dedicated to your success http://dentalbooks-drbassam. blogspot.com i Celta Le ergy aohttp://dentalbooks-drbassam.blogspot.com/ Contents 2 Restorative 43 Oral Surgery 27 4____OralMedicine 5 Oral Pathology 193 6 and Ri 219 7___ Human Disease and Therapeutics 245, 8 General 301List of Contributors Dr A W Barrett BDS MSc PhD FDS RCS (Ed & Eng) FRCPath Consultant Oral Pathologist Queen Victoria Hospital East Grinstead Julia Costello BDS MSc Clinical Demonstrator Department of Periodontology Guys Hospital, Kings College London Richard Jones BDS MSc FDSRCS M. Orth.ACS. Specialist Orthodontic Practitioner Total Orthodontic Lid Sussex Dr Virginia J Kingsmill PaD BDS FDSRCS Lecturer Departement of Conservative Dentistry Barts and The London Queen Mary School of Medicine and DentistryIntroduction Methods of examining and assessing students have changed over recent years. Tradtional essay writing is not as popular as it once was and is cften replaced with short answer questions (SAQs). The advantage of SAQs over essays is that they allow ‘a wider range of topics to be examined ina single paper, anc the merking is cften more objective. They test knowledge recall as well as applicetion of knowledge and Understanding of principles. ‘The questions themselves can take a variety of formats, for example writing notes ‘ona subject, filing in blanks in a paragraph, selecting the appropriate response {rom a ist or one-fine answors. Questions offen have mary interelated parts. SAQs are usually not negatively marked so itis worth attompting all uetions. In most ‘examinations the questions usualy have equal marks alocatac to them unless cthemise stated. This often cives you a clue 2s to how much detail is expected in an ‘answer fora particular question. This book does not include a marking scheme, but ‘most questions ask fora paticular number of responses. ‘The aim of the book i to help candidates assess their knowledge and identfy the areas where they need to read more, as wel as providing valuable examination practice. Its intended to be used as a revision aid for students taking the undergraduate or postgraduate examinations in dentistry, such 2s BDS, IQE and MFDS. Commmon and popular topics have been covered but it was not possible to ‘cover the entire scope of dentistry comprehensively in the book! We hope that you will {ind this book to be helpful anc easy to use. Good luck for the fortheoming exams,i Child Dental Health and Orthodontics http://dentallwcgitaeor a Uespot.com/| CHILD DENTAL HEALTH AND ORTHODONTICS | http://dentalbooks-drbassam.blogspot.com/ 1.1. Fillin the missing detaiis about tooth formation in the table below. eile — ‘Upper As = Lower 85‘SAQs FOR DENTISTRY /ui0s";0dsZo]q'wesseq.1p-syooqyejuap//:dy34CHILD DENTAL HEALTH AND ORTHODONTICS EA) 1.2 (@) Name two conditions that may result in delayed eruption of primary teeth, () Name two local conditions and a systemic condition that may delay permanent tooth eruption (different from your answer to question 1.2 (6) above). (© Is hypodontia more common in the primary or permanent dentition? (6) How common is hypodontia in the primary and permanent dentition? (€) Which sax is it most common in?HIB] 2:0: F08 oeunisiew http://dentalbooks-drbassam.blogspot.com/ Rieti cat IE Me Ben dint SA (@ Any two of he folowing conatuons: + Pretecm bith + Chremosomal abnarmaitis, og Down's syndrome, Turners syndrome + Nutritional deficiency + Hereditary gingiva ibromatosio (0) Local condiions~ any two ofthe folowing + Supermureray teeth + Crowding + Cyste change around te toot fticle ‘+ Ectopic position ofthe tooth germ Genera! conditions ~ any one ofthe following ‘+ Gleidocrania dysostosis ‘+ Chromosomal abnormantis (Down's syndrome, Tumer’s syndrome) ‘+ Nutrtional detciency ‘+ Herecitay gingival oromatsis “+ Hypothyroidism + Hypopitutarism (©) Permanent dentition (@) The prevalence of hypodontia inthe primary dentition is less than 1% and in the ‘permanent dentiton itis about 3.5-6.5% (DiBiase, 1971, Denta Practitioner). (@) Isit more common in females.CHILD DENTAL HEALTH ANO ORTHODONTICS EAI 1.3 (2) What do you understand by the term ‘infraocclusion’ and how is it graded? (b) An 11-year-old boy presents with an inftaocciuded lower second ‘aciduous molar, What percentage of primary molars are affected by this condition? © 35% + 58% = 818% + 15-20% (6) How would you manage this problem? (4) When would you refer for surgical removal? (@) If there is @ permanent successor and the second deciduous molar {s sill nfraoccluded and is below the gingival tissue, what could hhave happened to the second deciduous molar? What will you need to consider after removal of the second deciduous molar? http://dentalbooks-drbassam.blogspot.com/FOR (6) Infraocsluded teeth aro teeth that fll to maintain their occlusal relationship with ‘opposing or adjacont testh. They were previously called submerged or ankylosed teeth. Infraocclusion most commonly affects the deciduous mandibular frst molars. itis graded 2s follows: '* Grade 1 - the occlusal surface of the tooth is above the contact point of the adjacent tooth. ‘+ Grade Il - the occlusal surface of the tooth is at the contact point of the adjacent tooth * Grade Ill-the occlusal surface of the tooth is below the contact point of the adjacent tooth. (0) 814% (©) Take a radiograph to see if there is a permanent successor. If there is one, itis likely that the infraoccluded second deciduous molar will exfoliate at the same time as the contralateral tooth, when the permanent successor starts to erupt. (@) When there is no permenent successor and the tooth wil probably ‘disappeer’ bbelow the gingival margin. (©) The second deciducus molar may have ankylosed. Space maintenance will ‘need to be considered after the extraction to allow eruption of the permanent ‘molar.(LD DENTAL HEALTH AND ORTHODONTICS EE 1.4 (@) A fitand healthy 12-year-old girl attends with her mother following an accident in which she fell off the apparatus at her gym club. She has banged both her upper anterior teeth. Examination reveals no extreoral injuries, but both the upper central incisors are mobile and the crowns are palatally displaced. What special tests would you carry out and why? (b} The upper central incisors are fractured in the mid:-third of the roots. What treatment would you carry out and how long must that treatment be done for? {c) If the coronal portion of the tooth became non-vital what treatment would you carry out? (d) If there were no root fractures, would your management have changed? (@) Ifa dentoalveolar fracture had been diagnosed, would your management have changed and if so how?HE so: 0 Answer (a) The following tests are recommended: ‘Vitality tests of all upper and lower incisors as they may have been injured in the accident. + Poriapical radiographs or an upper standard occlusal view to see if the roots are fractured. (b) Splint the teeth using a fexible spint that alows physiological tooth movement. ‘Awire spit that is bonded tothe injured teeth and one healthy tooth on either side ofthe injured teeth using acid-etched composite is easy to construct and wall tolerated ‘The splint must be keptin place for 2-3 weeks. Previous treatment regimens sed rigid spins for 2-3 months; this is now thought not to give the best results. (6) The pulp should be extirpated up to the fracture tine. The root canal filed with ‘non-setting calcium hydroxide to encourage barrie formation coronal to the fracture line, The calcium hydroxide should be changed every 3 months untl the barrier forms, at which point the coronal root canal should be filled with gutta, percha, and the tooth kept under review. (6) The teeth are mobile and palatal displaced so they must have undergone ‘sore type of displacement injury. These would sill require flexible splinting, usualy for 2-3 weeks. (0) Dentcalveoiar fractures are bone fractures and therefore requite rigid splinting {or atleast 3-4 weeks.CHILD DENTAL HEALTH AND ORTHODONTICS FIRM 1.5 (a) What do you understand by the term ‘behaviour management?’ (0) Name three types of communicative management. (6) Ha child is unable to tolerate dental treatment, drugs may be ‘administered to help the child cope with the procedure. One way of 3 mm orthodontic treatment may be needed when the canines erupt to ‘approximate the incisors ‘Ifthe upper canines are erupted then the incisors will require ‘orthodontic approximation or restorative treatment i reduce the gap, ‘+ If there is a prominent freenum, the patient should be reterred for an ‘opirion/treatment ofthe aenum. Surgical treatment would involve a12 + Wa supemumerary or odontome is present then reler Tor surg removal 28 ‘+ tfteeth are missing, consider closing the midine dastema and a ‘restorative option forthe space created further laterally 4+ Ifthe upper labial segment is procined,a full orthodontec assessment is ‘needed to determine its treatable by orthodontics alone or may require surgical intervertion at alter date. + Ithe upper central and lateral incisors are very narow with spacing then it may be possible to refer for restorative treatment to restore the teath with composite, porcelain veneers or crowns o increase the width and minimise the gaps. {@) How common is cleft ip and palate in western Europe? = 1:200 births = 1:700 births = 121000 biths (b) Atwhat age do most units carry out cosure of the clet lip? ‘+ Neonatal period © 3 months © 6 months © 9 months (© Atwhat age do most units carry out repair of the cleft palate? (@) Name two dental anomalies that often occur in clett patients? (©) Atwhat stage may orthodontic treatment be needed?26 (@) 1700 births () 3 months (0) Between 9 and 18 months (8) Any two of the following: + Hypodontia + Supemumerary teeth ‘+ Delayed eruption of teeth + Hypoplasia (2) In the mixed and/or permanent dentition: ‘+ Mixed dentition ~ proctination of upper incisors may be necessary f they erupt in inqual ocdlusion, otherwise orthodontic treatment is better deterred unt just prior to alveolar bone grafting. Orthodontic expansion of the collapsed arch and alignment ot upper incisors is required prior to alveolar bone grating ‘+ Permanent dentition -fxed appliances are usually required for ‘lgnment and space closure. Orfhognathic surgery and associated ‘orthodontic teatment is cated cut when growrh is completed. Patients classicaly have a hypoplaste maxila with a clas ll maloclusion, and corthognathic surgery is considered for improvementin aesthetics and function, (f) Aveolar bone grating (grafting or placement of cancellous andier cortical bone {rom another site, eg hip or tibia, tothe cleft alveolus) is carried cut to make a ‘one-pisce maxila. The grafting is usually done between the ages of Band 11 years when the canine root is two-thirds formed, to provide bone for: the canine ta erupt into; support forthe alar base ofthe nose; provide an intact arch to ‘low tooth orthodontic movement; and aid closure of any oronasal fistulaCHILD DENTAL HEALTH AND ORTHODONTICS EEA 1.13 (a) How does fluoride affect teeth prior to eruption? (b) How does fluoride affect teeth after eruption? (©) What are the possible consequences of fluoride overdose? (0) Fill in the blanks in the table below to incicate the recommended fluoride supplement regimen for children aes wilt ihn 6 months -3 years 9-6 years Over 6 years. (© Teeth start forming before the age of 6 months so why are fluoride supplements not given to younger children?HBB 0: co ennistay {@) Effects of fluoride prior to eruption: ‘+ The teeth have more rounded cusps and shallower fissures. '» The crystal structure of the enamel is more regular and less acid soluble. (b) Effects of fuoride aftor eruption: ‘+ Decreases acid production by the plaque bacteria ‘© Prevents demineralisation and encourages remineralssation of early caries + Romineralised onamol is more resistant to further acid attacks: * Can inhibit bacterial growth and glycolysis: (0) Possible consequences of fluoride overdose: ‘+ Dental effects - enamel fluorosis, mottling, pitting * Toxic effects ~ gastrointestinal © ees ae se a aCHILD DENTAL HEALTH AND onTHODONTICS ERS 1.14 (a) What are the factors that would put a child at high risk for developing caties? (0) How would you carry out a diet analysis for a child? (©) Ust four pieces of dietary advice that you would give to a parent! Patient.(@) Social factors: ‘+ Family belonging to a lower socioeconomic group ‘regular dental attendance + Poor knowledge of dental disease Siblings with high caries rates Dietary factors: + Easily avaiable sugary snacks + Froquont sugar intake Oral hygiene factors: + Poor plaque contro! + No fluoride Medical history factors: + Reduced salivary flow, or reduced butferng capacty ‘Medically compromised + Physical dsabilty ‘+ Cariogenic mecicine taken long term ‘+ High Streptococcus mutans and Lactobacillus courts () You need to ask the parents (carer) to record on a sheet the time, the food and the amount of everything that is eaten over a 3-4-day period. Try to include one {day from the weokend as diatary habits are often different hen. (0 Encourage: ‘+ Safe snacks (but beware of high-salt foods), eg nuts, fruit, bread, cheese ‘+ Sale drinks ~ water, milk, tea with no sugar * Tooth brushingCHILD DENTAL HEALTH AND ORTHODONTICS ERI iit: ‘+The frequoncy of sugar-containing feod and drinks ‘+ Sweets to mealtimes or one day a woek ‘Avoid + Chewy sweets in paricular + Sweetened arinks in a botie Discourage: ‘There is some controversy surrounding long term breast feeding, but breast milk has a higher lactose content compared with cows’ mill, On demand breast ieeding may give rise to caries, hence try to discourage it Note: Always try to be postive and do not make the parent feel quit. 11.15 (a) Whatis meant by the terms balancing end compensating extractions? (b) Whatis the likely effect of premature loss of a deciduous canine? (6) Is the effect greater or less with the premature loss of a deciduous first molar than with a canine? (@) What would you recommend in a crowded mouth requiring the unilateral loss of an upper canine? (6) Whatis the effect of premature loss of deciduous second molars?WB 5205 For vennstay (@) Abalancing extraction is the extraction of the same or adjacent tooth on the ‘opposite side of the same arch. A compensating extraction is the extraction of ‘same or adjacent tooth in the opposing arch on the same side, (6) The primary effect of early loss of deciduous teeth in a crowded mouth is localised crowding. The extent will depend on several factors, including the Patient's age, extent of existing crowding and the site of the early tooth loss. in crowding, adjacent teeth will move into the extraction space, hence a centraline shift will occur with the unilateral loss of a deciduous canine. (©) Acentreline shift will occur to a lesser degree with the unilateral loss of @ deciduous frst molar compared with a deciduous canine. (@ The unilateral loss of a canine should be balanced as the correction of a contreline discrepancy is likely to need a fixed appliance and prevention is preferable to dealing with the problem, (6) The premature loss of deciduous second molars is associated with forward ‘migration ofthe frst permanent molars. This is greater ifthe deciduous second ‘molars are lost before eruption of the first permanent molars, so if possible, delay extraction of deciduous second molars until the first permanent molars are in occlusion. (f) NeitheCHILD DENTAL HEALTH AND ORTHODONTICS EEE 1.16 (a) An anterior open bite can occur with which types of malocclusion? (0) Give a simple classification of the causes of an anterior open bite. (©) An anterior open bite caused by one factor is relatively straightforward to treat. Which factor is this? (2) What other occlusal features may you see in ths situation? (e) How will you treat an open bite due to the factor in Question 1.16 (HBB) so: Fon vennstev (@ Itcan occur in a Ciass |, Class Il or Class Ill malocclusion. (0) Skeletal causes: ++ Increase in lower anterior face height (increased lower face height or increased maxilary to mandibular plane angle) + Localized failure of alveolar growth Soft tissue causes: + Endogenous tongue thrust Habits: * Digit su (0) Digit sucking (© Occlusal features that may be sean in this situation: + Retrociined lower incisors + Prociined upper incisors + Unilateral buccal segment crossbite with mandibular displacement (6) Itis best not to make @ big fuss of digit sucking. Most children grow out of the habit and the malocclusion usualy corrects itself after several years. However, if there are other aspects of the malocclusion that need treatment, this should not be delayed. Various appliances may help to break the habit.CHILD DENTAL HEALTH AND ORTHODONTICS FEM 1.17 (a) Name five ways in which fluoride is administered to children? (b) Give an advantage and disadvantage of each of the mathods you have listed. I eeRaia SS ROTTS D I Kc 3186 {) Any fvo of the methods listed in the table in answer 1.17 (t) can be given here.CHILD DENTAL HEALTH AND ORTHODONTICS ER 1.18 (@) What types of pulp treatment are there for deciduous molars? Briefly describe each type and when you would use them. {b) How would you restore a tooth that had undergone a pulpotomy?(@) Types of pulp treatment for deciduous molars: Vital puipotomy — this is done when there is a carious exposure in a symptomatic vital tooth. The coronal pulp is removed and the remaining Pulp stumps are dressed with formocresol or 15.5% ferric sulphate. This, is usualy a onevisit treatment and the tooth is restored. Non-vital pulpotomy ~ this is usually a two-visit treatment that is carried out when the pulp is non-vital or when there is infection. The coronal pulp is removed and a pledget of cotton woo! with Formocresol or Beectwood creosote is placed in the pulp chamber and sealed for 1-4 weeks. The tooth is restored with a temporary dressing. At the next appointment the cotton wool is removed and the tooth is restored if the symptoms have subsided. Devitalising pulpotomy - this is done when aneesthesia cannot be achioved for a vital pulpotomy. A plodgot of cotton wool with paraformaldehyde paste is sealed into the tooth for 1-4 weeks or an antibiotc/steroid type paste may be used instead for 1-2 weeks. AL the ‘next vist the coronal pulp is removed and the tooth restored as for a vital pulpotomy. Pulpectomy in tis treatment the entire pulpal tissue is removed. Itis done wnen there is non-vital tissue in the root canals. The canals are leaned and dried and filed with calcium hydroxide paste. (b) With a stainless steel crown usually.CHILD DENTAL HEALTH ANO ORTHODONTICS EERE 1.19 (@) Select the most appropriate word to fill the blanks in this paragraph about development of the maxilla and mandible, The maxilla is derived from the «un... pharyngeal arch and undergoes ossification. Maxillary growth ceases in girls than in boys. The mandible is derived from the ... pharyngeal arch and is a ‘membranous bone. The mandible elongates with growth at the condylar caarilage, at the same time bone is laid down at the ........... vertical ramus, and resorbed ON the... margin. Mandibular growth ceases than maxillary growth and is «in girls than in boys. 11 First, second, third 2 Intramembranous, endochondral 3 Earlier, ater 4 Anterior, posterior (©) What is the ditference between endochondral and intramembranous ossification? Give an example of where each occurs in the head.BB) 220: For oewnsray {@) The maxilla is derived from the first pharyngeal arch and undergoos intramembranous ossification. Maxilary growth ceases earlor in gits (15 years ‘and 17 years in boys). The mandible is derived ftom the first pharyngeal arch ‘and is a membranous bone. The randible elongates with growth at the ccondylar cartilage, at the same time bone Is lad down at the posterior vertical ramus and resorbed on the anterior margin, Mandibular growth ceases later then maxilary growth and is catia in girls (average 17 years in girls and 19 ‘years in boys) (0) Endochondral ossification occurs at cartlaginous growth centres where ‘chondroblasts lay down a matrix of cartilage within which ossification occurs. ‘This occurs at the synchondroses of the cranial base. Intramembranous ossification is the process in which bone is both laid down within fibrous tissue, there is no cartilaginous precursor. This occurs in the bones of the vauit of the skull and the face.CHILD DENTAL HEALTH AND ORTHODONTICS ER 1.20 a) List two localised and three generalised causes of abnormalities in the structure of enamel (0) What do you understand by the term enamel hypoplasia and how ‘does it difer trem hypocelatication? (0) Name three disturbances of dentine formation. (@) What do you understand by the term Turner teeth?aa () Localsed causes ~ any two ofthe following: Generalised causes - any two ofthe following: ‘+ Amelogenesis imperfecta ‘+ Infections: prenatal (rubella, syphilis) postnatal (measles) ‘+ At birth: premature bith; prolonged labour + Fluoride ‘© Nutriional deficiencies * Down's syndrome ‘= Idiopathic (©) Hypoplasia is a disturbance inthe formation of he matrix of enamel which gives tise to pitted and grooved enamel. Hypocaicification is a cisturbance in ‘mineraisation (calcification) ofthe enamel and gives rise to opaque white ‘enamel. (0) Any two of te fotowing: ‘+ Dentinagenesis imperfecta ‘+ Dentinal dysplasia type land I ‘+ Fibrous dysplasia of dentine + Regional edontodysplasia + Ehlere-Danlos syndrome + Vitamin D resistant rickets ‘+ Vitamin D dependent rickets ‘+ Hypophosphatasia () This is caused by infection ‘rom a deciduous tooth atecting the developing Urdertvina permanent tooth. It results in abnormal eramel and dentine,2 BCS SIOCeU om DIC IALUISIEAaesTorarve oennisTeY EES 2.1. (a) Name five causes of intrinsic discoloration of vital teeth, (b) The appearance of discoloured teeth can be improved by methods which require tooth preparation and those that do not. Please name two of each. (0) How would you remove extrinsic staining from tooth surfaces?(@) Any five of the following: ‘+ Trauma resulting in pulpal death * Tetracycine staining + Ameiogenesis imperfecta + Dentnogenesis imperfecta Fluorosis (0) Methods requiring preparation: © Veneer © Grown Methods not requitng preparation: + Bleaching ‘+ Microabrasion + Composite veneers (©) Removing extinsic stains: + Polishing the surfaces with pumice slurry and water or prophylaxis paste + Ultrasonic cleaners «Bleachingresroranive oennisTey EET 2.2 (a) What do you understand by the terms primary dentine, secondary Gentine and tertiary dentine? (b) What is the difference between internal and extemal resorption? (©) Are teeth with internal resorption likely to be vital or non-vital? (@) Are teeth with external resorption likely to be vital or non-vital? (©) Replacement resorption may result in ankylosis. What are the signs of ankylosis?[HEB] s.0: Fon oennistav {@) Primary dentine is formed betore eruption or within 2-3 years after eruption and ‘consists of mainly of circumpulpal dentine. i also includes mantle dentine in the ‘crown and the hyaline layer and granular layer in the root ‘Secondary dentine isthe regular dentine that s formed during the ite of the tooth and laid down in the floor and ceiling of the pulp chamber. tis a physiological type of dentine fter the ful length of root has formed. Tertiary dentine can be divided into reparative and reactionary dentine, both ‘of which are laid down in response to noxious stimul Reactionary dentine is laid 3.5 mm but <5.5 mm Coloured area is completely visble, no calculus but bleeding on probing Coloured area is completely visible: supra- or subgingival calculus detected or overhanging restorations ral hygiene instruction (OH: elimination of plaque retentive areas; scaling and rost surface debridement Complex treatment, referral to a specialist may be necessary OH Olt; ekminaion of plaque retentive areas; scaling and root surface debugerentRESTORATIV Em 2.4 (a) Name four general risk factors for periodontal disease. {b) Name two localised risk factors for periodontal disease. (©) Give two risk factors for gingival recession.BE 200060) Teenerba Si cables RR {@) Any four ofthe following: Poor access to dental healthcare ‘Smoking ‘Systemic disease, eg diabetes: Stress History of periodontal disease Genetic factors, (0) Any two of the following: (Overhanging restorations and detective restoration margins, Partial dentures Oral appliances Calculus (6) Risk factors for gingival recession: ‘Trauma - excessive toothbrushing, digging fingernails into gingWva, biting pencils ‘Traumatic incisor relationship. Thin tissues Prominent rootsRestorative oennsrrY EE 2.5 (a) How does fluoride affect teeth prior to eruption? (0) How does fluoride affect teeth after eruption? (©) What are the possible consequences of fluoride overdose? (@) What is the recommenced flucride concentration in the water supply for optimal caries prevention? (€) What do the following terms mean and at what dose do they occur? + Safely tolerated dose + Potentially lethal dose + Certainty lethal doseTHE) 20: For vennistay {@) Effect of fluoride on teeth prior to eruption: + Teeth have more rounded cusps and shallower fissures. namel is more regular and less acid (©) Effect of fluoride on teeth after eruption: ‘+ Decteases acid production by plaque bacteria. «Prevents demineralisation and encourages remineralisation of early caves. ‘+ Remineralisad enamel is more resistant to further acid attacks, ‘+ Thought to affect plaque and pellicle formation, (©) Possible consequences of flucride overdose: + Dental effects ~ enamel fluorosis, motti + Toxic effects - gastrcintestinal pitting (2) ppm (UK) (©) Terms and doses: ‘+ Safely tolerated dose ~ 1 mg/kg body weight. This is the level below ‘which symptoms of toxicity are unlikely to occur. + Potentially lethal dose - 5 mg/kg body weight. This is the lowest dose that has boon associated with a fatality. + Certainly lethal dose - 32-64 mg/kg body weight. At of the individual is unlikely. is dose survivalRESTORATIVE DENTISTRY BEML 2.6 (a) What is pulpitis? (b) Fill in tho blanks in the following sentences using the words in the table below. You may use more than one word/phrase if you think it is appropriate. Reversible pulpitis is a pain, set off by Itis localised and lasts for .. Irreversible pulpits is a localised and lasts for pain, set off by.. 2 MS Throbbing ain Several Hours Days ‘seconds well Poorly CEU Sweetthings — Hot/cold Biting -—-Spontanecusly pony things (c) What types of nerve bres are there in the pulp? (@) What special tests could you use to help diagnose reversible/ irreversible pulpitis? (e) What treatment is available for a tooth with irreversible pulpitis?Ez ‘OR, (@) Inflammation of the puip. (&) Reversible pulpitis is a sharp pain, set off by hot/cold things and sweet things. It is poorly localised and lasts for several seconds. Irreversible pulpits is a throbbing pain, set of by biting or spontaneously. It is wel localised end lasts for hours. (©) Nerve fe types in the pulp: * AB fibres are large, tast conducting proprioceptive fibres. + AG fibres are small sensory fibres. ‘+ Cfibres are small unmyelinated sensory flores. (©) Special tests: Percussion + Vitality teste © Radiographs (©) Treatments for ireversible pulptis: ‘= Root canal treatment © Extractionaesroratve cennisTay BA 2.7 (@) Patients may have thermal sensttivity following the placement of a restoration. One theory for this is the thermal shock theory. However, another theory for the cause of thermal sensitivity is now more widely accepted - what is it called and what is it based on? (b) How can restorative techniques limit thermal sensitivity? (C) What are cavity sealers used for? (4) Give the types of cavity sealer (e] What is meant by the term microleakage? () What are the consequences of microleakage?DM scosronoenmomy 0 MEDC SoS SU Sb whe 55 (@) Theory of pulpal hydrodynamics Fluid can move along dentinal tubules and when there is a gap between the restoration and the dentine, fuid will sowly flow outwards. A decrease in temperature leads to a sudden contraction in this fluid, and consequertly increased flow, which the patient will feel as pain. (b) When the thermal shock theory was widely accepted, insulating the cavity with ‘a base material was used to prevent pain. Now that the hydrodynamic theory is ‘more widely accepted the aim is to seal the dentine and increase the integrity of the interface between the dentine and the restorative material. (© To prevent leakage at the interface ofthe restorative material anc the cavity walls, and to provide a protective coating to the cavity walls. (@ Cavity sealers: ‘+ Varnishes (eg a synthetic resin based material or a natural resin or gum) '* Adhesive sealers which also bond at the interface between the restorative material and cavity walls (@9 glass ionomer luting cements) (€) Microleakage is the passage of bacteria, fluids, molecules or ions along the interface of a dental restoration and the wall of the cavity preparation (Kidd 1978). (f} Consequences of microleakag ‘© Marginal discoloration of restorations = Secondary caries + Pulpal pathologyoparive oennisTrY EEA 2.8 (@) You are cutting a cavity in a vital upper first permanent molar. You have removed all the caries but then you create a small exposure of ‘the pulp. How would you proceed? (0) Whatis this treatment called? (6) What are you hoping will happen to the tooth by carrying out this treatment? (@) When would this treatment not be appropriate? (@) What ave the advantages of using rubber dam for dental treatment?(a) Management of an exposure during cavity preparation: 1 Ifthe tooth is not isolated already ~ isolate the tooth with rubber dam. Dry the cavity Pace calcium hydroxide over the exposure Cover win cementiner, eg gass ionomer. Restore as normal. Inform the patent. 7 Arrange review. Note: There has been some work using dentine-bonding agents to cover pulpal exposures although tis isnot universal practice atthe present te. (©) Direct pulp capping (©) What may happen: ‘© A dentine bridge wil form, ‘©The pulp will remain vita (©) Comtrainaications of pulp capping: © Nonwital tooth ‘+ History of spontaneous pain - ireversibie pupitis, ‘+ Evidence of periapical pathology + Large exposure ‘+ Contamination ofthe exposure with saliva, oral flora or bacteria trom the caries ‘Also the clder the pulp the less the likelihood of success. (©) Advantages of using rubber dam for dental treatment: ‘+ Isolation and moisture contro - especialy important for moisture sensitive techniques, eg acd etching before composite restorationRestorative pennistry EER ‘+ Prevention of inhalation of small instruments, eg during endodontic treatment ‘+ Improved access to the tocthiteeth — no soft tissues, eg tongue in the way ‘+ Patients do not swallow waier and other irigants ‘+ Soft tissues protected from potentially noxious materials, eg etchant 2.9 (@) What restorative material is capable of adhesion to the tooth tissue without surface pretreatment? () How may adhesion be improved? (©) How does this material bond to tooth tissue? (¢) Besides the obvious advantage of being adherent, what oth advantages are there of using this materia? (© In what clinical situations is it used?WHR 8005 For vewnisty {a} Glass ionor (b) Using a polyalkenoic acid conditioner (©) Glass ionomer bonds by: + Micromechanicel interlocking - hybricisation of the hycroxyapatite- coated collagen fibril network ‘+ Chemical bonding - ionic bonds form between the carboxy! groups of the polyalkencic acid and the calcium in the hydroxyapatite (4) Other advantages of glass ionomer: + Itreleases fluoride. ‘+ Quick to use as limited pretreatment of the tooth surface is needed. (e) Glass ionomer is used: + Asa permanent direct restorative material, suitable for deciduous end permanent teeth + Asa temporary restoration + Asaluting cement + -Asacavity ining or base + -Asa.core build-up material + Asaretrograde root filing material + Asapit and fissure sealantresrorarive nenristay EER 2.10 (a) What do you understand by the term ‘the smear layer?” (©) Dentine can be treated with acid (or conditioned). What does this achieve? (©) Why are primers needed curing the process of creating an adhesive restoration? (@ What do you understand by the term hybrid layer and where would you find it? (©) What do dentine bonding agents do?HEE 2100 cor oenristev (@) When tooth tissue is cut, the debris is smeared over the tooth surface. This is callad the smear layer and it contains any debris produced by reduction or instrumentation of dentine, enamel or cementum. It is calcific in nature or a Contaminant that precludes interaction of restorative materials with the underlying pure tooth tissue. (8) Within dentine, acid treatment removes most of the hydroxyapatite and exposes ‘a microporous network of collagen. The smear layer is altered or dissolved. The bonding that results is diffusion based and relies on the exposed collagen fibril scaffold being infitrated by the resin ; (0 The dentine surface after conditioning is dificut to wet with the bonding agents. ‘The primer transforms this surface from a hydrophilic state into a hydrophobic state that allows the resin to wet and penetrate the exposed collagen fib. (©) The hybrid layer is the area in which the resin of the adhesive system has interlocked with the collagen of the dentine, providing micromechanical retention, {(@) Dentin bonding agents: ‘+ Form resin tags in the dantinal tubules. ‘© Stabile the hybrid layer. ‘+ Forma link between the resin primer and the restorative mrestorative centistaY BEA 2.11 (@) What are the aims of obturating a root canal? (0) Name the methods of fling a root canal with gutta percha? (c) Name three causes of intra-radicular failure of a root canal treatment. (0) Name two causes of extra-radicular failure of a root canal treatment, (e) What are the indications for an apicectomy (surgical endodontics)?emmeeaat o 0 S Co aa ametinae Biles {@) Aims of obturating a root canal: ‘+ To provont reinfection ofthe cleaned canal. ‘+ To provent periadicular exudate from entering into the root canal. ‘+ To seal any remaining bacteria in the root canal. (0) Methods of ling a root canal with gutta percha: ‘© Single cone method ‘+ Lateral condensation - warm or cold ‘+ Thermomecharical compaction ‘© Vertical condensation ‘+ Thermoplasticised gutta percha method ‘+ Carrer based techniques (0) Any three of the folowing: ‘© Necrotic material leftin the canal ‘+ Bacteria let in the root canal system (lateral or accessory canals) ‘© Contamination of the canal during treatment ‘© Lossiiack of coronal seal ‘© Persistent infection ter treatment (Two causes: © Root fracture ‘+ Radicular cysts (0) Indications for an apicectomy: ‘+ Infection due to a lesion that requires a biopsy, eg radicular cyst. ‘+ Instrument stuck in canal with residual infection ‘+ Impossible to fil apical tied of root canal due to anatomy or pulp calcifcation.RESTORATIVE DenTisTaY EEA ‘+ Perforation of the root. + Post crown with excellent margins but persistent apical pathology. Infected, fractured apical third of root 2.12 (a) What is acid etching of enamel? (b) What acid is commonly used and at what strength? In what form are ‘etchants produced (eg powder, liquid) and what effect do the different forms have on working properties? (€) How long should the acid be applied for? (@) What do you do after applying the etchant for the above length of time? (@) What is likely to damage the etched enamel surface and reduce the efficacy of bonding? (f) What do you understand by the term ‘total etch technique’ (or etch and rinse) and which acid would you use for it?PEEL 8405 ron vennstay (a) Application of a mild acid to the surface of enamel results in dissolution of ‘about 10 ym of tne surface organic component, leaving a microporous surface layer up 10 50 lm deep. The surface is thus pitted, and the unfiled resin of the restorative material is able to flow ito the imegularties to form resin tags that provide micromechanical retention. (&) 30-40% Phosphoric acid is commonly used. Eichants come as gel or liquid, however, in the newer systems the etchant is combined withthe dentine ‘conditioner. The etch produced is the same with a gel or iquid but gels take twice as long to rinse away. Gels are loss likely to drip onto areas where etching is not intended. (0) Usually 15 seconds, (@) Wash away the etchant with water for at least 15 seconds, (©) Blood and saliva, and mechanical damage may occur by probing the area, rubbing cotton wool over ito dry itor by scraping across the surface withthe suction tip or an instrument. {f) The total etch tochrique involves using an acid to etch the enamel and condition the dentine at the same time. Commonly used acids include phosphoric acid (10-40%), nitric acid, maleic acid, oxalic acid and citric acidresToraTive penmisTay EE 243 A20-year-old fit and healthy wornan attends your practice complaining of gaps between her upper anterior teeth. History and ‘examination reveal that she has missing upper lateral incisors. List the treatment options in the table below. Give an advantage and disadvantage of each option. (Note: the number of rows in the table does not correspond to the exact number of treatment options, therelore all rows ofthe table do not have to be file, or if you have more treatment options please write them below.)'NB. with the later 4 treatment options orthedontics may be required in cenjunetion.RESTORATIVE im 2.14 (a) Name thvee agents that are used for chemcal plaque control and ‘state how they are thought to work. (0) Some antimicrobials (antibictics) have been formulated in such a way that they are suitable for use within a periodontal pocket. Give {four advantages of administering a drug in this manner and name ‘one such antimicrobial?(@ Chamical plaque contra: (0.412% Chlorhexidine digluconate ~ bacteriostaic at low doses and bacteriocical at high concentraions, Bacterial cell wails are negatively charged due tothe phosphate and carboxy! groups, but chlorhexidine Is. positively charged. Electrostatic charges cause the chlorhexidine to bind ‘0 the bacterial cell wall atfecting the osmotic barrier and interfering with ‘transport across the cell membrane. Unwanted effects are staining of tooth and altered taste (Quaternary ammonium compounds - cetylpyriinium chloride, benzalkonium chloride, benzethonium chiride. Net positive charge reacts with the negatively charged bacterial cell wals, causing disruption of the call wal, ncrease in permeabilty and loss ofthe cell contenis. Pyrimicine derivatives ~ Hexetcine (nexahydropyridine derivative). has antibacterial and antifungal actity, affecting the rate of ATP synthesis in bacterial mitochondria Phenols ~ antibacterial agents that penetiate the lipid components of bactral coll walls. These also have an antintamratory action as they ‘hibit neuropht chemotaxis. Examples ere thymol(Listerin) bisphencl riclosay Sanguinarne~ this isa benzophenathidne akaloid and has antibacterial properties as it causes suppression of intracellular enzymes, Heavy metal sats ~ these ae thought to work by binding to the Ipoteichole ac on bactoral coll walls and altering tho surface charge hich in tu affects the ability ofthe bacteria to adhere to teeth. Enzymes ~ lactoperoxidase, hypothiocyanate. These are thought to interfore withthe redox mechanism of bacterial cel. Surfactants - these ater the surface energy (tension) of he tooth and ‘his intertores win plaque growth.| RESTORATIVE DENTISTRY fm {b) Any four ofthe folowing: ‘+ Drug is actually delivered to where it is needed, not throughout the whole body + High local drug concentrations can be achieved ‘+ Fewer systemic side elfects * Overall lower doses of the drug need to be administered «Drug delivery is not dependent on patient compliance + Prolonged drug release Example — any one of the following: + Antimicrobials + Tetracycline + Metronidazole 2.15 (a) What is a composite restorative material? (0) List the types of composite restorative material you know in the table below. Give an advantage/disadvantage of each type.(Ree 5 So RT 7 4 {@) It's a type of restorative material mace of a mixture of materials (hence the ‘name): organic resin matrix, an inorganic filer and a coupling agent () “Traditional composites Good mechanical ‘Surtace roughness; properties Cu,Sn, + y,; leaving ite or roy, (@) Lathe cut alloy is mde by chipping off pieces from a solid ingot of the alloy. ‘This results in partces of aifferent shapes and sizes. Spherical particles are ‘made by melting the ingredients ofthe alloy together and spraying them into an inert atmosphere. The droplets then solidi into sphercal pellets that are regular in shape and can be more closely packed together. This results in ‘amalgam that requires less condensation force and resuits in increased strength of the amalgam. (@) When amalgam is condensed the mercury rises to the surtace ofthe restoration. ‘To try to minimise the residual mercury let in the restoration it is usual to overil the proparation and the excess mercuryrich amalgam can be carved away leaving the lower mercury containing amalgam which has a greater strength ‘and better longevity (1) Ina sealed container under liquid, usualy xray fxative, solution,Restorative oenrisTrY RES 2.33 (@) What are dental ceramics made out of? (b) What aro the three technical stages in producing a porcelain jacket crown? (0) Give one advantage and disadvantage of porcelain jacket crowns. (0) How has the main disadvantage of porcelain jacket crowns been ‘overcome? (€) What does CAD-CAM mean in connection with ceramic restorations? (f) Give three requirements of a metal-ceramic alloy.FIRE 202 Fon vestry {@) Ceramics are made of feldspar silica (quartz) and kaotn. {b) The fist stage is compaction. The powder is mixed wit water and applied to the die so as to remove as much wate as possible and compact the material ‘uch hat there isa igh density of particles, which minimises firng shrinkage. ‘The next siage is fring. The crown is heated ina furnace to alow the molten {ass o flow between the powder particles and fil the voids. The last stage is Gazing, which is done to produce a smooth and impervious outer layer. (©) Advartages - any one ofthe following: ‘© Excellent aesthetics ‘© Low thermal conductivity ‘+ High resistance to wear ‘+ Glazed surface resists plaque accumulation Disadvantages - any one ofthe folowing *+ Poor strength and very brite, so often fracture + Firing shrinkage so must be overbuit (@) By fusing the porcelain to meta to produce metal ceramic restorations; by ‘making reinforced ceramic core systems; and by creating resin-bonded ceramics. (@) Computer assistedisided design, computer assisted/aided manutactu () Any tree of the following: ‘+ High bond strength to the ceramic ‘+ Noadverse reaction with the ceramic ‘+ Metting temperature must be greater than the fring temperature of the ceramic © Accurate fit + Biocompatibierestorarive penmisTay RRA + No corasion + Easy fo use and cast + High eestic modus + Low cost 2.34 (a) What are the uses of dental cements? (b) Give two examples of the types of material used for each purpose. (@) Which zinc-based cement bonds to tooth substance? (d) How should this material be mixed and why? (€) Which cement should not be used under composite restorations and why? (f) Which material is used for pulp capping and why? (@ Which cement is thought to reduce sensitivity of a deep restoration?[BRIE 00: Fon ozwnstay {@) Uses of dental cements: + Luting agents + Cavity linings and bases + Temporary restorations (b) Examples: + Luting agents - moaitied zinc phosphate, zinc oxide and eugenol, zinc polycerboxyiate, glass ionomer, resin modified glass ionomer, ‘compomers, resin coments ‘+ Cavity linings and bases - calcium hydroxide, zine oxide and eugeno! ‘Temporary restorations - zinc oxide and eugenol, glass ionomer (¢) Zine polycarbonate (d) On a glass slab as it must not be mixed on anything that absorbs water, also a glass slab can be cooled and this will increase the working time. (e) Zinc oxide and eugenol as the eugenol is thought to interfere with the proper setting of the composite material. (Calcium hydroxide as itis extremely alkaline (pH 11), which helps with formation cof reparative Gentine. It's also antibacterial and has a long duration of action. {g) Zinc oxide and eugenol is thought to reduce sensitivity due to the obtundent and analgesic properties of the eugeno!restorative oenristay EEE 2.35 (@) What are the indications for anterior veneers? (b) What materials are used for veneers? (c) What would you need to check prior to advising placement of veneers? (@) What is the tong term prognosis of veneers and what would you warn the patient about? (@) What is the thickness of the veneers? () What are the key points during tocth preparation?iaar23e 4 (2) Indications for anterior veneers: . . Discoloration of teeth For closure of spaces/midline diastema Hypoplastic teeth Fracture of teeth Modifying the shape of a tooth (b) Materials used: . Porcelain Composite (direct/indirect) (0) Ghack the following: Is the discoloration enough to warrant treatment or is it so severe that it will not be masked. The patient's smile line -this helps determine which teeth need treatment if for aesthetic reasons only, placement of cervical margin Is there enough crown present to support a veneer Any occlusal restrictions, eg edge to edge occlusion, imbrication ‘Any parafunctional activities |s there an alternative option, eg bleaching (d) May require replacement in the long term (eg approximately 4 years for composite veneers) as a result of: * Risk of chipping of incisal edge Debonding Need to keep good gingival healthRESTORATIVE iis | (Key points dizing tooth preparation: * Tooth reduction labialy ~ depth cuts are helpfu. * Chaméer finish line is helpful for the technician, ‘+ Margin - slightly supragingival unless discoloration, then margin can be subgingival + Extend into embrasure but short of contact point. + Incisally eter chamfer or wrap over onto palatal surface. 2.36 (a) Whatis the function of a post and core? (©) What is important to check prior to placement of a post and why? (©) What isthe ideal length cf the post? (@) Give a classification of a post and core system. (@) What are the ideal characteristics of a post? {() What measures can be taken to avoid post perforation? {(g) How would you manage a post perforation?Ree us [@) Provides support and retertion forthe restoration and distributes stesse. the root (b) The condition ofthe orthograde root ling and he apical conation as Pavement ofthe post wil makeit ciftcut fo redo the root cand! fling soit necessary repea!orthograde root canal treatment. (©) Ideal length is at least the length of the crown; approximaily two-thirds of the ‘canal length; and the apical seal must not be dsturbed so atleast 4 mm of well-condensed gutta percha should be let. (@) Classification of post and core system: ‘+ Profabriested or custom made ‘+ Parallel sided or tapered ‘+ Threaded, emooth or sorrated ‘+ Bo as parallel as possible ‘+ Have a roughened or serrated surface + Not otate in the root canal (), Caretu choice o post + Avoid large diameter postin small tapered rots. instead sed tapered ‘post and cement passively + Avoid tong post in curved roots + Avoid threaded post which wil increase interna stess within root cael (@) Depends onthe ocaton ofthe perforation. itis inthe corona third try to incorporate into the design ofthe post crown, eg diaphragm post and core reparation. Fora mirimal peroration in the middle third sea, the perforation (6a lateral condensation) and reposition the post. For a perforation i the apical twosthirds, use a surgical approach to try to reduce the exposed post and sea ‘he pertoraton. I attempting repair ot perforations, tne Use of MTA - mineral tioxide aggregate - would be preferable. Due tothe poor long-term prognosis, ecracion and implant placement may be favoured.aesrorarive cenmisTaY EEA 2.37 (a) Wnen are posterior crowns used? (b) What are the principles of tooth preparation for a posterior crown? (¢) How much tooth reduction is required for different materials used for Posterior crowns? (@) What features affect the retention and resistance form of the crown preparation? Give three for each form. (¢) What are the advantages of partial coverage crown over full coverage crown?'SAQ5 FOR DENTISTRY (@) Post crowns are used for: ‘© Bridge abutments, ‘+ Restoring endodontcally treated teeth. ‘+ Repairing tooth substance lost due to extensive ceries/remaining tooth substance requires protection. ‘+ Fractured teeth ‘+ Situations in which itis ditfcut to produce a reascnable occusal form in a plastic materal (0) Piincipies of tooth preparaton: ‘+ Remove enough tocth substance to allow adequate thickness of material (600 below). ‘+ Develop adequate rotention and resistance form. ‘+ Marginal integrity, supragingival and onto sound tooth where possible. (©) Tooth reduction required: ‘= Full veneer gold crown ~1.5 mm on functional cusp, 1 mm elsewhere + Porcelain fused to metal crown ~ same tooth reduction as for gold ‘crown except where porcelain coverage is required where more tooth ‘substance must be removed. ‘© Occlusal reduction - metal occlusal surlace requires same tooth reduction as for gold crown. ‘© All porcelain ~ occlusal surtace 2 mm supporting cusps and 1.5 mm ‘Ron: supporting cusps; buccal reduction 1.2-1.5 mm; margins 1.2-1.5 ‘mm; shoulder: if porcelan to tooth margin otherwise chamfer finish as for gold crown.restorative oennistey RRB (@) Advantages of partial coverage crown: + Preservation of tooth structure + Less pulpal damage ‘+ Margins more likely to be supragingival ‘+ Remaining tooth substance can act as a guide for the technician 2.38 (@) A 21-year-old woman presents with gingival recession affecting the lower incisors. How will you manage this? (0) Ifthe recession is mild on all except the lower lett lateral incisor how would you proceed? (©) What are the possible causes of gingival recession? (@) If the gingival recession continues on the lower left lateral incisor what other options may you consider? (@) Where is the free graft often taken trom?23820 (a) Take a thorough history: ‘© Present concems, sensitivity + ay penn cone * onal nay + Toobin. ney ad don ‘© Any previous orthodontic treaiment Tn sir hou ee seston pen page nests, probing depth, bleeding, amount of altached gingivae, presence of functional ‘ghgjvae, tooth mobility, vitality testing, occlusion, orl hygiene technique and instructions. (©) Target traumatic tooth brushing and improve plaque control; monitor the ‘progression with clinical measurements, photographs; and treat sensitivity. Take impression ‘or study models. (©) Causes of gingival recession: ‘+ Traumatic toombrushing ‘+ Incorrect toothorushing technique + Abrasive toothpaste ‘Traumatic occlusior/incisor relationship * Tooth outof arch ‘+ Orthodontic movement cf tooth labialy ‘+ Habits such as rubbing of gingivae with fingernail, pen etc. (@) Mucogingival surgery to correct recession by a: + Lateral pedicle graft ‘+ Double papilla taprestorative vewnistay SE + Coronally repositioned fap (these can be sown witha interpostional graft) © Free gingival graft to provide a wider and functional zone of attached gingivae + Thin acrylic gingival veneeristent (rarely used) (©) Paiate 2.39 (@) Give six clinical features of necrotising ulcerative gingivitis. (©) What organisms are implicated? (©) What are the risk factors for necrotising ulcerative gingivitis? (@) How would you treat it?122 (0) Ary ico the folowing: + Paint yelowish whe ucer '* Initially involve the interdental papillae + Spread tonvole the labial and lingual marginal gngivee + Metalic teste + Regional ymphaderopatry + Fover + Malaise '* Poor oral hygiene '* Sensation of teeth being wedged apart + Foto ors (©) Maxed picture: uro-sprochaetal organisms (Borel vincent, Fasobacterum {usiformis) and Gram-negative anaerobes including Porphyromonas, Trepenema ‘species, Selenomonas species and Prevotelia species. (©) Risk factors are: ‘+ Poor oral hygiene + Pre-existing gingivitis = Smoking + Stress ‘+ Malnourishmert and debilitation ‘+ Human immunodeficiency virus (HIV) infection () Treatment of necrotising ulcerative gingivitis:restoranve oennistay SER * Debridement + Chemical plaque conircl, eg chiothexidine ‘© Metronidazole 200-400 ma three times daily for 3 days it systemically unwell ‘+ Advice on managoment of risk factors, oral hygione instruction, nutitional advice 2.40 (a) How can you classify periodontal disease? (0) Define localised juveniie periodontitis? (©) How do you manage it? (@) Give four indications for periodontal surgery?AOE SCRE Reais N24 (@) Gingival disease: + Gingiits + Nocrotsing uleorative gingivitis (NUG) Periodontal cieoase: ‘© (Aggressive periodontitis) Earty-onset periodontitis (prepubertal, juvenile, periodontitis) + (Aagressive periodontitis) Reply progressive periadoniti, + Adult periodontitis: + Necrotising ulcerative gingivitis periodontitis '* HIV periogontitis Alternative classification of Periodontal disease (Armitage GC, 1996) © 1 - Chronic periodontitis: + I--Aggressive pericdontis ‘+l Periodontits asa manitesiaton of systemic disease '* IV-- Necrotising periodontal disease '¢ V-~ Abscesses of the periodontium © VI- Periodontitis associated with endodontic lesions ‘+ Vil Development of acquired deformities and conditions (0) An aggressive periodontitis occurring in an otherwise healthy adolescence, characterised by rapid loss of connecive issue attachment and alveolar bone Joss, Usually lcalsed to the incisors and frst molars although it can be ‘generalised. (0 Management of juvenile periodontitis: 1 Oral hygiene instruction. 2. (Microbiology culture and sensitivity) MCS of subsingival flora. 3. Scale and root} andlor access flap surrestorative oenrisTay BEER 4 Antibiotics (usually responds to tetracycine) 5 Consider surgical excision of pocket lining. (@) There are no strict indications of periodontal surgery but in certain clinical situations it's more tkely to be incicatec: + Pockets greater than 6 mm ‘+ Pockets associated with thick fibrous gingvae + Furcation involvement ‘+ Mucogingival deformities or extensive periodontitis lesion requiring reconstruction or regenerative treatment + Short clinical crown requiring increase in clinical crown height ‘+ Gingival hyperplasia3 O}celnelulce |= 101ORAL SURGERY. 3.1. (@) What does the term pericoronitis mean? Which testh are most commonly affected by i? (b) What are the signs and symptoms of pericoronitis? (©) How do you treat acute pericoronitis?HEBD s:0: ron (@) Pericoronitis means infection of the tissue surrounding the crown of a tooth. The lower third molars are most commonly affected. o Devens on the severity of the infection: Mild ~ swelling of sot tissue around the crown ofthe tooth, bad taste, pain + Moderate — lymphadenopathy, trsrrus, extraoral swelling + Severe - fever, malaise, spreading infection and abscess formation (6) Treatment depends on the severity of the infection, Management of mild infection includes: + Oral hygiene instructions such as clearing around the tooth end ‘operculum with chlorhexidine or hot salty water ‘+ Relief of trauma from opposing tooth — grind cusps or extraction of the tooth + Analgesics + Antibiotics (Metronidazole) ‘Severe infection may need hospitalisation, intravenous antbiotics, removal of the lower third molar andior incision and drainage.onat suaceey BERN 3.2 (@) What does the acronym NICE stand for? (0) NICE guicelines gives specific indications for removal ot wiscom teeth. List five such indications. (¢) What features on a radiograph would suggest that a wisdom tooth is associated with the inferior dental nerve? (@) What specific information must be given to a patient prior to removal ‘of an impacted lower wisdom tooth, which you would not give if you were removing an upper wisdom tooth?(@) National Institute of Health and Cainical Excellence (©) Surgical removal of impacted third molars should be limited to patients with evidence of pathology such as (any five of the following): Caries Nor-treatable pulpal and/or periapical pathology Cetutitis Abscess and osteomyelitis Intemal and external resorption of the tooth or adjacent tooth Fracture of tooth ‘Toothiteeth impeding surgery or reconstructive jaw surgery Tooth is within the field of tumour resection (©) Loss, deviation or narrowing of the ‘tramlines' ofthe inferior dental canal, and a radiolucent band across the root ofthe tooth, (@) Information spectfic 1 lower wiscom teeth: numbness/tingling of the lower lip, chin and tongue which may be temporary or permanent, This information needs to be given to the patient because of the possibilty of damage to the inferior dental nerve or the ingual nerve during the procedure,onat suacery EER 3.3. (@) What do you understand by the term meal-time syndrome? (b) Which gland does it affect most commonly and why? (©) What investigations would you carry out if it affected this gland? (@) How would you manage an acute episode?FEEBL s20: c08 cewtistay (2) Patients who have an obstruction in a duct of a major salivary gland often ‘complain of pain and swelling in the region of that gland on smelling or eating {ood and also on anticipation of food. (0) It most commonly affects the submandibular salivary gland because the saliva, procuced by this gland is a thick mucus-type, and the duct is long and has an Upward course wth a bend at the hilum. (6) Investigations: Bimanual palpation Plain radiography - usually @ lower occlusal view although @ calculus may be seen on a panoramic radiograph. Sialograpny Ultrasound Scintiscanning () Management of an acute episode: Encourage salvation, eg by massaging the oland Hot salty mouth baths Consider commencing antbictics Arrange review for definitive treatment when acute symptoms have subsidedoat sunceny REE 3.4 (@) A patient complains of an ulcer on their tongue. Which of the following features of the ulcer would make you suspect that it was malignant: + Indurated + Rolled edges © Healing + Pain + Size + Awhole crop of ulcers present ‘+ Present on the tip of the dorsum of the tongue + Present on the lateral border of the tongue + Healing (0) Which groups of people are most likely to have oral malignancies? ‘© Children/young adults/older acuts + Males/females (©) What are the risk factors for oral malignancy? (@) What is the most common malignancy of the oral cavity? (©) What treatment is available for the most common malignancy of the ‘oral cavity?(@) Features suspicious of malignancy: © indurated: + Rolled edges ‘+ Prosent on the lateral border of the tongue (0) People most likely to have oral malignancies: + Older adults © Males (@ Risk factors for oral maignancy: © Smoking ‘© Alcohol consumption + Intraoral use of tobacco products such as snuff ‘+ Bete! nut/pan chewing (@ Squamous cell carcinoma (©) Surgery: ‘© Excision and primary closure '* Excision and reconstruction Raciotherapy: ‘+ Surgery and radiotherapy (and/or chemotherapy) combined * Other modalities + Photodynamic therapyoratsuacery RERAE 3.5 (a) What does the term ‘internal derangement of the temporomandibular joint (TMu)’ mean? (0) What mignt a patient with an internal derangement of their TMJ complain of? Please give the underlying reason for the complaint. (6) Ifthe internal derangement was unilateral to which side would the ‘mandible deviate on opening and why? (d) If imaging of the TMJ were required, which type would be ideal?REE s20s con vennistey {@) A localised mechanical fault in the joint, which interferes with its smooth action, (W) Patients may complain of: + Clicking of the joint (displacement of the disc prevents the condyle from ‘moving smoothly and if the disc and condye ‘jump’ over each other, this is felt by the patient as a click or pop). * Locking of the joint the disc may be displaced and prevant the condyle {rom moving normally within the fossa. This may have the effect of focking of the jaw). ‘+ Pain in tho joint (may be due to the joint ital, and alteration in the ‘synovial fuid has been suggested as a cause for arthropathy. There may also be associated muscle spasm which can cause pain). (6) The mandible would deviate towards the side of the intemal derangement. This {is because the mancible is able to carry out the hinge movement normally, hence the mouth opens (usually about 1 cm). Further movement is usually due to translation of the condyle. I there is an obstruction on one side that condyle wil not translate and move forwards. The other condyle continues to move in a ‘normal manner and the midline moves towards the siatic condyle, ie the side with the internal derangement. (@) Magnetic resonance imaging (MRI)ona. sunccry REE 3.6 @ Which branch of the Trigeminal nerve is most frequently affected in trigeminal neuralgia? (b) In which sex and at what age does this occur more commonly? (© Iyou had @ patient with symptoms of trigeminal neuraigia who did riot fit into the common demographic group, what other condition might they have? (@) Give five features of the pain of trigeminal neuralgia. (0) Name two types of medication that are effective in trigeminal neuralgia? () Trigeminal neuralgia attecting the ID nerve of the mandibular branch of the Trigeminal nerve may be treated surgically. What procedures do you know that can be used on the distal (peripheral) aspect of the nerve? (g) Less commonly neuralgia may affect another cranial nerve and patients may present with pain to their dentist. Which nerve is involved?(@) Mandibular > maxillry > ophthalmic (0) Female > male, mid to old age {6) Differential diagnosis: Mutiple sclerosis A contra lesion (@) Any five of he follownng: ‘All the above procedures are do Paroxysmal Tigger area Does net disturb sleep Excrucatng pain Shooting ‘Sharp, electric shock, burning character Short acting Lamotrigine Oxcarbazepine Bacioten Cryotherapy ‘Alcohol injection Nerve sectioning the point where the nerve enters th ‘mandible athe lingua.ora. suncery REM 3.7 (@) What do you understand by the term ‘dry socket?’ (0) Give five factors that would predispose a patient to getting a dry socket? (6) How soon atter the extraction does the pain usually start? (2) How would you manage a patient with a dry socket?1 (0) Any five of the followit (@) Itis the localised osteitis that occurs in a socket following removal of a tooth. Smoking Oral contraceptives Difficult extractions Mandibular extractions: Posterior extractions Single extractions Immunosuppression Bony pathology (6) 2-8 days after the extraction. (@) Steps in the management of dry socket: Reassurance and explanation. Give analgesics. Debrice the socket with chlorhexidine or warm salty water. Gentle pack the socket with a dressing, eg Alvogyl Review if necessary.‘ORAL SURGERY. 3.8 (a) What are the common signs and symptoms of each of the following condltions? Choose the most appropriate from the lst below. Options may be used either once, oF not at all Unaisplaced unitateral tractured mandibular condyle Orbital blow-out fracture Bilateral displaced fractured condyles Le Fort i fracture Fractured zygomatic arch Fractured zygoma Fracture ofthe angle of the mandible Dislocated mandible ‘Anterior open bite Anaesthesia/paraesthesia ofthe infraorbtal nerve ‘Anaesthesia/paraesthesia ofthe inferior orbital nerve Limited eye moverents especially when trying to look upwards ¢ Tismus ereoanen 1 Pain on mandibular movements but no occlusal ateration 9 Anaesthesia/paraesthesia ofthe inferior dental nerve h_Anaesthesia/paraesthesia of the facial nerve |. Cerebrospinal fluid (CSF) leak from the rose | Umited mandibular movoment possible, but inabilty to occlude ‘oF open wide. The patient appears to have a class Il malocclusion, wth hollowing othe TMJ area. {b) What do you underetand by the term orbital blow-out? Which part ofL:: Answers @ 1 Noane Uncisplaced unilateral fractured mandibular condyle ~ pain on ‘mandibular movements but no coclusal aeration Orbital blow out fracture — limited eye movements especially when tying to look upwards Bilateral dispiaced fractured condyles — anterior open bite Le Fort Il fracture ~ CSF leak from the nose Fractured zygomatic arch -trismus. Fractured zygoma - anaesthesia/paraesthesia of the infraorbital nerve Fracture of the angle of the mandible ~ anaesthesia/paraesthesia of the inferior dental nerve Dislocated mandible — limited mandibular moverent possible, but inability to occlude or open wide, The patient appears to have a class Il ‘malocclusion, with hollowing of the TMJ area, (€) Orbital blow-out means that the rim of the orbit is intact but some part of the bony orbital wall has been fractured. Usually the floor or the medial wall fractures as the bone is thinnest in these regions.onarsuncery REE 3.9. @) For each of he following conditions select the most appropriate medicine from the list below. Each option may be used either once: or not at all. 1 Bell's palsy ‘Atypical facial pain ‘Acute periceronitis Post surgical pain relet ‘Angular ches Antibiotic cover for an extraction for a patient with a prosthetic heart valve 7. Prevention of postsurgical bleeding 8 Tigeminal neuralgia ‘+ Ibuprofen 40 mg three times daily for 5 days ‘+ Ibuprofen 400 mg three times dally for 5 days ‘+ Carbamazepine 100-200 mg twice daily ‘+ Prednisolone 0.5 ma/ka!12 hours for § days ‘© Aciclovir ‘+ Miconazole get ‘+ Nortriptyline 10 mg continuing prescription ‘+ Metronidazole 200 mg three times daily for § days ‘+ Motronidazole 200 mg four times daily lor § days ‘+ Tranexamic acid mouthwash three times dally for § days = Amoxicilin 3.9 (6) Name four local meesures that can be used to control post-surgical bleeding?REEL sos F08 vennistay @ Bell's palsy - prednisolone 0.5mg/kg/12 hours for 5 days ‘Atypical facial pain ~ nortriptyline 19 mg continuing prescription ‘Acute pericoronitis - metronidazole 200 mg three times daily for § days Post-surgical pain relief - ibuprofen 400 mg three times daily for 5 days ‘Angular cheiltis - miconazole ge! Antibiotic cover for an extraction for a patient with a prosthetic heart valve- amoxicilin 3.9 Prevention of post-surgical bleeding - tranexarric acid mouthwash three times daily for 5 days Trigeminal neuralgia ~ carbamazepine 100-200 mg twice daily (b) Any four of the following: Apply pressure ‘Adinister local anaesthetic with vasoconstrictor Pack with haemostatic cressing, 2g Surgical suture Bone wax Biting on a swab soaked wit tranexamic ac, tranexamic acid mouthwashes Acrylic suck-down splintona. surcery EEG 3.10 (@) What are the alms of management of a fractured mandible? {(b) What are the stages of managing a fractured mandible that needs active treatment? (©) The most common mode of treatment of fractures of the mandible nowadays involves the use of mini-bone plates across the fracture site. Why is intermaxillary fixation often done along with this? (©) Give three complications of a fracture of the mancible, {(@) What term is used to describe a fracture that involves both condyles ‘and the symphyseal region, and what is the characteristic mechanism of injury?DMB secs ros cons Answer 380 (a) Restoration of function and aesthetics, (b) Stages of treatmentimanagement + Reduction + Fixation + immobilisation ‘+ Rehabilitation. (c) Intermanillary fixation is done to re-create the patient's original occlusion whilst the fractured bone ends are fixed together-The IMF also allows extra traction to be appliod after the operation if needed. (d) Any three of the following: + Nor-union: + Malunion + Infection + Malocclusion + Norve damage (@} Guardsman tracture - itis thought to occur when a patient falls on their chin (traditionally Guardsman fainting on parade ~ hence the name) or suffers a blow to their chinoat sunceny BEBII 3.11 (@) What signs and symptoms would make you suspect that you have ‘created an oroantral communication following the extraction of an upper first permanent molar? (b) If you have created an oroantral communication how would you treat ite (© Ia root is pushed into the antrum how can a surgeon gain access to remove the root once the socket had healed?WEE cox ron {a) Signs and symptoms of an oroantral communication: ‘+A Visible defect or antral mucosa visible on careful examination of socket ‘+ Hollow sound when suction used in socket. + Bone with smooth concave upper surface (with or without antral mucosa, nit) between the roots. (b) Management of an oroantral communication: ‘+ Surgical closure of the dofect by: approximating the palatal and buccal mucosa, but there is usually inadequate soft tissue; buccal advancement flap alone or with buccal fat pad: or palatal rotation flap. ‘+ Advise the patient not to blow the nose for 10 days. ‘+ Some surgeons prescribe broad-spectrum antibicties, inhalation and nasal decongestants. (©) By raising a flap in the buccal sulcus in the region of the upper canine! ppromolars and removing bone - known as a Caldwell-Luc procedure.3.12 (@) Fill in the blarks from the list of options below. Beal's palsy is paralysis of the tmay be caused by a Treatment involves nerve which results in facial palsy. infection particularly . COUrSE Of .. as wellas TTigemina/glossopharyngeel facial Bacterialiprotezoalviral Herpes simplex/Epstein-Bar/bovine spongiform encephalopathy Shortintermediattlong Amoxiciln/prednisolonsigabapentin ‘Augmontinigentaricin/aciclovr en een a (b) How would you test the function ofthe nerve involved in Beis palsy? Select the correct options from the list below. ‘Ask the patient to look upwards and downwards + Ask the patient to look left to right + Ask the patient to close their eyes + Ask the patient to smile + Ask the patient to stick their tongue out + Ask the patient to purse their lips + Ask the patient to wrinkle their forehead light into the patients eye to assess their pupillary response ‘Check ifthe patient can detect sharp/biunt sensation in various positions all over the skin oftheir faceHEI 22:07 Answers (@) Beis palsy is paralysis of the facial nerve which results in a facial palsy. t may bbe caused by a viral infection particularly Herpes simplex. Treatment involves a short course of prednisolone, as well as aciolovir. i © ‘Ask the patient to close their eyes ‘Ask the patient to smile ‘Ask the patient to purse their ips ‘Ask the patient to wrinkle it forehead (@ Early treatment may prevent permanent disabilty and disfigurement.onal suacery BER 3.13 What are the risks of undertaking elective extractions in the following patients and how can the risks be minimised? (@) A patient who underwent radiotherapy for an oral squamous call cancer last year (b) A patient who underwent ‘cancer 25 years ago therapy for an oral squamous cell (© A patient who has haemophilia A (©) A patient who is HIV positive (@) A patient who has a prosthetic heart valve () A patient who had a myocardial infarction 3 weeks agoFOR {@) Patients who have had radiotherapy are at risk cf getting csteoradionecrosis| after extractions. Therefore prevention has a big role in these patients. However, if an extraction is needed, antibiotics are usualy given untl the socket has healed; this may mean a course of 4 weeks or more. (0) The effects of radiotherapy do not decrease with time; they are permanent, Hence this patient should be managed in the same way as the patient in Question 3:13 (a). (©) Such pationts have factor Vill defcioncy and therefore impaired cloting tines. ‘The severity of the condition depends on the level of factor Vl actvty. Al patients who require an extraction should only be treated in collaboration with ‘their haomatologist. Management usually involves preoperative blood tects, {olowed by transtusion ofthe missing factor and/or desmopressin (which stimulates factor Vill production). Other agents such as E-aminocaproic acid (Amica) and tranexamic acid (Cyklokapror) may be used along with local ‘measures: sutures and packing the socket with a haemostatic agent They are Usually treated as inpatients to alow postoperatve monitoring. (@) Interms of cross.infeciion contra, universal precautions should be used. With ‘regard to the extraction, depending on the patient's CD4:CD8 count they may ‘be more likely to get a postoperative infecton. This could mean that you would ive antibiotics ore readily than to afit and healthy patient (@) Patients who have prosthetic heart valves are at risk of infective endocarctis ‘and 80 require antibiotic prophylaxs prior 10 treatment. They are usualy taking ‘an anticoagulant, often warfarin, Hf they are, the extraction should be performed. ‘only when the international normalised ratio (INA) has been checked and is ‘ihn ie range that the operator is happy with. The socket is usually packed with a haemostate aid to help wth haemostasis. {Elective extraction should be delayed, The likeiniood of repeat myocardial infarction decreases with time from the first one (Elective surgical procecures, should be delayed for 6 months following recent myocardal infarction)ona suacery BEER 3.14 (a) From the list below choose the space(s) or site that infection typically ‘spreads into from the following teeth: maxillary lateral incisor, mandibular third molar, maxillary canino © Sublingual + Palatal area © Submancibular © Buccal + Submasseteric + Lateral pharyngeal © Retiopharyngeal + Infraorbital area (&) What are the boundaries of the submandibular space? (©) What are the principles of management of a patient with @ dental infection?DMMB srcsronvennsry (@) Buccal, sublingual, submandibular, buccal, sub-massetertc, lateral pharyngeal, retropharyngeal, palatal (0) © Lateraly: mandibie below mylohyoid line ‘= Medially: mylohyoid muscle ‘*Inferiody: deep cervical fascia and overiying platysma and skin (©) Identification and removal of the cause of the infection. Steps ae: 1. Establish drainage of the abscess (intraoral/extraoral) 2 Commence appropriate antimicrobial treatment. ‘3. Assess if there is any predisposing factors for infection, eg immunosuppression, diabetes, steroid therapy. 4. Supportive measures, analgesics, fluids, soft cet, ets.ona. suncery EBB 3.15 (a) What do you understand by the TMN classification system and what is it used for? (0) If patient with an intraoral tumour is staged as T2N1 MO what does itmean? (©) What does Mx mean? (@) Lesions may be treated by using a graft or a flap - what do you Understand by these terms?EBB cco: Fon (@) 11s a classification system for tumours and the letters stand for: + T- tumour + N=nodes + M—motastasos Itis used to stage tumours. (0) The patient had a tumour 2-4 om in size, with a single ipsilateral lymph node {ess than 3 cm in diameter and no metastases. This patient hes stage Il disease. (6) Distant metastases cannot be assessed. (@) A gratis a piece of tssue that is transferred by complete separation and gains # new blood supply by ingrowth of new biood vessels. A flap has its own biood supply. They can be ‘pecicled’ ie ther original blood supply is used, or ‘ree’, ie they have to be ‘replumbed’ into the blood supply at the recipient site,r Oral MedicineoraL mevicine EER 4.1 a) List four possible aetiological factors for recurrent aphthae. (0) What types of recurrent aphthae are there? How do you differentiate between the types? (eq size, location, number) (©) How may recurrent aphthae be treated?BEBE s1.0¢ For oennisrry (@) Any four of the following: * Genetic predisposition ‘© Immunological abnormaiities ‘+ Haematological deficiencies * Stress + Hormonal changes ‘= Gastrointestinal disorders ‘© Infections (0) Minor aphthae may occur singly or in crops and they affect the non-keratnised ‘and mobile mucosa. They are usually less than 4 mm diameter. Major aphthae usualy occur as single ulcers. which may be greater than 1 cm in diameter. The ‘masticatory mucosa and dorsum of tongue are often affected. Herpetiform ‘ephthae usually occur in crops of ulcers which are 1-2 mm in ciameter, ‘although they may coalesce to form larger ulcers. They occur on non: keratinised mucosa. (6) Treatment options: ‘+ Treat underying systemic disease ‘+ Benzydamine (Difflam) mouthwash * Corticosteroids (Corian pellets, Betnesol mouthwash) + Tetracyciine mouthwashes + Chiorhexidine mouthwashonaLMEDIOINe KEES 4.2 (@) What is angular cheiits (stomatitis)? (0) How does angular cheltis differ from actinic cheitiis? (0) Ust three predisposing factors for angular cheiltis. (d) Which organisms commonly cause angular cheiltis? (©) What medicaments could be used to treat this?(@) Intammation of the skin and the labial mucous membrane at the commissures: of the lips. (6) Actinic cheiitis is a premalignant condition in which keratosis of the lip is caused by ultraviolet radiation from sunlight. (c) Any three of the followit » Wearing dentures and having denture-related stomatitis. + Nutritional deficiencies, eg iron defccioncy + immunccompremised + Decreased vertical dimension resulting in infolding of the tissues at the ‘corner of the mouth allowing the skin to become macerated. (@ Staphylococcus aureus anc Candida albicans (0) Fusidic acid cream and miconazole gel{@) Any four of the following: ‘Acute atrophic canciciasis Chronic atrophic candidiasis Chronic erythematous candidiasis Chronic hyperplastic candidiasis ‘Chronic mucocutaneous candidiasis ‘Angular stomatitis Median rhomboid giossitis (b) Whitish yellow plaques or flecks cover the mucosa, but they can be wiped off, leaving erythematous mucosa undemeath. (¢) Smears are Gram-stained and show a tangled mass of Gram-positive fungal hyphae as well as leucocytes and epithelial cals, (@) Drugs used to treat candidal infections: ‘Azoles ~ any two of: Ketoconazole, miconazole, fluconazole, itraconazole Others - nystatin, amphotericin44 ORAL MEDICINE (@) Name the common types of white patches and what may cause them. (0) What would you call a white patch that cannot be characterised clinically or pathologically as any other disease and which is not associated with any physical or chemical causative agent except the use of tobacco? (c) What aro the clinical features of the different types of white patch referred to in Question 4.4 (b)? (@) Abbiopsy is usually done for these lesions. What type(s) of biopsy would be appropriate? (€) How are these lesions treated?{@) Common white paiches and ther causes: Frictional keratosis ~ triction Leukosdema - a variation of normal CCandidal infection - Candia albicans infection CCheek biting ~ trauma from cheek bing Fordyce spots/granules ~ developmental (sebaceous glards in the mucosa) LUchen planus ~ unknown (chen planus from graft versus host disease is uncommon) Lchenoid reactions - goldlantimalarialsidental amalgam ‘Skin grafts ~ previous free ap to transfer tissue to cover an intraoral detect (©) Leukoplakia (6) Types of leukoplakia: Homogeneous leukoplakias Nodular leukoplakia ‘Speckled leukoplakias (@) Incisional and brush bicpsy (6) Treatment options for leukoplakia: Removal of causative agent (smoking) Surgical removal (trastional surgical techniques or with a laser) Photodynamic therapy Retincids Specialist referral Regular review and biopsy as appropriateona veocne REE 4.5 (a) Sjogren's syndrome is a well-known cause of a dry mouth. Name four other causes of dry mouth. (b) What is the difference between primary and secondary SjSgren’s syndrome? (€} What type of biopsy is atten carried out to diagnose Sjagren’s syndrome and why? (d) What microscopic features would the biopsy show if the patient had ‘Sjogren's syndrome? (© What other investigations could be carried out 0 diagnose Sjégren’s syndrome?3 46 Hf 4 a i t g 3 lORAL MEDICINE 4.7 (a) What do you understand by the term ‘erythroplasia?” (b) What is often seen histologically? (©) Put the following lesions in order of malignant potential with the most malignant first. ‘White sponge naevus Erythroplasia Leukoplakia Speckied leukoplakia (d) In the following conditions coloured lesions may appear in the ‘mouth. What colour are they and are they localised or generalised? Kaposi sarcoma Haemangioma ‘Amalgam tattoo Addison disease Irradiation mucosttisora MevicIne EBA 4,8 (@) A45-year-old patient presents with a lump in the palate, Give four possible diagnoses. (b) List four factors in the history that may help with the diagnosis. (¢) Give four clinical features that may help you decide on the diagnosis. (@) What investigations may be used to aid the diagnosis?(@) Any four ofthe following: Torus palatinus Unerupted tooth Dental abscess Papiloma "Neoplasm (benign malignant) ~ salivary (pleomorphic adenoma/ ‘adenocarcinoma); squamous cell carcinoma; lymphoma (©) Any four ofthe folowing: Duration ofthe lump ‘Associated features, eg tooth ache/pericdontaly involved teeth ‘Any change in size/consistency. ‘Any exacerbating factors, eg loose denture, denture granuloma, trauma ‘Any medical conditions which may be associated with the lump, eg ‘neurofibromatosis, drugs, hormonal, other malignancies (@) Any four of the following: Postion of tne lump (eg inthe midiine - developmental torus palatinus| Consistency (Ruid ~ pus/Dlooc/cystc Mud; sof, frm, hard - tumour; ‘bony hard ~ tooth, torus palatnus) Colour (eg red vascular lesion or Kapesi sarcoma) Discharge (pus/blocdleystic uid) Surface texture (uniform nodular or ulcerated may indicated tumour; anemone-lke - papilloma)ora. meoicine REAM 4.10 (@) A30-year-old man presents with weakness on the lett side of his face, Name two possible intracranial and two possible extracranial causes. (b) How will you tell whether a nerve lesion causing a facial weakness had an upper motor neurone cause or a lower motor neurone cause? (©) What is Ramsay-Hunt syndrome? (@) What treatment is indicated?(@) Extracranial - any two ofthe following: + Ball's palsy + Malignant parotid neoplasm + Poatperotdectomy ‘© Sarcoidosis (Heerfordt syndrome) + Incorect administration of ocal anaesthetic + Melkersson-Rosenthal syndrome Intracranial ~ any two of the following: © Cerebrovascular accident (strokes) + Inracrenal umour ‘+ Multiple sclerosis . HV © Lyme disease © Ramsey-Hunt syndrome + Trauma to base of sll (©) a owermoter neurone lesion, the patent canrot winke tek forehead on te affected side, but in an upper motor neurone lesion they retain movement of their forehead. Hence to determine which one itis, you need to ask the patient to raise their eyebrows and wrinkle their forehead. (6) Herpes zoster infection of the geniculate ganglion which produces a facil paley. There wil also be vesicles in the regicn of the external auditory meatus and the palate due tothe vial infection.'SAOs FOR DENTISTRY (@) Any four ofthe folowing: Periodontal abscess Fibrous epuls Denturesinduced granuloma Pregnancy epuls Papiloma Giart celllesiovepuls Tumour (©) See according to what you have chosen from the above lst: Periodontal abscess - associated with deep periodontal pocket andlor ‘nonwital tooth, Fibrous epuls - frm, pinkired may be associated with poor oral hygiene, {an excisional biopsy. Denture-induced granuloma - excisional biopsy and treat the cause, ie pootty fitting denture, Pregnancy epulis - red lesion assosiatod with prognancy gingivitis, ‘excised post partum if stil present. Papiloma - white cauliflower-ike lesion, excisional biopsy. Giant call lesion/epuls - purple-red lesion, radiograph, excisional biopsy and curettage, blood tast to exclude central giant cell granuloma, ‘and hyperparatnyroidism. “Tumour - urgent referral to surgeon for incisional biopsy, raciogrephyy 10 ook for bony involvement and computed tomography (CT) and ‘magnetic resonance imaging (MAI to stage the disease.[HEEB 200: For oennistay (@) Patients have multiple vesicles in their mouth, which burst to leave painful Ulcers, There is often gingivitis. Patents feel generaly unwell with fever and malaise. There is cervical lymphadenopathy. (b) Herpes simplex virus (DNA virus) (c} Treatment of primary herpetic gingivostomatits: + Bod rest, soft diet, fluids, analgesics. + Chiothexidine or tetracycline mouthwash to prevent secondary infection of the ulcers. + Aciclovir in severe cases or medically compromised patients. (@) The virus remains dormant inthe trigeminal ganglion and can be reactivated by factors such as sunlight strass, menstruation, immunosuppression, common (cold oF fever (0) Lesions appear at the mucocutaneous junction of the lips. The patient often has | prodromal itching/prickling sensation prior to the appearance of the lesion, which starts off as a papule and then forms vesicles that burst leaving a scab. They usually heal without scarring after 7-10 days. ‘The lesions wll heal without treatment but if given early, ein the prodromal phase, antviral cream such as penciclovir or aciciovir may prevent lesions from ‘occurring or atleast speed ihe healingI{@) Lichen planus fichenoidreacton answer 4.15 190 (6) Any four of the following: ‘+ Reticular (as inthe picture in Question 4.15 (a)) + Atrophie * Erosive + Papular + Plaquetike (@} Dorsum of tongue end gingiva ( Exvaoral sites: + Pexor surtaces of wrists (purplish, papular, tchy) + Genitals (simitar to ora lesions) + als idges) + Head alopecia) (@ Any tnree of re folowing: + BBlockers + Oral nypoatycaemics ‘+ NSAIDs (non-steroidal ant-inlammatory drugs) © Gold + Pericitamine + Some tieyete antidepressants + Antimalarials + Thazide diurotice + Allopurine!ona.meoione EERIE 4.16 Fill inthe blanks using words from the list below. Each word can only be used once. . disease is due to sensitivity to - Patients may suffer from MaladSOMPLION OF ...rernney and may and have the following oral signs: .. . se NG . diseese is a chroric... that may affect any part of the gastrointestinal tract, but most commonly affects the... . Otal signs may be seen SUCH a8 MUCOSA 1298, esennvin eveminsenenine AMD 1 Crohn's/iritable bowel syncromelcoeliac disease/granulomatous. disease/ulcerative colitis 2 Glutenivitamin B, folateyiron/vitamin Clvitemin D 3 Cobblestone mucosa/lip swelling/oral uleeration/lichen planus/ angular cheiltis/glossitis/gingival swellings! 4 leum/jejunum/stomachOral Pathologyona parHoLocy BEES 5.1. @) Which of the following are histopathological features of epithelial dysplasia? + Drop-shaped rete ridges + Nuclear hypochromatism + Decreased mitotic activity «Loss of intercellular adherence + Loss of differentiation + Saw tooth rete ridges ‘+ Nuclear pleomorphism « Civatte bodies + Loss of polarity of celts (b) What is the difference between epithelial dysplasia, carcinoma and carcinoma? situ (€) What is the commonest cancer of the oral cavity? (@) Give three risk factors for this oral cancer (@) Ifa patient has a suspicious looking ulcer on the lateral Dorder of their tongue what type of biopsy would be carried out to aid diagnosis and why, and what should be included in the biopsy?{@) Histopathological features of epithelial cysplesia: + Drop shaped rete ridges ‘+ Loss of intercellular acherence ‘+ Loss of aiferentation, ‘+ Nuclear pleomorphism () Epithelial dysplasias usually graded histologically as mild, moderate and ‘severe, The tem carcinoma in situs often used to describe severe dysplasia in ‘hich the changes are seen inal he layers ofthe epithelium. However, the changes are confined to the epithelium in dysplasia and carcinoma in situ, ‘whereas in carcinoma the changes are seen to extend through the basement ‘membrane into the underlying connective tissue. (6) Squamous cell carcinoma (@) Any three of the following: + Alcoho! + Tobacco + Betel nut chewing + Human papiloma virus + Syphilis ‘+ Chronic candidal infection (©) incisional biopsy. Tis should include some normal surounding wssue ana a representative potion ofthe lsion.Ineisional biopsis are prefered so that ‘some of he lesion i lett aid the surgeon (who may not have performed the biopsy) should they need to completly remove the lesion a a later date.ORAL PATHOLOGY 5.2 (a) From the options below select the correct options describing giant call granulomas ‘+ They occur most commonly in the first to third decades/fourth to fith decades/sixth decade plus. «They are more common in males than females/females than males. ‘+ They affect the maxilla/mandible most commonly. ‘+ They occur anteriorly/posteriorly most commonly. (b) Name three pathological features that you might see in a giant cell granuloma. (©) Why would you do blood tests for a patient wih a giant cell granuloma? (@) What two blood tests would you do and why? (@) Name two other non-odontogenic benign tumours of bone that affect the jaws.FOR (a) Regarding giant coll granulomas: ‘+ They o:cur most commonly inthe first to third decades. + They are mere common in females than males. + They affect the mandible most commonly. ‘+ They occur anteriorly most commonly (©) Any three ofthe following: + Giant cells (osteoclasts) ‘+ Vascular stroma/connectve tissue + Spindle shaped calis ‘+ Haemosiderin (evidence of bleeding) ‘+ Frobiasts and evidence of collagen formation + Osteoid (c) Pathologically giant cell granulomas are identical to brown tumours of hyperparathyroidism. Blood tests help to distinguish between the two conditions, The blood chemist is normal in gant cll granuloma but altered in byperparathyroaism. (@) Any two of the following: + asma calcum levels - raised in hyperparthyroisism, nora in giant call grenuloma + Alkaline phosphatase levels ~ lowered in hyperparathyroidism, normal in gant call granuloma + Pasma phosphate levels ~ lowered in hyperparathyroidsm, normal in gant call granuloma ‘= Parathyroid hormone levels - raised in hyperparathyroidiam, normal in ant cal granulomaoat parhoLocy BERS 5.3 (a) What is the definition of a cyst? (0) Are the following lesions inflammatory/developmentalinon- neoplasm: + Keratocystic odontogenic tumours (odontogenic keratocysts) ‘+ Dentigerous cysts © Radicular cysts ‘+ Aneurysmal bone cyst (6) From what are dentigerous cysts thought to arise and why? (@) Where do dentigerous cysts occur most commonly? (¢) Describe what the lining and capsule of a dentigerous cyst would look like histologicallyWML sos ron pewnsmy i {@) A cyst is a pathological cavity, not formed by the accumulation of pus, with fluid, ‘semifuid or gaseous contents, and lined by epithelium. (0) Type ot lesion: ‘+ Keratooystic odontogenic tumours (odontogenic keratocyst) ~ developmental/neopiasm * Dentigerous cysts ~ developmental ‘= Racicular cysts inflammatory ‘+ Aneurysmal bone cyst~non-epithelial ‘According to the World Health Organization (WHO) classification (2005) keratocystic odontogenic tumours are now classified as neoplasms, whereas previously they were thought to be developmental (6) Dontigorous cysts are attached to an unerupted tooth in the region of the ‘amelocemental junction and so are thought to arise from the remnants of the enamel organ. The internal enamel epithelium lies over the enamel and the external enamel epithelium forms the cyst lining. (d) They ave associated with teeth that fail to erupt and so are most commonly associated with mandibular third molars and maxilary permanent canines. (@) The lining is a thin reguiar layer composed cf stratfied squamous epithelium, which may occasionally keratinise, The capsule is composed of colagenous fibrous tissue, which is usually free from inflammatory cells. There may be scattored nests of quioscent odontogenic epitheliumORAL PATHOLOGY 5.4 (@) Whatis the difference between a potentially malignant (premaiignant/epithelial precursor) lesion and a potentially malignant (premalignant) condition? (b) What do you understand by the term leukoplakia? (6) Puttthe following lesions in order with the one most likely to become malignant first: + Leukoplakia * Speckled leukoplakia + Erythroplasia (erythroplakia) (0) What malignancy would they turn into? {€) At which intraoral sites does oral cancer occur commonly? (f) How does this cancer spread? (g) What factors would affect survival from oral cancer?202 {@) A premalignant esion is a lesion in which carciroma may develop. A premalignant condition is a condition in which there is a risk of carcinoma developing within the mouth, but not necessarily in the pre-existing lesion. {b) Awite patch or plaque that cannot be characterised clinically or pathologically 1s any other disease and isnot associated with any physical or chemical agent except the use of tobacco. t camot be rubbed of. (©) Erythroplasia (erythroplakia) > speckied leukoplakia > leukoplakia {@) Squamous cel carcinoma {e) Common sites of oral cancer: ‘© Lateral border of tongue 1+ Floor of mouth ‘+ Retromoler area ()) Modes of spread Direct extonsion into adjacent tissues © Metastasis to regional lymph nodes + Late in tne disease there may be haematogerous spread @ © Delay in treatment ‘Size of tumour at presentation ‘+ Degtee of ditferentiation of tumour - poorly differentiated worse than ‘well itferntiaiod ‘+ Lymph node spread ‘+ Distant metastases ‘+ Position of tumour - more posterior worse prognosis, ‘© Malnutrition ‘© Age, worse with advancing ageOPAL PATHOLOGY 5.5 (a) in which gland do salivary calculi occur most commonly and why? (©) What symptoms might a patient with a salivary gland obstruction complain of? (© Are calculi a common cause of dry mouth? (@ ta salivary calculus is not treated what may happen to the gland and what would it look like histologically? (©) What do you understand by the term mucocoele, What are the types ‘of mucocoele and how do they differ?BEB s205 Fon vennsiay ‘Answer 5.5 (2) Submandibular salivary gland. This is because of the composition of saliva produced by this gland, and the length and anatomy of the duct. (b) Meal time syndrome they complain of pain and swelling in the region of the sland on seeing, smeling or tasting food. The swelling gradually subsides over time. The gland may also become infected. (@) No (6) The gland may become infected and the patient may develop chronic sialadenitis. There is dilatation of the ductal system, and hyperplasia of the ductal epithelium and development of squamous metaplasia, Ther

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