PP BDS4 Flashcards
Why might a first molar be impacted?
Angle of path of eruption
Small maxilla
Morphology of surrounding teeth
Ectopic crypt
What are the deleterious effects of impacted teeth?
Root resorption
Bone loss
Tooth loss
Ectopic teeth
Tilting and tipping of teeth
What features of the permanent dentition allow for replacement of primary teeth without crowding?
Slightly proclined permanent teeth
Natural space between the primary teeth allows for relief of crowding in permanent dentition
Leeway space (extra mesial- buccal - distal space occupied by primary molars)
- 5mm per side on upper
- 5mm per side on lower
What is an extrusion injury?
Partial displacement of the tooth out its alveolar socket characterised by partial or total separation of the PDL resulting in loosening of the tooth within its socket
What thickness of stainless steel wire would you use for a flexible splint?
0.6 mm
How long would you splint an extrusion injury for?
Flexible splint for 2 weeks
What are the different types of dentinogenesis imperfecta?
Type 1 = associated with osteogenesis imperfecta
Type 2 = not associated with osteogenesis imperfecta
Type 3 = brandywine isolate (rare condition)
What are the clinical signs of Dentinogenesis Imperfecta?
Loss of enamel
Discolouration
Both primary and permanent teeth affected
What are the radiographic signs of Dentinogenesis Imperfecta?
Bulbous crowns with apparent cervical constriction
Periapical radiolucency without any apparent pathology
Obliterated (missing) pulp chamber and canals due to deposition of dentine
Reduced root length with rounded apices
What are the risks of orthodontic treatment?
Root resorption Relapse Decalcification Gingival recession Trauma Loss of vitality
5 year old brought to clinic, she is pyrexic, in pain and has a swollen left side of face associated with gross caries in all primary molar teeth - you provisionally diagnose an acute periapical abcess
What should you establish prior to the examination of her?
What would be your short term management of this case?
Thorough history;
Pain history
Medical history
Dental history
Determine if airway is compromised;
If patient is unable to swallow or they are unable to push their tongue forward in the mouth, send to emergency services
Pain relief - ibuprofen Abscess drainage Antibiotics due to systemic involvement Amoxicillin capsules 250mg or oral suspension 125mg/5ml 500mg x 3 daily for 5 days Review patient in 5 days time
Advise that if pain or swelling gets worse, to go to A&E
What are the general indications for a pulpotomy?
Good child co-operation Medical history precludes extraction Missing permanent successor Overriding necessity to preserve the tooth e.g. space maintainer Child is under 9
What are the clinical indications for a pulpotomy?
Pulp minimally inflamed/reversible pulpitis
Marginal ridge destroyed
Caries extending >2/3rds into dentine
What are the clinical indications for a pulpectomy?
Exposure of hyperaemic pulp
Irreversible pulpitis
Acute abscesses
What are the advantages of non-vital bleaching?
Simple procedure
Tooth conserving
Original tooth morphology remains
What are the disadvantages of non-vital bleaching?
Risk of spillage of bleaching agent
May fail to bleach teeth effectively
Can over bleach the teeth
Can cause brittleness of tooth
Describe the bleaching inside-out technique
Open up access cavity of tooth
Ensure root filling is removed to below gingival level
Provide custom made mouthguard with windows cut out of the guard for the teeth that aren’t being bleached
Patient applies bleaching agent (10% Carbamide Peroxide) to back of tooth and tray
Patient keeps access cavity clean, replacing gel and removing debris every 2 hours except during the night
Tray should be worn at all times except when eating and cleaning
When does primary tooth eruption begin and end?
Begins at 6 months and ends around 2.5/3 years of age
What are the eruption dates for the permanent dentition?
6 yrs = 6s and lower 1s 7 yrs = upper 1s and lower 2s 8 yrs = upper 2s 9 yrs = lower 3s 10yrs = 4s and 5s 11 yrs = upper 3s 12 yrs = 7s
How long does it take for a permanent tooth root to complete apexogenesis?
3 years
Name 4 types of Amelogenesis Imperfecta
Type 1 = Hypoplastic
Type 2 = Hypo-maturational
Type 3 = Hypo-calcified
Type 4 = Mixed with taurodontism
What are the causes of Amelogenesis Imperfecta?
Caused by inherited gene mutations which are responsible for making proteins needed for normal formation of enamel
What orofacial injuries are suspicious of child abuse?
Bruising of face Bruising of ears Burns Lacerations Bites Neck marks Fractures
You wish to refer a child who you suspect may be victim to child abuse. Who do you refer to and how do you do it?
Observe the child - assess, take a history and examination
Record everything in notes
Communicate with patient and parents regarding concerns
Communicate with senior colleague or dental protection for advice
Refer to social services for suspicions of abuse, neglect or if child is at risk (confirm in writing)
Inform other relevant professionals e.g. GP, schoolteacher
Contact police if you feel the child is in immediate danger
Follow up within 48 hrs
3 year old child attends with blisters on gums - what is the likely diagnosis?
How might the blisters appear clinically?
Primary herpetic gingivostomatitis
Numerous vesicles which may rupture rapdily to form painful ulceration covered by a greyish slough
How would you manage a young patient with primary herpetic gingivostomatitis?
Reassurance advice;
Lesions heal spontaneously in 1-2 weeks
Advise on infectious nature to patients eyes and other people who are immunocompromised
Treatment;
Plenty of bed rest and high fluid intake to keep hydrated
Use of analgesics - NSAIDS
Refer to specialists if concerned about ability to eat and drink as patient may require aciclovir
OHI - use of CHX mouthwash and keep up brushing
What future issues may primary herpectic gingivostomatitis cause in the future?
Reactivation causing herpes labialis
Bells palsy
What are the indications for a SSC?
When there are >2 surfaces affected with extensive lesions
When there is impaired OH and high caries rate
If space is required to be maintained
Poorly co-operating children that would not cope with LA
After pulpotomy/pulpectomy
In severe MIH/enamel defect cases
Describe the appearance of dental fluorosis
Opaque white spots/streaks on teeth
Mottled patches in mild cases
Brown staining and putting of the teeth in severe cases
What is the most common cardiac defect in children? What condition is commonly associated with this condition?
Ventricular septal defect
Downs Syndrome
Name medical issues that are seen in patients with down’s syndrome
Leukaemia Epilespy Hypothyroidism Periodontal disease Coeliac disease Alzheimer's Ventricular septal defect
What are the indications for microabrasion?
Ortho decalcification
Fluorisis
Trauma
Pre-veneer
How is microabrasion carried out?
Pre-op photos, shade, sensibility
Teeth are cleaned with pumice and water
Polish with finest sandpaper disc and then with toothpaste
Ensure patient doesn’t eat coloured stained foods for 24-48hrs
Review after 4-6 weeks
Regarding Autism, what is the Triad of Impairment?
Used to describe the main features of people with autism;
Communication
Social interaction
Social imagination
What features do people with autism have?
Difficulties with;
Communication
Social interaction
Social imagination
Sensory sensitivity
Learning difficulties
Epilepsy
OCD
How may anxiety be measured in a child?
Modified child dental anxiety scale 9 questions regarding past dental experiences Scores range from 8-45 Score of 9 = dental anxiety Score over 27 = extreme phobia
Give behavioural management techniques for an anxious child
Desensitisation Positive reinforcement CBT Progressive relaxation Tell-show-do Distraction technique Modelling - learn about environment by observing others `
What are the 4 types of cerebral palsy?
How are they classified?
Spastic
Ataxic
Athetoid
Mixed
Hemiplegia
Diplegia
Paraplegia
Quadriplegia
What is cystic fibrosis?
It is an autosomal recessive condition caused by chromosome 7 mutation of the gene for CFTR
This causes thick, excessive mucous in the lungs, pancreas and salivary glands
What are the general signs and symptoms of cystic fibrous?
Recurrent chest infections
Thick salivary secretions
Respiratory problems
Under development
What are the dental considerations for cystic fibrosis?
Thick saliva can increase calculus production
Difficulties cleaning due to respiratory problems
Avoidance of GA and sedation
May have delayed eruption and enamel defects
What type of splint is recommended for an avulsion injury?
EADT <60 mins = flexible splint 2 weeks
EADT >60 mins = flexible splint 4 weeks
What is EADT?
Extra alveolar dry time
Time it takes from avulsion to placement in storage medium
This is a critical time, as the longer the EADT, the more damage to the PDL
What methods can be used to prevent orthodontic decalcification?
Correct case selection OHI Diet advice FS Regular GDP and hygienist appointments
Name intra-oral features than a patient with a class III malocclusion may have What systemic condition may the patient have if his mandible keeps growing?
Reverse overjet Anterior/posterior crossbite May have an overbite Maxilla often crowded Proclined upper incisors Retroclined lower incisors Tendency for displacement on closing
Acromegaly
What foramen does the i) opthalmic branch ii) maxillary branch iii) mandibular branch pass through?
i) Superior orbital fissure
ii) Foramen rotundum
iii) Foramen ovale
What is the origin, insertion, innervation and function of the masseter muscle?
Masseter;
Origin = zygomatic arch
Insertion = lateral surface and angle of mandible
Innervation = masseteric branch of mandibular division of trigeminal nerve
Function = elevates mandible
What is the pathology of a squamous cell carcinoma?
80% are moderately well differentiated (look similar to normal cells)
Local extension of disease
Increased mitotic activity (increased division of cells)
Abnormal keratinisation
Hyperchromatic nuclei (larger in size and stain darker)
Cellular pleomorphism (cells variant in size colour etc)
Basal cell hyperplasia (cells have increased size)
Elongated rete pegs
List signs and symptoms of a mandibular fracture
Pain Swelling Bruising Limitation of function Occlusal derangement Numbness of lower lip Mobile teeth Internal/external bleeding of the ear AOB Facial asymmetry Deviation of mandible
What two radiographs are required for a mandibular fracture?
OPT
PA mandible
CBCT
What factors can cause displacement of mandibular fractures?
Direction of the fracture line Opposing occlusion Magnitude of force Mechanism of injury Intact soft tissue Other associated fractures
List three management options for a mandibular fracture?
Undisplaced fracture = no treatment (monitor)
Displaced fracture =
closed reduction and fixation
or
open reduction internal fixation
You have extracted tooth 26 but the bleeding won’t stop
List how you would manage the situation and gain haemostasis
Ensure you have accurate medical and drug history
Identify where bleeding is coming from
Apply firm pressure using a damp gauze
Administer LA with vasoconstrictor
Haemostasis aids - Whitehead varnish pack
Suture socket
Ligation of vessels with Diathermy
What is the scientific term for a dry socket?
Alveolar/Localised Osteitis
What are predisposing risk factors for dry socket?
Molars more common Mandible more common than maxilla Smoking More common in females Oral contraceptive pill can increase risk Excessive trauma during procedure Excessive mouth rinsing post extraction Family history or previous dry sockets
What are the treatment options for a dry socket?
Supportive;
Reassure patient and give them information on dry sockets
Management;
Give LA to relieve pain
Irrigate socket with warm saline to wash out debris
Can use WHVP to encourage clot formation
Advise patient on analgesia and hot salty mouthwash use at home
What is pericoronitis?
Inflammation of a partially erupted tooth due to food and debris getting trapped under operculum resulting in inflammation and/or infection
How is pericoronitis treated?
Reassure patient and advise them on what pericoronitis is
If any abscesses present, adminster LA, incise and drain
Wash underneath operculum with CHX mouthwash
Possible extraction of 3rd molar
Advise patient on analgesic and CHX mouthwash use at home
Only prescribe antibiotics if patient systemically unwell or immunocompromised
If patient has large extra-oral swelling with systemic symptoms, refer to A&E
What radiographic signs show a close relationship of a lower 8 with the inferior alveolar nerve/canal?
Diversion of the inferior alveolar canal
Darkening of the root where crossed by the canal
Interruption of the lamina dura of the canal
Deflection of the root
Narrowing of the canal
Juxta apical area - radiolucent area lateral to the root rather than at the apex
What risks should be explained to the patient in regards to damage of the IAN when extracting the tooth
Dysaesthesia = painful, uncomfortable sensation of the lower lip, chin and tongue
Altered taste
Numbness (anaesthesia) or tingling (paraesthesia) of the lower lip, chin and tongue
Temporary IAN anaesthesia = 10-30% risk
Permanent IAN anaesthesia = <1% risk
What is the difference between an OAF and OAC?
An OAF is a chronic epithelial lined tract between the maxillary sinus and the oral cavity
An OAC is an acute communication between the max sinus and oral cavity which is not epithelial lined
What nerve supplies the TMJ?
Auriculotemporal and masseteric branches of the mandibular branch of the trigeminal nerve
What are the mechanisms of a bite splint?
Exact function is unknown but it is thought that they stabilise the occlusion and improve function of the masticatory muscles, thereby decreasing abnormal activity
What is arthocentesis?
Procedure in which the jaw joint is washed out with sterile saline and anti-inflammatory steroids
This breaks down fibrous adhesion and flushes away inflammatory exudate
What are the signs and symptoms of a ZOC (Zygomatico-orbital complex) fracture, involving the orbit floor?
Asymmetry Altered sensation Lacerations Sub-conjunctival haemorrhage (biggest indicator) Numb cheek Visual disturbances Pain on eye movement Peri-orbital ecchymosis (panda eyes)
What imaging would you request to confirm a ZOC fracture diagnosis?
Occipitomental (OM) views 15 and 30 degrees
CT scan
What are the management options for a ZOC fracture?
Leave alone and monitor
Open reduction and internal fixation
Closed reduction - Gillies lift
What factors does an implantologist consider before placing an implant?
Smoking status Medical and drug history Alveolar bone quality and quantity OH and periodontal status Patient motivation and compliance Overall occlusion Patient aesthetic Final prosthetic considerations
What bone dimensions are required for implants and how are these dimensions measured?
1.5mm horizontal bone around the implant
3mm between implants
7mm spacing between crowns
>5mm space for the papilla between the bone crest and contact points
2mm from adjacent structures e.g. max sinus
Assessed with a CBCT
How would you manage the loss of a tooth/root in the maxillary sinus?
Inform patient Confirm using post-op radiographs Surgical removal using Caldwell-luc approach Close with buccal advancement flap Or ENT involvement
What are the SIGN Guidelines for not advising the removal of wisdom teeth?
In patients whose 3rd molar would be judged to erupt successfully
In patients whose MH renders the removal an unacceptable risk (risk exceeds benefit)
In patients with deeply impacted 3rd molars with no history or evidence of pathology
In patients where the risk of surgical complications is judged to be unacceptably high
What type of flap is used for the removal of an impacted lower 8?
Envelope - 3 sided flap
What tissues may be responsible for the prolonged bleeding after an extraction and how would you manage each of these?
Soft tissues = LA use or suturing
Bone = WHVP or bone wax
Vessels = Diathermy
A patient is keen to pursue open flat curettage for his teeth which have 6-7mm pocket depths and BOP. He has previously. Completed HPT. What information would you give the patient. So he can give informed consent?
Explain the surgery;
Involves opening up the gum, removing calculus deposits, water irrigation, suction and suturing with stitches
Risks; Gingival recession Infection Bleeding, bruising and swelling Pain
Benefits;
Effectively debrides(cleans) the area to regenerate lost periodontal tissues
Has better outcomes than repeating NSHPT
Outcomes;
Surgical therapy has been shows to result in clinical improvement
Reduction in probing depths is greater following surgical treatment
Other options;
Repeat NSHPT
Regenerative therapy
Furcation resective treatment
Risks if they do not have treatment; Increased likelihood of tooth loss Increase mobility Increased pocket depths Possible pathologies may occur
Following surgical treatment, what do you want the patient to know to minimise the incidence of any post-operative complications?
Post-op surgical advice is highly important
Pain is common, you can take analgesics prior to the LA wearing off and then take regular doses as required but the pain should settle over the week
Bleeding can occur, if this does happen, use a damp piece of gauze to bite down on with firm pressure - if bleeding does not stop, go to GDP or A&E if out of hours
Ensure you do not explore or traumatise the area with finger, food etc.
Do not rinse out for 24hrs as this can dislodge the blood clot, after 24hrs rinse gently with warm salty mouthwash
Do not exercise or partake in strenuous activity
Avoid hard, sticky, hot food and drinks
Avoid alcohol and smoking for as long as possible as this will delay healing
Bruising is normal and can occur, use ice pack to reduce area if required
Pain and stiffness of TMJ is common and should settle over 1-2 weeks but it it prevents you from eating or lasts longer = seek advice
Sutures;
Leave sutures alone and do not pull them out
Inform patient if they have resolvable or non-restorable stiches and whether they need to return to have stitches removed
Mouthwash;
Use warm salty mouthwash or CHX 2-3 times a day
Name alternative techniques for an IAN block?
Gow-gates block
Akinosi block
How do you manage a patient if you accidentally inject into the parotid gland?
Inform patient and reassure them that it is a reversible condition
Provide eye protection until their blink reflex returns
Advise that length of paralysis can vary but will improve over a period of weeks
Review the patient
What does dentally fit mean?
Classed as dentally fit if you are free from any active disease prior to the start of cancer therapy
What is a multi disciplinary team?
It is a team of individuals from various disciplines/specialities who work together to provide the best holistic care and best treatment options for the patient
What oral risks is a patient at following radiotherapy?
Xerostomia Mucositis Osteoradionecrosis Increased risk of infection Poor wound healing Caries Ulceration
What are the oral risks of chemotherapy?
Xerostomia Mucositis Increased risk of bleeding and bruising Increased risk of infection Mouth ulcers Halitosis Reduced sense of taste
What are the grades of mucositis?
Grade 0 = nothing to note Grade 1 (mild)= oral soreness and erythema Grade 2 (moderate) = oral erythema and ulcers, solid diet tolerated Grade 3 (severe) = oral erythema and ulcers, liquid diet only Grade 4 (life threatening) = oral feeding impossible
How is Mucositis managed?
Sook on ice cubes for cooling effect
Morphine lollipops for pain management
UVB light therapy
Calcium and phosphate mouthwash
Smooth teeth and dentures to prevent further ulceration
Avoid smoking, alcohol, spicy food and drinking tea/coffee
How can mandibular fractures be classified?
A. Involvement of surrounding tissues;
Simple
Compound
Comminuted
B. Number of fractures present;
Single
Double
Multiple
C. Side of fracture;
Unilateral
Bilateral
D. Site of fracture; Angle Sub-condylar Para-symphyseal Body Ramus Coronoid Condylar Alveolar process
E. Direction of fracture line;
Favourable
Unfavourable
F. Specific fractures;
Green stick
Pathological
G. Displacement of fracture;
Displaced
Undisplaced
What factors can cause a mandibular fracture to be displaced?
Pull of attached muscle
Angulation and direction of fracture line
Integrity of periosteum (layer covering bone)
Extent of comminution
Force and displacement of blow
What are the signs and symptoms of a maxillary fracture?
Swelling Bruising Nose bleeds Restricted eye movement Malocclusion Tooth mobility Diplopia (double vision)
What is the Le Fort Classification system?
Type 1 = horizontal maxillary fracture, spreading teeth from the upper face (floating palate)
Type 2 = pyramidal fracture involving nasofrontal suture (floating maxilla)
Type 3 = maxilla is detached from base of skull (floating face)
What is a cyst?
A pathological cavity with fluid, semi-fluid or gaseous contents, not created by pus accumulation
Name 2 inflammatory cysts
Radicular cyst Residual cyst (cyst left after extraction)
Name 2 developmental cysts
KCOT (keratocystic odontogenic tumour)
Dentigerous cyst
Name 2 non-odontogenic cysts
Simple bone cyst
Nasopalatine cyst
Name 2 common treatment options for cyst removal/treatment, give advantages and disadvantages for both
Enucleation;
All of the cystic lesion is removed
Advantages;
Whole cyst lining is examined
Little after care needed
Allows primary closure
Disadvantages;
Incomplete removal can lead to recurrence
Damage to adjacent structures
Tooth loss can occur
Marsupialisation;
Creation of a surgical window in the wall of the cyst, removing the contents and suturing the cyst wall to surrounding epithelium
Advantages;
Simple to perform
May spare vital structures
Disadvantages;
Cyst may reform
Complete lining not available for histological sampling
Difficult to keep clean and lots of aftercare required
How does a radicular cyst develop?
They are dental cysts associated with the roots of the teeth and generally involved non-vital teeth
They usually have an inflammatory aetiology and is sequele to pulpitis
They develop from epithelial cell rests of Malassez
How do radicular cysts appear radiographically?
Well defined radiolucent around the apex of a tooth
Unilocular
Margins of lesion are continuous with lamina dura on either side of the root
How do radicular cysts appear histologically?
Epithelial lining often incomplete
Inflammation present in capsules
May form by proliferating epithelium with central necrosis
What is a dry socket and what is its official name?
Alveolar osteitis
It occurs when the blood clot at the site of the extraction site fails to develop, dislodges or dissolves before the wound has fully healed
This results in exposed and inflamed lamina dura
It is not associated with infections
How long should it approx. take for an extraction site to heal?
Initial healing 1-2 weeks
Soft tissue fully healed at 3-4 weeks
What is osteoradionecrosis?
Bone necrosis as a result of radiation injury
Any turnover of viable bone is very slow and self repair is ineffective - this can progress and get worse over time
What are the risks of orthognathic surgery?
Relapse Nerve damage Bleeding Unobtainable results for patients with high expectations Infections TMJD
Name 2 types of mandibular surgery
Bilateral sagittal split osteotomy (BSSO)
Vertical subsigmoid osteotomy (VSSO)
Name 2 types of maxillary surgery
Le fort 1
Anterior maxillary osteotomy
What are the principles of flap design?
Maximal access with minimal trauma
Wide based incision
Use scalpel in one firm continuous stroke
No sharp angles
Minimise trauma to dental papilla
No crushing of tissues
Flap reflection should be down to bone
Keep tissues moist
Ensure flap margins and sutures lie on sound bone
Ensure wounds are not closed under tension
Aim for healing by primary intention to minimise scarring
What do you assess on a radiograph prior to extracting a lower 8?
Angulation and orientation of impaction Access to tooth Crown size and condition Root number, length and morphology Alveolar bone levels Follicular width Relationship to maxillary sinus or IAN Any associated pathology Periodontal status of 7 and 8
What is the use of iodine in the extraction of a wisdom tooth?
Present in WHVP and Alvogyl
Used to manage dry sockets and achieve haemostasis
Name 3 types of nerve damage
Neuropaxia - blockage of nerve conduction due to contusion
Axonotmesis - myelin sheath damaged
Neurotmesis - nerve is transected
What are the aims of suturing?
To approximate and resposition tissues To compress blood vessels To cover bone Prevent wound breakdown Achieve haemostasis Encourage healing by primary intention
Name 4 types of sutures and give examples
Resorbable;
Monofilament = Monocryl
Multifilament = Vicryl Rapide
Non-Resorbable
Monofilament = Prolene
Multifilament = Mersilk
What might a patient complain of if they have a sialolith (saliva stone)?
Swelling associated with meals
Pain
Xerostomia
Bad taste
What gland is most commonly affected by a sialolith and why?
Submandibular gland
Due to position of gland and uphill path of saliva secretion
What investigations can be done for a sialolith?
Lower occlusal radiograph
Palpation of gland
Sialography
Isotope scan
How can you manage a sialolith?
Surgical removal
Sialography sialoendoscopic removal
Shock wave lithotripsy
Consider gland removal if fixed swelling
What are bisphosphonates and what conditions are they used for?
Bisphosphonates are a class of drugs that are used to help prevent and treat bone loss by increasing bone density Bisphosphonates reduce bone turnover by inhibiting osteoclast recruitment and function
Used for conditions such as; Osteroporosis Paget's disease Osteogenesis imperfecta Malignant metastasis Multiple myeloma
How is MRONJ diagnosed?
Patient must be on bisphosphonates or anti-angiogenic drugs
No history of head and neck radiotherapy
Exposed bone/lack of extraction site healing at 8 weeks review
How is a patient determined high or low risk of MRONJ?
Low risk;
Isolated osteoporosis patients with no other co-morbidities
Oral medication with treatment span of less than 5 years
High risk; Cancer patients Previous MRONJ patients Cumulative drug dose IV medication
How would you manage a patient taking bisphosphonates in general practice, if they are going to be receiving an extraction?
Advise patient on risk of MRONJ due to medication
Patient must have excellent OH
CHX use prior and after extraction
Drugs may be stopped prior to extraction but this must be consulted with physician in charge of patients care
Atraumatic technique
Use of haemostatic agents - suturing, WHVP
Post op instructions
Review
What is MRONJ?
Medication related osteonecrosis of the jaw
It is a severe, adverse drug reaction, consisting of progressive bone destruction in oral region of patients
What is osteoradionecrosis?
Bone necrosis as a result of radiation injury
Any turnover of viable bone is very slow and self repair is ineffective - this can progress and get worse over time
What are the risk factors for osteoradionecrosis?
Radiation of head and neck - especially >60 Kv
Mandible affected more than maxilla due to limited blood supply
When dental procedures have been carried out prior to radiation therapy (extractions at least 2 weeks before)
Poor OH
Post radiotherapy damage, trauma etc.
How is osteoradionecrosis managed?
Surgical debridement;
Irrigation and removal of necrotic and infected tissues
Surgical micro vascular reconstructive therapy;
To restore blood flow to the area
Grafts;
Bone and soft tissue grafts may be required
Hyperbaric oxygen therapy;
Increase vascular ingrowth
How can osteoradionecrosis be prevented?
Extracting teeth of poor prognosis at least 2 weeks prior to radiotherapy
Ensuring patient dentally fit prior to radiotherapy
Keeping good OH throughout
Use of CHX mouthwash before and after extractions
Atraumatic extraction technique
Name 3 types of elevators and name three movements that are used for elevators
Couplands
Cryer’s
Warwick James
Wheel and axel
Lever
Wedge
What are the uses of elevators?
To provide point of application for forceps
To loosen teeth prior to using forceps
To extract a tooth without the use of forceps
Removal of multiple root stumps
Removal of retained roots
Removal of root spices
What is the function of a luxation?
They break the PDL to aid forceps use
What is osteomyelitis?
It is a bacterial infection of bone resulting in inflammation of the bone marrow which in turn can cause necrosis due to an increase in tissue pressure
What are the risk factors for osteomyelitis?
Odontogenic infections Fractures of the mandible Immunocompromised patients Malnourished patients Patients receiving chemotherapy
How it osteomyelitis managed?
Referral to specialist services
Antibiotic treatment - may require IV in acute cases
Drain pus if possible
Removal of non vital teeth in area of infection
Corticotomy
If fractured mandible, remove any wires, plates, screws etc. in area
Removal of necrotic bone
What is the nerve supply for the submandibular gland?
Parasympathetic innervation - from the chorda tympani branch of the facial nerve which unifies with lingual branch of mandibular nerve at the submandibular ganglion
What does the submandibular gland secrete?
Mixed serous and mucous secretions
What is the innervation of the parotid gland?
Sensory innervation - auriculotemporal nerve and greater auricular nerve
Parasympathetic innervation - glossopharyngeal nerve and auriculotemporal nerve
What does the parotid gland secrete?
Serous secretion
What is the nerve supply of the sublingual gland?
Parasympathetic = chorda tympani of facial nerve which unifies with lingual branch of mandibular nerve at submandibular ganglion
What does the sublingual gland secrete?
Mixed serous and mucous secretions but predominantly mucous in nature
What information is required when taking a history and investigating a patient with a large extra oral swelling, prior to looking in the patients mouth?
Thorough history including pain history How long has swelling been present? If/when did it increase in size? Temperature Respiratory rate Heart rate
What things would you note about a facial swelling?
Site/location of swelling Size of swelling Airway compromised? Duration of swelling Palpation (firm/mobile) Pus present Heat from area Colour Clear or diffuse borders Associated fever or malaise?
What is the criteria perimeters for SIRS (systemic inflammatory response syndrome)?
> 2 positive SIRS factors +/- suspected/confirmed infection;
Temp <35 or >38 degrees
Respiratory rate >20/min
Pulse >90/min
WCC <4 or >12
What is Ludwig’s angina?
Characterised by a bilateral cellulitis infection of the sublingual and submandibular spaces which can compromise the airway
Features include;
Raised tongue
Difficulty breathing and swallowing
Drooling
Diffuse redness and bilateral swelling of submandibular region
Name 4 maxillary and mandibular spaces
Maxillary; Infraorbital space Infra temporal space Palatial space Buccal space.
Mandibular; Buccal space Sub-masseteric space Sublingual space Submandibular space
List the cranial nerves
I = olfactory - smell
II = optic - vision
III = occulomotor - eye movement
IV =trochlear - eye movement
V = trigeminal - MOM, sensory info. for head and neck
VI = Abducens - eye movement
VII = facial - taste, muscles of facial expression
VIII = vestibulocochlear - hearing
IX = glossopharyngeal - taste, sensory info for tongue, swallowing
X = vagus - gland function, digestion and cardiac systems
XI = accessory - head movement
XII = hypoglossal - tongue movement
List the LA maximum does for Lidocaine, Prilocaine, Articaine and Mepivicaine
Lidocaine 2% + 1:80,000 adrenaline
Max dose = 4.4mg/kg
Prilocaine 4% plain
Max dose = 6mg/kg
Articaine 4% + 1:100,000 adrenaline
Max dose = 5mg/kg
Mepivicaine 2% + 1:80,000 adrenaline
Max dose = 4.4 mg/kg
Why is written consent gained prior to the sedation process?
Consent process should begin at a separate appointment prior to treatment - this allows the patient sufficient time to consider the information provided
Consent should be reconfirmed verbally on the day of the procedure
Name 3 vital signs you would monitor before, during and after sedation?
Heart rate
Blood pressure
Oxygen saturation levels
Give advices you would give to a patient after they have received sedation
No operating machinery or driving
Stay off social media, emails, online shopping etc.
No physical activities for the next 24hrs
No signing legal documents
No important decision making
What is postural hypotension?
It is an excessive fall in blood pressure when an upright position is taken caused by a failure of the auto regulatory systems which normally maintain blood pressure on standing
Name in order, the actions which take place in the body when a patient begins to lose consciousness due to postural hypotension
Venous pooling in legs Poor venous return Fall in stroke volume Fall in cardiac output Patient continues to lose consciousness
What may cause a patient to collapse?
Fainting Fear/anxiety Hypoglycaemic shock Dehydration Postural hypotension
What would you do differently for a patient that has postural hypotension at the end of an appointment?
Allow chair to sit up gradually over a couple of minutes and encourage patient to take their time when standing and take slow deep breaths
Schedule appts for 30-60mins after eating and taking medication
What is ABCDE and how are they assessed?
A = Airway
Jaw thrust, check mouth for any obstruction
B = Breathing
Ear to mouth, look at chest for movement
C = Circulation
Check carotid pulse
D = Disability AVPU scale A = alert V = verbal P = pressure (pinch pt.) U = unresponsive
E = Exposure
Look for clinical signs on body
What are the indications and contraindications for inhalation sedation. ?
Indications;
Medical conditions aggravated by stress e.g. asthma, epilepsy
Social conditions e.g. phobia, strong gag reflex
Dental conditions e.g. traumatic procedures
Contraindications;
Unable to nose breath
Severe COPD
1st trimester of pregnancy
What safety features are present on the quantaflex MDM machine used for inhalation sedation?
Oxygen flush button Reservoir bag Scavenger system Coloured cylinders Pin index system Minimum oxygen at 30% Built in oxygen monitor One way expiratory valve
What are the advantages of inhalation sedation over IV sedation?
Quicker onset Rapid recovery Not metabolised so safer than midazolam Less post op side effects No needles required Can be used on children Useful for anxiety relief
What medications are in the dental medical emergency kit including quantities and uses?
Adrenaline IM injection (1;1000, 1mg/ml) = anaphylactic shock
Aspirin (300mg) = suspected MI
Glucagon IM injection (1mg) = hypoglycaemic shock
Glyceryl trinitrate spray (400ug/dose) = angina
Midazolam 10mg buccal = >5min epileptic seizure
Salbutamol 100ug per puff = asthma attack
When might a referral for GA be made?
Medical history contraindicates sedation
Patient unco-operative, phobic
Children under 12 and special needs children who require comprehensive dental treatment
When there is extensive, complex treatment procedures required to be carried out
Benefits of GA outweighs risk
What are the stages of anaesthesia?
Induction
Excitement
Surgical anaesthesia
Respiratory paralysis/overdose
What needs to be included in a referral letter for GA
Patient details Guardian details (if appropriate) GMP and GDP details MH DH and justification for GA referral Radiographs to back up justification Treatment plan for during GA
If you are shown a direct immunofluorescence performed by a lab due to suspected pemphigus vulgaris - what is this method of analysis called?
What would the pathologist report of if pemphigus vulgaris is present?
Name one condition that would represent the lesion in the same way clinically, but would be different histopathologically?
Histopathology and direct immunofluorescence
Presence of tzank cells
Elongated rete pegs
Basket weave pattern on IF
Drug induced pemphigus
What is Pemphigus Vulgaris?
What causes it to form?
Usually begins in the mouth and is seen as clear fluid filled blisters that burst and then spread
Caused by intra-epithelial bullae blisters and sores on skin and mucous membranes
What are the risk factors for an oral squamous cell carcinoma?
Tobacco use Betel nut chewing Alcohol use HPV virus Poor diet and nutrition Poor OH Immunodeficiency Socioeconomic factors
If a tumour is 5cm in width, there are bilateral lymph nodes palpated <2cm in size and the cancer has not spread to any other structures
What is the stage of this tumour using the TNM system?
T3 = tumour >4cm N2b = metastasis in bilateral lymph nodes, no more than 6cm MO = no metastasis
What are the different grades for dysplasia histopathologically?
Mild - observe and re-biopsy
Changes in lower 1/3rd of architecture
Mild atypia
Pleomorphism and hyperchromatism
Moderate - remove
Change into middle third of architecture
Moderate atypia
Pleomorphism and hyperchromatism
Severe - remove Change in upper third of architecture Severe atypia Pleomorphism and hyperchromatism Enlarged nuclei Abnormal stratification and keratinisation
Name 2 microorganisms involved with angular cheilitis
What type of sample would you take in this case?
S. Aureus
C. Albicans
Swab the comminuted of the mouth
Name 1 immune deficiency disease and 1 GI disease that can increase the risk of Candida infections and explain why these disease can make an individual more susceptible?
Name 1 intra oral and extra oral disease that could be associated with the above two infections
HIV
Patient is immunocompromised which allows for harmless organisms to become pathogenic and cause infection
Crohn’s disease
Impaired nutrient absorption linked with immunosuppressive therapy increases likelihood of infection to occur
Intra-oral = Oral Candidiasis Extra-oral = Orofacial Granulomatosis (OFG)
Why is Miconazole prescribed to a patient when microbiological sampling is not available?
Miconazole cream is effective against both Candida and gram positive bacteria such as S. Aureus so is appropriate to use in all patients prior to sampling results
However, should not be used in patients taking warfarin or statins
How does Trigeminal Neuralgia occur?
Demyelination of trigeminal nerve
As nerve exists brain stem it has become compressed from a blood vessel
What clinical investigations would you do for trigeminal neuralgia?
Trigeminal nerve reflex testing Full neurological examination OPT to rule out dental cause MRI brain scan Blood tests - FBC Positive response to Carbamazepine confirms diagnosis
What 2 neurological disorders can give rise to trigeminal neuralgia?
MS
Tumour compressing on trigeminal nerve
What is the 1st line drug management for trigeminal neuralgia?
What blood tests must be carried out before beginning this medication?
Carbamazepine 100mg
Send 20 tablets
1 tablet twice daily
FBC
U&E test (urea and electrolyte test)
What are the side effects of Carbamazepine?
Liver dysfunction Allergies Nausea Xerostomia Sedation Nightmares
What are the indications for surgery for treating trigeminal neuralgia?
When medical intervention is ineffective
When medication has adverse side effects
When condition is seriously affecting quality of life
What surgery can be carried out for trigeminal neuralgia?
Peripheral neurectomies
Trigeminal nerve balloon compression
Microvascular decompression
What are the clinical and radiographic signs of Paget’s disease?
Clinical; Localised pain and tenderness Increase in temp. over the affected bones Increased bone size Bowing deformities Decreased range of movement Dentures become ill fitting
Radiographic;
Osteoporosis circumscripta
Radiolucent lesions resembling cysts
Radiopaque lesions due to hypercementosis
What are the clinical and radiographic signs of Albright’s disease?
Clinical;
Fibrous dyplasia
Skin pigmentation
Endocrine hyper-function
Radiographic;
Bone fractures
Fibrous dysplasia
What are the clinical and radiographic signs of Cherubism?
Clinical;
Painless bilateral enlargement of the jaws
Round face with swollen cheeks
Dental malocclusion
Radiographic;
Multilocular radiolucencies
Mandible/maxilla replaced with fibrous tissue
Facial sinuses appear obliterated
Name and describe different types of orofacial pain syndromes
Dental; Generally gets better or worse over time Usually acute Examples include: Mucoskeletal e.g. TMJD pain Visceral e.g. caries Atypical odontalgia e.g. dental pain without detected pathology
Non-Dental; Generally acute Examples include; Neuropathic e.g. Trigeminal Neuralgia Psychogenic e.g. persistent idiopathic facial pain
What is Sjorgen’s Syndrome?
It is a chronic inflammatory autoimmune disorder that can increases B-cell proliferation which destructs exocrine glands
It particularly affects secretion production at the mucous membranes which causes dry mouth, reduced tear production etc.
There are 3 types of Sjorgens Syndrome;
Partial Sjorgen’s - dry eyes and mouth
Primary Sjorgen’s - no CT (connective tissue) disease
Secondary Sjorgen’s - CT disease
What antibodies are linked with Sjorgen’s Syndrome?
Anti-Ro
Anti-La
Anti-nuclear antibodies (ANA)
What are the 6 investigations used to help diagnose Sjorgen’s Syndrome?
Dry eyes = persistent troublesome dry eyes for >3 months
Oral symptoms = dry mouth for >3 months
Salivary flow test = unstimulated <1.5ml in 15mins
Auto-antibodies = Positive Anti-Ro +/- Anti-La antibodies
Histopathology = postive labial gland biopsy
Ultrasonography
What are the histopathological features of Sjorgen’s?
Minor gland;
Focal collection of lymphocytes (50+)
Acinar loss and fibrosis
Major gland;
Lymphocytic infiltrate
Acinar atrophy
Epithelial hyperplasia
Name 4 oral complications of Sjorgen’s syndrome?
Increased risk of oral candida infection
Increased caries and periodontal disease risk
Poor denture retention
Functional loss
What drug is used to manage Sjorgen’s syndrome?
Pilocarpine which is a salivary stimulant
What features of a parotid swelling would make you suspect malignancy?
Localised swelling - firm mass Painless Fast growing Asymmetry of the gland Obstruction of the gland Attached to underlying structures
Where would you most commonly find a salivary neoplasm?
Parotid 80% of all tumours
Submandibular 10% of all tumours
Minor glands 10% of all tumours
Sublingual 0.5% of all tumours
What is ectodermal dysplasia?
What are the associated symptoms?
It is a diverse group of genetic disorders that affect the skin. hair, nails, teeth and glands
Symptoms include; Hypodontia and peg shaped teeth Poor functioning sweat glands Abnormal nails Cleft lip/palate Decreased skin pigmentation Large forehead Thin/sparse hair
What is an ulcer?
It is full thickness loss of epithelium, where you can see underlying CT and there may be deposition of fibrin on the surface
Can only be diagnosed histologically
What is an erosion?
It is partial thickness loss of the epithelium
Can only be diagnosed histologically
How would you differ between recurrent major and minor aphthous ulcers?
Minor; Size = <10mm Shape = round or oval with red halo Number = 1-20 per episode Histology = non-keratinising mucosa Duration = heals within 1-2 weeks Outcome = heals without scarring Affects = children more commonly affected
Major;
Size = >10mm
Shape = oval or irregular
Number = <5 at a time
Duration = heals within 6-12 weeks
Outcome = heals with or without scarring
Affects = keratinsed or non-keratinised mucosa
What are the potential problems of recurrent aphthous ulcers?
Infections
Dehydration and malnutrition
Problems wearing dentures
Affects speech and mastication
What are the causes of recurrent aphthous ulcers?
Host factors;
Nutritional deficiencies - iron
Systemic disease - Crohn’s
Genetic - HLA type 2
Environmental factors; Trauma Allergies Smoking Stress
How is RAS (recurrent aphthous ulcers) treated?
Correct underlying cause; Replace nutrient deficiencies Treat systemic disease Remove trauma Remove allergies e.g. SLS free toothpaste
Medication; Betamethasone mouthwash 0.5mg twice daily CHX mouthwash 0.2% twice daily Benzydamine oromucosal spray 0.15% Prednisolone steroid medication
What would microcytic blood results show?
Reduction of;
MCV (mean corpuscular volume)
Hb
RBC
What can cause microcytic anaemia?
Coeliac disease Crohn's disease Ulcerative colitis Iron deficiency Lead poisoning
What oral conditions are associated with microcytic anaemia?
Recurrent aphthae
Poor wound healing
Increased risk of candida infection
Burning sensation of oral mucosa
A patient has white plaques that can scrape off easily and leave an erythematous base, what is the diagnosis?
Name local and medical conditions that may cause this?
Pseudomembraneous candidosis
Local; Oral steroid Inhaler use Nutritional deficiencies Broad spectrum antibiotics
Medical;
Diabetes
HIV
Immunocompromised
What 2 drugs does Fluconazole interact with and what effects does it have on these drugs?
Warfarin
Increases the anticoagulant effect of Warfarin and is classed as a severe interaction as it can increase the likelihood of a catastrophic bleed as it increases the INR
Statin
Fluconazole has been predicted to increase the exposure to simvastatin and is classed as a severe interaction as it can increase risk of hepatotoxicity
What information is required on a lab sheet if you are requesting a sample?
Patient details - name, address, DOB, CHI
GDP and GMP details - name, address, contact no.
Patient MH, DH and SH
Clinical description of problem
Provisional diagnosis
Tests previously done and tests required to be done e.g. culture
Antibiotic use previous and currently
Date and time of sample
Referring clinician name and signature
What are the classifications of denture induced stomatitis?
Newton type I = Localised inflammation and erythema
Newton type II = Diffuse inflammation and erythema confined to denture bearing mucosa without hyperplasia
Newton type III = Granular inflammation with erythema and papillary hyperplasia
What is Denture Induced stomatitis?
It is the adherence and colonisation of acrylic surfaces caused by co-aggregation and biofilm formation
Results in inflammation and erythema of the denture bearing mucosa
Patient will often experience discomfort on this area and may also experience halitosis
What instructions would you give to a lab regarding special trays?
Primary impressions - Special trays Please pour impressions in 50/50 dentals tone and construct upper and lower special trays Upper 2mm spacer, lower 1mm spacer Both with intra-oral handles Thank you
What epithelium is affected in smokers keratosis?
Stratified squamous keratinised epithelium of the hard palate
What is the clinical presentation of smokers keratosis?
Thickened white patch with some dark brown/grey areas on the palate
Painless area
Other areas in mouth will indicate tobacco related staining
What histological and clinical presentation of smokers keratosis could indicate malignancy?
Histological;
Hyperkeratosis Hyperchromatism Atypia Dysplasia Infiltrate of macrophages
Clinical;
Raised rolled border
Indurated (hard) lesion
Non-homogenous
Describe desquamative gingivitis.
It is a non-specific clinical description of the gingivae (redness, burning, erosion, pain and plaque) which involves several dermato-mucous disorders
It is noted as inflamed gingivae which extends beyond the mucogingival margin with erythematous shedding and ulceration
Name 3 conditions that you would see desquamative gingivitis in? (In order of likelihood)
Lichen planus
Pemphigoid
Pemphigus
What local factors may exacerbate desquamative gingivitis?
Smoking Poor OH Overhangs Partial dentures SLS toothpaste
How would you manage desquamative gingivitis?
Confirm diagnosis and any underlying conditions and manage these appropriately e.g. blood tests Treat underlying cause Improve OH Topical steroid use - Betamethasone Systemic immunosuppressant
Name a gingival disease (apart from desquamative gingivitis) that is typically painful on presentation?
Erythema multiforme where the mucosa is affected by ulcer crops making it very painful resulting in difficulty eating and drinking
This is linked with Steven-Johnston syndrome
Name 3 local and 3 generalised causes of pigmentation
Local;
Amalgam tattoo due to macrophages and granulation tissue surrounding the amalgam
Pigmented incontinence linked with chronic inflammation
Mucosal melanoma secondary to metastatic cancers
Vascular malformations
General;
Racial
Smoking which causes leakage of melanocytes and sub-mucosal fibrosis
Medications e.g. contraceptive pill
Addison’s disease
What is a haemangioma?
It is an abnormal growth of tissue, indigenous (native) to the side which it grows during normal growth
It usually stops growing when the patient stops growing
Name 2 types of haemangioma and give 2 histological differences between the 2
Capillary haemangioma;
Groups of lots of small vessels
Generally capillary haemangioma
Cavernous haemangioma;
Few large cavernous haemangioma
Dilated vascular spaces
What are the causes of a pigmented tongue both local and systemic?
Local;
Smoking Food colourings Medications - hydroxychloroquine (anti-malarial) Chromogenic bacteria Melanoma
General;
Chemotherapy Racial Addison’s disease Lead poisoning Haemochromatosis (increased iron)
A patient presents with TMJD - are there any other conditions that may present with similar signs and symptoms, and how may you exclude these conditions?
Dental cause = peri-apical/OPT to examine
Sinusitis = radiograph of sinuses
Atypical facial pain - usually does not involve clicking of TMJ
Salivary gland pathology =. Radiograph of salivary glands
Trigeminal neuralgia = history of exacerbations
You decide to construct a stabilisation splint for a patient with TMJD, what instructions would you give to the lab?
Please construct a hard acrylic splint with full occlusal coverage using upper and lower alginate impressions and face bow registration provided
Thank you
What is the aetiology for Bell’s palsy?
Bell’s palsy is a type of facial palsy that has an unknown cause, it affects the excitability of the facial nerve.
It is ultimately caused by inflammation around the facial nerve and this inflammation/pressure causes facial paralysis on the affected side
It results in unilateral paralysis of the whole side of the face including the eyebrows
How is Bell’s Palsy managed?
Reassurance that paralysis will get better
Prednisolone steroids given within 72hrs of symptoms to reduce inflammation of facial nerve
Protect affected eye with eye patch and eye drops to protect the cornea
Review +/- referral if full recovery is not obtained within 3 months
How can you differentiate between upper and lower motor neuron disease?
UMN (stroke);
Spasticity
Can wrinkle forehead and move eyebrows but cannot move lower portion of face
LMN (facial palsy);
Flaccidity
Cannot wrinkle forehead, move eyebrows or move lower portion of face
How does the difference between upper motor neuron and lower motor neuron disease occur?
UMN lesion occurs in the supra-nuclear lesion whereas a LMN lesion affects the nucleus of the facial nerve
Give possible causes for LMN disease?
LMN (facial palsy);
Motor neurone disease
Guillain-Barré syndrome
Bell’s palsy
Trauma/viral infection of ventral horn cells.
Give possible causes for UMN disease?
UMN (stroke);
Stroke Multiple sclerosis Traumatic brain injury Cerebral palsy Spinal cord injury
What conditions may require patients to be on long term steroids?
Asthma COPD Addison’s disease Arthritis Crohn’s disease Lupus MS
What are the signs and symptoms of adrenal suppression?
Hypoglycaemia Dehydration Weight loss Disorientation Weakness Postural hypotension Oral pigmentation on buccal mucosa
What emergency can be associated with adrenal insufficiency
Adrenal crisis which is a medical emergency and potentially life threatening situation caused by insufficient levels of cortisol hormone
Why are asthmatics more prone to erosion?
Asthmatic medications place patients at risk of dental erosion as they reduce saliva production and protection against extrinsic and intrinsic acids
Asthmatic patients may also be more prone to GORD which can also cause dental erosion
What is a syncope?
It is known as fainting, which is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone which is followed by spontaneous recovery
It is generally characterised by a fast onset, short duration and spontaneous recovery
What are the physiological aspects of a faint?
It is a temporary malfunction in the autonomic nervous system due to a trigger which interferes with the autonomic nervous system resulting in a drop in blood pressure, reduction in oxygen and interruption of blood flow to the brain causing the patient to lose consciousness for a short period of time
How would you manage a patient that has fainted in your practice?
Assess the patient
Lay patient flat, raise the patients feet and loosen any tight clothing around the neck
Administer 100% oxygen - 15L/min until consciousness is regained
What is the proper name for burning mouth syndrome?
Who is most likely to be affected by burning mouth syndrome?
Oral dysaesthesia
Females>males
Mostly menopausal women
Aged around 40-60
What are the causes of burning mouth syndrome?
Nutritional deficiencies - B12, iron,folate Xerostomia Fungal infections - lichen planus Poorly fitting dentures Allergies Parafunctional habits Endocrine disorders - diabetes Stress, anxiety
What are the signs and symptoms of burning mouth syndrome?
Severe burning or tingling in the mouth, commonly affecting the tongue
Sensation of dry mouth with increased thirst
Taste changes such as a bitter taste
Loss of taste
What investigations might you carry out for burning mouth syndrome?
Blood tests = FBC, HbA1c Salivary flow rate assessment Intra and extra oral assessment Denture assessment Psychiatric assessment Full MH, DH and SH
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
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%)
What are the histological features of a pleomorphic adenoma?
Mixed tumour = epithelium in ducts and sheets and myoepithelial cells present
Variable capsule
What histological feature is related to recurrence of a tumour?
Multifocal types due to non/poorly encapsulated
What are the histological features of a Warthin’s tumour?
Oncocytic (excessive mitochondria) distinctive epithelium with lymphoid tissue present and cystic spaces
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
How are salivary gland neoplasms diagnosed?
Fine needle aspiration
Core biopsy
Incisal biopsy - sample of tissue removed
Excisional biopsy - entire tumour removed
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
What solution of CHX is given to patients?
0.2% or 0.12% CHX mouthwash = 10ml x2 daily, rinse for 1 minute
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
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
Name 3 stages in the formation of clots?
Vasoconstriction -> temporary blockage of a break via a platelet plug -> blood coagulation/formation of fibrin clot
How does aspirin affect clotting?
Aspirin inhibits platelet aggregation by altering the balance between thromboxane A2 and prostacyclin
How does Warfarin affect clotting?
Warfarin inhibits the synthesis of vitamin K dependant clotting factors 2, 7, 9, 10 and protein C&S
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
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
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
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
What are the stages of colonisation of a biofilm?
Adhesion
Colonisation
Accumulation
Complex community
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
What is the aetiology of plasma cell gingivitis?
Hypersensitive reaction - SLS
Idiopathic
Rare condition
What may worsen plasma cell gingivitis condition?
Failure to remove causative agent
Poor OH
Plaque retentive factors
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
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
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
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
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
Name 3 sugar substitutes
Xylitol
Aspartame
Sucralose
Name 3 salivary proteins
Salivary - IgA
Muffins
Proline-rich proteins
Name 3 salivary enzymes
Lysozyme
Amylase
Lipase
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
Give 5 ways in which antibiotics work
Cell wall destruction Protein synthesis inhibition DNA synthesis inhibition DNA replication inhibition Cell membrane inhibition
Give 4 disadvantages of antibiotics
Antibiotic resistance
GI upset
Interactions with other medications
Hypersensitivity/anaphylaxis
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.
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
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
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
What are the signs and symptoms of asthma?
Shortness of breath
Wheezing sound when exhaling
Coughing
Chest tightness or pain
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
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
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)
How is dysplasia graded according to WHO 2005?
Hyperplasia
Dysplasia;
Mild
Moderate
Severe
Carcinoma-in-situ
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
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
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
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
How does cancer spread?
Locally
Lymphatic spread
Through the blood
What is the metastatic cascade?
Local invasion and intravasation
Survival in circulation
Arrest in distant organ/tissue
Extravasation
Micro metastasis
Macro metastasis
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
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
How does necrotisising sialometaplasia appear histologically?
Hyperplasia
Surface slough of necrotic tissue
Squamous metaplasia of ducts and acini
Necrosis of salivary acini
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
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
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
How does a mucocele appear histologically?
Cystic macrophage lined cavity surrounded by granulation tissue wall and foam cells
If a mucocele is present in the floor of the mouth - what is this called?
A Ranula - usually a sublingual extravasation (leaks fluid) type
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
What is the aetiology of orofacial granulomatosis?
Autoimmune condition
Allergens e.g. Benzoates, chocolate
Linked with Crohn’s disease and Sarcoidosis
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
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
How is Orofacial Granulomatosis managed?
Allergen testing - Dietary avoidance Antibiotic therapy with macrolides Lip ointment Intra-lesion steroid injections Oral steroids
Name 6 types of candida infections
Pseudomembraneous Erythematous Hyerplastic Angular cheilitis Median rhomboid glossitis Denture induced stomatitis
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
Give 3 methods of testing for candida?
Swab, oral rinse and foam pad = culture
Biopsy lesion = histology
Smear = microscopy
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
Name topical and systemic antifungals
Topical; Miconazole Nystatin CHX Amphotericin B
Systemic;
Fluconazole
Itraconazole
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
What is the rate of infection for HIV exposure, Hep C and Hep B?
HIV = 0.3%
Hep C = 3%
Hep B = 30%
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
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
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
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
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
How does smokers keratosis appear histologically?
Hyperkeratosis
Mild dysplasia
Infiltrate of macrophages
A patient presents with denture induced hyperplasia, give 2 differential diagnoses
Papillary hyperplasia of the palate
Giant cell granuloma
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
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
Name 2 histological features of denture induced hyperplasia?
Pseudo-epithelial hyperplasia
Hyperkeratotic and irregular epithelial cells
Hyperplastic rete pegs
Candida involvement
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
At a population level, name 3 fluoride delivery methods?
Water fluoridation
School water fluoridation
School milk initiative
Fluoridated salt
What 3 interventions are done in Scotland, on a population basis?
Smoking ban in public areas
School food policy
Sugar tax
Minimum wage
What is PICO?
Population;
Children with caries in primary teeth
Intervention;
Hall technique used
Comparison;
Compared with standard techniques
Outcome;
Rate of failures
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
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
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
Name 2 other things that you can do other than a clinical audit?
Peer review
Quality improvement programme
Continued professional development (CPD)
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.
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
What are side effects of opioid use?
Addiction Nausea, vomiting and constipation. Dry mouth Drowsiness Paranoia Respiratory depression Anxiety/depression
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
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
What 6 factors make up consent?
Informed Voluntary Valid Not manipulated With capacity Not coerced
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
What are the principles of waste disposal?
Segregation
Storage
Disposal
Document
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
What is clinical governance?
It is a systematic approach to maintain and improve patient care in the health system
What are the 3 divisions of NHS Scotland dental services?
Primary care - general dental practice
Public dental services - community services
Secondary care - hospital services
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
List the sinner circle
Time
Temperature
Chemical
Energy
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
What are the 4 pillars of ethics?
Respect for autonomy
Non-maleficence
Beneficence
Justice
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
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
How long should patient notes be kept for?
11 years after end of treatment or until age 25 for children
What criteria should patient notes fulfil?
Confidential Concise Accurate Legible Complete Current Retrievable Retained
Who is on the GDC board?
12 members - 6 registrants and 6 lay members
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
What is the English equivalent of the Adults with Incapacity Act 2000?
Mental Capacity Act 2005
What is the decontamination cycle?
Acquisition (purchase or loan) Cleaning Disinfection Inspection Disposal (scrap or return to sender) Packaging Sterilisation Transport Storage Use Transport
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
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
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
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
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
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
What is the cycle of behaviour change?
Pre-contemplation Contemplation Preparation Action Maintenance with progress or relapse at any stage
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
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
Give 4 responses to stress?
Direct action
Seek information
Do nothing
Coping
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
Give examples of coping mechanisms for stress?
Good work/life balance Exercise CBT/coping mechanisms for stress Knowing personal limits Setting targets/goals Mindfulness
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
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
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
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
How would you offer smoking brief intervention?
5As; Ask Advice Assist Assess Arrange
2A1R;
Ask
Advice
Refer
What muscles are affected by TMJD?
Masticatory muscles = masseter, temporalis, medial and lateral pterygoid
Sternocleidomastoid
Trapezius
If there is ankylosis of the TMJ joint, what symptom can be seen in the patient?
Rapid reduction in opening
What is Chrondroplasia?
Malformation of bone cartilage
What zones can be seen on the TMJ disc?
Intermediate zone (avascular)
Posterior zone
Anterior zone
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
What can cause degenerative changes in the TMJ?
How can this be managed?
Osteoarthritis
Arthritic changes
What type of bridge is used to replace missing laterals?
Mesial cantilever resin bonded bridge
Fixed-fixed bridge
What information is needed from a patient, for a technician to make a bridge?
Bridge design
Master impression
Bite registration
Shade of teeth
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
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
How does the clinical presentation of caries compare to a radiograph?
Caries is generally 2-3mm deeper clinically
What are complications of using a stainless steel file in a 20 degrees curved canal?
Ledges Blockages Zipping Perforations Fractured instruments
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
What are the constituents of PMMA?
Powder; Benzoyl peroxide (initiator) PMMA particles Plasticisers Pigments Co-polymer
Liquid;
Methacrylate monomer
Hydroquinone (inhibitor)
Co-polymer
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.
How is mobility graded?
0 = none 1 = <1mm horizontal movement 2 = 1-2mm horizontal movement 3 = >2mm horizontal movement
How is furcation graded?
1 = <3mm horizontal 2 = >3mm horizontal but not through and through 3 = through and through defect
How is gingival recession graded?
Millers classification
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
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
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
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
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
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
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
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
What are the constituents of alginate?
Calcium sulphate
Zinc oxide
Sodium phosphate
Alginic acid
What are the constituents of green stick?
Carnauba wax
Talc
Stearic acid
Why would a tooth have impression compound placed on it?
To utilise the copper ring technique for recording a single tooth crown preparation
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
Name 2 restorative materials that can bond amalgam to tooth?
RMGIC
GI
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
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
Name contraindicated groups for using the Dahl technique on?
Patients with... Active periodontal disease TMJ problems Post ortho treatment Bisphosphonates Implants
Name constituents of composite
Bis-GMA resin Glass silica Dimethacrylate - TEGDMA Camphorquinone Silane coupling agent
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
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
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
What luting cement is used for fibre posts?
Dual cure composite resin cement
What luting cement is used for porcelain veneers?
Resin luting cement with silane coupling agent
What luting cement is used for MCC adhesive bridges?
RMGI cement
What are the components of temp bond?
Base = Zinc oxide, starch and mineral oil
Accelerator = EBA, eugenol and carnauba wax
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
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
What microbes are involved in denture stomatitis.?
Candida sp = Candida albicans and candida tropicalis
Staphylococcus sp = S. Aureus and S. Epidermidis
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
What methods can dentists use to improve the fit of loose dentures?
Reline
Rebase
Remake
Identify features that may cause problems for denture retention on a patient’s palate?
Tori on the palate
High arched palate
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
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
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
What cement is used for adhesive bridgework?
Panavia
What is the 5 and 10 year survival rate for a RRB?
80% for both
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
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
What types of bridges can you get anteriorly?
Adhesive cantilever bridge
Fixed-fixed bridge
Conventional spring cantilever (for upper incisor teeth)
What material is used in a metal wing bridge?
CoCr
Nickel chromium
Ceramic
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
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
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
Define retention
Resistance to displacement in a vertical direction
Tested by pulling vertically on the anterior teeth
Define indirect retention
Resistance to rotational displacement of the denture
Tested by moving denture horizontally by pressing on pre-molar region
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
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
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
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
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
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
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
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
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
Give 3 ways that you can remove a fractured post that is visible?
Ultrasonic vibration
Masseran kit
Miskito forceps
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
If a patient has aggressive periodontitis - how would you decide on the prognosis of individual teeth?
Loss of attachment
Mobility
Furcation involvement
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)
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
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
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
Name constituents of GP
GP 25%
Zinc oxide 65%
Radio-pacifiers 10%
Plasticisers 5%
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
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
Why do we need to obturate?
To seal any remaining bacteria
To provide an apical and coronal seal
To prevent reinfection
Give 4 methods of obturation?
Cold lateral compaction
Warm vertical compaction
Continuous wave compaction
Thermafil (carried based obturation)
Name 4 post and core materials
Post;
Cast metal (type IV gold)
Ceramics (zirconia)
Fibre (glass fibre)
Core;
Composite
Amalgam
GI
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
What materials are used to cement a post and core?
GI luting cement
Composite resin luting cement
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.
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
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
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
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
Name types of intervention for inadequate bone levels?
Guided tissue regeneration
Bone grafting
Sinus lift
Describe the pattern of a vertical bony defect on a radiograph?
Generally v-shaped and are sharply outlined on a radiograph
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
How do we classify vertical bony defects?
1 wall defect
2 wall defect
3 wall defect
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
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
Name 4 different types of composite
Microfilled
Nana filled
Hybrid
Flowable
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
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
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
What factors can influence localised mobility?
Existing periodontal disease Occlusal trauma causing widening of the PDL Alveolar bone loss Resorption Smoking
Why is there a decrease in mobility after HPT?
Due to increased tissue tone and long junction along epithelium attachment
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
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
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
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
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
What are the constituents of LA?
Aromatic region - hydrophobic
Ester/amide bond
Basic amine side chain - hydrophilic
Preservatives - Methylparaben
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
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
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
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
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
What percentage of maxillary 1st molars have an MB2 canal?
93% have 4 canals
7% have 3 canals
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
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.
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
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
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
What radiographs would you request for a paeds root fracture or supernumerary?
PA and upper occlusal radiograph
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
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
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
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
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
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
What are the constituents of composite?
Resin =. Bis-GMA Glass = silica or quartz Light activator = Camphorquinone Low weight dimethacrylate = TEGDMA Silane coupling agent
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
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
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
What drug is commonly used for IV sedation and what preparation?
Midazolam
5mg/5ml
2mg bolus initially then 1mg increments every 60 seconds
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
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
What drug is commonly used for IV sedation and what preparation?
Midazolam
5mg/5ml
2mg bolus initially then 1mg increments every 60 seconds
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
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
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
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
What spacing is required for special trays for silicones and polyethers?
Upper 2mm spacing
Lower 1mm spacing
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
What histological presentations can indicate malignancy?
Hyperkeratosis Hyperchromatism Atypia Dysplasia Infiltrate of macrophages
What microbiological analysis can you do for aggressive periodontitis?
Swab of crevicular fluid from pocket of affected tooth
Oral rinse
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
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
What GI conditions can cause microcytic anaemia?
Coeliac disease
Peptic ulcer disease
Inflammatory bowel disease
Crohn’s disease
What oral conditions are associated with microcytic anaemia?
Apthous ulcers
Glossitis
Candida infection
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
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.
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
Name an intra oral and extra oral condition associated with angular cheilitis?
Oral candidiasis
OFG
Orofacial Granulomatosis
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
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
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
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
What epithelium is affected by smokers keratosis?
Stratified squamous keratinised epithelium
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
Why should you correct a mandibular displacement?
To improve aesthetics as displacement can cause facial asymmetries
To prevent TMJD and tooth wear
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
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
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
Where can fluoride be food in food?
Tea Potatoes Beer Bony fish Cucumber White rice
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
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
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?
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
What is the most common cause of fluorosis in the UK?
Fluoride in public water supply 1ppm
Give 3 diagnostic features of a subluxation injury
Increased mobility and TTP
No displacement of tooth
Bleeding from gingival sulcus
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
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
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
How would you manage internal inflammatory root resorption?
Intra-canal medicament of calcium hydroxide to reduce bacterial load
RCT and obturate with GP
