PPQs Flashcards
optimal dose of fluoride in drinking water
1ppm = 1mg/L
2 foods/drinks other than fluoridated water that are good sources of fluoride & have not have fluoride added by manufacturer
fluoridated milk
fluoridated salt
4 methods of topical fluoride application for an 8 year old
- fluoride varnish 22,600ppm 2x yearly
- fluoride toothpaste 1500ppm
- fluoride tablets 1mg fluoride daily
- fluoride mouthwash 225ppm
how does topical fluoride help prevent cavities
F slows down development of decay by stopping demineralisation of dentine, it makes enamel more resistant to attack from plaque bacteria, speeds up remineralisation & can stop bacterial metabolism at high concentrations to produce less acid. the fluoride that enters the tooth produces fluorapatite which makes the tooth stronger once remineralisation occurs
what daily dose of fluoride tablet would you give a 4 year old at high risk of caries who lives in an area with <0.3mm fluoride in water suply
0.5mg/day
rationale for use of antibiotics for perio caused by cancer
perio is a side effect of cancer treatment and when ptx undergoing cancer tx become immunocompromised they may require antibiotic prophylaxis to ensure that any bacteria present in the mouth that is causing the perio does not upset the ptx systemically
what problems limit the usefulness of antibiotics in tx of perio in cancer ptx
- antibiotics may be inactivated or degraded by non target organisms
- biofilm may resist antibiotics
- allergic reactions may occur
- antibiotic resistance can occur
- super infection can result where broad spectrum antibiotics are not suitable
when is it appropriate to prescribe a systemic antibiotic (5)
- ptx colonised with A.actinomycetemcomitans need systemic antibiotics as local delivery will not kill or inhibit bacteria
- when ptx presents with periodontal abscess of ANUG where systemic symptoms occur
- indication for use when there is ongoing disease despite mechanical therapy and good OH
- if ptx medically compromised
- if aggressive periodontitis & severe recurrent cases
advantages of systemic antibiotics
- delivered via serum to tissues & reaches reservoirs such as tonsils & tongue
- less costly than time required for tx
- must be accompanied by mechanical therapy to reduce bacterial load & disrupt biofilm
types of systemic antibiotics
- amoxicillin 500mg & metronidazole 400mg
- metronidazole alone
- azithromycin
- doxycycline
- tetracycline
3 reasons for carrying out obturation of prepared root canal
- inhibits bacterial growth
- can be easily removed
- seals the canals laterally & apically
describe steps involved in obturating root canal in upper central incisor
- apply dental dam & disinfect access area
- remove provisional restoration using sterile round bur
- irrigate using sodium hypochlorite to remove CaOH medicament; starting with size 10 or 15 introduce files sequentially to confirm access to working length & prepared apical stop
- dry canal with narrow bore aspiration & correct size and length of matching paper points in locking tweezers
- select master gutta percha point which will fill canal at working length & give tug back
- mix root canal sealer (AH+) & coat walls of apical part of root canal thinly using master point itself
- coat tip of master point with sealer & reinsert slowly to working length held in sterile locking tweezers & seat point firmly to the apical stop
cold lateral compaction
- take size A finger spreader, set a silicone stop at 1-2mm from CWL and place into canal alongside master point for 20secs
- coat an extra fine ‘A’ accessory point with sealer, gently remove finger spreader by rotating & immediately insert A point into space left by sealer
- repeat until 3-4 A points have been used or use B spreaders & points if coronal area still wide
- use a heated plugger to remove excess gutta percha within pulp chamber
which part of the root canal filling is the most important in ensuring long term success
good coronal seal is most important for ensuring higher success rate & preventing infection
what is meant by Watt & Macgregor’s biometric guidelines
biometric guide is one of the methods of designing complete dentures
uses remnant of the lingual gingival margin in the buccolingual placement of prosthetic teeth
when applying biometric guides what anatomical feature is used as fixed reference point
positional relation to the central incisors which are about 8-10mm anterior to the incisive papilla
the biometric guide gives you information about the location of the maxillary canines - a perpendicular drawn posterior to the centre of the incisive papilla to the sagittal plane that passes through the canines
average horizontal bone loss for the fixed reference point in the following maxillary tooth positions
central incisors - 6.3mm
canine - 8.5mm
premolar - 10mm
molar - 12.8mm
minimum data set that should be recorded onto occlusal record block
OVD - distance between jaws with teeth in occlusion
centre line - centre of ptx mouth symmetrical with face
occlusal plane - central occlusal plane indicates where incisal level of tooth will be
high lip line
canine line - line extended from inner canthus of eye
arch form - width:lip support
give history, symptoms & presentation of periodontal abscess
localised acute exacerbation of pre existing pocket (chronic perio) caused by trauma to pocket epithelium, or obstruction of pocket entrance
symptoms - pain on biting/constant pain, swelling, discharge release causing halitosis
O/E - swelling adjacent to periodontal pocket, tooth may be TTP, suppuration (discharge through sinus or pocket), tooth mobility, more likely to have pain on lateral movement, more likely to have generalised horizontal bone loss
tx - drainage via incision or via pocket with instrumentation to dilate, gentle sub gingival debridement, hot saline mouthwash, XLA of teeth with poor prognosis, antibiotic use if systemic involvement
follow up - HPT, surgery if required & maintenance
history, symptoms & presentation of periapical abscess
can be chronic / acute but both due to inflammatory reaction to pulpal infection where there is localised collection of pus around apex of non-vital tooth as a result of necrosis
chronic characteristics - gradual onset, little or not discomfort, intermittent discharge of pus through associated sinus tract
chronic radiography - sign of osseous destruction i.e. radiolucency at apex
acute characteristics - rapid onset, spontaneous pain, extreme tenderness to pressure, pus formation, swelling of associated tissues, systemic signs of malaise, fever, lymphadenopathy
acute radiography - may be no signs
tooth can be mobile, TTP vertically, non vital tooth, loss of lamina dura
history, symptoms & presentation of occlusal trauma
causes tooth mobility which is progressively increasing & associated symptoms, radiographic evidence of increased PDL width; in combination with plaque induced inflammation this may exacerbate loss of attachment
tx - control of plaque induced inflammation, correction of occlusal relations, splinting required when:
- mobility is due to advanced LoA
- mobility causing discomfort or difficulty when chewing
- when teeth need stabilised for debridement
history, symptoms & presentation of periapical periodontitis
symptomatic / asymptomatic
symptomatic:
- represents inflammation of apical periodontium that extends beyond root canals
- causes resorption of alveolar bone & LoA
- painful response to biting, palpation, percussion
- can be accompanied by radiographic changes i.e. periapical radiolucency
- severe TTP indicative of degenerating pulp & RCT required
asymptomatic:
- inflammation & destruction of periapical periodontium of pulpal origin
- apical migration of junctional epithelium
- appears as apical radiolucency & does not present clinical symptoms i.e. TTP or palpation
risk factors = plaque accumulation, diabetes, stress
history, symptoms & presentation of chronic gingivitis
inflammation confined to gingival tissue characterised by redness & swelling of marginal gingival tissue
swelling leads to formation of gingival pocket which manifests as increase in probing depth where epithelium lining of pocket is friable & easily traumatised
there is altered microbial colonisation, increased flow of GCF, influx of neutrophils, lymphocytes, monocytes & plasma cell infiltrate
proliferation & ulceration of junctional epithelium, dilated vessels, vascular proliferation, increased collagen loss & very few plasma cells present
chronic can be localised (<30%) or generalised (>30%)
symptoms = bleeding, swollen, red gingivae, false pocketing with no LoA
risk factors = pregnancy, leukaemia, puberty related, poor OH
tx = OH, HPT if required for removal of plaque / calculus
branches of maxillary nerve & where they pass through
trigeminal nerve has 3 branches:
1. ophthalmic - exits through superior orbital fissure
2. maxillary - exits through foramen rotunda
3. mandibular - exits through foramen ovale
maxillary nerve then has branches from the pterygopalatine fossa - zygomatic through zygomatic foramen, nasopalatine through sphenopalatine foramen, posterior superior alveolar nerve, greater & lesser palatine nerve, pharyngeal nerve
maxillary nerve also has branches from infraorbital canal - middle superior alveolar, anterior superior alveolar, infraorbital nerve
recommended alcohol limit for males & females
no more than 14 units per week spread evenly over 3 or more days
what acts regulate alcohol in scotland
- licensing (scotland) act 2005
- alcohol (scotland) act 2010
- criminal justice and licensing (scotland) act 2010
- air weapons and licensing (scotland) act 2015
- local government (scotland) act 1973
what has reduced alcohol consumption in scotland (5)
- changing scotland’s relationship with alcohol; framework for action plan
- minimum pricing per unit alcohol
- ban on multi buy drink promotions
- increased investment in alcohol treatment & care services with available access
- introduction of scottish lower drink drive limit of 22mg of alcohol / 100ml
chair side interventions that can be used to help someone with an alcohol problem
5A’s - brief intervention;
- Ask ptx about alcohol consumption
- Advise ptx
- Assess ptx
- Assist ptx on getting help
- Arrange follow up for ptx
2A’s & 1R;
- ask ptx about alcohol
- advise your ptx on alcohol
- refer to stop alcohol services
ABIs - alcohol brief interventions which are opportunistic & effective
4 different types of candidosis
- pseudomembranous; thrush
- erythematous; denture induced stomatitis, atrophic HIV related & candida leukoplakia
- hyperplastic - candida leukoplakia
- angular chelitis - poor OH, dry mouth, anaemia, immunocompromised, over closed denture from reduced OVD
how to treat each candidosis infection
pseudomembranous -
- nystatin oral 1ml 4x daily for 7 days
- chlorhexidine 3ml rinse for 7 days
- fluconazole 50mg daily for 7 days
- miconazole oromucosal gel pea sized amount after food 4x daily
- itraconazole 10-20mg OD for 14 days
erythematous -
- if steroid related rinse with mouth wash after using inhaler / spacer device
- if denture induced ensure thorough hygiene instructions given with milton for 20mins or chlorhexidine, advise removing denture at night
- drug tx = fluconazole capsules 50mg for 7 days or miconazole oromucosal gel pea sized amount to fitting surface of upper denture after food 4x daily
hyperplastic -
- confirm diagnosis through microbiology & histopathology
- systemic antifungals i.e. fluconazole 50mg OD or itraconazole 10-20mg OD
- iron, folate or B12 may be required if deficient
angular chelitis -
- chlorhexidine mouthwash 3ml per rinse for 7 days
- miconazole cream (2%) apply to angle of mouth 2x daily; use for 10 days after lesions have stopped
- sodium fusidate ointment 2% apply to angles of mouth 4x daily
- miconazole 2% & hydrocortisone 1% cream applied to angles of mouth 2x daily
ensure miconazole is not prescribed for those on warfarin or statins
mechanism of antifungal medication
azoles mechanism of action is the inhibition of the cytochrome P450 dependent enzymes (particularly 14a-demethylase) which is involved in the biosynthesis of ergosterol which is required for fungal cell membrane structure & function
what is azole resistance
candida species C.krusei & C.glabrata are naturally resistant to fluconazole & some strains of C.abicans have formed sensitivity & resistance to fluconazole systemic tx
this is why it may be important to carry out sensitivity & subtyping to ensure what candida species is causing the candidosis
what features should be present on maxillary & mandibular master imps
maxillary features:
coverage of tuberosity, hamular notch, extension anterior to vibrating line for post dam, functional depth & width of sulcus to create good peripheral seal & ensure hard palate & residual ridge are functional for primary support
mandibular features:
coverage of pear shaped pad & buccal shelf, retromolar pad & extension into lingual pouch should occur, functional width & depth of sulcus, ensure area of primary support of buccal shelf & retromolar pad
general features:
ensure denture bearing areas covered, good functional sulcus, good surface detail with no airblows
what indicates posterior border of maxillary denture
- post dam should sit 1-2mm anterior of vibrating line between junction of hard & soft palate
- should be at level of hamular notch to produce a good posterior seal which is located between distal surface of tuberosity & hamular process of medial pterygoid plate of maxilla
what impression materials are used for primary & master imps
primary:
1. impression compound - non elastic material which records poorer surface detail, not cheap, can be messy but good for primary due to high mucocompressive viscosity
2. alginate - elastic material that flows into undercuts & records adequate surface detail for primary imps
master:
1. silicone - dimensionally stable & can be made into variety of consistencies which means it accurately records surface detail
2. polyether/impregum - dimensionally stable & accurate recording of surface detail
3. alginate - elastic so will flow into undercuts if present
what is parkinson’s disease
a disabling progressive disease process thought to be caused by degeneration of dopaminergic neurones in basal ganglia (substantia nigra) or brain but reason for this degeneration is unclear
4 cardinal signs of parkinsons
- postural instability; impaired gait & falls, impaired use of upper limbs
- resting tremor
- bradykinesia; slow movement & slow initiation of movement
- rigidity; increased motor tone
features noticed in ptx with parkinsons
mask like face, slow speech & difficult swallowing, impaired dexterity, abnormal posture & difficulty walking (shuffling gait), memory problems
dental relevance of parkinsons
difficulty accepting treatment; tremor of body at rest, often facial remorse reduces purposeful movement e.g. mouth opening, lack of control of oral muscles
dry mouth common due to anti-cholinergic effects of drug treatment (benztropine)
increased risk of drug interactions
signs that a ptx who can’t communicate is in pain
general - fidgeting, pacing, repetitive motions, refusal to eat or cooperate, crying, groaning
facial - frowning, grimacing, teeth clenching, biting, rubbing area that is sore
behavioural - aggressive, depression, isolation, sleep disturbances, withdrawal
difference in ptx with parkinsons & ptx with cerebral palsy in regards to tremors
parkinsons presents as intention tremors & tremor at rest; intention tremor is present when tremor amplitude increases during visually guided movements towards target at the termination of movement
ataxia cerebral palsy typically presents with action intentional tremors which is especially apparent when carrying out precise movements
what is chlorhexidine & its mechanism of action
Chlorhexidine is an antiseptic and disinfectant that helps reduce the number of bacteria in mouth / skin
mechanism of action - Chlorhexidine is a cationic surfactant synthetic biguanide with broad-spectrum antibacterial and less pronounced antifungal activity. It disrupts microbial cell membranes and coagulates cytoplasmic proteins & has a residual activity of several hours
what factors influence use of chlorhexidine
- contains bisbiguanides which is the gold standard for active use against gram +/- bacteria, fungi, yeasts & viruses
- no known bacterial resistance or superinfection reported with use
- has 12hr substantively
- good safety record, available without prescription
- requires little to no skill or motivation to use
dosage of chlorhexidine
chlorhexidine mouth rinse 0.2%
10ml x2 daily for 1 min after breakfast & before bed for 1-2wks
what is substantivity of chlorhexidine
usually 12hrs but depends on:
- absorption to oral surfaces
- maintenance of antimicrobial activity
- slow neutralisation of antimicrobial activity
- other drugs
- certain food & drinks
- sodium lauryl sulfate
indications for using chlorhexidine
- short term for specific problems such as candidosis (pseudomembranous / erythematous)
- to clean dentures causing denture stomatitis
- post oral or perio surgery
- in disabled ptx where good OH is not easy to maintain
- immunocompromised ptx can benefit from use to prevent oral infections spreading to systemic infection
- tx of ANUG
- management of aphthous ulcers
- irrigant during RCT
- management of mucositis in cancer ptx
side effects associated with use of chlorhexidine
anaphylaxis, hypersensitivity, mucosal irritation, parotid gland swelling, reversible brown staining of teeth / comp restorations, taste distrubance, tongue discolouration, burning of gums if not diluted properly
can potentially impair fibroblasts & normal periodontal healing
incidence v prevalence
incidence:
no of new disease cases developing over a specific period of time in a defined population, incidence rate = no of new cases of a disease in a period / no of individuals in the population at risk, incidence estimates are obtained from longitudinal studies
prevalence:
number of disease cases in a population in a given time, prevalence = no of affected individuals / total no of persons in population, prevalence estimates are obtained from cross sectional studies or derived from registers which can relate to attributes to absence or presence of disease
what is SIMD & what is it used for
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 data zones in order of deprivation from most to least deprived, with 1 being most deprived
what are the 7 factors of deprivation
- employment status
- income
- health & health care services
- geographic access to services
- crime
- housing, living & working conditions
- education, skills, training
what does the ARAB acronym stand for
A - active component - induces a force by introducing displacement forces
R - retention - resistance to displacement forces
A - anchorage - resistance to unwanted tooth movement, newton’s 3rd law: for every action there is an equal & opposite reaction
B - baseplate - to provide anchorage, connector for retentive components, cohesion, adhesion & stability
write a prescription to correct an anterior crossbite
Aim - please construct a URA to correct an anterior crossbite on patient’s 12
A - Z spring (double cantilever spring) on 12; 0.5mm HSSW
R - 16, 14, 24, 26 Adam’s clasps; 0.7mm HSSW
A - yes
B - self cure PMMA posterior bite plane
write a prescription to correct a posterior crossbite
Aim - please construct a URA to expand the upper arch
A - midline palatal screw
R - 16, 14, 24, 26; Adam’s clasps; 0.7mm HSSW
A- reciprocal anchorage
B - self cure PMMA - posterior bite plane; most incorporate all posterior teeth to prevent unwanted tooth eruption
how often should an active component be activated
anterior - 1 activation per month
posterior - 1 activation per week
should only be 1-2 teeth moving 1mm pr month for bone remodelling
what components of a URA can be used for retention (4)
- adam’s clasps - 4s & 6s 0.7mm HSSW (0.6mm in deciduous teeth)
- southend clasps - 1s & 2s 0.7 HSSW
- labial bows - 0.7mm HSSW
- c clasps - 0.7mm HSSW
what in anchorage
anchorage is resistance to unwanted tooth movement described by newton’s 3rd law -
for every action there is an equal & opposite reaction
used to ensure only 1-2 teeth are moved at a time
what can thumb sucking cause in the skeletal pattern
proclination on upper anteriors & retro-clination of lower anteriors with localised anterior open bite (AOB) or incomplete open bite (OB); it can also narrow the upper arch with a unilateral posterior crossbite
sucking effects will also be superimposed on existing skeletal patterns & incisor relationships & can cause lisping while talking
2 types of haemorrhage that can occur post XLA
- immediate post op period:
- reactionary & rebound bleeding which occurs within 48hrs of XLA
- caused by vessels opening up as the vasoconstriction effects of LA wears off, sutures become loose / lost, or ptx traumatising socket with finger / tongue / toothbrush / food - secondary bleeding
- often due to infections commonly occurring 3-7 days post XLA
- usually a mild ooze but can cause major bleed
how do you stop bleeding after an XLA
- apply firm pressure by biting on damp gauze packs / using finger
- LA reapplied with vasoconstrictor
- surgical oxidised cellulose / gelatin sponge inserted to act as framework for clot formation
- whitehead’s varnish pack containing iodoform, gum benzoin etc ribbon gauze soaked in WHVP sutured into socket will require removal
- bone wax
- thrombin liquid & powder in socket
- fibrin foam into socket
- suture socket with interrupted / horizontal mattress suture
- ligation of vessels & diathermy may be used
nerves affected by an IBD
inferior alveolar nerve
lingual nerve
some fibres of incisive & mental branches
how to know if anaesthesia has worked
- numbness of lip & chin on same side of IDB
- numbness of lingual gingivae & 2/3s of tongue
- check teeth on that side & tooth being XLA by walking probe down long axis of tooth & checking it ptx can feel it
what is xerostomia
consistent dryness in the mouth which generally develops when flow of saliva decreases to around 1/2 the normal unstimulated rate - 0.3ml/min
very common & often seen as side effect to polypharmacy
what medications are likely to cause xerostomia
tricyclics anti depressants - amitriptyline & nortriptyline
anti psychotics - phenothiazine
benzodiazepines - diazepam, lorazepam
anti-cholinergic - atropine
beta blockers - atenolol, propanolol
antihistamines - cetirizine, loratadine
non drug causes of xerostomia
medical tx - radiotherapy of head & neck, chemotherapy, removal of salivary glands
medical conditions - sjogren’s, undiagnosed diabetes, HIV, AIDS, alzheimer’s, cystic fibrosis, rheumatoid arthritis, stroke
nerve damage
severe dehydration
how do you treat xerostomia
- stimulate salivary glands
- chew sugar free gum / sweets - substitute saliva
- oral lubricants
- biotene system which is a salivary LPE enzyme system that helps to maintain oral environment - treat / modify underlying causative disease / problems causing it in the 1st place e.g. diagnose & treat diabetes
- drug use
- pilocarpine used for tx following irrigation for head & neck cancer & for dry mouth in sjogren’s; only effective in ptx who has residual salivary gland function - management techniques
- suck on ice cubes & frequent sips of water
- avoid mouthwash containing alcohol
- avoid dry hard food
- avoid alcohol / caffeine
- avoid sweet / sugary food
- moisten food when eating with water & sauces
draw and label posselt’s envelope
working clockwise
T, R , RCP, ICP, E, Pr
what is the border position in posselt’s envelope & why is it important
- centric relation (retruded arc) which is a dynamic relationship between maxilla & mandible is not in a static position
- said to occur when condyles are in their most superior position in the articular fossa & is determined by anatomy of TMJ
- it is a border movement and is reproducible over a period of treatment
describe areas on posselt’s envelope
T - maximal mandibular opening with full anterior - inferior translation of condylar heads
R - maximal mandibular opening with the condylar heads in reproducible retruded position but no anterior-inferior condylar translation. the arc R-RCP has its centre of rotation passing through the condylar heads (terminal hinge axis). in edentulous ptx the point at which prosthetic tooth contact is made along this arc (OVD) is determined by dentist as RCP
RCP - retruded contact position
ICP - intercuspal position
RCP-ICP = path is termed a slide, has the potential for horizontal, vertical & lateral components; lateral element cannot be seen in the sagittal plane
E - edge to edge position of incisors
Pr - maximum protrusion
what 2 records are required for mounting casts
- jaw reg
- occlusal rims - setting upper teeth in wax rim and setting lowers to upper in RCP
note - tooth shade & mould should also be recorded
4 radiographic signs a tooth has become non vital
- furcation bone loss
- external and / or internal resorption
- radiolucencies
- periapical periodontitis - widening of PDL
what is included on a trauma stamp (8)
- sinus/tender in sulcus
- colour
- TTP
- mobility
- EPT
- ethyl chloride thermal testing
- percussion note
- radiographs
tx of ED#
tx:
- bond fragment to tooth or place composite bandage
- take 2 periapical x ray to rule out root fracture or luxation
- sensibility testing & evaluate tooth maturity
- place definitive restoration
follow up at 6-8wks & 1yr:
- x ray checked for width & length of root canal development, compare tooth with contralateral
- check for internal & external inflammatory resorption & periapical pathologies
prognosis:
- 5% risk of pulp necrosis in 10yrs
tx of EDP#
evaluation:
- size of pulp exposure
- time since injury
- associated PDL injuries
tx:
<24hrs = pulp cap:
- LA & dental dam ->clean area with water, disinfect with NaOH, apply CaOH (dycal) or MTA white to pulp exposure -> restore with CR
- dam not required if associated luxation injuries
- review 6-8wks, then 1yr
> 24hrs = partial (Cvek) pulpotomy:
- LA & dental dam -> clean with H2O then NaOH, remove 2mm of pulp with high speed rough diamond bur (if no bleeding or cannot arrest bleeding proceed to full coronal pulpotomy), place saline coated (ferric sulfate?) CW pellet over exposure until haemostasis achieved, apply CaOH then vitrebond then restore with CR
full coronal pulpotomy:
- begin with partial then assess haemostasis, remove all of coronal pulp if hyperaemic or necrotic, place CaOH in pulp chamber, seal with GIC lining & quality coronal restoration
follow up 6-8wks, 1yr. aim to preserve pulp vitality and avoid full extirpation unless tooth is clearly non vital
symptoms of trauma
pain
oedema
bruising
changes in bite
missing part of tooth
inability to close mouth
tooth discolouration
lacerations in mouth
different types of waste disposal streams
BLACK - non infected household waste i.e. paper towels, food containers, put in wheelie bin to be lifted by council
ORANGE bag - low risk waste; dressings, swabs, disposables i.e. PPE, other items that have been in contact with ptx. bags filled to manufacture line, securely sealed with ratchet tag / swan tie then lifted by specialist services for heat disinfection (HDS)
ORANGE bin - low risk waste i.e. broken glass, blood & contaminated liquids inc bags & tubes, filled to line, label completes & source identified on bin, picked up for HDS
YELLOW stream - high risk i.e. recognisable body parts e.g. teeth without amalgam fillings, medicines & anaesthetics, used / unsure sharps or drug vials, contaminated metal parts or surgical instruments, highly infectious waste such as infectious blood, containers filled to line, labelled & picked up for incineration
RED stream - for amalgam, amalgam capsule, teeth with amalgam etc, filled to line, label completed, picked up as it requires specialist waste reprocessing so chemicals can be recovered
4 key aspects of waste transfer note
- description of waste
- origin source of where waste has come from
- quantity
- transport & destination
how long should a waste consignment transfer note be kept for
min 3 yrs
regulations that control waste disposal
- special waste (amendment) regulations 2004
- health & safety at work act 1974
- COSHH 2002
- environmental protection act 1990
- health & safety executive HSE
- scottish environmental protection agency SEPA
types of dementia
- alzhiemer’s; reduction in size of cortex, severe in hippocampus, presence of plaques which are deposits of protein fragments of beta-amyloid that build up in spaces between nerve cells & tangles
- vascular - caused by reduced blood flow to brain which damages & eventually kills brain cells
- dementia with lewy bodies - deposits of abnormal protein (lewy bodies) inside brain cells
- frontotemporal - frontal lobe has associated ubiquitous clumps of protein linked with TDP-43 found on it
rarer forms = parkinson’s, HIV, corticobasal degeneration, MS
what legislation protects against dementia
- human rights act 2000
- disability discrimination act 2005
- equality act 2010
- adults with incapacity act (scotland)
- mental capacity act (england & wales)
who is involved in multi disciplinary team care for dementia
GP
dentist
consultant neurologist
dementia nurse
macmillan nurse
physio
carers
symptoms of early, middle & late stage dementia
EARLY - misattributed to stress, bereavement or normal ageing:
- loss of short term memory
- confusion, poor judgement, unwilling to make decisions
- anxiety, agitation, distress over perceived changes
- inability to manage everyday tasks
- communication problems; decline in ability or interest in talking, reading etc
MIDDLE - increased obvious symptoms
- more support required inc reminders to eat, wash, dress, use bathroom
- increasingly forgetful & will fail to recognise people
- distress, aggression, anger, mood changes
- risk of wandering & getting lost
- behave inappropriately
- experience hallucinations, throw back memories
LATE - progressive symptoms
- inability to recognise familiar faces, objects, surroundings
- increasing physical frailty, start to shuffle / walk unsteady
- difficulty eating & sometimes swallowing, weight loss, gradual loss of speech, associated incontinence
- progressive & irreversible
how would you reduce a tooth for a MCC
- occlusal reduction:
- retain some morphology but reduce cusps & marginal ridges
- take into consideration relative thickness of metal & porcelain
- use diamond tapered fissure bur or round/rugby ball diamond bur - separation:
- use long tapered diamond bur to separate from adjacent tooth - buccal reduction:
prepare in 2 planes:
i) using diamond tapered shoulder bur for 1st reduction plane
ii) use the same for 2nd reduction plane but keep handpiece following incline of cusp
- avoid buccal pulp horns
- interproximal margin should follow gingival contour - palatal / lingual reduction:
- completed in 1 plane for premolars & molars
- follow palatal contour for canines & incisors
- both should use diamond chamfer bur - shoulder & chamfer finish:
- use both burs to finish shoulder margins or corresponding sides
measurements for reductions for MCC
non functional cusps = 2mm
functional cusps = 2.5mm
incisal = 2mm
buccal shoulder / heavy chamfer = 1.2-1.3mm (2 plane)
palatal chamfer margin = 0.5mm (1 plane)
between 10-20o taper
ideal properties of IM for offsite laboratory construction of a crown
- silicone (addition cured silicone putty) is placed over crown prep as it is dimensionally stable, has variety of consistencies, resistant to tear & records very accurate surface detail
- alginate impression can be then placed which is cheaper to use & is elastic so can flow into undercuts
what is the index of suspicion for child abuse/neglect
- delay in seeking help & delayed presentation of injuries
- story vague, lacking in detail, vary with telling person to person
- account not compatible with injury
- parents mood is abnormal
- parental behaviour gives cause for concern i.e. refusal to allow proper tx or hospital admission, unprovoked aggression towards staff, explanation inconsistent with injuries
- child appearance & interaction with parent is abnormal
- history of previous injury
- suspicious injuries / facial bruising
- history of violence within family
what to do if you suspect child abuse
OBSERVE - child’s behaviour & injuries
RECORD - always record conversations & findings in ptx notes
COMMUNICATE - with child & parents; ask how they got injuries, does it math description, reason for delayed presentation
REFER for assessment - if still concerned contact child protection for advice, follow up in writing & speak with health visitor, GP, school etc to investigate further, continue with referral to social services
duty of care to share concern about risk to a child’s wellbeing with child’s named person
how do we manage dental neglect
3 stages -
1. preventative dental team management; single unit approach = raise concerns with parents, offer support, set targets, keep records & monitor progress
2. preventative multiagency management =
- lease with other professionals to see if concerns are shared i.e. health visitor, GP
- child may be subject to common assessment framework (CAF)
- check if child is subject to child protection plans
- agree joint plan of action, review at agreed intervals
- letter to health visitor of children u5 who fail appointments & failed to respond to letter from practice
3. child protection referral -
- in complex or deteriorating situations
- follow local guidelines
- referral to social services if required
4 types on inherited bleeding disorders
- von willebrand’s - deficiency and/or defect of blood factor (von willebrand’s factor) that promotes platelet adhesion
- haemophilia A - factor VIII deficiency, 25% cases
- haemophilia B - factor IX deficiency (Christmas factor), 5% cases
- rarer forms - 10%
what is platelet dysfunction
may be due to a problem in the platelets themselves or to an external factor that alters the function of normal platelets
can be inherited or acquired with both increasing the risk of excessive & spontaneous bleeding
what is thrombocytopenia
condition characterised by abnormally low levels of thrombocytes (platelets) in the blood
diagnosed when below the normal limit of 150x10 to the 9/L
what 3 blood tests can confirm bleeding disorders
FBC - haematology
coagulation screen - prothrombin time PT, partial thromboplastin time PTT, activated partial thromboplastin time APTT, APTT ratio, INR
thrombophilia & haemophilia factor screen
what blood test is required for warfarin patients regularly
INR screen to determine how long it takes for your blood to clot as warfarin affects Vit K dependent clotting factors 2, 7, 9, 10
INR = 1 indicates level of coagulation equivalent to an average person not on warfarin but >1 indicates longer clotting time and so longer bleeding time
INR < 4 = allow for tx to occur without interrupting anti coag medication; safest between 1.5-2.5
what types of injections can be given to people suffering from bleeding disorders
regular injections of the clotting factor they are missing
- haemophilia A; berlate P injection which is recombinant factor VIII // DDAVP
- haemophilia B; benefix injection which is recombinant Christmas factor
-vWD; desmopressin (DDAVP)
- thrombocytopenia; platelet transfusions, INR
- rare conditions; FFP intravenously to replace all factors if recombinant factors are not available
dental injections - all injections can be used except lingual infiltration & IDB
what are the risk factors for oral cancer
- tobacco use
- alcohol use
- prolonged sun exposure
- HPV
- gender
- age
- poor OH
- poor diet & nutrition
- weakened immune system
what is a biofilm
a biofilm comprises of an aggregate of microorganisms whose cells adhere to one another & embed in a surface
the adherent cells become embedded within a self produced matrix of extracellular polymetric substances which allows adherence to a surface
what is a niche
an ecological niche is the role & position a species has in its environment, how it meets its needs for food & shelter, how it survives & reproduces
a species niche includes all of its interactions with the biotic & abiotic factors of its environment
what are the stages of colonisation in a biofilm
- adhesion
- colonisation
- accumulation
- complex community
- dispersal
give examples of 2 types of biofilms
- streptococcus spp = produce linking film i.e. strep mutans in caries development
- actinomyces spp = cause coaggregation & reconditioning of the film i.e. actinomyces actimomycetemcomitans A.a in perio
or candida albicans in candidiasis
what factors are involved in the adherence of bacteria
microbial adhesion:
- fimbrillar adhesins which are virulence factors used to help invade membrane vesicles of host cells by binding to cellular inetgrins
- LPS (cell wall component of outer membrane) of gram - bacteria with potential structural diversity to mediate specific adherence
- lipotechoic acid = cell wall components of gram + bacteria that may be involved in non specific / specific adherence
- protein fimbriae are filamentous proteins on surface of bacterial cells that may behave as adhesins for specific adherence
- lectins are any proteins that bind to a carbohydrate
- cell wall proteins
host receptors = glycolipid, glycoproteins, integrins, collagen, heparin
what 3 factors are required for successful colonisation
requires adherence, substrate & liveable environment i.e.
1. host - mucosa surface, pellicle, acid rich police proteins, minerals, lectins
2. saliva - mechanical washing, bactericidal enzymes, buffering, secretor IgA
3. bacterial - adhesins, LTA, protease, virulence factors
what is the aim of suturing
- approximate & reposition tissues
- compress blood vessels
- cover bone
- prevent wound breakdown
- achieve haemostasis
- encourage healing by primary intention
4 different types of sutures
- resorbable
a) monofilament i.e. monocryl
b) multifilament i.e. vicryl rapide;
holds tissue edges together temporarily, vicryl breakdown via absorption of water into filaments causing polymer to degrade - non resorbable
a) monofilament i.e. prolene
b) multifilament i.e. mersilk - black silk
if extended retention periods are required use these but must be removed post op, usually for closure of OAF or in exposure of canine teeth
4 different types of flap design
triangular
rectangular
semilunar
envelope
general oral surgery principle that should be adhered to when carrying out flap surgery
- create maximal access with minimal trauma as bigger flaps heal just as quick as smaller ones
- wide based incision should be used for circulation
- use scalpel in 1 firm continuous stroke
- no sharp angles
- minimise trauma to dental papilla
- flap reflection should be down to bone and done cleanly
- no crushing of tissues
- keep tissues moist
- ensure flap margins & sutures lie on sound bone
- make sure sounds are not closed during tension
- aim for healing by primary intention to minimise scarring
what hand piece is used to cut bone and why
straight electrical hand piece with saline cooled bur:
round or fissure tungsten carbide burs
air drive hand piece may lead to surgical emphysema embolism to form
what are the long term effects on permanent teeth after trauma
- discolouration - immediate may indicate vitality and intermediate change over wks can indicates non-vitality
- delayed exfoliation of primary tooth - may not resorb normally after trauma so XLA necessary or permanent successor will erupt ectopically
- enamel defects (44% cases) -
- hypomineralisation; yellow/white spots, normal thickness of enamel, tx = mask with composite, localised removal & restore with composite, external bleaching
- hypoplasia; yellow/brown spots, less than normal enamel thickness, tx = repair with composite / porcelain veneers when gingival level is stabilised at 16yrs - abnormal root morphology -
- crown/root dilacerations; requires surgical exposure & ortho
- delayed eruption; premature loss of primary teeth may result in delayed eruption of up to 1yr due to thickened mucosa, take radiographs if >6mths, surgical exposure & ortho may be required - ectopic tooth positions
- arrest in tooth formation (RCT/XLA)
- complete failure of permanent tooth to form
- odontome formation (surgical removal)
- underdeveloped tooth germ; may sequester spontaneously or require removal
nursing caries pattern of decay
- usually affects all of the maxillary teeth as smooth surface caries around the gingival margin
- lower incisors are protected by tongue but mandibular canines can be infected
advice for parents whose child is suffering from nursing caries
- ensure they’re using F- toothpaste suitable for age group i.e. 1000ppm < 3 and 1500ppm <10 high risk
- ensure free flow spout from 6mths with no sugar in cup
- don’t give bottle at night, only before brushing
- keep to meal times and don’t let child sip on sugar all day
normal pattern of decay in permanent dentition
1st & 2nd molar pits & fissures susceptible & usually first
interproximal areas where there are tight contacts between teeth
normally not smooth surface unless extremely bad
what is a post & core
core gains interradicular support for definitive coronal restorations such as a crown
post then retains the core holding onto the coronal restoration; however, this will weaken the tooth
what types of posts are available
- manufactured; preformed or prefabricated / custom made
- material; cast metal (type IV gold / Au), steel, zirconia, carbon / glass fibre
- shape; parallel sided, tapered
- surface; non threaded passive, serrated, smooth, cement retained
what is the difference between parallel & tapered posts
parallel sides -> avoid wedging, greater retention than tapered, less likely to cause root fracture as load is not dispersed horizontally; transfers down long axis
tapered posts -> high strength & stiffness, conservative, less retentive than parallel or threaded posts, should be used in small circular canals & avoid in flares canals
what length & width should a post be
length:
at least equal to crown height
2/3 of root length
4-5mm root filling should be left apically so apical foramen is sealed
never extend past a bend in the root
should reach alveolar crest height
width:
no more than 1/3 of root width at narrowest point
1mm of remaining circumferential coronal dentine
should fit for AL preparation & anti-rotational design
what is the function of a baseplate
used to provide anchorage, connector for retentive components, cohesion, adhesion & stability
what forces can displace a URA (5)
- gravity
- mastication
- tongue
- talking / vibrations
- active components
what is the formula for force in a wire
force is proportional to deflection x radius4/length3
what are the instructions for fitting a URA for the first time (10)
- check it is correct appliance for ptx
- check it is correct design & matches prescription
- check for any sharp / protruding areas on polishing & fitting surface which could cause trauma
- check integrity of wire work i.e. areas of damage (dark spot where the chromium layer is damaged which can lead to corrosion/fracture) or areas of work hardening (darkness caused by bending back & forth)
- try in ptx mouth
- check for signs of blanching, damage & trauma to soft tissues
- check occlusion: 1. flyover of posterior retention; high flyover can cause metal fatigue & wire fracture, undercut area moving so it won’t engage & causes gum stripping. 2. arrowheads. 3. check anterior retention
- active components should be in passive state so this is when they can be activated to allow 1mm of movement/ month
- demonstrate to ptx correct insertion & removal & get them to demonstrate back
- book review in 4-6wks
difficulties ptx must have with URA (4)
- likely to impinge on speech so get them to read aloud with device in
- will feel big & bulky so reassure they will get used to it quickly
- once activated will feel mild discomfort so indicates appliance is working & can take analgesia if needs be at start
- likely to have excess salivation (will pass in 24hrs)
instructions to give ptx when they receive their appliance (6)
- wear 24/7 including meal times
- take out & clean with soft brush after every meal
- store in safe container if taking part in active / contact sports
- non compliance will significantly lengthen tx
- avoid hard & sticky food, caution with hot food & drink
- give emergency contact details if components fail
how would you monitor progress & what would you do at subsequent visits for URA
- check wear on acrylic
- reactivate appliance
- monitor through overjet measurement; ensuring space between UR3 & UR4 are reducing & ensuring OJ has not changed
- check overbite reduction
- check MR in case anchorage is slipping
- if compliance is good, tx should only take 6-9mths
how are ghost images formed and what would cause them
produced as the x ray tube start position directs the bra posteriorly towards then opposite TMJ region and then moved behind ptx head, when the image of the premolar is being created the beam is coming from a more posterior point on opposite side & ghost products such as earrings are usually more anterior due to this
ghost images that occur are always higher due to vertical beam angulation of 8o and be horizontally magnified & usually further forwards due to change in anterior-posterior position
ghost images can occur when there is horizontal distortion if ptx is in incorrect position relative to focal plane
typical ghost images = earrings, metal restoration, soft tissue calcification, soft palate, hyoid bone, denture & fixed appliance
indications for an OPT
when you require a full view of dentition & surrounding structures inc TMJ & condyles; it will show:
- fractures & elevation of trauma
- 3rd molar & relationship to ID canal on lowers
- bone loss in generalised perio disease
- large lesions that wouldn’t be seen on occlusal, bitewings or periapical
- retained/unerupted teeth & development of dentition
- developmental & acquired anomalies
- TMJ evaluation
- inability to tolerate intra oral radiographs
define a stroke
a stroke is an acute neurological defecit resulting from cerebrovascular disease and lasting more than 24hrs or causing earlier death due to hypoxia of brain tissue; 2 types:
1. no local cerebral flow; infarction of tissue or haemorrhage into brain tissue
2. temporary ischaemia; TIA (transient ischaemic attack)
what are the dental considerations with a stroke (6)
- impaired mobility & dexterity; reduced attendance, importance of OH & techniques for getting into mouth
- communication difficulties; dysphonia & dysarthria issues, cognitive difficulties
- risk of cardiac emergencies; MI & further stroke are at increased risk
- loss of protective reflexes; aspiration risk, techniques for managing saliva
- loss of sensory information; difficulty in adapting to new oral environment i.e. denture
- stroke pain; CNS generated pain perception may be enhanced
risk factors of stroke occurring
hypertension - DBP >110mmHg x15 risk compared to 80mmHg, sustained BP of 140/90 or above
smoking
frequent & heavy alcohol consumption
ischaemic heart disease
atrial fibrillation
diabetes mellitus
previous strokes
prolonged stress
methods to reduce stroke (5)
- reduce risk factors; smoking, stress & alcohol reduced, diabetes & hypertension controlled
- anti platelet action - decreases platelet aggregation & inhibits thrombus formation effective in arterial circulation e.g. aspirin, clopidogrel, dipyridamole
- anti coag action - suppressing synthesis or function of various clotting factors and prevent formation of blood clots in veins & arteries; if at emboli risk such as AF, left ventricular thrombus given warfarin / heparin
- carotid endarterectomy - used when there is severe stenosis & previous TIAs under age of 85
- neurosurgery - aneurysm clips or AV malformation correction
tx available for stroke
ACUTE PHASE:
1. limit damage:
- calcium channel blockers for survivable ischaemia
- thrombolysis within 3hrs to improve blood flow & O2
- achieve normal glycaemia levels
2. reduce future risk:
- remove haematoma if possible
- give 300mg aspiring daily & anticoagulants if required
CHRONIC PHASE
1. rehabilitation:
- immobility support
- speech and language therapy
- occupational therapy
2. reduce future risk with medication
where is an IDB inserted
needle injected at junction of buccal fat pad in pterygomandibular, lateral to pterygomandibular raphe and medial to coronoid notch of the ramus of the mandible, 1cm above occlusal plane of molars
position of needle is approached from opposite premolar region and advanced until you reach bone then retract 1cm; aspirate & begin slow administration
what happens if LA inserted into parotid gland
facial palsy as LA injected (too posteriorly) into facial nerve which runs through parotid
causes eye on affected side to shut similar to stroke symptoms & cannot move eyebrows as temporal branch affected
to manage - reassure, cover eye with pad until blink reflex returns to normal, book review
list common psychiatric disorders
- neuroses (person contact is retained with reality) - anxiety states, phobic, OCD, hypochondria, depressive
- psychoses (persons contact is lost with reality) - manic depression, schizophrenia, korsakoff’s psychosis
- mood disorders - dementia, depressive, dysthymia, bipolar, cyclothymia
- eating disorders
- personality disorders
difficulties in treating patients with psychiatric disorders
- anxiety - denture intolerance, oral somatostatin, parafunction, TMD issues, oral dysesthesias (dry, burning, facial pain but no cause)
- psychoses - may be hyperactive / aggressive, delusional, hallucinations, poor concentration, poor insight, reckless behaviour
- mood disorders - reduced interest & motivation, poor concentration, appetite disturbance, unreasonable self approach
- eating disorders - xerostomia, recurrent ulcers, infections, bleeding, dental erosion
general - poor attenders, local dental care facility may not be able to provide specialist care, may not accept care due to anxiety so need sedation / GA, problems with capacity & consent
