PP BDS4 Flashcards

1
Q

Why might a first molar be impacted?

A

Angle of path of eruption
Small maxilla
Morphology of surrounding teeth
Ectopic crypt

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2
Q

What are the deleterious effects of impacted teeth?

A

Root resorption

Bone loss

Tooth loss

Ectopic teeth

Tilting and tipping of teeth

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3
Q

What features of the permanent dentition allow for replacement of primary teeth without crowding?

A

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)

  1. 5mm per side on upper
  2. 5mm per side on lower
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4
Q

What is an extrusion injury?

A

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

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5
Q

What thickness of stainless steel wire would you use for a flexible splint?

A

0.6 mm

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6
Q

How long would you splint an extrusion injury for?

A

Flexible splint for 2 weeks

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7
Q

What are the different types of dentinogenesis imperfecta?

A

Type 1 = associated with osteogenesis imperfecta

Type 2 = not associated with osteogenesis imperfecta

Type 3 = brandywine isolate (rare condition)

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8
Q

What are the clinical signs of Dentinogenesis Imperfecta?

A

Loss of enamel
Discolouration
Both primary and permanent teeth affected

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9
Q

What are the radiographic signs of Dentinogenesis Imperfecta?

A

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

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10
Q

What are the risks of orthodontic treatment?

A
Root resorption
Relapse
Decalcification
Gingival recession
Trauma
Loss of vitality
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11
Q

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?

A

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

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12
Q

What are the general indications for a pulpotomy?

A
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
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13
Q

What are the clinical indications for a pulpotomy?

A

Pulp minimally inflamed/reversible pulpitis
Marginal ridge destroyed
Caries extending >2/3rds into dentine

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14
Q

What are the clinical indications for a pulpectomy?

A

Exposure of hyperaemic pulp
Irreversible pulpitis
Acute abscesses

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15
Q

What are the advantages of non-vital bleaching?

A

Simple procedure
Tooth conserving
Original tooth morphology remains

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16
Q

What are the disadvantages of non-vital bleaching?

A

Risk of spillage of bleaching agent
May fail to bleach teeth effectively
Can over bleach the teeth
Can cause brittleness of tooth

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17
Q

Describe the bleaching inside-out technique

A

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

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18
Q

When does primary tooth eruption begin and end?

A

Begins at 6 months and ends around 2.5/3 years of age

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19
Q

What are the eruption dates for the permanent dentition?

A
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
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20
Q

How long does it take for a permanent tooth root to complete apexogenesis?

A

3 years

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21
Q

Name 4 types of Amelogenesis Imperfecta

A

Type 1 = Hypoplastic
Type 2 = Hypo-maturational
Type 3 = Hypo-calcified
Type 4 = Mixed with taurodontism

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22
Q

What are the causes of Amelogenesis Imperfecta?

A

Caused by inherited gene mutations which are responsible for making proteins needed for normal formation of enamel

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23
Q

What orofacial injuries are suspicious of child abuse?

A
Bruising of face
Bruising of ears
Burns 
Lacerations 
Bites 
Neck marks
Fractures
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24
Q

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?

A

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

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25
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
26
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
27
What future issues may primary herpectic gingivostomatitis cause in the future?
Reactivation causing herpes labialis | Bells palsy
28
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
29
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
30
What is the most common cardiac defect in children? What condition is commonly associated with this condition?
Ventricular septal defect | Downs Syndrome
31
Name medical issues that are seen in patients with down's syndrome
``` Leukaemia Epilespy Hypothyroidism Periodontal disease Coeliac disease Alzheimer's Ventricular septal defect ```
32
What are the indications for microabrasion?
Ortho decalcification Fluorisis Trauma Pre-veneer
33
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
34
Regarding Autism, what is the Triad of Impairment?
Used to describe the main features of people with autism; Communication Social interaction Social imagination
35
What features do people with autism have?
Difficulties with; Communication Social interaction Social imagination Sensory sensitivity Learning difficulties Epilepsy OCD
36
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 ```
37
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 ` ```
38
What are the 4 types of cerebral palsy? | How are they classified?
Spastic Ataxic Athetoid Mixed Hemiplegia Diplegia Paraplegia Quadriplegia
39
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
40
What are the general signs and symptoms of cystic fibrous?
Recurrent chest infections Thick salivary secretions Respiratory problems Under development
41
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
42
What type of splint is recommended for an avulsion injury?
EADT <60 mins = flexible splint 2 weeks | EADT >60 mins = flexible splint 4 weeks
43
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
44
What methods can be used to prevent orthodontic decalcification?
``` Correct case selection OHI Diet advice FS Regular GDP and hygienist appointments ```
45
``` 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
46
``` 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
47
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
48
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
49
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 ```
50
What two radiographs are required for a mandibular fracture?
OPT PA mandible CBCT
51
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 ```
52
List three management options for a mandibular fracture?
Undisplaced fracture = no treatment (monitor) Displaced fracture = closed reduction and fixation or open reduction internal fixation
53
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
54
What is the scientific term for a dry socket?
Alveolar/Localised Osteitis
55
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 ```
56
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
57
What is pericoronitis?
Inflammation of a partially erupted tooth due to food and debris getting trapped under operculum resulting in inflammation and/or infection
58
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
59
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
60
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
61
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
62
What nerve supplies the TMJ?
Auriculotemporal and masseteric branches of the mandibular branch of the trigeminal nerve
63
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
64
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
65
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) ```
66
What imaging would you request to confirm a ZOC fracture diagnosis?
Occipitomental (OM) views 15 and 30 degrees | CT scan
67
What are the management options for a ZOC fracture?
Leave alone and monitor Open reduction and internal fixation Closed reduction - Gillies lift
68
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 ```
69
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
70
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 ```
71
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
72
What type of flap is used for the removal of an impacted lower 8?
Envelope - 3 sided flap
73
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
74
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 ```
75
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
76
Name alternative techniques for an IAN block?
Gow-gates block | Akinosi block
77
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
78
What does dentally fit mean?
Classed as dentally fit if you are free from any active disease prior to the start of cancer therapy
79
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
80
What oral risks is a patient at following radiotherapy?
``` Xerostomia Mucositis Osteoradionecrosis Increased risk of infection Poor wound healing Caries Ulceration ```
81
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 ```
82
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 ```
83
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
84
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
85
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
86
What are the signs and symptoms of a maxillary fracture?
``` Swelling Bruising Nose bleeds Restricted eye movement Malocclusion Tooth mobility Diplopia (double vision) ```
87
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)
88
What is a cyst?
A pathological cavity with fluid, semi-fluid or gaseous contents, not created by pus accumulation
89
Name 2 inflammatory cysts
``` Radicular cyst Residual cyst (cyst left after extraction) ```
90
Name 2 developmental cysts
KCOT (keratocystic odontogenic tumour) | Dentigerous cyst
91
Name 2 non-odontogenic cysts
Simple bone cyst | Nasopalatine cyst
92
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
93
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
94
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
95
How do radicular cysts appear histologically?
Epithelial lining often incomplete Inflammation present in capsules May form by proliferating epithelium with central necrosis
96
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
97
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
98
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
99
What are the risks of orthognathic surgery?
``` Relapse Nerve damage Bleeding Unobtainable results for patients with high expectations Infections TMJD ```
100
Name 2 types of mandibular surgery
Bilateral sagittal split osteotomy (BSSO) | Vertical subsigmoid osteotomy (VSSO)
101
Name 2 types of maxillary surgery
Le fort 1 | Anterior maxillary osteotomy
102
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
103
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 ```
104
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
105
Name 3 types of nerve damage
Neuropaxia - blockage of nerve conduction due to contusion Axonotmesis - myelin sheath damaged Neurotmesis - nerve is transected
106
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 ```
107
Name 4 types of sutures and give examples
Resorbable; Monofilament = Monocryl Multifilament = Vicryl Rapide Non-Resorbable Monofilament = Prolene Multifilament = Mersilk
108
What might a patient complain of if they have a sialolith (saliva stone)?
Swelling associated with meals Pain Xerostomia Bad taste
109
What gland is most commonly affected by a sialolith and why?
Submandibular gland | Due to position of gland and uphill path of saliva secretion
110
What investigations can be done for a sialolith?
Lower occlusal radiograph Palpation of gland Sialography Isotope scan
111
How can you manage a sialolith?
Surgical removal Sialography sialoendoscopic removal Shock wave lithotripsy Consider gland removal if fixed swelling
112
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 ```
113
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
114
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 ```
115
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
116
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
117
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
118
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.
119
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
120
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
121
Name 3 types of elevators and name three movements that are used for elevators
Couplands Cryer’s Warwick James Wheel and axel Lever Wedge
122
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
123
What is the function of a luxation?
They break the PDL to aid forceps use
124
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
125
What are the risk factors for osteomyelitis?
``` Odontogenic infections Fractures of the mandible Immunocompromised patients Malnourished patients Patients receiving chemotherapy ```
126
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
127
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
128
What does the submandibular gland secrete?
Mixed serous and mucous secretions
129
What is the innervation of the parotid gland?
Sensory innervation - auriculotemporal nerve and greater auricular nerve Parasympathetic innervation - glossopharyngeal nerve and auriculotemporal nerve
130
What does the parotid gland secrete?
Serous secretion
131
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
132
What does the sublingual gland secrete?
Mixed serous and mucous secretions but predominantly mucous in nature
133
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 ```
134
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? ```
135
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
136
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
137
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 ```
138
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
139
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
140
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
141
Name 3 vital signs you would monitor before, during and after sedation?
Heart rate Blood pressure Oxygen saturation levels
142
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
143
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
144
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 ```
145
What may cause a patient to collapse?
``` Fainting Fear/anxiety Hypoglycaemic shock Dehydration Postural hypotension ```
146
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
147
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
148
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
149
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 ```
150
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 ```
151
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
152
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
153
What are the stages of anaesthesia?
Induction Excitement Surgical anaesthesia Respiratory paralysis/overdose
154
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 ```
155
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
156
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
157
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 ```
158
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 ```
159
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 ```
160
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
161
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) ```
162
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
163
How does Trigeminal Neuralgia occur?
Demyelination of trigeminal nerve | As nerve exists brain stem it has become compressed from a blood vessel
164
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 ```
165
What 2 neurological disorders can give rise to trigeminal neuralgia?
MS | Tumour compressing on trigeminal nerve
166
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)
167
What are the side effects of Carbamazepine?
``` Liver dysfunction Allergies Nausea Xerostomia Sedation Nightmares ```
168
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
169
What surgery can be carried out for trigeminal neuralgia?
Peripheral neurectomies Trigeminal nerve balloon compression Microvascular decompression
170
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
171
What are the clinical and radiographic signs of Albright’s disease?
Clinical; Fibrous dyplasia Skin pigmentation Endocrine hyper-function Radiographic; Bone fractures Fibrous dysplasia
172
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
173
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 ```
174
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
175
What antibodies are linked with Sjorgen's Syndrome?
Anti-Ro Anti-La Anti-nuclear antibodies (ANA)
176
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
177
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
178
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
179
What drug is used to manage Sjorgen's syndrome?
Pilocarpine which is a salivary stimulant
180
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 ```
181
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
182
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 ```
183
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
184
What is an erosion?
It is partial thickness loss of the epithelium | Can only be diagnosed histologically
185
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
186
What are the potential problems of recurrent aphthous ulcers?
Infections Dehydration and malnutrition Problems wearing dentures Affects speech and mastication
187
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 ```
188
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 ```
189
What would microcytic blood results show?
Reduction of; MCV (mean corpuscular volume) Hb RBC
190
What can cause microcytic anaemia?
``` Coeliac disease Crohn's disease Ulcerative colitis Iron deficiency Lead poisoning ```
191
What oral conditions are associated with microcytic anaemia?
Recurrent aphthae Poor wound healing Increased risk of candida infection Burning sensation of oral mucosa
192
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
193
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
194
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
195
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
196
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
197
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 ```
198
What epithelium is affected in smokers keratosis?
Stratified squamous keratinised epithelium of the hard palate
199
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
200
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
201
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
202
Name 3 conditions that you would see desquamative gingivitis in? (In order of likelihood)
Lichen planus Pemphigoid Pemphigus
203
What local factors may exacerbate desquamative gingivitis?
``` Smoking Poor OH Overhangs Partial dentures SLS toothpaste ```
204
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 ```
205
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
206
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
207
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
208
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
209
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) ```
210
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
211
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
212
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
213
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
214
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
215
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
216
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.
217
Give possible causes for UMN disease?
UMN (stroke); ``` Stroke Multiple sclerosis Traumatic brain injury Cerebral palsy Spinal cord injury ```
218
What conditions may require patients to be on long term steroids?
``` Asthma COPD Addison’s disease Arthritis Crohn’s disease Lupus MS ```
219
What are the signs and symptoms of adrenal suppression?
``` Hypoglycaemia Dehydration Weight loss Disorientation Weakness Postural hypotension Oral pigmentation on buccal mucosa ```
220
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
221
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
222
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
223
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
224
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
225
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
226
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 ```
227
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
228
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 ```
229
How is burning mouth syndrome managed?
Reassurance Correct any underlying causes = nutrient replacement, diabetes treatment, correcting dentures, management of stress/parafunctional habits Conservative advice = staying hydrated Pharmacotherapy = Gabapentin, CBT
230
What benign and malignant tumours affect the salivary glands, order by incidence
``` Pleomorphic adenoma (75%) Warthin’s tumour (10%) Adenoids cystic carcinoma (5%) Mucoepidermoid carcinoma (3%) Acinic cell carcinoma (<1%) ```
231
What are the histological features of a pleomorphic adenoma?
Mixed tumour = epithelium in ducts and sheets and myoepithelial cells present Variable capsule
232
What histological feature is related to recurrence of a tumour?
Multifocal types due to non/poorly encapsulated
233
What are the histological features of a Warthin’s tumour?
Oncocytic (excessive mitochondria) distinctive epithelium with lymphoid tissue present and cystic spaces
234
What are the histological features of an adenoid cystic carcinoma?
Cystic spaces, malignant cells with a cribiform architecture with a peri-neural spread No capsule present and the tumour can be tubular or solid in nature
235
How are salivary gland neoplasms diagnosed?
Fine needle aspiration Core biopsy Incisal biopsy - sample of tissue removed Excisional biopsy - entire tumour removed
236
What is the mechanism of action of CHX?
It has a dicationic action as the positively charged CHX molecules react with the negatively charged microbial molecules This damages the microbial cell envelope as there is an increase in permeability resulting in cell content leakage and resultant cell death
237
What solution of CHX is given to patients?
0.2% or 0.12% CHX mouthwash = 10ml x2 daily, rinse for 1 minute
238
What are the side effects of CHX?
``` Mucosal irritation Parotid gland swelling Reversible brown staining of teeth and restorations Taste disturbances Tongue discolouration Burning of mouth and gums Hypersensitivity Impaired fibroblast action ```
239
What are the indications for the use of CHX?
Treatment for candidosis Cleaning dentures Pre and post oral and periodontal surgery In physically or mentally disabled patients where OH is difficult to maintain Immunocompromised patients Management of ANUG, xerostomia and mucositis Used as irrigant for RCT High caries risk patients Patients with jaw fixation
240
Name 3 stages in the formation of clots?
Vasoconstriction -> temporary blockage of a break via a platelet plug -> blood coagulation/formation of fibrin clot
241
How does aspirin affect clotting?
Aspirin inhibits platelet aggregation by altering the balance between thromboxane A2 and prostacyclin
242
How does Warfarin affect clotting?
Warfarin inhibits the synthesis of vitamin K dependant clotting factors 2, 7, 9, 10 and protein C&S
243
How does NOAC affect clotting?
NOAC’s affect clotting by inhibiting factor X inhibitors which inhibits the conversion of prothrombin to thrombin thereby stopping the production of a fibrin clot
244
Why is aspirin and clopidogrel used in conjunction?
Dual antiplatelet therapy is used in the management of acute coronary syndromes as they decrease platelet aggregation and inhibit thrombin formation Aspirin reduces the production of prostaglandins and inhibits COX-1 Clopidogrel is an anti-platelet pro-drug which inhibits the activation of platelets and the cross linking of fibrin
245
What is the pattern of Von Willebrands disease?
Autosomal dominant condition with different inheritance patterns; Type 1 = Autosomal dominant, quantitative deficiency of normal vWF molecules Type 2 = Autosomal dominant, qualitative deficiency of normal vWF molecules Type 3 = Autosomal recessive, quantitative and qualitative deficiency of normal vWF molecules
246
How does Von Willebrands disease affect bleeding?
The vWF protein stabilises FVII and enables platelet interaction with the blood vessel wall Therefore if this vWF protein has a poor quality or quantity, the function of platelets is reduced which can result in a haemorrhage
247
What are the stages of colonisation of a biofilm?
Adhesion Colonisation Accumulation Complex community
248
Name methods of identifying organisms in microbiology
Microbiological culture; Culture on suitable agar medium Isolate bacteria Identify with API (analytical profile index) DNA probes PCR (polymerase chain reaction)
249
What is Lichen Planus?
It is a chronic inflammatory condition that can affect the mucous membranes of the mouth or any other areas of the body It affects mainly females aged 30-50 Patients who suffer from severe lichen planus have an increased 1% risk of developing oral malignancy in a 10 year period
250
What are the histological features of lichen planus?
“Hugging” band of chronic inflammatory cells - lymphocytes and macrophages present with a destructed basal cell layer caused by apoptosis Keratinisation, atrophy and sometimes hyperplasia of tissues Saw edge retention pegs Loss of intra-cellular attachment
251
What are the different types of lichen planus?
Reticular = spider web like lacy white lines Atrophic = white/blueish plaques with central atrophy Papular = white plaques Bulbous = development of fluid filled vesicles and bullae Plaque = plaques arranged in lines Erosive = ulcerative appearance Desquamative gingivitis
252
What are the causes of lichen planus?
``` Autoimmune Stress Idiopathic Hep C has a higher incidence Drugs - beta blockers, NSAIDS, hypoglycaemic Plaque build up in desquamative gingivitis Amalgam SLS allergy ```
253
When would you decide to biopsy a lesion?
When a lesion appears in a smoker When a symptomatic/erosive lesion appears in all patients When a lesion is in a high risk area such as floor of mouth or lateral border of tongue
254
How is lichen planus managed?
Asymptomatic; Observe and CHX mouthwash use ``` Symptomatic; Identify and treat underlying cause e.g. removal of AM rest. OHI Biopsy any white patches Topical steroid use - Betamethasone Systemic steroid use - Prednisolone ```
255
What is Lichen Planus?
It is a chronic inflammatory condition that can affect the mucous membranes of the mouth or any other areas of the body It affects mainly females aged 30-50 Patients who suffer from severe lichen planus have an increased 1% risk of developing oral malignancy in a 10 year period
256
What are the histological features of lichen planus?
“Hugging” band of chronic inflammatory cells - lymphocytes and macrophages present with a destructed basal cell layer caused by apoptosis Keratinisation, atrophy and sometimes hyperplasia of tissues Saw edge retention pegs Loss of intra-cellular attachment
257
What are the different types of lichen planus?
Reticular = spider web like lacy white lines Atrophic = white/blueish plaques with central atrophy Papular = white plaques Bulbous = development of fluid filled vesicles and bullae Plaque = plaques arranged in lines Erosive = ulcerative appearance Desquamative gingivitis
258
What are the causes of lichen planus?
``` Autoimmune Stress Idiopathic Hep C has a higher incidence Drugs - beta blockers, NSAIDS, hypoglycaemic Plaque build up in desquamative gingivitis Amalgam SLS allergy ```
259
When would you decide to biopsy a lesion?
When a lesion appears in a smoker When a symptomatic/erosive lesion appears in all patients When a lesion is in a high risk area such as floor of mouth or lateral border of tongue
260
What is anaemia?
It is a condition caused by a reduction in haemoglobin in the blood, caused by a reduced production, increased loss or increased demand It results in the reduction of the oxygen carrying capacity of the blood
261
What are the general signs and symptoms of anaemia?
``` Weakness Dizziness Shortness of breath Noticeable paleness and coldness Loss of consciousness Low blood pressure Palpation ```
262
What are the oral signs of anaemia?
``` Recurrent oral ulceration Candida infections Glossitis or smooth tongue (iron deficiency) Beefy tongue (B12 or folate deficiency) Oral dysaethesia Mucosal pallor ```
263
Name different types of anaemia from the MCV(Mean Corpuscular Volume (Size of RBC))?
Microcytic (small RBC) <80fl; Iron deficiency Thalassaemia Normocytic (normal RBC) 80-95fl; Internal bleed Pregnancy Sickle cell anaemia Macrocytic (large RBC) >95fl; B12/Folate deficiency Liver disease/hypothyroidism
264
What is the clinical appearance of plasma cell gingivitis?
Generalised erythema and oedema which can extend from free marginal gingiva on to the attached gingiva Gingiva is friable and will bleed easily Normal gingival stippling is lost Often accompanied by cheilitis (lip swelling) or glossitis
265
What is the aetiology of plasma cell gingivitis?
Hypersensitive reaction - SLS Idiopathic Rare condition
266
What may worsen plasma cell gingivitis condition?
Failure to remove causative agent Poor OH Plaque retentive factors
267
How is plasma cell gingivitis managed?
Histological sampling to diagnose condition Preventing exposure to causative agent Immunosuppressive medication e.g. Tacrolimus has been thought to improve condition
268
What are the causes of xerostomia?
``` Local; Mouth breathing Steroid inhalers Alcohol Smoking Candidosis Radiotherapy ``` ``` Systemic; Medications - Antihistamines, Diuretics and Amitriptyline Chemotherapy Diabetes, Addison’s disease Sjorgen’s syndrome Dehydration Psychogenic ```
269
How can you assess xerostomia intra-orally?
Measure unstimulated saliva flow rate for 15mins; Abnormal = <1.5ml in 15mins Palpate and assess salivary gland ducts for secretions Mirror stick test to cheek and tongue Check for saliva pooling
270
What are the oral signs and symptoms of xerostomia?
``` Swallowing difficulties Problems with speaking Oral soreness Poor denture control Altered taste Increased cervical caries Frothy saliva Increased candida infections Halitosis Tongue fissuring Increased periodontal disease ```
271
How can xerostomia be managed?
``` Remove/manage causative agent; Consider alternative medications - discuss with GP Control of any medical conditions Alcohol and smoking cessation SLS free toothpaste Assess mouth breathing Moderate caffeine intake Increase water intake ``` ``` Salivary substitutes; Sprays - saliva orthana Lozenges - salivax Stimulants -pilocarpine Biotene ```
272
Name 3 sugar substitutes
Xylitol Aspartame Sucralose
273
Name 3 salivary proteins
Salivary - IgA Muffins Proline-rich proteins
274
Name 3 salivary enzymes
Lysozyme Amylase Lipase
275
Give examples of when antibiotics are indicated for dental treatment
When oral infections have evidence of spreading infection e.g. cellulitis, lymph node involvement or systemic involvement e.g. malaise In cases of ANUG or pericoronitis where there is systemic involvement or persistent swelling despite local treatment In cases of sinusitis where there are persistent/severe symptoms In patients with severe cardiac conditions where there is a risk of bacteraemia therefore cardiac consultant may request antibiotic prophylaxis to prevent infective endocarditis
276
Give 5 ways in which antibiotics work
``` Cell wall destruction Protein synthesis inhibition DNA synthesis inhibition DNA replication inhibition Cell membrane inhibition ```
277
Give 4 disadvantages of antibiotics
Antibiotic resistance GI upset Interactions with other medications Hypersensitivity/anaphylaxis
278
Name 3 antibiotics used in dental treatment and include their regime
Dental abscess + systemic involvement; Amoxicillin capsules 500mg for 5 days; Send: 15 capsules Label: One capsule, three times daily.
279
What are the mechanisms of antibiotic resistance?
Enzyme degradation of antibacterial drugs Alteration of bacterial proteins that are antimicrobial targets Changes in membrane permeability to antibiotics altering their metabolism and reducing accumulation
280
You have an asthmatic patient who takes 2 inhalers,, what kind of inhalers will these likely be?
Beta-agonist salbutamol inhaler - blue | Corticosteroid Betamethasone inhaler - brown
281
What is asthma?
Asthma is caused by a reversible airflow obstruction characterised by; Inflammation and swelling of mucosa Excessive mucous secretions Smooth muscle airway contraction All as a result of a bronchial hyper reactive trigger
282
What are the signs and symptoms of asthma?
Shortness of breath Wheezing sound when exhaling Coughing Chest tightness or pain
283
What are the dental effects of inhalers and what advice should be given?
Increased Candida infections due to effects and longevity of steroids in oral cavity; Should rinse mouth out after using inhaler Increased erosion due to intrinsic and extrinsic acidity; Ensure regular dental check-ups and use of fluoride Decrease in saliva producing exacerbating xerostomia and caries risk; Increase fluid intake Ensure patient using their inhaler correctly
284
What other dental considerations should be given in an asthmatic patient?
Colophony allergy in fluoride varnish Not using fluoride varnish in children who have been hospitalised in past 3 years with asthma attack Medical emergencies for asthmatic attack Treating periods for long periods of time who have severe asthma or cold/flu - shorten appt. time
285
What percentage of people in Scotland are being treated for asthma?
6.4% according to ScotPHO in 2015/2016 | 1 in 14 people in Scotland receive treatment for asthma (asthma.org)
286
How is dysplasia graded according to WHO 2005?
Hyperplasia Dysplasia; Mild Moderate Severe Carcinoma-in-situ
287
What are the histological differences between Pemphigus and Pemphigoid?
Pemphigus; Supra-basal split (intra-epithelial) Basket weave IF pattern Presence of Tzank cells Pemphigoid; Sub-basal split Linear IF pattern Presence of fibrin - large amounts
288
How does Pemphigus and Pemphigoid differ clinically?
Pemphigus; Intra(supra)-epithelial bullae blisters affecting surfaces Superficial clear fluid filled blisters that burst then spread Pemphigoid; Thick walled blisters affecting full epidermis layer usually filled with blood
289
How may you investigate Pemphigus and Pemphigoid conditions?
Direct immunofluorescence using IgG antibodies looking for a basket weave or linear pattern Indirect IF using patients serum and testing for IgG antibody levels
290
What are the signs and symptoms of oral cancer?
High risk sites; Floor of mouth Lateral border of tongue Soft palate ``` Signs; Persistent hoarseness for >6 weeks Ulceration or oral swelling for >3 weeks Unexplained white/red patches >3 weeks Dysphagia >3 weeks (difficulty swallowing) Unresolving neck masses >3 weeks ``` ``` Symptoms; Bleeding Numbness Pain Ulcer with rolled border ```
291
How does cancer spread?
Locally Lymphatic spread Through the blood
292
What is the metastatic cascade?
Local invasion and intravasation Survival in circulation Arrest in distant organ/tissue Extravasation Micro metastasis Macro metastasis
293
What is the TNM staging system?
``` T = Tumour Tx = no available info on primary tumour To = no evidence of primary tumour TIS = only carcinoma in situ T1 = <2cm T2 = 2-4cm T3 = >4cm T4 = >4cm, other involvements ``` ``` N = Node Nx = cannot be assessed No = no clinical nodes present N1 = single, ipsilateral <3cm N2a = single, ipsilateral 3-6cm N2b = multiple, ipsilateral <6cm N3a = single/multiple, ipsilateral, >6cm N3b = bilateral >6cm N3c = contralateral >6cm ``` ``` M = Metastasis Mx = cannot be assessed Mo = no evidence M1 = distant metastasis present ``` Scores are then combined to give an overall stage of cancer 1-4 increasing in severity
294
What is a necrotising sialometaplasia? What is the aetiology?
It is a benign, ulcerative lesion usually caused by vascular damage of the palatine vessels causing blockage of the minor salivary glands Can be caused by smoking, trauma, LA injections, bulimia, infections or ionising radiation
295
How does necrotisising sialometaplasia appear histologically?
Hyperplasia Surface slough of necrotic tissue Squamous metaplasia of ducts and acini Necrosis of salivary acini
296
How is necrotising sialometaplasia managed? What could be other differential diagnoses from its clinical appearance?
Spontaneous healing over 6-10 weeks Squamous cell carcinoma Salivary gland carcinoma
297
A patient presents with a swollen lower lip - Give differential diagnoses
``` Much else OFG Trauma Benign fibrous overgrowth Squamous cell carcinoma Soft tissue abscess Schwannoma ```
298
What is a mucocele? How is it managed?
It is a recurrent swelling found most commonly in the lower lip due to a damaged/blocked minor salivary gland which can burst and recur It can be superficial, deep, extravasation (leaks fluid) or retentive (retains fluid) The mucocele can be excised or the gland can be excised
299
How does a mucocele appear histologically?
Cystic macrophage lined cavity surrounded by granulation tissue wall and foam cells
300
If a mucocele is present in the floor of the mouth - what is this called?
A Ranula - usually a sublingual extravasation (leaks fluid) type
301
What is orofacial granulomatosis?
It is a condition where there is a lymphatic obstruction from a giant cell granuloma which causes fluid accumulation in tissues and resulting oedema It is associated with type IV hypersensitivity to food and also linked with Crohn’s and Sarcoidosis (accumulation of granulomas) disease
302
What is the aetiology of orofacial granulomatosis?
Autoimmune condition Allergens e.g. Benzoates, chocolate Linked with Crohn’s disease and Sarcoidosis
303
What is the histological appearance of Orofacial Granulomatosis?
``` Giant cell formation which can be seen as having; Increased tissue fluid production Granuloma formation Lymphatic obstruction Dilated blood vessels ```
304
What are the signs and symptoms of orofacial granulomatosis?
``` Lip, cheek and gingivae swelling Skin changes Angular cheilitis Buccal - cobble stoning Ulceration Aphthous ulceration. Mucosal tags Tissue oedema ```
305
How is Orofacial Granulomatosis managed?
``` Allergen testing - Dietary avoidance Antibiotic therapy with macrolides Lip ointment Intra-lesion steroid injections Oral steroids ```
306
Name 6 types of candida infections
``` Pseudomembraneous Erythematous Hyerplastic Angular cheilitis Median rhomboid glossitis Denture induced stomatitis ```
307
Where does median rhomboid glossitis occur? What are the histological features?
Affects the dorsum of the tongue anterior to sulcus terminalis Candida hyphae infiltration Elongated rete ridges Hyperplastic rete ridges
308
Give 3 methods of testing for candida?
Swab, oral rinse and foam pad = culture Biopsy lesion = histology Smear = microscopy
309
What are the virulence factors for candida?
Adhesins Hydrologic enzymes; Haemolysin = facilitates hyphae infiltration Proteinase = facilitates adhesion to epithelial cell Extra cellular enzymes Acidic metabolites
310
Name topical and systemic antifungals
``` Topical; Miconazole Nystatin CHX Amphotericin B ``` Systemic; Fluconazole Itraconazole
311
What information should be on a prescription?
``` Patient name, address, CHI Patient age if under 12yrs Date of prescription (valid for 6 months) Name and address of prescriber Status of prescriber Signature of prescriber in ink Name of drug written clearly Form and strength of prescription Dose and dose frequency of prescription Duration of treatment Total quantity of drug (SEND) Instructions for how and when (LABEL) Residual space on form scored out ```
312
What is the rate of infection for HIV exposure, Hep C and Hep B?
HIV = 0.3% Hep C = 3% Hep B = 30%
313
Name 6 oral lesions associated with HIV?
``` Candidosis infections e.g. Pseudomembraneous Erythematous Denture induced stomatitis Angular cheilitis etc. ``` Hairy leukoplakia Kaposi’s sarcoma Non-Hodgkins lymphoma Periodontal disease
314
How is HIV diagnosed and treated?
Diagnosed via; ELISA antibody test (6-12 weeks post infection) HIV RNA testing Treatment; Highly active anti-retroviral therapy (HAARTs) which consists of 3 or more drugs; 2 x NRTIs (nucleoside reverse transcriptase inhibitors) 1 x NNRTI Protein inhibitor
315
What is a fibrous epulis? What is its aetiology? How does it appear histologically? How does it appear on other sites than the gingivae?
It is a reactive non-neoplastic condition that affects the gingiva as a result of chronic irritation, resulting in localised fibrous enlargement It is caused by low grade, local chronic irritation Histologically appears as; Ulceration Granulation tissue Metaplastic bone formation Appears as fibro-epithelial polyps on other sites
316
What is a pyogenic granuloma? How does it appear histologically?
It is granulation tissue which can be found at any mucosal site usually in response to trauma and requires histological sampling Appears as granulation tissue with blood vessels present
317
Name a hereditary white patch How does it appear histologically?
White spongy naevus which is a hereditary condition with increased production of keratin Appears as intra-cellular oedema and presence of parakeratosis
318
How does smokers keratosis appear histologically?
Hyperkeratosis Mild dysplasia Infiltrate of macrophages
319
A patient presents with denture induced hyperplasia, give 2 differential diagnoses
Papillary hyperplasia of the palate | Giant cell granuloma
320
What factors can result in denture induced hyperplasia?
Ill fitting dentures causing chronic trauma to the tissues | Fibrous reaction of the gingivae caused by pressure from denture Falange
321
How would you manage denture induced hyperplasia?
LA then surgical excision of the fibrous tissue overgrowth Addressing causative factor to prevent recurrence of lesion Use of soft tissue conditioner to help heal the tissue while a new denture is being made
322
Name 2 histological features of denture induced hyperplasia?
Pseudo-epithelial hyperplasia Hyperkeratotic and irregular epithelial cells Hyperplastic rete pegs Candida involvement
323
You have been shown a graph which shows D3t, mt and ft What is D3t, mt and ft? Name 3 reasons why D3t shows a difference between two areas? What does the 3 in D3t mean?
``` D3t = Decayed deciduous teeth Mt = missing teeth (XLA due to decay) Ft = filled teeth ``` Socioeconomic status of the area Ethnicity status Individual health board involvement in area. The 3 in D3t means obvious decay into dentine of the tooth using visual methods only
324
At a population level, name 3 fluoride delivery methods?
Water fluoridation School water fluoridation School milk initiative Fluoridated salt
325
What 3 interventions are done in Scotland, on a population basis?
Smoking ban in public areas School food policy Sugar tax Minimum wage
326
What is PICO?
Population; Children with caries in primary teeth Intervention; Hall technique used Comparison; Compared with standard techniques Outcome; Rate of failures
327
What is confidence intervals?
Confidence intervals; The range of values the absolute risk difference will take in the population If CI does not overlap 0 = there is sufficient evidence If CI does overlap 0 = there is insufficient evidence A narrow CI is better as the larger the sample, the narrower the CI
328
What is relative risk?
It is the ratio of incidence rate in exposed groups to incidence rates in non-exposed groups It is a measurement of proportionate increase in disease rates of exposed groups
329
What are the 5 steps of clinical audits?
Identify problem or issue Set criteria and standards Observe practice/data collection Compare performance with criteria and standards Implement change
330
Name 2 other things that you can do other than a clinical audit?
Peer review Quality improvement programme Continued professional development (CPD)
331
What are the 6 dimensions of healthcare and briefly explain each?
Safe = avoiding harm to patients from the care that is intended to help them Effective = providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit Patient centred = providing care that is respectful and responsive to individual patient preferences, needs and values Timely = reducing waits and delays for both those who receive and those who give care Efficient = avoiding waste of equipment, supplies and energy Equitable = providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, location etc.
332
What head, neck and oral features can occur with cocaine use?
``` Perforation of nasal septum and palate Gingival lesions Erosion and attrition of tooth surfaces TMJD Orofacial pain Cluster headaches GORD Nasal drip ```
333
What are side effects of opioid use?
``` Addiction Nausea, vomiting and constipation. Dry mouth Drowsiness Paranoia Respiratory depression Anxiety/depression ```
334
What group does methadone belong to? What is a complication of methadone containing sugar? What is the risk of a sugar free preparation of methadone?
Opioid class A drug High caries and periodontal risk Does not contain chloroform so could be injected May cause diarrhoea
335
Give 3 types of consent?
``` Implied = patients actions clearly indicate their wishes Verbal = patient clearly states their consent for procedure Written = patient signs declaration that they consent to procedure ```
336
What 6 factors make up consent?
``` Informed Voluntary Valid Not manipulated With capacity Not coerced ```
337
Who carries consent for a 16 year old patient?
The patient has the legal capacity to consent on their own behalf to any surgical, medical or dental procedures The clinician must ensure that the child has the capability to understand the nature and possibility of consequences of the procedure
338
You are working as a GDP and you see 2 nurses getting off the bus in their uniforms - name 2 concerns that you would raise with the nurses?
Infection control - should not be wearing uniform out with the practice Practice and professional reputation as the nurses are wearing uniform which shows where they work
339
Name 6 key learning outcomes when it comes to PPE
Always wear PPE when carrying out procedures Wear fresh PPE when cleaning Change PPE between patients and cleaning Correct disposal of PPE in orange stream waste Protection of hands, eyes and clothing with PPE Protect patients with glasses and apron
340
Why do we need to do manual cleaning in Decon?
To remove gross contamination as these deposits prevent direct contact between steam and instrument surfaces that is necessary for effective sterilisation. To remove any organic material as this may become fixed during sterilisation and may be more difficult to remove later To remove any restorative materials To aid disinfection and sterilisation Medico-legal requirement Restore function of equipment
341
Why do we need to test the washer disinfector and steriliser?
To ensure it is working correctly and is working to its optimum Testing ensures validity and warranty of the machine Testing helps to detect any procedural errors and malfunctions Chemical indicators verify that sterilising agent has penetrated package and reached the instrument inside
342
Describe the 5 steps of the washer disinfector
1 = Pre-wash/flush <45 degrees to remove gross contamination 2 = Washing Physical force of water, chemical action of detergent and thermal heat activates action of detergent to remove any remaining soil 3 = Rinsing Removal of cleaning agents 4 = Disinfecting Temperature only with holding time of 1-10 minutes 5 = Drying Circulation air heated to 90 degrees for 20minutes to clear chamber of remaining moisture
343
What are the differences between type B and type N sterilisers?
Type N (non-vacuum); This cycle is intended for the sterilisation of non-wrapped products Air is displaced passively from the chamber and steam is generated within the chamber Holding time is 3 mins at a temp. of 134 degrees Items should be used immediately and not stored after processing Type B (vacuum); This cycle is intended for the sterilisation of wrapped products The vacuum pump actively removes air from the chamber Products are vacuumed packaged and are sterile at point of use and can be stored prior to use Holding time temp of 134-137 degrees
344
Name 4 personnel involved in the decon process and give a description of each of their roles
Decontamination user; Person responsible for the day-to-day management of the steriliser (dentist, senior nurse etc.) They maintain records and ensure tests and maintenance are carried out Operator; Trained in the operation of all equipment, performs simple housekeeping and maintenance Manager; Person who is ultimately responsible for the decon process (generally the practice owner) Authorising engineer; Provides expert advice and performs independent audits quarterly and annually
345
What type of water is used in the final rinse cycle of a washer disinfector and why is this used as opposed to mains water?
Demineralised water - reverse osmosis water, deionised water etc. Mains water contains organic and mineral compounds making it unsuitable for sterilisation Demineralised water types do not contain bacterial endotoxins which makes it safe for humans and there will be no mineral deposits present which reduces formation of limescale on instruments
346
What is CPD?
Continuing professional development This is the process of tracking and documenting the skills, knowledge and experience you have gained throughout your career, beyond any initial training, to advance your professional development It is a requirement of the GDC that a registered member must adhere to specific CPD training ever 5 years in order to stay registered CPD supports dental care professionals in maintaining and updating their skills and knowledge throughout their working life
347
How many hours of CPD are to be done in a 5 year cycle and how many are to be verifiable?
At least 250 hours of CPD every 5 years | 75 hours must be verifiable CPD
348
Give 3 suggested CPD topics and the hours required per cycle
Medical emergencies = at least 10 hours in every CPD cycle, 2 hours per year Disinfection and decontamination = at least 5 hours every CPD cycle Radiotherapy and radiation protection = at least 5 hours every CPD cycle
349
What are the 7 components of clinical governance?
``` Clinical effectiveness and research Audit Risk management Education and training Service user, carer and public involvement Clinical information and IT Staffing and staff management ```
350
What is a clinical audit, what is it used for?
It is a quality improvement process that seeks to improve patient care and outcome through systematic review of care against explicit criteria It is used to observe gaps in knowledge, learning, attitude, protocols and training
351
What are the stages of significant event analysis? (SEA)
1 = identify significant event 2 = collect and collate as much information as possible relating to the event 3 = convene a meeting with a non-threatening, no blame, educational focus 4 = undertake a structured analysis 5 = monitor progress of all actions agreed upon 6 = write up event analysis 7 = seek educational feedback - peer review
352
What is the name and concentration of a chlorine releasing agent that is used for spillages? How long is it left on for?
``` Sodium Hypochlorite (Actichlor) - 10,000ppm Left on spillage for 5 mins ```
353
Name different waste streams and give an example of each one
``` Black - domestic waste Orange (low risk) - PPE Yellow (hazardous) - sharps Red (hazardous) - amalgam Brown - confidential documents. ```
354
What are the principles of waste disposal?
Segregation Storage Disposal Document
355
How long does a consignment note need to be kept for and what info does it contain?
3 years ``` Description of waste Quantity of waste Destination of waste Origin of waste Transport of waste ```
356
What is clinical governance?
It is a systematic approach to maintain and improve patient care in the health system
357
What are the 3 divisions of NHS Scotland dental services?
Primary care - general dental practice Public dental services - community services Secondary care - hospital services
358
List the 9 GDC standards for dental professionals?
Put patient’s interests first Communicate effectively with patients Obtain valid consent Maintain and protect patients information Have a clear and effective complaints procedure Work with colleagues in a way that is in the patients best interests Maintain, develop and work within your professional knowledge and skills Raise concerns if patients are at risk Make sure your personal behaviour maintains patient confidence in you and the dental profession
359
List the sinner circle
Time Temperature Chemical Energy
360
Name all 10 SICP’s
Patient placement Hand hygiene Respiratory and cough etiquette PPE Safe management of care equipment Safe management of care environment Safe management of linen Safe management of blood and body fluid spillages Safe disposal of waste (including sharps) Occupational safety - prevention and exposure management including sharps
361
What are the 4 pillars of ethics?
Respect for autonomy Non-maleficence Beneficence Justice
362
What is negligence?
The omission to do something which a reasonable dentist would do, or, doing something which a reasonable dentist would not do The failure to meet standards of ordinary care which can ultimately result in harm
363
What is the criteria for clinical negligence?
The dentist owned a duty of care The duty standard of care was breached The breach caused or contributed to damage The damage was reasonably foreseeable and had negative consequences and effects
364
How long should patient notes be kept for?
11 years after end of treatment or until age 25 for children
365
What criteria should patient notes fulfil?
``` Confidential Concise Accurate Legible Complete Current Retrievable Retained ```
366
Who is on the GDC board?
12 members - 6 registrants and 6 lay members
367
What type of study provides the highest level of evidence?
Cochrane reviews which are systemic assessments of all the relevant randomised controlled trials (RCT’s) which give the highest level of evidence
368
List 4 aspects of a cochrane review? Name 4 other study designs?
Randomised double blind reduces bias Inclusion and exclusion criteria Randomisation facilitates statistical analysis Compares one treatment to a placebo to investigate any statistical significance Randomised controlled trial - looks at effectiveness of treatments Cohort studies - prospective study Case control studies - retrospective study Case study - one patient report
369
What is incidence?
It is the number of new disease cases developing over a specific period of time in a defined population Incidence rate = no. of new cases of disease in a period/no. of individuals in population at risk
370
What is prevalence?
It is the number of disease cases in a population at a given time Prevalence = no. of affected individuals/total no. of individuals in population at risk
371
What is SIMD?
Scottish Index of Multiple Deprivation which is an area based index which uses a range of data to decide which neighbourhoods are most deprived by ranking date zones in order of deprivation from quantile 1 - most deprived to quantile 10- least deprived
372
Give 7 factors which influence deprivation
``` Employment status Income Health and health care services Geographic access to services Crime Housing, living and working conditions Education, skills and training ```
373
What are the advantages and disadvantages of a split mouth study design?
Advantages; Both control and intervention group are exposed to the same environment Each of 2 treatments are randomly assigned to either the right or left halves of the dentition on the same environment It removes inter-individual variability from the estimates of treatment effect There is no carry over effect for the intervention or outcome Disadvantages; Patient can not be blinded Adds more bias into the reporting Incorrect reporting risk
374
What is a P value?
Used to determine the significance of your results | P value <0.05 means you reject the null hypothesis and your results are statistically significant
375
What are the signs and symptoms of Alzheimer’s?
``` Confusion Memory and condition problems Communication difficulties Mood swings Being withdrawn Loss of confidence Confused over every day activities Aphasia (language impairment) ```
376
What are the signs and symptoms of Parkinson’s?
``` Mask like face Bradykinesia (slow movement) Rigidity Postural instability Resting tremor Shuffling gait Loss of protective reflexes ```
377
What are complications of dental treatment for an individual with Alzheimer’s or Parkinson’s?
``` Resting tremor Loss of protective reflexes Reduced self care - poor OH Reduced manual dexterity Reduced communication - unable to communicate pain Assessing capacity to consent Access to practice may be difficult ```
378
What are the principles of the adults with incapacity act 2000?
The Adults with Incapacity Act 2000 refers to consent and capacity issues and ensures no-one can make decisions for you, if you can make decisions for yourself Principles include; The benefits for the adult Minimum intervention Take into account present and past wishes of the adult Consultation with the adult and relevant others Encourage the adult to use their skills and encourage further development of these
379
What is capacity?
An individual has the capacity to consent when they can; Retain memory of a decision They can act (decide) Can make a reasoned decision Can communicate decision Can understand a decision - repeat back in own words
380
Who can consent under the Adults with Incapacity Act 2000?
Power of Attorney; Adult with capacity has made the decision to appoint someone to make decisions about their welfare medically and financially while they still have the capacity to do so This is then passed through the court system so that the appointed person makes decisions on the adults behalf when their capacity is lost Welfare Guardianship; Adult who had never had the capacity, the court will appoint someone to look after the adults welfare and make decisions for them
381
What is the English equivalent of the Adults with Incapacity Act 2000?
Mental Capacity Act 2005
382
What is the decontamination cycle?
``` Acquisition (purchase or loan) Cleaning Disinfection Inspection Disposal (scrap or return to sender) Packaging Sterilisation Transport Storage Use Transport ```
383
Name 4 legislations for decontamination
``` The health and safety at work act 1974 The medical device directive 2007 The national health service regulations 2010 Consumer protection act COSHH ```
384
Give 5 common reasons for handpiece faults
Incorrect compressor settings and lack of maintenance Damaged or over sized bur fitted which damages the chuck Incorrect instrument usage Poor or inadequate cleaning Inadequate lubrication
385
Briefly describe immersion and non-immersion manual washing
Immersion; Re-usable cleaning brushes used to remove gross contamination Neutral enzymatic detergent used (30ml to 8L of water) at 30-34 degrees Sterile and dry disposable towel used to aid the drying process Non-Immersion; Used for lumened hand pieces and items that would be damaged by the immersion technique Disposable wipes are used to wipe down the instruments
386
Briefly describe the ultrasonic bath used for decon
Ultrasonic cleaners work by applying a high frequency sound wave The sound wave produces micro-bubbles which cause cavitation when they implode, this energy released helps to remove soil from the surface of the instrument Degassing must occur as oxygen will inhibit cavitation Ultrasonic cleaners should only be used as a pre treatment to the washer disinfector and should only be used go remove gross contamination
387
What maintenance tests are carried out for a washer disinfector?
Daily test - automatic control test to ensure machine is operating as designed - used on 1st cycle with instruments Weekly test - cleaning efficiency of machine is carried out at the same time as the daily test Quarterly/Annually validation - series of tests carried out and checked against original manufacturers specification by authorised test personnel
388
What maintenance and tests are carried out for sterilisers?
``` Daily; Wipe door seal and chamber clean Check door safety device Drain and refill Check printer paper Change water Automatic control test Steam penetration test with Bowie-dick Chemical colour change from yellow to blue when sterilised ``` Weekly; Automatic control test Vacuum leak test Air detection test
389
What is the cycle of behaviour change?
``` Pre-contemplation Contemplation Preparation Action Maintenance with progress or relapse at any stage ```
390
What is primary appraisal in stress?
``` A persons judgement about the significance of an event/initial assessment of stressor; Irrelevant Benign Harmful/threat Harmful/challenge ```
391
What is secondary appraisal in stress?
Reaction to the primary appraisal/An individuals consideration on their ability to cope with the primary appraisal; Harm Resistance Exhaustion
392
Give 4 responses to stress?
Direct action Seek information Do nothing Coping
393
What is burnout?
This is the process whereby a previously committed professional disengages from his or her work in response to stress experienced in the job A person will be exhausted mentally and physically causing them to develop a negative attitude towards life
394
Give examples of coping mechanisms for stress?
``` Good work/life balance Exercise CBT/coping mechanisms for stress Knowing personal limits Setting targets/goals Mindfulness ```
395
What are the recommended allowances for alcohol intake for male and females?
14 units per week with at least 2 alcohol free days | Spreading units of alcohol but having no more than 3 units in one day
396
How may you screen for alcohol abuse?
``` Thorough history after gaining rapport with patient; CAGE assessment; Cutting down on alcohol intake? Annoyed at criticism? Guilty? Early morning drinking? ``` Liver function tests from GDP if concerned
397
What brief intervention can be used for alcohol abuse?
``` Alcohol brief intervention; Raise the issue about if they drink Screen and give feedback of risks Listen for readiness to change Suitable referral/information and advice ```
398
How do you calculate how many cigarette packs a person has per year?
20 per day is 1 pack year | 20 per day for 20 years is 20 pack years
399
How would you offer smoking brief intervention?
``` 5As; Ask Advice Assist Assess Arrange ``` 2A1R; Ask Advice Refer
400
What muscles are affected by TMJD?
Masticatory muscles = masseter, temporalis, medial and lateral pterygoid Sternocleidomastoid Trapezius
401
If there is ankylosis of the TMJ joint, what symptom can be seen in the patient?
Rapid reduction in opening
402
What is Chrondroplasia?
Malformation of bone cartilage
403
What zones can be seen on the TMJ disc?
Intermediate zone (avascular) Posterior zone Anterior zone
404
Describe TMJD symptoms when there is disc reduction and no disc reduction? What is the only way that disc displacement can be diagnosed?
With reduction = Clicking noise, disc is anterior Without reduction = Limited mouth opening with no clicking, disc will not move MRI scan
405
What can cause degenerative changes in the TMJ? | How can this be managed?
Osteoarthritis | Arthritic changes
406
What type of bridge is used to replace missing laterals?
Mesial cantilever resin bonded bridge | Fixed-fixed bridge
407
What information is needed from a patient, for a technician to make a bridge?
Bridge design Master impression Bite registration Shade of teeth
408
What would happen to an upper arch if the lower arch was not provided with a partial denture (Patient has upper complete denture and lower teeth 35-45)
Combination syndrome resulting in a flabby ridge This is caused by forces directed at the anterior region where the upper complete denture displaces This results in excessive and rapid bone loss of the maxillary anterior ridge which is replaced by excess fibrous tissue
409
How is combination syndrome managed?
Take a mucostatic impression so that the tissues are recorded at rest Use a stage 2 impression with a medium body silicone and cut out the impression material and make a hole in the tray over the flabby ridge, then take a 2nd impression with a light body silicone Or, you can use a window technique where relief holes are cut in special tray to allow flow of impression material which leaves the tissues undisplaced
410
How does the clinical presentation of caries compare to a radiograph?
Caries is generally 2-3mm deeper clinically
411
What are complications of using a stainless steel file in a 20 degrees curved canal?
``` Ledges Blockages Zipping Perforations Fractured instruments ```
412
What are the ideal properties of a denture base?
``` Dimensionally accurate High softening temperature High hardness/abrasion resistance High thermal conductivity Biocompatible High impact strength Easy/inexpensive to manufacture and repair ```
413
What are the constituents of PMMA?
``` Powder; Benzoyl peroxide (initiator) PMMA particles Plasticisers Pigments Co-polymer ``` Liquid; Methacrylate monomer Hydroquinone (inhibitor) Co-polymer
414
Give 4 possible faults that can occur during the production of a PMMA denture base
Contraction porosity = too much monomer and insufficient pressure Gaseous porosity = monomer boiling in bulkier parts of denture Granularity = not enough monomer Crazing = internal stresses due to fast cooling rate.
415
How is mobility graded?
``` 0 = none 1 = <1mm horizontal movement 2 = 1-2mm horizontal movement 3 = >2mm horizontal movement ```
416
How is furcation graded?
``` 1 = <3mm horizontal 2 = >3mm horizontal but not through and through 3 = through and through defect ```
417
How is gingival recession graded?
Millers classification
418
List 4 endo stainless steel file mishaps/faults and explain how they occur
Ledges; Can occur when working short of length and are difficult to bypass Canal blockage; Caused by dentine debris getting packed into the apical portion of the root Attempting to remove this can result in possible perforation Apical zipping; Occurs as a result of the tendency of the instrument to straighten inside a curved canal which can result in under preparation and teardrop shaped canal Perforations/broken file; Too much pressure applied when using the instruments
419
Describe the endodontic process including calculation of working length until the obturation stage
``` Pre-op radiographs to calculate EWL Rubber dam and LA Coronal access to root canal Use apex locator to calculate CWL Root canal system instrumentation, preparation and irrigation with Sodium Hypochlorite using ProTaper technique Obturation of root canal using GP sized matched cones Coronal seal Final restoration ```
420
What are the benefits of a copper enriched amalgam?
Copper increases strength and hardness of amalgam material | Results in less creep, higher corrosion resistance and increased marginal durability
421
What is the function of zinc in amalgam?
Zinc is the scavenger molecule during production of amalgam Zinc is no longer incorporated as it reacts with water and causes a poor marginal seal
422
Explain the process of delayed expansion in amalgam restorations?
Alloys containing zinc, if contaminated with moisture can result in a large expansion occurring This is due to the release of hydrogen gas within the restoration creating an internal pressure This expansion can lead to pressure on the pulp causing pain, greater susceptibility of corrosion and restoration fractures
423
What is creep?
Creep is the slow internal stressing and deformation of amalgam under stress as the material is repeatedly stressed for long periods at low stress levels
424
What are the Kennedy classifications?
It is an anatomical classification system that describes the number and distribution of edentulous areas present Class I = Bilateral free end saddle Class II = Unilateral free end saddle Class III = Unilateral bounded saddle Class IV = Anterior bounded saddle crossing the midline
425
Why do we place rest seats in denture designs?
They provide bracing as they transmit force on that tooth and they also provide indirect retention
426
What are the constituents of alginate?
Calcium sulphate Zinc oxide Sodium phosphate Alginic acid
427
What are the constituents of green stick?
Carnauba wax Talc Stearic acid
428
Why would a tooth have impression compound placed on it?
To utilise the copper ring technique for recording a single tooth crown preparation
429
A patient attends with a fractured MOD AM and GP that has been exposed for 6 months - what is your treatment plan?
Requires to be re-root treated as the root has been exposed to the oral environment for more than 3 months which puts the tooth at risk of bacterial invasion
430
Name 2 restorative materials that can bond amalgam to tooth?
RMGIC | GI
431
A patient attends with a space between the 13 and 14 | Other than aesthetics, why would restoring this space be challenging?
Space is relatively small and if the teeth are of good prognosis you would be reluctant to remove healthy tooth tissue to place veneers or crowns Composite could be used to make either the 13 or 14 bigger to help close the space but this may be more noticeable to the patient
432
What are the different types of tooth wear?
Attrition = physical wear of tooth substance as a result of tooth to tooth contact e.g. bruxism Abrasion = physical wear of tooth substance through abnormal mechanical process e.g. toothbrushing Erosion = loss of tooth substance by chemical process that does not involve bacterial action e.g. acidic drinks Abfraction = loss of tooth substance from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum of the tooth
433
Name contraindicated groups for using the Dahl technique on?
``` Patients with... Active periodontal disease TMJ problems Post ortho treatment Bisphosphonates Implants ```
434
Name constituents of composite
``` Bis-GMA resin Glass silica Dimethacrylate - TEGDMA Camphorquinone Silane coupling agent ```
435
What is the mechanism of action of an RPI?
The rest acts as an axis of rotation, as the proximal plate and I bar rotate downwards and mesially during occlusal load The I bar and proximal plate disengage from the tooth, thus avoiding harmful torque to the tooth
436
How does vertical bone loss occur?
The radius of destruction of plaque determines the pattern It is approx. 1.5-2mm and if the interproximal bone is greater than this then the pattern is vertical/angular in nature
437
What are the treatment options for vertical bone defects?
Open/closed RSD to allow healing by repair Pocket elimination with osseous resection, where the flap is repositioned apically Regenerative techniques for new bone, PDL and cementum
438
What luting cement is used for fibre posts?
Dual cure composite resin cement
439
What luting cement is used for porcelain veneers?
Resin luting cement with silane coupling agent
440
What luting cement is used for MCC adhesive bridges?
RMGI cement
441
What are the components of temp bond?
Base = Zinc oxide, starch and mineral oil Accelerator = EBA, eugenol and carnauba wax
442
Can you bond zirconia?
No it cannot be etched so it will not chemically bond However, it has micro mechanical retention as self etching composite with Relyx underneath bonds well to sandblasted zirconia
443
Are lithium disilicate crowns strong?
They have good flexural strength and can be used in bridge work as crack propagation through the material is very difficult
444
What microbes are involved in denture stomatitis.?
Candida sp = Candida albicans and candida tropicalis Staphylococcus sp = S. Aureus and S. Epidermidis
445
A patient is unable to tolerate their new dentures - what can be the differences between old and new dentures?
``` OVD may have changed Path of insertion may have changed Flange extension ... Palatal extension ... Toot shade and si ```
446
What methods can dentists use to improve the fit of loose dentures?
Reline Rebase Remake
447
Identify features that may cause problems for denture retention on a patient’s palate?
Tori on the palate | High arched palate
448
What things should be checked at the try-in stage of a denture?
``` Extensions Retention and stability. Occlusal plane Occlusion (RVD, OVD and FS) Appearance Speech ```
449
What is the shortened dental arch?
SDA is a dentition where most of the posterior teeth are missing but there is still satisfactory oral function without the use of an RPD SDA concept can be used when there are 3-5 occlusal units remaining Pair of occluding premolars = 1 unit Pair of occluding molars = 2 units
450
Why is Periodontal disease a contraindication for the SDA concept?
Failure to establish stable periodontal health will have negative consequences for the dentition There will be drifting of periodontal compromised teeth under occlusal load There will be loss of alveolar bone Distal tooth migration can occur due to an increase in anterior load
451
What cement is used for adhesive bridgework?
Panavia
452
What is the 5 and 10 year survival rate for a RRB?
80% for both
453
What are the indications for a SDA?
Missing posterior teeth but patient still has 3-5 occlusal units remaining Sufficient occlusal contacts to provide sufficient occlusal table Favourable prognosis of remaining anterior and premolar teeth Patient is not motivated to pursue a prosthesis treatment plan or when financial resources are an issue for the patient
454
What are the contraindications for SDA?
``` Poor prognosis of remaining dentition Untreated or advanced periodontal disease TMJD Pathological tooth wear Severe class II or III malocclusion ```
455
What types of bridges can you get anteriorly?
Adhesive cantilever bridge Fixed-fixed bridge Conventional spring cantilever (for upper incisor teeth)
456
What material is used in a metal wing bridge?
CoCr Nickel chromium Ceramic
457
What bridge design would you do for a 12 to minimise the risk of de-bonding?
An adhesive cantilever bridge from tooth 11 If this de-bonded it would fall out and wouldn’t become a plaque trap thereby reducing risk of caries Adhesive cantilever bridge is also less destructive on tooth tissue than alternative bridge designs
458
Give methods of checking if a bridge has de-bonded clinically?
Use probe to assess around the bridge abutments, pontics and wings Check visually to see if there are any areas that have deboned Check mobility of bridge Push bridge and check for any air bubbles that may appear Floss around the bridge
459
What are the edentulous classifications for the maxilla?
Atwood, Cawood and Howell Classification Class I = pre-extraction (dentate) Class II = post extraction Class III = rounded ridge, adequate height and width Class IV = knife edge ridge, adequate height but inadequate width Class V = flat ridge, inadequate height and width Class VI = depressed/submerged ridge
460
Define retention
Resistance to displacement in a vertical direction | Tested by pulling vertically on the anterior teeth
461
Define indirect retention
Resistance to rotational displacement of the denture | Tested by moving denture horizontally by pressing on pre-molar region
462
Describe the method of how composite bonds to dentine
Dentine conditioner is used (acid etch, 35% phosphoric acid) for 20 seconds on enamel surface, this allows for the retention of composite to enamel via micro-mechanical retention For dentine, the dentine conditioner allows for the removal of the smear layer which exposes the collagen network and allows for subsequent penetration by the dentine coupling agent Dentine coupling agent (Bis-GMA resin & HEMA) is used as it is a bivalent where the hydrophilic end sticks to the dentine through penetration and micro-mechanical retention of the dentine tubules The other hydrophobic end, bonds through molecular entanglement to the resin in the adhesive - this then forms a hybrid layer of collagen plus resin
463
Describe how porcelain is treated to improve its retention
Porcelain is treated with hydrofluoric acid to etch the surface which produces a rough retentive surface The porcelain is then treated with silane coupling agent to produce a strong covalent bond
464
Describe how a resin based luting cement bonds to porcelain?
Porcelain is treated with HF to roughen the surface, then a silane coupling agent (surface wetting agent) is applied to this surface which produces a silane molecule C=C bond which reacts with the composite resin luting cement forming a strong bond
465
Name an advantage of placing a crown as a posterior restoration?
A crown reinforces and strengthens the underlying tooth more than a posterior restoration would do Restorations also do not offer as much protection as a crown does therefore fracturing of the tooth tissue could occur in restorations
466
You have placed a large composite MOD restoration but the patient attends days later complaining of pain on biting — give potential causes for these symptoms?
Pulpal exposure Uncurled resins entering the pulp and causing irritation Fluid from tubules occupying space under restoration Poor moisture control when placing restoration Deep cavity with no liner placed Insufficient coolant when preparing the tooth
467
Describe 4 intra-oral signs of ANUG
Halitosis Grey necrotic tissue slough that wipes off to reveal ulcerative tissue Crater like ulcers Painful ulceration of tips of interdental papillae Reverse gingival architecture
468
What treatment would you carry out for a patient who has ANUG?
Remove supra-gingival and sub-gingival deposits Provide OH using TIPPS Smoking cessation Use of 6% hydrogen peroxide or 0.2% CHX mouthwash Metronidazole tablets, 200mg for 3 days when there is systemic involvement Review and if no resolution, review patients general health and consider referral to specialist services
469
What is TIPPS?
``` Talk = about causes of periodontal disease Instruct = best ways to perform effective plaque removal Practice = cleaning teeth and using interdental aids in surgery Plan = how the patient will fit OH in daily life Support = follow up with patient ```
470
A fracture occurs at the junction of a post and core, explain why this can happen?
Traumatic fracture due to stress or parafunctional habits e.g. bruxism Inadequate ferrule for crown margin to be placed onto which increases likelihood of fracture Bacterial interaction causing caries and decay resulting in fracture
471
Give 3 ways that you can remove a fractured post that is visible?
Ultrasonic vibration Masseran kit Miskito forceps
472
What are the features of aggressive periodontitis?
Generalised pattern of attachment loss affecting at least 3 other teeth except from the 6s and incisors Generally affects patients under age of 30 years Vertical bony defects present Rapid progression of bone loss Plaque levels inconsistent with level of disease seen Clear episodic nature of destruction of periodontal attachment and associated structures
473
If a patient has aggressive periodontitis - how would you decide on the prognosis of individual teeth?
Loss of attachment Mobility Furcation involvement
474
What are the requirements for a lingual bar connector?
8mm clearance from gingival margin to floor of mouth (3mm from gingival margin and 1mm above raised functional depth of floor of mouth)
475
Why would mechanical root surface debridement not be successful in eliminating pocket bacteria?
Inadequate RSD due to poor technique or lack of operator experience Specific pocket sites may be inaccessible to instrumentation meaning the bacteria can not be reached Failure to disrupt the biofilm Patient not adhering to OHI
476
Why may antibiotics not be effective in eliminating pocket bacteria?
Antibiotics should only be used if there is systemic involvement or patient is immunocompromised Antibiotic resistance meaning biofilm is able to resist the antibiotics Antibiotics alone are not able to disrupt the biofilm and reach pocket bacteria
477
How would you manage a periodontal abscess that has systemic involvement?
Carry out careful sub-ginigval scaling short of the base of the pocket to avoid iatrogenic damage If pus is present, drain by incision or through the periodontal pocket Give patient advice on taking analgesics for pain relief Use of 0.2% CHX mouthwash Prescribe antibiotics due to systemic involvement; Amoxicillin capsules, 500mg for 5 days Send 15 capsules Label 1 capsule three times daily Or Metronidazole tablets, 200mg for 5 days Send 15 tablets Label 1 tablet, three times daily
478
Name constituents of GP
GP 25% Zinc oxide 65% Radio-pacifiers 10% Plasticisers 5%
479
Name types of sealer that are commonly used for obturation
``` Calcium hydroxide (dycal) Epoxy resin sealer Bioceramic sealer (calcium silicate and calcium phosphate) ZOE RMGI ```
480
How do you assess obturation on a radiograph?
Check that the length of obturation is correct and that it isn’t too long or too short Check that there is a correct taper Ensure density is correct and that it is well compacted All canals should be filled with GP and sealer
481
Why do we need to obturate?
To seal any remaining bacteria To provide an apical and coronal seal To prevent reinfection
482
Give 4 methods of obturation?
Cold lateral compaction Warm vertical compaction Continuous wave compaction Thermafil (carried based obturation)
483
Name 4 post and core materials
Post; Cast metal (type IV gold) Ceramics (zirconia) Fibre (glass fibre) Core; Composite Amalgam GI
484
What factors can determine post length?
Custom posts; Cast directly from patients mouth as an impression of post hole and wax up of post in lab Post placement; 4-5mm of root filling should be left apically Sufficient alveolar bone support; At least 1/2 of post length must go into the root Maximum of 1:1 post length/crown height ratio Ferrule; Must be at least 1.5mm in height and width of remaining coronal dentine
485
What materials are used to cement a post and core?
GI luting cement | Composite resin luting cement
486
A patient arrives with a swelling above tooth 11 with no systemic symptoms - there is a 10mm probing depth on the palatal surface of the tooth, what may have caused this swelling?
A periodontal abscess which is an acute exacerbation of an existing periodontal pocket caused by trauma to the pocket epithelium or obstruction of pocket entrance Bacteria and food can colonise inside the pocket and without adequate cleaning the pocket becomes further infected causing an abscess to form.
487
Explain the main features of mastication and ingestion
Ingestion; Movement of food from external environment into the mouth Lips provide an anterior oral seal Orbicularis oris and buccinator help to control bolus and prevent spillage Stage 1 oral transport; Food is gathered on tongue tip, tongue retracts pulling the material to the level of the posterior teeth Associated with retraction of hyoid bone and narrowing of oropharynx Mechanical processing; Solid foods broken down and mixed with saliva Bolus squashed by tongue against hard palate Stage 2 oral transport; Bolus moved anterior to poster by squeeze back mechanism of tongue and hard palate Bolus moved through faucets to pharyngeal surface of tongue Swallowing; Involuntary movements push bolus through pharynx to oropharynx Peristalsis occurs to move bolus towards stomach
488
Give 3 aspects of oral function regarded by proponents of the shortened dental arch as acceptable in older patients
Sufficient occlusal stability Occlusal attrition Satisfactory oral function
489
Tooth 15 is root treated with a 9mm pocket and vertical bonds defects present radiographically Give 3 differential diagnoses?
Perio-endo lesion Endo-perio lesion True combined lesion
490
A patient would like an implant, what general and local factors. Would you consider?
General = smoking status and MH (bisphosphonate use) Local = alveolar bone quantity and quality, sufficient space to place implant, 7mm between crowns
491
Name types of intervention for inadequate bone levels?
Guided tissue regeneration Bone grafting Sinus lift
492
Describe the pattern of a vertical bony defect on a radiograph?
Generally v-shaped and are sharply outlined on a radiograph
493
What is the mechanism of a vertical bony defect?
The radius of destruction of plaque determines the bone defect It is approximately 1.5-2mm and if the interproximal bone is greater than this then the pattern is vertical/angular in nature
494
How do we classify vertical bony defects?
1 wall defect 2 wall defect 3 wall defect
495
Define an RPI
It is a stress relieving class system which is used in free end saddle deigns to prevent stress on the last abutment tooth and can also provide reciprocation
496
What are the restorative requirements for a cavity to be suitable for amalgam?
Internal dimensions of the cavity must be greater than the access to it Undercut required Adequate bulk - at least 2mm space for the placement of amalgam Dovetails required in cavity design to prevent dislodgement of restoration Cavosurface margin between 90-120 degrees - butt joint
497
Name 4 different types of composite
Microfilled Nana filled Hybrid Flowable
498
What are the clinical disadvantages of composite and how are they minimised?
Polymerisation contraction stress - consider configuration factor, ensuring it is low Post-op sensitivity - ensure adequate moisture control and bonding procedure Moisture sensitive - use of dental dam Soggy bottom - place <2mm composite increments
499
Give 3 advantages of composite over amalgam
Extended working time - on demand set Minimal preparation - less healthy tooth tissue removed Better aesthetics Composite has high bond strength to the tooth
500
``` What’s a; Healthy periodontium Healthy but reduced periodontium Periodontitis periodontium Response to traumatic occlusion? ```
Healthy periodontium; Widening of the PDL No LOA or inflammation Will resolve once occlusion amended Healthy but reduced periodontium; Widening of the PDL No LOA or inflammation Will result in increased mobility due to reduced PDL ``` Periodontitis; Widening of the PDL LOA Increase in mobility BOP ```
501
What factors can influence localised mobility?
``` Existing periodontal disease Occlusal trauma causing widening of the PDL Alveolar bone loss Resorption Smoking ```
502
Why is there a decrease in mobility after HPT?
Due to increased tissue tone and long junction along epithelium attachment
503
Why may a denture not fit on a patient who has Paget’s disease?
Paget’s disease causes increased bone turnover (increased osteoclasts and osteoblasts activity), meaning that bone swelling can occur resulting in poor fitting dentures
504
A patient is on bisphosphonates and you require to extract a tooth What precautions will you take?
Accurate MH = is patient on oral or IV bisphosphonates, how long have they been taking them? Seek advice from OS/OMFS specialist about treatment CHX twice daily for 1 week pre-op, immediately before XLA and post-op for 2 months Maintain OH Use atraumatic technique and achieve healing by primary intention on closure Post-op follow up Refer to specialist services if complications develop
505
You have extruded sodium hypochlorite through a tooth apex, what would be your immediate and post action?
Inform and reassure patient than complication can be controlled LA for pain relief Irrigate canals with copious amounts of saline Dress tooth with non-setting CaOH Provide a DatAX and note incident in patients notes Advice cold compress during first few days and then warm compress for resolution of soft tissue swelling Analgesic use - OTC Review within 24 hrs Prescribe antibiotics if systemic symptoms occur Refer to specialist services if severe reaction
506
How can you prevent an incident involving the extrusion of sodium hypochlorite?
Careful pre-op assessment to gain CWL Provide patient with protective eyewear and bib Always use dental dam Use saline to test that seal has been made via dental dam Ensure all syringes are labelled correctly Do not wedge the needle in canal or put a lot of pressure on the syringe Ensure silicone stop is 2mm short of CWL Do not rush, and take your time cleaning the canals
507
What is the distribution of LA for a infiltration and a block?
Infiltration = deposited around terminal branches of the nerves Block = deposited beside the nerve trunk
508
What are the constituents of LA?
Aromatic region - hydrophobic Ester/amide bond Basic amine side chain - hydrophilic Preservatives - Methylparaben
509
What are the clinical signs of erosion?
Enamel surface detail loss Surface becomes flat and smooth Dentine can become exposed leading to cupping of occlusal surfaces Typically bilateral, concave lesions without a chalky appearance Increased translucency of incisal edges Amalgam and composite restorations will stand proud on the tooth
510
What are the characteristics of an ideal post?
Parallel sided - avoids wedging and is more retentive Non-threaded passive - smooth surface incorporates less stress on remaining tooth Cement Retained = cement acts as a buffer between masticatory forces and post/tooth
511
What is the hybrid layer?
A layer of dentine that has been conditioned to remove the smear layer and into which adhesive rein has penetrated to form a collagen/resin matrix This solubilised surface has no water content, allowing the solvent primer to be the interface between dentine and the restorative material
512
What are the different types of dentine and how do they affect bonding?
Primary dentine laid down during development - open tubules and good for bonding Secondary dentine laid down during function - allows for sufficient bonding Tertiary dentine is reactionary laid due to mild stimuli and reparative laid due to intense stimuli - poor bonding ability due to poorly organised tubules and sclerosed tubules
513
What changes have been made to modern amalgam to improve it?
Y2 phase has poor strength and abrasion resistance so this has now been removed as modern amalgam has a high copper content to reduce this Zinc is also no longer used as it reacts with water and causes a poor marginal seal. Modern day amalgam is now spherical cut
514
What percentage of maxillary 1st molars have an MB2 canal?
93% have 4 canals 7% have 3 canals
515
What are the 3 design objectives of endodontic?
Create a continuously tapering funnel shape Maintain apical foramen in original position Keep apical opening as small as possible
516
What are the advantages of the crown down technique?
Removes bulk of infected tissue allowing for reservoir for irrigant Keeps reference point for WL Makes straight line access easier Limits spread of infected material at apical foramen.
517
What is HPV?
Human Papilloma Virus HPV is a very common group of viruses that can affect the mouth, throat and genital area HPV has no symptoms, so an individual may not know they have it In some cases, HPV can cause genital warts and cell changes which can be linked to cancer There is no treatment for HPV
518
Why should azoles not be prescribed to a patient on warfarin or statin?
Warfarin; Azoles increase the patients INR which can increase chance. of catastrophic bleed Statin; Azoles can cause hepatoxicity and rhabdomylosis
519
If you have an enamel dentine fracture, What cement would you use to restore?
RMGI dual cure cement as it has a higher bond strength and prevents leakage better than GI Or Etch and bond then flowable composite
520
What radiographs would you request for a paeds root fracture or supernumerary?
PA and upper occlusal radiograph
521
What is Ramsay Hunt Syndrome?
RHS is a complication of shingles that is caused by the Varicella Zoster virus which affects the facial nerve causing inflammation Symptoms include; P = Severe pain in ear, head, face, mouth U = Unsteady, vertigo R = Red rash P = Palsy (facial) L = Loss of hearing E = Exception - there isn’t always a rash! Treatment; Treatment within 72hrs of symptoms can greatly improve recovery Place eyepatch over affected eye Antiviral (Aciclovir) and steroid (Prednisolone) therapy Pain relief
522
What is the function of green stick in impression taking?
Used to extend impression tray Used for “stops” to the space prescribed in the canine and post dam regions which allows preformed space for the impression material Used for border moulding or peripheral sealing for complete dentures
523
Name restorative materials that can bond amalgam to tooth?
Resin luting cement e.g. panavia RMGIC e.g. vitrebond Sealing and Bonding agent e.g. scotch bond
524
What are the features of a Nayyar Core?
2-4mm of GP removed from canal and replaced with amalgam This creates retention from the undercuts in the divergent canals and pulp chamber Immediate placement and coronal prep. Can be done at same appointment
525
What is a BEWE?
Basic Erosive Wear Examination ``` 0 = no erosive wear 1 = initial loss of surface texture 2 = distinct defect of hard tissue <50% of surface 3 = hard tissue loss >50% of surface ```
526
Why would you use RMGI instead of composite resin for a cervical abrasion cavity?
Difficult to gain moisture control which is a requirement of composite RMGIC has less polymerisation shrinkage and is best suited for cervical abrasion lesions where moisture control is an issue
527
What are the constituents of composite?
``` Resin =. Bis-GMA Glass = silica or quartz Light activator = Camphorquinone Low weight dimethacrylate = TEGDMA Silane coupling agent ```
528
What can determine the prognosis of a traumatised tooth when discussing with parents?
``` Stage of tooth development of that tooth Size of fracture Time of pulpal exposure Size of pulpal exposure Damage to PDL Damage to the alveolar bone Presence of infection ```
529
What are the risks of ortho treatment?
``` Decalcification Relapse Resorption Gingival recession Soft tissue trauma Periodontitis Increased mobility of teeth Loss of vitality Wear to adjacent teeth ```
530
What factors can cause displacement of mandibular fractures?
``` Direction of fracture line Opposing occlusion Magnitude of force Mechanism of injury Intact soft tissue Other associated fractures ```
531
What drug is commonly used for IV sedation and what preparation?
Midazolam 5mg/5ml 2mg bolus initially then 1mg increments every 60 seconds
532
Name 6 key learning outcomes on PPE
Protect patient with glasses and bib Protection of hands, eyes, face and clothing with PPE Wear fresh PPE when cleaning Change PPE between patients Always wear PPE when carrying out procedure Correct disposal of PPE into orange stream clinical waste
533
Why are severe class II or III malocclusions contraindicatein SDA cases?
May not have sufficient occlusal contact and may not be able to achieve the necessary 3-5 occlusal units needed for a SDA approach
534
What drug is commonly used for IV sedation and what preparation?
Midazolam 5mg/5ml 2mg bolus initially then 1mg increments every 60 seconds
535
Name 6 key learning outcomes on PPE
Protect patient with glasses and bib Protection of hands, eyes, face and clothing with PPE Wear fresh PPE when cleaning Change PPE between patients Always wear PPE when carrying out procedure Correct disposal of PPE into orange stream clinical waste
536
Why are severe class II or III malocclusions contraindicatein SDA cases?
May not have sufficient occlusal contact and may not be able to achieve the necessary 3-5 occlusal units needed for a SDA approach
537
Why is periodontal disease a contraindication for the SDA?
Drifting of periodontally compromised teeth under occlusal load Loss of alveolar bone leading to a compromised denture bearing area in long term Loss of space (neural zone) for denture teeth in long term
538
What is your second line of treatment for denture induced stomatitis?
Fluconazole 50mg once daily for seven days Miconazole oromucosal gel 20mg/g for seven days after lesions have healed Apply pea sized amount to fitting surface of denture after food four times daily Nystatin oral suspension, 100,000 units/ml Send 30ml Label 1ml after food four times daily for 7 days
539
What spacing is required for special trays for silicones and polyethers?
Upper 2mm spacing | Lower 1mm spacing
540
What bridge design minimises risk of de-bonding? What can cause a bridge to de-bond?
Have large surface area to bond wing onto Do a 180 degrees wrap around retainer Place vertical grooves into preparation Moisture contamination during bridge cementation Parafunctional habits - bruxism Unfavourable occlusion Trauma to face
541
What histological presentations can indicate malignancy?
``` Hyperkeratosis Hyperchromatism Atypia Dysplasia Infiltrate of macrophages ```
542
What microbiological analysis can you do for aggressive periodontitis?
Swab of crevicular fluid from pocket of affected tooth | Oral rinse
543
What is mandibular disablement on closing
Occurs when inter-arch width discrepancy causes upper and lower posterior teeth to meet cusp to cusp which results in mandible being forced to deviate to one side to achieve ICP
544
What can you use to correct a bilateral posterior crossbite? Design a URA to correct a bilateral posterior crossbite
URA with mid palatal screw Quadhelix Rapid maxillary expansion device ``` A= mid palatal screw R = 16 + 26 Adams clasps 0.7mm H.S.S.W 64 + 74 Adams clasps 0.6mm H.S.S.W A = tick B = Self cure PMMA with flat posterior bird plane and mid palatal screw ```
545
What GI conditions can cause microcytic anaemia?
Coeliac disease Peptic ulcer disease Inflammatory bowel disease Crohn’s disease
546
What oral conditions are associated with microcytic anaemia?
Apthous ulcers Glossitis Candida infection
547
List 8 risks of ortho treatment
``` Relapse Decalcification Resorption Gingival recession Soft tissue trauma Wear/damage to adjacent teeth Loss of vitality Periodontal disease Increased mobility of teeth ```
548
What are local risk factors for the delayed onset of bleeding?
LA with vasoconstrictor with wears off | Patient causes tissue trauma to socket via finger, tongue etc.
549
Name one immune deficiency disease and one GI disease that is associated with angular cheilitis and explain how this occurs
HIV = patient is immunocompromised meaning that harmless organisms can become pathogenic and cause infection Crohn’s disease = patient has impaired nutrient absorption and malabsorption which increases likelihood of infection to occur
550
Name an intra oral and extra oral condition associated with angular cheilitis?
Oral candidiasis OFG Orofacial Granulomatosis
551
Why is periodontal disease a contraindication for the SDA?
Periodontally compromised teeth can drift under occlusal load Loss of alveolar bone leading to compromise of denture bearing area in long term Loss of space in the neutral zone for future prosthodontic needs and teeth
552
Why are sub-alveolar fractures poor prognosis?
Moisture control is difficult when placing restoration Unable to take an impression of sub-alveolar preparation which compromises the final prosthesis Difficult to splint this tooth in order to achieve stabilisation as there is no coronal tissue Patient unable to keep restoration clean as they cannot reach sub-alveolar area
553
What is your second line of treatment for denture induced stomatitis?
Fluconazole 50mg One tablet taken daily for seven days Miconazole Oromucosal Gel 20mg/g Apply pea sized amount to fitting surface of denture after eating, four times daily Keep applying until 7 days after lesions have healed Do not prescribe the above to patients taking warfarin or statins Nystatin oral suspension 100,000 units/ml
554
What bridge design would you do to minimise risk of de-bonding?
Ensure wings bond to a large surface area to increase retention Do a 180 wrap around retainer Place vertical grooves into preparation
555
What epithelium is affected by smokers keratosis?
Stratified squamous keratinised epithelium
556
What is mandibular displacement on closing?
Occurs due to the inter-arch width discrepancy which forces mandible to one side when closing to allow for ICP of the upper and lower posterior teeth
557
Why should you correct a mandibular displacement?
To improve aesthetics as displacement can cause facial asymmetries To prevent TMJD and tooth wear
558
Design a URA to correct a posterior bilateral crossbite
A = Mid palatal screw R = Adams clasps on 16 and 26 - 0.7mm HSSW Adams clasps on 54 and 64 - 0.6mm HSSW A = satisfactory B = Self cure PMMA posterior bite plane with mid palatal screw
559
Discuss the different types of sterilisers used in decon?
Type B Active air removal from chamber Cycle intended for sterilisation of wrapped, solid, hollow and porous products Products that are vacuum packaged are sterile at point of use and can be stored before use Type N Passive air removal from chamber Cycle intended for sterilisation of non-wrapped products Not intended for lumened products Items are not wrapped and should be used immediately after processing and not stored
560
Describe the appearance of dental fluorosis?
Presence of opaque white spots on teeth Diffuse mottling of the teeth in mild cases Brown staining and putting of teeth in severe cases
561
Where can fluoride be food in food?
``` Tea Potatoes Beer Bony fish Cucumber White rice ```
562
Give the best treatment options for fluorosis and give advantages of these treatments
Microabrasion; Easy to perform Fast acting Vital bleaching; Patient can do this at home Conservative Good level of result Composite restoration; Easy to perform Can disguise area of tooth affected
563
Give an advantage and disadvantage of an oral swab and oral rinse
Oral swab; Site specific Easy to perform May be sensitive for patient Oral rinse; Records whole mouth Not site specific Patient may find rinse process difficult to do
564
Child has ingested fluoride - what 3 questions would you ask the mum?
How old is child? What is the strength of the toothpaste? How much toothpaste have they swallowed?
565
A patient has ingested a possible toxic dose - what is your advice?
``` <5mg/kg = give calcium orally (milk) and monitor 5-15mg/kg = give calcium orally (milk) and admit to hospital for monitoring >15mg/kg = Admit to hospital immediately for IV calcium gluconate and cardiac monitoring ```
566
What is the most common cause of fluorosis in the UK?
Fluoride in public water supply 1ppm
567
Give 3 diagnostic features of a subluxation injury
Increased mobility and TTP No displacement of tooth Bleeding from gingival sulcus
568
What features would you assess radiographically when reviewing a subluxation injury?
Root development = width and length of canal Assess for any internal or external inflammatory resorption Compare with teeth on either side to identify if any changes are present to the damaged tooth
569
What are the clinical and radiographic signs of internal inflammatory root resorption?
Clinical; May have positive response to sensibility testing Often asymptomatic with no clinical signs present Radiographic; Fairly uniform, oval radiolucent enlargement of pulp canal Outline of root canal will be distorted
570
What is the mechanism of internal inflammatory root resorption?
Protective odontoblast and pre-dentine layer has been damaged and this has exposed the canal wall to odontoclasts If left untreated, this can continue to form pulp necrosis and apical periodontitis
571
How would you manage internal inflammatory root resorption?
Intra-canal medicament of calcium hydroxide to reduce bacterial load RCT and obturate with GP