PP BDS4 Flashcards
Why might a first molar be impacted?
Angle of path of eruption
Small maxilla
Morphology of surrounding teeth
Ectopic crypt
What are the deleterious effects of impacted teeth?
Root resorption
Bone loss
Tooth loss
Ectopic teeth
Tilting and tipping of teeth
What features of the permanent dentition allow for replacement of primary teeth without crowding?
Slightly proclined permanent teeth
Natural space between the primary teeth allows for relief of crowding in permanent dentition
Leeway space (extra mesial- buccal - distal space occupied by primary molars)
- 5mm per side on upper
- 5mm per side on lower
What is an extrusion injury?
Partial displacement of the tooth out its alveolar socket characterised by partial or total separation of the PDL resulting in loosening of the tooth within its socket
What thickness of stainless steel wire would you use for a flexible splint?
0.6 mm
How long would you splint an extrusion injury for?
Flexible splint for 2 weeks
What are the different types of dentinogenesis imperfecta?
Type 1 = associated with osteogenesis imperfecta
Type 2 = not associated with osteogenesis imperfecta
Type 3 = brandywine isolate (rare condition)
What are the clinical signs of Dentinogenesis Imperfecta?
Loss of enamel
Discolouration
Both primary and permanent teeth affected
What are the radiographic signs of Dentinogenesis Imperfecta?
Bulbous crowns with apparent cervical constriction
Periapical radiolucency without any apparent pathology
Obliterated (missing) pulp chamber and canals due to deposition of dentine
Reduced root length with rounded apices
What are the risks of orthodontic treatment?
Root resorption Relapse Decalcification Gingival recession Trauma Loss of vitality
5 year old brought to clinic, she is pyrexic, in pain and has a swollen left side of face associated with gross caries in all primary molar teeth - you provisionally diagnose an acute periapical abcess
What should you establish prior to the examination of her?
What would be your short term management of this case?
Thorough history;
Pain history
Medical history
Dental history
Determine if airway is compromised;
If patient is unable to swallow or they are unable to push their tongue forward in the mouth, send to emergency services
Pain relief - ibuprofen Abscess drainage Antibiotics due to systemic involvement Amoxicillin capsules 250mg or oral suspension 125mg/5ml 500mg x 3 daily for 5 days Review patient in 5 days time
Advise that if pain or swelling gets worse, to go to A&E
What are the general indications for a pulpotomy?
Good child co-operation Medical history precludes extraction Missing permanent successor Overriding necessity to preserve the tooth e.g. space maintainer Child is under 9
What are the clinical indications for a pulpotomy?
Pulp minimally inflamed/reversible pulpitis
Marginal ridge destroyed
Caries extending >2/3rds into dentine
What are the clinical indications for a pulpectomy?
Exposure of hyperaemic pulp
Irreversible pulpitis
Acute abscesses
What are the advantages of non-vital bleaching?
Simple procedure
Tooth conserving
Original tooth morphology remains
What are the disadvantages of non-vital bleaching?
Risk of spillage of bleaching agent
May fail to bleach teeth effectively
Can over bleach the teeth
Can cause brittleness of tooth
Describe the bleaching inside-out technique
Open up access cavity of tooth
Ensure root filling is removed to below gingival level
Provide custom made mouthguard with windows cut out of the guard for the teeth that aren’t being bleached
Patient applies bleaching agent (10% Carbamide Peroxide) to back of tooth and tray
Patient keeps access cavity clean, replacing gel and removing debris every 2 hours except during the night
Tray should be worn at all times except when eating and cleaning
When does primary tooth eruption begin and end?
Begins at 6 months and ends around 2.5/3 years of age
What are the eruption dates for the permanent dentition?
6 yrs = 6s and lower 1s 7 yrs = upper 1s and lower 2s 8 yrs = upper 2s 9 yrs = lower 3s 10yrs = 4s and 5s 11 yrs = upper 3s 12 yrs = 7s
How long does it take for a permanent tooth root to complete apexogenesis?
3 years
Name 4 types of Amelogenesis Imperfecta
Type 1 = Hypoplastic
Type 2 = Hypo-maturational
Type 3 = Hypo-calcified
Type 4 = Mixed with taurodontism
What are the causes of Amelogenesis Imperfecta?
Caused by inherited gene mutations which are responsible for making proteins needed for normal formation of enamel
What orofacial injuries are suspicious of child abuse?
Bruising of face Bruising of ears Burns Lacerations Bites Neck marks Fractures
You wish to refer a child who you suspect may be victim to child abuse. Who do you refer to and how do you do it?
Observe the child - assess, take a history and examination
Record everything in notes
Communicate with patient and parents regarding concerns
Communicate with senior colleague or dental protection for advice
Refer to social services for suspicions of abuse, neglect or if child is at risk (confirm in writing)
Inform other relevant professionals e.g. GP, schoolteacher
Contact police if you feel the child is in immediate danger
Follow up within 48 hrs
3 year old child attends with blisters on gums - what is the likely diagnosis?
How might the blisters appear clinically?
Primary herpetic gingivostomatitis
Numerous vesicles which may rupture rapdily to form painful ulceration covered by a greyish slough
How would you manage a young patient with primary herpetic gingivostomatitis?
Reassurance advice;
Lesions heal spontaneously in 1-2 weeks
Advise on infectious nature to patients eyes and other people who are immunocompromised
Treatment;
Plenty of bed rest and high fluid intake to keep hydrated
Use of analgesics - NSAIDS
Refer to specialists if concerned about ability to eat and drink as patient may require aciclovir
OHI - use of CHX mouthwash and keep up brushing
What future issues may primary herpectic gingivostomatitis cause in the future?
Reactivation causing herpes labialis
Bells palsy
What are the indications for a SSC?
When there are >2 surfaces affected with extensive lesions
When there is impaired OH and high caries rate
If space is required to be maintained
Poorly co-operating children that would not cope with LA
After pulpotomy/pulpectomy
In severe MIH/enamel defect cases
Describe the appearance of dental fluorosis
Opaque white spots/streaks on teeth
Mottled patches in mild cases
Brown staining and putting of the teeth in severe cases
What is the most common cardiac defect in children? What condition is commonly associated with this condition?
Ventricular septal defect
Downs Syndrome
Name medical issues that are seen in patients with down’s syndrome
Leukaemia Epilespy Hypothyroidism Periodontal disease Coeliac disease Alzheimer's Ventricular septal defect
What are the indications for microabrasion?
Ortho decalcification
Fluorisis
Trauma
Pre-veneer
How is microabrasion carried out?
Pre-op photos, shade, sensibility
Teeth are cleaned with pumice and water
Polish with finest sandpaper disc and then with toothpaste
Ensure patient doesn’t eat coloured stained foods for 24-48hrs
Review after 4-6 weeks
Regarding Autism, what is the Triad of Impairment?
Used to describe the main features of people with autism;
Communication
Social interaction
Social imagination
What features do people with autism have?
Difficulties with;
Communication
Social interaction
Social imagination
Sensory sensitivity
Learning difficulties
Epilepsy
OCD
How may anxiety be measured in a child?
Modified child dental anxiety scale 9 questions regarding past dental experiences Scores range from 8-45 Score of 9 = dental anxiety Score over 27 = extreme phobia
Give behavioural management techniques for an anxious child
Desensitisation Positive reinforcement CBT Progressive relaxation Tell-show-do Distraction technique Modelling - learn about environment by observing others `
What are the 4 types of cerebral palsy?
How are they classified?
Spastic
Ataxic
Athetoid
Mixed
Hemiplegia
Diplegia
Paraplegia
Quadriplegia
What is cystic fibrosis?
It is an autosomal recessive condition caused by chromosome 7 mutation of the gene for CFTR
This causes thick, excessive mucous in the lungs, pancreas and salivary glands
What are the general signs and symptoms of cystic fibrous?
Recurrent chest infections
Thick salivary secretions
Respiratory problems
Under development
What are the dental considerations for cystic fibrosis?
Thick saliva can increase calculus production
Difficulties cleaning due to respiratory problems
Avoidance of GA and sedation
May have delayed eruption and enamel defects
What type of splint is recommended for an avulsion injury?
EADT <60 mins = flexible splint 2 weeks
EADT >60 mins = flexible splint 4 weeks
What is EADT?
Extra alveolar dry time
Time it takes from avulsion to placement in storage medium
This is a critical time, as the longer the EADT, the more damage to the PDL
What methods can be used to prevent orthodontic decalcification?
Correct case selection OHI Diet advice FS Regular GDP and hygienist appointments
Name intra-oral features than a patient with a class III malocclusion may have What systemic condition may the patient have if his mandible keeps growing?
Reverse overjet Anterior/posterior crossbite May have an overbite Maxilla often crowded Proclined upper incisors Retroclined lower incisors Tendency for displacement on closing
Acromegaly
What foramen does the i) opthalmic branch ii) maxillary branch iii) mandibular branch pass through?
i) Superior orbital fissure
ii) Foramen rotundum
iii) Foramen ovale
What is the origin, insertion, innervation and function of the masseter muscle?
Masseter;
Origin = zygomatic arch
Insertion = lateral surface and angle of mandible
Innervation = masseteric branch of mandibular division of trigeminal nerve
Function = elevates mandible
What is the pathology of a squamous cell carcinoma?
80% are moderately well differentiated (look similar to normal cells)
Local extension of disease
Increased mitotic activity (increased division of cells)
Abnormal keratinisation
Hyperchromatic nuclei (larger in size and stain darker)
Cellular pleomorphism (cells variant in size colour etc)
Basal cell hyperplasia (cells have increased size)
Elongated rete pegs
List signs and symptoms of a mandibular fracture
Pain Swelling Bruising Limitation of function Occlusal derangement Numbness of lower lip Mobile teeth Internal/external bleeding of the ear AOB Facial asymmetry Deviation of mandible
What two radiographs are required for a mandibular fracture?
OPT
PA mandible
CBCT
What factors can cause displacement of mandibular fractures?
Direction of the fracture line Opposing occlusion Magnitude of force Mechanism of injury Intact soft tissue Other associated fractures
List three management options for a mandibular fracture?
Undisplaced fracture = no treatment (monitor)
Displaced fracture =
closed reduction and fixation
or
open reduction internal fixation
You have extracted tooth 26 but the bleeding won’t stop
List how you would manage the situation and gain haemostasis
Ensure you have accurate medical and drug history
Identify where bleeding is coming from
Apply firm pressure using a damp gauze
Administer LA with vasoconstrictor
Haemostasis aids - Whitehead varnish pack
Suture socket
Ligation of vessels with Diathermy
What is the scientific term for a dry socket?
Alveolar/Localised Osteitis
What are predisposing risk factors for dry socket?
Molars more common Mandible more common than maxilla Smoking More common in females Oral contraceptive pill can increase risk Excessive trauma during procedure Excessive mouth rinsing post extraction Family history or previous dry sockets
What are the treatment options for a dry socket?
Supportive;
Reassure patient and give them information on dry sockets
Management;
Give LA to relieve pain
Irrigate socket with warm saline to wash out debris
Can use WHVP to encourage clot formation
Advise patient on analgesia and hot salty mouthwash use at home
What is pericoronitis?
Inflammation of a partially erupted tooth due to food and debris getting trapped under operculum resulting in inflammation and/or infection
How is pericoronitis treated?
Reassure patient and advise them on what pericoronitis is
If any abscesses present, adminster LA, incise and drain
Wash underneath operculum with CHX mouthwash
Possible extraction of 3rd molar
Advise patient on analgesic and CHX mouthwash use at home
Only prescribe antibiotics if patient systemically unwell or immunocompromised
If patient has large extra-oral swelling with systemic symptoms, refer to A&E
What radiographic signs show a close relationship of a lower 8 with the inferior alveolar nerve/canal?
Diversion of the inferior alveolar canal
Darkening of the root where crossed by the canal
Interruption of the lamina dura of the canal
Deflection of the root
Narrowing of the canal
Juxta apical area - radiolucent area lateral to the root rather than at the apex
What risks should be explained to the patient in regards to damage of the IAN when extracting the tooth
Dysaesthesia = painful, uncomfortable sensation of the lower lip, chin and tongue
Altered taste
Numbness (anaesthesia) or tingling (paraesthesia) of the lower lip, chin and tongue
Temporary IAN anaesthesia = 10-30% risk
Permanent IAN anaesthesia = <1% risk
What is the difference between an OAF and OAC?
An OAF is a chronic epithelial lined tract between the maxillary sinus and the oral cavity
An OAC is an acute communication between the max sinus and oral cavity which is not epithelial lined
What nerve supplies the TMJ?
Auriculotemporal and masseteric branches of the mandibular branch of the trigeminal nerve
What are the mechanisms of a bite splint?
Exact function is unknown but it is thought that they stabilise the occlusion and improve function of the masticatory muscles, thereby decreasing abnormal activity
What is arthocentesis?
Procedure in which the jaw joint is washed out with sterile saline and anti-inflammatory steroids
This breaks down fibrous adhesion and flushes away inflammatory exudate
What are the signs and symptoms of a ZOC (Zygomatico-orbital complex) fracture, involving the orbit floor?
Asymmetry Altered sensation Lacerations Sub-conjunctival haemorrhage (biggest indicator) Numb cheek Visual disturbances Pain on eye movement Peri-orbital ecchymosis (panda eyes)
What imaging would you request to confirm a ZOC fracture diagnosis?
Occipitomental (OM) views 15 and 30 degrees
CT scan
What are the management options for a ZOC fracture?
Leave alone and monitor
Open reduction and internal fixation
Closed reduction - Gillies lift
What factors does an implantologist consider before placing an implant?
Smoking status Medical and drug history Alveolar bone quality and quantity OH and periodontal status Patient motivation and compliance Overall occlusion Patient aesthetic Final prosthetic considerations
What bone dimensions are required for implants and how are these dimensions measured?
1.5mm horizontal bone around the implant
3mm between implants
7mm spacing between crowns
>5mm space for the papilla between the bone crest and contact points
2mm from adjacent structures e.g. max sinus
Assessed with a CBCT
How would you manage the loss of a tooth/root in the maxillary sinus?
Inform patient Confirm using post-op radiographs Surgical removal using Caldwell-luc approach Close with buccal advancement flap Or ENT involvement
What are the SIGN Guidelines for not advising the removal of wisdom teeth?
In patients whose 3rd molar would be judged to erupt successfully
In patients whose MH renders the removal an unacceptable risk (risk exceeds benefit)
In patients with deeply impacted 3rd molars with no history or evidence of pathology
In patients where the risk of surgical complications is judged to be unacceptably high
What type of flap is used for the removal of an impacted lower 8?
Envelope - 3 sided flap
What tissues may be responsible for the prolonged bleeding after an extraction and how would you manage each of these?
Soft tissues = LA use or suturing
Bone = WHVP or bone wax
Vessels = Diathermy
A patient is keen to pursue open flat curettage for his teeth which have 6-7mm pocket depths and BOP. He has previously. Completed HPT. What information would you give the patient. So he can give informed consent?
Explain the surgery;
Involves opening up the gum, removing calculus deposits, water irrigation, suction and suturing with stitches
Risks; Gingival recession Infection Bleeding, bruising and swelling Pain
Benefits;
Effectively debrides(cleans) the area to regenerate lost periodontal tissues
Has better outcomes than repeating NSHPT
Outcomes;
Surgical therapy has been shows to result in clinical improvement
Reduction in probing depths is greater following surgical treatment
Other options;
Repeat NSHPT
Regenerative therapy
Furcation resective treatment
Risks if they do not have treatment; Increased likelihood of tooth loss Increase mobility Increased pocket depths Possible pathologies may occur
Following surgical treatment, what do you want the patient to know to minimise the incidence of any post-operative complications?
Post-op surgical advice is highly important
Pain is common, you can take analgesics prior to the LA wearing off and then take regular doses as required but the pain should settle over the week
Bleeding can occur, if this does happen, use a damp piece of gauze to bite down on with firm pressure - if bleeding does not stop, go to GDP or A&E if out of hours
Ensure you do not explore or traumatise the area with finger, food etc.
Do not rinse out for 24hrs as this can dislodge the blood clot, after 24hrs rinse gently with warm salty mouthwash
Do not exercise or partake in strenuous activity
Avoid hard, sticky, hot food and drinks
Avoid alcohol and smoking for as long as possible as this will delay healing
Bruising is normal and can occur, use ice pack to reduce area if required
Pain and stiffness of TMJ is common and should settle over 1-2 weeks but it it prevents you from eating or lasts longer = seek advice
Sutures;
Leave sutures alone and do not pull them out
Inform patient if they have resolvable or non-restorable stiches and whether they need to return to have stitches removed
Mouthwash;
Use warm salty mouthwash or CHX 2-3 times a day
Name alternative techniques for an IAN block?
Gow-gates block
Akinosi block
How do you manage a patient if you accidentally inject into the parotid gland?
Inform patient and reassure them that it is a reversible condition
Provide eye protection until their blink reflex returns
Advise that length of paralysis can vary but will improve over a period of weeks
Review the patient
What does dentally fit mean?
Classed as dentally fit if you are free from any active disease prior to the start of cancer therapy
What is a multi disciplinary team?
It is a team of individuals from various disciplines/specialities who work together to provide the best holistic care and best treatment options for the patient
What oral risks is a patient at following radiotherapy?
Xerostomia Mucositis Osteoradionecrosis Increased risk of infection Poor wound healing Caries Ulceration
What are the oral risks of chemotherapy?
Xerostomia Mucositis Increased risk of bleeding and bruising Increased risk of infection Mouth ulcers Halitosis Reduced sense of taste
What are the grades of mucositis?
Grade 0 = nothing to note Grade 1 (mild)= oral soreness and erythema Grade 2 (moderate) = oral erythema and ulcers, solid diet tolerated Grade 3 (severe) = oral erythema and ulcers, liquid diet only Grade 4 (life threatening) = oral feeding impossible
How is Mucositis managed?
Sook on ice cubes for cooling effect
Morphine lollipops for pain management
UVB light therapy
Calcium and phosphate mouthwash
Smooth teeth and dentures to prevent further ulceration
Avoid smoking, alcohol, spicy food and drinking tea/coffee
How can mandibular fractures be classified?
A. Involvement of surrounding tissues;
Simple
Compound
Comminuted
B. Number of fractures present;
Single
Double
Multiple
C. Side of fracture;
Unilateral
Bilateral
D. Site of fracture; Angle Sub-condylar Para-symphyseal Body Ramus Coronoid Condylar Alveolar process
E. Direction of fracture line;
Favourable
Unfavourable
F. Specific fractures;
Green stick
Pathological
G. Displacement of fracture;
Displaced
Undisplaced
What factors can cause a mandibular fracture to be displaced?
Pull of attached muscle
Angulation and direction of fracture line
Integrity of periosteum (layer covering bone)
Extent of comminution
Force and displacement of blow
What are the signs and symptoms of a maxillary fracture?
Swelling Bruising Nose bleeds Restricted eye movement Malocclusion Tooth mobility Diplopia (double vision)
What is the Le Fort Classification system?
Type 1 = horizontal maxillary fracture, spreading teeth from the upper face (floating palate)
Type 2 = pyramidal fracture involving nasofrontal suture (floating maxilla)
Type 3 = maxilla is detached from base of skull (floating face)
What is a cyst?
A pathological cavity with fluid, semi-fluid or gaseous contents, not created by pus accumulation
Name 2 inflammatory cysts
Radicular cyst Residual cyst (cyst left after extraction)
Name 2 developmental cysts
KCOT (keratocystic odontogenic tumour)
Dentigerous cyst
Name 2 non-odontogenic cysts
Simple bone cyst
Nasopalatine cyst
Name 2 common treatment options for cyst removal/treatment, give advantages and disadvantages for both
Enucleation;
All of the cystic lesion is removed
Advantages;
Whole cyst lining is examined
Little after care needed
Allows primary closure
Disadvantages;
Incomplete removal can lead to recurrence
Damage to adjacent structures
Tooth loss can occur
Marsupialisation;
Creation of a surgical window in the wall of the cyst, removing the contents and suturing the cyst wall to surrounding epithelium
Advantages;
Simple to perform
May spare vital structures
Disadvantages;
Cyst may reform
Complete lining not available for histological sampling
Difficult to keep clean and lots of aftercare required
How does a radicular cyst develop?
They are dental cysts associated with the roots of the teeth and generally involved non-vital teeth
They usually have an inflammatory aetiology and is sequele to pulpitis
They develop from epithelial cell rests of Malassez
How do radicular cysts appear radiographically?
Well defined radiolucent around the apex of a tooth
Unilocular
Margins of lesion are continuous with lamina dura on either side of the root
How do radicular cysts appear histologically?
Epithelial lining often incomplete
Inflammation present in capsules
May form by proliferating epithelium with central necrosis
What is a dry socket and what is its official name?
Alveolar osteitis
It occurs when the blood clot at the site of the extraction site fails to develop, dislodges or dissolves before the wound has fully healed
This results in exposed and inflamed lamina dura
It is not associated with infections
How long should it approx. take for an extraction site to heal?
Initial healing 1-2 weeks
Soft tissue fully healed at 3-4 weeks
What is osteoradionecrosis?
Bone necrosis as a result of radiation injury
Any turnover of viable bone is very slow and self repair is ineffective - this can progress and get worse over time
What are the risks of orthognathic surgery?
Relapse Nerve damage Bleeding Unobtainable results for patients with high expectations Infections TMJD
Name 2 types of mandibular surgery
Bilateral sagittal split osteotomy (BSSO)
Vertical subsigmoid osteotomy (VSSO)
Name 2 types of maxillary surgery
Le fort 1
Anterior maxillary osteotomy
What are the principles of flap design?
Maximal access with minimal trauma
Wide based incision
Use scalpel in one firm continuous stroke
No sharp angles
Minimise trauma to dental papilla
No crushing of tissues
Flap reflection should be down to bone
Keep tissues moist
Ensure flap margins and sutures lie on sound bone
Ensure wounds are not closed under tension
Aim for healing by primary intention to minimise scarring
What do you assess on a radiograph prior to extracting a lower 8?
Angulation and orientation of impaction Access to tooth Crown size and condition Root number, length and morphology Alveolar bone levels Follicular width Relationship to maxillary sinus or IAN Any associated pathology Periodontal status of 7 and 8
What is the use of iodine in the extraction of a wisdom tooth?
Present in WHVP and Alvogyl
Used to manage dry sockets and achieve haemostasis
Name 3 types of nerve damage
Neuropaxia - blockage of nerve conduction due to contusion
Axonotmesis - myelin sheath damaged
Neurotmesis - nerve is transected
What are the aims of suturing?
To approximate and resposition tissues To compress blood vessels To cover bone Prevent wound breakdown Achieve haemostasis Encourage healing by primary intention
Name 4 types of sutures and give examples
Resorbable;
Monofilament = Monocryl
Multifilament = Vicryl Rapide
Non-Resorbable
Monofilament = Prolene
Multifilament = Mersilk
What might a patient complain of if they have a sialolith (saliva stone)?
Swelling associated with meals
Pain
Xerostomia
Bad taste
What gland is most commonly affected by a sialolith and why?
Submandibular gland
Due to position of gland and uphill path of saliva secretion
What investigations can be done for a sialolith?
Lower occlusal radiograph
Palpation of gland
Sialography
Isotope scan
How can you manage a sialolith?
Surgical removal
Sialography sialoendoscopic removal
Shock wave lithotripsy
Consider gland removal if fixed swelling
What are bisphosphonates and what conditions are they used for?
Bisphosphonates are a class of drugs that are used to help prevent and treat bone loss by increasing bone density Bisphosphonates reduce bone turnover by inhibiting osteoclast recruitment and function
Used for conditions such as; Osteroporosis Paget's disease Osteogenesis imperfecta Malignant metastasis Multiple myeloma
How is MRONJ diagnosed?
Patient must be on bisphosphonates or anti-angiogenic drugs
No history of head and neck radiotherapy
Exposed bone/lack of extraction site healing at 8 weeks review
How is a patient determined high or low risk of MRONJ?
Low risk;
Isolated osteoporosis patients with no other co-morbidities
Oral medication with treatment span of less than 5 years
High risk; Cancer patients Previous MRONJ patients Cumulative drug dose IV medication
How would you manage a patient taking bisphosphonates in general practice, if they are going to be receiving an extraction?
Advise patient on risk of MRONJ due to medication
Patient must have excellent OH
CHX use prior and after extraction
Drugs may be stopped prior to extraction but this must be consulted with physician in charge of patients care
Atraumatic technique
Use of haemostatic agents - suturing, WHVP
Post op instructions
Review
What is MRONJ?
Medication related osteonecrosis of the jaw
It is a severe, adverse drug reaction, consisting of progressive bone destruction in oral region of patients
What is osteoradionecrosis?
Bone necrosis as a result of radiation injury
Any turnover of viable bone is very slow and self repair is ineffective - this can progress and get worse over time
What are the risk factors for osteoradionecrosis?
Radiation of head and neck - especially >60 Kv
Mandible affected more than maxilla due to limited blood supply
When dental procedures have been carried out prior to radiation therapy (extractions at least 2 weeks before)
Poor OH
Post radiotherapy damage, trauma etc.
How is osteoradionecrosis managed?
Surgical debridement;
Irrigation and removal of necrotic and infected tissues
Surgical micro vascular reconstructive therapy;
To restore blood flow to the area
Grafts;
Bone and soft tissue grafts may be required
Hyperbaric oxygen therapy;
Increase vascular ingrowth
How can osteoradionecrosis be prevented?
Extracting teeth of poor prognosis at least 2 weeks prior to radiotherapy
Ensuring patient dentally fit prior to radiotherapy
Keeping good OH throughout
Use of CHX mouthwash before and after extractions
Atraumatic extraction technique
Name 3 types of elevators and name three movements that are used for elevators
Couplands
Cryer’s
Warwick James
Wheel and axel
Lever
Wedge
What are the uses of elevators?
To provide point of application for forceps
To loosen teeth prior to using forceps
To extract a tooth without the use of forceps
Removal of multiple root stumps
Removal of retained roots
Removal of root spices
What is the function of a luxation?
They break the PDL to aid forceps use
What is osteomyelitis?
It is a bacterial infection of bone resulting in inflammation of the bone marrow which in turn can cause necrosis due to an increase in tissue pressure
What are the risk factors for osteomyelitis?
Odontogenic infections Fractures of the mandible Immunocompromised patients Malnourished patients Patients receiving chemotherapy
How it osteomyelitis managed?
Referral to specialist services
Antibiotic treatment - may require IV in acute cases
Drain pus if possible
Removal of non vital teeth in area of infection
Corticotomy
If fractured mandible, remove any wires, plates, screws etc. in area
Removal of necrotic bone
What is the nerve supply for the submandibular gland?
Parasympathetic innervation - from the chorda tympani branch of the facial nerve which unifies with lingual branch of mandibular nerve at the submandibular ganglion
What does the submandibular gland secrete?
Mixed serous and mucous secretions
What is the innervation of the parotid gland?
Sensory innervation - auriculotemporal nerve and greater auricular nerve
Parasympathetic innervation - glossopharyngeal nerve and auriculotemporal nerve
What does the parotid gland secrete?
Serous secretion
What is the nerve supply of the sublingual gland?
Parasympathetic = chorda tympani of facial nerve which unifies with lingual branch of mandibular nerve at submandibular ganglion
What does the sublingual gland secrete?
Mixed serous and mucous secretions but predominantly mucous in nature
What information is required when taking a history and investigating a patient with a large extra oral swelling, prior to looking in the patients mouth?
Thorough history including pain history How long has swelling been present? If/when did it increase in size? Temperature Respiratory rate Heart rate
What things would you note about a facial swelling?
Site/location of swelling Size of swelling Airway compromised? Duration of swelling Palpation (firm/mobile) Pus present Heat from area Colour Clear or diffuse borders Associated fever or malaise?
What is the criteria perimeters for SIRS (systemic inflammatory response syndrome)?
> 2 positive SIRS factors +/- suspected/confirmed infection;
Temp <35 or >38 degrees
Respiratory rate >20/min
Pulse >90/min
WCC <4 or >12
What is Ludwig’s angina?
Characterised by a bilateral cellulitis infection of the sublingual and submandibular spaces which can compromise the airway
Features include;
Raised tongue
Difficulty breathing and swallowing
Drooling
Diffuse redness and bilateral swelling of submandibular region
Name 4 maxillary and mandibular spaces
Maxillary; Infraorbital space Infra temporal space Palatial space Buccal space.
Mandibular; Buccal space Sub-masseteric space Sublingual space Submandibular space
List the cranial nerves
I = olfactory - smell
II = optic - vision
III = occulomotor - eye movement
IV =trochlear - eye movement
V = trigeminal - MOM, sensory info. for head and neck
VI = Abducens - eye movement
VII = facial - taste, muscles of facial expression
VIII = vestibulocochlear - hearing
IX = glossopharyngeal - taste, sensory info for tongue, swallowing
X = vagus - gland function, digestion and cardiac systems
XI = accessory - head movement
XII = hypoglossal - tongue movement
List the LA maximum does for Lidocaine, Prilocaine, Articaine and Mepivicaine
Lidocaine 2% + 1:80,000 adrenaline
Max dose = 4.4mg/kg
Prilocaine 4% plain
Max dose = 6mg/kg
Articaine 4% + 1:100,000 adrenaline
Max dose = 5mg/kg
Mepivicaine 2% + 1:80,000 adrenaline
Max dose = 4.4 mg/kg
Why is written consent gained prior to the sedation process?
Consent process should begin at a separate appointment prior to treatment - this allows the patient sufficient time to consider the information provided
Consent should be reconfirmed verbally on the day of the procedure
Name 3 vital signs you would monitor before, during and after sedation?
Heart rate
Blood pressure
Oxygen saturation levels
Give advices you would give to a patient after they have received sedation
No operating machinery or driving
Stay off social media, emails, online shopping etc.
No physical activities for the next 24hrs
No signing legal documents
No important decision making
What is postural hypotension?
It is an excessive fall in blood pressure when an upright position is taken caused by a failure of the auto regulatory systems which normally maintain blood pressure on standing
Name in order, the actions which take place in the body when a patient begins to lose consciousness due to postural hypotension
Venous pooling in legs Poor venous return Fall in stroke volume Fall in cardiac output Patient continues to lose consciousness
What may cause a patient to collapse?
Fainting Fear/anxiety Hypoglycaemic shock Dehydration Postural hypotension
What would you do differently for a patient that has postural hypotension at the end of an appointment?
Allow chair to sit up gradually over a couple of minutes and encourage patient to take their time when standing and take slow deep breaths
Schedule appts for 30-60mins after eating and taking medication
What is ABCDE and how are they assessed?
A = Airway
Jaw thrust, check mouth for any obstruction
B = Breathing
Ear to mouth, look at chest for movement
C = Circulation
Check carotid pulse
D = Disability AVPU scale A = alert V = verbal P = pressure (pinch pt.) U = unresponsive
E = Exposure
Look for clinical signs on body
What are the indications and contraindications for inhalation sedation. ?
Indications;
Medical conditions aggravated by stress e.g. asthma, epilepsy
Social conditions e.g. phobia, strong gag reflex
Dental conditions e.g. traumatic procedures
Contraindications;
Unable to nose breath
Severe COPD
1st trimester of pregnancy
What safety features are present on the quantaflex MDM machine used for inhalation sedation?
Oxygen flush button Reservoir bag Scavenger system Coloured cylinders Pin index system Minimum oxygen at 30% Built in oxygen monitor One way expiratory valve
What are the advantages of inhalation sedation over IV sedation?
Quicker onset Rapid recovery Not metabolised so safer than midazolam Less post op side effects No needles required Can be used on children Useful for anxiety relief
What medications are in the dental medical emergency kit including quantities and uses?
Adrenaline IM injection (1;1000, 1mg/ml) = anaphylactic shock
Aspirin (300mg) = suspected MI
Glucagon IM injection (1mg) = hypoglycaemic shock
Glyceryl trinitrate spray (400ug/dose) = angina
Midazolam 10mg buccal = >5min epileptic seizure
Salbutamol 100ug per puff = asthma attack
When might a referral for GA be made?
Medical history contraindicates sedation
Patient unco-operative, phobic
Children under 12 and special needs children who require comprehensive dental treatment
When there is extensive, complex treatment procedures required to be carried out
Benefits of GA outweighs risk
What are the stages of anaesthesia?
Induction
Excitement
Surgical anaesthesia
Respiratory paralysis/overdose
What needs to be included in a referral letter for GA
Patient details Guardian details (if appropriate) GMP and GDP details MH DH and justification for GA referral Radiographs to back up justification Treatment plan for during GA
If you are shown a direct immunofluorescence performed by a lab due to suspected pemphigus vulgaris - what is this method of analysis called?
What would the pathologist report of if pemphigus vulgaris is present?
Name one condition that would represent the lesion in the same way clinically, but would be different histopathologically?
Histopathology and direct immunofluorescence
Presence of tzank cells
Elongated rete pegs
Basket weave pattern on IF
Drug induced pemphigus
What is Pemphigus Vulgaris?
What causes it to form?
Usually begins in the mouth and is seen as clear fluid filled blisters that burst and then spread
Caused by intra-epithelial bullae blisters and sores on skin and mucous membranes
What are the risk factors for an oral squamous cell carcinoma?
Tobacco use Betel nut chewing Alcohol use HPV virus Poor diet and nutrition Poor OH Immunodeficiency Socioeconomic factors
If a tumour is 5cm in width, there are bilateral lymph nodes palpated <2cm in size and the cancer has not spread to any other structures
What is the stage of this tumour using the TNM system?
T3 = tumour >4cm N2b = metastasis in bilateral lymph nodes, no more than 6cm MO = no metastasis
What are the different grades for dysplasia histopathologically?
Mild - observe and re-biopsy
Changes in lower 1/3rd of architecture
Mild atypia
Pleomorphism and hyperchromatism
Moderate - remove
Change into middle third of architecture
Moderate atypia
Pleomorphism and hyperchromatism
Severe - remove Change in upper third of architecture Severe atypia Pleomorphism and hyperchromatism Enlarged nuclei Abnormal stratification and keratinisation
Name 2 microorganisms involved with angular cheilitis
What type of sample would you take in this case?
S. Aureus
C. Albicans
Swab the comminuted of the mouth
Name 1 immune deficiency disease and 1 GI disease that can increase the risk of Candida infections and explain why these disease can make an individual more susceptible?
Name 1 intra oral and extra oral disease that could be associated with the above two infections
HIV
Patient is immunocompromised which allows for harmless organisms to become pathogenic and cause infection
Crohn’s disease
Impaired nutrient absorption linked with immunosuppressive therapy increases likelihood of infection to occur
Intra-oral = Oral Candidiasis Extra-oral = Orofacial Granulomatosis (OFG)
Why is Miconazole prescribed to a patient when microbiological sampling is not available?
Miconazole cream is effective against both Candida and gram positive bacteria such as S. Aureus so is appropriate to use in all patients prior to sampling results
However, should not be used in patients taking warfarin or statins
How does Trigeminal Neuralgia occur?
Demyelination of trigeminal nerve
As nerve exists brain stem it has become compressed from a blood vessel
What clinical investigations would you do for trigeminal neuralgia?
Trigeminal nerve reflex testing Full neurological examination OPT to rule out dental cause MRI brain scan Blood tests - FBC Positive response to Carbamazepine confirms diagnosis
What 2 neurological disorders can give rise to trigeminal neuralgia?
MS
Tumour compressing on trigeminal nerve
What is the 1st line drug management for trigeminal neuralgia?
What blood tests must be carried out before beginning this medication?
Carbamazepine 100mg
Send 20 tablets
1 tablet twice daily
FBC
U&E test (urea and electrolyte test)
What are the side effects of Carbamazepine?
Liver dysfunction Allergies Nausea Xerostomia Sedation Nightmares
What are the indications for surgery for treating trigeminal neuralgia?
When medical intervention is ineffective
When medication has adverse side effects
When condition is seriously affecting quality of life
What surgery can be carried out for trigeminal neuralgia?
Peripheral neurectomies
Trigeminal nerve balloon compression
Microvascular decompression
What are the clinical and radiographic signs of Paget’s disease?
Clinical; Localised pain and tenderness Increase in temp. over the affected bones Increased bone size Bowing deformities Decreased range of movement Dentures become ill fitting
Radiographic;
Osteoporosis circumscripta
Radiolucent lesions resembling cysts
Radiopaque lesions due to hypercementosis
What are the clinical and radiographic signs of Albright’s disease?
Clinical;
Fibrous dyplasia
Skin pigmentation
Endocrine hyper-function
Radiographic;
Bone fractures
Fibrous dysplasia
What are the clinical and radiographic signs of Cherubism?
Clinical;
Painless bilateral enlargement of the jaws
Round face with swollen cheeks
Dental malocclusion
Radiographic;
Multilocular radiolucencies
Mandible/maxilla replaced with fibrous tissue
Facial sinuses appear obliterated
Name and describe different types of orofacial pain syndromes
Dental; Generally gets better or worse over time Usually acute Examples include: Mucoskeletal e.g. TMJD pain Visceral e.g. caries Atypical odontalgia e.g. dental pain without detected pathology
Non-Dental; Generally acute Examples include; Neuropathic e.g. Trigeminal Neuralgia Psychogenic e.g. persistent idiopathic facial pain
What is Sjorgen’s Syndrome?
It is a chronic inflammatory autoimmune disorder that can increases B-cell proliferation which destructs exocrine glands
It particularly affects secretion production at the mucous membranes which causes dry mouth, reduced tear production etc.
There are 3 types of Sjorgens Syndrome;
Partial Sjorgen’s - dry eyes and mouth
Primary Sjorgen’s - no CT (connective tissue) disease
Secondary Sjorgen’s - CT disease
What antibodies are linked with Sjorgen’s Syndrome?
Anti-Ro
Anti-La
Anti-nuclear antibodies (ANA)
What are the 6 investigations used to help diagnose Sjorgen’s Syndrome?
Dry eyes = persistent troublesome dry eyes for >3 months
Oral symptoms = dry mouth for >3 months
Salivary flow test = unstimulated <1.5ml in 15mins
Auto-antibodies = Positive Anti-Ro +/- Anti-La antibodies
Histopathology = postive labial gland biopsy
Ultrasonography
What are the histopathological features of Sjorgen’s?
Minor gland;
Focal collection of lymphocytes (50+)
Acinar loss and fibrosis
Major gland;
Lymphocytic infiltrate
Acinar atrophy
Epithelial hyperplasia
Name 4 oral complications of Sjorgen’s syndrome?
Increased risk of oral candida infection
Increased caries and periodontal disease risk
Poor denture retention
Functional loss
What drug is used to manage Sjorgen’s syndrome?
Pilocarpine which is a salivary stimulant
What features of a parotid swelling would make you suspect malignancy?
Localised swelling - firm mass Painless Fast growing Asymmetry of the gland Obstruction of the gland Attached to underlying structures
Where would you most commonly find a salivary neoplasm?
Parotid 80% of all tumours
Submandibular 10% of all tumours
Minor glands 10% of all tumours
Sublingual 0.5% of all tumours
What is ectodermal dysplasia?
What are the associated symptoms?
It is a diverse group of genetic disorders that affect the skin. hair, nails, teeth and glands
Symptoms include; Hypodontia and peg shaped teeth Poor functioning sweat glands Abnormal nails Cleft lip/palate Decreased skin pigmentation Large forehead Thin/sparse hair
What is an ulcer?
It is full thickness loss of epithelium, where you can see underlying CT and there may be deposition of fibrin on the surface
Can only be diagnosed histologically
What is an erosion?
It is partial thickness loss of the epithelium
Can only be diagnosed histologically
How would you differ between recurrent major and minor aphthous ulcers?
Minor; Size = <10mm Shape = round or oval with red halo Number = 1-20 per episode Histology = non-keratinising mucosa Duration = heals within 1-2 weeks Outcome = heals without scarring Affects = children more commonly affected
Major;
Size = >10mm
Shape = oval or irregular
Number = <5 at a time
Duration = heals within 6-12 weeks
Outcome = heals with or without scarring
Affects = keratinsed or non-keratinised mucosa
What are the potential problems of recurrent aphthous ulcers?
Infections
Dehydration and malnutrition
Problems wearing dentures
Affects speech and mastication
What are the causes of recurrent aphthous ulcers?
Host factors;
Nutritional deficiencies - iron
Systemic disease - Crohn’s
Genetic - HLA type 2
Environmental factors; Trauma Allergies Smoking Stress
How is RAS (recurrent aphthous ulcers) treated?
Correct underlying cause; Replace nutrient deficiencies Treat systemic disease Remove trauma Remove allergies e.g. SLS free toothpaste
Medication; Betamethasone mouthwash 0.5mg twice daily CHX mouthwash 0.2% twice daily Benzydamine oromucosal spray 0.15% Prednisolone steroid medication
What would microcytic blood results show?
Reduction of;
MCV (mean corpuscular volume)
Hb
RBC
What can cause microcytic anaemia?
Coeliac disease Crohn's disease Ulcerative colitis Iron deficiency Lead poisoning
What oral conditions are associated with microcytic anaemia?
Recurrent aphthae
Poor wound healing
Increased risk of candida infection
Burning sensation of oral mucosa
A patient has white plaques that can scrape off easily and leave an erythematous base, what is the diagnosis?
Name local and medical conditions that may cause this?
Pseudomembraneous candidosis
Local; Oral steroid Inhaler use Nutritional deficiencies Broad spectrum antibiotics
Medical;
Diabetes
HIV
Immunocompromised
What 2 drugs does Fluconazole interact with and what effects does it have on these drugs?
Warfarin
Increases the anticoagulant effect of Warfarin and is classed as a severe interaction as it can increase the likelihood of a catastrophic bleed as it increases the INR
Statin
Fluconazole has been predicted to increase the exposure to simvastatin and is classed as a severe interaction as it can increase risk of hepatotoxicity
What information is required on a lab sheet if you are requesting a sample?
Patient details - name, address, DOB, CHI
GDP and GMP details - name, address, contact no.
Patient MH, DH and SH
Clinical description of problem
Provisional diagnosis
Tests previously done and tests required to be done e.g. culture
Antibiotic use previous and currently
Date and time of sample
Referring clinician name and signature
What are the classifications of denture induced stomatitis?
Newton type I = Localised inflammation and erythema
Newton type II = Diffuse inflammation and erythema confined to denture bearing mucosa without hyperplasia
Newton type III = Granular inflammation with erythema and papillary hyperplasia
What is Denture Induced stomatitis?
It is the adherence and colonisation of acrylic surfaces caused by co-aggregation and biofilm formation
Results in inflammation and erythema of the denture bearing mucosa
Patient will often experience discomfort on this area and may also experience halitosis
What instructions would you give to a lab regarding special trays?
Primary impressions - Special trays Please pour impressions in 50/50 dentals tone and construct upper and lower special trays Upper 2mm spacer, lower 1mm spacer Both with intra-oral handles Thank you
What epithelium is affected in smokers keratosis?
Stratified squamous keratinised epithelium of the hard palate
What is the clinical presentation of smokers keratosis?
Thickened white patch with some dark brown/grey areas on the palate
Painless area
Other areas in mouth will indicate tobacco related staining
What histological and clinical presentation of smokers keratosis could indicate malignancy?
Histological;
Hyperkeratosis Hyperchromatism Atypia Dysplasia Infiltrate of macrophages
Clinical;
Raised rolled border
Indurated (hard) lesion
Non-homogenous
Describe desquamative gingivitis.
It is a non-specific clinical description of the gingivae (redness, burning, erosion, pain and plaque) which involves several dermato-mucous disorders
It is noted as inflamed gingivae which extends beyond the mucogingival margin with erythematous shedding and ulceration
Name 3 conditions that you would see desquamative gingivitis in? (In order of likelihood)
Lichen planus
Pemphigoid
Pemphigus
What local factors may exacerbate desquamative gingivitis?
Smoking Poor OH Overhangs Partial dentures SLS toothpaste
How would you manage desquamative gingivitis?
Confirm diagnosis and any underlying conditions and manage these appropriately e.g. blood tests Treat underlying cause Improve OH Topical steroid use - Betamethasone Systemic immunosuppressant
Name a gingival disease (apart from desquamative gingivitis) that is typically painful on presentation?
Erythema multiforme where the mucosa is affected by ulcer crops making it very painful resulting in difficulty eating and drinking
This is linked with Steven-Johnston syndrome
Name 3 local and 3 generalised causes of pigmentation
Local;
Amalgam tattoo due to macrophages and granulation tissue surrounding the amalgam
Pigmented incontinence linked with chronic inflammation
Mucosal melanoma secondary to metastatic cancers
Vascular malformations
General;
Racial
Smoking which causes leakage of melanocytes and sub-mucosal fibrosis
Medications e.g. contraceptive pill
Addison’s disease
What is a haemangioma?
It is an abnormal growth of tissue, indigenous (native) to the side which it grows during normal growth
It usually stops growing when the patient stops growing
Name 2 types of haemangioma and give 2 histological differences between the 2
Capillary haemangioma;
Groups of lots of small vessels
Generally capillary haemangioma
Cavernous haemangioma;
Few large cavernous haemangioma
Dilated vascular spaces
What are the causes of a pigmented tongue both local and systemic?
Local;
Smoking Food colourings Medications - hydroxychloroquine (anti-malarial) Chromogenic bacteria Melanoma
General;
Chemotherapy Racial Addison’s disease Lead poisoning Haemochromatosis (increased iron)
A patient presents with TMJD - are there any other conditions that may present with similar signs and symptoms, and how may you exclude these conditions?
Dental cause = peri-apical/OPT to examine
Sinusitis = radiograph of sinuses
Atypical facial pain - usually does not involve clicking of TMJ
Salivary gland pathology =. Radiograph of salivary glands
Trigeminal neuralgia = history of exacerbations
You decide to construct a stabilisation splint for a patient with TMJD, what instructions would you give to the lab?
Please construct a hard acrylic splint with full occlusal coverage using upper and lower alginate impressions and face bow registration provided
Thank you
What is the aetiology for Bell’s palsy?
Bell’s palsy is a type of facial palsy that has an unknown cause, it affects the excitability of the facial nerve.
It is ultimately caused by inflammation around the facial nerve and this inflammation/pressure causes facial paralysis on the affected side
It results in unilateral paralysis of the whole side of the face including the eyebrows
How is Bell’s Palsy managed?
Reassurance that paralysis will get better
Prednisolone steroids given within 72hrs of symptoms to reduce inflammation of facial nerve
Protect affected eye with eye patch and eye drops to protect the cornea
Review +/- referral if full recovery is not obtained within 3 months
How can you differentiate between upper and lower motor neuron disease?
UMN (stroke);
Spasticity
Can wrinkle forehead and move eyebrows but cannot move lower portion of face
LMN (facial palsy);
Flaccidity
Cannot wrinkle forehead, move eyebrows or move lower portion of face
How does the difference between upper motor neuron and lower motor neuron disease occur?
UMN lesion occurs in the supra-nuclear lesion whereas a LMN lesion affects the nucleus of the facial nerve
Give possible causes for LMN disease?
LMN (facial palsy);
Motor neurone disease
Guillain-Barré syndrome
Bell’s palsy
Trauma/viral infection of ventral horn cells.
Give possible causes for UMN disease?
UMN (stroke);
Stroke Multiple sclerosis Traumatic brain injury Cerebral palsy Spinal cord injury
What conditions may require patients to be on long term steroids?
Asthma COPD Addison’s disease Arthritis Crohn’s disease Lupus MS
What are the signs and symptoms of adrenal suppression?
Hypoglycaemia Dehydration Weight loss Disorientation Weakness Postural hypotension Oral pigmentation on buccal mucosa
What emergency can be associated with adrenal insufficiency
Adrenal crisis which is a medical emergency and potentially life threatening situation caused by insufficient levels of cortisol hormone
Why are asthmatics more prone to erosion?
Asthmatic medications place patients at risk of dental erosion as they reduce saliva production and protection against extrinsic and intrinsic acids
Asthmatic patients may also be more prone to GORD which can also cause dental erosion
What is a syncope?
It is known as fainting, which is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone which is followed by spontaneous recovery
It is generally characterised by a fast onset, short duration and spontaneous recovery
What are the physiological aspects of a faint?
It is a temporary malfunction in the autonomic nervous system due to a trigger which interferes with the autonomic nervous system resulting in a drop in blood pressure, reduction in oxygen and interruption of blood flow to the brain causing the patient to lose consciousness for a short period of time
How would you manage a patient that has fainted in your practice?
Assess the patient
Lay patient flat, raise the patients feet and loosen any tight clothing around the neck
Administer 100% oxygen - 15L/min until consciousness is regained
What is the proper name for burning mouth syndrome?
Who is most likely to be affected by burning mouth syndrome?
Oral dysaesthesia
Females>males
Mostly menopausal women
Aged around 40-60
What are the causes of burning mouth syndrome?
Nutritional deficiencies - B12, iron,folate Xerostomia Fungal infections - lichen planus Poorly fitting dentures Allergies Parafunctional habits Endocrine disorders - diabetes Stress, anxiety
What are the signs and symptoms of burning mouth syndrome?
Severe burning or tingling in the mouth, commonly affecting the tongue
Sensation of dry mouth with increased thirst
Taste changes such as a bitter taste
Loss of taste
What investigations might you carry out for burning mouth syndrome?
Blood tests = FBC, HbA1c Salivary flow rate assessment Intra and extra oral assessment Denture assessment Psychiatric assessment Full MH, DH and SH
