Short answers

From a personal experience, do not write too much in the short answers
exam; write just heading or points of the procedures or description

SAQs, March 2006

1) Pt. gave h/o Warfarin treatment in the assessment. What will be the
changes in the management of such patient ( compulsory )

2) Pt. has missing upper lateral incisor. How u will manage this patient.

3) Pt. has mobile upper anterior teeth. Pt. is in her 50s. what will be the
differential dignosis and its management.

4) Pt. has abcess in 46. Already 4.4 ml. of 1: 80000 lignocaine with
adrenaline is injected. Discuss the possible management options.

5) how do u manage a 2 1/2 year old child patient who is visiting a dental
clinic for the first time,what do u ask the child & parent?

SAQs, March 2005

1 (compulsory): your assistant told u that she has accidentally injured herself.
How do u manage?

2: management of an 8 yr child needing nitrous oxide.

3: complications of surgical extraction of upper 6

4: saliva and its role in dental caries and erosion

5: a patient comes to your clinic with an acute gingival condition,

lymphadenopathy and fever...

Discuss your clinical examination, differential diagnosis and quick account

on treatment of the diseases u have mentioned in the differential diagnosis.
SAQs, 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 patient’s 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 swelling…etc
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 patient’s
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?
Gathering general information including but not limited to name,
age, sex, previous major operations, any medication is taken at the
time she is presented…etc. mostly this is prepared and universal
for all patients.
Building the medical and the dental history to help building 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.
Clinical examination in both directions Extra and intra. Extra
examination includes the general morphology, skeletal base, skin
colour and lesions, eyes, lymph nodes, lip, breathing, TMJ and
masticatory muscles. Intra orally starts with soft tissues and oral
mucosa and muscles followed by the dental examination by
examining the teeth and focusing on the tissues, bone and teeth
next to tenderness and the blow area; and look for any attrition,
abrasion, erosion, or hypominerlization on the tooth surface or any
abnormality in the gingivae or hard tissues “Faceting, fracture or
caries of the enamel” then examine the periodontal tissues and
record any tooth mobility or badly restored teeth.
Check the occlusal view if possible and the result of the blow on the
occlusal harmony and the other tissues.
Order any special tests required and in this case a periapical to
start with seems to be essential.
Assess the case and advise for a rigid splint or extraction and fixed
prothesis later…etc and this is completely demandant on the
outcome of the assessment.
Transfer the treatment options to the patient in a simple language
and this stage should include the approximate cost and any need
for future follow up.

3. A 13 year old patient has rampant caries and gingival swelling.

What are the causes? How to prevent them? What is your management?

Most probable cause of the rampant caries is the frequent intake of sugar,
then the oral hygiene methods that have been adapted by the patient. But we
must be able to visualize adequately a child’s teeth and mouth and have
access to a reliable historian for non-clinical data elements.

Prevention programme starts with assessing all 3 components of caries risk-

clinical conditions, environmental characteristics, and general health
conditions; a complete analysing of the diet regime; then build a new diet
system prevents less frequent take of carbohydrates and in sever cases could
include changing sugar to carbohydrate free substitute. Endorsing a good oral
hygiene plan that suits the patient and the advice for a regular topical fluoride
application is as important as the diet. Systemic fluoride may be applicable
depends on the case and the water fluoridation program in the area.
The management includes,
Gathering general information including but not limited to name,
age, sex, previous major operations, any medication is taken at the
time she is presented…etc. mostly this is prepared and universal
for all patients.
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.
Clinical examination in both directions Extra and intra. Extra
examination includes the general morphology, skeletal base, skin
colour and lesions, eyes, lymph nodes, lip, breathing, TMJ and
masticatory muscles. Intra orally starts with soft tissues and oral
mucosa and muscles followed by the dental examination by
examining the teeth and focusing on the tissues, bone and teeth
next to tenderness; look for any attrition, abrasion, erosion,
hypominerlization or any abnormality in the gingivae or hard tissues
“Faceting, fracture or caries of the enamel” then examine the
periodontal tissues and record any tooth mobility or badly restored
teeth.
Check the occlusal view if possible and the result of the blow on the
occlusal harmony and the other tissues.
Assess the case and treat according to the diagnosis outcome;
bearing in mind that the target is to treat the acute problems or
manage any source of pain then reserve as much as possible of
the child teeth tissues.

4. Patient with chronic periodontic disease.

What are the factors that will influence the management and outcome of
this patient?

The overall clinical factors are:

Patient age: for two patients with comparable level of the remaining
connective tissues attachment and alveolar bone, the prognosis is
better in the older of two. For the younger patient, the prognosis is
not as good because of the short time frame in which the
periodontal destruction has occurred. In some cases this is maybe
because the younger patient suffers from an aggressive type of
periodontitis.
Disease severity: Studies have demonstrated that a patient’s
history of previous periodontal disease may be indicative of their
susceptibility for future periodontal break down. Prognosis is
adversely affected if the base of the pocket is close to the root
apex. Also the height of the 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
patient’s attitude and desire to retain natural teeth, and willingness
and ability to maintain good oral hygiene. Without these, treatment
can not succeed.

There are systemic and environmental factors such as:

Smoking: Epidemiologic evidence suggests that smoking may
be the most important environmental risk factor impacting the
development and progression of periodontal disease. Therefore
it should be made clear to the patient that a direct relationship
exist between smoking and the prevalence and incidence of
periodontitis. Also patient should be informed about the effects
of smoking on the healing process.
Systemic disease /condition: the patient’s systemic background
affects overall prognosis in several ways. For example, studies
have shown that the severity of periodontitis is significantly
higher in patients with type I and II diabetes than in those
without diabetes. Patients with diabetes or with newly diagnosed
diabetes should be informed about the impact of diabetic control
on the development and progression of periodontal disease.
Genetic factors: periodontal diseases represent a complex
interaction between microbial challenge and the host’s response
to that challenge, both of which may be influenced by
environmental factors such as smoking. There also is evidence
that genetic factors may play an important role in determining
the nature of the host response.
Stress: physical and emotional stress, as well as substance
abuse, may alter the patient’s ability to respond to the
periodontal treatment performed.

The Local Factors:

Plaque /calculus: the microbial challenge presented by bacterial plaque

and calculus is the most important local factor in periodontal diseases.
Therefore in most cases, having a good prognosis is dependent on the
ability of the patient and the clinician to remove these etiologic factors
Subgingival restorations: may contribute to increased plaque
accumulation, increased inflammation and increased bone loss when
compared with supragingival margins.
Anatomic factors: may predispose the periodontium to disease, and
therefore affect the prognosis, include short, tapered roots with large
crowns, cervical enamel projections (CEPs) and enamel pearls,
intermediate bifurcation ridges, root concavities, and developmental
grooves.
Tooth mobility: the principle causes of tooth mobility are the loss of
alveolar bone , inflammatory changes in the periodontal ligament, and
trauma from occlusion. However, tooth mobility resulting from loss of
alveolar bone is not likely to be corrected.
Prosthetic / restorative factors: the overall prognosis requires a general
consideration of bone level and attachment level to establish whether
 enough teeth can be saved either to provide a functional and aesthetic
dentition or to serve as abutments for useful prosthetic replacement of the
missing teeth.
Caries, non vital teeth , and root resorption: for teeth mutilated with extensive
caries, the feasibility of adequate restoration and endodontic therapy should
be considered before undertaking periodontal treatment.

5. Class two amalgam restoration on a molar.

What factors do you consider when preparing a good proximal contact
area?

The extent of the cavitation of the proximal enamel will dictate the
classification and, ultimately, the outline form of the cavity. There is no need
to remove sound enamel, particularly from the gingival floor, just because it is
undermined following removal of caries. The enamel at the gingival is not
under occlusal load and can be retained, thus keeping the restoration margin
out of the gingival crevice, in case we are going to use the lamination
“sandwich” technique. If not ditches and grooves are the best methods of
developing retention; pronounced groove along the gingival floor of the mesial
proximal box of 2mm depth provides a good positive retention. The main
retentive form in the proximal box should be placed within the dentine at the
gingival floor as well as in the facial and lingual walls. Now if the separate
sections of the restoration are individually self retentive, there will be no
failure at the narrow isthmus that joins the occlusal extension to the proximal
box and there is no need to widen it in this case. Other wise extending it just
over the contact area with the adjacent teeth is indicated and bevelling the
step as well to strengthen the amalgam in this area and extra retention will be
gained.

SAQs, 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.
Mechanical damage happens as a result of the process of avulsion
and replantation; the damage is seen on both cells and tissues.
These areas of damage appear as surface resorption defects.
Socket: curettage of the socket wall and the presence or removal of
a blood clot had a little influence on the healing pattern of the
replanted teeth. Therefore this need not be done unless the clot
prevents proper seating of the tooth. However, alveolar bone
should be moulded back into position following replantation, this
 aids in bone healing and allows good adaptation of soft tissues.
Splinting: minimal splinting and non-rigid splints permit
physiological jiggling movement of the tooth which result in lower
incidence of ankylosis. Care must be taken in the placement of the
splints, keep it simple and avoid gingival tissues. Studies have
shown that normal and hard diet resulted in significantly less
ankylosis and a higher incidence of normal periodontal ligament
compared with soft diet.
Antibiotics: High dose of a broad spectrum antibiotic is
recommended followed by at least two weeks of oral administration.
Intrapulpal application of antibiotic is indicated if bacterial invasion
of the pulp occurs prior to systemic antibiotic.
Endodontic treatment: teeth with immature apices should be
monitored clinically and radiographically since revascularisation of
the pulp is possible. Teeth with mature apices rarely < 1% regain
vascularity and so necrosis and infection would follow, so an
endodontic treatment is advised as soon as possible. Extra oral
endodontics should not be perform prior to replantation as the
excessive handling of the tooth will increase the risk of additional
damage to the periodontal membrane. And the filling material may
increase the risk of inflammatory resorption.

2. Discuss the choices for an MOD direct restoration for a lower molar.

Amalgam- Sandwich Technique- Composite- Pins-

3. 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
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.
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.
Oral findings in patients with uncontrolled diabetes are thought to be related to
excessive loss of fluids through urination, altered response to infection,
microvascular changes, and possibly increased glucose concentrations in saliva.

Early diagnosis and treatment of the diabetic state may allow for regression of
these symptoms, but in long-standing cases the changes may be irreversible.

Potential Drug Interaction. While patients with well-controlled diabetes can be

given general anesthetics, management with local anesthetics is preferable.
General anesthetics should be used with caution because they can produce
hyperglycemia.
 4. Your dental nurse has suffered a needle stick. What is your
management for the case?

IMMEDIATELY WASH THE INJURY WITH SOAP AND WATER

· If splashed with a bodily fluid, thoroughly irrigate the affected area
· Cover the injured area with a bandage for protection
There is no need to apply agents such as bleach to the injury

Risk assessment
Report the incident to the practice principal/manager following first aid
· Document as much of the following as possible to determine risk:
1. How did the injury occur?
2. What type of injury is it, and what is the extent of the injury?
3. What was the source of the sharp or bodily fluid?
4. How much of the source material came into contact with the affected person?
5. Was any protective clothing being used?
· After initial risk assessment, seek further management and treatment
If appropriate, post-exposure treatment should be implemented as soon as
possible

Injury management:

The affected person may wish to attend their usual doctor for further care

The following matters should be addressed by the treating doctor:

- Infection status of source material (blood)
- Counselling of the patient
- Blood testing to determine whether infection has occurred
- Hepatitis B immunity status of the patient (is a booster shot required?)
- Need for HIV Post-Exposure Prophylaxis (PEP)
· The practice must follow up the incident and make a final report
- Do practice procedures need to be reviewed as a result of the incident?
- Do arrangements need to be made with insurers, NSW WorkCover, etc?
24-Hour Needlestick Hotline phone 1800 804 823

SAQs, Sep. 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 and decongestants to be prescribed, the patient to be
instructed to avoid Valsalva manoeuvres (tasks which build up pressure in the
sinus like nose blowing and bearing down forcefully) and the patient
reappointed for follow-up. Most often this results in an uneventful healing
period with no further treatment being required. Occasionally, the area will
heal open rather than closed in which case an additional small surgical
procedure will be required to close the communication.

The lower third molars often have roots that lie very near or even wrapped
around the inferior alveolar nerve. This is the nerve that supplies feeling to the
lip, teeth and tongue on each side of the mouth. Occasionally, when a lower
third molar is removed, that nerve will be bumped or bruised and if so a
change in sensation may be noted on that side. It is important to understand
that this is a sensory nerve and does not affect the ability to move the parts of
the oral cavity to which it gives sensation (feeling). In most cases, the nerve
heals itself but, because nerves heal slowly, it may take six months to one
year before return of normal sensation. Very rarely, the damage to the nerve
is permanent.

Finally, the normal precautions, risks and benefits of extraction of any tooth

Choose two of the following four questions:

1. What are the factors that will reduce the radiation exposure of
patient, describe how each factor affects the reduction of patient
exposure.

The largest single contributor of man-made radiation exposure to the

population is medical and dental diagnostic radiology. In total, such radiations
account for more than 90% of the total man-made radiation dose to the
general population. It is generally agreed by experts in the scientific
community that radiation exposure to patients from medical and dental
radiographic sources can be reduced substantially with no decrease in the
value of diagnostic information derived.

The risk to the individual patient from a single dental radiographic

examination is very low. However, the risk to a population is increased by
increasing the frequency of radiographic examinations and by increasing the
number of persons undergoing such examinations. For this reason, every
effort should be made to reduce the number of radiograms and the number of
persons examined radio-graphically, as well as to reduce the dose involved in
a particular examination.

To accomplish this reduction, it is essential that patients not be subjected to

unnecessary radiological examinations and, when a radiological examination
is required, it is essential that patients be protected from excessive radiation
exposure during the examination.

The recommendations outlined below are directed toward the dentist and the
operator of dental X-ray equipment. These recommendations are intended to
provide guidelines for the elimination of unnecessary radiological
examinations and for reducing doses to patients. Also, included are
recommended upper limits on patient doses for certain common dental
radiographic examinations.

9.1 Guidelines for the Prescription of Dental Radiographic Examinations

The dental practitioner is in the unique position to reduce unnecessary
radiation exposure to the patient by eliminating examinations which are not
clinically justified. The dental practitioner can achieve this by adhering to
following basic recommendations.

A radiographic examination should be for the purpose of obtaining

diagnostic information about the patient to aid in a clinical
evaluation of the patient and treatment when warranted.
Routine or screening examinations, in which there is no prior
clinical evaluation of the patient, should not be prescribed. It is
considered a bad practice to radiograph patients unnecessarily, as
in a standard survey, and this is especially deplored when done on
children. It is also considered bad practice to take radiograms
before a clinical examination by the dentist. These two practices
constitute the largest potential abuse of radiology in dentistry.
It should be determined whether there have been any previous
radiographic examinations which would make further examination
unnecessary or allow for an abbreviated radiographic examination.
When a patient is transferred from one practitioner to another, any
relevant radiograms should accompany the patient or should be
requested from the previous dentist.
The number of radiographic views required in an examination
should be kept to the minimum practical, consistent with the clinical
objectives of the examination.
In prescribing radiographic examinations of pregnant or possibly
pregnant women, full consideration should be taken of the
consequences of foetal irradiation. The developing foetus is
sensitive to radiation damage that can result in congenital defects.
In dental radiology, good radiation protection practice reduces the
foetal dose to an acceptable minimum and dose levels which do not
constitute a significant hazard. It should be emphasized that
precautions to reduce radiation exposure to the patient should be
taken all the time because a woman of child bearing capacity may
be unaware of her pregnancy.
Repeat radiographic examinations should not be prescribed simply
because a radiogram may not be of the "best" diagnostic quality,
but does provide the desired information.
A patient's clinical records should include details of all radiographic
examinations carried out.
9.2 Guidelines for Protecting the Patient During Radiographic
Examinations
It is possible to obtain a series of diagnostically acceptable
radiograms and have the patient dose vary widely because of
differences in the choice of loading factors and film speeds. It is the
responsibility of the operator and dental practitioner to be aware of
this and to know how to carry out a prescribed examination with the
lowest practical dose to the patient. The recommendations that
follow are intended to provide guidance to the operator and dental
practitioner in exercising responsibility towards reduction of
radiation exposure to the patient.

The operator must not perform any radiographic examinations not

prescribed by the dental practitioner responsible for the patient.
The dose to the patient must be kept to the lowest practical value,
consistent with clinical objectives. To achieve this, techniques
appropriate to the equipment available should be used. It is
recommended the X-ray loading factors charts be established when
using X-ray units which do not have preprogrammed anatomical
feature settings. The loading factors chart must be established after
optimizing the film processing procedure.
 Fluoroscopy must not be used in dental examinations.
Dental radiography must not be carried out at X-ray tube voltages
below 50 kilovolts (peak) and should not be carried out at X-ray
tube voltages below 60 kilovolts (peak).
Dental X-ray equipment should be well maintained and its
performance checked routinely. Accurate calibration of the
equipment should also be carried out on a regular basis.
The quality of radiograms should be monitored routinely, through a
Quality Assurance program, to ensure that they satisfy diagnostic
requirements with minimal radiation exposure to the patient.
The patient must be provided with a shielded apron, for gonad
protection, and a thyroid shield, especially during occlusal
radiographic examinations of the maxilla. The use of a thyroid
shield is especially important in children. The shielded apron and
thyroid shield should have a lead equivalence of at least 0.25mmof
lead. In panoramic radiography, since the radiation is also not
adequate and dual (front and back) lead aprons should be worn.
The primary X-ray beam must be collimated to irradiate the
minimum area necessary for the examination.
The primary X-ray beam should be aligned and the patient's head
positioned in such a way that the beam is not directed at the
patient's gonads and is not unnecessarily irradiating the patient's
body.
The fastest film or film-screen combination consistent with the
requirements of the examination should be used. The film
processing technique should ensure optimum development and
should be in accordance with the recommendations given in section
6.1. Sight developing must not be done.
Dental X-ray films must be examined with a viewbox specifically
designed for this purpose.
While recommended dose limits have been defined for radiation
workers and the general population, no specific permissible levels
have been recommended, to date, for patients undergoing
diagnostic radiographic procedures. For patients, the risk involved
in the radiographic examination must always be weighed against
the requirement for accurate diagnosis. Information from the Dental
Exposure Normalization Technique (D.E.N.T.) program is used to
provide realistic sets of limits. These recommended upper and
lower limits are presented in Table 4. Any patient skin dose greater
than the upper limit presented is an indication of poor film
processing techniques or sub-standard equipment performance.
The lower limits indicate the point where any gain in dose reduction
may be reflected by a loss of diagnostic quality of the film.
http://www.hc-sc.gc.ca/hecs-sesc/ccrpb/publication/99ehd177/chapter9.htm

2. 11 years child has a class II division I malocclusion; he is a thumb

sucker; discuss the causes and how you would manage the case

3. Woman has been wearing an excellent upper denture for sometimes. She
 has lost all of the lower molars but the anterior teeth are still present. What
are the important considerations that you would discuss with the patient in
order to accept a lower partial denture?

4. A woman comes to you and you find that she is on Tricyclic Anti-
depression medication.
How would you manage this patient? Has been answered before

Unknown Dates:
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 Ringer’s 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.

Acute Adrenal Insufficiency

Conscious,

1. Position patient semi-reclining

2. Monitor and record vital signs
3. Administer Oxygen
4. Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV
5. May have to transfer to hospital for lack of fluids

Unconscious

1. Position patient supine

2. Monitor and record vital signs
3. Administer Oxygen
4. Call 000
5. Reviews patient history
6. Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV
7. Administer vasopressor (epinephrine 0.5ml)
8. Rapid transfer of patient to hospital.