Professional Documents
Culture Documents
From a personal experience, do not write too much in the short answers exam; write just heading
or points of the procedures or description
March 2000
1. From the medical history you find the patient is on Tricyclic Anti-depression
medication.
How would you manage this patient?
Complete building the medical and the dental history to reach a proper
diagnosis and find the aetiology of the chief complaint so I can start
assessing the case by evaluating the available information; the overall
case assessment is an essential step that allows the considerations of
treatment options and a provisional treatment plan to be formulated.
Consult the patients GP for any precautions should be taking or any
modification to the treatment should be followed.
Resolution of any acute problems and stabilisation or elimination of
active disease.
If it is not possible to get in contact with the GP refer to the MIMs to
get more information about the drug to find out what I can or I can not
prescribe
Assessing and managing accordingly any emergencies situations that
exist, acute pain, bleeding swellingetc
Eliminating any acute problems or active diseases I will assess the
periodontal tissues and elimination of any active diseases, regeneration
of the periodontal attachment loos and stabilisation of gingival
contours would be my next step in managing the patient.
Reassessment of the periodontal situation by assessing the patient
occlusal stability and plan for any restorative or prosthetic
management.
Finally and it is an important part is the patient consultation to present
and discuss the treatment plan and give the alternative options,
obtaining a patient consent/s, arrange for appointments and financial
considerations
Reconfirm the definitive treatment plan and make sure the patients
expectations are what the result would be.
Tricyclic has a side affects on the oral cavity by causing dry mouth;
and systemically it causes blurred vision, constipation, and difficulty in
urination; postural hypotension; tachycardia, increased sensitivity to
the sun; weight gain; sedation (sleepiness); increased sweating. Some
of these side effects will disappear with the passage of time or with a
decrease in the dosage.
Bear in mind all this information should be recorded appropriately for
future follow up and to adhere to the Australian Dental Board policies.
2. A 23 year-old female comes to you with Gingival abscess in the right upper
central incisor region which she had a blow to 10 days ago; since then the tooth
is a bit loose, now she is complaining of pain and tenderness started two days
ago.
What is your management?
remaining bone, all these should be weighed against the benefits that
would accrue to the adjacent teeth if the tooth under consideration
were extracted.
Plaque control: bacterial plaque is the primary etiological factor
associated with periodontal disease. Therefore effective removal of
plaque on daily basis by patient is critical to the success of the
periodontal therapy and to the prognosis.
Patient complaisance/ cooperation: the prognosis for patients with
gingival and periodontal disease is critically dependant on the patients
attitude and desire to retain natural teeth, and willingness and ability to
maintain good oral hygiene. Without these, treatment can not succeed.
March 1999
1. List the factors that determine the prognosis of an avulsed, traumatised
upper central incisor.
The single most important factor determining the prognosis of a
replanted tooth is viability of the periodontal membrane left on the root
prior to replantation.
If the root surface is left dry, approximately 50% of the periodontal
ligament cells are dead after 30 minutes; after 60 minutes, almost no
cells are viable. Replantation of such tooth results in extensive
pulpally-derived inflammatory resorption, or ankylosis. The critical
time of dry storage seems to be between 18 and 30 minutes
A storage media must be of correct osmolality and PH. Saliva allows
storage for 2 hours. Normal saline solution allows the same time, while
milk on the other hand allows up to 6 hours.
2. Discuss the choices for an MOD direct restoration for a lower molar.
Amalgam- Sandwich Technique- Composite- Pins3. An insulin dependent 45 year old male needs a full clearance and full upper
and lower dentures. Discuss how you would manage this case.
Medical considerations.
Take a thorough medical history for all patients diagnosed with diabetes.
Ascertain the identity of the physician treating the patient and the date of the last visit.
Obtain information concerning the type of diabetes, the severity and control of the
diabetes, and the presence of cardiovascular or neurologic complications.
Refer any patient with the cardinal symptoms of diabetes or findings that suggest
diabetes (headache, dry mouth, irritability, repeated skin infection, blurred vision,
paresthesias, progressive periodontal disease, multiple periodontal abscesses) to a
physician for diagnosis and treatment.
Diabetic patients who are receiving good medical management without serious
complications such as renal disease, hypertension, or coronary atherosclerotic heart
disease, can receive any indicated dental treatment.
Those with serious medical complications may require an altered plan of dental
treatment. When the severity and degree of control of diabetes are not known,
treatment should be limited to palliation.
Food intake and appointment scheduling. To preventing insulin shock from occurring:
Verify that the patient has taken medication as usual.
Verify that the patient has had adequate intake of food.
Schedule appointments in the morning, since this is a time of high glucose and lowinsulin activity. Afternoon appointments are a time of low-glucose and high-insulin
activity which may predispose the patient to a hypoglycemic reaction.
Instruct patients to tell the dentist if at any time during the appointment they feel
symptoms of an insulin reaction occurring. A source of sugar, such as orange juice,
must be available in the dental office should the symptoms of an insulin reaction
occur.
Oral surgery concerns.
It is important that the total caloric content and the protein/carbohydrate/fat ratio of
the patient's diet remain the same so control of the disease and proper blood glucose
balance are maintained.
IDDM diabetics who are going to receive periodontal or oral surgery procedures may
be placed on prophylactic antibiotic therapy during the postoperative period to avoid
infection.
Consultation with a patient's physician before conducting extensive periodontal or
oral surgery is advisable. The physician may, in fact, recommend that the patient be
treated in a hospital environment where infection, bleeding, and dysglycemia can be
better managed.
Dangers of acute oral infection. Any diabetic patient with acute dental or oral
infection presents a problem in management. This problem is even more difficult for
patients who take high insulin dosage and those who have IDDM. The infection will
often cause loss of control of the diabetic condition, and as a result the infection is not
handled by the body's defenses as well as it would be in a nondiabetic patient. The
patient's physician should become a partner in treatment during this period.
Oral complications. The oral complications of uncontrolled diabetes mellitus may
include:
Xerostomia,
Infection,
Poor healing,
Increased incidence and severity of periodontal disease, and
Burning mouth syndrome.
Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, or
pain in the oral region.
September 1999
The compulsory question: what factors will you discuss with a patient for whom
an impacted lower third molar is to be removed under local anaesthic before the
surgery?
I will explain for the patient first about in a basic word about the difference
between Partial Bony impaction and complete bony impaction and the
complications of both of them.
1. Complete Bony Impaction when the wisdom teeth are completely covered in
bone. When the tooth is completely covered with bone it will remain completely
covered with its "developmental sack" in which all teeth develop. Later in life,
this sack may undergo changes and enlarge and develop into a cyst. This cyst will
enlarge at the expense of the bone of the jaw. These cysts should be removed and
examined by a pathologist.
2. Partial Bony Impaction when the teeth begin to erupt but are not able to erupt
completely. In this situation, the upper third molars usually are positioned towards
the cheek while the lower third molars usually lean forward with only part of the
crown sticking through the gum. This situation can to decay and gum disease
around the second molar directly in front of it.
The most common complication of the partial bony impaction is that the flap of
gum tissue which partially covers the erupting third molar creates a pocket where
bacteria that are present in the mouth can grow and cause an infection known as
pericoronitis. The swelling and infection can become very serious. The treatment
for pericoronitis is extraction of the third molar tooth.
Then I will discuss the risks and complications involved in the removal of third
molars which are:
PAIN
Surgical removal of the third molars can lead to some discomfort and pain. This is
usually treated with pain medication.
INFECTION
Because of the large number of bacteria present in the mouth post surgical
infection is always possible. Patients are usually placed on prophylactic antibiotics
to prevent infections from developing.
SWELLING
Following surgery patients may experience swelling and bruising. These
symptoms vary between patients.
BLEEDING
Some post surgical bleeding is considered normal. This is usually minimal and is
easily controlled with the pressure of biting on gauze.
Inform the patient that third molars can be removed with local anaesthesia alone
but many people prefer I.V. sedation during surgery.
Finally there are some risks/complications that are unique to the removal of third
molars.
The upper third molars have roots which often are separated from the maxillary
sinuses by only a very thin layer of bone. Occasionally, a small communication is
established between the sinus and the oral cavity when one of the upper third
molars is removed. If this is the case, the normal procedure is for the area to be
sutured closed, the patient to be informed of the finding, appropriate antibiotics
Unknown Date:
1. Patient in dental surgery got unconscious, breathless and decrease of pulse
rate; how would you manage this condition and what is your diagnosis?
The unconsciousness is caused by Cerebral Hypoxia, my diagnosis is Syncope and/ or
Physical Shock.
The management,
Lower head slightly and elevate legs and arms / for pregnant women,
roll on left side/
Administer Oxygen at 10L flow/minute
Administer spirits of ammonia
Apply cold compresses to forehead
Keep monitoring and recording vital signs
To manage the slow pulse,
Administer 0.4 mg atropine IV to increase heart rate
Repeat up to 1.2 mg, then consider use of additional vasopressors /epinephrine
0.3-0.5 mg SC or IM, IV with ACLS training/
If there is no pulse start CPR and treat as Cardiac arrest accordingly.
2. 8 years old patient shows with small occlusal carious lesions on 46, what is
your management?
3. 20 years old patient comes with a fracture in the middle third of the root of 21,
what sort of management you would suggest?
4. 46 years old attends your clinic complaining of pain in TMJ area with clicking
during the opening of his mouth; how would you manage this case?
5. 30 years patient attends your clinic seeking a bleaching to his teeth after he has
read about a new way of getting white teeth in a magazine; what would you
do?
Emergency Treatments
Unconsciousness
1. Lower the head slightly and elevate legs and arms ( for pregnant women, roll
on left side)
2. Administer O2 at 10L. Flow/min
3. Administer spirits of ammonia
4. Apply cold compresses to forehead
5. Monitor and record vital signs
6. Reassure patient
- in case of low blood pressure,
a. Lower head and raise arms and legs
b. Start 5% dextrose and lactated Ringers IV
c. Administer vasopressor drug (epinephrine 0.3-0.5 mg SC or IM, IV with
ACLS training
- Slow Pulse less than 60 beats per minute:
a. Administer 0.4 mg atropine IV to increase the heart rate
b. Repeat up to 1.2 mg, then consider use of additional vasopressors
Cardiac Arrest
1. Airway- lift chin, clear airway if necessary, and observe for breathing
2. Breathing- inflate lungs with mouth to mouth resuscitation, give 2 initial quick
breaths, and perform endotracheal intubation and positive pressure Oxygen
3. Circulation- check carotid pulse; if pulse is absent, compress sternum 2 t o3
finger widths above xiphoid process.
a. One operator: 15 compressions, 2 inflations-rate of 80 compressions/min
b. Two operators:15 compressions, 2 inflations-rate of 80compressions/min
-continue resuscitation until spontaneous pulse return
4. Drugs IV- start 5% dextrose lactated ringers with ( ACLS training)
a. Epinephrine 0.5-1.0 ml 1:1000, repeat every 5 minutes prn
b. Sodium bicarbonate 1m Eq/kg initially and initial dose every 10 minutes until
circulation is restored (or as governed by arterial blood gas measurement)
c. Atropine sulfate indicated if pulse is less than 60/min and systolic blood
pressure below 90- initial dose of 0.5mg, repeat every 5 minutes but not to exceed
2.0 mg total dose
5. Other drugs used cardiac arrest (with ACLS training)
a. Lidocaine (anti-arrhymic agent)
b. Calcium chloride (increase in myocardial contractility)
c. Morphine sulphate (for pain relief)
Monitor and record vital signs, drug administrations, and patient response.
Ambulance, emergency room, and medical assistance should be called.
Diabetic coma
1.
Place patient in supine position
2.
Administer Oxygen
3.
If patient is conscious, give patient a high sugar-containing
drink as Glucola or orange juice
4.
If patient is unconscious, a glucose paste can be applied to
the buccal mucosa. A dentist with ACLS training can start an IV 5% dextrose and
run IV as fast as possible
5.
Monitor and record vital signs
6.
Activate EMS system by calling 000
7.
Transport patient to emergency room if some improvement
is not fairly rapid. And if in doubt treat as an insulin shock.
- Response to treatment,
a. Insulin shock rapid improvement following carbohydrate administration.
b. Diabetic coma, no improvement after carbohydrate administration and slow
improvement (6-12 hours) after insulin administration.
Unconscious
1.
2.
3.
4.
5.
6.
7.
8.
1.
R: At first is important to know her medical history and we should be in contact with
her GP. Patients on antidepressant therapy may have some humour and behaviour
changes which is important to know. The symptoms and treatment may have effect on
her management.
Tricyclic antidepressant may cause postural hypotension so the treatment should be
carried out in the supine position. Care must be taken to upright the patient slowly to
avoid ataxia when ambulant and before discharge. TCA have atropine-like action that
may cause xerostomia so it might increase the patient risk of caries and periodontal
disease and in edentulous patient it may interfere on complete denture retention and
predispose to candidiasis. GA should be avoided once TCA increase risk of
arrhythmias with GA. The use of opioid may cause Hypo or hypertension. There is no
clinical evidence about TCA interaction with LA containing epinephrine (adrenaline)
leading to hypertension.
2.
First of all we have to inform her importance of using each tooth, so she will
understand the importance of replacement of lost teeth. Since she has no lower
molars, she cant eat properly because she just grinds food with lower anterior teeth
which can cause problems like:
early attrition of superior anterior teeth on denture
She cant grind food correctly which may cause an increase in acid producing by the
stomach.
Affect aesthetic in anterior region of denture
Explain what changes a RPD would be result in her face since the absent of molars
the bone will shrink and her cheek would have a shrinking appearance.
Her tmj could be affected because the absent of molars.
3.
What factors will you discuss with a patient for whom an impacted
lower third molar is to be removed under local anaesthesia, before
the surgery?
Before the surgery we have to explain clearly about how taking care, the management
and casual emergency that may happen post-operatively. Everything should be given
in noted in a sheet and a talking reinforcement.
Furthermore, patient should be make aware of the possibility of some problems like
nerve damage, trismus and swelling.
Also an advice on a suitable analgesic (e.g. Ibuprofen) that should be taken before the
LA wears off. Sometimes the user of an antibiotic should be useful when considered
portion of bone will be removed or chronic infection is evident.
The use of chlorhexidine 0,05% mouthwash could be useful against infections.
4.
What are the factors which will reduce the exposure of the patient to
radiation in a dental surgery? List the factors and describe how
each affects the reduction of patient exposure.
Thumb sucking is a deleterious habit and is greatly related with class II division I
malocclusion. It is also not an easy problem to correct in children once it could be
connected with psychological and social factors. The mother is a paramount key in
helping child to stop thumb sucking so we have to explain her about what this habit
cause once class II division I may cause some problems like gingivitis, bad breath
because of incompetent lips. Furthermore, the vestibular inclinations of incisors cause
a greater risk of trauma fracture.
In the management we have to aim the reduction of overjet and overbite. So, deep
assessment would be done. Removable appliance should be useful in aid stop thumb
sucking if the child is cooperative. If not some visits to a psychologist should be
considered. The key to planning is the canine relationship; we have to tip canine back
into class I relationship. Once canines are in class I, retro cline upper incisors to
reduce overjet. The best way for achieve this is by two-arch fixed appliance as we can
control overjet and overbite.
By the and of the treatment the thumb sucking habit must be stopped.
6.
Moisture control
Once it is not cost effective to seal all occlusal surface we should select some cases
which include patient selection:
Children with impairment (special needs)
Children at high risk (caries in the primary dentition)
Teeth at high risk (teeth with deep fissure or pits)
Sealant should be applied as soon as practicable and within 2 years of eruption. Only
sound teeth should be sealed. If there is suspicion of caries, investigate with a small
bur and provide sealant restoration.
Technique:
Prophylaxis (clean with rotatory bristle brush and pumice to remove pellicle)
Wash, isolate and dry the tooth
Etch for the time recommended by the manufacturer with 30 50% phosphoric acid.
Wash for 15 seconds , if salivary contamination, re-etch
Dry tooth very well
Apply sealant and cure
Check try to remove
Check occlusion
Moisture control is crucial. Salivary contamination lead to markedly reduction of the
retention.
8.
What advise would you give to a patient who has a darkened upper
central incisor?
There is some precaution we should take in managing diabetics patients for surgery.
Once the major concern for dental practioner treating diabetic patients is
hypoglycaemia, we should take some precautions like:
Perform the surgery soon after meal times
Try to manage patient in short appointment
A morning appointment should be better
Patient should maintain oral hypoglycaemic drugs and carbohydrate intake as usual
Ensure emergency glucose and drugs to hand.
Prescribe antibiotic and analgesics judiciously for prophylaxis to prevent infection
secondary to delayed healing.
Premedication in anxious patient with benzodiazepines
Use gradual position changes to avoid postural hypotension
Medical considerations.
Take a thorough medical history for all patients diagnosed with diabetes.
Ascertain the identity of the physician treating the patient and the date of the
last visit.
Obtain information concerning the type of diabetes, the severity and control of
the diabetes, and the presence of cardiovascular or neurologic complications.
Refer any patient with the cardinal symptoms of diabetes or findings that
suggest diabetes (headache, dry mouth, irritability, repeated skin infection,
blurred vision, paresthesias, progressive periodontal disease, multiple
periodontal abscesses) to a physician for diagnosis and treatment.
Diabetic patients who are receiving good medical management without serious
complications such as renal disease, hypertension, or coronary atherosclerotic heart
disease, can receive any indicated dental treatment.
Those with serious medical complications may require an altered plan of dental
treatment. When the severity and degree of control of diabetes are not known,
treatment should be limited to palliation.
Food intake and appointment scheduling. To preventing insulin shock from
occurring:
Schedule appointments in the morning, since this is a time of high glucose and
low-insulin activity. Afternoon appointments are a time of low-glucose and
high-insulin activity which may predispose the patient to a hypoglycemic
reaction.
Instruct patients to tell the dentist if at any time during the appointment they
feel symptoms of an insulin reaction occurring. A source of sugar, such as
orange juice, must be available in the dental office should the symptoms of an
insulin reaction occur.
Dangers of acute oral infection. Any diabetic patient with acute dental or oral
infection presents a problem in management. This problem is even more difficult for
patients who take high insulin dosage and those who have IDDM. The infection will
often cause loss of control of the diabetic condition, and as a result the infection is not
handled by the body's defenses as well as it would be in a nondiabetic patient. The
patient's physician should become a partner in treatment during this period.
Oral complications. The oral complications of uncontrolled diabetes mellitus may
include:
Xerostomia,
Infection,
Poor healing,
10. Discuss what precautions you might take, and what post-operative
instructions you might give a patient for whom you had removed a
tooth at 5pm on a Friday afternoon, if you were leaving immediately
for the weekend away yourself.
Some precautions should be take to avoid post operative complications specially if T
would a take a weekend off. Precautions include:
Advice the patient to do not intake any medication that contains acetylsalicylic acids.
Eg: asprin
Gathering patients health information to the correct post-operative management.
Minimize as much as possible any osseous trauma to avoid swelling.
Inform about possible bleeding and swelling.
Cold compress and compression is useful in the management of bleeding and
swelling.
Prescription of a non-steroidal anti-inflammatory to take after surgery .
Chlorhexidine 0,05% mouthwash will aid against infections.
11. Outline the different factors that may affect the stabilization and
retention of full upper and lower dentures.
On both:
Peripheral seal : over-extension will result in denture that is displaced in function
Contact area between denture and tissues: As close an adaptation of denture base to
mucosa as possible to maximize the surface tension effects of saliva.
Close fit
Viscosity/volume of saliva: xerostomia decrease retention
Placement of teeth in neutral zone
Balanced occlusion free from interfering contacts
Correct shape of polished surfaces so that muscle action tends to re-seat the denture.
Muscle action
Greater vertical dimension freeway space
On upper dentures:
Post dam
Lower denture:
Usually a problem because the residual ridge is often not enough to gain retention
12. Design a brief list of medical history questions to be used as part
of a patients overall history-taking procedure.
Some questions as follow should be formulated for gathering some medical history
information from patient in order to achieve the best way of management in dentistry:
Are you fit and well?
Have you ever been admitted to hospital? If yes, give the details
Have you ever had an operation?
Have you ever had any heart trouble or high pressure?
Have you ever had any chest trouble?
Have you ever had problems with bleeding?
Have you ever had asthma, eczema , hay fever?
Are you allergic to any other drugs?
Have you ever had:
Rheumatic fever?
Diabetes?
Epilepsy?
Tuerculosis?
Jaundice?
Other infection disease?
Are you pregnant?
Are you taking drugs, medications or pills?
Who is your doctor?
13. Write short notes on the diagnosis and management of dry socket.
Diagnosis: Pain onset 24 to 48 hours after extraction, frequently with noticeable odour
and bad taste. The socket is in extremely pain and looks inflamed and exposed bone is
usually visible.
Management: Irrigation under LA or not and dress the exposed bone with
ALVOGYL or ZOE packs. Topical metronidazole is an alternative. Chlorhexidine
mouthwash may help. NSAIDs are analgesic of choice.
14. Write short notes on the clinical assessment phase of the insert visit
for a removable partial denture.
Once any fitting surface roughness is eliminated, the denture are tried in separately,
adjusting undercuts contacts if required. The extension, occlusion and articulation are
then adjusted if necessary. Give the patient written and verbal instructions about oral
hygiene, how to clean dentures correctly and the natural teeh once using of denture
will increase plaque accumulation.
15. Write short notes on alternatives to removable partial denture
forsingle maxillary anterior tooth replacement.
Alternatives in replacement a single anterior tooth could be:
Fixed Bridges: if the adjacent teeth are greatly restores and the patient is disposed on
afford with the cost.
Cantilever bridge: Depend on which tooth is absent. Indication is in replacement of
anterior tooth with low occlusal forces. Eg lateral incisors.
Adhesive bridge: In low occlusal forces, one or two abutment could be used. When
adjacent teeth are sound. Dont need greatly reduction of teeth, just in palatine or
lingually
Implant
16. What would be your recommendation tohte parents on fluoride for a
3 years old boy?
We should explain to parents that child with 3 years old should have a daily ingestion
dose of fluoride which aid in prevention of caries and fluoride will aid in
mineralization of pr-eruptive teeth (permanent) and in prevention of caries and
remineralization on desmineralized post-eruptive teeth. Depending on water fluoride
supply we will advice a daily fluoride tablet which will vary the dosage(will vary
between 0-0,5mg) depending on the concentration of fluoride in water supply.
I would explain about amount of toothpaste on childs toothbrush that will be not
bigger than a pea size. And in spite of toothpaste pleasant taste, the child should spit
out everything when finishing brushing.
TOPICAL FLUOR ?
17. Osseointegrated implants. Explain to the patient advantages and
disadvantages so he can make a decision.
Advantages:
As our life span increases, a permanent dental replacement like implants is
increasingly important as we get older. While dentures and removable bridges are
usually loose and unstable, implants provide you with dental replacements that are
both natural looking and very functional. Implants look much better, and feel better,
than traditional removable bridges, and offer the same force for biting as bridges that
are fixed in place. Implants will last your lifetime.
Disadvantages:
Implants are a major investment and not without risk. The extensive use of implants
can cost tens of thousands of dollars to achieve a great result. It is also a very time
consuming procedure when having many implants placed. As this procedure is
surgery, it is very important to research and find a well credited cosmetic dentist that
you are comfortable with. For some people there are varying degrees discomfort or
pain, which subsides in a couple of days. As with similar types of surgery, bruising
and minor swelling might also develop shortly after the procedure. The crown (false
tooth placed on top) will need to be replaced in ten to fifteen years.
18. Patient had hepatitis 10 years ago. What would be your additional
information that you have to get from patient and how can that effect
your dental management of that patient?
19. A 15 years old patient, still have deciduous canine present in the
mouth, no evidence (clinically) of permanent successor. What would
be your treatment?
A 15 years old patient in general should has the canines been erupted. Once the
presence of the teeth cant be observed by visualization, palpation should be done in
order to feel by touching the ridges buccaly and palataly to find ant protuberance.
If not felt by touching, I would take a R-ray to investigate the presence of a possible
impacted canine. Usually more than one r-ray should be take in order to see the
correct position of an impacted canine tooth. When impacted canine tooth is
diagnosed, an orthodontic extrusion following a surgery to access the tooth should be
realized.
20. Describe the procedures that would ensure the correct sterilization
of dental burs and handpieces. Discuss types of sterilization
methods and verification procedures to ensure correct sterilization.
Used burs should be considered as contaminated and appropriate handling precautions
should be taken during reprocessing. Gloves, eye protection and a mask should be
worn. Other measures may be required if there are specific infection or crosscontamination risks from the patient.
The burs can be transported wet or dry and should be protected from damage to the
cutting edges. If transported wet there is an increased chance of staining or corrosion.
Prolonged storage in disinfectant solutions may result in corrosion and should be
avoided.
PREPARATION FOR CLEANING
There are no special requirements unless infection controls require the use of a
disinfectant, in which case a disinfectant agent validated for processing of dental burs
must be used and the disinfectant manufacturers instructions must be followed
DRYING
Dry the burs using paper towelling or dry heat not exceeding 140C.
PACKAGING FOR STERILIZATION
If using a vacuum autoclave pack the burs in dedicated bur stands or pouches
validated for sterilization.
If using a non-vacuum autoclave the burs should not be packed or wrapped but be
contained in dedicated bur stands with perforated lids.
STERILIZATION
Autoclave the instruments for a holding time not less than three minutes at a
temperature of between 134 and 137C. Other validated time/temperature regimes
may be used. The holding time is the minimum time for which the minimum
temperature is sustained.
Handpiece Sterilization/Asepsis
The following outlines the accepted protocol for sterilization/asepsis of dental airpowered handpieces.
NOTE: The motor of your slow-speed handpiece cannot be sterilized.
Before removing handpiece from the hose following treatment, wipe all visible debris
from handpiece and briefly operate air/water system to flush water and air lines.
Remove handpiece from hose and clean all external surfaces with gauze or scrubbing
brush saturated with isopropyl alcohol. Do not use ultrasonics. Dry thoroughly with
gauze.
Clean internal parts of handpiece to remove aspirated debris and wear products.
Lubricate if required. Refer to manufacturers maintenance and lubrication.
CRITICAL STEP: Insert a bur, disc, or prophy cup in handpiece, connect to delivery
system tubing, and operate for 15-20 seconds to distribute lubricant throughout
handpiece. Omitting this step prior to sterilization may lead to excess lubricant
accumulating in the working assembly and "gumming" up the rotating assemblies
during the heat cycles. This may cause subsequent slowing and/or stoppage of the
handpiece. Wipe away excess oil expelled at the head of the handpiece during this
step. Fiberoptics: remove all excess lubricant from fiberoptic interfaces and exposed
surfaces. Lubricant and/or dirt can be forced between individual fiber strands during
pressure sterilization and lead to darkening or dimming of fiberoptic bundle. Do not
use strong solvents on fiberoptic faces or the epoxy binder between the fibers may
dissolve.
Remove bur, disc, or prophy cup and disconnect handpiece from tubing. Make sure
hand- piece or component is clean and dry both internally and externally.
Place handpiece in a sterilization bag and deliver it to Central Sterilization.
Before attaching sterilized handpiece to unit hose, flush air-water lines of hose for 2030 seconds.
Attach handpiece to unit hose and run for 20-30 seconds. Handpiece is now ready for
patient use.
compounds) It is very important not to scrub the injury since this may inoculate the
virus into the tissues
Pressure above the wound to induce bleeding from the contaminated injury should
also be performed
cover the wound with appropriate dressing.
Establish hepatitis antibody status of injured party.
Need for HIV Post-exposure Prophylaxis (PEP)
Blood testing to determine whether infection has occurred.
Take detailed information about the injury, including how long ago it happened, how
deeply the skin was penetrated, whether or not the needle was visibly contaminated
with blood, and any first aid measures used.
The appropriate agency notification of injury form which includes:
. Name of the source individual (affix patient ID label);
. If the source of the blood in unknown, this must also be documented
25. Discuss those aspects of full denture construction that you would
check at the try-in stage.
On this stage of full denture construction I should check if the vertical dimension of
occlusion is correct , check the horizontal jaw relationship, anterior and posterior
occlusal planes, check stability , extension, the position of teeth, aesthetic and
phonetic.
The trial denture should be examined critically prior to insertion. Asses tooth position
and if not a chairside adjustment should be done. On this stage , the patient will see
how denture will appear so I must allow him to opine about tooth shape, shade and
colour. Only when dentist and patients are satisfied, the trial dentures may be sent to
the technician.
26. Discuss the adverse effects that removable partial dentures may
have on dental-oral tissues.
27. Discuss the role of the dental surveyor in removable partial denture.
The dental surveyor is used on constructions of RPD. Some of its function is:
-
In office environment I would assess completely the local of injury, look for soft
tissues injury, fracture of the alveolar bone.
In managing the tooth I would just handle it by the crown and rinse with saline
solution. I would anaesthetise the socket, and gently irrigate and aspirate (without
entering) in order to remove foreign bodies and clot. Then reimplant the tooth
manually into the socket and suture soft tissues. Then a acid-etch splinting with
orthodontic wire should be done and remain for 7 to 10 days but if the tooth is still
mobile, the splint should remain until the tooth become with acceptable mobility.
Advice parents and child about home care which include:
a. No biting on splinted teeth
b. Soft diet
c. Maintenance of good oral hygiene
Prescription an analgesic and antibiotics(?) and referral to a physician for tetanus
vaccine.
Advice parents that the tooth should be reviewed each 3 to 6 month for surveying the
degree of success of reimplantation.
33. A patient with a lower molar extracted one week ago presents with
pain associated with both TMJs. what is the possible diagnosis and
treatment?
The possible diagnosis is a TMD probably caused by too much pressure by the
dentist on the jaw or pushing the jaw posteriorly when extracting the tooth.
Treatment includes a soft diet, moist head, a mild pain medication and limited jaw
function for 1-2 weeks. Prescribe an analgesic (e.g. Paracetamol 1000mg, 4 hourly)
34. A patient who requires extraction of an impacted 3 rd molar has a
history of bleeding after extractions. What would be your
management of the case?
First of all take a complete medical history in order to gathering information about
bleeding disease and ask about anticoagulant therapy. In general some precautions
should be taken prior to a dental extraction. I should ensure that platelet level of > 5075 x 10(9)/l , levels lower than this require platelet transfusion with IV anti-histamine
and hydrocortisone cover prior to surgery. Local measures avoiding bleeding should
be done in surgery. Suture is always needed on these cases. Advice cold compress
35. Discuss the effects of cigarette smoking on general health and its
impact on oral health. What would you tell your patients to
encourage them to stop smoking?
Smoking is now identified as a major cause of heart disease, stroke, several different
forms of cancer, and a wide variety of other health problems. The vast majority of
deaths caused by smoking occur through development of heart disease and lung
cancer, followed by chronic bronchitis, stroke, peripheral vascular disease and other
circulatory diseases, and cancers other than lung.
Smoking has several negative effects on the mouth and teeth.
Smoking stains the teeth and calculus brown.
Smoking also greatly increases the risk of gum disease. Smoking reduces the blood
flow to
the oral tissues and gums, hence lowering the resistance to plaque bacteria.
Smoking is also a major cause of oral cancers. The type and appearance of oral
cancers
varies greatly. The most common sites for oral cancer include the lips, side of the
tongue,
and under the tongue on the floor of the mouth.
Also smoking cause bad breath and loss of taste.
I would explain him everything about smoking damage to health and oral health that
would make him think about stop smoking. I also would emphasise his oral
appearance that would be much better after stop smoking.
substitute for the missing wall so that adequate condensations forces can be
applied
permit re-establishment of a proper contact point with the adjacent tooth
restrict extrusion of amalgam and prevent the formation of an overhang at the
gingival margin
Provide adequate physiological texture to the proximal surface, especially in the
area of the contact point
To ensure correct proximal surface a matrix band should be selected, fitted to the
tooth and used in conjunction with a wedge. The gingival edge of the matrix should
extend 1mm gingival (if possible) to the gingival margin. The occlusal height of the
band should be at least 1mm above the height of the marginal ridge crest. The wedge
is inserted and its body should be gingival to the gingival cavosurface margin. The
matrix band should be in contact with the adjacent tooth during condensation. The
wedge will slightly separate the teeth to compensate for the thickness of the matrix
band and ensure that the final restoration has a suitable contact point.
On condensation:
Place small increments of amalgam into the deepest part of proximal box and
condense using vertical and lateral condensation forces. Condense amalgam at the
proximal box and then in reminder of cavity preparation. Over pack the occlusal
surface by 1 2mm.
Carving:
Do not initiate carving unless the production of amalgam shaving. Always carving
parallel to cavosurface margin. First cave within matrix band with a discoid carver to
expose the occlusal cavosurface margin of preparation. Carve the height of the
marginal ridge to correspond to the height of the marginal ridge of adjacent tooth.
Carve the occlusal embrasure using the tip of an explorer. Remove the matrix band
and wedge. The proximal contour should require a little carving. Amalgam excess on
the vertical walls of the proximal box may be removed. Any amalgam excess and
overhang should be removed.
37. Discuss the possible sequelae of preparing and placing full veneer
crowns with subgingival margins.
Progressive
Severe
hypotension (shock)
bronchospasm (wheezing)
Note: The onset of severe clinical features may be extremely rapid without prodromal features.
Management:
- Cease administration of any suspected medication
- Place patient supine with legs raised, if possible
- Inject adrenaline IM: - 0,25ml for small adults ( > 50Kg)
- 0,50ml for average adults (50 100Kg)
- 0,75ml for large adults (< 100kg)
- Up to 500mg of hydrocortisone IV.
- Up to 20mg of chlorpheniramine slowly IV
- O2 by mask,
It is important to enquire about previous denture history and asses the reason for
failure or success.
Relief of pain and any emergency treatment.
History and exam, including a thorough clinical and radiographic assessment of
remaining teeth and edentulous areas. It is important an oral and extraoral
examination.
Unless immediate dentures planned, extract any teeth with poor prognosis
Oral Hygiene and periodontal treatment
Preliminary design of partial denture
Carry out restorative treatment required
Modify design if necessary and commence prosthetic treatment.
Patient should be managed in a quiet and calm environment that reduces anxiety
and stress.
- Sedation with medication should be considered in anxious patient.
- effective local anaesthesia - max 0.040 epinephrine
- avoid anticholinergic drugs
- monitor blood pressure, pulse use pulse oximeter
- antibiotic prophylaxis in some heart disease (e.g. rheumatic heart disease)
- avoid GA
- avoid fatigue
- avoid routine invasive care for 6 months s/p MI myocardial infarct
- consider that this patient usually are under anticoagulant therapy
- Consult patients physician to clarify any doubt about the disease.
- do not use epinephrine in retraction cords and astringent
medications
-
Advantages:
alveolar bone preservation around retained tooth.
Improved retention, stability and support
Preservation of proprioception via PDL
Improved crown to root ratio, which decrease damaging lateral forces
Increase masticatory forces
Additional retention possible using attachments
Aids transition from partial denture to full denture
Disadvantages:
RCT probably required
To avoid excessive bulk in region of retained tooth, denture base may need to be
thinned, which increase likelihood of fracture
Increase maintenance for both patient and dentist
Indications:
Motivated patient with good oral hygiene.
Because of decreased retention and stability of lower denture and greatly rate of
mandibular resorption. Overdentures are particularly useful for lower dentures or
free-end saddle.
Cleft lip and palate
Hypodontia
Severe toothwear
Choosing abutment teeth
Ideally: bilateral, symmetrical with minimum of one tooth space between them.
Order to preference: canines, molars, premolars and incisors.
Healthy attached gingival, adequate periodontal support (> root in bone), and
no or limited mobility
Is RCT required and if so is it feasible?
Preparation of abutment teeth
Removal undercuts only
Preparation of crown for thimble/telescopic gold coping.
RCT, tooth cut to dome shape and access cavity restores with amalgam or an
adhesive restoration
RCT and gold coping over root face
RCT and precision attachment
Clinical procedures:
Assessment. Warn the patient about the effects of resorption and the need for
early rebasing/replacement.
Primary impressions
Second impressions in alginate or silicone
Recording occlusion. Where there are sufficient posterior teeth remaining, a wax
wafer should suffice, and this can be taken at the same visit as impressions are
recorded.
Try-in. ??
Extraction of remaining teeth as atraumatically as possible
Finish. Repeated removal and insertion of the denture should be avoided,
therefore adjustments should be limited to making the patient comfortable. They
should instructed not to remove the denture before the review appointment in
24h.
Review. The fitting and occlusal surfaces are adjusted as required. If the dentures are
unrententive they will require temporary reline.
Recall. Regular inspection of immediate dentures is important as rapid bone
resorption means that they will require rebasing early. However, this should be
deferred, if feasible, for at least 3 months after extractions. A possible regimen is 1
week, 1 month, 3 months, 9 months, and than yearly.
Problems denture unrententive and gross occlusal error
49. How do you manage a patient on steroid therapy and long standing
rheumatoid arthritis?
A patient with rheumatoid arthritis requires a special dental management since
Rheumatoid arthritis is a serious systemic disease which is painful and fatiguing and
can lead to significant disabilities that make it difficult for patients to look after their
teeth and gums. Furthermore these patients often are in medication therapy which can
deal with increase risk of infections and bleeding.
In managing these patients we should take some precautions as follow:
- Gathering information by taking medical history with attention to the disease.
E.g. How long do you have arthritis? Can you brush your teeth? Flossing? Type
of medications?
- Dental care needs to be planned according to the individual needs of the patient,
their degree of disability, their comorbid conditions, age, and the drugs they are
taking.
- Short dental appointments: Patients often have pain on TMJs when maintain
mouth opened for a long time.
- Asses if aspirin or NSAIDs are affecting platelet function If intake
- call the persons physician or specialist if any concerns.
- Reduce the stress as it can deal with adrenal crisis
- When in steroid therapy, asses for how long time and quantity
- Steroid therapy may cause increase risk of infection, difficulty wound healing and
increase bleeding and hypotension.
- Antibiotic prophylaxis for this cases
- Patients undergoing minor surgical procedures under local anaesthesia are at very
low risk, if any, for developing adrenal crisis so they just need to keep their usual
dose. However, patients taking high doses of steroids should double the usual
dose on the day of the surgery.
- Thus, for patients undergoing general anaesthesia for minor surgery 100 mg
hydrocortisone intramuscularly should be administered and the usual
glucocorticoid medications maintained. For major surgery 100 mg hydrocortisone
delivered as a bolus pre-operatively followed by 50 mg 8-hourly for 48 hours is
adequate.
- in case of adrenaline insufficiency pat should be given a shot of 100mg
hydrocortisone
50. Write a prescription for Penicillin and Analgesic for a 8 year-old
child.
Dr. Rafael Maia
35 Guapore Street
Phone: 3455-5597
Name: Joao da Silva
years
Address:32 Stanhope Street
12/0
Newton , SA
Age: 8
D.O.B:
Rx Ibuprofen 200mg
200 mg 34 times daily preferably after food
Rx - Amoxicillin oral suspension 250 mg/5 mL
250 mg (5ml) 3 times daily
Number of items: 2
Phase I Therapy
1.Diagnosis
Before any treatment is performed or prescribed, the patient must have a complete
diagnosis. This must include:
2. Risk Assessment
Risk Assessment and the determination of prognosis is essential in order to develop
the most appropriate therapeutic alternatives.
3. Treatment Plan
If acute infection, accompanied by diffuse non-localised oedema, suppuration and
pain, the dentist may consider adjunctive antibiotics at this time. The goal for this
possible use of systemic antibiotics to take the patient out of a potentially dangerous
situation. This occurs when the appropriate antibiotic is prescribed and consumed by
the patient.
In an acute situation, fever, pain and malaise are often present. Antibiotics should be
accompanied by local mechanical treatment in order to attempt to establish drainage
and remove any foreign body that may be contributing to the infectious process or
preventing its resolution.
The antibiotics of choice for acute periodontal infections are:
NOTE: It is imperative that the dentist follows up with the patient within the first 24
hours to determine if he or she is responding to the treatment. If the response is not
satisfactory, referral to a dental specialist or physician is essential and mandatory.
3. Scaling and root planing
Most periodontal lesions will respond to scaling and root planing. This difficult to
perform procedure reduces oedema, inflammation and probing pocket depths. It
accomplishes this desired clinical outcome by physically removing plaque, calculus
and other pocket contents.
The routine use of systemic chemotherapeutic adjuncts is not recommended because
its use will only suppress the etiologic agents, lead to adverse side effects and the
development of resistant strains.
Adjunctive local antimicrobials are often used at this time with varying degrees of
success. Chlorhexidine rinses twice a day are excellent ways to help the patient
control plaque.
4. Oral hygiene instructions
Oral hygiene instructions are paramount for the long-term reduction of plaque and the
maintenance of the clinical status of the patient.
Failure to properly insure that the patient has the appropriate tools to control plaque
will lead to the perpetuation or initiation of periodontitis.
5. Elimination of local factors
Elimination of local factors other than plaque and calculus that may contribute to
periodontal destruction should be performed as part of initial therapy. These include
but are not limited to:
1. Eliminating restorative overhangs and over-contoured crowns
2. Correction of ill-fitting prosthetic appliances
3. Restoration of carious lesions
4. Orthodontics
Diabetes
Smoking
Pregnancy
Medications
Substance abuse
Re-evaluation
After initial therapy a minimum of 2- 4 weeks is usually needed to be able to evaluate
specific areas for continued breakdown and or stability. Signs of poor response to
initial therapy include:
In sites that had periodontal surgery, more time is needed to allow complete healing of
the periodontium. A minimum time of 3 months post operatively is suggested. Signs
of a desirable outcome include:
It is an extensive, rapidly progressing caries affecting many teeth in the primary &/or
permanent dentition caused by frequent ingestion of sugar &/or reduced salivary flow
Severe early childhood caries may also be caused by the prolonged and frequent
intake of sugar-based medications; however, both pharmaceutical companies and
doctors are more aware of the problem and the number of alternative sugar-free
preparations is increasing.
Management:
- Removal of aetiological factors (education, artificial saliva)
- Fluoride rinses for older age groups (daily 0.05%)
- 1 dentition may need to extract teeth of poor prognosis and concentrate on
prevention for permanent dentition
- 2 dentition need assessment of long-term prognosis for teeth. Final treatment
plan should be drawn up in consultation with orthodontist
55. A patient comes to you and complains of bad breath. What are the
different investigations.
Bad breath has different etiologic factors, I would investigate what probably is
causing bad breath.
- What you eat affects the air you exhale. Certain foods, such as garlic and onions,
contribute to objectionable breath odor. Once the food is absorbed into the
bloodstream, it is transferred to the lungs, where it is expelled.
- Brushing and flossing. If dont brushing and flossing correctly particles of food
remain in the mouth, collecting bacteria, which can cause bad breath
- Tongue brushing. Ask about tongue brushing and evaluate it.
- Periodontal disease. Evaluation regarding plaque accumulation, calculus.
- Xerostomia. Saliva is necessary to cleanse the mouth and remove particles that
may cause odor.
- Tobacco.
- Bad breath may be the sign of a medical disorder, such as a local infection in the
respiratory tract (nose throat, windpipe, lungs), chronic sinusitis, postnasal drip,
chronic bronchitis, diabetes, gastrointestinal disturbance, liver or kidney ailment.
56. Vertical dimension in RPD.
57. Management of Class V (size2) lesion in a 15 year-old
Although cervical cavities are seen less frequently in younger patients, they are an
increased problem in older age-groups with gingival recession. Resin composite,
compomer or Glass Ionomer are the preferred material in this situation. Amalgam
should be avoided due to possibility of lichenoid reaction.
Once caries has been removed the occlusal margin should be bevelled. The cervical
margin should not be bevelled as it has been shown to increase microleakage. The
materials are ideally placed incrementally under rubber dam isolation.
58. A patient comes to you for a recall visit and informs you she is 3
months pregnant. What is your line of management?
Oral care is an essential component of the overall health of a pregnant patient but
there are several issues that dentists should consider when managing pregnant
patients.
Should avoid elective dental procedures at first trimester of pregnancy, only hygiene
instruction and cleaning. I would advise she to come back in a few weeks once the 2nd
trimester is the safest period for routine dental care.