Procedures and Patient Management Flashcards
1
Q
Explain the screening procedure:
A
- introduce self and check name and DOB
- explain what screening is for (checking suitable for work, can’t guarantee work with the school, longer waiting times, longer procedures but good standard and checked by tutor)
- go through covid questions
- suitability top 4 questions and any time any day
- medical history form
- let patient read consent
- sign off by tutor
- extra oral and intra-oral exam
- findings and finish suitability form
- place referal
- write up notes
2
Q
How do we numb the UR3 - full procedure
A
Infiltration with a 27 guage 0.4mm diameter 19mm needle and 2.2ml catrage of 2 % lidocaine at 1: 80,000 adrenaline.
- provide 5% topical lidocaine ointment if nervous
- retract lip with mirror to see frenal attachment taut
- tell patient to look away and there will be a sharp scratch
- go in at 45 degree angle toward apex of tooth
- until hit bone
- aspirate to ensure not in blood vessel
- release 1/2-2/3 cartraige
- repeat on palatal aspect
- wait a few minutes and question about numbness
3
Q
before any operative treatment is given, what do we do?
A
PREVENTION
- OHI
- PMPR
- get oral hygiene under control with duraphat, mouthwash, high fluoride toothpaste
4
Q
why is it a negative thing that we remove dentine during RCT?
A
Dentine can distribute mechanical load laterally within a tooth (e.g. premolar) however if the singular root is canaled and filled, this reduces proprioception and mechanical integrity so under occlusal force, the restoration/tooth tissue can fracture.
5
Q
What parts of the RCT process cause the dentine have less integrity and fracture strength?
A
- dentine is removed so less
- NaOCl for dissolution of superficial (canal wall) collagen (organic material)–
- Eugenol – component of sealer for the finished root canal and increases dentine microhardness, makes dentine more brittle
- EDTA – dissolution of superficial (canal wall) calcium hydroxyapatite (inorganic material).
6
Q
why is partial caries removal preferred over complete caries removal?
A
- less chance of pulpal exposure
- less tooth tissue lost, more tooth integrity
- affected dentine can remineralize
7
Q
why do we use cooled burrs?
A
- irreversible structural damage occurs to dentine over 70 degrees
- burs generate lots of heat by them self
- dentine is very sensitive and burning heat can be felt by patient
- pulp will lay down tertiary dentine reducing the pulp chamber
8
Q
what is RDT? why is ti important
A
remaining dentine thickness. determines how the pulp reacts, vitality of tooth and integrity of tooth
9
Q
what is the difference in how we treat fully necrosed pulp and partially infected pulp?
A
fully necrosis = pulpectomy removing all of the pulp and RCt
partial necrosis = partial pulpectomy removing the necrosis and re-establishing healthy pulp
10
Q
what is indirect pulp capping?
A
where pulp has not been exposed but as a precaution we place GIC or capping material close to base and then cover with composite/amalgam to protect the pulp.
11
Q
what is direct pulp capping?
A
when we have breached the pulp chamber and we try to stimulate dentine bridge formation to close exposure as pulp has no epithelium.
12
Q
explain pulp capping procedure
A
- rubber dam
- remove blood clot
- Establish Haemostasis and clean with Chlorhexidine, Sodium hypochlorite or Saline.
- gently place capping agent (dycal, CaOH) not applying pressure of pulp dispalced and necrosis
- cover in GIC or hard cement or CaOH will dissolve
- seal with permanent restoration
- review in 1 week for symptoms
- review in 6 months to check dentine bridging and tertiary dentine with no pain
13
Q
what is the main factor in pulp cap survival rate?
A
if the cap was placed within 2 days of exposure
14
Q
when would we provide a pulp cap or RCT with pulp exposure?
A
pulp cap when mechanical exposure due to operator, immediate
RCT if carious pulpal exposure as very low prognosis
15
Q
what is a pulpotomy and pulpectomy and when are they done
A
pulpotomy = coronal pulp removed as emergency treatment to then be capped and finished as pulpectomy at later date OR in deciduous teeth pulpectomy = full pulp removal for RCT
16
Q
what is the EWL?
A
EWL is the radiographic length from the highest point of the tooth to the tip of the root. We then minus 1mm from this.
17
Q
what pre-op checks do we take before PD work
A
any active caries? any current restorations? fractures? any tooth wear? rotation/inclination? Pulp vitality and Sensibility level of coronal damage; damage extending into the root; viability of restoration after root canal treatment
18
Q
what are the stages to RCT?
A
access cavity pulpal chamber removal coronal 2/3 cavity apical 1/3 cavity step back apical gauging dryiing obturation
19
Q
explain enamel access of an anterior teeth
A
- anaesthetise and rubber dam and seal with oraseal
- with a round diamond bur, drill in small motions a triangle (with single point apical) on palatal surface into the dentine
- expose pulp and now use round rose head bur to clear the chamber
- use upward motions to break roof of pulpal chamber
- use endodontic explorer to identify the pulp canals
- Use lateral movements of a gates glidden bur or endo-Z bur to flare and finish the walls of the access cavity. this forms a flared entrance to the canal
20
Q
what do we use to irrigate the canals in RCT? why do we do this?
A
NaOCl - bleach, antimicrobial
EDTA - removes smear layer
To kill bacteria, remove smear layer, flush out debris and bacteria
21
Q
why do we need such a tight seal of rubber dam for RCT?
A
to prevent any cross infection from the oral cavity into the pulp or pulpal bacteria into the oral cavity
also to prevent bleach NaClO getting into the mouth or digestive system
22
Q
even when the pulp has been removed, how may pain still occur after RCT if the patient is not anaesthetised?
A
water potential of the sealant causes hydrostatic pressure at the apex or lateral canals can cause significant pain
23
Q
why is single tooth isolation better than multitooth isolation for RCT?
A
recues chances of leakage
24
Q
if a file is struggling to fit down a canal, what can we use to help?
A
canal lubricant like glyde
25
why is straight line access important?
so that when working on root preparation the files bend as little as possible. This reduces chances of apical perforations, zipping, and file fractures
26
explain the coronal 2/3 preperation
Find the 1/3 mark up from the apex is roughly ¼ up of the whole tooth so find 3/4 of the working length and round UP 15.75 = 16mm.
Prepare up to 16mm with size 30 K file to open far enough for gates gliddens. Irrigate with NaHCl very slowly so it doesn't come out of the apex.
Use a size 4 gates glidden to 12mm, size 3 to 14mm and size 2 to 16mm and irrigate and use k file size 15 in-between each
Now place the largest k file that snuggly fits to the EWL, usually size 15, and take a EWL radiograph
If the apex is within 1mm of the EWL then this is now the AWL. If the EWL is more than 1mm from the EWL then adjust the EWL and retake the radiograph so the AWL is 0.5mm from apex. Adjust coronal ⅔ accordingly. AWL = 23.5
27
explain the apical 1/3 RCT
Increase the AWL file (which was size 15) by two sizes to at least 25 so that there is enough space for Master GP and filling material.
Do this by working up the sizes e.g 15, 20, 25.
In-between each, irrigate and recapitulate with k file size 10. This gives us the master apical file master apical file (MAF - 25)
28
explain step back preperation in RCT
now we work backwards in increments of 1mm, increasing the k file size by 1 from the MAF We do this 5 times to meet the coronal ⅔ prep. 23.5mm = 25, 22.5mm = 30, 21.5mm = 35, 20.5mm= 40, 19.5mm =45
If this doesn't meet the ⅔ coronal, adjust the gate's glidden sizes to meet to give a correct taper
Irrigate and repiculate between each step with size 10 K file to AWL
29
explain apical guaging
Get the MAF (25) to AWL and pull. If there is resistance (pull back) this is correct.
Set the next size up (30) to AWL and press down, this should stop 1mm from the rubber stop. If this does not happen, adjust the MAF and step back.
30
how do we dry canal in preperation for obturation?
Use the 3 in 1 gently
cotton wool buds to dry the cavity as much as possible.
Now use paper points equal or smaller than MAF to fully dry the canal until they come out dry
31
explain obturation of RCT, excluding cut back
Get the master GP point (MGP - equal to MAF) and crimp to AWL.
Place it in the tooth. There should be resistance to 'tug back'.
Take a master GP radiograph. Should be no voids and should go to AWL. If not, adjust.
Now mix sealant (2 equal pastes) and then coat the MGP in sealant and press it in. Use finger spreader with rubber stop 1mm from AWL to press against side with high lateral/apical force and then coat an accessory GP size B and press in to 1mm from AWL. Repeat this, stepping back 1mm each time.
When three GP points are in, take a mid obturation radiograph to ensure no voids.
Carry on using the finger spreader to make sure the canal is completely packed with GP.
32
Explain obturation cut back and how to finish the restorations
Cut off the top of the GP as close to the ECJ with heated excavators
Use a small rosehead to finish off.
Measure the ECJ on the outside of the tooth with rubber stop and then ensure this height is achieved on the inside.
Top with a ZnOE liner and then fill with a composite (with etch and bond)
33
explain how to give inter-treatment medication as a temporary filling for mid-RCT
Irrigate for 1 minute
Dry the canals and preperation
Place pea sized amounts of non setting CaOH onto a K file smaller than MAF and place as deep into the canal as possible.
Use increasing increments with the paste to fill up to the CEJ.
Don't get any on the sides of the access cavity.
Press down with cotton wool and then take an x-ray to ensure full.
Place a sponge and temporary restoration on top.
Recall within 4 weeks.
34
in what circumstances can we not provide RCT
-rubber dam cannot be placed if crown is heavily carious
-caries below the bone
-very poor restorability/prognosis
-terrible oral hygeine
-presence of peripaical lesions
-
35
what is the aim of RCT
- prevent or cure apical periodontitis by eliminating source of infection
- stop pain for patient
36
why is gutta percha only used up to the CEJ
if it was within the crown, this would cause staining and be visible outside the tooth
37
why do we irrigate?
-remove debris
-dissolution of dentine walls to remove bacterial biofilm
-To clean the parts of the root canal system which are inaccessible (e.g: Lateral canals)
-To facilitate instrumentation and prevent root canal blockages by acting as a lubricant
Removal of debris
Lubrication of instruments
Antisepsis
Decomposition and removal of blood and tissues
Remove smear layer
38
why is obturation done in the root of a RCT tooth
- Completely seal all anatomical parts
- Prevent reinfection of the root canal system by denying access to oral bacteria
- Resolution of signs and symptoms of disease
- Restore the integrity of the tooth
39
what are some general outlines of an access cavity
smooth walls
tapered walls
no overhands/underhands
40
what probe and burs do we use for RCT
- DG 16 Endodontic explorer
- long shank rose heads to increase visability
- endo-Z burs or gates gliddens for tapering
41
what would happen if we leave some debris/bacteria in a RCt tooth
discolouration and re-infection
42
what is the crown down approach
where we remove all of the debris and bacteria/pulp from the crown pulpal chamber and then slowly move down the canals
43
if there is a lack of full length glide path in a root treated tooth, what can occur?
Ledge formation
Transportation of the apical foramen
Zip formation apically
Perforation
44
why do we stop 0.5mm away from the AWL?
- we want to prepare the RCT to the apical constriction not the foramen as it constricts and forms a good blockage to the peri-apex (so less SA of 'forein' filling material can be attacked by immune)
- if we break through the apex, over instrumentation can cause fractures which lead to lesions very hard to fix
45
if we use over instrumentation at the apex of a tooth, what may happen?
- Damage to the root apex and periapical tissues
- Extrusion of debris which may contain microorganisms, elements of necrotic pulp, and infected dentine chips
- The presence of excess root filling material in the PA tissue which may act as foreign matter and be attacked by the body causing a lesion
- irrigation with NaOCl may enter the periodontium which requires immediate MaxFax treatment
- zipping and translocation of apex
46
radiographic (2D) evidence of WL may not be enough. how else can we find the AWL?
tactical feedback with experience.
electronic apex locator
paper point (if it has blood on it, it is at the apex)
47
what is zipping/apical transportation and how does it happen/how do we prevent
zipping is connecting two apacies
apical transportation is perforating the lateral wall forming another apex on a bending root
causes by a poor glide path and not removing ledges
48
what must an irrigant be?
```
Antimicrobial
Cheap
Able to dissolve pulp tissue
Able to remove the smear layer
Easy to use
Long shelf-life
Compatible with dentine
Tissue-friendly
Substantive (remain in the root-canal for a sustained period)
Non-corrosive for dental instruments
Non-toxic
```
49
what is a smear layer and why is it important
an amorphous film of organic and inorganic material generated from instruments contacting the root canal walls. It ‘plugs’ the dentinal tubules and delays the penetration and effects of antimicrobials.
50
what is apical enlargement
when we enlarge the apex by 2 k file sizes to get the MAF
51
How do we avoid irritant getting into the periodontium?
inject very slowly
dont over-instrument the apex
work the irritant 2mm from apex
52
what percentage EDTA do we use and what is its main function
17%
Remove the smear layer (mineralised inorganic component)
Unable to dissolve organic matter
Should be used in conjunction with NaOCl
53
why must we remove the smear layer
smear layer harbours bacteria and nutrition for the bacteria
| acts as a barrier for medications and prevents good seal/penetration of canal sealer
54
during RCT, what is the procedure for different irrigants?
use NaOCl throughout for disinfection and debris removal
when canal is open, use EDTA to remove smear layer for 1 minute
use NaOCl to disinfect again
55
what percent of root canaled teeth still harbour bacteria?
50%
56
What is inter-visit medication and what do we use for it
a medication filled into the canal between RCT steps to disinfect the canals and root
We use non-setting Ca(OH)2 with very high 12 pH
57
why do we obturate?
-Prevent coronal leakage of microorganisms or potential nutrients to support their growth
into the dead space of the root canal system
-Prevent periapical or periodontal fluids percolating into the root canals and feeding
microorganisms
-Entomb any residual microorganisms that have survived within the root canal system
following mechanical and chemical preparation
-Completely seal all anatomical portals of entry/exit to the root canal system
-Prevent reinfection the root canal system by denying access to oral bacteria
58
why would discolouration of the crown follow RCT?
- if root filing material is left above the CEJ
- by products produced by remnants of dead pulp that were not removed
- staining from coronal restoration e.g. if amalgam
59
what is tug back
when we place the master GP point in a tooths canal and when we pull, there is slight resistance showing the master GP is the correct size
60
what method do undergraduates use for obtruation
cold lateral condensation
61
why is inter visit medication important
to keep the root canals in a bacteriocidic environment in between the sections of treatment during an RCT
62
how do we complete intervisit medication
hypo Cal up to the CEJ
use ZnOE (cavit or cotosol) or a sponge but NOT cotton wool above
use GIC to temporarily seal the cavity
63
why is cavit used underneath GIC in inter visit medication
to provide support underneath the GIc on posterior teeth to rpevent collapse of the inter visit medication
64
what should we avoid when placing the CaOH for intervisit medication
pushing it down hard enough to breach the apex
| getting it on the coronal cavity walls as it impedes the adherence of the GIC
65
why do some inter visit medications involve corticosteroids
to reduce the inflammation of the pulp/periodontium
66
why should we not overfill an RCT with GP points (past the CEJ) (2)
- difinitive leakage pathway for bacteria
| - staining of the crown
67
what is to be expected after an RCT? How do we treat this? what do we advise against
residual pulpal/periodontal inflammation
pain common 2-3 days after, peaks at 5-7 days and lasts 10-12 days
analgesics NSAIDS, not steroids as these will not help
68
why is it a problem if we only fill 2/3 of the root in an RCT?
there is residual bacteria that will still cause inflammation e.g. abscess
69
what happens first 8 days post extraction in a healthy state
blood clot forms with lots of blood clot over the extraction site to prevent bleeding
neutrophils slowly move into the blood clot to form a protective barrier
granulation tissue forms at the base of the extraction socket and up to the blood clot
70
at ~8 days post extraction what begins to happen to an extraction socket
epithelium proliferates from either side of the socket (gingival epithelium) at the level of the granulation tissue neutrophil border to cover the socket
71
at 18 days post extraction what would we see in a healthy case
granulation tissue filling whole socket
epithelium covering the whole socket
woven bone forming either side of the base of the socket with osteoblasts
foci of chronic inflammatory cells e.g. lymphocytes under epithelium
72
would all granulation tissue in an extraction socket be turned into woven bone?
no, some becomes connective tissue to underlie the epithelium
73
2 months post extraction what would a histological slide of a socket look like
most socket filled with woven bone, very pink with high collagen
connective tissue underlying epithelium
scattered chronic inflammatory cells
74
3 months post extraction what would see histologically
cancellous bone formation
remodelling to remove ridgid edges
resorption of bone replaced with adipose - marrow space
75
a patient has recently had a tooth extracted and is complaining of a foul taste in mouth. What should we do and what are we likely to find. what is causing the foul taste?
take radiograph
bone fragment still within socket
pus leaking from abscess formation of inflammatory cells and necrotic tissue
76
what is good practice after extraction?
OHI
radiograph to ensure no remaining tooth/bone
Pack and suture
77
what risk factors increase risk of improper healing of extraction tooth sockets
```
smoker
poor OHI
MRONJ risk - bisphosphonates + steroids / IV bisphosphonates
High exercise
Radiation exposure
```
78
how do we avoid haemorrhage after extraction with antiplatelet users
usually fine if only on 1
if more than 1 ask haematologist
usually fine just pack and suture
79
how do we avoid haemorrhage after extraction with haemophilia or VWBD
give factor VIII and IX
| Or desmopressin
80
what type of haemorrhage can occur after extraction and what causes them
primary: starts straight after extraction due to local factors or bleeding disorder
reactionary: within 48hrs of extraction ,exercise, heat, anaesthetic wearing off (we tell them not to drink alcohol, exercise or put heat on to prevent vasodilation)
secondary: approximately 1 week after surgery, due to infection (vascular response) after tonsils have been taken out this increases in chance
81
what post operation instructions do we give to prevent haemorrhage after extraction and why
don't do vigorous exercise, drink alcohol or get warm 48 hours after extraction
prevents reactionary haemorrhage due to vasodilation and blood thinning
82
what do we do immediately after extraction
apply firm pressure with gauze and ask patient to bite down
| compress socket
83
if someone is bleeding without clot what tests do we take
```
PT prothrombin time test
APTT activated partial thrombinogen time test
full blood count to check platelet count
check for VWBF
Check medication
```
84
how do we stop a bony bleed and a gingival bleed post extraction
bony - haemostatic pack the socket
| gingival - suture
85
if stopping a bony bleed, what can we use to pack and absorbs clot?
Packing is done with surgicel or curicel which are packed into the socket and are resorbable oxidised cellulose which helps clot form.
We can also use gelatin sponges which absorbs up to 45 times their own weight in blood - pressure tamponades bleed.
86
what are gelatine sponges
sponges used for packing extraction sites that absorb 45x their own weight of blood
87
what is surgicel made from and when is it used
resorbable oxidised cellulose
| helps form blood clot after extraction
88
what should we hear when opening a syringe/cartraige
snap
| if not, it is not sterile so use new
89
what is primary intention
wound edges are opposed (brought together) and held in place by mechanical means (sutures). Can't always do this as the underlying tissue e.g. glands, ducts and nerves will keep leaking so they have to be fixed first.
90
when can we do primary intention
tissue is clean
little loss of tissue
if blood vessels/nerves/glands are invovled
91
why is primary intention good
improves rapid wound healing
minimises scarring
Prevents infection
92
what is secondary intention
wounds left open and edges come together naturally and heal.
93
when do we do secondary intention and why
when there is little connective tissue
when the wound is large and lots of tissue lost as stitching would put a lot of pressure on the wound and cause more scarring
94
in most cases post-extraction, do we practice secondary or primary intention? when would we do the other
secondary
| if bleeding a lot, we would do primary intention
95
what do we use to separate teeth during electric pulp testing
cellulose strip
96
how do we do a cold sensibility test
spray endofrost on a cotton wool bud
place on mid-labial surface
wait for positive response
test contralateral teeth
97
how do we do an electric pulp test
dry tooth and separate from other teeth with cellulose strip
apply conducting medium to electrode e.g. toothpaste
apply to flat surface on tooth and slowly increase voltage
record positive or negative
98
what number should we set the 'change in stimulus' for electric pulp testing
4 or 5
99
why would we get false positives during electric pulp testing (4)
if the patient is anxious
partially necrotic but still needs RCT
metal restorations conduct to adjacent teeth
inadequate isolation
100
why might we get false negatives during electric pulp testing
nerve damage due to trauma
| sclerosed canals/pulp chambers due to reactionary dentine
101
how can post-extraction problems be classified (3)
local (haemorrage) or distant site (endocarditis)
minor (removal of alveolar bone) or major (haemorrage)
general (pain, swelling) or specific (loss of sensibility)
102
what is a oro-antral communication OAC and what is its most common cause
a passage created between the mouth and the MAS which is already connected to the nose
commonly caused by extraction of upper molars with partial involvement with the MAS
103
what are some signs and symptoms of OAC oro-antral communication
symptoms
drink water and it comes out of nose
failure to make oral seal
air passes into mouth when mouth closed
```
signs
small eggshell bone on extracted root
void into sinus
antral lining visible/prolapse
bubbles in socket
```
104
what are two outcomes of oro-antral communications
if small perforation: with good POI, it will heal over
| if large perforation: epithelial covering forms oro-antral fistula which needs removing
105
what is an oro-antral fistula
where a thin, weak epithelial covering covers a large oro-antral communication that needs removing
106
what POI should be given if we create a small oro-antral communication
don't blow nose or sneeze
dont fly due to increased cabin pressure
avoid injury and dont swim
107
what can be prescribed for a patient with a small, healing oro-antral communication
decongestants e.g. epinepherine naal spray to releive blocked nose preventing need for blowing nose
anitbacterial like amoxicillin
108
what POI should be given in regards to swelling with posterior extractions
pain and swelling is common and normal
| however if a swelling begins to disrupt airway or passage of food, call immediately
109
why might burnt lip occur during procedures
instrument heating
double gloving prevents sharps injuries but reduces operators sensitivity to heat
pt under anaesthetic or sedation so dont stop when pain
110
how long does it take for dry socket to form post XLA
48 hours
111
which extractions definitely require radiographs, why and what other imaging can be done
molar extractions
upper molars close to MAS
lower molars (especially 8s) close proximity to IAN
check nerve proximity with CT scan
112
what is the maximum weight for dental chairs
20 stone - 140kg
113
what might be found on an x-ray that can complicate extractions (5)
```
within MAS
near nerve - IAN
root filled tooth with less integrity
heavily carious tooth
recurrent caries
long, curved root
ankylosis
```
114
what are the implications of possibly extracting a stand alone upper 7
possibly within the MAS
| MAS may have moved into root space of 6 or 8 by pneumatization making MAS in close proximity
115
what are 3 phases of failed socket management
Anticipatory phase: prevent, POI, make refferal, xrays/CT
Immediate phase: sutures, use instruments to removed fractures
Palliate phase: treat wound, dressings, CHX M/W, antibiotic prophylaxis
116
what is a luxator
sharp, relatively straight ended instrument used to break sharpeys fibres in PDL to loosen tooth
117
what is a cowhorn used for
extraction of lower molars, gets under the furcation to ply up
118
what are eagle-beak forceps used for
removal of lower molar by initiating the furcation
119
what tools can we use to help removal of partially removed teeth as immediate phase of extraction
luxators to break PDL to loosen
| cowhorn or eagle beak forceps to get under furcation and bring out roots
120
what is the trans-alveolar surgical removal of teeth
used to remove roots that fracture during extraction
flap up the buccal muco-periosteal flap
use bur to remove, section, sever, elevate root
replace flap and suture
121
what is surgical removal of a fractured root
trans-alveolar surgery
122
how can we surgically cover an oro-antral communication (3 ways)
Buccal advancement flap: we raise buccal flap, undermine periosteum, pull mucosa over the gap and seal with water tight seal. This may be very thin.
Can use buccal fat pad of cheek to form bilayer closer on top of communication and mucosa over this. Done for very thin buccal mucosa.
Palatal rotational flap using flap from palatal side with palatal artery to maintain vitality, this is keratinized and thicker to form a thicker, stronger seal over communication.
123
what is the advantage of using palatal rotational flap vs a buccal advancement flap
palatal mucosa is keratinized so is stronger and more resistant
palatal artery involvement leads to durability and vitality
124
when would we use a buccal fat pad for covering a oro-antral communication
used when the buccal advancement flap is too thin so buccal fat pad used to form a bilayer
125
what part of the mandible can came off with an upper wisdom tooth
maxillary tuberosity - end of the alveolar process of the maxilla
126
what are signs of the maxillary tuberosity being removed with an upper molar
large chunk of bone with tooth
indirect oro-antral communication
tearing of palatal mucosa
mobility of adjacent teeth
127
what is an endoscopy
using small wires and cameras to surgically remove things
128
what is the duty of candour
duty to tell the truth to our patients when something goes wrong and be patient centered and work for them
129
how do we refer an extraction problem
by letter if non-urgent e.g. bone removed with tooth
| by fax/phone if urgent to local MAXFAX surgery if urgent e.g. haemorrage
130
explain a plaque score test breifly
rub vasaline on lips to stop staining
give plaque disclosing
rinse to remove stained salivary proteins
mark gingival plaque scores (not coronal)
find score
131
how m much force do we use for BPE
20-25g force - enough to blanch hand but not hurt
132
what probes can we use for BPE and 6PPC
williams probe (small increments of silver and black)
WHO BPE probe with incrementas at 3.5mm, 5.5mm and so on
UCF with only silver 1mm increments
133
how is mobility measured
grade I (1mm movement), grade II (2mm of movement) or grade III (more than 3mm movement)
134
how do we stage furcation involvmenet
Grade I = can see furcation but probe doesn't go through. Grade II = probe goes through upto 3mm but not all the way and Grade III = through and through.
135
what is the procedure for syncope
fainting
lay down with feet raised
glucose drink
cold compress on head
136
what are the different coarsness of prophy pastes used for
very coarse - removal of plaque and heavily stained enamel
coarse - plaque and stained enamel
fine - plaque and light discoloration
extra fine - finishing restorations, removal of plaque dislcosing
137
name some hand scalers
H6/H7
| scaler 204
138
explain how to use a scaler for anterior calculus deposits
scalers (H6/H7 /scaler 204) have 2 cutting edges with triangular cross section
put tip of cutting edge under deposit, perpendicular to tooth
provide lateral force and stroke upwards to remove deposit
139
what is a curette and what is it used for
a curved instrument with 2 cutting edges (bendy scaler) and semi-circular cross section
used for removing large deposits of calculus distally
140
what is a hoe and what is it used for
a long instrument with a slight bend at the end corming a lip
used to get under heavy deposits and break them off of teeth
141
what are the two main files used and what is their function during hand held PMPR
```
Hirschfeld file (small file end) and blunting file (longer file end)
to slowly abraise calculus with their rigid, staggered toe
```
142
what are the three types of non-handinstrument scalers we can use
sonic - uses air
(ultrasonic) piezoelectric - uses charged quartz crystal which expands and contracts
(ultrasonic) magnetostrictive - uses electric current to form megnetic field
143
how fast are sonic and ultrasonic handpeices
sonic: 3-8 kHz
ultrasonic: 25kHz - 35kHz
144
how do ultrasonic scalers work
use either current to form a magnetic field (magnetostrictive) or a charged quartz crystal (Piezoelectric) to create vibrations
Water is released as well
vibrations cause cavitation of the water - causing it to implode and cause acoustic streaming , extending working area of tip
145
what is cavitation of water
where high frequency vibrations cause water molecules to implode and create acustic streaming
This extands the working vibrating area of an ultrasonic scaler to remove calculus
146
why is cavitation advantageous for scaling
reduced patient bleeding
increases speed of plaque removal
disrupts biofilm
works at a distance away from the tip
147
why is ultrasonic better than hand scaling for the patient and for the dentist
patient:
- more comfortable
- quicker
- less painful and less bleeding
dentist:
- water flow clears blood and increases visibility
- cavitation improves calculus and biofilm disruption
- cavitation causes less blood vessel rupture
- faster
148
what are some disadvantages of ultrasonic scaling
```
no tactile feedback
water in mouth is uncomfortable for patient
more expensive
cause heating of tooth and irritate pulp
needs power and water supply
can loosen crowns and bridges
```
149
how do we use hand scalers
place under deposits and lift up with lateral force in small 1mm up and down storkes
150
what is the only cutting instrument with 1 sharp cutting edge
Graceys scaler
151
how far gingival can we put handpeice scalers
1-2mm under gingival margin
152
how do we stay safe during procedures
good posture for back and neck strength
PPE to prevent cross contamination and things getting in eyes
ask for COVID screening and test for AGP
hard shoes to prevent falling sharps injuries
follow proper protocol in emergencies
153
explain steps to applying fluoride varnish
investigate allergen to colophony
clean teeth with prophy paste to remove biofilm and isolate from saliva
wipe teeth clean with guaze
apply thin layer of 22,600ppm F- varnish to tooth surfaces with microapplicator
POI
154
what POI is given for fluoride varnish
dont eat or drink for 30 minutes
avoid heavy chewing for 4 hours
dont brush teeth this day, resume fluoride toothpaste brushing day after
155
what is minimal intervention and what are its pro's
where we remove as little tooth as possible - partial caries removal
reduces damage to adjacent teeth
reduces risk of entering the pulp
reduced removal of sound tooth so increased integrity of tooth
156
where do we find the crash kit and what does it contain
2nd floor RD2 near reception
red trolly with kit
anaphylaxis (on all floors in red box), first aid, oxygen, hyperglaecemia kit
157
what number do we call to report fire or crash team
2222
158
what are advantages of rubber dam
prevents sharps/instruments falling into mouth
prevents ingestion toxic e.g. bleach, acid etch
prevetns bacteria from mouth getting into cavities and bacteria spreading into mouth
reduces inhalation of amalgam
keeps teeth dry and isolates from other teeth
159
if we are struggling to get a view of the mouth, what can the nurse use to open the mouth
soft tissue retractors
160
what are 3 moisture control techniques
rubber dam
cotton wool rolls in vestibule
cellulose pads on stensons duct of parotid
161
what can we place over salivary glands to absorb moisture
cellulose pads
162
what is the brand name of cellulose pads
dry tips
163
disadvantages of rubber dam
```
uncomfortable
time consuming
latex allergy (not in dental school - we use nitrile)
LA needed for clamped technique
claustrophobic
lack of communication
```
164
what clamp is used for single tooth isolation
butterfly clamp
165
when we apply fissure sealant, what reduction in caries do we see
57% reduction in 4 years
| 1 in 10 lesions still develope
166
when is fissure sealant used
on non-cavitated carious lesions for remineralization
| non-carious, high risk carious fissures/pits
167
what is the function of fissure sealants (3)
cut off food supply to bacteria to arrest their action and prevent demineralization
fill deep fissures to make smooth surface, easier to brush and keep clean
arrest non-cavitated lesions and cause remineralisation
168
when do we not use fissure sealant
cavitated lesions
if we cannot dry/isolate tooth are most are resin based and interact with water
no caries experience or risk
169
explain how to place fissure sealent
1. use pumice and slow speed cup bur to remove biofilm
2. isolate or rubber dam
3. use phosphoric acid etch to remove smear layer for micromechanical locking
4. apply sealant with capsule on composite gun
5. move around with probe to remove bubbles and set with blue light
6. use probe to check surface smoothness and margins
7. use articulating paper to check occlusion, adjust with finishing burs if needed
170
how do we remove etch from a tooth
use suction
rinse with 3 in 1
suction
gently use air from 3 in 1 only breifly as we don't want to dry out the tubules
171
why can we not over dry etched dentine
open dentinal tubule as smear layer removed
drying creates osmatic pressure and forces odontoblasts up the dentinal tubules
this kills the odontoblasts
painful and kills cells
172
how do we know a tooth is correctly etched
white and frosty
173
how long do we cure fissure sealent
20 seconds
174
how can fissure sealents fail
failed adherence due to improper technique/isolation
margins not smooth so act as PRF causing secondary caries
wrong occlusal checks lead to increase occlusal forces, failing the sealent
175
what are the 4 steps of caries removal
enamel access
ADJ clear
manage unsupported enamel
manage body of lesion to affected dentine
176
explain caries removal breifly
enamel access: high speed pear shaped diamond bur access caries to ADJ
ADJ: clear ADJ with small slow rose head bur until all clear
Unsupported: remove unsupported enamel with high speed
Body: remove with large rose head in brushes until at affected dentine
177
how do we know we are at affected dentine during caries removal
between using slow rose head bur
use excavator and scrape along base
infected would scape off forming debris, affected would not
178
what hand instruments can we use for removing enamel and dentine
enamel:
- gingival margin trimmer (bent with cutting edge on side)
- chisel (straight with cutting edge at toe)
- hatchet (bent with cutting edge at toe)
dentine:
-spoon excavator
179
what speed are high and slow handpeices
slow: 40,000 rpm
high: 450,000 rpm
180
how do high and fast speed burs stay in the handpeice
```
high = friction grip
slow = latch
```
181
what are 2 alternative caries removal than rotary
Chemomechanical - Carisolv/Papacarie
| air abrasion/Ultrasonic
182
briefly explain how Chemomechanical works. give positives and negatives
further breakdown of damaged collagen, dissolving remaining tissue to be scooped out
only removes infected dentine, partial caries removal
good for places with no rotary instruments
no noise so good for anxious patients
only used for open cavities as no enamel access
scooping is more fatiguing
183
explain adv and disadv of air abrasion caries removal
```
time consuming
no tactile feedback
good for anxious patients
no pain, noise
improves bonding surface for filling material
```
184
what size do rose head burs come in
3, 5 and 7
185
why do we use the crown down approach
clears bacteria before going deeper into the cavity and possibly spreading bacteria
186
why do we clear the ADJ before body of lesion
to understand full extant laterally of the cavity
to clear ADJ of bacteria
gain better visiibilty
187
what are some ideal properties of a cavity prep
```
straight walls
flat floor
slight undercut but not major
no unsupported enamel
no staining/bacteria left
affected dentine on base
```
188
how long is the pear shaped diamond bur
3mm
189
what is a bevel and what are ideal characteristics
a small groove created on the edge of two surfaces
to create a smoother transition over materials
should be 1-2mm thick and uniform
190
what are the steps to class 2 cavity prep
1. isolation
2. initial enamel access inside marginal ridge
3. down to ~3mm (size of pear shaped diamond)
4. lateral movements very close to proximity
5. remove thin enamel wall with hand instruments
6. use gingival margin trimmers to remove sharp floor edges
191
how can we separate teeth prior to restorations
apply a separating ring between teeth 3-7 days prior
192
how far away can the light cure be from the composite
maximum 3mm
193
which shades of composite light cure better
lighter shades cure more readily and deeper
194
what wavelength does photoinitiation occur
470nm
195
what three proximal structure of teeth need to be resorted during class II restorations
embrasure space to allow food passage
marginal ridge for strength and integrity
Contact point to prevent food trapping
196
how can we ensure good axial support of a restoration (3)
```
flat floor perpendicular to long axis of tooth and straight vertical walls
rounded internal angles
no unsupported enamel
Undercut
Slots in lateral walls
```
197
how do we get good lateral support of restorations
straight vertical walls parrallel to the long axis of tooth
198
what are advantages of metal and plastic matrix bands
metal are malleable so contourable to adjacent tooth better contact point
metal more rigid and stay in place
plastic are translucent allowing photoinitiation through matrix band
199
where must we place a matrix band
above marginal ridge of adjacent teeth
| below cavity borders
200
how do we place a class II restoration matrix band
```
narrow side apically with handle coming out of mouth
above marginal ridge
below cavity prep
with wedges below cavity prep
burnish
```
201
what is the difference between composite and amalgam cavity prep
amalgam require more retention
| small 0.5mm grooves in floor
202
how do we place a wooden wedget
```
with apex of triangle pointing cervical
after placement of matrix band
from side
opposite to handle side of matrix
ensure secure contact with probe inside matrix
```
203
what are 4 checks to ensure good matrix band placement
tight and stable - no wobbling
good margins over marginal ridge and under cavity prep
good apical seal
smooth contour/burnished proximal wall creating tight contact
204
what instrument do we use for carving amalgam contours
wards carver
205
What is the criteria for good amalgam cavity prep
Undercut
90 degree cavosurface angle
No unsupported enamel
206
What is the ideal taper of a restoration
5-7 degrees
207
How many pairs of occluding teeth are involved in the shortened dental arch
9-10
208
Describe an endo z bur
Bur with tapered edges and non cutting tip
209
Which bur is used in endodontic procedures to widen access cavities but not perforate floor
Endo Z because it has a blunt tip
210
What concentration do we use CHX as root canal irrigant
0.2-2%
211
What antimicrobial level is 2% CHX equal to
5.25% sodium hypochlorite
212
what is enamel prophylaxis and when is it important
cleaning teeth with prophy paste to remove enamel pellicle, bacteria and salivary proteins
important before enamel resin restorations to improve enamel bond
213
what can be done to prevent class I caries
fissure sealents
214
why do we minimise the entry/exit points on occlusal cavity preps
diamond pear shaped bur is tapered
when bur is 2mm in, it creates the ideal 5% taper
if we bring it out, it gets wider and removes taper
leads to a requirement of further expending the cavity
215
why do we try to provide smooth, rounded termini in class I preps
risk reduction of propagating a fracture
216
describe 2 different etch techniques
complete etch - etch dentine and enamel together
| selective etch - etch dentine 15-20 seconds and enamel 30 seconds separately
217
what is the difference in amalgam and composite prep and placement
prep undercut
minimum 2mm depth for amalgam, no minimum for composite
bulk fill and overfill with amalgam, composite fill in oblique wedges, not overfill
composite finish immediately
amalgam finish ideally after 24 hours of placement
218
which cavity preps are wedged placement of composite most important
```
Class V, III and I
only 1 side not binding to tooth surface
high C factor - 5
high stress put on tooth structure during polymerisation shrinkage
likely to get microleakage
```
219
what is 'flash' of a restoration
excess material protruding out of the cavity prep to be removed
220
what is the purpose of finishing a restoration
removal of flash of excess to remove PRF
remove non-polymerized opaque oxidised layer (composite)
remove mercury rich layer (amalgam)
provide a smooth contoured surface, comfortable for pt and less plaque retentive
improve aesthetics
221
what is the difference in the way we finish amalgam and composite restorations
overfill amalgam, don't overfill composite
finish amalgam before setting, finish composite after setting
amalgam needs mercury rich layer removing (burnishing)
composite needs opaque oxidised layer removing
after amalgam is set, any finishing further required must be doe 24 hours after set
222
what tools can we use for finishing composite restorations
microfine rugby bur for occlusal adjustments
microfine needle bur for interproximal flash and smoothen transitions on smooth surface
soft flex discs to smoothen smooth surfaces and improve transition
white stone burs similar to microfine, less abrasive
interproximal strips for interproximal contouring and removing flash
223
what types of soft flex disc are there and how do we use them
```
red most coarse
red/orange next
orange next
yellow most fine
large and small size
use on a latch grip mandrel attachment on a slow speed handpiece
always go down in coarseness to yellow
```
224
What probe is used for checking furcation involvement
Nabers probe split into 3 quadrants
225
how may recurrent caries occur after restoration placement
```
contamination
polymerisation shrinkage
poor condensation of amalgam leading to microleakage
improper bond technique
poor matrix band and margin
```
226
how does poor matrix band placement cause secondary caries
```
improper marginal seal at lower border of class II restorations
cause flash and overhangs acting as PRF
```
227
what are positive ledges
cavity overfilled
| ledge exceeds cavity margin providing PRF
228
what are negative ledges
where cavity is underfilled
| acts as a PRF
229
what are the 4 functions of a matrix
provide strong contact point between teeth
help build up proximal wall and contain restoration to cavity
good margins between restoration and tooth
contour edges to make a smooth, non-PRF, cleansable surface
230
what are the (dis)advantages of the matrix systems we use in CCDH
```
Pro-Matrix
non-reusable so less sterilisation
more waste
plastic
circumferential
```
231
why do we not use sectional matracies
more expensive
harder to sterilise
harder to use - require extra tools and extra sterilisation
do not encircle the whole tooth
232
which way do we inset wooden wedges
lingual/palatal
233
how do we remove a matrix system
remove wooden wedge
loosen fully
wiggle and rotate, holding down on the restoration
slowly pull up and release
234
what are 4 checklist items of a class II restoration
reproduce contours of previous tooth?
smooth surface?
contact point achieved?
smooth marginal adaptations
235
how do we prevent mercury poisoning from amalgam
use filtered sinks for amalgam waste water
use correct PPE
well ventilated rooms for hot vaporized mercury
use good air suction when finishing/removing
ensure we click capsule and safely secure in mixer before pressing go
put all waste into waste amalgam pot
avoid spills and know correct spill procedure
236
what do we do in an amalgam spillage
Stop work immediately
switch off amalgamator.
Inform clinical supervisor.
Confine spill to a minimum, avoid getting mercury on the floor.
Increase ventilation.
Continue wearing PPE
Locate mercury spillage kit (red plastic box on tutor station) - dispensary
Never use a vacuum cleaner or aspirator to pick up mercury and never dispose of mercury in the sharps bin.
Using the scoop provided, move the globules of mercury together to form one pool. Pick up as much of this pool using the syringe and place the mercury in the waste container. Return the empty syringe to the spillage kit.
Mix equal amounts of SULPHUR and CALCIUM HYDROXIDE using a plastic dappens pot and spatula located in the kit box. Spread this mixture onto the spillage area. A little water can be added to this mix to form a paste if preferred.
Keep working the powder or paste on the spillage area using the brush and scoop for 2 - 3 minutes.
Brush the powder or paste into the scoop and transfer this to the waste container which should then be capped tightly. Replace in the spillage kit in a well ventilated place away from sources of heat
Alloy wool located in the kit can be used instead of the sulphur and calcium mixture.
Break off a piece of alloy wool - form a sphere of a 1” or 2.5cm diameter, then place the flattened area gently on top of the loose mercury, leave for 20 seconds. The mercury will adhere to the alloy wool.
Place contaminated alloy wool into the waste container, secure lid then return to the spillage kit.
Complete incident form
237
what do we use to soak up an amalgam spillage
from red amalgam kit from dispensary
| equal parts of sulphur and calcium hydroxide OR alloy wool
238
what is the last thing we do after amalgam spillage
incident report form
239
what are some ideal characteristics of amalgam cavity prep
flat floor (axial support) and straight walls (lateral support)
90 dgeree +-10 cavosurface angle
rounded internal angles
slight undercut - not near marginal ridges
240
how long do we usually have for working time of amalgam and how does this change with increased mixing time
7 minutes
| increased mixing time = more working time
241
what tools would we use in amalgam restorations in order with functions
amalgam condenser to place GIC at base
amalgam carrier to pick up amalgam from dampens pot
amalgam condenser to condense amalgam into site
wards carver/half Hollenbeck carver to carve anatomical structures
pear shaped/ball burnisher for removing mercury layer and smoothening the surface
cotton wool (maybe wet) to remove excess amalgam and clean surface
probe to check smoothness and margins
242
what 2 carvers can we use during amalgam placement
wards carver
| half Hollenbeck carver
243
what must we place below amalgam restorations and why
GIC as a liner
| prevent conduction of heat to pulp which would cause damage and inflammation and pain
244
why is the high mercury layer good and bad
good as it allows adherence of different layers of amalgam
| bad as it is weaker and needs to be removed from surface
245
how many degrees should the undercut be for an amalgam restoration
2-5 %
246
how should we provide retention for a class II amalgam restoration
at least 2mm depth
2-5% undercut taper
axial grooves (on step wall) prevent vertical dislodgment
lateral grooves in floor prevent lateral dislodgment
247
what are some retention methods for amalgam fillings
```
dovetail or follow fissure pattern with bur
slight 2-5% taper undercut
axial grooves
lateral grooves
amalgapins - outdated
```
248
when would we leave infected dentine
in a carious tooth where we suspect caries to be very close to pulp
fill with GIC or temperary restoration
in this case this is step-wise caries removal
in 6 months come back and fill properly
Or when doing the hall technique for PMC
249
what matrix band do we use for class II restorations and any proximal restoration
circumferential matrix band
250
do we remove the working or non-working side contact point of a matrix first
non-working
251
what methods are there for retaining large amalgam restorations
amalgapins
amalgam ledges
shelves
slots
252
what is an Amalga pin and how does it help
2mm deep, 0.8mm wide holes in gingival floor with gradual transition into gingival floor
gives good lateral retention
253
what is a amalgam slot, how do we produce and what are the risks
rim of concavity within the gingival floor
use an inverted cone bur to form a small slot
risk of entering pulp as making deeper than cavity
254
what are amalgam grooves
circumferential ledge around the periphery of the supporting enamel
at least 2mm deep so we don't get thin portions of amalgam
255
how deep should shelves, grooves and Amalga pins be
shelves and Amalga pins 2mm
| grooves 0.5mm
256
when adding retentive factors for amalgam restorations, what must we ensure
entering the pulp
creating unsupported enamel
retention for all directions
257
how does amalgam bond work
tooth tissue etched to form porous collagen layer and opening dentinal tubules
composite resin placed on dentine forming hybrid layer for molecular entanglement and entering tubules for interlocking
amalgam condensed on top of unset resin
resin sets quickly when being condensed as lack of oxygen speeds up setting
resin and amalgam interlock through micromechanical interlocking
258
what are some problems with amalgam bond
bonds with stainless steel (matrix band)
requires dry and isolated area (so would just use composite)
bond layer slightly soluble so at margins would slowly dissolve forming microleakage
259
what precautions are needed or amalgapins
curved roots - dont go into periodontium (1/3 do)
large pulp chamber - dont go into pulp chamber
dont leave any thin dentine/amalgam
260
what is a Nayyar core
using amalgam to fill a root as a retentive factor
261
if an amalgapin entered the pulp what would we have to do
endodontic treatment to trim pin from the inside
262
if an Amalga pin went into the periodontium, what would w eod
open a flap to enter periodontium
trim from the outside
seal the periodontium
263
compare a lock and a slot for amalgam retention
slot is a retention groove in the horizonal transverse plane
| lock is a retention groove in the vertical longitudinal plane
264
why might we remove a cusp
if a carious lesion has got very close to the cusp edge, when restored this would fracture
we remove the remaining cusp to provide a stronger restoration
265
what is the name of a amalgam-resin bond
panavia
266
how and when do we place GIC
as a base to replace dentine and act as a thermal insulator, temporary or restoration near the gingiva
place in bulk 1 increment up to ADJ leaving 2mm for definitive restoration
place, condense with amalgamator
use minimal contact as sticky and easy to overwork
set if Fuji 2 or leave for 6 minutes for chemical set
267
where should we enter for a class III restoration
palatally or lingually
| reduce affects on aesthetics
268
how do we ensure good aesthetics for a class III restoration
enter cavity palatally or lingually
use composite or another tooth coloured material
if cavity is buccal/labial, create a 45 degree 2mm bevel to ease transition of material
restore tooth contours and shape
finish to give shiny, smooth appearance and feels
269
what 2 functions does a bevel have
increased aesthetics creating a good margin between material and tooth
increases retention by increasing SA of material
270
what are 3 advantages of plastic Mylar strips
transparent = allows light cure
flexible to adapt contour of restoration
reduces oxygen inhibition layer of polymerisation = reduces need for finishing
Smooth surface
271
what are 3 checks for a mylar strip
sit between restoring side and adjacent tooth
extend above and below restoration margins
have a solidly placed wedge
272
how long do we have to mix and work with setting CaOH
mixing time of 10 seconds, working time of 2 minutes and setting time of 2-3 minutes.
273
when do we surgically remove impacted wisdom teeth
when infected, cellulitis, inflamed periodontal tissue, disease
not just if causing pain - give OHI
274
what are the 4 purposes of wooden wedges
stabilise matrix
create good apical contact and restoration-tooth margin
separate teeth
push rubber dam and papilla apically
275
what are the steps of a class IV restoration (not including materials e.g. etch)
```
mylar strip and wooden wedge placement
bevel on labial surface
palatal wall build up to be a very thin margin, in line with palatal ridge of anterior
proximal wall build up for contact
bulk of restoration build up
finish
occlusal checks
```
276
what are the 3 aims of a carious restoration
Aid plaque control & thereby manage caries activity at this specific location.
Protect the pulp-dentine complex & arrest the lesion by sealing it.
Restore the function, form & aesthetics of the tooth
277
how, why and when do we use a retraction cord
```
if we cannot place rubber dam due to class V caries
A cord that is packed into the gingival sulcus to retract the gingivae
improve visibility, access and moisture control.
```
278
what can we use to access caries near gingival margin
retraction cord
279
what is the main difference between root and enamel carious removal
root does not need high speed
280
when is Fuji 9 used
Affected or sclerotic dentine (we cannot use composite here)
Use suboptimal (yet still reasonable) isolation
Lesion at gingival margin
Substrate to bond to is mainly dentine and of questionable quality
Lower aesthetic concerns
281
when do we place a temporary restoration
Fractured teeth or restorations
Lacking time to restore the tooth definitively
In the management of extensive gross caries: stabilisation technique - step-wise caries removal
Root Canal Treatment
If the treatment session ends suddenly – medical conditions/anxiety/patient has to be somewhere else…
Help control pain
282
how should we replace cusp/fissure patterns and what should we not do (with composite)
build up each cusp individually
fissure pattern comes naturally
do NOT use a needle bur to create fissure pattern = PRF
283
when do we use composite or amalgam for cusp replacement
amalgam posterior = les time consuming, higher strength, higher compressible strength
composite anterior = more time consuming, less aesthetic, adhere to tooth surface increasing integrity of tooth
284
what size do preformed crowns come in
2-7
285
describe what a preformed crown is
a stainless steel bulk manufactured crown cover made without the need for impression
set sizes 2-7 with different bulbosities for each tooth
narrow toward the gingiva
286
when do we use a PFC preformed crown
primary teeth when:
Teeth with large or multi-surface carious lesions; conventional restorations will fall out and due to larger pulps, we need a good seal.
Pulp treated teeth - good coronal seal
Trauma
Enamel and dentine defects
Abutment for crown-loop space maintainer
Infraoccluded teeth to maintain mesial/distal space
```
secondary teeth:
Hypomineralized molars - hanging on for orthodontic treatment
Amelogenesis imperfecta - temporary
Dentinogenesis imperfecta - temporary
Temporary restoration
Severe erosion
```
287
when should we not use a PMC for a child's teeth
```
Unrestorable tooth - XLA
Failed pulp therapy -XLA
Soon to exfoliate - more than ⅔ root resorption - leave alone
Cautions
+Severe wear / severe space loss
+Pre-cooperative - have to be able to sit still to remove risk of dropping tooth into oral cavity
+Poor motivation?
+Multiple grossly carious teeth
```
288
when do we use a preformed crown on secondary teeth
```
Hypomineralized molars - hanging on for orthodontic treatment
Amelogenesis imperfecta - temporary
Dentinogenesis imperfecta - temporary
Temporary restoration
Severe erosion
```
289
what are the advantages of PFC
Straightforward technique
No need for impressions
Quick and cheap
Evidence of excellent longevity, low failure rates, compare well with other materials
Failure, if occurs, is easily corrected
shown to have positive affects on pain releif
290
what are the disadvantages of PFC
Poor aesthetics - silver
May impede eruption of adjacent teeth if too big
May cause gingival inflammation if cement not removed completely
Theoretical nickel allergy risk
anaesthetic needed
291
what us the conventional method for placing a PMC conventionally
1. try to place rubber dam and seat pt up to prevent swallowing of crown
2. Occlusal reduction: Take 1mm off of the occlusal portion of the tooth following the cups and contours
3. Mesial and Distal reduction : remove 1 mm of this section and make sure we make no ledges. The buccal and lingual sides do
not get reduced as the bulbosity creates retention.
4. Start at a size 4 and select the right size crown for the tooth. Roll the crown on from lingual to buccal to get over the major
bulbosity of the tooth. They should sit slightly subgingival. If the size is a bit big we can use the crimpers to squeeze the
buccal/lingual aspects to make a better gingival fit. This may cause gingival blanching but this will resolve over time.
5. We need to use GIC as a clotted cream consistency to adhere the restoration to the tooth tissue. We then need to use floss to
remove excess when squeezed onto the tooth.
292
what can we use to slightly alter the shape of PMC
crimpling pliers
293
what do we use to cement PMC to a tooth
GIC at a clotted cream consistency
294
how do we prepare a tooth for PMC conventional method
occlusal reduction by 1mm along the contours and cusps, evenly taking of 11
mesial and distal reduction by 1mm
do not remove any lingual/palatal/buccal as this acts as retention
295
how do we test which PMC to use
when crown has been reduced to correct size
start at size 4 and pace lingual side to gingiva and roll over in a buccal direction until just sit over bulbosity
should be tight
remove and add cement
295
how do we test which PMC for conventional to use
when crown has been reduced to correct size
start at size 4 and pace lingual side to gingiva and roll over in a buccal direction until just sit over bulbosity
should be tight
296
what must we do after placing a PMC = conventional
use floss ad instruments to remove excess GIC
297
what side affects (2) can occur from PMC conventional placement
gingival blanching will resolve over time
| nickel reaction
298
explain the advantages of Hall technique over conventional technique
```
no aerosols produced - covid
keep more of the tooth
less anxiety created by drilling
more tooth maintained for temporary's in secondary dentition
no anaesthetic needed
```
299
what differences between conventional/hall technique do we have for patient selection
hall cannot use highly carious teeth or risk of endocarditis as we leave caries in tooth
need an opposing tooth
used on asymptomatic teeth not hurting
300
what is an added side effect of using Hall over conventional technique
occlusion will feel raised
301
explain the procedure for placing Hall technique
Orthodontic tooth separation 1 week in advance if needed. Half below and half above the contact points.
Topical anaesthetic if needed however it is used less now as children don’t like their tongue going numb.
Chose crown out of boxes by using middle size and going up or down
Place airway protection
Place the crown to the contact point and assess size.
Fill the crown with the GIC and then push the crown on as far as possible.
Then ask the child to bite down on a band seater or cotton wool roll (more even pressure).
Remove excess cement with wet gauze.
Ask the child to bite down hard whilst it sets to prevent any voids forming.
Explain that it may be uncomfortable as it is sitting under gingiva and high contact point.
302
what differences are there in the procedure for Hall over conventional PMC placement
orthodontic separation 1 week prior for hall
anaesthetic and caries removal not done in hall
no tooth preparation so higher restoration in Hall
303
how do we ensure minimal voids in PMC
ask pt to bite down on orthodontic band seater to compress setting GIC to remove any voids
304
what must we tell a parent and child when explaing a PMC for a primary tooth
show them what it will look like e.g. iron man tooth
brush like any other tooth
it will be on until tooth falls out
occlusion may feel high and strange initially
glue tastes like lemon/salt and vinegar
305
what POI comes with PMC hall technique
brush like any other tooth
will fall off when tooth falls out
occlusion may feel odd initially but will adjust
gingival blanching will go over time
306
what checks must we make before placing a PMC
check pt and parent consent to procedure
radiological evidence of no periapical pathology
radiological evidence of successful RCT
no allergy to nickel
check no risk of endocarditis for Hall technique
307
how can we alter floss to fit in slightly wider areas e.g. post PMC
tie a knot
308
what does a correctly placed orthodontic separator look like and what happens if it is incorrectly placed
one half of the ring under the contact point
one half of the ring above the contact point
PDL may damage and very hard to remove if incorrectly placed
309
how can we reduce pain for placing a PMC via hall technique and why might we not
topical anaesthetic on gingiva
| may numb the tongue and some children don't like this
310
what might a patient complain about
restoration
communication
consent
311
how can we make a complaints process easy
strong positive communication
take on feedback and complaints
have a good complaints system
have a complaints manager role in practice
have a complaints coordinator role in practice
written complaints policy
312
how can we avoid later complaints when walking through a treatment plan
talk very clearly without jargon, ensuring the pt fully understands the process before giving consent
manage expectations properly, don't use word like 'permanent' or 'promise'
313
what acronym is used for how to deal with complaints
```
REACH
R - respond immediately
E - empathy, active listening
A - action - ensure that action will be taken to improve services and explain timecourse
C - compensation - not always money
H - honesty
```
314
if we don't deal with a complaint well, what will happen
the GDC will investigate and get involved
315
how should a complaint be given
written
| written complaints policy is a GDC guideline
316
what should be included on a written complaint
date
date of complaint
everything form the patients aspect + signature
reflection from the dental team + signature
317
what is the escalating system of seriousness for complaints
```
inhouse complaint
NHS/DCS processes
parliamentary + health services ombudsman involvement
GDC investigation
lawsuit
```
318
when does the DCS get involved?
dental complaints services
after an inhouse complaint has been taken to a higher level
only in private practice
319
what is the NHS trust policy 1 on complaints
Acknowledge complaints within 2 working days and call them personally as this often de-escalate the situation
To ensure a thorough and fair investigation of all complaints
To respond to complaints within 25 days of receipt of the original letter. It shouldn't take this long and if it is going to take this long we should call them quickly and let them know about the time scale of the process.
To ensure appropriate action is taken to improve services where necessary
320
what is the NHS trust policy 2 on complaints
To ensure performance is monitored and reported as appropriate
To resolve complaints informally wherever possible
To share good practice and lessons learnt across the NHS
To feedback to senior managers with the trust the main themes so that the action can be taken wherever necessary
321
how fast should we acknowledge and respond to a complaint
acknowledge within 2 days
| respond within 25 days BUT if its going to take this long, call them immediately to tell them timescale
322
if a patient feels as if they are unjustified in the complaints complaint system where can they go and what timescale comes with this
parliamentary and health services ombudsman
| within 1 year of complaint
323
how log after an incident can we wait until complaining
12 months
324
what can we use if the root for an RCT is bendy
Nickle Titanium files are more flexible and reduce chances of breakage
325
when do we recall after an RCT
always 9 months to review and radiograph
326
when can we place an indirect restoration on an RCT
after 9 month review
327
what forceps are used for upper anterior extractions
straight (upper) conical (anterior) forceps
328
what are used for lower anterior extractions
curved conical shaped forceps
329
describe extraction breifly
straight for uppers, curved for lowers
conical for anterior
use forceps to grip onto the root of the tooth
apply apical pressure and rotate
330
when is it safest to provide surgery for a pregnant woman
2nd trimester as 1st (growth) and 3rd (near birth) are the most problematic
331
describe the UNC-15 probe
used for perio assessment
university of north carolina-15
coloured increments every millimetre up to 15
large increments at 4 and 8
332
what is a nabers probe and describe its use
curved probe with increments every 3 mm to check furcation invovlement
333
describe the use and structure of williams probe
blunt ended
used for perio assessment
colored increments at 1,2,3,5,7,8,9,10
334
explain the CPITN-WHO probe
straight blunt ended probe for BPE with small ball on the end
3.5-5.5 band, 8.5-11.5 band
335
what are the three probes used for perio assessment and compare
williams probe - increments at 1,2,3,5,7,8,9,10mm
UNC-15 probe - 1-15mm increments coloured
CPITN WHO probe - 0.5mm ball on end, increments at 3.5mm-5.5mm and 8.5mm to 11.5mm
all blunt ended
336
how big is the ball at the end of a CPITN WHO probe
0.5mm
337
why are based placed
reduce post op sensitivity
no polymerisation so less leakage
thermal insulation
GIc releases flouride
338
why may a patient need 'steroid cover'
pt on steroids alters production of cortisol
become dependent on steroids for hormones
going into stressful situation they will produce more cortisol
need higher dose of steroids to combat this with hormone regulation
339
how do we treat dentine sensitivity
```
depress nervous response with drugs
close dentinal tubules :
-liners over dentine
-composite bond on tooth
-small composite restorations
-high flouride varnish
```
340
how do we reduce pain when giving a dental injection
```
pull tissues taut
ensure room temp
use topical fluoride
inject slowly - especially in palatal
slowly remove needle
distract senses by probing surrounding tissues
don't penetrate nerve
```
