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Question 1

When a patient seeks treatment without an appointment, dentists can respond in different ways depending on the circumstances. Other than asking the patient to make an appointment or come back another time, list five different options open to a dentist when responding to a request for unscheduled dental attention. For each option, comment on whether or not it entails a duty of care

Answer 1

• Advise the patient that if it is an emergency to contact NHS 24 on 111 (as the patient is not registered with this dentist, they do not have a duty of care)
• Register the patient & provide a temporary solution to their problem with their tooth (as the patient is now registered, the dentist now has a duty of care)
• Refer them to another practice nearby that may be able to see them if they are still open (as they are not registered there is no duty of care)
• Provide them with details of out of hours arrangements of dental care (does not entail a duty of care)
• Since it is the end of the day register the patient and get them to come back for an appointment the following day (now a duty of care)

Question 2

With her dental nurse present, Ms Lee examines Mr Drummond, with his consent, and finds that his mouth has been badly bleeding as the result of a lower lateral incisor being knocked out in an accident. The blood flow from the wound has now stopped but the avulsed tooth was lost earlier after spitting it out. The gum and lower lip are otherwise intact. Having checked his medical history, she is satisfied that the injury is uncomplicated and can be safely allowed to heal before commencing treatment on a future occasion.

Given the clinical picture arising from Ms Lee’s examination of the patient, list five separate tasks that she should perform on this initial occasion in fulfilment of professional standards

Answer 2

• Record details of what happened during her consultation with Mr. Drummond in her notes
• Provide the patient with options to proceed with treatment
• Provide benefits of going ahead with treatment
• Provide issues that may occur if Mr. Drummond does not go ahead with treatment
• Provide Mr. Drummond with costs of each treatment option with a written treatment plan
• Ask for patient’s consent to treatment by asking them to read and then sign the treatment plan with explanations of the treatment given prior to this

Question 3

After he leaves, Mr Drummond is convinced that more should have been done and contemplates taking legal advice on whether Ms Lee was negligent in her actions

List the four criteria for clinical negligence in general (not specific to Ms Lee’s actions in this case). Further, given that in the legal system there are two different standards of evidence used in different types of court case, state which one of these applies in establishing negligence

Answer 3

• Dentist should have a duty of care towards the patient
• Dentist breached the duty of care (standard of care)
• The breach in duty of care lead to harm to the patient (causation)
• The damage/harm caused was reasonably foreseeable & has negative consequences & effects (damage)
• Balance of probability applies to negligence

Question 4

Which 4 things would need to be shown to prove a breach in duty of care?

Answer 4

Duty: It must be established that the defendant had a duty of care towards the plaintiff. This means that the defendant had a legal obligation to act in a way that would not cause harm to the plaintiff.

Standard of care: It must be shown that the defendant breached the standard of care that was owed to the plaintiff. This means that the defendant failed to take the necessary precautions or actions that a reasonable person in the defendant’s position would have taken to avoid causing harm to the plaintiff.

Causation: It must be shown that the defendant’s breach of duty caused the plaintiff’s harm. This means that the plaintiff’s harm was a direct result of the defendant’s actions or inaction.

Damages: It must be shown that the plaintiff suffered actual harm or damages as a result of the defendant’s breach of duty. This can include physical injuries, emotional distress, or financial losses.
To establish a breach of duty of care, all four of these elements must be proven.

Question 5

name two legal systems to prove a breach in duty of care

Answer 5

NEGLIGENCE = BREACH OF DUTY
STRICT LIABILITY = PROOF THAT ACTIONS CAUSED HARM

The two legal systems that are commonly used to prove a breach of duty of care are:

Negligence: This is the most common legal system used to prove a breach of duty of care. In a negligence claim, the plaintiff must prove that the defendant had a duty of care towards the plaintiff, breached that duty of care, and caused the plaintiff’s harm as a result of that breach. Negligence is a civil wrong that can result in damages being awarded to the plaintiff.

Strict liability: In a strict liability claim, the plaintiff does not need to prove that the defendant was negligent or breached a duty of care. Instead, the plaintiff must only prove that the defendant’s actions caused the plaintiff’s harm. Strict liability is often used in cases where a product has caused harm to a consumer, and the manufacturer may be held liable even if they were not negligent in their actions.
Both negligence and strict liability can be used to prove a breach of duty of care, but they have different requirements for proving liability.

Negligence requires proof of a breach of duty of care, while strict liability only requires proof of causation. The choice of legal system used will depend on the circumstances of the case and the specific laws in the jurisdiction where the case is being heard.

Question 6

Pregnant girl in your surgery and you ring her house and she is not in. Your nurse discusses the pregnancy with her mother. Definition of informed consent

Answer 6

• Voluntary and continuing permission of an appropriately informed individual
• Individual has capacity to consent and has sufficient knowledge of the purpose, nature, likely effects & risks of a treatment
• Must be aware of likelihood of success of procedure & any alternatives
• Informed consent-patient has enough information to make decision
• Voluntary decision making-patient has made the decision themselves
• Ability to make informed decision
• Assumption of capacity in patients over 16 unless assessed otherwise
• Implied consent for minor procedures. Expressed consent for major invasive procedure
• Oral & written consent are equally lawful if a record is kept

Question 7

Negligence when:

Answer 7

• Dentist owed a DUTY OF CARE: There is a usual and normal practise
• The duty was BREACHED: Dentist did not adopt that practise
• Course the dentist adopted is one which no dentist of ordinary skill would have taken if acting with ordinary care.
• Breach caused or contributed to HARM: Harm resulting from dental treatment is negligent if the dentist’s practise does not meet standard of ordinary care
• Damage was REASONABLY FORSEEABLE and had negative consequences

1. Document any steps taken, precautions taken with x-rays e.g working lengths
2. GDP judged by standard of other GDPs
3. Risk of instrument failure is well known and is therefore foreseeable-assessment should be conducted prior to using any equipment

Question 8

8 thing gdc advise to gain consent

Answer 8

Discuss the proposed treatment

Discuss alternative treatment options

Discuss the risks and benefits of the proposed treatment

Discuss the likely outcome of the proposed treatment

Discuss any significant risks

Assess the patient’s capacity:

Obtain the patient’s consent

Document the consent process

Question 9

what is valid consent

Answer 9

Valid consent requires that the patient has the capacity to understand the information provided, has been given sufficient information to make an informed decision, and has voluntarily given consent without coercion or pressure from others.

In order to obtain valid consent, healthcare professionals must follow certain legal and ethical standards, which include providing the patient with clear and accurate information about the proposed treatment, discussing any significant risks or potential complications, and ensuring that the patient has had adequate time to consider the information provided before making a decision.

Question 10

what is legal consent

Answer 10

In order to be considered legally valid, consent must be given voluntarily and with full knowledge of the risks and benefits of the proposed treatment, and the patient must have the capacity to understand the information provided.

Question 11

Practice is planning to make a questionnaire. What will allow it to face validity?
Give two examples of points that need to be taken into consideration?

Answer 11

Define the purpose
Use clear and concise language
Pilot test the questionnaire
Use a diverse sample

Target audience – age, sociodemographic
What treatment they have under taken
Clear and specific questions - no jargon
Avoid bias and leading questions

Question 12

List three common anxiety provoking and maintaining factors

Answer 12

Negative dental experience
Modelling parents anxiety
Media

Question 13

Give three examples of the psycho-social effects of stigma around the oral-facial appearance?

Answer 13

Inability to carry out daily tasks
Depression
Inability to communicate
Inability to enjoy food

Question 14

Define “phobia”

Answer 14

Severe anxiety manifested as a marked or persistent anxiety in relation to clearly discensible situations or objects in general

A phobia is an excessive and irrational fear of a specific object, situation, or activity that poses little or no real danger.

Question 15

What three psychological/behavioural treatments can be used in overcoming dental phobia?

Answer 15

Exposure therapy and cognitive coping strategies
Muscle relaxation therapy
Refer to psychologist
Give patient control – real/illusionary?

Question 16

Briefly outline four factors associated with the development and maintenance of anxiety about dental treatment.

Answer 16

Past traumatic experience
Fear of loss of control
Fear of judgement
Perceived pain or discomfort

Question 17

You decide to assess how anxious she is about elements of dentistry. What assessment tool/questionnaire do you have available that you could use to assess her anxiety? Describe the questionnaire and give two examples of the questions it asks.

Answer 17

the Dental Anxiety Scale (DAS), Modified Dental Anxiety Scale (MDAS), and Corah’s Dental Anxiety Scale.

The MDAS is a five-item self-report questionnaire that measures dental anxiety. It asks about anxiety related to specific aspects of dental treatment, including scaling and polishing, local anesthesia, and drilling. The questionnaire uses a 5-point Likert scale (1 = not anxious, 5 = extremely anxious) to rate the level of anxiety for each item.

Here are two example questions from the MDAS:

“How anxious would you feel about having a tooth drilled?”
“How anxious would you feel about having an injection in your mouth?”

Facial Image Scale in kids

Question 18

You are going to give Susan some assistance with her anxiety. List four treatments available that you could use to help her manage her anxiety

Answer 18

1. General attitude and the application of a general anxiety reducing treatment style:

Acknowledge patient’s feeling of anxiety
Foster a trusting relationship
Provide realistic information
Provide a high level of predictability (explain the appointment goals at the start)
Provide Control

2. Teach coping strategies:
   Relaxation – simple breathing awareness, to techniques like progressive muscle relaxation (lots of apps out there to help)

Distraction – General friendly discussion, visualisation and imagery, (children – teaching a magic tricks, sums in head, a squeeze ball)

3. Specific pharmacological support:
   If necessary prescribe a benzodiazepine (adults) prior to treatment nitrous oxide sedation

Behavioural - fear hierarchy
waiting room -> fear -> seeing the needle -> holding the needle -> feeling the needle on the gum -> intra-oral injection

In practice, exposure therapy is often combined with teaching the patient (called psycho-education) cognitive coping strategies:

Using pleasant and positive imagery, identifying

Use of coping statements. “I can and I will, this is fine”

Exploring The Evidence Supporting The Thoughts
elief – “I have never coped well with pain and I’m rubbish at everything”
Exploring: ”Have you had any experiences of a lot of pain before?”
Response: “Yes, when I gave birth to my first child”
Exploring: “Yeah, I’ve heard how painful that can be! What was it like once your child was born?”

Question 19

Choose two from the list of anxiety-reducing treatments you are considering and outline the points with regards to relative effectiveness and practicality that you will discuss with Susan.

Answer 19

Provide high level of predicatability

Question 20

vicious cycle model of dental anxiety and fear

Answer 20

fear/anxiety -> avoidance -> deterioration in dental status -> feelings of shame and inferiority

Question 21

4 factors associated with development and maintenance of anxiety about dental treatment

Answer 21

parents views, past experiences, media, poor knowledge of pain relief

Question 22

4 treatments to manage anxiety

Answer 22

knowledge
hypnosis
drugs - diazepam - benzodiazepines - not for asthmatic though
sedation
relaxation training
give control - stop signals

Question 23

give comment on effectiveness of anxiety treatments

Answer 23

sedation = relaxed and don’t remember
drugs = short-term
relaxation training = jacobson’s deep muscle relaxation technique

Question 24

a Likert scale

Answer 24

The Likert scale typically has five to seven points, with the midpoint representing a neutral point or a lack of opinion. For example, a Likert scale for measuring attitudes towards a particular food item might look like this:

Strongly like
Like
Neither like nor dislike
Dislike
Strongly dislike

Question 25

List provoking and maintaining factor in relation to dental anxiety

Answer 25

• Provoking – bad experience, depression & anxiety, high neuroticism
• Maintaining – high neuroticism, selective memory and attention, biased judgement

Question 26

Outline some anxiety psychological help methods

Answer 26

• Deep muscle relaxation to calm at time of stress
• Simple desensitisation and fear hierarchy
• Anxiolytics eg benzodiazepine
• Give patient control
• Provide high level of predictability

Question 27

Elaborate relative effectiveness of anxiety treatments

Answer 27

• Control – effective if dentist adheres to it. Useful as allows patient to trust dentist. They feel less anxious as they feel they know they can stop the treatment at any time
• Anxiolytics – very effective at reducing anxiety but not a cure to the cause of anxiety. However, if they allow for a good experience then patient will be less anxious for future appointments

Question 28

Relative effectiveness of anxiety treatments

Answer 28

• Control – effective if dentist adheres to it. Useful as allows patient to trust dentist. They feel less anxious as they feel they know they can stop the treatment at any time
• Anxiolytics – very effective at reducing anxiety but not a cure to the cause of anxiety. However, if they allow for a good experience then patient will be less anxious for future appointments

Question 29

name 9 protected characteristics

Answer 29

age
disability
gender
gender reassignment
marriage/civil partnership
pregnancy and maternity
race and ethnicity
religion and belief
sexual orientation

Question 30

Select two protected characteristics from the above question, and for each characteristic, describe the relationship with two aspects of oral health or dental care on which the characteristic impacts.

Answer 30

Socioeconomic status:
Individuals from lower socioeconomic backgrounds may have limited access to dental care due to financial constraints or lack of dental insurance.
They may also be more likely to have poorer oral health outcomes, such as higher rates of dental caries and periodontal disease, due to factors such as poor nutrition and inadequate oral hygiene.

Race and ethnicity:
Individuals from certain racial and ethnic groups may have higher rates of oral health disparities, such as tooth decay and gum disease, compared to other groups.
They may also be more likely to face cultural or language barriers when seeking dental care, which can impact their ability to understand instructions and communicate their needs to dental providers.

Gender:
Women may be at higher risk for certain oral health conditions, such as periodontitis, due to hormonal changes throughout the menstrual cycle, pregnancy, and menopause.
Women may also face unique challenges in accessing dental care, such as scheduling appointments around menstrual cycles or pregnancy-related appointments.
It is important to consider these protected characteristics and their impact on oral health and dental care in order to provide equitable and accessible care to all individuals. Dental providers can work to address barriers to care, provide culturally competent care, and tailor treatment plans to meet the unique needs of each individual.

Question 31

In relation to the tooth structure, what level of severity of dental caries is recorded by “obvious caries experience”?

Answer 31

Obvious caries experience typically refers to the presence of VISIBLE, CLINICALLY OBVIOUS dental caries, also known as cavitated carious lesions. These are cavities that have progressed to the point where there is a hole or pit in the tooth structure, indicating that decay has penetrated the enamel and dentin layers of the tooth.

Likely refers to the presence of ICDAS codes 3-6, indicating cavitated carious lesions of varying severity. The exact severity level would depend on the specific classification system used and the extent and depth of the lesions present in the teeth.

Question 32

Briefly outline the observed differences in levels of dentinal caries for children of different ethnic minority groups in UK:

Answer 32

Caries and oral cleanliness

Asian (Indian, Pakistan, Muslim)- Primary dental health
* Primary dentinal caries in Asian children higher than white boys
* Significantly lower prop. of Asian kids had good to fair oral cleanliness scores

Vietnamese & Chinese
* Higher levels of dental caries in primary teeth than white counterparts
* No significant difference between Chinese/White oral cleanliness

Black dental health
* No significant difference between primary or permanent dentition either relating to caries or oral cleanliness

Question 33

Discuss the explanations for difference in levels of care in children from different ethnic minority that have been put forward for this

Answer 33

• High proportion of Muslims and Asians brush daily, however there is a marked decline in number who use toothpaste in comparison to white boys -Religious reasons
• Much less Asians use a toothbrush & toothpaste compared with whites but still clean daily
• Socio-economic status, religion, fluency language all risk factors
• The second generation of ethnic minorities are influenced by the attitudes of their elders.
• This may be a lack of understanding of the importance of oral hygiene and diet. There have been reports of alternative teeth cleaning methods.
• It is also due to the attitude towards the dentist. Ethnic minorities tend to visit the dentist to solve problems; not for prevention.
• There is also a level of mistrust towards the dentist here, perhaps caused by a language barrier

Question 34

What types of oral health intervention and care might be particularly appropriate to address caries in children of minoric groups?

Answer 34

• The second generation are pivotal as their attitudes will be passed onto the next generation
• We should try influence the attitude rather than provide info
• There is evidence that second generations have differing attitudes from parents due to acculturation. There is a shift towards acceptance of standard oral health measures
• Through persistently trying to raise awareness of the importance of correct oral hygiene and diet the general attitudes of ethnic minorities can be changed

1. Their influence on next generation is crucial
2. Vital importance dental health education is targeted at this group

Question 35

what is Townsend Index Score

Answer 35

Index of material deprivation (unemployed, houses, overcrowding, household without car)

Question 36

Name 4 socio-demographic factors

Answer 36

age
gender
ethnicity
class

Question 37

Name 4 demographic factors (characteristics of a population, expressed statistically):

Answer 37

Gender, age, postcode, employment status, religion, birth rate, death rate

Question 38

Name 4 types of questionnaires

Answer 38

• Open
• Closed
• Scales (Likert scales)
• Yes/No
• Rhetoric

Question 39

You are a young VT dentist in general dental practice. You are about to see Joe Green, 40, who is a regular attender at the practice and is complaining of jaw pain. You have treated him before, and he is generally quite relaxed and jovial. As he enters your surgery, reading his body language, you can see that he is unusually tense and distracted.
1. You are about to start your consultation with Joe. There are six steps in structuring a consultation, with the first initiating, and the last closing the consultation. What are the other four elements?
(4 marks)

Answer 39

1. initiation
2. gathering the info
3. physical examination
4. diagnosis and treatment planning
5. explanation and discussion
6. closing

Question 40

Joe reports his wife says that he is grinding his teeth in the middle of the night and keeping her awake. Give examples of the questions you might ask early on the consultation?
* To check in re patient’s reason for the dental visit. (1 mark)
* Pain history (2 marks)
* Other habits (1 mark)

Answer 40

Can you tell me more about the teeth grinding that your wife has noticed? When did she first notice it? Does it happen every night or just occasionally?

Have you noticed any pain or discomfort in your teeth or jaw? If so, when does it usually occur and how long does it last?

Have you ever been diagnosed with bruxism (teeth grinding)?

Have you noticed any changes in your teeth or bite?

Do you have any other habits or conditions that could be related to teeth grinding, such as anxiety, stress, or sleep apnea?

Have you been experiencing any other dental or oral health issues recently?

Have you tried any remedies or treatments for teeth grinding in the past?

Are you currently taking any medications or supplements that could be contributing to your teeth grinding?

Question 41

You’ve continued the history taking, checked the past medical history, and during your social history, your patient reveals that after he’d been furloughed, he’d lost his job due to the pandemic, things are financially difficult, and he’s visibly upset and stressed. How would you deal with this information, and what statements could you make to reassure the patient?
(2 marks)

Answer 41

“I’m sorry to hear that you’re going through a tough time right now. It’s understandable to feel stressed and upset given the current circumstances.”

“It’s important to know that you’re not alone in this. Many people are facing financial challenges due to the pandemic.”

“We can work together to explore resources that may be available to help you during this time.”

“It’s important to take care of both your physical and mental health, especially during times of stress. Is there anything specific that has helped you cope in the past?”

“Please don’t hesitate to reach out to me or our clinic if you need support or resources in the future.”

Question 42

On further examination you notice evidence of tension in his muscles of mastication around the TMJ on his right side. What information would you give him in relation to possible cause?
(2 marks)

Answer 42

stress and anxiety
bruxism
malocclusion
arthritis

Question 43

The face is key to judgments of attractiveness. Please list THREE findings from psychology that support this notion.
(3 marks)

Answer 43

facial symmetry is a key of attractiveness

the golden ratio = 1:1.618

babyface features - round face, large eyes, small nose and mouth

Question 44

The face is key to judgments of attractiveness. Please list THREE findings from psychology that support this notion.
(3 marks)

Answer 44

facial symmetry is a key of attractivenes

the golden ratio = 1:1.618

babyface features - round face, large eyes, small nose and mouth

Question 45

People who are smiling are perceived more positively. Please list THREE traits or characteristics that smiling people are rated to be higher on.
(3 marks)

Answer 45

approachability
likability
competence

Question 46

What proportion of people living with facial disfigurement report that their healthcare professionals had no or little understanding of their condition?
(1 mark)

Answer 46

According to Changing Faces, a UK charity that supports people with visible differences, around 75% of people with facial disfigurement have reported that their healthcare professionals had no or little understanding of their condition.

Question 47

Please list TWO hurtful behaviours that people living with facial disfigurement are often subjected to.
(2 marks)

Answer 47

staring and unwanted attention
discrimination

Question 48

Please list THREE of the psychological consequences of living with cleft lip and palate?).
(3 marks)

Answer 48

low self esteem
body image dissatisfaction
social anxiety

Question 49

Describe THREE reasons why people who score higher on neuroticism tend to have poorer body image.
(3 marks)

Answer 49

heightened self-consciousness
negative effects are experienced more negatively
perfectionism

Question 50

One afternoon in the middle of a normal working week a 10-year-old child comes into the dental practice on his own. He tells the receptionist he has a sore tooth and asks if he can be seen. The dentist, Ms Sim, sits him down so she can have a talk with him.

Ms Sim’s primary responsibility in the situation is to the child’s welfare. List FIVE priority areas of information gathering in this respect when she speaks with the boy.

(5 Marks)

Answer 50

pain assessment
medical history
dental history
family situation
consent

Question 51

Ms Sim then decides that it would be appropriate to conduct a dental examination.

You may assume:

• It is not an emergency situation.
• There is no bleeding or trauma to oral tissues.
• The administrative tasks around patient registration and creating a record have been dealt with.
• Ms Sim has consulted with a colleague and/or defence organisation before proceeding, and has documented in the notes any advice received.Apart from the examination work itself, list FIVE tasks for Ms Sim in relation to this.

Answer 51

explain the steps of examination
obtain consent
asses pain and anxiety levels
document findings
provide post-op instructions

Question 52

Contributory negligence applies when

Answer 52

The patient’s own actions of a neglectful nature also contributed to the harm