first line Tx
■ Metronidazole or Amoxicillin
■ Benefits: good results
■ Risks: doesn’t treat the cause, manageable with localised treatment, doesn’t
disrupt the biofilm, risks of AB’s (vomiting etc), very low proportion reaches
the sites
○ Patient should be referred to a specialist if no change
Class 3 tx options 20yrs old
Class 3 treatment options, pt is 20 yr old (6 mins)
● Accept and Monitor
● Intercept with a URA - procline uppers
● Growth Modification: with functional appliance (reverse twin block) or (RME + protraction
headgear) - notice pt’s age in scenario - this might not be possible
● Camouflage: with fixed appliances (accept underlying skeletal classification problem, move
teeth to hide it, usually together with XLA U5s & L4s, better when growth stopped as growth is
unfavourable)
● Orthognathic surgery with combined orthodontics (arch alignment, arch coordination, decompensation)
You overhear a nurse bad mouthing about a patient to a colleague in a public place in
the surgery. They refer to them in a derogatory manner and joke about potentially
posting this on social media. The patient and family are easily identifiable from the
information discussed as well. Discuss this issue with your nurse
○ Facts: facts of the situation, what, when, where, how? Ask the individual for their
account of the situation
○ Issues: What is the issue here? Explain the issue to the individual and why it is bad.
Quote GDC standards. I.e breach of confidentiality, brings profession into disrepute
○ Options: if involves patient, what options are there to manage this event
(short/medium/long term). What is in the patient’s best interest?
○ Now: what issues do you need to deal with right now. E.g. delete those posts
immediately
○ Advice/ask: Advise yourself and get advice from someone more senior (defence
union, VT trainer.) Ask the individual if they would be willing to undertake training or
education on this matter e.g. tell the nurse to not do it again,
○ Record: document conversation
BBV sharps injury to nurse
● Explain the nature incident:
● Risk: are to the nurse only and NOT the patient (2)
● Explanation of risks
○ Risk of BBV: to the dental nurse e.g HIV (give risk 1:300)
● Explanation of standard procedure to manage the sharps injury: applied to pt
○ Explanation of requirements for source, a blood sample. Clarify this a universal
process applied to patients and it’s nothing personal.
○ Approach to request a blood sample from the patient: professionally and sensitively
○ There’s absolutely no pressure to comply, but compliance would be helpful
○ Re-confirm the patient decision: ask questions
○ Undertake review of Medical history: medical condition (don’t need to necessarily ask
these question for the mock)
○ have you ever been diagnosed with HIV? Hepatitis B, Hepatitis C?
○ Have you ever injected drugs? Have you ever had sex with someone
who has?
○ Have you ever had sex with another man?
○ Have you ever had sex with someone from a country outside of the
UK, Western Europe, Canada, USA, Australia, New Zealand (please
state the country)
○ Have you ever had a blood transfusion not in a country listed above?
Have you ever received dental treatment in a country not listed
above? (please state the country)
○ Are you from a country that is not listed above? (please state the
country)
○ Have you ever had a tattoo/body piercing done by an unlicensed
artist in the UK or in a country outside the UK?
○ Yes to any of the above indicate indicate high risk.
● Ask patient understands options: provide opportunity for patient to ask
questions
● Conclude: pt would like to give the blood test
Direct Pulp Cap: assume dam placed, tooth with cavity close to pulp (Assuming dental dam has
been applied, please place a direct pulp cap on an exposed 36 following a pulpal exposure on the
mesial axial wall.) (Irrigate with CHX, get haemostasis with saline soaked cotton wool, Dycal CaOH
then Vitrebond RMGIC
● Explain to pt: pulp exposed and requires pulp cap (explain what is) - likely no actor so no
need. Address the need: vital therapy and risk of possible death of tooth which requires RCT
● Asymptomatic, vital, no history of pulpitis (e.g. prolonged pain, toothache)
● Haemorrhage from exposed pulp: copious irrigation with sterile saline (arrest bleeding with
saline)
● Cavity cleaned with chlorhexidine (0.2%) (Clean with chlorhex, do not arrest bleeding)
● Cavity is blotted dry using sterile cotton wool pledgets. (Do not air dry)
● Exposed pulp covered with hard-setting calcium hydroxide cement (Dycal or Life)
● RMGI lining placed (Vitrebond) and the restoration completed as planned.
● Continuing vitality monitored: if symptomatic RCT required.
● Only do direct pulp cap: non-carious pulp exposure (instrument, bur = accidentally or when
removing stained dentine) = says otherwise in clinical synopsis????
3.1 Carious pulp exposure.
● Dam already placed
● Extirpate/Pulpectomy
● Discuss with pt again: RCT or XLA
Odontopaste (or ledermix) in anticipation of RCT
● Cotton wool roll + GIC
3.2 Indirect pulp cap
● Cleanse cavity with 0.2% w/w chlorhexidine.
● Stained firm dentine is left in situ and covered with a setting calcium hydroxide cement
(Dycal or Life).
● A stronger lining material is placed (RMGIC – Vitrebond) to protect the Ca(OH)2 and the tooth
is restored with a provisional restoration (GI or RMGI).
● The tooth must be vital, asymptomatic and have no history of previous pulpitis. • The tooth is
monitored for 3 months and if vital and asymptomatic, the provisional restoration should be
removed, stained dentine carefully excavated and definitive restoration placed.
● If there have been any pulpitic symptoms, then RCT should be undertaken.
A 25-year-old patient has an unrestorable 11 tooth. Please break the bad news of this to the
patient. Please discuss management options for this in the immediate term, and the longer
Term. Breaking Bad News: SPIKES formula
● Setting:
○ Privacy, is the room ok for the conversation?
○ Sitting down at the same level as the patient
○ Look calm and attentive, allow time to arrange follow-up questions
● Perception
○ Ask before you tell (have you any idea what might be wrong)
○ What does the patient understand has happened up until now? (are you aware of
what this might be?)
○ Use simple language (not jargon)
○ Don’t use euphemisms (cancer is not a little ulcer)
○ Don’t confront denial
● Invitation
○ Inform patient you’re about to discuss/give results
○ Ask them if they are okay to discuss the results etc
● Knowledge
○ Give a warning shot
■ ‘I wish I had better news’
■ ‘I’m afraid the news are not good’ …. pause for a bit
○ Present the news in the patient’s language
○ Avoid jargon
○ Tailor the rate of delivery, small chunks
○ Allow pauses and let patient dictate the pace of the conversation
■ They might want to know loads of info really quickly or they might be in shock
○ Clarify understanding: do you understand everything
○ May need to impart information several times
● Empathy
○ Emotion appreciation
○ Not sympathy - sympathy is shared suffering
○ A good bedside manner
■ ‘This must be very hard for you’
■ ‘This must have come as a real shock’
■ ‘I can see that you are upset by this news’
● Summary and close
○ Summarise what you’ve told them and the plan going forward
○ Allow time to ask questions
■ ‘I understand you must have lots and lots of questions…do you have anything
that comes to mind?’
○ Ensure the patient has a clear plan of what will happen next and your roles
○ Give written material if available
○ Realistic reassurance regarding ongoing support
○ Offer a follow-up/a phone number for any questions
Unrestorable front tooth: Breaking bad news about losing tooth due to vertical root fracture
and giving missing tooth options - patient crying
○ Setting:
■ Sitting down at same level as them
■ If they’ve just been going through treatment make them as confortable as
possible, ask them to rinse etc
○ Perceptions:
■ What does the patient understand has happened up until now?
● ‘Are you aware of what might be wrong?’
○ Information:
■ Inform patient that you would like to discuss the prognosis of the tooth
■ Ask them if they would like to discuss that…they’ll say yes
○ Knowledge
■ Give a warning shot
● ‘I wish I had better news’
● ‘I’m afraid the news are not good’ …. pause for a bit
■ Give them the knowledge of what you know
● ‘Your tooth is unrestorable and requires to be extracted’ …big
pause…
■ Let it sink in and let them dictate the pace of the conversation from here
● They might want to know loads of info really quickly or they might be
in shock
○ Empathy:
■ Words to the effect of
● ‘I am deeply sorry to break this to you’
● ‘I understand this must be hard for you’
○ Summary and close:
■ Summarise what you’ve told them and the plan for going forward
● ‘We will aim to restore this tooth as soon as possible for you’
● Immediate denture in the short term then extraction (or direct
polycarbonate bridge)
● Bridge, Denture, Implant (need 3 months for bone to stabilise except
for implant which can be placed immediately)
● Do NOT mention unrealistic interventions - assess by case
■ Allow them time to ask any questions they might have
■ Ensure the patient has a clear plan of what will happen next and your roles
■ Offer them a follow-up appointment or phone number for any questions
■ Give written material if available
Discuss biopsy confirming oral cancer
Setting:
■ Private room, 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
○ 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:
■ 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
E/O Orbito-Zygomatic # (Photo provided of a patient with facial features of a ZOC fracture). State
the fracture type most likely from the photo available and clinical history. Perform an E/O exam (on a
mannequin) to assess this patient for the facial fracture. Suggest further investigation for this fracture
type, what you can see on the investigation, and further management if you had this patient present to
you in a standard dental surgery.)
● Diagnosis of fractured cheek bone from photograph (e.g. fractured right cheekbone)
○ Orbito-zygomatic fracture
● E/o examination
○ Any loss of consciousness, nausea, vomiting
○ Laceration, swelling
○ Palpating of zygoma, correct gentle palpating of bone margins (bilaterally)
(supra/infra-orbital rims, zygomatic arch)
○ Assessment of nasal bleeding and limitation of mandibular movement
○ Examination of sensation of infra-orbital region (both blunt and sharp sensation)s
■ Identification of 3 areas supplied by infraorbital nerve
● Upper lip, lower eyelid, lateral nose
○ Exam all the CNV branches
○ Eye examination
■ Periorbital ecchymosis, subconjunctival haemorrhage
■ Eyeball mobility (6 points: top, top right, top left, bottom left, bottom, bottom
right)
■ Presence of double vision (Diplopia)
■ Assessment of vision/pupillary reaction to light
● Intra-oral features
○ Tenderness of Zygomatic buttress
○ Bruising, swelling, haematoma, Lacerations
○ Occlusal derangement and step deformities (e.g. Tooth mobility)
○ Altered sensation to upper quadrant on the fracture side
● Further investigations:
○ Radiographs: OM 15/30, CBCT (if orbital blow out esp.)
■ Radiographic report: fracture identified (zygoma), radiopacity of the sinus
● Management:
○ Call Max Facs or A and E: for advice and referral URGENT
○ Surgical management: ORIF
- Recurrent Aphthous Stomatitis: (e.g. Recurrent Minor Ulcers, FBC provided: Microcytic anaemia
caused by fe deficiency) (27-year old patient presents with ulcers looking like this (Photo- Minor
aphthous). The patient’s ulcers are no more than 10mm in size (history provided) etc etc. Using this
information and the available lab results (patient has low iron and folate) discuss the lab
findings, the diagnosis and management options for this condition with the patient. You do
not need to gain any more information from the patient.)
History:
○ When, How many, Size, Where, How long they last, Any time you’re ulcer free?,
Period between flare ups, Do they completely heal, Symptoms (pain), Anything
making it worse, spicy foods etc, Genital or eye ulcers
● Aetiology
○ Trauma, stress, allergy, nutritional deficiency, systemic disease (see below)
● Other associated conditions:
○ GI conditions: ulcerative colitis or Crohn’s can cause ulcers but need
gastroenterologist to check
○ Genetic: Behcets
○ Lupus
● SI
○ Blood tests - FBC, haematinics
○ TTC - Test for coeliac
○ Take pictures
○ SLS? Benzoates? Notice things in their diet? = Patch testing
○ Stress?
● Management
○ Correct deficiency/systemic disease/ trauma
○ Dietary avoidance: cinnamon, chocolate, benzoates, SLS
○ CHX, difflam moving up to local steroids (beclomethasone inh, betamethasone m/w)
and then systemic steroids (possible from oral med)
● Explanation to patient:
○ Reassure it’s a common condition (20% of people in their lifetime)
○ Many/Uncertain causes: Blood deficiency(could be dietary deficiency or
menstruation), systemic disease, menorrhagia, trauma, smoking, SLS, diet
(cinnamonaldehyde/benzoates/chocolate)
○ Special investigations: explain
○ Management: explain
○ Healing -
■ Minor/ Herpetiform - 1-2 weeks with no scarring
■ Major - 6-12 weeks usually with scarring
○ Refer to oral med
- Dental Dam 13 to 23 (Please isolate teeth 13-23 and secure with wedjets. Please place floss
ligatures on tooth 11 and 21.)
● Floss ligatures: 1,2’s. Wedgets on 3’s
● Template: use a pen to identify holes
● Place opaldam + test the dam with CHX
● Don’t cover nose!
Ortho (Unerupted UL1 + retained ULA): (Photos of discoloured 61 and labial/buccal segments of
an 8 year old). (XR of a dilacerated floating 21 that could be anything). Please identify the problem
present for this patient and discuss its further investigation/management with your examiner.
● Talk to pt about the possible cause, management and treatment?
● Causes of retained ULA/Unerupted 21
○ Trauma to A
■ Ankylosis
■ Arrested tooth (21) formation
■ Damage to 1: dilaceration or displacement
○ Lack of permanent successor/Hypodontia
○ Ectopic tooth germ
○ Crowding
○ Supernumerary: tuberculate most common
● Signs:
○ Discolouration of A, retained A
○ Radiographic
○ Lateral erupted before central
● Management:
○ Palpate: usually buccal and central (high)
○ Radiographic: PA, occlusal anterior (dilaceration present)
○ Refer to orthodontist (if no A: preserve leeway space, URA) for management
■ Extract A, expose and align and preserve with leeway space for 1.5 yrs
Charting (Please work with your nurse to chart the dentition present (in the mannequin) head.)
● Look carefully for buccal restoration
● Communication with nurse while charting and checking her charting
. TMD (A 27-year old teacher presents with a bunch of E/O and I/O signs of a jaw condition (TMD)
Please discuss the diagnosis with the patient, and conservative management for this condition. You
do not need to obtain further information from the patient.)
Assessment - History
○ Pain
■ location, nature, duration, exacerbating/ relieving factors, severity,
frequency, time of occurrence (morning/evening), referred pain (neck,
shoulders)
○ Associated symptoms
■ limited mouth opening (<35mm), joint sounds (clicks/pops/crepitus),
tender/swollen MoM
■ headaches, TMJ locking, difficulty eating
○ Social history
■ occupation, stress, home circumstances, sleeping pattern, recent
bereavement, relationships, habits
○ Dental history
■ recent dental treatment, details of GDP
○ Medical history
■ full PMH as usual, ask particularly about other joint disturbances. May be
IBS or low back pain.
● Assessment - Examination
● E/O
○ Begin with nodes, asymmetries and move towards TMJ and MoM
○ TMJ tenderness
○ TMJ sounds
■ click on opening or closing, is it early or late?
■ crepitus suggests arthritic changes.
○ Range of movement/excursions – watch path from above
■ extent, trismus, deviation on opening or closing, measure inter-incisal
opening accurately
○ Muscle tenderness – masseter, temporalis
○ Facial asymmetry – mandibular position – posturing habits
● I/O
○ Inter-incisal mouth opening – using Willis bite gauge (should be >35mm)
○ Signs of parafunctional habits
■ Cheek biting
■ Linea alba
■ Tongue scalloping
○ Occlusal NCTSL – wear facets, high spots
○ ICP/RCP, group function
○ Muscle tenderness – lateral pterygoid, medial pterygoid
● Special investigations
○ Radiographic – Open/Closed OPT – to rule out odontogenic pain/suspicion of
arthritic changes
○ Blood tests – check inflammatory markers (ESR, PC, CRP)
○ Arthrography – radiopaque dye injected into joint – when meniscal tears are
suspected
○ MRI – most useful – soft tissue anatomy including disc
○ Ultrasound – muscle pathology
○ CBCT
● Causes:
○ idiopathic, stress, trauma including dental procedures (mostly bilateral) & bruxism
● Conservative advice
○ Counselling
■ Reassurance, Soft diet, Bilateral mastication, Avoid wide opening, No
chewing gum, Avoid incising foods, Cut food into small pieces, Stop
parafunctional habits – nail biting, grinding, Support mouth when yawning
– no stifling yawns
○ BRA; Stabilisation splint
○ Massage
○ Heat therapy
○ Physiotherapy, Acupuncture, US therapy, Hypnotherapy
○ Medication
■ Analgesia (ibuprofen and paracetamol)
■ Diazepam (2mg x3 daily, 5 days), amitriptyline
■ Botox
● Explanation to patient:
○ “Mrs Smith, you have a very common condition, in fact around 75% of the
population get it at one point in their life. It is called TMD … 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.”
○ (Draw a wee diagram to show disc and explain that when muscles not in harmony
= disc pulled at wrong time to create clicking noise or disc trapped in front of jaw
bones crushing the tissue that can cause pain).
○ “The way we manage this is very simple - involves resting joint - avoid
parafunction/chewing gum/chewy foods and then give all conservative advice including analgesics and general stress reduction
- ANUG (30 yrs pt not registered with GDP with CO: of signs of ANUG. Pt smoke 20 cigarettes
daily. Otherwise fit and well. Has cervical lymphadenopathy. Discuss diagnosis with pt, and proposed
management. No need to obtain more information from the pt.
● Aetiology
○ Poor OHI
○ Stress
○ Smoking
○ Immunocompromisation
○ Malnourished
● Signs/symptoms
○ Painful, red, gingiva
○ Halitosis
○ Punched out ulceration of interdental papilla areas/blunted papillae
○ Grey necrotic sloughing
● Management
○ OHI
○ NsHPT inc RSD (under LA)
○ Smoking cessation
○ M/W: CHX 0.2% or hydrogen peroxide, 6%
○ If systemic involvement/ lymphadenopathy
■ Antibiotic prescription
● Metronidazole (400mg, Take 1 capsule 3 times per day, for 3 days)
○ No alcohol: vomiting, nausea
● Amoxicillin (500mg, Take 1 capsule 3 times per day for 3 days),
○ Recommend optimal analgesia
○ Advise register with GDP
○ Review within 10 day
■ Referral if no changes on review
Nursing Bottle Caries (Parent has brought 2-year old child in C/O pain. Take a brief pain history
then (Photo of decayed 52-62) provided. Explain diagnosis to parent, prevention and management
options (GA).
Concerned mother with 2 year old in pain (taking calpol). Pic shows carious and broken down
upper incisors, D’s, lower canines (lower incisors protected by tongue). Discuss concerns
following tx and go through prevention
● Questions to ask:
○ Take pain history - how long for?, any analgesia (calpol)? - how much analgesia
(within limits)
○ Feeding bottle to bed?
○ What is in the feeding bottle?
● Advice:
○ Feeder cup replacing bottle from 6 months
○ No feeding at night (lactose in milk - decreased salivary flow and held in mouth)
○ No on-demand breastfeeding
○ No sweetened milk, soy milk (unless medically advised)
○ Milk and water only between mealtimes
○ Sugarfree variations of drinks/foods/medicine (e.g. sugar-free calpol)
○ Safe snacks include, cheese, breadsticks, fruit, plain crisps
○ Toothbrushing:
■ Assist the child until 7yo
■ Brush in the morning and last thing at night
■ No food/ drink except water after brushing
■ Spit don’t rinse
● Management:
○ Extraction of carious teeth under GA: as in pain (discuss GA risk and benefit)
○ GIC remaining teeth and review: if no pain (acclimatisation)
○ Fluoride (supplements + varnish)
● Extra points for empathy
● Consenting and referral for GA:
○ Process
■ Discussion of GA risks/benefits and all other alternative options
■ Referral to hospital for specialist to assess - if any other teeth of poor
prognosis they will be added to this plan to avoid future GA
■ GA will involve day in hospital - need to monitor for full recovery
■ Need of chaperone throughout.
○ Risks
■ Very common minor risks:
● Headache, nausea, vomiting, drowsiness
● Sore throat or sore nose/nose bleed from intubation
■ Risks from treatment:
● Pain, bleeding, swelling, bruising, infection, loss of space, stitches
■ Rare major risks:
● Brain damage
● Death (say as follows):
○ 3 in a million. Need a machine to breathe during op and there
is a very small risk that you will not be able to breathe
independently again on waking - ie never waking again.
■ Upset when coming round - can make underlying anxiety worse
■ Malignant hyperpyrexia (v. rare - important to ask for FH
○ Conditions requiring special care (can be contraindications)
■ Sickle cell disease (or any hypoxia)
■ Diabetes - can’t fast in same way
■ Down’s syndrome
■ Malignant hyperpyrexia
■ CF or Severe asthma
■ Bleeding disorders
■ Cardiac or Renal conditions
■ Epilepsy
■ Long QT syndrome
○ Referral
■ 1. Patient name
■ 2. Patient address
■ 3. Patient/Parent contact numbers (landline and mobile)
■ 4. Patient medical history
■ 5. Patient GP details
■ 6. Parental responsibility
■ 7. Justification for GA
■ 8. Proposed treatment plan
■ 9. Previous treatment details
● Letter must include:
● Recent radiographs or if not available an explanation of why (e.g. pt
uncooperative)
○ Assessment appointment:
■ For treatment planning ONLY and plan may change with specialist opinion
■ **Informed consent - MUST be written
■ GA process, side effects and complications
■ Adult escort with no other children
■ Pre-operative fasting
■ Post-operative arrangements
■ Post-operative care and pain control
Complete Denture Faults (F/F provided on articulated casts. Please identify 6 faults with this
denture and how to rectify these.)
Looseness:
○ Impression surface
■ Causes: Distortion of impression, Poor adhesion to tray, Warped
denture base, Lack of post-dam (should be at vibrating line on border
of soft palate), Poor denture bearing foundations, Flabby ridge, Bony
prominence, Atrophic mandibular ridges
■ Solutions
● Reline/rebase (remove undercuts, wash impression)
● Remake
● Add post dam using reline or chairside technique
○ Occlusal surface
■ Causes: Premature occlusal contact, Centric occlusion/centric relation
not coincident, High lower occlusal plane: restricting the tongue,
Locked or wedged occlusion, Anything causing movement
○ Polished surface
■ Causes: Peripheries overextended, Peripheries underextended, not
placed in neutral zone: cheeks and lips are in equilibrium with those of
the tongue (zone of minimal conflict)
■ Solutions: Adjust overextension, Add greenstick to underextended
areas and reline, Remake denture if modification needed are
extensive, Lower dentures: check lingually for overextension,
Pressure indicated paste, Common areas = labial frenum and flange
area or tuberosities
○ Denture bearing foundations
■ Atrophic ridge
■ Solutions
● Cuspless teeth: lateral excursions and protrusion without
displacement
● Extension
● Soft liners
○ Anatomical factors
■ Palatine/mandibular tori
■ Solution: provide area of relief on cast over this before processing
○ Flabby ridge
■ Mucostatic impression: not impression compound
○ Fraenum
■ Allow fraenal relief
● 56-year old lady has breast cancer and is going to undergo chemotherapy; you’re given
radiograph(s) and photos. So you need to talk to the patient about getting them dentally fit
and oral hygiene & looking after their oral health
○ Radiographs: to identify teeth of poor prognosis (OPT, PA)
○ Tx to be carried out: Remove any dubious prognosis teeth or areas of possible
infection + full mouth scaling (XLA need 10 days to heal)
○ Side effect of tx: caries, mucositis, infection, dry mouth, altered taste
○ Impression for soft splint
○ Oral hygiene
■ X2 brushing daily at least 2 mins time at a time
■ Prescribe 2800ppm duraphat (0.619%)
■ Interdental cleaning: how to use
○ Fluoride therapy: tray, duraphat toothpaste, varnish
○ Smooth down sharp teeth
○ Diet advice: avoid spicy and hot foods, avoid fizzy drink, fruit juices, acidic fruit
○ Smoking and alcohol advise if relevant to SH
Cancer patient management
○ Early detection of soft tissue lesions
○ Pre-treatment: Assessment and dental care
■ Full assessment, SI’s, full mouth scale, imps for soft splint, ++ fluoride (OHI!)
■ Reduce treatment complications
● avoid unscheduled interruption of chemotherapy regimen
● avoid exacerbation of mucositis
● remove potential sources of infection
■ Plan prevention and rehabilitation
○ Mid-treatment: minimal role unless emergency +/- manage pathology
■ Mucositis:
● Radiotherapy/Chemotherapy Induced
○ Inflammation and ulceration
○ Severe pain = requires analgesia
○ Impacts on eating and oral hygiene
○ Exacerbating factors
● Management:
○ General: Avoid smoking, spirits, spicy foods, tea, coffee, nonprescription medicine
○ Topical: topical lignocaine, saline, sodium bicarbonate,
benzydamine hydrochloride, gelclair, caphasol, tea tree oil
mouthwash, oral cooling – ice
■ Candidosis: Pseudomembranous candidosis - antifungals
■ Herpes simplex reactivation: painful ulceration, more aggressive than normal
○ Post-treatment: Maintenance of oral and dental health
■ Prevention: diet, OH, fluoride
■ Monitoring: check-ups (increased frequency), dry mouth management, pros
■ Xerostomia:
● Decreased Salivary Flow
○ 50-60% in first week
○ Further 20% in next 5-6 weeks
● 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
■ MRONJ
○ Palliative care
■ Long term care and monitoring
Pathology form
Filling in the form
○ Patient sticker on form and sticker on sample:
■ Chi number, Hosp number, Name , Sex, Address , DOB
■ More:
● Hospital department
● Date/time
● Consultant
● Requested by
● Phone number
○ Clinical details: History
■ Pain, swelling etc
■ Provisional diagnosis
○ Specimen details: type of sample (e.g. pus aspirate) and site
○ Investigation:
■ Culture and sensitivity: bacterial, fungal
■ PCR and viral load: virus
■ Histopathology: tissue biopsies
● Packing the sample
○ Marks for placing PPE, making sample safe (e.g. removing needle), dispose of
sharps, capping the sample (needle cap or pot lid).
○ LABEL THE SAMPLE and place in bag.
11D Cavity
Smoker + Alcohol + Acid Erosion/NCTSL + Perio disease + Impacted 8’s. ACTOR ST
35-year old male, C/O BOP on brushing and shortened clinical crowns. Smokes 20 cigarettes daily,
drinks 25 units alcohol weekly and 1-litre full fat fizzy juice daily. Casts provided- show lower
crowding. Photos provided- show erosive wear, gingival erythema. Full mouth PA views on viewerimpacted lower 8, mild bone loss upper anterior teeth.
Spend 3-4 minutes looking at these, then diagnose the conditions present in this patient’s
mouth, and outline your treatment plan.
● Treatment Planning
○ Immediate
■ Pain: pericoronitis?
○ Initial
■ HPT:
● Diet advice: including erosion
● Consider medical referral if GI acid
● Smoking cessation, alcohol advice
● Supra-gingival scaling, RSD
■ Removal of non symptomatic teeth of poor prognosis: Impacted 8’s
● Inform of risks: pain, swelling, bleeding, bruising, infection, dry
socket, IDN numbness
■ Caries management
■ Endodontic treatment
○ Re-evaluation
■ Perio
○ Re-constructive
■ Dentures, fixed pros
○ Maintenance
■ Perio
Hall Crown + Separator placement (2-part station. Part 1 place a separator (phantom head),
remove a pre-placed separator, size a hall crown, and select correct cement (Kalzinol, Ultracal and
Aquacem all sitting out). Part 2 child starts choking on hall crown (Mannequin)- deal with the
emergency appropriately.)
Technique
○ Place separators between medial and distal contacts
■ Floss 2 pieces of floss through the orthodontic separator
■ Pull tight and move down between contacts of the tooth (not subgingival)
○ Leave in place for 2-7days
○ Remove with a BLUNT probe
○ Select correct Hall crown
■ Mesial to distal size
○ Try in with a sticky stick
■ Numbers to buccal side
■ Ensuring airway protection
○ Cement
■ Cement the crown with GI (Aquacem)
■ Remove excess cement
Choking child on hall crown
● Child starts choking on the hall crown
○ ABDCE
○ Are you choking?
○ 5 back slaps between shoulder blades
■ Child can be lying on thigh or across knees
○ 5 abdominal thrusts between belly button and sternum
○ Continually check for object dislodging
○ Re-evaluate ABCDE
○ BLS if still not resolved
○ Call 999 to check for rib fracture and tell parents
Primary herpatic gingivostomatitis
● Introduce yourself: Name & Designation
● History from parent
○ Number of days symptoms have been noted for
○ Is the child pyrexic?
○ Is the child less active than normal?
○ Have analgesics been used?
○ Did analgesics work?
● Diagnosis from photograph
○ Recognition of primary herpetic gingivostomatitis and explanation in lay persons
terms - It is a contagious mouth infection caused by HSV1. It most often occurs in
young children and is usually the first exposure a child has to herpes virus (which is
also responsible for cold sores & fever blisters). Often will present with blisters on the
tongue, cheeks, gums, lips & roof of the mouth. After the blisters pop, ulcers will form.
Other symptoms include high fever(before blisters appear), difficulty swallowing,
drooling, pain & swelling. Also, because the sores make it difficult to eat & drink,
dehydration can occur.
● Discuss diagnosis with parent
○ Caused by infection with herpes simplex virus
○ Tells parent that condition is self-limiting and will disappear in 7-10 days
○ High carriage rate in the population
○ Most initial infections are subclinical, but can present as this florid(red/flushed
complexion) infection, explain in lay terms
○ May or may not have cold sores in the future
● Treatment
○ Push fluid intake
○ Analgesics - will control pain & fever
○ Bed rest, take it easy
○ Tell parents that as Sam has had problems for 3 days and is otherwise fit & healthy
antiviral medication is not recommended
○ To clean teeth use a damp cotton wool roll or cotton cloth to rub around gums
○ Can use dilute chlorhexidine to swab the gums
● Actor marks
○ The candidate described treatment in an understandable manner, they were
supportive & empathetic regarding Sam’s condition
Ectopic canines
● Problems
○ Increased OJ
○ Increased OB
○ Peg Lateral
○ Ectopic Canine
● Dental Health Implication
○ Risk of trauma from OJ
○ Risk of trauma from OB
○ Risk of root resorption
○ Risk of cyst formation
● Position determination from radiographs provided - detailed use of parallax
○ Parallax – had OPT and oblique occlusal radiograph and had to explain how you get
your answer. Vertical parallax. SLOB
○ Explanation: the tube head shifted up from OPT to oblique occlusal, the canine
moved together with the tubehead compared to the incisor, according to SLOB rule,
the canine is palatal to the incisor
Denture induced stomatitis (on warfarin)
Professional introduction: Full name & designation
● Acknowledges diabetic history & asks about control
● Ask is denture worn at night?
● Ask about denture hygiene
● Explanation of clinical findings (implying correct diagnosis) - clear with no jargon
● Advise leaving denture out at night
● Advise denture hygiene - brushing and soaking
● Palate brushing
● Would check fit or provide new denture
● Checks understanding
● Examiner asks “what antimicrobial agent would you prescribe to treat this condition?”
○ None or Chlorhexidine
● Actor marks: Communication - understood everything
Denture design
Denture design - average value, bracing
● What kind of articulator are these casts mounted on?
○ Average value
● Upper design
○ Design correctly and neatly copied. Rests, major connectors, saddle areas and
clasps all drawn correctly onto prescription
● Lower design
○ Design correctly and neatly copied. Rests, major connectors, saddle areas and
clasps all drawn correctly onto prescription
● Lab prescription supplied
○ Position of all 8 occlusal rest seats identified
○ 4 i bars correctly identified
○ 2 occlusally approaching and 2 ring clasps identified
○ Mid palatal strap and lingual bar
● Area providing reciprocation
○ Reciprocation is provided by any part of the denture that is directly opposite a clasp
arm. Should indicate all 8 areas
● Indicate what bracing is and what parts of denture provide bracing
○ Bracing is the resistance to lateral movements
○ Correctly identify elements that provide resistance to lateral movement
● Alternatively: draw the denture design of the denture provided
Cleanliness Champions/Cross-infection – What is wrong with this bae? identify dangers on bracket
table + how to rectify – LA needle unsheathed, scalpel, tooth in forceps- know waste stream, sharps
box on floor, gloves in sink, endo files on bracket table, sharps bin on floor, blood spillage + how to
deal with it. How would you dispose amalgam, sharps, blood spillage
● Identify dangers on bracket table and how to rectify
○ LA needle unsheathed, scalpel, tooth in forceps
● Know waste streams, sharps box on floor
○ Black: household waste - packaging, hand towels
○ Orange: low risk clinical waste
■ Swabs, dressings and other non-sharp clinical waste e.g. dam, micro brush
○ Yellow: high risk clinical waste (we don’t have this on clinic)
■ Body parts including teeth
○ Red: Specialist, hazardous waste
■ Dispose of amalgam in white box with red lid.
■ Spill/leak proof. Mercury vapour suppressant in lid.
■ Amalgam waste, amalgam capsules, amalgam filled teeth
○ Blue: Sharps including vials with medication or pharmaceuticals remaining
○ Sharps in sharps bin (orange stream): 3As, 2Ns
■ Always dispose of sharps in the sharps box immediately after use
■ Always keep out of reach of children and non-authorised personnel
■ Always close sharps box between use using temporary closing mechanism
■ Never retrieve anything from sharps box
■ Never fill more than ¾ full
■ Extra: Place sharps box at waist height on a flat surface
● Blood spillage and how to deal with it
○ Stop what we are doing
○ Apply appropriate PPE
○ Cover spill with disposable paper towels
○ Apply sodium hypochlorite/sodium dichloroisocyanurate – liquid/powder/granules with
10,000ppm chloride concentration.
○ 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
Oral med- white patch on FOM, had to discuss need for biopsy + possible oral cancer – pt risk
factors smoking + alcohol
● Possible causes of white patch:
○ Hereditary
○ Keratosis
■ Smoking
■ Traumatic
○ Lichenoid
○ Lupus
○ Pseudomembranous or Chronic Hyperplastic Candidiasis (not in this site)
○ Carcinoma/SCC
● Discussing the lesion
○ The lesion on the FOM has a number of possible causes. Some of these are
harmless and benign. However, some causes could be more serious and possibly
cancerous. As the site is a high risk for oral cancer, and you have other risk factors, it
would be appropriate to refer you on to have this looked at/biopsied. In order to be
sure we will need to send you for a biopsy so that a laboratory can make a diagnosis
as an Urgent referral.
● Management of Risk factors
○ Smoking cessation
○ Reduce alcohol consumption
● Information on what to expect at OM:
○ Biopsy, post-op advice
● Urgent cancer referral guidelines:
○ Persistent unexplained head and neck lumps for >3weeks
○ Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks
○ All red or speckled patches of the oral mucosa persisting for >3weeks
○ Persistent hoarseness lasting for >3weeks (request chest x-ray at the same time)
○ Dysphagia or odynophagia (pain on swallowing) lasting for >3weeks
○ Persistent pain in the throat lasting for >3weeks
Aciclovir prescription for primary herpetic gingivostomatitis with systemic involvement – teen pt
● Aciclovir only prescribed: Immunocompromised patients & severe infections in the nonimmunocompromised
○ NB: remember to refer immunocompromised patients (both adults and children) to
hospital
● Primary response to herpes simplex virus
○ Sore mouth and throat, enlarged lymph nodes
○ Also: period of malaise and fever (!!systemic symptoms!!)
○ Happens once (or twice – two types), self-limiting 10-14 days
○ Bed rest, antipyretic, CHX, fluid intake, diet
● Aciclovir
○ 200mg tablets or oral suspension (200mg/5ml or 100mg/5ml)
○ Send 25 tablets
○ Label 1 tablet 5 times daily
○ (5x 200mg from 2years old upwards, 5 x 100mg under 2 years old)
OAF – take a history, explain diagnosis from images + X-ray + history, explain management +
surgical closure
How to diagnose oro-antral communication?
○ Radiographic position of roots in relation to antrum
○ Bone at trifurcation of roots
○ Bubbling of blood
○ Nose holding test
○ Good light and suction
● Chronic OAF, patients may complain of:
○ Fluids from nose
○ Speech and singing of nasal quality
○ Problems playing wind instruments
○ Problems smoking or using the straw
○ Bad taste/odour, halitosis, pus discharge
○ Pain/sinusitis type symptom
● Management of oro-antral communication:
○ Inform patient
○ If small or sinus intact – encourage clot, suture margins, antibiotics, post-op
instructions
○ If large or lining torn – close with buccal advancement flap, antibiotics and nose
blowing instructions
● Post-operative instructions for OAC :-
○ Refrain from blowing nose or stifling a sneeze by pinching the nose
○ Steam or menthol inhalations
○ Avoid using a straw
○ Refrain from smoking
● Antibiotics
○ Amoxicillin, 500mg, send - 21 capsules, label take 1 capsule 3 times daily - 7 days
○ Doxycycline 100mg, send - 8 capsules, label take 1 capsule daily (take 2 on day 1)
for 7 days
Mandibular fracture – diagnose from pic from one of lectures, - show how to do eo exam on
phantom head + signs and symptoms for IO, radiographs, Management
Initial General History
○ Headache?
○ Any loss of consciousness?
○ Nausea or vomiting?
○ Numbness of face?
○ Police involvement?
○ Examine and record injuries elsewhere
● Examination
● E/O:
○ Lacerations, Bleeding, Swelling, Facial asymmetry, painful
○ Palpation of mandible bilaterally (condyle, ramus, body, symphysis)
○ Limitation of mandibular movement? (Reduced interincisal opening)
○ Mandibular deviation on opening and lateral movement?
○ Tenderness of TMJ?
○ Examination of sensation of lower lip/chin region
■ Areas supplied by mental nerve (mandibular division of trigeminal nerve)
● I/O:
○ Lacerations (esp. gingivae), Bruising/swelling/haematoma
○ Occlusal derangement and step deformities
○ Loose or broken teeth
○ Anaesthesia/Paraesthesia of teeth in lower jaw on side of fracture
○ AOB – due to bilateral ramus/sub-condylar fracture
● Classifications
○ Soft tissue involvement: simple, compound, comminuted
○ 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
● Factors influencing displacement of mandibular fractures
○ Pull of attached muscle
○ Angulation & direction of fracture line
○ Opposing occlusion
○ Magnitude of force
○ Mechanism & direction of injury
○ Intact soft tissue
● Further investigations:
○ TWO Radiographs: OPT + PA mandible
○ CBCT most commonly used now
● Management:
○ Call Max Facs or A&E: for advice and referral URGENT
○ Surgical management: ORIF (if symptomatic or displaced)
○ Max facs way advise: Conservative management if undisplaced and asymptomatic
Ortho decalcification
● Ortho decalcification: shape of backet
● Management:
○ Pt selection (high risk: caries history evidence of decal, NCTSL)
○ OHI: x2 brushing minimum with soft toothbrush, but also try to brush after meals as
braces are plaque traps. Don’t wet toothbrush before applying toothpaste, spit don’t
rinse, brush in methodical manner, work from upper right clockwise to lower right,
brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in
short scrubbing motion for a minimum of 2 minutes, spit don’t rinse. Use single tufted
toothbrushes around brackets, interdental brushes and superfloss. Use disclosing
tablets to identify areas missed
○ Diet: avoid hard, hot, sticky food, fizzy drink, sport drink, lollipop type sweet. Avoid
snack between meal, limit intake of sugar substances to less than 3 times per day.
Ideal drinks are water or milk, crackers, cheese, fruit is acceptable snack but be
careful of fat in cheese and natural sugar/acid in fruit, watch out for hidden sugars in
foods such as tomato soup and ketchup.
○ Fluoride: varnish x4 yearly (Proflurid - Not duraphat), tp 2800ppm (if brush more than
2x, only use 2800ppm tp twice per day), use fluoride mouthwashes 225ppm fluoride
at times other than brushing
■ Prescription: Sodium Fluoride Toothpaste 0.619% (2800ppm)
■ Send: 75ml
■ Label: brush teeth for 1 minute after meals using 1cm before spitting out,
twice daily
■ Prescription: Sodium Fluoride Toothpaste 1.1% (5000ppm)
■ Send: 51g
■ Label: brush teeth for 3 minute after meal using 2cm, before spitting, 3x daily
Paeds caries
) Paeds – diagnose caries on bitewings , explain prevention + TB advice to mum
● Caries risk assessment: clinical evidence, diet, MH, SH, saliva, plaque control, fluoride
exposure
● Prevention: radiograph, diet advice, toothbrushing instruction, strength of fluoride in
toothpaste, fluoride supplement, fluoride varnish, fissure sealant, sugar free medicine
● Prevention: High risk
- Toothbrushing advice:
- Assist child with brushing until able to brush independently (7yrs)
- X2 daily with fluoride toothpaste, spit don’t rinse
- Demonstrate on child 6 monthly, get parent to demonstrate in front of you
- Methodical approach
- Diet advice
- Avoid sugar snacks/drinks
- Snack on healthier foods: carrot sticks, breadsticks, fruit in moderation
- Milk and water only (between meals)
- If nursing bottle: no bottle to bed at night, no soy milk or sweetened milk, no
on demand breast feeding
- Do not eat or drink after brushing teeth at night
- Fluoride:
- Varnish x4 yearly to children >2yrs (5%, 22600ppm)
- 1450 ppm paste (smear < 3yo pea > 3yo)
- >10yrs: 2800ppm
Bridge prescription conventional cantilever
Bridge prescription for conventional cantilever
● 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
● Please pour up impressions with improved stone, mount on semi-adjustable articulator and
construct a metal ceramic (NiCr) conventional mesial cantilever bridge to replace tooth XX.
Use XX as abutment and XX as pontic. Ridge-lap pontic (depends on tooth to be replaced)
(dome shape: upper posterior, lower anterior, lower posterior. Modified ridge lap: upper
anteriors.) Shade XX. Staining and special effects, Surface features and finish
● Type of the occlusal registration provided: wax bite etc
● Pt requests
● Please return bridge with cast.
● Signature
Endo restored molar options
Endo restoration options for molar explain to pt
● Gold standard: cuspal coverage onlay
○ Gold, composite, porcelain, zirconia
○ Less likely for tooth fracture/catastrophic failure, less microbial leakage/better seal
● Full coverage: MCC, GSC, all ceramic, all zirconia
○ If less tooth: in order to cover and protect
● Composite or amalgam direct (if only occlusal cavity present)
○ Not as favourable: more leakage, more likely to fracture
● Core build up if necessary:
○ Composite core: gold standard
○ Explain to pt the tooth has been hollowed out need to put filling material to fill up the
space and retain the crown
○ Less acceptable: nayyar core
● Metal cast post if necessary: not favourable
What cement to use for each system
● When to use each cement:
○ Panavia > Adhesive bridge (RBB)
○ Aquacem (GIC) > Metal post, MCC, Gold restorations, Zirconia restorations
○ Nexus (NX3) > Fibre post, Composite/ porcelain restorations, Veneers
● Pre-cementation checks
○ Check on the cast
■ Rocking, contact points, marginal integrity, aesthetics
■ Is the restoration as asked for
● Post-cementation checks
○ Is excess cement removed, is restoration cleansable
○ Margins, clear interproximally, occlusion, aesthetics
Surveying cast
Mount
● Tripod: draw three lines with analysing rod and pencil
● Analysing rod: to analyse abutment teeth + soft tissue undercut (only)
● Pencil rod: mark survey line of all abutment teeth and soft tissue undercut. Do not overmark
(in the common path of displacement)
● Determine whether the cast needs to be tilted: i.e. when undercuts unfavourable. To change
the path of insertion to highlight undercuts in this path. (mainly for soft tissue)
● If cast needs to be tilted, re-tripod with red marker, then mark new survey line with red rod
● In the common path of displacement (path of insertion and removal if altered), find
appropriate location for clasps with undercut gauges (normally buccal of upper molars and
lingual of lower molars)
○ 0.25mm > CoCr
○ 0.5mm > wrought Gold
○ 0.75 > wrought SS
Hall Crown + separators
se size for hall crown, place without cement, identify cement to use, place ortho separator
● Technique
○ Place separators between medial and distal contacts
■ Floss 2 pieces of floss through the orthodontic separator
■ Pull tight and move down between contacts of the tooth (not subgingival)
○ Leave in place for 2-7 days
○ Remove with a BLUNT probe
○ Sit child upright
○ Place gauze swab to protect the airway
○ Choose the crown: aim to fit smallest size of crown that will seat (sticky stick)
○ Select one that covers all the cusps and approaches the contact points with slight
feeling springback (do not full seat the crown
○ Dry the crown, fill with GIC/aquacem, dry the tooth, no LA
○ If cavity large: place some GIC in the cavity
○ Place the crown over the tooth
○ Seat the crown with finger pressure - first method
○ Child can seat the crown by biting on it, can use gauze - second method
○ Remove excess cement with CWR
○ Get pt to bite down for 2-3mins or finger pressure
○ Make sure all excess cement has been removed
○ Floss between contacts
Angina and anaphylaxis mx emergency
GTN spray
○ Heart attack (MI), stable angina, any ischaemic heart diseases affecting myocardium
○ Stable angina = heart rate returns to normal after exercise stops
○ Unstable angina = constant
■ GTN only if acute stable angina
■ 2 actuations sublingually, 400μg – do not administer without good radial
pulse
■ Works by vasodilation reducing preload, to reduce supply volume reducing
BP
■ If condition doesn’t improve in 3mins it might be MI or unstable angina
(aspirin and call 999)
● Aspirin
○ If MI or unstable angina
○ 300mg - chewed in mouth or pre-crushed
○ Takes 10mins to work
○ Referred immediately to hospital - 999
● Adrenaline
○ Any anaphylactic shock = airway constriction, bronchoconstriction, vasodilation,
shock = inability to perfuse organs
○ Any life threatening condition – powerful vasoconstrictor, bronchodilator & increases
contractility of myocardia
○ ½ of a 1ml ampule 1:10000 = 500μg IM injection *Aspirate as can generate
arrhythmias
○ Z-track technique
SR8 + Complications
The treatment is to have the lower L/R third molar removed surgically under local anaesthetic
● You will be awake throughout the procedure
● The procedure will involve having a couple of injections in your mouth, raise a bit of your gum,
remove bone, the tooth will be sectioned and removed piece by piece. This will involve
drilling, similar to the one used for fillings. Then we will clean the area and place some
sutures to close up the wound. 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, temporary/permanent numbness, prolonged nerve pain, tingling due to
damage to nerve (<1% perm, 10-20% temp), damage to adjacent tooth
DO AM
Remember to Vitrebond the cavity floor
● Dam would normally be placed
● Remember to check occlusion and for overhang
MRONJ
Clinical picture of a broken down tooth
● Explain to patient why they need a dental assessment before Alendronic acid
● Given radiograph of unrestorable tooth
● Discuss clinical findings, Diagnosis, Possible treatment options and confirm diagnosis and Tx
fluoride toxicplan to examiner
● Explain that alendronic acid is a bisphosphonate
● Bisphosphonates reduce bone turnover
○ Accumulate in sites of high turnover
● Risk of poor healing following tooth XLA
● Need to remove teeth of poor prognosis before drug therapy
● Important to do everything possible to prevent further tooth loss in the future
● Reduced turnover and vascular can lead to death of the bone and lead to bone death
(necrosis)
○ Name MRONJ
○ Risk of MRONJ in osteonecrosis is Low
● Diagnosis - chronic periapical periodontitis
○ Gross caries in tooth 36
● Explain clinical diagnosis in simple terms
○ Area of infection associated with left back tooth
● Tooth too decayed to restore
○ Tx options - XLA only option
○ Tooth is grossly carious below gum and therefore unrestorable
● There is. Risk of MRONJ if tooth is left
● Ask the patient if the have any questions
FV, Toxicity, OHI
● Reassure the patient: fluoride varnish is placed on the tooth and is minimally invasive. It
involves dry the teeth and painting a gel on to the tooth
● Contraindicated in: severe uncontrolled asthma (hospitalised in the last 12 months) or allergy
to colophony (sticking plasters)
● We can use a colophony free version if needed
● Fluoride varnish; promotes remineralisation (hardening of tooth) and prevents
demineralisation (softening of tooth). Prevents acid production
● Instructions afterwards
○ Don’t eat/drink for 1 hour
○ Soft diet for the rest of the day
■ No dark coloured foods
○ Avoid fluoride supplements today
● Fluoride toxicity:
○ 5mg/kg: milk
○ 5-15mg/kg: ipecac syrup, milk and possible referral
○ >15mg/kg: hospital referral
AWD and steriliser – also asked the parameters for steriliser. Also asked to see 2 packaging
of instruments – one looks like typical dental school packaging, the other has a tape across the
packaging – the tutor asks are they safe to use – I said yes to the dental school one and no to the
tape one – and had to explain why – I mentioned some bullshit about the seal being damage and
whatnot – but I had a look and he wrote I got the answers wrong for both of them…
Testing done daily, weekly, quarterly, annually
● Type N – Normal, non vacuum. Passive air removal, not wrapped, not hollow or lumened
● Type B – vacuum, active air removal, packaged instruments, lumened or cannulated
○ Type B – Daily test (steam penetration using helix or bowie Dick = yellow to blue.
Yellow (fail), blue (pass)
○ Weekly test (vacuum leak test, air detector function test)
● Sterilisers – water to be used (RO, distilled, sterile, de-ionised)
● Sterilizing temperature – 134-137 degrees, 2-2.3bar for a minimum holding time of 3 minutes
● AWD stages – flush, wash, rinse, disinfect, dry
● AWD daily test – automatic control test
○ Weekly test – cleaning efficacy test
● Testing ultrasonic cleaners – Weekly (cleaning efficacy test)
● Quarterly (foil ablation test)
● Manual cleaning – immersion or non-immersion method. Non-immersion method for lumened
cannulated eg. Handpieces. Detergent should be neutral or enzymatic 30ml to 8litres water.
No metal brushes. Water temp 30-35 degrees. Rinse/immerse instruments in purified water
after cleaning then dry
● Ultrasonic cleaner – must keep records (operator, contents, detergent concentration, when
the water and detergent was changed)
● Following all types of cleaning inspect dry instruments for cleanliness using lit magnifier
Ortho problems, models of teeth
Upper arch: Peg-shaped lateral, missing permanent canine one side, one side deciduous
canine and canine bulge present.
● Lower arch: Crowding on lower model.
In occlusion: increased overet and increased overbite.
● What are the dental health issues with this
○ Risk of: trauma from OJ, trauma from OB, root resorption,cyst fromation
○ Peg lateral - aesthetics
○ Missing permanent canine - functional problems
○ Increased OJ - trauma risk from falls etc
○ Increased OB - Trauma to soft tissue
● How would you assess the position of the canine?
○ Parallax – had OPT and oblique occlusal radiograph and had to explain how you get
your answer. Vertical parallax. SLOB
○ Explanation: the tube head shifted up from OPT to oblique occlusal, the canine
moved together with the tubehead compared to the incisor, according to SLOB rule,
the canine is palatal to the incisor
● X-rays SLOB horizontal or vertical. Vertical parallax; opt and upper oblique occlusal view.
lingual/ palatal
Pain history and provisional diagnosis
Site
○ Where
● Onset
○ When did this begin
● Character
○ Describe the pain, trouble sleeping?
● Radiation
○ Spread to other sites?
● Association
○ Swellings, TTP, sore to bite, headaches in addition to the pain
● Timing
○ When does the pain usually happen? How long does it last?
● Exacerbating/ relieving factors
○ Anything that makes the pain better or worse (hot/ cold/ biting/ pain killer)
● Severity
○ 1-10, 10 being the most pain you’ve ever felt in your life (getting squared in the balls)
Denture induced stomatitis station – actor present. Had to advise the patient what the
condition is, how to deal with it – so local measures. Also had lab report of sample taken
previously – resistant to fluconazole and itraconazole, sensitive to nystation – so could prescribe
nystatin
● Signs of Stomatitis
○ Redness, of the denture bearing areas of the hard palate
○ Discomfort - stingy
● Management
- OHI
- Rinse mouth after inhaler use
- Blood: FBC, iron, glucose
- Diet: lower sugar diet
- Correct denture fault
- Stop smoking
- Denture hygiene instruction
- Take out at night
- Chlorhexidine mouthwash
- Soak for no more than 15 minutes, do not use
- After meals clean the denture with a soft toothbrush and nonabrasive denture cream (or detergent) to remove debris etc
- Effervescent peroxides (steradent) = powder or tablets and soak the
denture in them. Bubble action is relatively effective but are less
effective than alkaline hypochlorites. Also, they can cause bleaching
or use of hot water can damage the denture base.
- Alkaline Hypochlorites (milton) = preferred option w/ superior
cleansing properties, but do not soak in denture cleanser for more
than 10 mins as risk of bleaching denture. Avoid these in metal
based dentures as corrodes metal
- Others: acids, enzymes, disinfectants
Extraoral exam checking for swollen lymph nodes and you should be able to name the different ones.
Then you get given a picture of a lesion and you need to tell the actor they have cancer. Need to
console patient and tell them they’ll be referred urgently and what happens next
te LNs: submental, submandibular, facial, preauricular/parotid, (internet suggested postauricular, jugulo-digastric, jugulo-omohyoid
● Breaking bad news: – see above for notes –
OPT Report + discussion
D: demographics (type of X-ray, age, date etc)
○ Q: quality (grade 1: diagnostically excellent, no positioning errors, grade 2: diagnostically
acceptable with error in positioning/elsewhere, grade 3: diagnostically unacceptable)
○ D: dentition (teeth erupted, teeth missing, permanent/primary/mixed, heavily/moderate/mild
restored, overhangs on restorations, impacted/unerupted teeth, sub-gingival calculus)
○ S: Systemic disease review: caries, periodontal bone levels, periapical pathology
○ PAID: other pathology, TMJ, anatomical findings, incidental findings, diagnosis
Prescription for antibiotics
Steriliser cycle and types of water
Cycle: air removal, sterilizing, drying, cooling
● Type of water: reverse osmosis, distilled water, Sterile water for irrigation, De-ionized water
● Type n: no active air removal, air escape by passive displacement
● Type B can process lumened instrument or packaged instrument
● If instruments lie on top of steriliser and not sure which stage are they at, start from the
beginning again (cleaning
Post-op xla
- Introduce yourself
- Big - BLEEDING:
- If bleeding does occur, arrest with wet gauze using firm pressure for 20 minutes, if
unable to arrest, contact the emergency number provided
- If it doesn’t stop bleeding, phone emergency contact first
- If continues to bleed/out of hours go to A&E - Racks - Rinsing
- Do not rinse the area, for the first 24 hrs
- After 24hrs you should rinse mouth with warm saline/salt water gently 3-4 times day - Come - Care
- Do not bite lip, cheek or tongue while numb
- Do not disturb socket with finger, tongue or toothbrush, avoid probing the site
- Brushing other teeth as normal, avoid that area
- Inform the patient that they may experience swelling and bruising, swelling should
peak at 48hrs, if increasing after this, contact the GDP
- Avoid hot and hard foods
- Avoid excessive exercise
- Eat soft foods on opposite side to extraction for a few days
- Avoid/Cut down smoking over the next few days/week
- Avoid alcohol for as long as possible (24 hours)
- Gentle rinsing after the first day with warm salty water
- Swelling: peaks at 48 hours, resolves in around 7 days. Can use ice pack today when
you go home (5 mins on, 5 minutes off for an hour)
- If sutures: give appropriate advice - Pricey - Pain
- Expect some pain at first
- Painkillers before analgesia wears off fully
- Take normal painkillers: Ibuprofen and Paracetamol
- If pain worsens after 2-3 days return to the practice: possible infection or dry socket
- Take analgesia as for a headache for 1-3 days after the op and begin before LA
wears off - Give emergency contact number
Cancer – asking to take biopsy, discussing differential diagnosis, Tx options
LA injection around the site of the sample
○ Taking a small amount of tissue to send to the lab for analysis
○ In most cases, a suture would be used to close up the wound. This can take around
2-4 weeks to dissolve and fall off.
○ It will be sore for a week after the procedure, similar to having an ulcer
○ Review appointment to be booked to discuss findings.
OHI, diet advice to child with caries
Post and core crown: no endo tx, explain options, explain advantages and disadvantages..lingual
caries but no pain. pt says he wants no tx
Leave/monitor if asymptomatic - risk of infection/abscess/tooth breakdown/ root fracture
● Remove crown and remove caries - restore with new crown if restorable:
○ Adv: removes risk of post removal
○ Dis: not actually resolving the problem of no endo (risk of periapical infection)
● If not:
● Remove post core and replace +/- re-RCT.
○ Risk of removing post and core: root fracture, core/post fracture
● Explain risk of tooth being unrestorable and requiring XLA
○ Leave space
○ Restore w bridge
○ Restore w denture
○ Restore w implant
Reline + material + prescription
● Check all the occlusal relationships are acceptable and appropriate
● 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 in the
mouth
● Impression is taken as a functional impression so 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 100% dental stone, mount on articulator and reline denture to
new fit
Pericoronitis/ anug prescription + alcoholic
Effects of chemotherapy
Effects of chemo: mucositis, pain, swelling, MRONJ/osteonecrosis, xerostomia, hair loss,
candidosis, periodontal disease, sialadenitis, herpes simplex reactivation,
Tooth wear tx plan
Treatment Planning
○ Immediate
■ Pain
○ Initial
■ HPT:
● Diet advice: including erosion
● Consider medical referral if GI acid
● Smoking cessation, alcohol advice
● Supra-gingival scaling, RSD
■ Removal of non symptomatic teeth of poor prognosis: Impacted 8’s
● Inform of risks: pain, swelling, bleeding, bruising, infection, dry
socket, IDN numbness
■ Caries management
■ Endodontic treatment
○ Re-evaluation
■ Perio
○ Re-constructive
■ Dentures, fixed pros
○ Maintenance
■ Perio
● Tooth wear:
○ Explain:
■ Erosion: extrinsic acid (fizzy drink, fruit juice, alcohol) or intrinsic
(GORD/bulimia/vomiting/acid reflux)
■ Attrition: parafunction, bruxism, stress
■ Abrasion - tooth brushing, habits,, pipe smoking, nail biting
○ Management options
■ Prevention!! Remove cause
■ Abrasion: remove foreign object/substance involved in causing abrasive wear
● Change toothpaste
● Alter brushing habits/technique
● Change habits – nail biting, wire stripping, biting piercings, pen
chewing
● Cervical toothbrush abrasion – simple GIC/RMGIC (or even
composite) restorations can be used without preparation to protect
tooth (composite may look better but GICs have better retention)
■ Attrition:resolve parafunctional habit
● More difficult to address as generally parafunctional habit is related to
life stressors
● Cognitive Behavioural Therapy or Hypnosis
● Splints
■ Erosion: remove causing agent
● Even when not best fit for diagnosis, very often still part of the
problem
● Aspects of prevention depend on source of acid (Intrinsic vs
Extrinsic)
● Fluoride – toothpaste, mouthwash
● Desensitising agents – (stannous fluoride, potassium nitrate)
symptomatic relief more than prevention
● Dietary management: change habits – don’t swill drink around mouth,
use straws, watch ‘healthy eating’ acids (5-a-day), avoid sports
gels/drinks - drink milk/water instead , chew gum, eat cheese
● Medical - may require discussion with pt GMP and referral to
specialist (needs consent)
Tx planning for child (mucocele, caries, PA pathology, hypodontia); parent considering making a
complaint (previous dentist didn’t notify)
● Arrest caries and prevention
○ Start with prevention, assign a caries risk and work with least invasive restorations
(fissure sealant to then LA procedures)
○ Prevention: radiographs, diet advice, tooth brushing instruction, F varnish toothpaste
and supplements, sugar free medicine, fissure sealant
● Mucocele: leave and review, remove surgically
○ Explain the procedure: LA around site of swelling, surgical removal
○ Risks: pain, swelling, bleeding, bruising, infection, numbness in area etc
● Hypodontia:
○ Space maintenance: ura etc
○ Referral to orthodontist at 6-7yrs
○ Tx options
■ Nothing
■ Restorative only: composite, veneers, RBB, RPD
■ Ortho only
■ Restorative + ortho: space closure and reshape the canines
● Possible refer for treatment under sedation or GA (gauge question)
● + complaints procedure above
Access cavity 26
● quadrilateral shape
● 3 roots
● 93% 4 canals (MB1, MB2, D, P), 7% 3 canals
● Remember to use endoZ if available
Gold crown fitted onto cast
● Pre-cementation checks
○ Is it the restoration as asked for?
○ Check on the cast
■ Rocking, M/D contact points, marginal integrity, aesthetics
■ Check contact points on adjacent teeth on cast to ensure not damaged
■ Occlusal interference on excursions
■ No natural teeth contacting (checked with shimstock 8μm)
■ Inadequate reduction DL cusp
○ Remove crown from cast
■ Check if the natural teeth occlude properly now
■ Check if tooth is under-prepped
■ Measure crown thickness using calipers
● Minimum 0.5mm circumferential
● Minimum 1.5mm for functional cusps (1.0mm for non-functional)
● Avoiding fault in future
○ Measure temp crown thickness before cementing
○ Use sectioned putty index when prepping
● Management
○ Check amount of interference by dropping incisal pin and calculate the difference
■ If do-able to reduce crown without making it too thin then adjust and cement,
otherwise…
○ Re-do prep and send back to lab
URA aftercare + activate palatal finger spring
fitting an appliance; adjusting and Pt instructions
All prescription details correct – wires and sizes etc
Exam: arrowhead fault and flyover fault – adams clasps
AC adjusted with adams pliers
Active comp adjusted with spring formers – 1-2mm activation
Fitting a URA
● Check that the appliance is for the correct patient
● Check the appliance is asked for
● 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 about insertion and removal
● Ask patient to demonstrate insertion and removal
● Review: 4-6 weekly
Instructions to patient
● Will feel big and bulky
● Likely to impinge on speech
○ Start reading a book aloud to prevent this by speeding up adjustment of
Teeth
● May have ‘mild discomfort’ - particularly on teeth being moved - but this is a sign
that the appliance is working
● Initial increase in saliva – 24-48 hours
● Wear 24 hours/day including meal times
● Can remove the appliance to clean with a soft brush after each meal or when taking part in
active/ contact sport – store in a safe place
● Avoid hard and sticky foods
● Be cautious with hot food and drinks as base plate acts as an insulator
● Non- compliance will lengthen treatment
● Give an emergency contact number – do not wait till next appt. if there is a problem
Epithelial dysplasia: alcohol
biopsy results: dysplasia
Establish what Pt knows about biopsy and implications (dysplasia – potential malignancy)
Focus around reducing alcohol
Unit of alcohol, weekly intake and revised reduction in units for men
Evidence change
Effect of white patch – transformation to malignancy
Impact on dental Tx – spontaneous bleed, clotting
Eye contact, open body lang
Pt: non judgemental tone and clear advice
● Tell the pt the diagnosis is epithelial dysplasia which has a potential to be cancerous.
● Stress to the patient: that this is not cancerous YET
● However, the risk is HIGHER
● The good news is that this can be prevented by removing the factors that can cause cancer:
i.e. reducing risks
○ Alcohol
○ FRAMES Counselling approach
■ Short, non-judgemental, motivational
■ F – feedback - given to patient about behaviour
■ R – responsibility - for change is placed on patient
■ A – advice - how to do that change, given by practitioner
■ M – menu of options - self-directed change options and treatments offered
■ E – empathetic - warmth, respect and understanding
■ S – self-efficacy - is engendered to encourage change
○ 4A’s 1R
■ Ask: How much do you drink/units? What kind? Eye-opener? Family
concerns?
■ Advise: effects on general health as well (increased risk of stroke, cardiac
disease)
● Stress: that alcohol increases the risk of oral cancer
● Other effects orally: fungal, caries, dry mouth, perio, poor wound
healing, dental erosion, bruxism
● Increased bleeding, less clotting
■ Assess: whether the pt is willing to reduce drinking, inform them that this if
fundamental to prevent oral cancer
■ Refer: alcoholics anonymous
■ Guidelines - 14 units per week alcohol with 2-3 drink free days
■ In your case you should consider cutting alcohol out completely due to it
being a risk factor for your dysphasia turning to cancer
Broken endo file, you’ve temporised
Intro (name and designation), state separated instrument and explain; possible consequences
Tx: dress and monitor; accept and obturate to file; bypass; attempt removal; specialist: retrograde;
XLA
Questions – check understands and confirms an option
Pt: professional; enough info to gain consent
Calmly explain to the patient that there is a file separated in to the canal of the tooth
I’ve tried to remove the file and failed and you will arrange a referral to see a specialist.
Tx options
● If they can see the separated file they will attempt to remove it with forceps.
● Remove the broken file with an ultrasonic instrument
● bypass the fragment using a small file alongside the instrument and EDTA to soften the
dentine
● If they remove it: complete RCT as normal
● If it is not possible to bypass the fragment, the specialist may clean and fill the root canal to
level of the blockage. I.e. Aim to remove the file and/or try to complete the RCT
● Needs kept under observation
○ apicectomy/peri-radicular surgery (Where they remove the tip of the root)
● XLA: last resort
● Do nothing
● Any questions, do you understand?
Cleaning bay
Wipe down bay in prep for next patient
Dispose of sharps, etc.
● Wear appropriate PPE
● Dispose all sharps, then clinical wastes and domestic wastes
● Start from the top: dental light - control surfaces, full length of all cables. Then change a new
wipes: dental chair, spittoon. New wipes again: bench top surfaces, computer keyboard and
mouse.
Place dam on 35 mod
Rubber dam placement for 35 mod
Select correct clamp, clamp chart provided
Can use nurse for assistance
Place dam over 36-34: due to contacts
Use wedget and floss
MOD restoration
N.B marks for correct clamp, correct number holes, ligature, wedgets, frame on outside of dam,
efficiency
Suggested clamps:
Anterior : E or C
Premolars : E or EW
Molars : A or AW or FW or K
M14 cavity prep
tooth 14MO
N.B. marks for no damage to adjacent teeth, CSMA, no sharp line angles, not excessive prep (all
‘caries’ removed) etc
Required to fit upper removable appliance to a 9-year old. Examine the prescription and the
appliance, look for defects and answer the examiners question.
Faults: Z-spring encased in acrylic, UR6 adam’s clasp tag, UL6 adam’s clasp flyover
Prescription: Southend clasp included meaning appliance won’t work, adam’s clasp on ULC
not ULD, FABP not PBP
How would you rectify these errors?
Re-make URA by taking new impression
Surgical trolley
Came up in past paper: Warwick James elevator, Howarth’s periosteal elevator, Cryers
elevator, Alice forceps (tissue), Bone rongeurs
1. Dental elevator for removing teeth and roots especially upper 8s
2. Used to raise mucoperiosteal flaps + retraction of flap
3. Dental elevator used to elevate roots and remove interradicular bone
4. Used to hold soft tissues, 1 mark for saying can be used to pick up teeth (used for removing
5. Also known as bone nibblers, used to trim bone, remove spicules and septae
Surgical trolley 2
- For LA injection
- Soft tissue retraction, indirect vision
- Test for LA before XLA, test surface
- Handle cotton pledget (with cross pattern), remove sequestrae
- Incision to raise a flap or biopsy
- Retract the cheek, retract soft tissue
- Elevate soft tissue flaps, flap deflection, periosteum separation
- As above
- Elevate soft tissue flaps, flap retraction
- Elevate root and tooth, create space for insertion of forceps
- As above
- As above
- Elevate tooth/ root, especially upper 8s
- As above
- As above
- Dental elevator used to elevate roots and remove interradicular bone
- As above
- Picking up sequestrate or fractured instruments or posts, artery clips
- Remove spicules, septae and to trim bone
- Flap deflection, scratchin your back
- Smooth down rough bit of bone by pull stroke
- Remove granuloma or cyst from periapical tissue and remove granulation tissue from
socket - Removing sharp bone spicules, exposing canines, apicectomy
- Picking up teeth, removing sharp bone spicules
- As above
- Holding needle for suturing
- As above forceps
- Holding needle for suturing
- Manipulation of suture
- Cutting suture
- Depressing tongue, retracting tissue
- Clipping things on tray table
BBV high,med or low
Explain nature of injury- Risk to nurse not to patient (2 marks)
Explain risks- Risk of transmission is low (2 marks)
Explain procedure- Explanation of routine procedure, applies to everyone (2 marks)
Explain no pressure to comply- To reassure dental nurse, don’t have to
comply (2 marks)
Undertake review of MH- Covered all issues relating to BBVs (4 marks)
Patient understands options and can ask questions (2 marks)
Confirm patient’s decision (2 marks)
Was low risk for all BBVs (3 marks)
Communication (2 marks)
A patient has a sore denture and sore palate, test done previously to confirm condition and
you have received the results. Denture-induced stomatitis affecting the hard palate, provided
with picture showing this as well as results of swab. Medical history includes diabetes type 2
and on warfarin for atrial fibrillation.
Explain findings to the patient, recognise the multifactorial condition and provide oral hygiene
advice to the patient.
Professional introduction- Name and designation (2 marks)
Acknowledge diabetic history and ask about control- Clearly acknowledges and asks about
control (2 marks)
Ask if denture is being worn at night (1 mark)
Ask about denture hygiene (1 mark)
Explain clinical findings and imply diagnosis- Clear no jargon (2 marks)
Advise leaving denture out at night (1 mark)
Denture hygiene (2 marks)- Brushing denture with brush over sink with toothpaste/steradent
Talk about brushing palate (1 mark)
Plans to check fit or provide new denture (1 mark)
Checks understanding- asks if there are any questions (1 mark)
What antimicrobial agent?
None or CHX (2 marks) soak denture in for 15 min
● Chlorhexidine 0.2% solution
● Send: 300ml
● Label: Soak denture for 15 minutes twice daily
Nystatin suspension (1 mark) remember to swallow it
● Nystatin oral suspension 100000 unit per ml
● Send 30ml
● 1ml after food x4 daily for 7 days
● Advise to rinse suspension around mouth and then retain near lesion for 5 mins before
swallowing
● Continue use for 48 hours after resolution
Can’t use azole antifungal due to interaction with warfarin
Communication- Understands everything (2 marks) Understands most things (1 mark)
Severe pericoronitis, pus supperating
Patient’s name- Correct place (2 marks)
Patient’s address, postcode- In full (2 marks)
Patient’s CHI- Correct area (2 marks)
Number of days treatment- Correct number of days 3-5 (2 marks)
Acceptable drug and formulation- Amoxicillin, capsules (1 mark)
Correct drug dose- 500mg (2 marks)
Correct frequency- 3x a day (2 marks)
Correct duration of treatment- For three days (2 marks)
Total number of capsules- 9 (2 marks)
Prescription signed and dated- Correct area (2 marks)
Written in indelible ink- Pen used (2 marks)
● Amoxicillin, 500mg
● SEND: 9 capsules
● LABEL: please take 1 capsule 3 times daily for 3 days
A patient brings her child to the clinic, he is not feeling well and is distressed. You are
provided with an image.
Take a history, provide a diagnosis to the mother, provide ways to treat the condition and
answer any questions the mother may have
Introduce- Name & designation (2 marks)
History- Number of days, pyrexia, taking analgesia (2 marks)
Diagnosis- Primary herpetic gingivostomatitis, explaining what it is to patient virus, etc. (2
marks)
Caused by herpes simplex (2 marks)
Self-limiting, disappears in 7-10 days (2 marks)
High carriage rate in population, common (2 marks)
Most infections are not clinical but can present like this (2 marks)
Child may or may not develop cold sores (2 marks)
Use analgesia to control fever (2 marks)
Take fluids (2 marks)
Get bed rest (2 marks)
Clean teeth with damp cotton wool roll (2 marks)
Acyclovir not recommended (2 marks)
Empathy and understanding- (1 mark)
A 28-year old female patient who works in television has had an accident in which she injured
her face. There are no other injuries and you have completed the examination as well as taken
a radiograph. You have diagnosed the tooth as having a root fracture and is unrestorable.
Explain your findings to the patient and how you would treat them.
Student listens and is empathetic
Asks patient what patient is expecting outlook to be or what they want from appointment
Asks permission to continue findings
Break news slowly in chunks
Avoids jargon, or explains if used
Allows patient time to take in information and gives chance to ask questions
Repeats the news
Summarises what they’ve said
Gives patient replacement options
Actor asked if they understood, been shown empathy
Complete Dentures- Edentulous Pt- select tray for edentulous lower Primary Imp.
Select handle and place in correct place. What position would you stand in for IMP.
What material would you use for this IMP. Write this stage on lab card.
● Edentulous trays (blue) are shallower
● Primary imp material for lower edentulous: alginate, impression compound
● 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)- nonperforated,
OFG - History of patient given- swollen lips all his life. Chat to patient get a history, ask
and ascertain local and systemic signs. Chat about how you would manage it going
forward. Asked patient about any bowel problems he said yes, informed of potential
chrons.
● 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
Give IDB, patient gets facial palsy
Injection in parotid gland → Facial nerve.
● Diagnosis: Test branches of facial nerve.
● Symptoms: generalized weakness of the ipsilateral side of the face, inability to close the
eyelids, obliteration of the nasolabial fold, drooping of the corner of the mouth, and deviation
of the mouth toward the unaffected side.
● Confirmation: Temporal branch affected if stroke patient can still wrinkle forehead
● Management: Reassurance, Cover eye with pad until blink reflex returns. An eye patch
should be applied, especially during night time, while artificial tears can be used during the
day, along with sunglasses, to prevent exposure keratitis.Treatment for delayed type of palsy
can also be treated similarly for patients with idiopathic facial nerve palsy. The main drug
therapy is steroids.
Paeds question deal with parent and child with staining or missing teeth? Can’t
remember was shown x rays given clinical info had to reassure parent.
●
● Staining:
○ Causes: MIH, fluorosis, dentinogenesis imperfecta, trauma, amelogenesis
imperfecta, decal, tetracycline
○ Treatment:
■ microabrasion: easily to be done, effective, removal of tooth
structure, use of acid
■ vital extrinsic bleaching: may not work, gingival recession, sensitivity,
will not bleach restoration, relapse, overbleach
■ localised comp addition: add bulk to tooth, may not mask totally
■ comp/porcelain veneer: good aesthetic, tooth prep needed, need to
wait until 18 for stable gingival level
■ MCC: destructive
● Missing teeth:
○ Causes: Hypodontia, trauma causing arrested tooth formation, ectopic,
dilaceration, supernumerary
○ Treatment: RBB, essix retainer, RPD, implant if above 18y/o, ortho to close
space
Child needs tx, previous dentist didn’t do anything
● Explain tx needed
○ Sedation, GA
○ Depends on case
● Mom ask about previous dentist didn’t take radiograph/ advise tx?
● Tell mom I can’t give comment on it because I don’t know the full story
● I can only offer you this treatment at this present time
● Whatever was offered previously, will not change what treatment is required now
● Tell mum if she is intended to complain, she can go back to the practice, they will have a
standard complaint procedure = only if the patient asks (do not offer!)4
● It will be unhelpful for me to be involved in this matter as I don’t know the background behind
treatment that was or wasn’t done and would be unfair for me to speculate on it
Perio comparing pre and post op. Reasons for failure
Missing teeth - identify the causes
● Gingival margin - from the ACJ, recession
● Probing depths - difficulty of tx
● Loss of attachment - severity of disease
● Bleeding on probing - disease active or not
● Furcation - furcation involvement more difficult to treat
● Mobility - give rise to symptom, poorer prognosis
● Reasons for failure
○ Smoking
○ Patient not compliant: OH is poor
○ Inability for patient to practice OH effectively
■ Hard to reach areas - furcations, lone standing teeth
■ Poor manual dexterity - dementia/parkinsons/age
○ Systemic factors: stress, diabetes, pregnancy, malnutrition/poor diet
○ Difficulty accessing for debridement/Inadequate debridement (time constraint, pt
cannot tolerate)
○ Iatrogenic factors: overhangs, poor margins
Veneer prep
Remember PPE, don’t get too worried about stages of prep but be mindful of burrs
Failed RCT reasons and tx options
Overfilled, underfilled, poorly compacted, accessory canals missed, missed canal,
inadequately prepared, extrusion of debris, perforation, RCF of incorrect shape,
vertical root fracture, endo file fracture, blockage/ obstruction of canal, poor coronal
seal - failed restoration
● Tx options:
○ leave and monitor: no active tx, but may infection including abscess may flare
up later
○ orthograde retreatment: no surgery needed, but chances of success
decreased, if post core present, removing may cause vertical root fracture
○ periradicular surgery: if retreatment not possible, surgery more difficult to
tolerate, invasive, time consuming, expensive, nerve damage, reduced
support, scarring
○ XLA: tooth loss, need replacement or non-functional and poor aesthetic
Notice faults on crown preps
E.g. Not enough occlusal reduction, too much prep
IN/IV sedation
● Normal O2sat = 97-100, Alarm at 90, Hypoxic at 85
○ If dropping: stimulate patient - ask to breathe
○ If alarm:
■ supplemental oxygen: nasal cannulation 2L/min
■ reverse with flumazenil (500micrograms/5ml)
● Minimum O2 delivery = 30% (max N2O 70%)
● C/I for InhSed: common cold, tonsillitis, nasal blockage, severe COPD, MS,
pregnancy (1st trimester), claustrophobia (fear of the mask)
Dry mouth patient, amytriptyline
History:
○ How dry mouth is affecting the pt? Need water to swallow/ affect
speech, uncomfy
○ What medications pt is taking? Alcohol? Smoking?
○ Medical history - diabetes/epilepsy/anxiety/stroke/sjogrens/CF/HIV
● Usual features/symptoms:
○ Swallowing difficulty, clicking speech, discomfort, altered taste,
cervical caries, halitosis, candidiasis,
● Management
○ Treat cause: Hydration, Chew gum, Modify drugs, Control
diabetes/somatoform disorder, reduce caffeine, Stop smoking/alcohol
○ Prevent diseases: Caries (High F- toothpaste), Candida / Angular
cheilitis (CHX)
○ Saliva substitutes: Spray/Lozenges: Orthana, Stimulants: Pilocarpine
● Contact medical practitioner to query if changing medication is possible
Lichen planus tx and explain
So you’ve got these white patches around your mouth
● Lichen planus can present anywhere on the skin but in some cases it present in the
mouth and it is definitely one of the most common conditions they get to see in the
oral medicine department.
● The whiteness arises from extra keratin deposition. Keratin is a protein that is present
all around your skin and the body can be stimulated to make more by several factors
like friction (in the case of skin producing calluses).
● Lichen planus is kind of an allergic reaction to something and in most cases we don’t
really know what causes it. Most common culprits are reactions to medications or
metal in silver fillings.
● 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. It’s important to note though
that it’s a spectrum disease which ranges from simple asymptomatic white patches to
more sinister erosive sore ulcerated areas. Depending on what area of the spectrum
you’re on the risk of malignancy can be higher or lower.
● This is not something we can treat other than if possible remove the causing factor if
we know it but we can manage the symptoms.
● Mostly start by avoiding SLS toothpaste or MW and other allergens like benzoates.
Chlorhexidine can sometimes be helpful and soreness can be managed with difflam.
In later stages medicines like corticosteroids (local and then systemic) can be used
to. In the mouth it can usually take 3-5 years to resolve (skin it’s ~18 months) and in
the meantime we would like to keep an eye on it by taking some pictures and
reviewing you every 4-6 months (if sinister type then by OM dept, if common type
then by GDP) in order to monitor any changes
Testing cranial nerves
● 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
(probably not one to test)
● CN 11 (Accessory) - can patient shrug?
● CN 12 (Hypoglossal) - can patient protrude tongue? Is there deviation on protrusion?
Is there asymmetry
Facial pain
Pain history -
○ SOCRATES
○ Site - may migrate from one site to another, can cross anatomical boundaries
○ Onset - often chronic, patient may relate it to a specific episode of treatment
○ Character - varied, often a continuous sharp ache, can be throbbing
○ Radiation - often radiates across anatomical boundaries
○ Associations - no local signs of inflammation
○ Timing - generally continuous
○ Exacerbating/Relieving factors - associated with stimuli that usually do not
elicit pain, analgesia generally not effective
○ Severity - very severe
● Special Investigations
○ Radiographs for caries
○ Sensibility
○ Mobility
○ Perio disease
○ Tooth Slooth
Referral letter for xla of Lower 8
Patient Details
● Practice Details
● Patient Complaint
● Your concerns: why you are referring? Urgent/ routine? Pt in pain/ swelling?
● MH
● DH
● SH
● Summary of oral health status
● Details of Request: for advice or to see patient
● Enclosing details: radiographs, investigations
10 iatrogenic/developmental faults in the dentition
Iatrogenic faults:
○ RCT: fractured file, perforated file, ledging, GP overfill/underfill, extruded
sealer, missed canal
○ Restorations: overhangs, fractured, poor margins, post w/o RCT, perforated
post
○ External inflammatory/surface/ replacement, internal inflammatory, cervical
root resorption?
● Developmental:
○ Cysts: dentigerous, radicular, erupted, keratocyst
○ Unerupted/ectopic/impacted teeth
○ Dentinogenesis (amber radiolucency, bulbus crown, abscess, pulp canal
radiolucency) /Amelogenesis imperfecta
○ TMD
● Trauma
○ Bone fracture, Tooth fracture, displacement
Decon
● Instruments on top of autoclave: restart whole decon procedure from cleaning in
washer disinfector or manual cleaner
● No packaged/lumened instruments in type N sterilizer
● No overlapping, open hinged instruments
● Colour changes:
○ Helix/ Bowie Dick: Yellow to Blue
○ Instrument packaging: Brown to Pink
● Sterilisation parameters: 134-137C, 2-2.3 bar, 3 mins minimum
● 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)
Candidal leukoplakia
● Fungal infection of the cheek side of the mouth
● Potentially malignant, can progress to oral cancer
● Risk factors: OH, steroid inhaler, diet diabetes, deficiency, dry mouth, antibiotic,
immunosuppression
● Management: incisional biopsy, OHI, reduce carbohydrate, rinse mouth after inhaler,
correct deficiency, diabetes, correct denture fault, stop smoking, systemic antifungal,
review after 7 days
● Systemic antifungal
○ Fluconazole 50mg
○ Send: 7 tablets
○ Label: 1 tablet to be taken once per day for 7 days
Non accidental trauma
● Extra oral signs:
○ Bruising of face - punch, slap, pinch
○ Bruising of ears - pinch, pull
○ Abrasions and lacerations
○ Burns and bites
○ Neck - choke or cord marks
○ Eye injuries
○ Hair pulling
○ Fractures (nose>mandible>zygoma)
● Intra oral signs
○ Contusions
○ Bruises
○ Abrasions and lacerations
○ Burns
○ Tooth trauma
○ Frenal injuries
● Index of Suspicion
○ Delay in seeking help
○ Story vague, lacking in detail, vary with each telling and person to person
○ Account not compatible with injury
○ Parents mood abnormal. Preoccupied.
○ Parents behaviour gives cause for concern
○ Child’s appearance and interaction with parents is abnormal
○ Child may say something contradictory
○ History of previous injury
○ History of violence within the family
● Taking action
○ Provide any urgent dental treatment
○ Tell parent: unless this will put child at risk.
■ Explain your concerns honestly, inform them of your intention to refer
■ “These types of injuries have to be reported”
○ Seek parents consent to share info
○ Record incident and conversation
○ Refer to social services/police - b be specific about reaasons
○ Confirm referral acted upon
○ Arrange dental follow up
○ Be prepared for reporting in case of court
○ Always discuss with colleague
LA formulations and dosages
● Lidocaine 2% 1:80000 adrenaline: 7mg/kg
● Articaine 3% 1:100000 adrenaline: 6mg/kg
● Prilocaine w/ felypressin 0.03IU/ml: 8mg/kg
Explain to dad EDP # management
● Pa provided. Child stepped out of surgery. Parent says child is anxious and would like to
know what would be done today
● Explain the nature, Tx for today only, you are happy with trauma and MH
● Explanation of the inherent in simple language
○ Enamel dentine pulp fracture in language the patient can understand (never exposed)
● Baseline sensibility test
○ Testing injured and adjacent teeth
○ Tests will be required as a baseline reading for long term monitoring
● Explain treatment
○ What, when, where, how: where is the fragment
○ Pulpotomy - as large exposure of nerve, treatment of choice is a pulpotomy. This
involves partial removal of the pulp to keep the undamaged pulp tissue alive. So the
tooth can continue to grow.
■ LA injection to gum keep patient comfortable/ numb
■ rubber dam (rubber sheet over tooth and area sterile and prevents
swallowing)
■ Drilling (remove pulp tissue and aim to leave good tissue)
■ Dressing: setting calcium hydroxide/ MTA
■ Restoration - will be an aesthetic restoration (white composite)
■ Check for understanding
Complaints – pp question – pt annoyed that had to wait an hour + receptionist was rude +
complaints procedure
● Take concerns seriously, Answer questions as able:
○ hello there, what seems to be the problem?
○ Can i offer some assistance?
● ‘’I can see that you’re upset and I am sorry that you feel this way.’’ (Acknowledge anger)
○ This does not accept blame. DO NOT ACCEPT BLAME
● Try to offer practical help:
○ Offer investigation with receptionist and provide feedback to the patient
○ Still have time for us to see you? If you can offer another appointment
○ 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? I will send a letter detailing the
complications
● 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 organization 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.
