Restorative - Midterm Learning Objectives

Question 1

1.1 Define restorative dentistry.

Answer 1

Restorative dentistry includes all of the operative procedures involved in the restoration of defects in the enamel and/or dentin, in both primary and permanent dentition. The goal of restorative dentistry is to best restore the patient’s bite (occlusion) into a natural function for healthy mastication. Replacing natural tooth structure with restorative materials is done in the following circumstances:

Initial or recurring decay (cavity)
Replacing a failed restoration
Abrasion or wearing away of tooth structure
Erosion or wearing of tooth structure
Esthetics - restoring the tooth to its original function or esthetic appearance.
Discoloration - either intrinsic or extrinsic (inside or outside the tooth)
Anomalies caused by development disturbances
Abnormal spacing between teeth
Trauma

Question 2

1.2 Identify the methods of classifying cavities using Black’s classification.

Answer 2

Cavity classifications designed by Dr. Black are made based on the anatomic surfaces of teeth. Six Cavity Classifications:
Class I - Pit and fissure surface of teeth. Occlusal of Buccal pits on premolars or molars. Lingual pit on incisors.
Class II - Include at least one interproximal surface of a bicuspid or molar.
Class III - Interproximal surfaces of anterior teeth that do not involve the incisal edge.
Class IV - Interproximal surfaces of anterior teeth that require restoration of the incisal edge.
Class V - Smooth surface of the cervical one-third lingual or facially on any tooth.
Class VI - Incisal edges or cusp tips of teeth; usually caused by abrasion, wear, or anatomical defects.

Decay is also classified by nomenclature based on the names of the tooth surfaces that are affected with decay. Nomenclature examples are:
MO - Mesial occlusal or mesio-occlusal
DO - Distal occlusal or disto-occlusal
L - Lingual
V - Vestibular
F - Facial
I - Incisal

Question 3

1.3 Discuss procedures used to diagnose decay.

Answer 3

The following procedures may be performed by a Registered Dental Assistant (RDA) in order to assist the dentist in a diagnosis of decay. * Diagnosing decay is not in the Dental Assistants scope of practice.

Exam - use the mirror and explorer to detect decay on accessible tooth surfaces and existing restorations

Xrays

Indicator dyes

Caries Detection devices - These devices function through different ways such as through detecting bacterial by-products, measuring differences in tooth structure and lasers which can reveal bacterial activity under the enamel surface

Question 4

1.4 Describe the dental assistant’s role in understanding dental materials.

Answer 4

The dental assistant must be able to:

1. Describe the Behaviour of Materials - materials all have specific behaviours once placed into the oral cavity which can affect success of a restoration. The material should present no harm to the patient, be easy to use, be able to withstand the patient’s oral conditions
2. Handle Materials Safely - Understanding the physical, chemical, and mechanical properties of materials are very important, as it influences their handling. Proper handling of materials is a major factor in its success or failure. If materials are properly stored, mixed, and placed, improved patient care will result.
3. Assess & Prepare Materials Prior to Treating Patient - The assistant must be aware of the manufacturer’s instructions and guidelines for the use of all materials used in the practice.
4. Educate the Patient - Dental assistants are responsible for educating patients regarding treatment options, including comparing one dental material to another. Knowledge of dental materials is critical to ensure that the patient is provided with complete, and accurate answers to assist in treatment choices.

Question 5

2.1 Define topical anesthesia.

Answer 5

Topical anesthesia has a temporary effect on the sensory nerve endings of the surface of the oral mucosa.

Topical Anesthetic can be used to:

-Numb tissue prior to injecting a local anesthetic
-Provide temporary relief from the pain of ulcers, wounds, or denture sores
-Prevent a patients gag reflex from occurring when taking X-rays or a Dental Impression

Active ingredients are Benzocaine or Lidocaine

Question 6

2.2 Identify the dental assistant’s role when applying topical anesthetic.

Answer 6

The dental assistant checks with the dentist for instructions on the type of anesthetic and needle for the procedure. The dental assistant is then responsible for setting up all required materials and supplies for the procedure, reviewing the patient medical history, explaining the procedure to the patient and then applying topical in the area where treatment is to be performed. The dental assistant is then responsible for monitoring the patient for any concerns or adverse reactions while the topical anesthetic is placed.

Question 7

2.3 Discuss indications and contraindications for the use of topical anesthetic.

Answer 7

Indications:
-In preparation of a local anesthetic injection
-Prevent gagging in procedures such as radiography or impressions
-Temporary pain relief from oral ulcers, wounds or inflammation

Contraindications:
-Allergy to ingredients (i.e. red food dye in flavored topical anesthetic
-Heart conditions or High Blood Pressure (if a vasoconstrictor is on ingredient list)

Question 8

2.4 Use materials and instrumentation when applying topical anesthetic.

Answer 8

Types of Formulations *Always follow manufacturers instructions for correct use and timing

-Liquid Viscous (thick) - The patient swishes a small amount of the liquid around in his/her mouth and the excess is removed with the high volume evacuation tip.

-Gel topical - Gel is pre-dispensed on a cotton-tipped applicator and placed onto the tissue at the site of injection

-Spray topical - Delivers a continuous spray stream of anesthetic. There is a risk of placing a high dose of the agent, so it is typically not recommended for use.

-Patch - placed at the site of injection or can be used for denture sores or ulcers

Question 9

2.5 Provide pre-operative, operative, and post-operative information/instructions for the application of topical anesthetic agents.

Answer 9

Pre & Post-Operative Instructions should include:

Where the topical anesthetic will be placed in the mouth
Inform the patient that topical anesthetic provides a temporary numbing effect in the area it is placed
How long the numbing effect will last (15 min)
How long the patient will expect to have the topical placed on their tissue (30 sec - 2 min)
Let the patient know that although topical anesthetic is safe to swallow, it is recommended that they try not to

Question 10

3.1 Define local anesthetic.

Answer 10

Local anesthetic can be defined as a localized anesthetic that reduces the patient’s pain and provides comfort during dental care.

Characteristics of a LA:

Non-irritating
Minimal toxicity to body systems
Takes effect quickly
Provides profound anesthesia
Remains effective throughout the procedure
Reversible (short term duration time)
LA can be sterilized without deterioration
Method of Action:

A liquid anesthetic that is injected close to the nerve and diffuses (spreads) around the nerve and prevents the nerve from releasing its normal pain response. The dentist must inject a sufficient amount of anesthetic to ensure that the nerve fibers are completely permeated. The flow of the bloodstream will create a slow reverse the anesthetic response and the patient with eventually lose the numbed feeling in the area of the mouth that was anesthetized.

Question 11

3.1 Define local anesthetic - CHEMICAL COMPOSITION

Answer 11

Two chemical groupings:
Esters are typically used for topical anesthetics and metabolized by a patient’s plasma.
Amides are used for local anesthetic and are metabolized by the patient’s liver.

Vasoconstrictors: Small quantities of vasoconstrictors can be added to an anesthetic to slow the uptake into the bloodstream to extend the duration time.

Types of vasoconstrictors
Epinephrine
Levonordefrine
Neo-Cobefrin

Ratio examples follow. (descending from the strongest to the weakest dose)
1: 20 000
1: 50 000
1:100 000
1:200 000

Contraindications of Vasoconstrictors

Heart Conditions such as, (Angina, Bi-Pass Surgery, Prior heart attack)

Question 12

3.1 Define local anesthetic - TIME SPAN

Answer 12

Induction Time: the time it takes for the anesthetic to take effect after the injection

Duration Time: the time it takes for the anesthetic to reverse back to the patient feeling no numbness
It depends on the type of anesthetic used.
Short acting: 30 minutes
Intermediate acting: 60 minutes (most commonly used in restorative dentistry)
Long acting: 90 minutes

Question 13

3.2 Identify procedures in which local anesthetic is used.

Answer 13

Local anesthesia is used for dental procedures that have the potential to cause discomfort or pain.

It blocks sensations from teeth, soft tissue, and bone in the area of anesthetization and is used for many dental procedures.

Examples include:
Root planning and scaling
Restorative procedures (restoring teeth into function or esthetics)
Surgical procedures (extractions)
Prosthodontic procedures (crown and bridge)
Endodontic procedures (root canals)
Periodontal procedures (gingival surgery)

Question 14

3.3 Assess the local anesthetic carpule and contents.

Answer 14

The anesthetic carpule is typically clear glass or plastic and contains the anesthetic solution.

Each carpule typically contains 1.8 ml of anesthetic solution and is labeled with the following information:

1. The type of anesthetic solution (generic and common name)
2. Percentage of concentration of anesthetic in the solution.
3. Type of concentration of vasoconstrictor present
4. Expiration date

The following carpule components must be checked and assessed prior to the injection in order to ensure patient safety.
1. The silicon rubber stopper must be flush with the glass.
- If it is pushed out it may indicate that the solution may have been frozen
- If it is pushed in, it may have already been used.
2. The carpule must not be chipped, cracked or damaged
-The glass may shatter during the injection and may have been contaminated (IPC breach)
3. The solution must not be cloudy or discoloured.
- may indicate expired, contaminated and no longer effective

Question 15

3.4 Demonstrate the assembly of the local anesthetic syringe.

Answer 15

Assemble Local Anesthetic Syringe
* The needle length is chosen based on the location of the injection.
* The dentist determines the type of anesthetic to use (based on patient’s medical/dental history).
* Load carpule: Note: Always assemble out of patient view.
* Load the stopper end first (avoid contaminating the diaphragm). *
* Break the seal and connect needle to syringe. *
Place loaded syringe on the counter top to the right of the plastic instrument tray.

Safe Disposal
* Carefully remove needle from syringe. *
* Discard needle into the ‘Sharps’ container. *
* Discard the anesthetic carpule into the ‘Sharps’ container.
This is done prior to leaving the dental treatment area.

Question 16

3.5 Assist with the placement of local anesthetic.

Answer 16

Safety First:

When a dental assistant reviews the patient’s medical history, it is important to ask the patient if they have ever had local anesthetic prior to the procedure. If they have had anesthetic, ask them if they have had any negative reactions. If so, ask them to describe the reaction? Notify the dentist to ensure that they further investigate prior to injecting the LA.
Follow safe procedures when handing LA instrumentation and materials to prevent injuries and to maintain infection control. (use needle guards)
Once the anesthetic has been injected, it important for the Dental Assistant to stay with the patient in case a negative reaction or medical emergency occurs.
Document topical and LA used in the patient chart.
Depending on the injection site, patients must be cautioned not to bite their lip, tongue, or chew on their cheek (pending injection site). *Hot liquids and foods must also be avoided to prevent burns.

Communication: Instructor Tip

A Dental Assistant can describe the numbness to the patient by stating the following.

You will feel of warm tingling sensation in the (lip, tongue, nose, cheeks - depending o region of anesthetic).
The tingling sensation will gradually change to numbness. Although your tissue continues to look normal, it may feel large and swollen. It will slowly wear off after treatment.
Note: The duration time of the anesthetic will depend on the following variables:
The dose of a vasoconstrictor (if used)
Patient heart rate will increase blood flow (based on exercise, caffeine or level of anxiety)

Question 17

3.5 Provide pre-operative, operative, and post-operative information/instructions for administration of local - POST OP

Answer 17

Post-Operative Instructions for Local Anesthetic:
* Foods and beverages to avoid (hot)
* Chew on other side of mouth (if necessary)
* Avoid biting/chewing/poking their cheek, tongue and/or lip (depends on the nerves anesthetized)
* Length of time local anesthetic will last? up to approx. 90 minutes (type of injection, type of anesthetic, amount of
anesthetic and location of anesthetic will determine the duration of the anesthetic: could last 2-4 hours or sometimes
longer).

Question 18

3.5 Provide pre-operative, operative, and post-operative information/instructions for administration of local - PRE OP

Answer 18

Pre-Operative Instructions for Topical/Local Anesthetic:
How do we communicate with our patient before topical and local application?
* Review medical history (allergies, medications, health concerns etc.)
* How long topical anesthetic lasts (up to 15 mins)
* What to expect during local anesthetic placement
* How long the local anesthetic can last: up to approx. 90 minutes (type of injection, type of anesthetic, amount of
anesthetic and location of anesthetic will determine the duration of the anesthetic: could last 2-4 hours or sometimes
longer).
* Explain where the patient should expect to feel numb (depending on the area being worked on)

Question 19

4.1 Discuss the pharmacological indications and effects of intravenous and inhalation anesthetics used for conscious sedation in dentistry.

Answer 19

Intravenous (IV) Sedation: Anti-anxiety drugs IV are administered throughout the procedure at a slower pace, providing a deeper stage I analgesia. Conscious IV sedation is frequently used by an oral surgeon during such procedures as the extraction of third molars, especially in difficult cases, such as when teeth are impacted and surgical removal of bone is necessary. Local anesthesia is administered once the patient’s condition is stable with IV conscious sedation. This also helps ease postoperative pain until oral analgesics can be taken.

Inhalation Sedation - also referred to as nitrous oxide/oxygen analgesia. The patient inhales these gases (N2O) through a nosepiece, feeling the effect almost immediately. Gas enters the bloodstream through the lungs & travels to the brain - causing a feeling of calmness & relaxation.

Question 20

4.1 Discuss the pharmacological indications and effects of intravenous and inhalation anesthetics used for conscious sedation in dentistry - FOUR STAGES OF ANESTHESIA

Answer 20

Stage 1 - Analgesia:
- patient is relaxed & fully conscious
- able to keep mouth open without assistance & can follow directions
-has a sense of euphoria / reduction in pain
- vital signs are normal
- can move into different levels of anesthesia

Stage 2 - Excitement:
- patient is less aware of immediate surroundings
- starting to become unconscious
-may become excited & unmanageable
-nausea/vomiting may occur
-UNDESIRABLE stage

Stage 3 - General anesthesia:
- Although the patient is thought to feel no pain, local anesthesia is usually given to control bleeding throughout the procedure & at or near the end to help with postoperative pain control.
-throat pack is placed
-this stage begins when patient becomes calm after stage 2
-no sensation or feeling of pain
- will become unconscious
- can only be done under guidance of an anesthesiologist under controlled setting (hospital)

Stage 4 - Respiratory failure/cardiac arrest
- lungs and heart will slow down or stop functioning
-if staged not reversed quickly, patient will die
-patient must be well informed because of this risk

Question 21

4.2 Describe the pharmacological indications and effects of CONSCIOUS sedation used in dentistry.

Answer 21

Conscious Sedation
Most patients will not remember the actual dental procedure, even though they are conscious.
The patient can still speak and respond to the requests of others.
All body functions remain healthy, and the person can breathe on their own.
There is a state of profound relaxation.
A local anesthetic is typically still used

There are three forms of conscious sedation:
-Inhalation Sedation: In dentistry, nitrous oxide/oxygen is the most common inhalation sedation method.
-Oral Sedation: Medication is administered in a pill or liquid form. These agents are considered to have both sedative and anti-anxiety effects.
-Intravenous (IV) Sedation can be performed in a dental office or a surgical suite. The process of starting, monitoring, and removing IV sedation can only be administered by an individual who is trained and certified in this area. (Dentist or nurse)

Question 22

4.2 Describe the pharmacological indications and effects of UNCONSCIOUS sedation used in dentistry

Answer 22

General Anesthesia: A controlled state of unconsciousness with a loss of protective reflexes—including the ability to maintain an airway independently and to respond appropriately to physical stimulation or verbal command—that produces stage III general anesthesia.
General anesthesia is indicated for severely medically compromised or mentally disabled individuals who cannot be adequately treated in a regular dental setting. Because of the loss of protective reflexes with general anesthesia, the patient is intubated, usually through the nose (to keep the oral cavity clear), for delivery of oxygen and anesthetic gases; other medications are administered simultaneously by way of an IV line.

Pharmacologic makeup:
Combination of gases
N2O/O2
Halothane or enflurane mixture
IV agents such as thiopental sodium and methohexital sodium

Question 23

4.3 Discuss indications and contraindications for the use of dental sedation.

Answer 23

Inhalation Sedation:
Advantages
-administration is simple/easily managed by dentist
-Anesthetic is not required
-very safe/minimal adverse effects
-relaxing/pleasant experience for patient
-patient is awake/communicative
-recovery is rapid
- can be used on all ages
Contraindications
- may experience nausea/vertigo
- patients with behavioral challenges may react adversely

Anti-Anxiety Agents:
Advantages
-administered orally, IV or inhalation
-help calm a nervous patient
-good for young children or mentally challenged needing extensive treatment
Contraindications
-dentist must have specific credentials
-drugs can induce drowsiness
-can not drive themselves to/from appointment

IV
Advantages
-minimal depressed level of consciousness
-can maintain an open airway
-can respond to verbal/physical stimuli
-deeper stage 1 analgesia
Contraindications
- must be done by somebody trained/certified to do so
-too much sedation an cause respiratory depression

General Anesthesia
Advantages
- controlled state of unconsciousness
-stage 3 analgesia
Contraindications
-loss of protective reflexes
-unable to maintain airway by themself
-cannot respond to physical/verbal stimuli
-must not eat/drink 8-12 hours prior to procedure
-cannot drive after
-small risk of death
- patient may be sensitive to medications used causing nausea and/or vomiting.

Question 24

4.4 Provide written and/or verbal pre-operative, operative, post-operative, and home care information/instructions for dental sedation and general anesthesia

Answer 24

SEDATION PRE-OPERATIVE INSTRUCTIONS:
If you have any questions about these instructions prior to surgery, please reach out to the office.
Physical examination maybe required prior to general anesthesia.
Lab work may be requested at the doctor’s request prior to your appointment
Discuss any medications you are currently taking with the DDS prior to your appointment
DO NOT eat or drink for 2-8 hours before your appointment (depending on the type of sedation being completed)
Take any pre-operative medications prescribed to you as directed with a small sip of water
You will need a responsible adult to drive you to and from your appointment

SEDATION POST-OPERATIVE INSTRUCTIONS (excluding nitrous oxide inhalation sedation)
Written and verbal post-operative instructions are provided to the patient and a responsible adult.
Patients who have been administered oral and IV sedative drugs are still subject to the drug effects including drowsiness.
You will be discharged to the care of a responsible adult.
The patient is NOT to operate hazardous equipment or drive a motor vehicle or for the next twenty-four (24) hours
A 24-hour contact number is provided and the patient is to call if there are any concerns.
Explain to the patient and responsible adult the procedure for accessing emergency care if required.
Notify the office of an unexpected admission to the hospital that has occurred within 10 days of treatment.
Follow all post-operative instructions regarding the treatment you had completed today.

Question 25

5.1 Define dental isolation.

Answer 25

For the best results in a dental procedure, a tooth, quadrant or maybe an entire arch must be kept dry and isolated from its environment. To protect the too/teeth from moisture, debris and maintain a dry environment for the placement of dental materials the following characteristics should be met when choosing an isolation technique:

• Easy to apply
• Protects hard and soft surfaces
• Comfortable for the patient
• Retraction that provides better visualization for the operator
• Prevents moisture contamination
• Isolation of the area of concern

Question 26

5.2 Discuss types of isolation used in restorative dentistry.

Answer 26

The three most common isolation techniques used in dentistry are:

Cotton-roll - rolls of tightly formed absorbent cotton that are pre-shaped to be positioned close to the salivary ducts. The cotton rolls are positioned to absorb the saliva flow and excess water.

Dry-angle - triangular cotton pads that placed along the buccal mucosa as an alternate isolation technique to block the parotid duct (Stensen’s duct) when working the posterior teeth in both the maxillary and mandibular arches. The dry angle blocks the flow of saliva and protects the tissues in this area from injury caused by the dental bur or other instruments used during the procedure.

Dental dam - a thin stretchable rubber-like material like material that acts as a barrier applied to selected teeth. that acts as a barrier when the dam is properly placed, the isolated teeth are the only teeth exposed or visible in the operative field. This allows a clearer field of vision for the operator to the restorative site

Question 27

5.3 Explain the function of a dental dam.

Answer 27

Indications for dental dam:
Serves as an essential infection control barrier in the preparation of teeth
Safeguards the patient’s mouth against constant debris, dental materials, or other liquids
Protects accidental aspirating or swallowing debris
Protects the tooth from contamination by saliva or debris if pulpal exposure occurs
Protects the oral cavity from exposure when an infected tooth is open during endodontic treatment
Provides moisture control that is essential for placement of restorative materials
Improves access by retracting the lips, tongue, and gingiva
Provides better visibility because of the contrasting colors of the dam and tooth
Increases dental team efficiency by discouraging patient conversation, reducing the time required

Contraindications:
Physical conditions may cause discomfort for the patient, such as asthma, nasal congestion, or lesions around the area of placement.
Patient concerns such as claustrophobia.
Conditions in the mouth such as mobile teeth, partially erupted teeth, or severe misalignment of teeth.

Question 28

5.4 Identify the materials ad instruments used in the placement and removal of a dental dam.

Answer 28

Instruments for Dental Dam:

1. Dental Dam - thin rubber like material. available in different sizes/materials/scents/thickness, etc.
2. Dental Dam Clamp - means of anchoring a dental dam. The clamps are made of chrome- or nickel-plated steel and can be sterilized and reused. Dental dam clamps are available in many sizes and designs to accommodate different needs. The jaws are designed to fit the cervical area, or collar, of the tooth. Parts of the clamp include; Bow, Jaws, Points & Forceps Holes
3. Dental Dam Forceps - for placement of the clamp
4. Dental Dam Punch - a precision instrument with a rotating disc, containing holes of various sizes and an opposing sharp stylus to cut cleanly through the dental dam.
5. Dental Dam Napkin - fit over patient face to prevent irritation from the dam/absorb moisture
6. Dental Dam Frame - to stabilize the rubber in position on the patient’s face (can be metal or plastic)
7. Tucking Instrument - A blunt-ended instrument used to invert or turn the edge of the rubber dam around the cervical margin of the tooth to prevent leakage and maintain a dry working field.
8. Ligatures on Camps - dental floss attached to clamps for safety incase clamp becomes dislodged
9. Lubricant - A water-soluble lubricant used on the patient’s lips and on the underside of the dam to make it easier to slip over the teeth (if tight contacts exist)
10. Cotton tipped applicator - for lube
11. Scissors - for removal
12. Basic 3 instruments - mirror, explorer, cotton forceps

Question 29

5.5 Identify the proper dental clamps needed when placing a dental dam.

Answer 29

W = WINGLESS

MOLARS
12A Clamp - Mandibular right molars/ Maxillary left molars (quads 2 or 4)
13A Clamp - Mandibular left molars/ Maxillary right molars (quads 1 or 3)

W14A/14A - Maxillary or mandibular molar, which is only partially erupted.

7/W7 - Normally erupted mandibular molar.

W3 - Small mandibular molar.

W8 - Normally erupted maxillary molar.

PREMOLARS
-W2A or 2A clamp - Maxillary or mandibular small bicuspids - The jaws of the #2A clamp extend downward to firmly grip the bicuspid beneath the gingiva

-W2 or 2 - Maxillary or mandibular large bicuspids. The small, flat jaws of the #2 clamp render it adaptable for anchoring the rubber dam to a bicuspid

Question 30

5.7 Identify the infection prevention and control standards to be followed in isolation procedures.

Answer 30

Spaulding Classification and Managing Contaminated Surfaces, Patient Care Items-Modified Spaulding Classification

Critical: Penetrates soft tissue or bone
Management - pose a high risk of infection, items that are not single use disposable must be sterilized and stored wrapped until used, single use items must not be reprocessed
Item - Dental dam clamps

Semi-Critical: Touches intact mucous membrane or non-intact skin
Management - pose a moderate risk of infection, reusable items must be sterilized, may be stored unwrapped in a clean, dry, covered area, and handled with clean hands or forceps.
single use items must not be reprocessed. Heat sensitive items must receive high-level disinfection between patient use.
Items - single use cotton rolls, dental dam frame, dental dam clamp forceps, dental dam

Non-Critical: Contacts intact skin only
Management - These items pose a low risk of infection. Items must be disinfected between uses.
Items - Dental Dam Punch