Systemic diseases

Diabetes

Blood glucose levels in a type I 4 – 7 mmol = normal

diabetic patient  <4mmol = treat for hypo if symptomatic
<0.6mmol = rpt test & seek med advice + treat for hypo
>33mmol = rpt test & seek med advice

Management of the diabetic patient  Signs – aggression/fitting/confusion/shakes/sweat/headache

MGT –
O2 +glucose drink/biscuit+ Hypostop gel (sublingually) –rpt 10-
15 minutes
1mg Glucagon IM (unconscious &>8yrs; 0.5mg if <8yrs)
Rpt 10 minutes

- Treatment best done in morning (post bfast)/afternoon

(post lunch)

Blood

The extrinsic blood clotting pathway (PT)  Prothrombin time (PT) 

 Factors II VII IX X
 Released TF
 12-14 sec …or INR (2.0)

Prothrombin time (PT)   The extrinsic blood clotting pathway 

 12-14 sec …or INR (2.0)

INR Therapeutic range

- AF / DVT / PE= 2-2.5

- PROSTHETIC VALVES = 3-4

Causes of iron deficiency anaemia  Causes – diet + malabsorption

Interpretation of a full blood count; iron - HB,RBC,MCV,Hct,MCH,MCHC

deficiency anaemia  -

Causes of macrocytic anaemia  - HB, RBC,Hct+ MCV + Normal MCH,MCHC

- Causes = B12/Folatedef. + Drugs (hydroxyurea) + myelodysplasia +
hypothyroidism+ alcohol + pregnancy + liver disease + myeloma +
reticulocytosis

Causes of microcytic anaemia  Causes – iron deficiency, thalassaemia, sideroblasticanaemia (failure to

dev. Porphyrin rings), Anaemia of chronic diseases

 Blacks have 0.5-1g/dl less HB

Causes of prolonged bleeding; Platelet  PLT Activation is via adhesion to collagen

 defects  (von willibrand) thorughvWF& GP-Ib
 von willibrand disease
= adhesion prob.
= auto dominant (males &females)
= F VIIIc = low + R:Ag& R:RCo defi.
= prolonged bleeding time
= Mucosal purpura

MGT

– in specialist centre ( as hamophilia)

- type I variant mgt = desmopressin +

tranexamic acid + local measures
- avoid NSAIDS & Aspirin

Haemophilia and haemophilia carrier states; - initial haemostasis followed by bleeding within
evaluation of blood clotting  an hour.
- Factor VIII (Hae.A - Vw disease)
- APTT..PROLONGED
- X-linked

Disorders of the blood; thrombocytopenia  - Quantitative PLT disorder

- Bleeding time prolonged (<100k/uL)
- Bleeding in trauma (approx.10k/uL)
- Spontaneous, CNS bleeding (<10k

- Thrombotic thrombocytopenic purpura(TTP)

- PLT aggregation disorder
- Due to lack of metalloprotein to break down
large Vwfi.e large Vwf
 Low PLT + intravascular haemolysis + RBC
fragmentation
 Fanconi (aplastic an.); megaloblastic
anaemia

Estimation of blood loss  - Normochromic anaemia

- HB,RBC,Hct, + Normal MCV,MCH,MCHC

Pregnancy (physiological) anaemia - RBC expand by 25% during pregnancy

- Plasma expand by 50%

Alcohol / Liver

Pathological effects of chronic alcohol - Yellow discoloration of the sclera (may

abuse - Jaundice  include skin and mucous membrane

Systemic features of chronic alcohol abuse  - Induction of carcinogenesis

- Impaired drug metabolism
 - GI symptoms, insomnia, sweating,
anxiety, tachycardia, irritability, raised
BP, sweating>confusion, disorientation,
hallucinations, coarse tremor, ataxia,
possible convulsions

Alcohol limits - One UK unit = 10ml or 8g of pure

NEEDS UPDATING alcohol
- Men: 3-4 units a day/ 21 units per
week
- Women: 2-3 units a day/ 14 units/week
- 4.5 times more likely to get cancer of
the mouth, neck and throat
- 3.5 times more likely to get cancer of
the liver
- 2-4 times as likely to get hypertension
- More than twice as likely to have a
cardiac arrhythmia
- Women are 2.5 times more likely to get
breast cancer
13 times more at risk of liver cirrhosis
- a unit could be half a pint of normal
strength beer (4%), a single 25ml measure
of spirits or a 125ml glass of wine (9%).
-

Endocrine / autoimmune

Oral ulceration; Erythema - Skin lesion (TARGET or Iris lesions) + oral ulcers
multiformae  - Haemorrhaegic crusting (fibrin-covered erosion) of lips + conjuctival
scarring blindness
- Widespread necrosis of keratinocytes, with eosinophilic changes,
progressing to epithelial vesicle or bullae formation
- Usually affect young males (SJ Syndrome)
- Self-limiting hypersensitivity
 Triggers
Microbes - HSV; Mycoplasma pneumonia;
DRUGS – barbituates, carbamazepine/phenytoin)

Differential diagnosis of Sjogrens - Gritty sensation in eyes + inflammation

syndrome  - Disturbed taste / eating & swallowing / speech
- Predisposition to infection
Grave's disease and related - Hyperthyroidism (thyroid stimulating autoantibodies)
autoimmune - Exophthalmic goiter + oral ulceration
conditions (endocrinopathies) - Hair thinning + warm hands + heat intolerance + anxiety
- Inhalation sedation may be best, as GA may trigger
thyroid crisis (dyspnoea/ tachycardia/tremor)
Differential diagnosis of cervical - Pt may become anaemic and weak
lymphadenopathy; Hodgkin?s - Affects mainly males
disease  - Bi-nucleate cells on histology
- Clinical staging I-sigle group of Lnodes / II -2 or more
groups on same side of diaphragm/ III – both sides /IV –
extralymphatic organs (liver / bone etc)
- Progressive lymph npde enlargement + remittent fever +
night sweat + weight loss + pruritis
Thyrotoxicosis  - Increased body metabolism
- Increased excess of thyroxin
- Increased pulse rate + excessive sweating + excitability
+ hand tremors
Oro-facial features of acromegaly  - due to hypersecretion of GH (associated with anterior
pituitary gland adenoma)
- on time of onset – children with open epiphysis =
gigantismvsfused epiphysis = acromegaly
(enlargement of bones having potential to growth)
 condylar growth(mandibular prognathism, with teeth
spacing)
 thickened lips/nose (coarsening of the face)
 enlarged tongue
systemic complication
 elevated intracranial pressure
 headaches+blindness+hypertensioncardiomyopathy
 diabetis mellitus

Oro-facial features of Down's - Widely-spaced eyes
syndrome  - Brushfield spots in the iris
- Epicantic fold
- Class III malocclusion
- Hypoplasia / hypodontia / microdontia / anodontia /
delayed exfoliation
- Mid-face hypoplasia
- Weak atlanto-axial (paralysis during dental procedures)
- Anterior open-bite + increased periodontits

Digestive / eating disorders

Clinical features of Crohn?s disease - One of 2 irratable bowel syndromes (+

ulcerative colitis)
- Full-thickness inflammation
(transmural) of GI tract (including the
mouth)
- Mainly the terminal ileum and asc.
Colon
- Oral ulceration predate any other
symptom
- ULCER (1% of cases)– purplish-red
non-haemorrhagic…cobble stoning of
buccal mucosa + glossitis + mucosal
 rags + swelling of the lips.

Oral presentation of eating disorders  - Eroded Smooth plaque-free surface

(with proud restorations)
- Selective Palatal and incisal surface
erosion…ALSO seen in pt who swirl
carbonated drinks before swallowing

NB: dietary acid cause erosion on

labial/buccal surfaces

Clinical features of bulimia nervosa (binge- - As above…due to binge-eating followed

eating without weight loss) vs anorexia by vomiting to maintain a STABLE
nervosa – weight reduction BODY WEIGHT
- Parotid gland enlargement
- Erosion of dental enamel with increased
dental caries resulting from gastric acid
in the mouth
- Sore throat, esophagitis, mild
hematemesis
- Mallory-Weiss esophageal tears

 Russell's sign - an indicator of self-induced - Scarring of the dorsum of the hand

vomiting…bulimia nervosa used to stimulate the gag reflex

Viruses

Hepatitis B - markers of infectivity  - HBsAg– surface marker – acute or chronic

infection – person is infectious
- Anti-HBs – recovery from HepB – acquisition of
immunity post vaccination
- Total anti-HBc – acute infection – persist for life
– indicate past or ongoing infection
- IgM anti-HBv – acute or recent inf. – present for
approx. 6 months
- HBeAg–high degree of infectivity – high degree
of virus replication
- HBV-DNA – infectivity – virus replication

- Sharps injury – 30% risk of transmission

- As little as 0.1 ml of blood is infective, therefore
degree of injury is immaterial
- Satisfactory antibody response to vaccine =>
 100 mUL/ml
- Single booster every 5 yrs

- Markers of Hep B infectivity – Hep B e

antigen or >1000 viral particles
- Immunization sequence for Hep B – 0>1-2>4-
6 months
- Protection after each immunization stage –
1st=30-50%; 2nd= 75%; 3rd = 96%
- Incubation time for HepB = 60-90 days
- HBeAg positive = no EPPs
- HBeAg negative but HBV-DNA > 103GE
(Genome equivalent)/ml = noEPPs
- HBeAg negative but HBV-DNA < 103GE = con
do EPPs (but, must test annually)
- HBeAg negative but HBV-DNA 103 105 GE/ml
= can do EPPs (If pretreated)

Recognition of the severity of a HIV infection  - Sharps injury - risk of infection => 3 per 1000
injuries(0.3%)
CD4 count per mm3 in a healthy individual
- Splash of infected blood onto broken skin =>1
600-1800 per 1000 (0.1%) risk of transmission
- CD4 (T-helper cell) count => indicator of
immunosuppression + stage of the disease +
effectiveness of treatment
- >500 cells/ul = normal
- 200-500 = minor opportunistic inf.
- <350 = consider HAART
- <200 = risk of maj. Opportunistic inf.
- <50 potentially fatal complicatoins
- AIDS: CD4 cells<200 cells/ml (cf 500-1600).
-

The CD4+ lymphocyte count as a marker of - >500 cells/ul = normal

the severity of HIV infection 
- 200-500 = minor opportunistic inf.
- <350 = consider HAART
- <200 = risk of maj. Opportunistic inf.
- <50 potentially fatal complicatoins
 AIDS: CD4 cells<200 cells/ml (cf 500-1600).

Transmission of HIV infection from mother to About 1 in 3 untreated pregnant women with HIV
child  pass the infection on to their babies during pregnancy
or childbirth
treatment with anti-HIV drugs during pregnancy
greatly reduces the risk of passing on the virus
Having a caesarean section to deliver the baby
reduces the risk even further
HIV can also be passed to babies through breast milk
during breastfeeding.

Genetics / cancer

X linked inheritance; - X-linked Recessive disorder (no father-to-son transmission)

Haemophilia A/B - Predominantly males (females also affected)
- Bleeding dependent on level of FVIII/IX activity + level of trauma
- Initial haemostasis (Plt Plug) then bleeding.
X linked inheritance; - A dominant / A recessive / X-linked - most common
amelogenesisimperfecta  - primary and secondary teeth affected
- may be syndromic (ectodermal dysplasia)
- class 1hypoplastic – difficien matrix – pits;groved; but hard
- Class II hypomaturation – white/brownish-yellow opaque fleck – similar to fluorosis
but soft and vulnerable to attrition
- Class III –Hypomineralisation -weak & opaque/chalky - enamel chipped away, leaving
a shoulder
Single gene defects; - expressed in individuals who have just one copy of the mutant allele
characteristics of autosomal - each offspring (of affected parent) has a 50% chance on inheriting the mutant
dominant patterns of allele
inheritance 
Autosomal Recessive If both parent are carrier
- 25% chance of being homozygous wild-type (unaffected); a 25%
Sickle cell + Cystic Fibrosis chance of being homozygous mutant (affected); or a 50% chance of
being heterozygous (unaffected carrier).
Leukoedema  - Blue-grey or white appearance of mucosa
- Faint white buccalstriae
- Similar to lichen planus BUT
- Disappear when skin is stretched
Multiple sclerosis  - immunologically mediated
- Young adults
- Plaques of demyelination in the CNS
- Cranial nervedamage = visual disturbance + sensorydeficit + trigeminal
neuralgia _2º neuralgia)+ facial paralysis
- No effective Rx = Corticosteroid &interfone may help.
- Dysphagia
Mechanisms of VIRAL (HPV 16 & 18) / alcohol / smoking
carcinogenesis  Conditions
- Erosive lichen planus
- Submucous fibrosis
- dyskeratosis congenital
- Patterson-Brown-Kelly/Plummer-Vinson syndrome (dysphagia +
 microcytic hypochromic anaemia + koilonychia + angular cheilitis +
premalignant post-cricoid web/membrane on anterior oesophageal wall
– dysphagia)
- Speckledleukoplakia
MECHANISM
- Multistage/sequential/aquisition of additional characteristics
(angiogenesis / protease syn)
- Initiation => progression
- Normal=>keratosis(hyperplasia)=>dysplasia=>carcinoma=>metastasis
GENETIC CHANGE
- Deletion / Point mutation / chromosome rearrangement
- Proto-oncogene => Oncogene = cancer development
- TSG => Suppress cancer development (bcl-2= apoptosis / p53 –
sensedamaged DNA / retinoblastoma –regulate S-phase of cell cycle)
-

Staining

Causes of tooth discolouration  EXTRINSIC Agents (diet; CHX)

- Green / Orange / Brown /Black
(GOBB)
INTRINSIC Agents (Tetracycline (in utero) /
Necrotic pulp / RCT medicaments)
- Blue-brown (tet)/ Red (pulp)/ Grey /
yellowing = pulp calcification

Trauma / paeds

Endo
Use of ferric sulphate in pulpotomy  - 15.5%
- haemostasis via formation of metal-
protein clot
- Cotton wool onto stump for 4-5 min +
irrigate + dry
- 93% success rate
Pulpotomy/pulpectomy  pulpectomy 
- Treatment of choice in non-vital 1o
(clean to within 2-3mm of apex and
dress with non-setting ZOE or GIC (no
CaOH – SDLE)+ SS)
- But not realistic
Pulpotomy
- Give consistently best results vs
capping
- F. sulphate=>ZOE=>SS
Management of the fractured tooth with an - Pulp cap or traditional pulpotomy or
incomplete apex  Cvekpulpotomy (remove 2mm vital
exposed pulp) +
- MTA or Non-setting CaOH
- Bonded restoration
Treatment planning for the carious deciduous Direct pulp capping
molar - Only recommended for small
tooth; pulp capping vspulpotomy  exposures, due to involvement of
coronal pulp
Pulpotomy
- Recommended Rx for 1o molars
Medicaments used in pulpotomy  MTA (v promising, but expensive)
- Regenerative/medicament
- stimulate cytokine release from pulpal
fibroblast, which stimulate hard tissue formation
- PERFORATION REPAIR + PULP CAPPING +
INDUCE APICAL CLOSURE OF IMMATURE ROOTS
Ferric sulphate
- Most recommended (mitchel’s)
CAOH – Regenerative/medicament
- 77-87%
- Internal resorption

Trauma
 

Concussion luxation injury results from injury to the tooth

supporting structures, resulting in no mobility with
pain on percussion
Intrusion Displacement of the tooth into the alveolar bone
and fracture of the socket
Extrusion Partial displacement of the tooth out of its socket,
partial or total separation of the PDL
Subluxation Injury to the tooth supporting structures, resulting
in increased mobility and bleeding from gingival
sulcus

Lateral luxation Displacement of the tooth other than axially

accompanied by a palatal/labial alveolar fracture
Management of dental trauma; protocols Rigid splint => 3-4 wks
for splinting following root fracture - 2 teeth on either side
- Dento-alveolar fracture
Functional splint
- Avulsion = 7 – 10 dys
- Luxation or Root Fracture = 2 – 3 wks,
then RCT
Management of the luxated upper ?displaced towards successor => XLA
central incisor tooth 
NB:Upper 2o T germ – initially palatally (age 2-3),
then labially by age 4-5 as 1o root resorb

?not as above => review

Management of displaced upper
deciduous upper incisors following As Above
trauma 
Acute management of dento-alveolar - LA => finger pressure labially&lingually to
trauma reposition displaced segment => Clean =>
suture, if required => flexible splint for 4wks
- Soft diet for 1 wk
- Radiographs =.6-8wk=4mths=6mths=1yr =
then annually for 5 yrs

Dento-alveolar trauma - patient - Space management via

 management following loss of several prosthesisrehabilitation
deciduous teeth
Crown fracture 1o dentition
- Uncomplicated = smooth + etch + bond
- Complicated => XLA
2O Dentition
- Smooth + etch + bond OR
- Partial pulpotomy or RCT
The avulsed upper central incisor tooth  - acute mgt. – clean + re-implant (2o) or
sulcus/saliva; saline; milk)
- <45 min + Open apex – LA + clean tooth& socket
2o teeth ONLY [saline] + re-implant + splint [7-10dys]+X-ray +
soft diet + Abs; CHX;vaccine
- >45 min + Open Apex - as above+review7-
10dys, then
- RCT + Ledermix =>7-10 dys review =>RCT +
CaOH
- review every 3 MONTHS for 2-3 yrs& replace
hypocal until barrier form, the fill with MTA
etc.
Management of the avulsed deciduous
incisor tooth DO NOT REIMPLANT!
Sequelae to reimplantation of an avulsed Resorption
tooth - External (asymmetrical on Xray)
- Internal (symmetrical)
- Replacement (PDL space replaced by
bone)..Ankylosis
Pulp canal obliteration
Pulp necrosis
Arrest of root development
Complications of exodontia in the - Loss of LEEWAY space
deciduous dentition  - Damage to underlying tooth germ
- Alveolar osteitis (dry socket)
- Dislocated mandible
Use of stainless steel crowns  Indications
- Extensive caries (but enough to retain
crown)
- Molars needing multi-surface restoration
- NO PULPAL INVOLVEMENT
- Developmental anomaly / hypoplastic teeth
- Abutment space maintainer
- Patient co-operation (no inhalation risk)
Placement of stainless steel crowns - - Gauze to protect airway
Hall technique - No tooth prep (orthodontic spacer may be
placed 3-5 dys prior to placement)
- Fit & cement
- Warn pt will feel high BUT Dahl will correct
occlusion
Management of the extensively broken - SS Crown..if NO PULPAL INVOLVEMENT
down lower first permanent molar tooth 

Fractures

Fractures of the mandible; Features of a Bilateral displaced mandible – ANTERIOR Open

 mandibular fracture; compound fractures bite
Undisplaced unilateral condyle – pain on
OPG + a Posterior-Anterior view of the
mandible is best movement BUT no occlusal alteration
Buckethandle f. – bilateral parasymphyseal Angle of mandible – anaesthesia/paraesthesia of
f. the inferior dental nerve– most common fracture
Compound – bones fragments exposed Dislocated – ltd movement + unable to occlude
externally
Comminuted – fragmented into several or open wide + apparent class III with hollowing
pieces. of TMJ area
Greenstick – incomplete Guardsman fracture – involves both condyles
Open reduction internal fixation (ORIF) –
&symphyseal region – INDIRECT fracture = falling
most common surgical Rx
on/blow to chin

Oral surgery / maxillofacial trauma  Zygoma – anaesthesia/paraesthesia of the

infraorbital nerve
Zygomatic arch – trismus
Orbital blow out = rims intact but area of bony
wall fractured (usually floor or medial wall –
thinnest areas

Recognition of mandibular fracture in a - Malocclusion

child  - Pain
- Facial asymmetry

Priorities in emergency management of Airway MGT - in skull fracture and oral

facial trauma  airway obstructed…then gentle insertion of
nasopharyngeal airway may be life-saving…
benefit outweigh the risk..RC 2011
A=>B=>C=>D=>E

Prevention, Flouride, OHI

The mechanism of arrest of root caries by - Eliminate plaque stagnation spots

toothbrushing - Twice daily cleaning with fluoride =
letharly or hard lesion with decreased
activity and an arrested caries process
- SELF-CLEANING

fissure sealants; British Society Paediatric - Deep occlusal pits in medium risk caries
Dentistry Policy Document patient
- Lower 6's when the upper 6's have had
caries
- Plaque retentive cingulum pits in a high risk
caries patient
- To seal a small occlusal carious
- Patients with special needs

Paediatric dentistry; fluoride overdose in 1mg/kg = safe

 a child 
5mg/kg = potentially fatal => large vol of MILK (if
<5mg or refer to hospital for gastric lavage if
NOT TO BE USED IN CHILDREN UNDER 6 >5mg F/ml)
MONTHS…due to inadequate renal function 32 - 64mg/kg => definitely fatal
to excrete fluoride!!!

NB: 1000ppm = 1mgF/ml + 1500ppm =

1.5mgF/ml + 1.23% = 12.3mg F/ml

NB: 5yr old would OD (5mgF/ml) on

- 95 (1mg F) tablets
- 63ml of 1500ppm toothpaste
- 7.6ml of 1.23% APF gel

Choice of toothpaste for the high caries Up to 3yr – 1000ppm

risk child  3 – 6yrs => 1350 – 1500ppm + 2.2% F varnish 2x
Above 6yrs - >1350ppm + + 2.2% F varnish 3x –
4x
POM – Toothpaste

- 8+ = daily F mouthwash
- 10+ = 2800ppm
- 16+ = 5000ppm

Preventive dentistry; constituents of  1000ppm = 1mgF/ml

toothpaste   1500ppm = 1.5mgF/ml
 1.23% = 12.3mg F/ml

Preventive dentistry- xylotol better than  Sugar alcohol

other sugar substitutes or sugar   reduces plaque formation and bacterial
adherence
 inhibits enamel demineralization /
reduces acid production
 direct inhibitory effect on Strep. mutans

Caries

Caries removal - how much is necessary?   Stained dentine, if solid

 Over the pulpal surface, stained dentin should
remain so long as it is reasonably hard
Restoration of the deeply carious tooth   CaOH liner
Bacterial colonisation and the development 3-4hrs (1st 2 dys) = strep mutans
of dental plaque  2-6dys = rods
6-10dys = vibrios&spirochaetes (gingivitis)
Acquired pellicle=>Early stage (12-24hrs)
=>late stage (1-3dys)
Description of the carious lesion 
White spot – different refractive index (H2O
– 1.33; Air – 1.0; Enamel – 1.62)
Leathery& soft – root caries
(actinomycetes)– U-SHAPED
…INTERNATIONAL CARIES DETECTION AND Pits/Fissures (lactobacilli)– INVERTED V
ASSESSMENT SYSTEM (ICDAS) Smooth surface (strep) - V-SHAPED –
apex at ADJ

ICDAS
SOUND - 0
EARLY STAGE DECAY – 1 (1st visual
change in enamel) or 2 (distinct visual
change)
ESTABLISHED DECAY – 3 (localized
enamel decay) or 4 (underlying dentine
shadow)
SEVERE DECAY 5 (distinct cavity with
visible dentine) or 6 (extensive cavity
within visible dentine)

Enamel

- outer half (E1)

- inner half (E2)

dentine

- outer third (D1)

- middle third (D2)
- inner third (D3)

** priority is to treat a E2 cavity

before E1; D3 before D2 etc

Clinical features of the earliest carious HISTOLOGY

lesion; Changes in enamel structure during  Intact surface zone (zone 1_
the early stages of cariogenesis   Body (5-25% porosity)
 Dark zone (2-4%)..possibly some
remineralisation occurring
 Translucent zone (zone 4 -
advancing front 1% pore volume)
Knowledge of DMFT distribution; statistical Mean
terms…2003 children dental health survey - Average= total DMFT score/total
patients
….uk..43% of children had obvious Mode
signs of decay experience by age 5 - Most frequently observed value
Median
…uk…57% of 8yr olds had obvious - The mid-most number, when all the
decay values are arranged numerically
Standard deviation (SD)
- Variability from the mean
Sensitivity
Specificity
 Positive predictive value
Negative predictive value

Bottle induced caries in young children 

Progression of early dental caries under At-risk..
fissure sealants under sealants; necessity All permanent molars shoulde be sealed
for frequent review if the sealant is placed High risk..
over dentine caries All pits?fissures..SIGN 47
‘sealed caries beneath well maintained
fissure sealant is unlikely to progress’…
review at every checkup,SIGN47,,,but, if
caries clinically into dentine..carious dentine
should be removed and tooth
restored..SIGN47
Pathology of the deep carious lesion  3-4hrs (1st 2 dys) = strep mutans
2-6dys = rods
6-10dys = vibrios&spirochaetes (gingivitis)
Acquired pellicle=>Early stage (12-24hrs)
=>late stage (1-3dys)
Management of caries in upper incisor SIGN47 – SMOOTH SURFACE CARIES
teeth  - 2X daily brushing with ≥1000ppm
F
- PLAQUE REMOVAL
- DIET ADVICE
Management of the grossly carious upper AMALGAM + FISSURE SEALING OF
premolar  REMAINING CARIES-FREE FISSURES…
SIGN47 (EXTENSION FOR PREVENTION)
Management of interproximal caries + - No restoration is recommended, if
Radiographic recognition of interproximal lesion confined to enamel, or just into
caries  dentine on X-ray
- SIGN47 = 2X daily brushing with
≥1000ppm F + flossing + diet
advice
- Should be given the chance to
remineralised…KIDD 2010
Diagnosis of caries  White spot – different refractive index (H2O
– 1.33; Air – 1.0; Enamel – 1.62)

Ortho

Principles of cephalometric analysis  S Sella: Mid-point of sellaturcica

PoPorion: Upper most point on bony external
auditory meatus
Or Orbitale: Most inferior anterior point on
margin of orbit
A point: Position of deepest concavity on anterior
profile of maxilla
 B point: Position of deepest concavity on anterior
profile of mandibular symphysis
N Nasion: Most anterior point on fronto-nasal
suture

S - N Line: Indicates orientation of anterior cranial

base.
N - A indicates relative position of maxilla the
cranial base
N - Bindicates relative position of maxilla the
cranial base

ANB 2-4o= Class I skeletal pattern

ANB > 4o= Class II skeletal pattern
ANB < 2o= Class Ill skeletal pattern

SNA = 81o (±3)

SNB = 79o (±3)
ANB = 3o(±2)

Realistic growth prediction requires at least 2 or 3

cephs captured at 6-12 month intervals
cephalometric analysis  MAXILLA to CRANIAL BASE - SNA; NA – FH

MANDIBLE to CRANIAL BASE – SNB;SN –Pg; NPg– FH

MAXILLA to MANDIBLE – ANB

MANDIBULAR PLANE - SN – MP; FH - MP

CL - Camper's line - the line connecting ANSand P;

Frankfort plane plane passing through the lowest point in
the floor of the left orbit (orbitale) and the
highest point on the external auditor
meatus of the skull (porion – Po) – it is
horizontal when the head is in the normal
upright position

Frankfort plane and other cephalometric - Achieving balanced articulation (equal

planes important in denture contact left-right and back-front, during
construction 
function)….denture stability, as proposed
by hanau’s quintet

Orthodontic treatment planning for the - Extrusion of teeth due to severe

compromised dentition  periodontal damage canbe corrected by
aligning using light orthodontic forces
(intrusion)…produce reduction in clinical
crown length + better bone support +
improve facial esthetics& function
Orthodontic diagnosis in the mixed - Occasionally involve 1o teeth extraction or
dentition interceptive measures such as …moving a
tooth over the bite
…chestnut pp. 344 & 360 
Orthodontics: Removable Appliances  Active –designed to move)tip tooth via active
components (wire; springs; screws)

Passive – designed to maintain teeth position…i.e

a space maintainer or a retainer

- Used if simple tooth-tipping alone is

required…tipping upper incisor over the
bite..i.e. an upper incisor in linguo-
occlusion

Criteria for case selection for simple A removable appliance incorporating a Z-

orthodontics in general practice; moving spring (or T) + posterior bite capping to
an incisor tooth over the bite free the occlusion

...e.g a Clark functional appliance

Index of Orthodontic Treatment Need Aesthetic component (attractiveness of teeth)

(IOTN); Recognition of the characteristics 1,2,3,4 – No slight need
of IOTN 2. 
5,6,7 – borderline need
8,9,10 – need
Dental component (MOCDO)
1,2 – No/slight need
3 – Borderline need
4,5 - Need

Routine management of the patient who Retainer at the end of treatment…relapse may
has just completed fixed orthodontic sometime occur
treatment  

Balancing extractions; considerations when Same arch, opposite side – to maintain symmetry
extracting deciduous molar teeth  and centerline relationship…vs compensating –
maintain inter-arch relationship

Impression materials for orthodontic study The impression material most commonly used
models  by orthodontists is alginate
for the purposes of recording the anterior open
bite silicone impression material has more
advantageous dental material properties
allowing the impression to be taken without the
need for an impression tray..use a jig + injected
paste
Development / eruption

Canine

Management of the impacted upper canine tooth  • Incidence: 2% of

population
• Palatal : buccal = 85% :
15%
• Females : Males = 70% :
30%
• Resorption of lateral incisors
in 12%
• Aetiology : guidance theory
..Proclined upper lateral incisors due to buccally ectopic or genetic
canines •
- Canines should be palpable
buccally at 10 years, if not,
investigate
- Clinical features commonly
associated:
- Retained deciduous canines
- Missing or peg-shaped lateral
incisors
- Proclined lateral if 3 over-
lying root of 2
-
- Expose & bond, if feasible
- Surgical removal of impacted
canine ± deciduous canine
(depending on its long-term
prognosis – root length &
aesthetics of crown
- Transplantation ± pre-surgical
orthodontics
- Extract deciduous canines –
only effective in well-aligned
Class I occlusions
- Carried out at 10-13years of
age, this can be successful in
80% of cases
- Unlikely to be further
improvement after 12 months
- Review long-term – risks:
resorption, cyst formation
-

Location of the impacted upper canine tooth using the SLOB

parallax (movement of an object Same – Lingual (tooth
against a background, caused by a change magnified/crown moves with tube
in observer position) method  = palatal)
Upper right
Opposite – Buccal (tooth size
Upper
occlusal
canine palatally diminish)
placed.
Canine has
moved upwards - if lying beyond the dental
towards apex of
Original incisor apices = review
position of
canine radiographically,
relative to
central annually..and, warn patient of
incisor
root
risk of complications (cyst
Upper left
slightly palatal – development; migration with
evidence of adjacent root resorption)
relatively more
root resorption -
of ULc than URc
OPG VERTICAL PARALLAX… DPT/OPG and
an anterior occlusal film
HORIZONTAL PARALLAX..two intra-
oral films (peri-apical and/or anterior
occlusal)
Features of the ectopically placed upper canine tooth  …palatal bulge
…distaltipping of the lateral incisor
…labial flaring ofthe lateral incisor
Interpretation of radiographic features found in association SLOB
with an unerupted upper canine Same – Lingual (tooth
magnified/crown moves with tube
= palatal)
Opposite – Buccal (tooth size
Impacted canine – palatal or diminish)
buccal? Tip of canine has
moved occlusally on moving
from OPG to occlusal film –
opposite direction to X-ray
tube.

The development and eruption of permanent maxillary Palpable as bulge in buccal sulcus
canine teeth  by age 9 – 10

Abnormal development
Consequences of a midline supernumary  Diastema / root resorption / dilacerations
tooth  /loss of vitality
 Crowding
 Failure of eruption of adjacent
permanent teeth (30-60% of cases)
 Displaced or ectopically erupted
supernumary or adjacent teeth

Mixed dentition; premolar crowding in a 12 Early loss of 6s

-year-old  Use a functional appliance

permanent incisors and canines are usually

larger than the corresponding deciduous teeth
whereas the premolars are smaller (leeway
space).

combined mesio-distal widths of the upper

permanent teeth are about 3mm greater than the
deciduous teeth;

lower permanent teeth are about 1mm larger

than their deciduous
predecessors.

The last tooth of a group of teeth to erupt is often

the one most affected by crowding.
Consequently,
in the late mixed dentition, the permanent
canines
or second premolars are the most frequently
affected teeth.

Developmental abnormalities of teeth; CAUSE

congenitally absent lateral incisors + - Pathological lesion
management - Crowding
- Dilacerated/displaced due to trauma ( not
like if bilaterally missing
MGT
- OPT / PA / Upper OCCLUSAL
- Leave alone
- Orthodontic repositioning transplantation
etc.
Always refer to an orthodontic professional.
The mixed dentition; Consequences of Little or no effect on permanent, if no crowding is
premature loss of a deciduous molar  present
Space loss in upper arch is greater
Second molar loss cause larger space loss, and
… E space…. difference between the combined
 mesiodistalwidth of the D and E vs the 4 and even complete loss of 2nd premolar space
5. Unilateral loss of Cs & Ds likely to cause centr-
… the 4 is the exact size of the D
while the 5 is smaller than the E ………so in line shift
effect the leeway space is actually the E space.
If more than one of the first permanent molars
has
a doubtful prognosis, then extraction of all four
…This Leeway space is greater in the maxilla first molars may be indicated.
than in the mandible

Optimal space closure occurs when the timing of

these extractions is carefully managed and the
advice of a specialist
should be sought. Chronological age – 9 -10 or
DENTAL AGE - Lateral incisors and first premolars
should have erupted but not the
remainingbuccal teeth. Calcification of the
bifurcation of the roots of the second permanent
molars should have just commenced
Causes of retained second deciduous molar most common
teeth  - mandibular primary second molars,
followed by maxillary primary canines
…toothless period.. 0-6 days after exfoliation
frequent reason
of primary molars….mandible, it is 2weeks for
the central incisor; 6 weeks for the lateral - congenital absence of successors
incisors and canine - impaction of the successor teeth
- Microdontia of permanent dentition
….In the maxilla, it is 6weeks for the central - pathology, such as cysts, tumours,
incisors, and 4 months for the lateral incisors and odontoma under the primary
and canines.
- Translation or transmigration of
This may be 1year when there is crowding successor teeth (maxillary canine/1st
PM)
- Ankylosis
- Following pulp therapy (pulpotomy,
pulpectomy)
- Defective osteoclastic activities
resulting in poor rootresorption

Mixed dentition; Features and consequences of SYNDROMIC HYPODONTIA

retained deciduous teeth 
- Down syndrome
- CLP
- Hypohidrotic ectodermal dysplasia
- Chondroectodermal dysplasia

Normal development

Dental development: teeth mineralizing at birth  DECIDUOUS

6-4 months in-utero
 PERMANENT
6s – 32 wks or AT BIRTH
The mixed dentition, normal patterns of Age 6 7 8 11 12
tooth eruption 
L1 - 1 U1 – 1 U2 - 2 L 3s U 3s
..Root formation in primary teeth = 1 – 1.5 yrs
L6 - 6 L2 - 2 L 4s U 5s
….Root formation in secondary teeth = 2.5 – 3
yrs U6 - 6 U 4s L 5s

U 7s

L 7s

Management of erupting first permanent CARIES IN PRIMARY

molars; Recall intervals 
- 3 MONTHS

Normal features of the physiological exfoliation ROOT RESORPTION

of deciduous teeth  ..completion of crown formation
&beginning of root formation
..In the incisors, resorption starts from
the lingual aspect of the root surface
because of the initial position of the
tooth bud
…molars, the tooth bud are position
apical to the root surface. Root
resorption starts from here

Tooth development in the latter part of the UGLY DUCKLING STAGE

mixed dentition stage  - Fanning out of crowns of upper
incisors. Particularly the laterals
- May have a mid linediastema
- Space normally close with eruption of
canines
Surgical exposure of an unerupted incisor tooth  - Normally done under GA
- Bonding a bracket & gold chain to pull
into place

Anatomy
Lateral pharyngeal (parapharyngeal) space Mandibular teeth to:
infections  - Submandibular space via lingual plate
- Pterygomandibular space
- Lateral pharyngeal space
- Down the neck
- Trismus with extension into the
submasseteric space…due to lateral
spread..2nd MOLARS
- Bucally, if lingual …may be submental
or submandibular depending on the
attachment of the myolohyoid
- …pericoronitis tracking bucally along
 inner aspect of buccinators to present
in lateral pharyngeal space
Spread of infection from a lower third - Submandibular space via lingual
molar plate
- Pterygomandibular space
- Lateral pharyngeal space
- Down the neck

…pericoronitis tracking bucally along inner

aspect of buccinators to present in lateral
pharyngeal space
Spread of infection from the apicies of a - Bucally to submasseteric space
lower first molar tooth; tissue spaces of - Lingually to submental or
the oro-facial region  submandibular depending on
drainage or level of myolohyoid
attachment
Lymph drainage of the oral cavity; Lymphandenopthy may lead to
significance of deep cervical suppurationandfinally focal abscess
lymphadenopathy formation.
…tonsillitis may lead to peritonsillar abscess. If not
treated successfully, peritonsillar abscess may spread
to the lateral pharyngeal space. From there, infection
spreads to the posterior pharyngeal and prevertebral
spaces and into the chest. Mediastinitis and empyema
may ensue, leading to death.
Morphology of the maxillary first molar - Largest occlusal table(rhomboid)
tooth  - 4 cusps, or 5 if Carabelli present (on
mesiopalatal)
- Largest cusp = mesiolingual
- Smallest cusp = distolingual
…palatal root of the upper first molar usually - Oblique ridge (mesiolingual –
curve towards - Facial / buccal buccodista)
- Lingual groove/ distolingual grove
- Three roots
- Often 4 canal (MB2 – 60-70%)
Clinical features of a mandibular Lingually, in premolar region
torus (Bone Pathology) - Often bilateral
- May prevent insertion of denture
- Surgical reconturing
Normal oral mucosa; Fordyce spots  - Collection of small yellowish spots
- Enlarged sebaceous glands
- Commisures and retromolar areas
Anatomy of inferior alveolar anaesthesia - XLA of molar or restoration of
posterior (mandibular teeth)
Anatomy for local anaesthesia relevant to INFRAORBITAL Nerve block
the extraction of an upper lateral incisor - Needle parallel to long axis of
tooth/ Innervation of the cheek and upper premolars + advance 1.5mm vertically
incisors  to foramen, aspirate & inject
- From premolar to midline mucosa
NASOPALATINE nerve block
- Anterior hard palate mucoperiosteum
- From canine to incisors
Tooth Morphology  - cusp of carabelli MAXILLARY FIRST MOLARS
 Tooth Morphology  TEETH WITH 2 CANALS MAXILLARY TEETH WITH 2 CANALS (%)
(%) 1STPM - 84%
2nd PM – 40%
1ST MOLAR (MB root) – 60-70%
2nd MOLAR – (MB root) – 40-60%
MANDIBULAR TEETH WITH 2 CANALS (%)
INCISORS – 40%
CANINES – 18%
1ST PM – 23%
2ND PM – 6%
1ST MOLAR (distal root) – 30%
2nd MOLAR – (distal root) – 5%

Surgical anatomy of the facial nerve  MARGINAL MANIDIBULAR

- Approx. 1cm anterior to angle of the
mandible
…marginal mandibular…motor for - Just below the angle of the manidible
…depressor angulioris / depressor proximal and superficial to the
labiiinferioris / orbicularis oris (inferior posterior facial vein and within the
fibres) / mentalis submandibular fascia
- Injury avoided by dissecting anteriorly
and posteriorly, then elevating the
nerve as part of the skin flap
- Level 1b (submandibular) disection

Management

Management of the uncooperative child CONSIDER CONSCIOUS SEDATION –

requiring extraction of deciduous teeth  UNLESS…MOUTH BREATHER (DOWNS) OR
<12 WKS PREGNANT (neural tube defect)

Special needs dentistry: management of - NO ID BLOCKS!!...potential airway

normal dental development in a child with obstruction due tohaemotoma in
a bleeding disorder  pterygoid or retromolar space

Management of the child patient (and the Reschedule appointment if unable to

anxious parent)  complete clinical intervention.

Mandible Changes
 Physiological changes following loss of the - Neuromuscular disorders in the mandible
natural teeth  - Decrease the bite effect
- Decreased OVD
- Residual ridge resroption

Patterns of resorption of the alveolar ridges Most prominent in first year

in the edentulous patient  3 – 4 times moe in the mandible than maxilla
Eventually approx. 0.2 mm/year for mandible
(less for maxilla)
MAXILLA

- Mainly labially/bucally, in the anterior

region…incisive papilla appear more
prominently on the crest of the ridge

MANDIBLE

- Mainly labially&bucally towards the

anterior
- Tends to retain its width, or wider
posteriorly

Patterns of bone resorbtion in the after mandibular frontal teeth extraction,

edentulous mandible following loss of the the distal part of the mandible is more in use
teeth  and the resorption process is more extensive

Pain

Recognition of irreversible pulpitis  - Prolonged pain, post stimuli

- Provoked=>spontaneous=>continuous
- Cold stimulates=>cold relieves
- microabscess
Differential diagnosis of odontogenic - Brief / provoked pain / on stimulus
pain; reversible pulpitis  - not well-localised / referred
- focal pulp inflammatoin
Radiological features of a LOSS OF LAMINA DURA IN PERIAPICAL AREA (≥10 DYS)…
reversible pulpitis  chestnut

Diagnosis and management of dental 

500mg paracetamol:2every 6hrs (4x/day)..send :40
pain  tablets.
 MGT with long-acting analgesia if unable to get
2 positive indicator of endodontic disease.
Features and management of a periapical - Swelling over tooth apex/ localised or diffuse
abscess cellulitis
- Draining sinus tracking to tooth paex
- Intense throbbing pain
- Lymphadenopathy and malaise / fever
- TTP, especially in axial direction
 Pathogenesis of chronic periapical - May lead to the development of granuloma or
infections cyst
- resorb local bone to accommodate
- Generally asymptomatic – often only diagnosed
by radiograph
- Size of lesion time related
- May present as condensing osteitis
- usually treated by extraction or RCT.
Acute periradicular periodontitis - continual pain
- exquisitely tender to percussion
- localised inflammation within PDL
…PHOENIX ABSCESS..acute flare up of CHRONIC
PERIRADICULAR PERIODONTITIS
lateral periodontal abscess - not derived from the pulp
- caused by destruction of the periodontium
- collect as pus
- Drain through the gingiva or a periodontal pocket
- painful and usually associated with localized
periodontal pockets
Diagnosis of pericorontis  Partially erupted L8s

Features of an externally draining Periapical abscess

sinus 

Electric pulp testing; biology of A-DELTA FIBRES – terminate in plexus of raschow /

nociceptive responses from the reversible pulpitis / low threshold pain / dentine
dental pulp  sensitivity…response to EPT

C-Fibres–unmyelinated / terminates near BVs / high

threshold pain / response to inflammation / NO RESPONSE
TO EPT…Irreversible pulpitis

Pulp pathology following trauma - INFLAMMATION = REVERSIBLE PULPITIS

- NECROSIS = IRREVERSIBLE PULPITIS

Headaches&Facial pain (NON-ODONTOGENIC PAIN)

Differential diagnosis of facial pain ODONTOGENIC
NON-ODONTOGENIC
- TMJ (Arthritis & facial arthromyalgia)
- Neural (1o – TGN/Vasoglossopharyngeal; or
2oneuralgias – MS/VZV/Nasopharyngeal carcinoma
{trotter’s syndrome – pain I base of tongue &fauces, on
chewing/coughing swallowing}
- Salivary (acute sialadenitis or malignant tumours –
adenoid cystic carcinoma)
Significance of common medications taken by migraine headaches 
dental patients and reported in the medical - Mainly males (9:1)
history; treatment of migraine headaches  - Cluster or weeks
- Mainly at night (alarm clock)
- Unilateral / midface / around eye
- Nasal congestion / lacrimation
- Paroxysmal / 15 miutes – 3hrs
MGT
 - STEROIDS
- CALCIUM CHANNEL BLOCKERS
- SEROTONIN AGONIST – SUMATRIPTAN
- LITHIUM
Differential diagnosis of non-odontogenic facial Bell palsy
pain; facial nerve palsy  - acute lower motor neurone paralysis of the face due to
HSV
- demyelination of CN VII in the stylomastoid canal,
leading to inflammation and oedema
- FACIAL PALSY ……….WITHOUT RASH

Ramsay Hunt syndrome

lower motor neurone facial palsy due to VZV of the
geniculate ganglion, affecting CN VII
Ipsilateral vesicles Vesicle - pharynx + external
auditory canal + face
Recognition and management of post-herpetic Ipsilateral vesicles Vesicle - pharynx + external auditory canal +
neuralgia  face…PLUS PAIN = POST VZVNEURALGIA..herpes zoster of the
geniculate ganglion
MGT..ACICLOVIR..some also suggest a short course of high-dose
steroid
Differential diagnosis of facial pain; Trigeminal - may be due to central vascular complression
neuralgia  - mainly in females (>50s)
- unilateral paroxysmal electric or shooting pain
- lasting seconds or minutes
…similar features in glossopharyngeal neuralgia - touching a trigger zone
- MRI to rule out central vascular compression; CT to rule
out central mass
MGT
surgical decompression, glycerol or alcohol injection

DRUGS
carbamazepine (tegretol), clonazepam, phenytoin,
gabapentin
Differential diagnosis of non-odontogenic facial DEMYELINATING DISORDER…affecting any part of the CNS…
pain; multiple sclerosis  VARIABLE AND UNPREDICTABLE
..Cranial nerve palsies and neuralgias are common in MS
patients
…trigeminal neuralgia may be indicative of underlying MS in
a young individual
..Therefore patients <50 should receive full neurological
investigation and exam
Differential diagnosis of facial pain; Temporal - giant cell [affects walls of medium-sized arteries]
arthritis - A chronic inflammatory disease of large arteries/
autoimmune vasculitis of the temporal artery
- mainly FM 50-85
- unilateral throbbing, followed by intense
aching/burning pain = may be initiated by eating
(masticatory pain due to ischaemia of masticatory
muscles
- retro-orbital pain (or blindness) due to ischemia of the
optic nerve associated with retinal artery involvement
generalised inflammation with an infiltrate of giant cell &
elevated ESR (increased Igs)
 Rx = high-dose systemic steroid

Restorations / cavity design

Galvanic reactions between metallic Galvanic corrosion

restorative materials 
- Within amalgam between gamma1 and gamma2
phase (2 corrodes faster)..i.e. different phase with
different oxidation rates…creation of a galvanic cell

galvanic effect

- tow metal with different electronegativity, in close

proximity, in an electrically conducting medium
(saliva)…corrosive breakdown of the most
electronegative metal…metallic taste or discomfort

Liners for deep cavities  - CaOH or ZnOeugenol

Cavity design for class II amalgam - Cavo-surface (angle bw cavity wall and occ. Surface…
restorations  CSA = 90-110o..PEAR-shaped bur
- retension grooves in buccal& lingual walls of
..gamma..strongest phase box..using small ROSE-head bur…NOT NEEDED FOR
MO/DO
… gamma1..intermediate
- rounded internal line-angles
..gamma2..weakest..Sn6-8 Hg - remove unsupported enamel
- undercut dentine at diametrically opposite aspects of
cavity..rose-head bur

Retention for large amalgam restorations - rounded internal line-angles

- undercut dentine at diametrically opposite aspects of
cavity..rose-head bur
- CSA = 90-110o..PEAR-shaped bur
- Or seal cut dentine with a dentine bonding
agent..epoxy-based sealer

Cavity preparation for an amalgam - Cavo-surface (angle bw cavity wall and occ. Surface…
restoration in a lower second deciduous CSA = 90-110o..PEAR-shaped bur
molar tooth  - retension grooves in buccal& lingual walls of
box..using small ROSE-head bur…NOT NEEDED FOR
MO/DO
- rounded internal line-angles
- remove unsupported enamel

undercut dentine at diametrically opposite aspects of

cavity..rose-head bur
Use of a pinned amalgam  - Stainless / titanium / gold
- Pins are threaded
- Hole is slightly smaller than pin..
- elasticity of the dentine ‘girps’ the pin

Pulpal exposure and perforation are problems

Dealing with concerns about amalgam as a - removal and placement under rubber dam
restorative material  - safety concerns for…MS / Pregnancy / fetus
- v. small % exhibit selective mercury absorption with
signs of mercury toxicity..removal, as above
- v. small % exhibit lichnoid reaction adjacent to
amalgam..confirmed by skin patch testing

Clinical behaviour of posterior composites in- - marginal failure and subsequent secondary caries due
situ  - ??Soggy bottom to shrinkage…avoided by incremental packing/curing
- marginal staining/leakage..soggy bottom
- restoration displacement,
…>60% filler loading for posterior
- tooth fracture
- post-operative sensitivity…overdrying

…avoid..due to greater polymerization shrinkage…

marginal leakage & post-op sensitivity

Cavity design for posterior composite Bevel if enamel is available…moe area for acid etching &
restorations  bonding…also, expose transversely cut enamel rods =
stronger bond
Avoid occlusalbevel..thiscreats thin section of cured
composite, unable to withstand occlusal stress
BEVEL

- 1mm
- On buccal or lingual cavo-surface margin of box
- Placed on gingival margin ONLY if above ECJ, due to
technical challenge

Composites; acid etch and micromechanical - Creating margins on enamel will create a stronger
bonding  bond less likely to fail
- 37% orthophosphoric acid (20s)
- Resin tags
- Primer (amphiphilic) + adhesive (hydrophobic)

Indirect pulp capping - CaOH or ZnOeugenol

Technical considerations when placing - Creating margins on enamel will create a stronger
composite restorations in permanent molar bond less likely to fail
teeth - 1mm bevel On buccal or lingual cavo-surface margin
of box
- more area for acid etching & bonding…also, expose
transversely cut enamel rods = stronger bond

Prognostic factors in direct pulp capping  - Dependent on complete caries removal

SEDATION

Legal aspects of treatment under conscious WRITTEN, INFORMED CONSENT IS NEEDED FOR
sedation; consent  SADATION AND GA…GDC

Awareness of sedation monitoring BP—NORMAL = SBP120/DBP80

techniques and their interpretation 
PULSE OXYMETRY
- not routine used with inhalation sedation
(oxygen is being administered – minimum
30%)
- fall of 4-5% must be corrected (ask patient to
breath
- below 90% should be treated as potentially
serious
PATTERN/DEPT OF RESPIRATION/clinical
monitoring
- observe reservoir bag
- mouth breathing = decrease in bag movement
with normal chest movement
- skin colour (blue – hypoxia / red – allergy)

Management of patients receiving Max nitrous oxide..70%

inhalation sedation  Excort NOT MANDATORY

- will not work without the hypnotic suggestion

of the operator
- allowed to breath 100% O2 for 2 minutes
- hygienist and therapist who have
undergone training can administer sedation,
with dentist on the premises

Anaesthesia
Inferior alveolar nerve paresthesia as a INTRA-OPERATIVEMAJOR COMPLICATION (nerve
complication of minor oral surgery   damage)

Selection and usage of local anaesthetics  3% PRILO + Felypressin

- synthetic hormone similar to vasopressin

- mild oxytocic effect
- may impede foetal circulation
- best to avoid during pregnancy

ARTICAINE

manufacturer does not recommend articaine use in children

younger than four years of age

Awareness of the constituents of a local Lidocaine/ 2% Xylocaine (Epinephrine + Lidocaine

anaesthetic cartridge; Complications of Hydrochloride)
local anaesthetic usage; Anaphylaxis  Prilocaine/ 3 oe4% Citanest (Epinephrine or felypressin+
Prilocaine Hydrochloride)..also without vasoconcstrictor
Articaine hydrochloride (amide with Ester SIDE
 strong acid salt (hydrochloride salt) CHAIN)4% (40 mg/mL) and epinephrine 1:100,000
- LA long dental procedures such as implants one can
 vasoconstrictor use 0.5% Bupivacaine+1:200,000 Epinephrine
 physiological saline MAXIMUM DOSAGE
 antioxidant (sodium bisulphite) Lidocaine + Adre – 4.4mg/kg
Prilocaine – 6mg/kg
Articaine – 7mg/kg
sodium bisulphite………a sulfite that may …………….FIT, HEALTHY, AVG WEIGHT ADULT
cause allergic-type reactions including
2% LIDO + ADREN – 6-7 Cartridges of 2.2ml
anaphylactic symptoms and life-threatening
or less severe 3% PRILO + Felypressin – 5-6 Cartridges of 2.2ml
asthmatic episodes in certain susceptible 4% PRILO - 4 Cartridges of 2.2ml
people. 4% ARTI - 4 Cartridges of 2.2ml
– 2.2 ml of 2% soln. containing 44mg of active agent
+ 20kg 3-5 yr old, then 2 (3) cartridges of 2.2ml is
max. + healthy 80kg adult 7 (8) catridge of 2.2ml

AMIDE – metabolized by liver & excreted by

kidney

Equal analgesic efficacy and a lower systemic toxicity (a wide

therapeutic range) allows articaine use in a concentration
higher than other amide Las

The direct technique of inferior alveolar - index finger/thumb lies in the retromolar
anaesthesia  triangle (formed by external oblique line
&myolohyoid line)
- needle introduced from contralateral
premolar
- needle inserted lateral to
 pterygomandibular raphe & halfway up
the fingernail
- advance 2.5cm – withdraw 1-2mm
- aspirate, then inject slowly

Mechanism of action of local Block Na ion channels

anaesthetics 
- prevents nerve conduction via inhibition
of depolarisation..i.e. no influx of Na ions

In general, the progression of anesthesia is

related to the diameter, myelination and
conduction velocity of the affected nerve fibers.

Clinically, the order of loss of nerve function is as

follows: (1) pain, (2) temperature, (3) touch, (4)
proprioception, and (5) skeletal muscle tone

Cross infection control

Potential consequences of needle stick HepB

injury  - 30% risk of transmission from as little as 0.1
ml of blood
HIV (0.1-0.5%).
- Sharps injury - risk of infection => 3 per 1000
injuries(0.3%)
 Splash of infected blood onto broken skin
=>1 per 1000 (0.1%) risk of transmission

HBV risk= 5 - 40% / HCV risk= 3 - 10% / HIV risk = 0.2 -

0.5%

Management of needlestick injuries  Encourage to bleed

Wash under running water
Plaster = risk assess – HepB status
assessed
Responsibilities if you are diagnosed with Hep B
an infectious illness  - Satisfactory antibody response to
vaccine => 100 mUL/ml
- Single booster every 5 yrs
- Markers of Hep B infectivity – Hep
B e antigen or >1000 viral
particles
- HBeAg positive = no EPPs
- HBeAg negative but HBV-DNA > 103GE
(Genome equivalent)/ml = noEPPs
- HBeAg negative but HBV-DNA < 103GE = con
 do EPPs (but, must test annually)

HBeAg negative but HBV-DNA 103 105 GE/ml =

can do EPPs (If pretreated)

WASTE DISPOSAL

Control of infection - disposal of endodontic - Care needs to be exercised in the cleaning

instruments  of re-usable endodontic reamers and files
- owing to the variability in dilution during
manual washing, the files/reamers should
be washed separately from other
instruments.
- Where endodontic reamers and files are
designated reusable, they should be
treated as single patient use or single use
– regardless of the manufacturer’s
designation – to reduce the risk of prion
transmission
- SHARPS BIN

Disposal of waste amalgam  AMALGAM SEPERATOR AS PART OF

SUCTION UNIT (mandatory in UK)+
STORED IN SOLUTION UNTIL DISPOSAL BY
SPECIALIST CONTRACTOR

- DISPOSAL RECORD KEPT FOR 3 YEARS

- exempt from the requirement to notify
if less than 200kg of hazardous waste is
produced at the premises

Health and safety; disposal of 'non- Hygiene Waste/OFFENSIVE WASTE

infectious offensive waste' 
- licensed landfill, incinerator or
alternative treatment facility
- incontinence waste/nappy/FAECES/1ST
AID PLASTER
- Yellow bag with black stripe (tiger bag)
used for offensive/hygiene wastes

Practice management; current protocols for SHAPRS BIN

the disposal of waste  YELLOW BAGS
ORANGE BAGS

Sterilizing / cleaning

Control of bacterial contamination from Self-contained water bottles (bottled water

 dental unit water lines  system)
- removed, flushed with distilled or RO
water and
- left open to the air for drying overnight.
- stored inverted
if visual contamination present,
- flushing with a disinfectant (Sodium
hypochlorite and isopropanol)
- thorough washing
Practice management -cleaning of dental AS ABOVE, plus
unit waterlines  drained down between patients & at least at
the end of each working day
- MONITORING - (100-200 cfu via dip
slides incubated @ 22Oc)

Optimum conditions for sterilisation 134-137oC x 3 minutes @ 207kpa

using a steam autoclave  121-124oC x 15 minutes @ 104kpa
Type N
- air removalby passive displacement
with steam.
- non-vacuum sterilizers
- designed for non-wrapped solid
instruments
Type B (vacuum)
- incorporate a vacuum stage
- designed for hollow, air-retentive and
wrapped loads
Type S
- specific wrapped load types, as per
manufacturer’s instructions
Regulations relating to the storage of Wrapped instruments may be stored up to
sterilised instruments 1 year
- pre-sterilization wrapped if type B or S
- post-sterilization wrapped if type N
HTM 01-05 (03/2013)-: Unwrapped instruments in the clinical area:
maximum storage 1 day
Unwrapped instruments in a non-clinical
area can be stored for 1 week
Use of personal protective equipment (PPE) UNIVERSAL PRECAUTION
- all pts treated with equal x-infection
measures EXCEPT
- Suspected spongiform
encephalopathy/new variant
creutzfeldt-Jacob disease = single
use

Treatment planning

Replacement of a missing upper lateral Maintain or close the space

incisor 
Options for the replacement of an upper Maintain or close the space
central incisor in a 16 year old boy 
 Treatment planning for bridge work; Correction of the overerupted molar is prioritybefore
management of an over-erupted molar other procedures can be started.
- orthodontic intrusion,
tooth.
- prosthodontics reduction,

Occlusion

Centric relation  (CR) maxilla-mandibular relationship

condyles in ananterior-superior position
against the slopes of the articular
eminenceswith the disks properly
interposed
position Is independent of tooth contact

Centric Occlusion (CO) Mandible - maxilla relationship when the

teeth are in maximum occlusal contact
(ICP)
condyles are centrally positioned in the
mandibular glenoid fossae of the temporal
bone
- the standard position to asses the ‘bite’ of the
patient
Mandibular movement in the saggital plane; RCP – mandible
Posselt's envelope position when condyle
in most retruded
position/may be more
retruded than the
centric relation
position ….First tooth
contact, when closing
in CR…Teeth then
slide into ICP.
R – maximal
mandibular opening
with condyles in a
reproducible retruded
position, but no
anterio-inferior
condylar translation
T - maximal
mandibular opening
with full anterio-
inferior condylar
translation
E – edge to edge
incisor position
Pr – maximum
protrusion
Use of the 'Face bow'; semi-adjustable non- Facebow
arcon articulators  - equates the horizontal and vertical
axes of rotation between the
 articulator and the mandible
- it equates the horizontal axis of the
articulator with the Frankfort plane
semi-adjustable non-arcon articulators
- Dentatus
- Condylar element on upper member
of the assembly
Dénarfacebow record   Record:
- Relation of the maxillary teeth to the
..semi-adjustable arcon articulators axis of rotation of the mandible (an
arbitraryterminal hinge position)
- Orientation of the occlusal plane to a
horizontal axis (maxillary occlusal
plane to the franfort plane)
- Scallhorn found that 95% of the axis
points located 13 mm anterior to the
posterior margin of the tragus on the
tragus-canthus line to be within a 5
mm radius of the kinematically
located axis Anterior reference point
- 43mm above UR2 or UR3 incisal edge
= dentate patients
- 43mm from lower border of upper lip
at rest/above lower lip when its at
rest
ARTICULATED CAST
- Shows the interocclusal clearance
present
- Crown height
- Over-eruption or tilting of teeth
Use of the Dentatus articulator  - NON ARCON
- Condylar member on top of assembly
- Used in complete denture construction
to aid production of bilaterally
balanced occlusion
ARTICULATED CAST
- Shows the interocclusal clearance
present
- Crown height
- Over-eruption or tilting of teeth
Dahl appliance  Over-erupted tooth can be intruded by a
Dahl appliance
- Removable or cemented appliance
…Dahl considers that patietnsredily - CoCr appliance
accommodate an increase in OVD of up to - Ceramic veneers
2mm  Space is created by compensatory
oveeruption of the posterior teeth &
intrusion of the anterior teeth

–Little periodontal support

–Large horizontal slide
–Occlusally aware
 2mm thick over palatal surfaces

•Buccal clasps on canines and PM’s

•Constant wear
–compliance

Features of a normal occlusion  normal occlusion

- Defines nothing more than a state of
interarch tooth contact
Malocclusion – departure from
definition..class I/II/III
Definition and use of an occlusal splint  DEFINITION
- removable dental appliance that
…… Conservative splints covers several, or all of the upper or
Michigan- type splint - diagnostic and lower teeth.
treatment device - reduces muscle
hyperactivity + help condyles to reposition in a TYPES/USES
way that promotes healing of internal TMJ Stabilization or flat plane splint
structures -. This splint is not a flat occlusal - covers all the upper teeth
splint and it does not have incisal guidance. Modified Hawley splint
Cuspal guidance is created to provide a rise in - fits on the upper jaw
lateral and protrusive movements, so that all - contact with only the six lower front
mandibular teeth, except the cuspids, are teeth.
discluded at protrusive and lateral movements. - Occludes posteriors, and prevents
Plane splints. For aesthetic reasons, some both clenching and grinding.
patients may prefer to have splints without NTI-tss (Nociceptive Trigeminal
cuspal guidance. Balanced contacts with all Inhibition Tension Suppression
opposing supporting cusps are mandatory but System)
some clinicians believe that better results are - fits on the upper anteriors
achieved if the contacts between the incisors - designed to prevent tooth clenching
and the splint are very light or even removed. and grinding.
Thin splints are often too fragile for heavy Repositioning splint.
bruxers - move the lower jaw either forward or
Bite splint according to Shore. This splint has a backward.
design similar to the conventional plane splint
but does not extend onto the facial or buccal
surfaces of the teeth and it covers the entire
palatal area.
Sved plate. Only the opposing anterior teeth
make contact with this splint. It is
recommended for patients with acute or
chronic muscle pain if the plane splint is
ineffective. The Sved plate is usually placed on
the upper teeth. It is mostly used only at night
and not more than 10 to 12 hours a day.There
is a risk for intrusion of teeth, which has to be
explained to the patient before delivery.
Gelb splint. The Gelb appliance is made in the
lower jaw, covering only the premolar and
molar teeth. It is used to correct mandibular
displacement, reduce TMJ dysfunction and
oral/facial pain, and to provide occlusal stability
with the patient's natural dentition serving as
the anterior guidance. Some dentists fear that
this splint can cause intrusion of the posterior
teeth.
Repositioning splints. Repositioning splints
guide the mandible into a position different
from (mostly anterior to) the habitual one at
closing. The purpose is to facilitate
repositioning of the TMJ disks and to reduce
the load on pain-sensitive areas. These splints
may be indicated for short-term use to keep a
recaptured disk in a normal superior position
(e.g., when a displaced disk has been
recaptured by manipulation).
A repositioning splint is most often removable
but can be fixed. Such a splint, often called a
cap splint, can be described as an intermediary
between a splint and a bridge. It is useful for
temporary reconstruction before final decision
about design, vertical dimension, etc. It is often
made in metal with the occlusal surface in hard
acrylic.

What is the definition of a facebow? A caliper-like instrument used to record the

spatial relationship of the maxillary arch to the
rotational hinge axis and then transfer this
relationship to an articulator
What are the two types of facebows? Kinematic
Arbitrary
What is the kinematic facebow used to The true physiologic axis of rotation
locate?
Where is this true physiologic axis 8mm in front of the tragus of the ear, on
located? each side of the face
What are the two types of arbitrary Facia-bow
facebows? Ear-bow
What does the arbitrary facebow An arbitrary hinge axis by using anatomical
locate? How? landmarks
What are the three “points” of the Beyron Point
arbitrary hinge axis location? - A point 13mm anterior to the
posterior margin of the tragus on the
tragus-canthus line
Gysi Point
- A point 13mm anterior to the anterior
margin of the external auditory
meatus on the line from the upper
margin of the external auditory
 meatus to the lateral canthus of the
eye
Bergstrom point
- A point 10mm anterior to the center
of a spherical insert in the external
auditory meatus and 7mm below the
Frankfurt horizontal plane
What is the Frankfurt horizontal plane? A line that passes through the patient’s
external auditory canal and the lowest
border of the bony orbital rim
What does the facebow orient the maxillary The hinge axis in three reference plane
cast to?
Where are the three points that are Two on each side of the face
required by the reference plane? One on the anterior face
What should the 3rd reference point be? Repeatable, reproducible
What determines the 3rd reference point? The type of facebow

What is the 3rd point of reference for a Maxillary incisor incisal edge
Danarfacebow?
What is the 3rd point of reference for a Nasion
Whip Mix facebow?
What is the 3rd reference point for a Orbitale…infra-orbital fissure (not sure
springbowfacebow which or if they’re the same thing or
something)
What is the definition of an articulator? A mechanical device to which mandibular
and maxillary casts are attached and which
stimulates some jaw positions and
movements
Ideally, what does an articulator replicate? - Jaw positions and movements
- Angulations (Bennett, Condylar
protrusive, Lateral)
- Pathways
- Timing of movements
- Orientation of jaw in skull
- Distance of elements
What are the uses of articulators? - Diagnostic mounting (in CR or CO)
- Treatment planning
- Discussion of care with patient
- Fabricating prosthesis
What are the basic components of an articulator? - Upper member/arm/frame
- Lower member/arm/frame
- Anterior or incisal pin
- Condylar mechanism
- Intercondylar distance adjustment
- Anterior guiding mechanism
- Mounting ring – guide and retention
system
What are the three classifications of articulators? 1. Simple/hinge/non-adjustable
2. Semi-adjustable
3. Fully adjustable
What are some characteristics of the - Most basic articulator
simple/hinge/non-adjustable articulator? - No adjustments possible
- Does not accept a facebow
What are some characteristics of the semi- - Replicates some but not all of the
adjustable articulator? patient’s movements
- Accepts a facebow
- Can be programmed
- What we use at PDS
What is another classification of Classification according to condylar
articulators? element
What are the two types according to this Arcon
classification? Non-arcon
What is the arcon articulator? The condylar element is on the lower
member and the guiding mechanism is on
..ARticulatorCONdyle ..ARCON the upper member..whipmix&Denar
- Allow progressive and immediate
side-shifting/Bennett Angle
- Able to adjust the guidance angles of
both condyles
- Adjust incisal guidance plate..i.e..able
to customerised to the anterior
guidance
- TMJ to incisor distance
- Antero-posterior positions of the
condyles can be adjusted to provide
identifiable positions for CR and CO
- Has a fixed intercondylar distance
What is the non-arcon articulator? The condylar element is on the upper
memberand the guiding mechanism is on
the lower member
What are the three steps for mounting 1. Correct positioning of the maxillary
casts? cast in relation to the rotational axis (face-
bow transfer)
2. Relating the maxillary cast to the
mandibular cast (mounting)
3. Program the articulator (condylar
element)
What records do you use to program the Using protrusive or lateral records
condylar element (last step in the mounting
cast procedure)?
What is the outcome of relating the The same path of opening and closure as in
maxillary cast to the mandibular cast the mouth
What are the two positions the mandibular Centric Relation (CR)
cast can be mounted in? Maximum Intercuspation position (MIP)
What is centric relation? Term used to define a position of the
condyles when the condyles are in the
most anterior-superior position in the
glenoid fossa
How can you take a centric relation record? Teeth must be separated by a centric
record made with wax, polyvinylsiloxane,
acrylic resin
What are the four types of adjustments 1. Condylar angle 25o
allowed with a semi-adjustable articulator? 2. Bennett angle 15o
3. Intercondylar distance
4. Anterior Guidance
What are advantages of semi-adjustable - Uses facebow
articulators - Can mount casts in MIP or CR
 - Can program condylar and anterior
guidance
- Can program and stimulate with
good accuracy eccentric movements
- More anatomical although maybe
not exactly resemble the patient
- Restorations require less
adjustment
- Ridge and groove pattern more
closely resembles patients
- Less chairside time
- Suitable for most work once
limitations are understood
What are sources of error for semi- - Arbitrary hinge axis location
adjustable articulators? - Protrusive vs. lateral record
- Curved vs. straight condylar path
- Intercondylar distance
What is the error produced by arbitrary 3mm off produces a 0.2mm error at the
hinge axis location? second molar region (Weinberg)
What is the error produced by protrusive vs. 5 degrees off produces an error of about
lateral record? 0.1mm at the second molar region
What is the error produced by curved vs. 0.2mm (can’t create curved surfaces)
straight condylar path?
What is the error produced by intercondylar Affects ridge and groove pattern
distance (when assumed to be 110 mm)?
How accurate is your semi-adjustable Sufficiently accurate for most procedures.
articulator? Biggest limitation is in increasing vertical
dimension – need a kinematic facebow.
How is the facebow transferred? Usually an arbitrary facebow transfer.
Casts more correctly related to the
condyles.
Opening and closing pathways closely
resemble those of the patient.
What types of records are used for the Protrusive records
condylar angle? Lateral records
**Some articulators only accept protrusive,
some accept protrusive and lateral
Static records
What record is used for the Bennett angle? Lateral record (protrusive record does not
record the Bennet angle)
What is intercondylar distance? distance between the condyles according to
the patient’s intercondylar distance
What do most semi-adjustable articulators 110 mm
have the intercondylar distance set at?
Surgical / XLA

Extractions

planning dental extractions   TIMING

Optimal space closure
- Chronological age – 9 -10
- DENTAL AGE
 Lateral incisors and first premolars
should have erupted but not
theRemainingbuccal teeth.
 Calcification of the bifurcation of the
roots of the second permanent
molars should have just
commenced
Surgical techniques used in the Incisors
extraction of teeth prior to the placement - Apical pressure + rotation + labial
of immediate denture delivery
Canines
- Labial force + rotation + labial delivery
Premolars
- Buco-palatal displacement + delivery
down through the socket (upper 4s)
- As above + rotation for 5s & lowers…
for LOWERS = Never displace bucally
= root fracture
Molars (uppers)_
- Bucco-palatal displacement + buccal
delivery
- LOWERS – FIGURE OF 8
Uses of aluxator - Held in the palm, with Index finger
placed along the long axis
Used to incise PDL, with little or no force
Elevators - Used as levers and wedges
- Placed between tooth and bone
- rotate on their long axis to dislodge
tooth/root
Straight
- Coupland chisels #1, 2, 3
Angled
- Cryers RIGHT & LEFT
- Warick James – RIGHT, LEFT, Straight
Choice of instruments for extraction of an MOLAR FORCEPS (beaks to cheeks)
upper first molar tooth - buccal beak fits into the bifurcation
with concavities on either side which
fit around the buccal roots
- Broad concave palatal beak
- ForcepsDesigned to allow the beaks to
be adapted closely to the roots
- Forces are distributed more evenly
- Lower the risk of tooth fracture
Surgical anatomy of the lower left third The most common
molar tooth - Alveolar oesteitis
 - Bleeding
- Paraesthesia
- infection
Dislodgment (rarely) into any of the
adjoining anatomical areas –pterygoid
venous plexus / submandibular/sublingual
fossae
Indications for extraction of a lower third Unrestorable caries
molar; NICE guidelines Non-treatable pulpal/periapical lesion
Abscess and osteomyelitis
Internal external root resorption of adjacent
Disease of follicle (cyst/tumour)
Tooth involved in field of tumour resection
 Influence of pericoronitis on
recommendation remains unclear

Complications

Complications of upper molar extraction; Fistula – epithelialisedoro-antral

difference between an oro-antral fistula communication
and an oro-antral communication 
- Once surgically fixed advise the patient
not to blow their nose for 10 - 14dys
- Antibiotic and inhalations are often
prescribed

Complications of third molar surgery; Lingual parasthesia-associated problems

Lingual parasthesia  - drooling, tongue biting, burning sensation
of the tongue, anesthesia resulting in burns
during eating and drinking, pain, change
inspeech pattern, and a change in taste
perception (Dysgeusia and hypogeusia) of
food and drink as a result of the proximity
of the chorda tympani to the lingual nerve
within the nerve sheath.

Management of post operative bleeding Primary/immediate

following XLA  - Socket compression between fingers
- Biting on guaze
- Surgical + sutures
Reactionary (within 24hrs)
- Due to Relaxation of vessel spasm
- Identify bleeding point and suture
Secondary (7-14dys post XLA)
- Identify bleeding point and suture

Management of localisedalveolar osteitis - LA

 …pain starts 2-3DYS post XLA - Debride
- Irrigate with warm saline/0.2% CHX
- Impregnated eugenol (ALVOGYL) or
iodophore-based obtundent
- DO NOT pack socket full…prevents
space filling filling granulation tissue
- Prescribe NSAIDs..oropiod If excessive
pain.
- REVIEW in 2 dys
 Pain may start again a day/two
after, increasing in severity…BUT
should reduce after a few days.
- Socket should be filled with
granulation tissue in 10 dys

The relationship between osteoporosis and Osteoporosis

bone loss following dental extractions  - Reduction in bone mass/unit volume
- May be taking
bisphosphonates(BRONJ)
If multiple extraction, limit to one quadrant
at a time, until socket heals.

Other

dentures; intraseptalalveolotomy  - Interdentally septa removed after the

extraction of the teeth and then the
…davenport pp49-50 buccal outer cortical plate were
collapsed lingual to the inner plate
- Most common indication in association
Alveolotomy – intraseptal bone removed f fitting an immediate denture is the
reduction of a prominent Premaxilla to
Alveolectomy – labial cortical plate removed allow a more favourable placing of
anterior teeth on dentures
- To eliminate moderate labial undercut
Both done …in prominent premaxilla so that a flanged denture can be used
without too much distortion of the
upper lip, by the flange
Inferior alveolar nerve parasthesia as a Potential danger signs on Radiographs
complication of minor oral surgery - Loss of tram lines
- Narrowing of the tramlines
- Deviation of the tramlines
- Radiolucent banding across the root
Assessment of the chemotherapy patient Complete XLA before commencing
for routine oral surgery – BRONJ chemotherapy
Oral surgery / management of Only if increased risk of infection
infection /antibiotics - Diabetes
- Immunocompromised patients
- Infection present at time of treatment
 It needed
- Amoxicillin 500mg TDS (15
CAPSULES) or
- MTZ 200mg TDS (15 tablets) or
- Erythromycin 500mg QDS (20 Tablets)
 7 day regime for post –avulsion
implantation
Impact of common medications prescribed Warfarin + aspirin
for management of cardiovascular problems - Post XLA haemorrhage
- WARFARIN + Ca-CHANNEL BLOCKERS Calcium channel blockers
- Gingival hyperplasia
Oral surgery / maxillofacial trauma Mandibular fracture during XLA
Oroantral communication during XLA
Healing following dental extraction  WOUND
- Inflammatory stage (0-4dys) =
vascular and cellular events
- Proliferative stage (3-21dys) =
granulation tissue forms (wound
strength=70%)
- Remodelling phase(>21dys)
BONE
 Primary intention
 Secondary intention

Dentures

Full dentures

Correct placement of the posterior border Correct placement

of an upper full denture 
- At the vibrating line...but

…….. border should be smooth tapered and If a patient’s denture is underextended,

merge with the soft palate (not form a square but retentive (and a copy denture is
edge) being made) – retain the position of the
posterior seal on the old denture

Full denture construction; anatomical UPPERANTERIORS

landmarks useful in positioning the
teeth  - 12.5mm from posterior border of
incisive papilla, or
- 8-10mm from the middle of the
incisive papilla
- About 2-3mm of teeth should show
when lips apart
 UPPER POSTERIOR – Sligtly buccal to the
residual ridge and parallel to the ala-
tragus line

LOWER ANTERIORS – marginally in front

of the ridge crest, if there is little
resorption..or, over the buccal sulcus if
lots of resorption

LOWER POSTERIORS – Directly ovr the

ridge

Emily

• Set teeth more on ridge

• Use narrower or smaller teeth
• Flat cusp teeth
• Balanced articulation
• Molar set, in line with compensating
curve
• Full arch set, to show alignment of
teeth fossae
Emily Enigma guide
Anatomical landmarks lower
1. Retromolar pad
2. Bisected centre of alveolar ridge
(posterior)
3. Bisected centre of alveolar ridge (anterior)
Anatomical landmarks upper
1. Incisive papilla
2. Bisected centre of alveolar ridge
(posterior)
3. Bisected centre of alveolar ridge (anterior)
4. Palatal vibrating line

The Enigma Systemis more flexible in its

focus on individual dental naturalism and
neuromuscular compatibility.
starts with lip support and the face (using the
Alma Gauge) not with the teeth on the gums
Front and back teeth are no longer wedded in
a single occlusal
scheme - the anteriors can be put where they
look nice, the posteriors so that they mesh
well
Anatomical considerations when
recording a upper full impression  
Hamular notch-this narrow cleft
extends distally from the
 tuberosity to the pterygoid hamulus.
The posterior palatal seal (post
dam) is placed through the centre of
the deep part of the notch.
• Tuberosity-the most distal aspect of
the maxillary alveolar
process.
• Vibrating line-is the area at the
junction of the soft and hard
palates where movement is seen when
the patient says “Ahhhh”.
From this line the posterior extension
of the denture is determined.
• Fovea palatine-indentations on each
side of the midline slightly
posterior to the junction of the hard
and soft palates.
• Rugae-are raised areas of dense
connective tissue radiating from
the median suture in the anterior third
of the palate.
• Incisive papilla-the elevation of soft
tissue covering the incisive or
nasopalatine canal
Features to be recognised when taking Buccal frenum-a fold or folds of
impressions for full/full dentures 
mucous membrane connecting
Anatomical considerations when
recording a lower full impression   the residual alveolar ridge to the cheek
in the bicuspid region.
• Buccal shelf area-extends from the
buccal frenum posteriorly to
the retromolar pad and is bordered by
the external oblique ridge
and internally by the shape of the
alveolar ridge.
• External oblique ridge or line-the
bony ridge running downwardfrom the
anterior border of the ramus of the
mandible and out ontothe lateral
alveolar process and body.
• Retromolar pad-pad of tissue
behind the mandibular third molars.
 • Lingual frenum-presents avery
broad attachment close to the crest of
the ridge.
Lingual sulcus-lingual aspect of the
mandible - range of tongue
movements
• Mylohyoid ridge-on lingual surface
of the mandible - mylohoid muscle
attach

Diagnosis of denture problems; influence S sounds like "SH"

of dentures on speech  UPPER anteriors too far posteriorly
= Bulking of the tongue palatal contact area and
the area of the incisive papilla will facilitate
proper enunciation
……….. Using the /S/ sounds to establish
S pronounced Ch
phonetics and vertical dimension…let S be your
Thickening the denture base in the anterior
guide
palatal → lisping
Too high occlusal plane: tongue spread on the
lower teeth→ lisping
Decreased vertical dimension: leading to lisping
………. When the patient say S (sixty-six), the
Tongue make contact with the teeth prematurely
upper and lower teeth should be separated 2mm
→ affect lingupalatal sounds→ lisping
from each other (closest speaking space method)
T pronounced D
Thickening the denture base in the anterior
palatal → lisping
D pronounced T
………. Maxillary anterior teeth are positioned so
Decreasing the thickness of the denture base →
the incisal edges make a definite seal against the
whistling
lower lip, at or near the wet dry line when the
F pronounced V
patient is pronouncing the "F" or "V" sounds
Too high occlusal plane: tongue spread on the
lower teeth→ lisping
Upper anterior teeth Too far palatally
V pronounced F
Too low occlusal plane: difficulty in correct
positioning of the lower lip and tongue contact
occlusal surface during the speech

Full denture construction; occlusal vertical OVD - the denture(s) in occlusion

dimension and freeway space 
RVD – Lips/Denture slightly apart /at rest

- Head must be in a natural vertical

 position, supported by the neck
muscles
- WILLIS BITE GUAGE =lower border of
the nose to lower border of the
mandible

FREEWAY SPACE

- Difference between OVD & RVD

- 2-4mm
- Measured in the premolar region

Troubleshooting full dentures; increased Increased vertical dimension

OVD
- denture teeth make contact during
speech→ clicking,
- defect in Ch-C-J sounds,
- whistling,
- Th pronounced T due to failure of the
tongue to be placed between anterior
teeth

Troubleshooting upper complete dentures Rounded smooth line at the junction of the
-the post dam hard and soft palate

- Aids the peripheral seal of upper

denture

Management of the poorly retentive CAUSE

full/partial denture 
- Underextended in the posterior border
- Poor posterior border seal

Full denture construction; jaw relationships – ALAR-TRAGUS LINE = establish the

posterior occlusal plane (on the upper bite
rim) – FOX PLANE = establish the anterior
occlusal plane (parallel to the line between
the pupils/interpupillary line)

Frankfort plane and other cephalometric planes A line that passes through the patient’s
important in denture construction external auditory canal and the lowest
border of the bony orbital rim

- plane passing through the lowest

point in the floor of the left orbit
(orbitale -Or) and the highest point
on the external auditor meatus of the
skull (porion – Po) – it is horizontal
when the head is in the normal
 upright position

Partial dentures

Management of the patient with a CAUSE

fractured partial denture 
- Impact / work hardening / denture processing
problem / parafunctional habits

SOLN

- Midline complete denture fracture = fracture

area removed and new acrylic processed
- Tempory repair = with cyanoacrylate glue or
cold-cure acrylic

Evaluation of the poorly fitting Adjust with acrylic kit

partial denture  Reline (new material on fitting surface)/rebase

Partial denture design; direct and RETAINER

indirect retention 
- Component that resist displace ment of the
denture
…..Retention of an RPD can be achieved by:
• Using mechanical means such as clasps (1) which Direct
engage undercuts on the tooth surface.
• Harnessing the patient’s muscular control (2)
- Clasp assembly or precision attachment
acting through the polished surface of the denture.
• Using the inherent physical forces (3) which arise (requirements –
from coverage of the mucosa by the denture. retention/support[rest]/stability[resist hpri.
Mvment]/reciprocation/encirclement/passivity)

INDIRECT reduce tendency for denture base to

move in an occlusal direction, or rotate about the
fulcrum line
............The choice of retentive clasp for an
individual tooth depends upon the: - Auxiliary occlusal rest / canine rest/ canine
extensions from occlusal rest / cingulum bar
• Position of the undercut.
 Mainly important for free-end saddle + large
• Health of the periodontal ligament.
• Shape of the sulcus. anterior saddles

Choice of materials for clasps in the COCR - Maximum undercut = 0.25mm /Minimum length =
design of a mandibular partial 15mm
denture  
UNDERCUT

0.25-0.5mm – SS wire

0.5-0.75 – Wrought gold (easiest to adjust..also distort)

>0.25mm cast gold (or whiptam wire – cast CoCr)

 a cobalt chromium clasp arm, approximately l5 mm long,
should be placed in a horizontal undercut of 0.25 mm.

If the undercut is less the retention will be inadequate. If it is greater, the

clasp arm will be distorted because the proportional limit is likely to be
exceeded.
Surveying casts in partial denture OBJECTIVE
design 
- Establish path of insertion.removal
 GUIDE PLANE – need be only 2-3mm long
- Id undercuts for retention
- Id undercuts for blocking out

Lingual connectors in lower Lingual plate – cast CoCr or acylic = 2mm

partial denture design 
Sublingual bar is more rigid than a lingual bar

Lingual bar – requires> 7mm of space between the floor of the

mouth and the gingival margin

Lingual bar - requires 3mm clearance from the gingival margin

Lingual bar – contraindicated if incisors are retroclined.

the vertical height of a sublingual bar is less than a lingual bar it can be used
in shallower lingual sulci and be kept further away from the gingival
margins

PALATAL connectors in UPPER - If Palatal bar < 30mm long = width must
partial denture design  be 9mm + 0.7mm thickness or width
must be 4.5mm + 0.9mm thickness.
- If Palatal bar > 30mm = width must be
…horseshoe – CoCr or Acrylic 1.5- 10mm + 0.9mm thickness or width must
2.0mm..gaw be 6.5mm + 1.1mm thickness.

Connectors 3-5mm from gingivae to reduce fenestration - rare

phenomenon. Gingival fenestration means the exposure of the
tooth due to loss of the overlying bone and gingiva - Gingival
fenestration defects may create problems regarding plaque
control, root hypersensitivity, and esthetics

Impressions for the 'applegate 1.Equalize stress between ridge and abutments –
(altered cast)' technique  improve adaptation of the denture base-to-ridge to
minimize movement during function
2.Mandibular Class 11 or II
3.Framework is made – tray is added to framework
4.Tray seated in mouth (with ZOE)with pressure
ONLY over REST…NO MATERIAL UNDER REST OR
CONNECTORS

IN LAB
 - SECTION CAST + place retentive
groves in cast + sticky wax
framework into place +
impression is boxed + new ridge
areas is poured

Use of special trays in denture Free-end saddle

construction 
- Spaced 3mm stop over teeth
- 1mm space over saddle, no vents
- Greenstick for borders and addle
-

Spaced/perforated – alginate

Non-spaced/nonperforated – impregnum

 3mm spacing for impression plaster

 0.5mm for ZOE
 Ideally 2mm SHORT of functional sulcus
depth

Mucosal lesions associated with FLABBY RIDGE

denture wearing  Usually occurs when natural teeth oppose an edentulous
ridge - causes instability of the denture - due to fibrous
tissue deposition - frequently seen in the upper anterior
region
SOLN
Surgery – selective displacive impression technique –
window impression technique

papillary hyperplasia of the palatal mucosa

traumatic ulcer (overextended flanges)
angular cheilitis [overclosure]
fibrous hyperplasia/epulisfissarum (flange impinge on sulcus)
chronic atrophic candidosis/denture sore mouth [mainly on
palate]
denture-based hypersensitivity reactions

Every dentures  Designed to ensure gingival health

Restricted touse in the UPPER arch
Requires BOUNDED saddles
INCORPORATE

- Point contact between normal

teeth and denture teeth
- Wide embrasures
- Uncovered gingivae
 - Distal stabilisers
- A ‘free occlusion’

Or…davenport

All connector borders are at least 3 mm from the gingival margins.

 The 'open' design of saddle/tooth junction is employed.
 Point contacts between the artificial teeth and abutment teeth are
established to reduce lateral stress to a minimum.
 Posterior wire 'stops' are included to prevent distal drift of the
posterior teeth with consequent opening of the contact points. These
'stops' can also contribute to the retention of the RPD posteriorly.
 Flanges are included to assist the bracing of the denture.
 Lateral stresses are reduced by achieving as much balanced occlusion
and articulation as possible, or by relying on guidance from
the remaining natural teeth to disclude the denture teeth on excursion

Crowns / bridges / onlays

Crowns
Full gold crown preparation - ideal degree 5o is ideal – buccolingually & approximally
of taper 
6-10otaperor 5-10o / total convergence of
16o (prof Tredwinyr 3 lec
Crown preparation for a full gold CHAMFER MARGINS
crown Placement of crown margins  SHOULD FINISH SUPRAGINGIVALLY
1MM occlusal reduction
1.5mm functional cusp bevel

occlusal reduction = 1 mm (non-

functional); (1.5mm functional)

functional cusp bevel = min 1.5mm

lingual&buccal reduction = 0.5mm

Full gold crown - construction problems  Not enough tooth material removed =
crown overbulked or insufficient thickness
for wear and function.

Wear caused by porcelain jacket crowns in Some of the ceramic materials that are very
the opposing arch  tough and fracture resistant are also quite
abrasive against the opposing teeth.
Empress is the kindest to the teeth it chews
against
Crown preparation for PFM occlusal reduction = 1.5mm (0.5 – 0.7 mm
crowns placement of gingival margins   for metal &minimum 1.0mm for porcelain)
functional cusp bevel = 2mm
bucaal reduction = 1.5mm =>shoulder
palatal reduction = 0.5mm =>chamfer

Crown preparations for an upper anterior occlusal reduction = 1.5mm (0.5 – 0.7 mm
porcelain fused to metal cast restoration for metal &minimum 1.0mm for porcelain)
 functional cusp bevel = 2mm
bucaal reduction = 1.5mm =>shoulder
palatal reduction = 0.5mm =>chamfer
Labial SHOULDER
Palatal CHAMFER
Indications for use of an resin bonded Vs PFM - mechanically weaker and
'All-Ceramic' crown  need to be used in conjunction with
resin bonding cements.
two main factors:
……All-ceramic crowns belong to one of two families: 1. Underlying tooth/substrate colour
-need up to 2 mm of porcelain to block out
Low strength, etchable, glass based ceramics. Examples of dark underlying colour.9,10 For this reason,
these include: glass based, all-ceramic systems should not
be used on dark underlying surfaces
• IPS Empress and IPS emax (Ivoclar Vivadent, 2. The cementation system to be used
Lichtenstein) -which in turn is based on: i) resistance
form of the tooth preparation ii) margin
• Authentic (Jensen, CT, USA) location of the tooth preparation - if the
tooth preparation lacks adequate
• Finesse (DENTSPLY Ceramco, PA, USA)
• Traditional feldspathic porcelain
resistance form (tapered or short
preparations), a resin cement should
be used. If there is adequate resistance
High strength, non-etchable, alumina (Al) or zirconia (Zi)
form, the decision is then based on margin
based ceramics. Examples of these include:
location
• Procera (NobelBiocare, Sweden)
• Lava (3M ESPE, Minn, USA)
• In-Ceram (Vita, Germany)
• Zircon (DCS, Switzerland)

Use of stainless steel crowns Extensive caries precluding cavity

preparation
Following pulp therapy in primary teeth
Recurrent caries
Initial restoration in - amelogen.
Imperfect/dentinogenesis imperfect/ severe
enamel hypoplasia (thin enamel)
Types of crowns suitable for upper anterior PFM
teeth All ceramic/Porcelain jacket
Comparison of metal and porcelain as All-porcelain is generally not as strong as
materials for a full gold crown on a molar porcelain fused to metal
tooth  All-porcelain has to be bonded to the tooth
in order to have adequate strength for oral
function

Bridges
Management of the 'de-bonded' resin sandblasted metal ‘wings’, which
retained bridge  are bonded to the enamel of the abutment
teeth/tooth using appropriate resin-based,
chemically-active luting materials, such as
Panavia F
- Check for OCCLUSAL
INTERFERANCE + clean
tooth + clean bidge with
ultrasonic + resandblasted
+ RECEMENT
 - If problem persist,
consider conventional
bridge
Design of resin bonded bridges  Varies with the edentulous space
UPPER ANTERIOR REGION
- Simple cantilever last
longest
LOWER ANTERIOR REGION
- Fixed-fixed more
dependable because
enamel of surface of lower
is inadequate to support
cantilever
Indications for adhesive bridgework  Short span / sound enamel / favourable occlusion
(minimal or no overbite / small occlusal forces (no
bruxism) / intermediate restoration / missing lateral
incisors / young patient with large pulp
Adhesive bridges should not be used in
patients who have significant bruxist or
parafunctional activity.
are generally contra-indicated when the abutment
teeth are heavily restored.
One further contra-indication is a lack of clinical crown
height in the abutment teeth
Resolution of problems associated with 1.Dentine exposed during prep = use a
cantilever bridgework  dentine adhesive system
2.Metal showing through abutments = cut
wings away incisally before cementing or
use a more opaque cement
3.Caries under debonded wing = remove &
repair
4.Debonding
Complications of adhesive bridgework  AS ABOVE

PROGNOSIS five-year survival rates for bridgework as 87.7% for resin

bonded prostheses4 and just over 90% for conventional
bridges depending on design..

mean survival time = 7.5 years

Onlays
MOD onlays Preparation - gold onlay LOWER JAW
restorations  Occlusal box
 Flat floor
 1.5mmmin depth
 3rdbucco-lingual
width
Approximal box
 Flat floor
 Walls 3-6o(slightly
slanted)
 Eliminate all contact
points,NoUndercuts!
!
 - Buccal shoulder
 Provides material
stability in areas of
occlusal load
 1mm minimum
width
 900 relative to cusp
 Walls are parallel to
occlusal box wall
 Shoulder ends above
approximal box
- Occlusal load/OB cusp
reduction
 Should leave tooth in
anatomical form
 Minimum 1mm
reduction
- Lingual reduction
 1.5mmwidth,
internally &
externally
- Marginal reduction/BEVEL
 Placed circularly
around entire prep
 0.5-1.0mm, width

Other
Use of gingival retraction cord  Cord:plain or impregnated with chemical
solutions

HAEMOSTATIC AGENTS (not used if NUG)

- Ferric sulphate
- Ferric chloride
- Aluminium chloride
(Racestyptine)

Paste systems eg Expasyl

Foam Systems eg Gingifoam
twisted or knitted cord
Impregnated or pre-soaked cord
Single or double cord techniques
 Records gingival
or subgingival
finishing lines
 Place centre of
cord in sulcus
and work, out
towards ends

Porcelain veneers  Finish lines for porcelain veneers - Always

in enamel
 1-2 mm incisal reduction
0.3 – 0.7 mm overall labial/facial
reduction (NB. 2 or more planes)
Chamfered gingival & proximal margins
Problems with impressions for metal cast Voids on the margin
restorations  Tearing at the margin
Facial-lingula pulls tray-tooth contact
Lack of impression detail
Inhibited or slow setting
delamination

Post and cores

Determination of the length of a post  Well obturated root filling to enable 3-

when constructing a post crown  4mm GP to act as seal apically
Remember you need 4-5mm well obturated GP at
the apex

The post should be at least as long as the height

of the crown being replaced

As wide diameter as possible for optimal

strength - need 1mm around the post to stop the
root fracturing

Indications for posts  WHERE

 Upper anteriors
 Canines
 Premolars (palatal root used if 2 rooted
upper 4)
 Sometimes molars (palatal root usually
used in uppers as biggest)
 Lower ants normally have roots which are
too spindly and weak for placing posts
WHERE NOT
 Inadequate or compromised root
 Inadequate or compromised root filling
 Peri apical infection
 Inadequate or compromised bone
 As abutments for p/p or bridges (some
exceptions)
PREREQUISITE
 Root filled root
 Well obturated root filling to enable 3-
 4mm GP to act as seal apically
 Caries free, intact root
 Space
 Ferrule
 Ability to take impression

Principles of preparation for posts  AS ABOVE, PLUS

 Remove GP with gates glidden coronally
only
 Prep remaining space with para post drill
to optimum size
 Remove GP with gates glidden coronally
only
 Prep remaining space with para post drill
to optimum size

IMPRESSION POST = SMOOTH

BURN-OUT POST = SERRATED (SENT TO LAB)

CEMENTING
 Metal cast or direct use = ZnP or poly F or
aqua cem
 Fibre posts use panavia or other dual or
self cure resin based cement

Implants

Advantages/disadvantages of implants
compared to natural teeth  The peri-implant tissue has less blood supply

• There are no transeptal or gingivodental fibres

around implants

• There is a junctional epithelium attachment to the

implant abutment
… For young people with congenitally missing teeth, a
single tooth implant is undoubtedly the restoration of • There is no periodontal ligament associated with an
choice. implant, instead it is fused directly to the bone
(osseointegration)

• The implant lacks sensory feedback of occlusal

forces. Due to this, the monitoring of the occlusion, in
particular carefully noting:
- Screw loosening
- Fracture of the prosthesis
- Attrition
 - Redness, swelling, discomfort
- Denture ulcers

Survival rates of dental implants have been reported

to be in excess of 90% after 15 years. Systematic
reviews have also shown no significant difference in
survival rates between different implant systems.

Contraindications for implant treatment:

History of Periodontal Disease
• Radiotherapy to the jaw bone
• Untreated intraoral pathology or malignancy
• Untreated periodontal disease
• Uncontrolled drug or alcohol use (abuse)
• Uncontrolled psychiatric disorders
• Recent myocardial infarction (MI) or cerebrovascular
accident (CVA) or valvular prosthesis surgery
• Intravenous bisphosphonate (anti-resorptive)
therapy
• Immunosuppression -

• Inability to maintain high levels of plaque control

(e.g. reduced manual dexterity or mental capacity)

Endo

Immediate complications of root canal SHORT FILLING

treatment  Fractured instrument
Perforation
Zipping (or transportation

CORONAL LEAKAGE – main reason for

failure – good endo + good seal = 94%
success=> good endo + poor seal = 44%
success=>poor endo+good seal = 68%
success =>POOR + POOR = 18%

Diagnosis of perio-endo lesions Class 1

endodontic lesion draining throughthe
periodontal ligament
…endodontic lesion draining through the
Present as - isolated periodontalpocket or swelling
periodontal ligament => Class 1
beside the tooth.
The patientrarely complains of pain, although there
willoften be a history of an acute episode.
…  primarily endodontic with secondary periodon- Causeof the pocket is a necrotic pulp draining
tal involvement => Class 2 throughthe periodontal ligament.
 XRAYfurcation area ofboth premolar and molar teeth
may be involved - radiolucent area
....periodontal diseasegradually spreading along the
root surface => Class 3. DIAGNOSTIC -crestal bone levels onboth the
mesial and distal aspects appear normaland only
the furcation shows a radiolucent area
…. primarily peri-odontal with secondary endodontic Class 2.
involvement =>Class 4 (A Class 3 lesion If left untreated, the primary lesion may become
progresses to a Class 4) secondarily involved with periodontal breakdown.

A probe may encounter plaque or calculusin the

pocket.

The lesion will resolve partiallywith root canal

treatment but complete repairwill involve periodontal
therapy
Class 3.
caused by periodontal diseasegradually spreading
along the root surface.
Thepulp, although compromised, may remain vital.

The tooth may become mobile as PDL and

surrounding bone aredestroyed, leaving deep
periodontal pocketing.

Perodontal disease will usually be seen else-

where in the mouth unless there are local predis-
posing factors such as a severely defective
restoration or proximal groove

Class 4.
Primary periodontal lesions with secondary
endodontic involvement
A Class 3 lesion progresses to a Class 4 lesion
with the involvement of the main apical forami-
na or possibly a large lateral canal.
Management of an acute periapical Incision + drainage or RCT + drainage or XLA +
infection in an upper anterior tooth  drainage

Choice of antibiotics for the management If Local measures NOT effective or cellulitis:
of an acute periapical infection  ..ANY..

MTZ – 200mg TDS 15 TABLETS

AMOXICILLIN 500mg TDS 15 TABLETS
Pen G 250 2 TABLETS QDS 40 TAB
ERY 250mg QDS 20 TAB..if pen allergy

Choice of radiographs for investigation of PA

a suspected periapical lesion 
Endodontic treatment planning following REDO or surgical endo – main aim is to access the
failed root canal therapy to a apical 3RD
multirooted
The objective of mechanical preparation clean & shape
 of a root canal  -

Choice of restoration following root canal Crown / Post crown / or onlay if sufficient enamel
treatment 
Complications of root canal treatment; IF filling too short or long =>periapical lesions
Management of the 'short' root filling 
Materials used in the irrigation and Chlorhexidine – 3%- carcinogenic with
preparation of root canals (Sodium hypochlorite – use with saline/H20.
hypochlorite and EDTA)
Sodium hypochlorite = 0.5 – 5.25%
EDTA= 17% (Glyde Felize 18%) degrades
smear layer (30 sec) – reduces hypochlorite’s
efficiency

Concs of 1.3 and 2.5% NaOCl for 40mins ineffective

against E. faecalis…Combined use of EDTA and
NaOCL more efficient than NaOCL alone

MTAD (Mixture of tetracycline, acid and

detergents)…1-6% less effective against E. faecalis

Endodontic instruments; Hedstrom files  ?GOOD FOR OVOID CANALS = SHAPE LIKE
A TEAR DROP

Masseran kit  - TREPHINE DRILL FOR ENDO – Seperated

instrument

cutting flutes,designed to cut in an anticlockwise

direction

Success rate of endodontic treatment  95%

Stainless steel 0.2 taper

NiTi 3-5 Times more flexible than SS

Shape memory
• It exists in two crystallographic forms.
• Phase change is stress induced.

Protaper Eiffel tower

F1 = 7% TAPER
F2 = 8%
F3 = 9%

Perio
Anug

Mouthwash for use in the management Hydrogen Peroxide Solution 6% =>2–3 minutes
of ANUG …bnf with 15 mL diluted in half a tumblerful of warm
water 2–3 times daily

chlorhexidine gluconate 0.2% => rinse mouth with

10 mL for about 1 minute twice daily

Therapeutic dose of metronidazole; Mtz 400mg TDS=> send 9 tablets

management of ANUG..BNF

Immediate management of ANUG  Local

- Mechanical debridement
- OHI
SYSTEMIC – (Fever/pyrexia present)
- MTZ 400mg TDS send 9
Causative micro-organisms of ANUG  Vincent's infection
Anaerobes
SPIROCHEATE
FUSIFORMS

Recognition and pathogenesis of SITE – incisors & PE 8s

(ANUG)  CLINICAL
- Papilla necrosis
- Grey slough, easily
removed to reveal raw
bleeding (ulceration)
- Pain / halitosis
- Metallic taste
Lymphadenopathy/ fever/malaise, IF
SEVERE
Management of (ANUG)  Metronidazole (or amoxicillin if
metronidazole is inappropriate) for 3 days.

Paracetamol or ibuprofen for pain relief.

Chlorhexidine (0.12% or 0.2%) or hydrogen

peroxide 6% mouth wash.
Treatment of ANUG; Dosage of Mtz 200-250mg TDS=> send 9 tablets OR
antibiotics…BNF
Amoxicillin 500mg TDS => 9 tablets

Screening / examination / classification

Periodontal anatomy; distance from the alveolar crest to superior attachment of
Biological width 
attached gingival margin (2.04mm)... i.e. the dimension of the soft
tissue, which is attached to the portion of the tooth coronal to the crest of
the alveolar bone.

(a) Histological sulcus (0.69 mm)

(b) Epithelial attachment (0.97 mm)
(c) Connective tissue attachment (1.07 mm)

(d) Biologic width (b+c)

depends on the location of the tooth in the alveolus, varies from tooth to
tooth, and also from the aspect of the tooth
essential for preservation of periodontal health and removal of
irritation that might damage the periodontium (prosthetic
restorations, for example)

Classification of furcation 1 – into, but no more than 1RD

defects  2 - > 3rd, but NOT through
3 – fully through furcation

Treatment planning a tooth Code *

REPRESENTS - Moderate to severe chronic periodontitis or a site requiring
with a furcation
complex periodontal treatment
involvement 
Full Periodontal Assessment includes:Plq and bleeding scores, asix point pocket
chart, gingival recession, furcation involvement, mobility and suppuration

Appropriate levels of periodontal treatment - referral to a specialist may be

indicated

Bone defect  One wall defect – usually only one interdental wall remains and is called
hemi septum if remaining wall is proximal. Poor prognosis for periodontal
regeneration since it is difficult to stabilize the graft material to be used in
its proper place.
 Two wall defect – most prevalent bone defect found interdentally with
facial and lingual walls remaining, involves both the interproximal walls
which are mainly called crater defects or interdental crater defects.
 Three wall defect – occurs most frequently in the interdental region, usually
the remaining bony walls are facial, lingual and proximal can be
circumferential defects. The ideal osseous defect for a regenerative
procedure as this defect shape will favor the stabilization of a graft material
to be used.
 Combined defect – combination of one, two or three wall defect
  Fenestration – isolated areas in which the root is denuded of bone and the
root surface is covered only by periosteum and overlying gums. Marginal
bone is intact
 Dehiscence – areas where the defect extends through the marginal bone

Miller's index of tooth 0 - < 0.2 mobility = healthy

mobility  1- Horizontal 0.2 – 1mm
2- Horizontal >1mm
3- Horizontal & vertical
Diagnosis of chronic BPE ≥3 (pocket = 3.5-5.5mm=>Early chronic periodontal
inflammatory periodontal disease) =>upper section of lower black abnd still
conditions  visible
LOCALISED
 <30% Teeth are affected
GENERALISED
 >30% Teeth are affected
Diagnostic criteria for
generalised aggressive Usually <30 years of age but may be older
periodontitis 
–Poor serum antibody response to associated bacteria
–Pronounced episodic destruction of attachment and
alveolar bone
–Generalised attachment loss affecting at least 3
permanent teethother than the 1stmolars and incisors

- GENERALISED BONE LOSS ON ALL

TEETH ..opg

Treatment
•Aggressive Disease = Aggressive Treatment
•OHIesp. interdentally
•Adjunctive antibiotics–Doxycycline 100mg once daily for 14
days
OR–Amoxicillin 500mg tds and Metronidazole 400mg tds 14
days
•RSD
•During RSD extract any terminal prognosis teeth
•Reassess healing after 2 months

Recognition of localised Circumpubertal onset

aggressive
–Robust serum antibody to associated bacteria
–Localised 1stmolar/incisor presentation
 •Must involve 2 permanent teeth one of which is a 1stmolar
•No more than 2 teeth other than 1stmolars and incisors

Aetiology
Low levels of bacterial plaque;
Increased proportions of certain bacteria, in particular
Aggregatibacter actinomycetemcomitans
Defects in neutrophil function;
Root abnormalities;
Hyper-responsive macrophage phenotype
…Virulence factors triggers inflammatory response, leading
to bone and collagen destruction

Diagnosis and classification three major forms

of periodontal diseases 
 chronic,
 aggressive (LOCAL/GENERAL)
and
 necrotizing forms (NUG/NUP),
plus
 periodontal manifestations of
systemic disease

periodontitis  Differential Chronic

diagnosis of gingival and Amount of destruction is consistent with presence of local factors
periodontal lesions  Subgingival calculus is a frequent finding
Slow to moderate rate of progression
Most prevalent in adults, but can occur in children

aggressive (LOCAL/GENERAL) - AS ABOVE

necrotizing forms (NUG/NUP), plus

periodontal manifestations of systemic disease..DIABETES /

DOWNS / EHLERS-DANLOS etc

Interpretation of the six 6 measurements are made for each tooth in millimetres
point pocket chart   < 3mm – Shallow Pocketing / 4-6mm – Moderate
Pocketing / >6mm - Deep Pocketing

True recession value

Combine the score for the pocket depth with the free gingival
margin height to give you the true recession value:

FGM = 2mm (2mm below CEJ)

 Pocket depth = 6mm

True recession = 8mm

FGM = -6mm (6mm above CEJ)

Pocket depth = 6mm

True recession = 0mm

This helps to offset false pocketing scores

Recording and interpretation

of BPE measurements 

PERIODONTASL DISEASE SEVERITY

ASSESSMENT - Pocket probing depth
- Atachment loss
- Radiographic assessment of aleolar bone
loss
DISEASE PROGRESSION
- Increasing loss of attachment
- Increasing alveolar bone loss
DISEASE ACTIVITY
- BOP
- Suppuration
DISEASE PREDICTION
- Smoking
- Previous disease
- Local/systemic risk factors

Pathogenesis / bacteria
 Communication with a hygienist; Use of the Removal of subgingival calculus, plus
term 'root surface debridement'  infected cementum

Occlusal wear as a cause of localised Deep overbite; reverse overjet; teeth out of
periodontal breakdown  the arch - lead to enhanced levelsof
infl ammati on and periodontal
GINGIVAL RECESSION deteriorati on in the presence of plaque.

1999 International Workshop for Classification of

Diseases and Conditions - no clear evidence that
occlusal forces were a factor in plaque-induced
gingivial disease or connective tissue loss
STILLMAN’S CLEFT
Incipient lesion / narrow, deep, slightly curved /
extends apically from free gingival margin / aical
border becomes inflamed when cleft reaches
the mucogingival junction, due to poor plaque
control
McCall’c FESTOON
Rolled, thockenedgingival band / mainly
observed adjacent to the canines, when
recession approaches the mucugingival junction

Pregnancy

Choice of analgesia and antibiotics 1. Drugs – analgesic – paracetamol500-

during the first trimester of pregnancy  1000mgFIRST LINE

2. Drug – antibiotics – penicillin/ or

Cephalosporins (1st and 2nd generation)or
Erythromycin

3. Drug - LA –2% lidocaine+ adrenaline

rd
• …..The greatest risk period 3 to
11th week of pregnancy Anti-fungal of choice - Amphotercin B

AVOID

• Metronidazole avoid in 1st trimester

• Quinalones – avoid
 • Tetracyclines – fetal teeth staining

ARTICAINE (avoid 3% prilocaine +

felypressin [uterine contraction] & articaine
[methaemoglobinaemia]

Zovirax and Vectavir cold sore cream

duringpregnancy

Care of the pregnant patient  1. When to treat – 2nd Trimester [1st =

teratogens; 3rd = 10-15% risk of
supinehypotension from wk 24 – place on
left side, if need to treat]...Compression of
inferior vena cava & aorta
2.
3. No amalgam, removal or placement
4. No duraphat varnish – 33.8% ethanol

Almost all drugs reach the fetus

Xray
small dose to the fetus that the associated risk
can be regarded as negligible
given the option of delaying the radiography due
to emotive nature.

Management of routine dental problems 1. No amalgam, removal or placement

during the second trimester of
pregnancy 2. No duraphat varnish – 33.8% ethanol

10-15% risk of supinehypotension from wk 24 – place

on left side, if need to treat]

Treatment of a faint in a heavily supinehypotension

pregnant woman  • Third trimester - 10-15%
• Compression of inferior vena cava & aorta
– Decrease venous return to heart
– Decrease uteroplacental
perfusion and fetal distress
– The patient may complain of
dizziness and/or nausea
MGT
• Elevation the right hip 10~12cm with a
 small pillow (left uterine displacement)
• Teat the patient slightly sitting up (semi-
supine)

Pregnancy epulis  • Usually appears in the 3rd month of

pregnancy
• Incidence – 1.8 - 5%
• Mushroom-like flattened spherical mass
– Sessile or pedunculated base
– Protrudes from:
• The gingival margin
• Inerproximal space
– Red to dark blue colour
• Bleeds easily, if
traumatised
• May have numerous dark
red pinpoint markings
– Painless unless it interferes with
the occlusion
MGT
• Intense OHI
• Thorough debridement
• Removal of any local plaque retentive
factors
• Lesion usually resolves following
parturition
• Excisional biopsy:
– Doubtful regarding diagnosis
– No resolution following
parturition

Dento alveolar pathology

External inflammatory (root) resorption replantation of an avulsed tooth could

result in:
 A. Surface resorption / external resorption
C. Inflammatory resorption
D. Replacement resorption

Examination of a swelling Paget’s sign - index finger plus middle

finger, plus another finger – wave transmit
finger pressure = FLUCTUANT

Oral disease

Aetiology of apthous ulceration   Endocrine( menstrual cycle, pregnant; oral

contraceptives)
Systemic Conditions (Behçet syndromeCrohn)
Dietary deficiencies (folate or vit B12)
Allergen
SITE - non-keratinized

- inside of the lips,

- inside of the cheeks,
- floor of the mouth,
- ventral of the tongue

Risk factors for aphthous ulceration  genetic predisposition

Oral trauma
Certain foods
Anxiety or stress
Smoking cessation

Management of oral ulceration  short course of a low-potency topical

corticosteroid – hydrocortisone
antimicrobial mouthwash - CHX
topical analgesic - benzydamine hydrochloride

Recognition of potentially malignant ulcers  ROLLED BORDER; INDURATTED;

Differential diagnosis of ulceration of the PAINLESS; NON-HEALING >2WK; SUDDEN
lateral margin of the tongue  SIZE INCREASE

Oral ulceration; Erythema multiformae  Triggers

INFECTION- HSV; Mycoplasma pneumonia;
DRUGS – barbituates,
carbamazepine/phenytoin
Range from mild to severe (Stevens Johnson
syndrome)..mainly YOUNG MALES)

Haemorrhaegic crusting (fibrin-covered

 erosion) of lips + conjuctival scarring
blindness
AETIOLOGY
Widespread necrosis of keratinocytes, with
eosinophilic changes, progressing to
epithelial vesicle or bullae formation.
LESIONS
Target lesions (skin) + oral ulcers

Cysts/tumours

Radiographic appearance of a dentigerous Unilocular - dome-shaped - thin bony

cyst  margin of cortical bone - unerupted tooth -
attached at the CEJ
a) central type : the most common type, the
cyst is completely surround the crown
b) lateral type : the cyst projects laterally
from the side of the tooth.
c)circumferential type: the cyst durround
the crown and extends around the roots so
portion of roots appear to lie within the cyst.
Radiographic appearanceRadicular cysts  Unilocular or poorly defined radiolecency

COMMONEST CYST

At the apex of non-vital tooth

•    Cyst wall contains chronic

  
inflammatory cells
•    Hyaline bodies (Rushton bodies) are
   characteristic but are seen in only about
10% of cases
Radiographic appearance Ameloblastoma LINGUAL EXPANDING multilocular radiolucency
at the angle of the mandible

remnants of the dental lamina, enamel organ,

and cell rests of Malassez or From DENTIGEROUS
CYST - (lining of the cyst may undergoes
neoplastic transformation)a mural ameloblastom
 
 Age: 30-50 yrs old
 Site: Posterior mandible
Presents / Rad:Typically asymptomatic &
 appears as multiocular cyst radiographically -
septa in the radiolucency give it a soap bubble or
honeycomb appearance. Some ameloblastomas
are unilocular..resemble dentigerous cyst

 Caution:Maxillary ameloblastomas can

invade cranial base & be lethal.
Locally invasive but does not metastasise

Radiographic appearance Nasopalatine well-demarcated radiolucency in the midline

cysts of the palate, apical to the central incisor
teeth. The lucency varies from round to
oval or heart-shaped due to superimposition of
the nasal spine

HISTO
lined by stratified squamous, pseudo stratified
  and cuboidal epithelium
believed to arise from epithelial remnants of the
nasopalatine duct

Radiographic appearance Residual cysts  results where a collateral, lateral periodontal,

radicular, or any other cyst or
granuloma remains after the extraction of a
tooth or a root

A round unilocular, radiolucency with well

defined borders in an edentulous area.

Histological features of odontogenic cysts  DENTIGEROUS cyst

LINING =>Thin regular layer – stratified
squamous epithelium – may occasionally
keratinise
CAPSULE=> collagenous fibrous tissue –

usually free of inflammatory cell

lining of dentigerous cyst typically consists of

flattened stratified squamous
epithelium in which mucous (goblet) cells are
often present
structure of the cyst wall is otherwise similar
to thatof radicular cyst, but inflammatory
changes are typically absent

MGT=> marsupialization or enucleation

Histopathological features of an a “propensity to grow along the internal aspect

odontogenickeratocyst
 of the jaws, causing minimal expansion”
GROWTH – by by extension of projections into
marraow spaces..NOT expansion

cyst wall is thin

Pallisaded basal cell layer
epithelium is of uniform thickness, typically
about 7-10 cells thick without rete ridges
palisaded layer of tall basal cells in the
parakeratotic type
prickle cell layer which forms the bulk of the
epithelium

Differential diagnosis of
odontogenickeratocyst 

....-Keratocyst may present in jaws of edentulous

patients and in this case it cannot be diferentiated
radiographically from residual radicular cyst.

-Keratocyst may develop between two teeth an in

this case it gives the radiologic picture of lateral
periodontal cyst.

-Keratocyst may develop in the midline of maxilla

and in this case it mimics ( mimicking ) naso
palatine duct cyst.

Paradental cyst(Buccal bifurcation cyst) inflammatory cyst associated with

pericoronitis / an inflammatory dentigerous
cyst (or variant) formed on the buccal aspect
of the lower wisdom mainly ,but
inflammation here associated with
pericoronitis overlying vital tooth(lower
3rd molar).
Cementoblastoma (Neoplasm of cementoblasts

………Enucleation

Occurrence:

Age: Young adults

Site: Most common @ apex of vital lower 6

Presents / Rad: Radiopaque w/ a narrow lucent rim

Cherubism Bilateral radiolucency in the

mandibular rami
Enlargement begins before <5 yrs old
Smooth well-defined corticated lesions
Radiolucent with internal septa producing a
Multilocular appearance
Disruption of the dentition
Swelling and rounding of the posterior body
of the ramus of the mandible
Hereditary Bilateral variant of fibrous
dysplasia

Tumours

Differential diagnosis of odontogenic lesions; grows by expansion and is usually

adenomatoidodontogenictumours associated with an unerupted tooth
asymptomatic, small lesions are discovered
incidentally on radiographic examination or
when failure of tooth eruption is
investigated
65% of the cases occur in the maxilla
Radiographically well-circumscribed
unilocular lesion may be
completelyradiolucent or radiopaque
flecks of calcification
resembles a dentigerous cyst but
envelopes most of the tooth rather than
only the crown.
Radiological appearance of ameloblastoma multiocular(or unilocular..resemble dentigerous
cyst)cyst radiographically
septa in the radiolucency give it a soap bubble or
honeycomb appearance
 Presenting features of an ameloblastoma; *tumoris painless and remains
differential diagnosis of multilocular lesions asymptomatic as it enlarges
*patient notices a gradual jaw expansion
producing facial asymmetry
*cortex is often thinned but is seldom
penetrated by the growth
*recurrence rate is high after surgical
treatment – due to local infiltration of
surrounding bone

*Infiltrates the surrounding intact bone

before thedestruction is visible on a
radiograph=>the lesion is much larger
than its radiographic appearance.

most favored sites are the mandibular

molar region, angle of mandible, and
ascending ramus

most common radiographic image is that

of multilocular (soap-
bubble/honeycomb) cyst-like
radiolucencies.

Bone

Pathogenesis of osteogenesis imperfecta  Brittle bone disease

Type I collagen deficiency
features
•Tendency for bone fractures
•Geneti cabnormalities in collagen (esp.
collagen type I)
•DI is a feature of some forms (25% of
cases)
- Type I
•Autosomal dominant (AD) + Normal
birth weight + blue sclera + rarely
have multiple fractures
- Type II
•Autosomal recessive (AR) + infant
often still-born + multiple skeletal
abnormalities
- Type III
•Recessive + severe + fracture present
at birth (66%)+blue sclera + DI
- Type IV – AD or mixed
inheritance *pattern + similar to type
 I, but more severe + white sclera

Dentinogenesis imperfecta – Class 1

– defective collagen type 1 – concurrent
with OI[80% of OI type II &IV pts]–
blue sclera = due to defectieve
collagen giving way to underlying
pigment

Patterns of resorption of the alveolar ridges Most prominent in first year

in the edentulous patient  3 – 4 times more in the mandible
than maxilla
Eventually approx. 0.2 mm/year for
mandible (less for maxilla)
SEE ‘MANDIBULAR CHANGES’ STEM MAXILLA
- Mainly labially/bucally, in the
anterior region…incisive papilla
appear more prominently on the
crest of the ridge
MANDIBLE
- Mainly labially & bucally
towards the anterior
Tends to retain its width, or wider
posteriorly

Diseases of Bone; fibrous dysplasia  *A Metabolic bone disease

*monostotic/polystotic/Mclune’s
….most common bone abnormality during *becomes inactive at skeletal
growth…vs osteoporosis (during bodies decline)
maturation&*may undergo
sarcomatous changes (if treated with
radiotherapy)
*affects adolescents and children
(time of mutation) - Onset in 20s
*elevated ALP & Ca in Polycystic, in
contrast to monostotic
*Monostotic = M:FM, and often affects
the jaws
*Polystotic = FM3:1M,may be
widespread, with endocrine
involvement
*due to somatic mutation (GNAS 1
gene activation mutation on
chromosome 20q – G-protein)
*time of mutation determines the form
(the later, the simpler)
HISTO(slender trabeculae of woven
bone in very cellular fibrous matrix –
Chinese lettering
 XRAY (ground-glass or orange peel
=>inter-radicular + loss of lamina
dura) +

Diseases of bone; Paget's disease of bone - biphasic = have an active

(osteitis deformans) (vascular stage) & an inactive
(avascular phase
- active = vascular bone
- avascular = sclerotic / dense /
lytic lesions = poor post-XLA healing
- 30% of lesions are above the
clavicle
- Cold wet climates + may have
viral (zoonotic - ?dog) aetiology
- Osteoclastic resorption, then
disordered bone deposition
*mainly affects elderly
*teeth are often hypercented (difficult
XLA)
* Foramina narrowing and nerve
compressed
…COTTON WOOL-appearance
*irregular & exaggerated bone
resorption
*Maxilla more affected
*other lesions/signs/symptoms in
other bones..

Cement-osseous dysplasia (Osseous dysplasia) peri-apical/focal/florid…i.e. non-

neoplasia
The term “Cemento-Osseous Dysplasia” is a
histopathological term rather than a clinical or Periapical
- single or multiple incicisor Apex,
radiological term
- mainly mandibular & asymptomatic
- DD cem-ossifying, without
demarcatoin
- mainly afro-caribbean FM (10:1)
- initially similar to PA
granuloma, then become radio-
opaque
- asymptomatic
-localized lesion in the anterior mandible
PERIAPICAL -30 years of age
-black women
-Involved teeth test vital unless they are
coincidentally carious or have been
traumatized
Florid – GIGANTIFORM
CEMENTOMA
- posterior mandible
- multiple symmetrical lesion, due to
 sheets/fused masses of relatively
acellular bone/cementum-like
tissue
- mainly afro-caribbean FM (10:1), in
3rd -5th decade
- may lead to bony expansion or
osteomyelitis (post XLA)
- XRAY= radiopaque mass with no
FLORID demarcation/border
- DD hypercementosis when near
roots
Focal
- localised lesion, similar to florid…
MAIN DENTAL CONCERN
- Like florid..aim toPrevent infection
leading to osteomyelitis
MGT
MONITOR LESOIN RADIOGRAPHICALLY
Dif. Diag

- Benign cementoblastom
 Associated tooth XLA
- Cementifying fibroma
 Enucleation + XLA
- Odontogenic fibroma
 Excise lesion + XLA
- Pinborg tumour
 Excision of the area or block
excisoin

Cancer

Management of first presentation of a urgent 2 wk referal

suspected oral squamous cell carcinoma
in general practice

Oral cancer; indications for incisional *non-healing ulcer

biopsy  *sudden increase in size
*indurated (hard)
 *bleeding
*rolled & irregular borders

BIOPSY =>elliptical incision at the edge of

the lesion with affeacted and unaffected
tissue – 4% paraformaldehyde (10% buffered
formalin) – 10 x volume of tissue –overnight or 24
hrs for large samples.. prevents tissue necrosis

 Histological features of oral squamous cell *drop-shaped rete ridges

carcinoma  *nuclear hyperchromatism
*nuclear pleomorphism
*altered nuclear:cytoplasm ratio
*excess mitotic activity
*loss of cell polarity
*deep cell keratinisation
*disordered or loss of differentiation
* invasion into underlying structures, with
penetration through the basement membrane

Basal cell carcinoma (rodent ulcers) *RARELY possess meastatic potential

*Multiple naevoid basal cell carcinoma
…most common skin cancer (of the skin) present in GORLIN GOLZ
SYNDROME..LOCALLY INVASIVE
*mainly elderly
*sun-damaged skin – red nodule –
become ulcer = PEARLY ROLLED
BORDERS
*mgt by local wedge excision, with 4mm
of normal tissue margin – OR radiotherapy
*excellent prognosis

Appearance and differential diagnosis of Benign proliferation of stratified squamous

squamous papilloma  epithelium
Papillary or verrecous exophytic
pedunculated mass
Induced by HPV

 Benign, & in patient of 3rd – 5th

decade
 Mainly on soft palate, also dorsum &
lat. of tongue + lower lip
 Pedunculated or sesessile
cauliflower-like swelling
 HPV 6 or 11, in 80% of cases

DIFFERENTIAL DIAGNOSIS
*Fibroepithelial polyp
 Oral Precancerous Conditions; oral Leukoplakia with the worst prognosis
submucous fibrosis  (bilaterallymph drainage/metastasis)
*blanched opaque appearance with fibrous
bands
*lips / buccal mucosa / tongue
*epithelial dysplasia is a common finding
*mainly indian subcontinent
*strong association with betel nut
chewing

Dental issues in the radiotherapy patient xerostomia

Vesiculobulllous / pigmented

histopathological features of pemphigus *intercellular deposition of IgG on PRICKLE

vulgaris cells (changes occur between the cells
of the statum spinosum..just above
the basal layer)
*Supra-basilar bulla with Acantholysis
leading to cleft-like spaces
- TYPE II HYPERSENSITIVITY
- Circulating antibodies to
desmosome component (desmoglein 3)
- Autoantibody (IgG) against
desmosomal protein (e.g. desmoglein-
3), detected in >90% cases
- Ag-Ab comlex form intra-
epithelially→cell-cell
disruption→acantholysis→intra-epithelial
bullae forms
- Rupture of vesicle/bullae leaves
painful ragged erosoin
- Nikolsky’s signs– stroking the
mucosa will cause vesicle/bullae formation
Management of pemphigus vulgaris  PV – systemic vs BMMP – local
Without treatment death usually
follows
- Immunosuppressive treatment is
usually life-saving
- * biopsy + immunofluorescene to
detect DESMOGLEIN 3 (ICAM)
 80-100mg/day prednisolone +
azathioprine (1-1.5mg/kg daily)
histopathological features of pemphigoid *IgG deposition along the basement zone
(hemidesmosomes)
*Subepithelial bulla with intact basal
cells
**full-thickness epithelialseparation
from the lamina propria
Clinical features of lichen planus  - Oral lesions appear before
skin lesions, mainly on the
buccal mucosaOral lesions
bilateral, and sometimes
symmetrical

Type IV hypersensitivityfeatures (band-shaped

subepithelial Tcell and macrophage accumulation
(CD8+ cells mainly

HISTO – Saw-tooth rete ridges / hyperkeratosis / -

Civaette bodies•

*Band-like infiltrates in the juxta-epithelial layer(bw

dermis/epid)
*Lymphocyte infiltration of the epithelial layer
*wickman striae – popular lesion with white streaks

Malignant potential of oral lichen planus *risk of malignant transformation into squamous cell
carcinoma (SCC).
*1.2% to 3.2% in follow-up of up to 10 years
*OLPhas a higher rate of cell turnover, which may
increase the risk of genetic errors
*If exposed to a carcinogen, OLP may undergo
molecular changes leading to dysplasia and increased
cancer risk
*HPV-16 and -18 were identified in 9.2% of OLP
*toluidine blue may be helpful in biopsy site
selection, by binding to DNA, and lesions that have
increased mitotic activity or DNA abnormality may
stain blue.
Management of Oral Lichen Planus Depends on severity
*diet modification (acidic/spicy/salty)
*change medications
*topical steroids / analgesic mw
(benzydamine hydrochloride)
*severe cases = systemic steroids
Lichenoid tissue reactions to common - TYPE IV hypersensitivity
dental materials  - Inflammatory infiltrate may
be deep or focal
- Infiltrate may include PMNs
in addition to lymphocytes
- Red mucosal lesions with or
without ulceration, in contact
with the material, or at other
locations of the mucosa
 Civaette bodies (globular IgM deposits + apoptic
keratinocytes in the basal layer)

Differential diagnosis of a lichenoid tissue ‘deep infiltrates of perivascular

reaction  inflammatory cells’ – highly suggestive
of lichenoid reaction versus lichen planus
(localized to the connective tissue-
epithelial interphase)..DRUGS (ace
inhibitors/beta Bs)
Recognition of sinister signs in oral Malignant melanoma
pigmented lesions  Most cases involve hard palate and
maxillary alveolar ridge
Differential diagnosis of important peri-oral Melanotic macule
skin lesions  - Flat
- Localised area of
brown pigmentation
- Lower lip or buccal
mucosa
Malignant melanoma
- Deeply pigmented lesion
- May be ulcerated and
bleeding
- Affect skin,, mucosa &
eye
- Most cases involve hard
palate and maxillary
alveolar ridge

Smoking

Generalized hyperkaratosis
Sparing of the gingival margins
Inflamed openings of Minor salivary gland

…RED on a WHITE background

Clinical features of stomatitis nicotina 

Other

Indications for incision and drainage of Fluctuant swelling, with spreading cellulitis
an oral swelling 

Investigation of dry mouth  500ml daily saliva production / < 2ml in 10

 minutes unstimulated whole saliva
(0.2ml/min)=>xerostomia>0.5ml/min
stimulated saliva flow rate 

Lateral pharyngeal (parapharyngeal) From roots of molar, depending on the

space infections  location of apices (above/below muscle
attachment)

Management of suspected orbital MTZ 400mg

cellulitis  AMC 500mg

Recognition of the dental features of If maxillary sinus = all teeth associated with
sinusitis 
antrum will be tender = postural change
induce pain, if fluid in antrum
generally self-limiting condition that has an
average duration of 2. Weeks

Antibiotic therapy should only be used for

persistent symptoms and/or purulent
discharge lasting at least seven days or if
symptoms are severe.
Advise the patient to use steam inhalation
Ephedrine‡ Nasal Drops, 0.5%
Amoxicillin Capsules, 500mg tds
Oro-facial features of acromegaly  Excess GH production AFTER closure of the
bony epiphyses
spacing of the teeth
large pulp chambers (taurodontism) and
excessive deposition of cementum on the roots
Progressive mandibular prognathism

tongue enlargement

frontal bossing/protruded glabella and

increased anterior face height

jaw thickening are due to deposition of

periosteal bone in response to the excess growth
hormone

The lips become thick and negroid. due to

deposition of glycosaminoglycan and increased
collagen synthesis by the connective tissue

hypertrophy of palatal tissues which may cause

or accentuate sleep apnea,
 Gigantism is the childhood version of growth
hormone excess and is characterized by the
general symmetrical overgrowth of the body
parts

Oro-facial features of Achondroplasia Retrusion of mid-third of the faceClass III

Defective growth of the skull base
 normal trunk & head

short limbs + normal intelligence

most common form of short-limb dwarfismcaused by

mutation in fibroblast growth factor 3 (FGFR3) on
chromosome 4, causing a defect in the maturation of
chondrocytes in the cartilage growth plate relative
macrocephaly,
depressed nasal bridge / maxillary hypoplasia

midfacial Underdevelopment /
Oro-facial features of Down's syndrome 
hypoplasiaprognathic Class III open bite
The bridge of the nose, bones of the midface
and maxilla are relatively smaller in size
tongue is of normal size but the oral cavity is
decreased in size due to underdevelopment of
the mid-face
palate narrow with a high vault
hypodontiain both the primary and
permanent dentitions
high rate of periodontal disease

Differential diagnosis of acute herpetic p sore throat and moderate to high fever.
gingivostomatitis; streptococcal Headache, nausea, vomiting, and abdominal pain
pharyngitis 
are frequent.
the pharynx is distinctly red. The tonsils are
enlarged and covered with a yellow, blood-tinged
exudate.
petechiae or doughnut-shaped lesions on the
soft palate and posterior pharynx.
The uvula may be red, stippled, and swollen.
Anterior cervical lymph nodes are enlarged and
tender to touch
Gingivostomatitis is characteristic of herpes
simplex virus-1

Clinical features of Infectious  palatal petichiae

Mononucleosis 
  ulceration
 pharyngeltonsillar enlargement
 lymphadenopathy + fever
 children or early adolescence
 monospot test – Positive Heterophile
antibody-positive

Tuberculosis; Causes of cervical Unilateral nodal enlargement

lymphadenopathy  Night sweats / Productive cough
Hilar mass, with partial collapse of upper
lobe
Ulcers with indurated margins, on the
posterior aspect on dorsal surface of the
tongue / deep painful ulcers

Radiographic radiolucencies, due to

calcifications whithin lymph nodes

Differential Diagnosis of sore throat; Pharyngitis

cervical   lymphadenopathy Infectious mononucleosis
Primary herpetic gingivostomatitis
Herpangina
SUBMANDIBULAR Infection of
head/neck/sinuses/ears/eyes/pharynx
SUBMENTAL Monucleosis syndromes /
EBV

TMJ/Jaw movement

Anatomy of jaw dislocation  Mouth is ‘gagged’ open

Condyle is anterior to articular eminence
Rx

- LA over condyle/around
the dislocated joint +
thumbs on the molar, and
apply downward and
backward pressure
- Advise to support jaw
when yawning

Crepitation - a symptom of TMJ disease Due to degenerative condition of the

articular surface (osteoarthrosis)
Pain on loading (chewing)
 Crepetis – crunching or grating noise
and sensation

Differential diagnosis of TMJ pain; Ear external, middle, and inner ear or infection
infections  generate symptoms in the face and jaws
&around the TMJ that are poorly localized
Middle ear disease can also refer pain
anteriorly tothe TMJ, masseter region,
and posterior maxillaryteeth

Disorders of the TMJ; internal Describes an instability or abnormal

derangement of the TMJ  position of the articular disc – usually
anterior
Give rise to clicking or locking(inability to
open) of the TMJ

Disorders of the muscles of Spasm of the muscles of mastication,

mastication;trismus  leading to restriction of jaw opening

Tongue

Lymphatic drainage from the lateral SUBMENTAL

margin of anterior 2/3 of the tongue  - tip of tongue and floor of
mouth
SUBMANDIBULAR
- Submental
- Lateral margins of anterior
2/3rd
JUGULODIGASTRIC
- Submandibular
JUGULO-OMOHYOID
- ALL of the above, plus
posterior 1/3rd of the tongue
Developmental anomalies of the tongue; Commonest variation of abnormal tongue
ankyloglossia  development – tongue tie
May be associated with microglossia
Rx - frenectomy

Salivary gland

Mucocele Primarily the lower lip minor salivary gland

Primary mucus extravasation cyst
Traumatizedsalivary duct, leading to leakage and
pooling
MGT – excision of damaged duct & gland
Sialolithiasis  MEALTIME SUNDROME
Submandibular gland obstruction
May lead to sialodenitis (painful swlling
 associated with eating/dinking)

HISTO – Hard-yellow lamellated concentric rings

(calcium phosphate nucleated on a microcalculi

MGT – gland excision and stone removal

Potential surgical damage to

- marginal mandibular (VII)
- Lingual (CN V)
- Hypoglossal (CN XII) –
primary nerve for majority
of tongue muscles

Sialosis (sialadenosis) Recurrent bilateral swelling

Primarily the parotids
Non-inflammatory, non-neoplastic
?abnormality of neurosecretory control
Underlying disorders may be present – liver
cirrhosis / eating disorder (bulimia) / drugs

Salivary Gland Disorders; ranula  Floor of the mouth

Arise from sublingual gland
Plunging ranula –
- crosses deep to the
mylohyoid
- appear as a neck & floor of
the mouth swelling
MGT
Excision of cyst and associated sublingual gland
Pharmacological management of a dry Salivary stimualnts, if residual salivary function =
mouth  pilocarpine (radiation-induced xerostomia)

Diagnosis of Sjogren?s syndrome ≤ 1.5ml in 5 minutes (not very useful in over 60s )

Management of xerostomia  Salivary stimualnts, if residual salivary function =

pilocarpine (radiation-induced xerostomia)
Saliva substistutes

 carboxymethyl cellulose-based
(salivese)
 mucin-based (saliva orthana)
 gels containing enzymes normally
present in saliva (biotene oral balance)

preventative advicd = 5000ppm F or MW

Bone Pathology; mandibular tori  Smooth Bony exostoses on lingual aspect of the
mandible
Below the canine/premolar area
Often bilateral

Bone Pathology; stafne’s bone cavity Normal Developmental depression in the

mandibular cortex
Formed around the submandibular land during
development
Radiolucent area at the angle of the mandible
Below the inferior alveolar nerve

Pleomorphic salivary adenoma  Benign epithelial tumor.

usually mobile with palpation
most common tumor in the parotid gland and
accounts for more than 50% of all tumors in this
gland….dome-shaped submucosal palatal swelling
with a surface of intact pink mucosa.
The myxochondroid areas show pink hyaline to fibrous
stroma (right arrow) embedded in blue myxoid
background (curved arrow). The myoepithelial elements
form clusters in a haphazard manner (arrowhead).
pink myxochondroid areas are a very
characteristic feature of this tumor and a helpful
finding in fine needle aspiration biopsies

Adenoid cystic carcinoma Malignant epithelial tumors

manifests as a slowly growing mass often
accompanied by pain and in some cases, facial
paralysis
perineural infiltration
cribiform or Swiss cheese pattern

Salivary gland disorders; mumps  Viral sialadenitis – painful enlargement of the

paratids
Paramyxovirus droplets
2-3 wks incubation
Usually bilateral, tender
Fever-malaise-trismus-sore throat
One episode usually confers immunity
Orchitis (gonadal swelling) in 20% males

Salivary Gland Disorders; mucous damaged minor salivary duct

extravasation cyst 
 Complications which may occur when the Sjogrens syndrome; ?mucositis
salivary glands are in a radiotherapy field

Viral

Varicella (Herpes) zoster infection- shingles  VZV Reactivation

ramsay-hunt syndrome–CN VII palsy -
severe facial palsy with throat pain + VZV
vesicles in the external ear

Immunology of herpes zoster  … grandfather unable to get vzv from

grandkid

Viruses in the pathogenesis of oral - Squamous cell papilloma

squamous cell carcinoma  - HPV 6 or 11, in 80% of cases
- Malignant – 16 & 18
- nasoharyngeal carcinoma
- EBV - HHV3
- burkits lymphoma
- EBV - HHV3
- Kaposi sarcoma
- HHV-8,along with other cofactors

Cell Type Infected

- VZV & HSV – Epithelial cells and
neurons
- CMV – ductal epithelium & leukocytes
- EBV – oropharyngeal epithelium & B
lymphocytes = diagnosis – heterophile
Ab +ve
- KSHV - endothelial & B-cells

Recognition and management of post-  CN V]– affect the elderly – confused with
herpetic neuralgia toothache)
 VZV Reactivation

Recognition and management of Herpes labialis 

secondary herpetic infections  post-herpetic neuralgia
bell palsy– facial paralysis without rash – HSV1
ramsay-hunt syndrome–CN VII palsy -
severe facial palsy with throat pain + VZV
vesicles in the external ear

Herpes labialis  HSV SECONDARY infection of HSV1

keratinised mucosa [palate+attached gingiva]

&vermillion border of lip
Differential diagnosis of acute oral viral Cocksackie A
infections in children 
(herpangina& hand foot and mouth – school-age
children –mild vesiculating stomatitis &vesiculating
rash on extremities)

Koplick’s spots 

measles or rubella – 1-2mm yellow-white necrotic

ulcers + erythematous borbers – buccal mucosa

Infectious mononucleosis

 EBV - pharyngeltonsillar enlargement

 palatal petichiae

HHSV1

 (primary infection – 10 herpetic stomatitis

– children – all sites, but hard palate and
dorsum of tongue are main areas
 -dome-shapes vesicles 2-3mm – vesicles
followed by shallow ulcer with greyish floor
and red margins – lymphadenopathy &
fever)

Infectious mononucleosis IM  palatal petichiae

 ulceration
 pharyngeltonsillar enlargement
 lymphadenopathy + fever
 children or early adolescence
 monospot test – Positive Heterophile
antibody-positive
- Kaposi sarcoma
 neoplasm characterised by abnormal
angiogenesis that requires infection
with HHV-8,along with other cofactors
 purplish/reddish-blue/dark-brown/black
– macules or plaques & nodules on
skin.
Fungal

Causes and management of angular Atrophic – denture stomatitis + angular cheilitis

cheilitis 

Acute pseudomembranous candidosis Acute infections – acute pseudo. (thrush) + acute

(Thrush)  antibiotics induced Candidosis

Differential diagnosis of candidal stomatitis  1. Dimorphic condition-dependent - yeast

(single cell) & mycelium (filamentous
network of hyphae) - Hyphal form is
considered to be the pathogenic form
2. Acute infections – acute pseudo. (thrush) +
acute antibiotics induced Candidosis
3. Chronic – AHEM – atrophic – hyperplastic –
erythematous – mucocutaneous (4)

Chronic hyperplastic candidiasis  mid-age adult males

thick hyperkeratotic plaque

persistent plaque that resist removal

Med emergencies
Asthma

Recognition of asthma as a medical LIFE-THREATENING

emergency in the dental surgery  Bradycardic = HR <50/min
Cyanosis/resp rate = <8/min
ACUTE SEVERE
Tachycardic = HR >100/min
Resp rate = >25/min
Unable to complete sentence in 1 breath
May or may not wheeze (lower airway Ob)

The aetiology of asthma a potential LIFE-THREATENING

emergency condition which may be Bradycardic = HR <50/min
encountered in the Cyanosis/resp rate = <8/min

Salbutamol; a drug recommended for the bronchodilator, short acting b2-

management of medical emergencies in the adrenergic receptior agonist

Medical emergencies; management of an Asses pt / Sit patient upright.

asthmatic attack 
 100% O2 (10L/min)

administer a salbutamol
inhaler, 4 puffs (100 μg per
actuation) repeat as needed.

If does not respond

to treatment with bronchodilators within 5
minutes of administration,
they should also be transferred to hospital
as an emergency.

Diabetic

Type 1 diabetes; management of Asses pt.

hypoglycaemia  100% O2 (10L/min)

If the patient remains conscious and

cooperative: oral glucose (10–20 g),
repeated, if necessary, after
10–15 minutes

If the patient is unconscious or

uncooperative: Administer glucagon, 1
mg, i.m. Injection
Administer oral glucose (10–20 g)
when the patient regains
consciousness.

MI

Management of medical emergencies in the 30 chest complressoins - rate of 100 – 120

dental surgery; CPR  min- (press down on the sternum 5 - 6 cm)

2 rescue breaths - two breaths should not

take more than 5 s.

Medical emergencies in the dental surgery; Asses pt.

left sided chest pain; myocardial infarction  100% O2 (10L/min)

Administer glyceryl trinitrate (GTN)

spray, 2 puffs (400 μg per metered
 dose) sublingually, repeated after
3 minutes if chest pain remains

Administer aspirin, 300 mg

dispersible tablet, orally.

Epilepsy

Medical emergencies; epilepsy  Sudden loss of consciousness, patient

may become rigid, fall, might give a cry
and becomes cyanosed (tonic phase)

Jerking movements of the limbs; the

tongue might be bitten (clonic phase)

Fitting might be associated with other

conditions (e.g. hypoglycaemia, fainting).

if the epileptic fit is repeated or prolonged

(5 minutes or longer), continue
administering
oxygen and Administer 10 mg midazolam
topically into the buccal cavity.
Use either buccal liquid‡ (10 mg/ml)
or injection solution§ (5 mg/ml)

if this was the first episode of epilepsy for

the patient, the convulsion was atypical,
injury occurred or there is difficulty
monitoring
the patient, call for an ambulance.

Shock / Faint

Pathophysiology of vasovagal syncope  triggering of a neural reflex results in a

usually self-limited episode of systemic
hypotension characterized by both
bradycardia (asystole or relative
bradycardia) and peripheral vasodilation
 Neurocardiogenic syncope (also known as
vasovagal syncope) is a benign condition
characterised by a self-limited episode of
systemic hypotension

Stimulation of the medullary vasodepressor

region of the brain stem may occur owing to
activation of various receptors, such as cardiac C
fibres (mechanocardiac receptors),
cardiopulmonary baroreceptors, cranial nerves,
cerebral cortex, and gastrointestinal or
genitourinary mechanoreceptors ..reduce cardiac
filling

Differential diagnoses include carotid sinus

hypersensitivity (resulting from an extreme
reflex response to carotid sinus stimulation)
and orthostatic hypotension (failure of the
autonomic reflex response)

MGT

is education of the patient to avoid situations

that predispose to syncope,

anxiety management,

coping skills, and reassurance of the patient

and others that this is a benign condition
Recognition and differential diagnosis of fainting medical student…
syncope  hyperactive automic activity
Clinical features of shock  insufficient circulation of oxygen in your
body

•Low blood pressure

•Altered mental state, including reduced
alertness and awareness, confusion, and
sleepiness
•Cold, moist skin. Hands and feet may be
blue or pale
•Weak or rapid pulse
•Rapid breathing and hyperventilation
Medical emergencies; vasovagal attack  Patient feels faint, dizzy, light-headed
• Slow pulse rate
 • Loss of consciousness

*Pallor and sweating

• Nausea and vomiting

Assess the patient

raise the patient’s feet. Loosen any tight

clothing around the neck.

Administer 100% oxygen –flow rate: 10

litres/minute until consciousness is
regained
Recognition and management of a panic by signs of terror, such as chest pain, palpitation,
attack  and shortness of breath.
Reassurance + O2
sedation…beware additive effects of Benzo

xerostomic effects of psychiatric medications used

to treat it

Anaphalxis

Complications of LA usage; Anaphylaxis  Sodium metabisulphit – anti-oxidzing agent

= sulphur allergy
Urticaria & rash (chest /hands/feet)
Mild bronchospasm…without…shortness of
breath

Medical emergencies; anaphylaxis  Asses pt / secure airway / raise feet

100% O2 (10L/min)
0.5ml (1:1000) adrenaline…0.3 if age 12-18

REPEAT AFTER 5 MINUTES if needed

Clinical recognition of anaphylaxic shock  Upper airway oedema & brochospasm =

stridor or wheezing
Tachycardia = HR >110/min
Abdo pain
Sense of impending doom
Flushing (pallor might also occur)
MILD ALLERGY
Urticaria & rash (chest /hands/feet)
Mild bronchospasm…without…shortness of
breath

Other
 Protocols for the management of medical 5 initial rescue breaths before starting chest
emergencies in the dental surgery; compressions
paediatric life support.  If alone, perform CPR for 1 min before
going for help.
Compress the chest by one third of its
depth.
 2 fingers for an infant <1 year;
1 or 2 hands for >1 year

The swallowed tooth !  Radiograph – determine if aspirated or

swallowed

Pharmacology

Blood
Clopidogrel  - inhibits ATP on platelets, irreversible
effect
Dipyridamol – inhibits thromboxane
Aspirin – inhibits COX 1 & 2
Choice of analgesic following dental paracetamol
extraction in a patient taking warfarin -
Prothrombin time (PT extrinsic pathway 10-12 secs
Intrinsic pathway – aPPT 30-40 secs
PTT 60-70 secs
Assessment of the patient taking anti-  Warfarin – VitK-dependent factor
coagulants – INR (Pt PT time/normal PT), antagonist (II,VII,IX,X) – binds VitK
normal 1 reductase..PT/INR

 Heparin – chelates/inactivate
prothrombin (II) – enhances anti-
thrombin (III)

 Dabigatran Etexilate– prodrug –

inhibit thrombin (thrombin converts
fibrinogen to fib) + monitor with
APTT & Thrombin time (TT)

 Rivaroxaban – inhibit Xa + monitor

with APTT & factor X assay
 Low-dose Aspirin75-300mg daily
Assessment of the patient taking ANTI- -Note that many patients self
PLATELETS medicate on low-dose aspirin.
 Clopidogrel (Plavix) – inhibit ADP-
receptor activation of PLTs –
IRREVERSIBLE

 Dipyridamole (Persantin, Persantin

Retard) – Stimulate PGI synthesis –
INHIBIT TXA2
 Abciximab – monoclonal
 antibody..PLT glycoprotein (GP
IIb/IIIa) receptor inhibitor

 Asasantin Retard- This is a

combination of dipyridamole and
aspirin.

Impact of common medications prescribed Gingival hyperplasia – Ca2+

for management of cardiovascular Angioedema - ACE
problems on oral health Lichenoid reaction - ACE

Therapeutics of anticoagulant therapy – inhibits

warfarin - vit k
factors 2,7,9,10
planning dental extractions - XLAunder 4 patient is on antiplatelet monotherapy
are:
o Simple extraction of up to three
teeth
o One surgical procedure
o S/P and RSD
• multiple appointments > 3 XLA

dual antiplatelet therapy (aspirin and

clopidogrel) should only have treatment in
the DEF following consultation with the
patient’s cardiologist. If the cardiologist
agrees to stop one of the drugs
(preferably clopidogrel

Analgesics
Choice of analgesia and antibiotics during AVOID
the first trimester of pregnancy  Metradiozole
aspirin , ibuprofen
Bupivicaine,
prilocaine containing felypressin
alprozolam and diazepam
• LA of choice
– Lignocaine with adrenaline
• Analgesia of choice
– Paracetamol (2X500mg
QDS)
• Antibiotic of choice
– Penicillin's 2x250mg QDS
SEND 40,
orCephalosporin's
• Local delivery antimicrobials
– Risk to benefit
– Clinical benefit – Evidence of
efficacy is very poor
Other
Significance of common 1/5 women & 5% of men
medications taken by Rise with puberty, but less common in elderly
dental patients and Precipitated by chocolate, cheese, mense, stress
reported in the medical Preceded by aura 20-30 minutes before headache
history; treatment of Visual disturbance (blurred vision/flassing lights)
migraine headaches MGT
aspirin/metoclopramide
sumatriptan
  Cluster headaches mainly males (9:1 M-FM)
(migrainous neuralgia) stabbing pain, rather than headache – more severe than migrane
steroids
calcium channel blockers
sumatriptan (serotonin agonist used in migraine
disorders;
lithium
Sumatriptan, an anti-migraine drug, is a selective agonist of
vascular serotonin - vasoconstriction and inhibtion of sensory
nociceptive (trigeminal) nerve firing and vasoactive neuropeptide
release - Norepinephrine and Serotonin act on endogenous
descending analgesic pathwa

Therapeutic dose of 200tdsmetronidazole…THREE (3) dys

metronidazole;
management of 500mg tdsamoxicillin … THREE (3) dys
necrotising ulcerative
gingivitis ANUG
Antibiotic doses for the 500mg tdsamoxicillin …5dys
management of oro- 200tdsmetronidazole…5dys
facial infection of dental 2x250MG qds Phenoxymethyl penicillin (penV)…5dys
origin  250mg erythromycin tds…5dys

2NDLINE

150mg Clindamycin qds…5dys

250/125mg Co-Amoxiclav tds…5dys
250mg Clarithromycin bd…7days

Choice of antibiotics for 500mg tdsamoxicillin…5dys

the management of an 200tdsmetronidazole…5dys
acute periapical 2x250MG qds Phenoxymethyl penicillin (penV)…5dys
250mg erythromycin tds…5dys
infection – (abscess)
2NDLINE
 150mg Clindamycin qds…5dys
250/125mg Co-Amoxiclav tds…5dys
250mg Clarithromycin bd…7days

Drugs used in the Class Principal action Representative

drugs
management of cardiac
arrhythmias - I (a/b/c) Sodium channel blockade Lidocaine,
Amiodarone  phenytoin,
A- prolong mexiletine,
repolarisation tocainide, Quinidine,
B- shorten procainamide,
repolarisation
disopyramide,
C- little influence on
repolarisaton moricizine

II Beta receptor blockade Propranolol, et al.

III Prolong repolarisation (action Amiodarone,sotalol

potential.

Blockade of rectifier K+
channels

IV Calcium channel blockade Verapamil, et al.

V Cardiac glycosides digoxin

Interaction between Gut flora alteration by antibiotic leads to entero-hepatic

penicillin prescribed in cyling of conjugated oestrogen, releasing oestrogen, which
dental practice and oral suppresses ovulation
contraceptives 
Mechanism of action of Inteferance with Cell wall synthesis (1 cell-layer thick in G-
penicillinand related ves)
antibiotics
WALL – Penicillin / = Antimetabolic action(sulphonamides – bac.static – G+v& G-v)
Vancomycin/CEPHs  Competitively inhibit dihydropteroatereductase, which is used in
50S– incorporation of para-aminobenzoic acid (PABA) in bacteria folic
C- chloram./clinda acid precursor...NB..not all bacteria synthesise their own folic acid.
M - macrolide = Inhibit Nucleic acid/DNA synthesis(Quinolones and MTZ)
L- Linzolid  MTZ – active form (hydroxymetabolite – hydroxylamaine) inhibits
Nucleus DNA synthesis and degradation of formed DNA.
T - trimetoprim  Quinolones (nalidixic acid & ciprofloxacin– bac.cidal– G+v& G-
F - quinolones v)....interfere with DNA gyrase, used in controlling the structure of
R - rifampin individual DNA strands...during replication and
S - sulphanamides transcription...produce a mechanical obstruction to replication.
M - Mtz = Inhibit protein
30S –
synthesis(aminoglycosides/clindamycin/erythromycin/tetracyclines/fusidic
T - Tetracyclin &
acid/chloramphenical – bacteriostatic but CIDAL AT HIGH [])
A - Aminoglycosides (gent)
= Inteferance with Cell wall synthesis (1 cell-layer thick in G-ves) –
Bacitracin/glycopeptides/betalactams (e.gpenicillins&cephs)

Bacteriostatic

- B
- F- usidic acid (inhibit protein synthesis)
- C- lindamycin (osteomyelitis Rx
- S– ulphanomides(inhibit folic acid synthesis)
- E – rythromycin (low-dose 250mg) – alternative for pen-
allergic patients
- T– etracyclins (t-RNA inhibitor)
- T–trimethoprim (inhibit folic acid synthesis)
- C– hloramphenical

Bacteriocidal

- C – iproflaxacin (fluoroquinolones..naladixic acid)

- V – ancomycin (glycopeptide)
- I -sonozid
- P - enicillins
- C - ephalosporins
- R – ifampicin/Rifamycin (broad spec. + TB Rxvia the
inhibition of DNA-dependent RNA polymerase)
- E– rythromycin (high dose – 500mg)
- A – minoglycosides
- M - tz

Pharmacological effects smooth muscle relax,

of adrenaline  increase HR,
contracts blood vessels,
 inhibits insulin secretion,
stimulates glycolysis so increases blood glucose
Cyclo-oxygenase 1. arachidonic acid (from membrane phospholipids or
pathway and control of from dietary linoleic acid) metabolism,
inflammation – inhibit to 2. initial cleavage by phospholipases (e.g. phospholipase
provide relief from infl. A2).
and pain 3. Further metabolism by 2 enzymatic systems
4. Lipoxygenase enzyme system&Cyclo-oxygenase
enzyme system
Lipoxygenase enzyme system
- 12 lipoxygenase (12 HETE synthesis –
chemotaxis)
- 15 lipoxygenase (Lipoxins A+B)
- 5 lipoxygenase (5HPETE =>Leukotrienes
=>chemotaxis/bronchoconsyriction/vascular
permeability)
Cyclo-oxygenase enzyme system
 products
- Prostaglandins– Vasodilation + pain [hyperalgesia +
fever + oedema ((PGE2; PGF2α; PGD2)
- Prostacyclin (PGI2 – Vasodilation + inhibit PLT
aggregation + sensitise nerve-endings to bradtkinnins)
- Thromboxane A2 (TXA2)– promote vasoconstriction +
platelet aggregation
 Enzymes
- COX1 (constitutive enzyme expressed in most cells -
(responsible for physiological functions)....TARGETTED
BYASPIRIN (jon bennet)
- COX2(induced by various cytokines & growth factors...
– suppressed by glucocorticoids...?clinical significance
of selective COX2 inhibitors...?side effect of.. gastric
irritation/cardiac dysrythymia)...CARDIAC PROBLEMS
WITH COX2 – SPECIFIC INHIBITORS

Dental treatment in >7.5mg = double dose on day of Rx

patients taking steroids - Complication - adrenal suppression / addisonian
crisisvomiting / abdo pain / profound weakness /
hypovolaemic shock
MGTPlace horizontalgive IV hydrocortisone
Monitoring of HIV Oral candidosis
infection; Effect of
inhaled steroids on the
oral mucosa 
Side effects of Nausea vomiting (disulfiram reaction –acute sensitivity to
Metronidazole  alcohol through inhibition of acetaldehyde dehydrogenase)
Oral side effects of Gingival hyperplasia
phenytoin 
(Rx Trigeminal neuralgia)
Medicaments used in Devitalisation
pulpotomy • Formacresol
• Paraformaldehyde
 • Gluteraldehyde
Preservation
• Ferric sulphate (haemostatic)
– After pulpotomy
– 93% success rate.
Regeneration
• CaOH (also preservation)
– Bacteriostatic
– High pH
– Use – direct + indirect pulp capping
– Internal resorption of tooth
– Induces hard tissue formation
• Mineral Trioxide aggregates (MTA)
– Lateral root perforations
– Root end fillings
– Direct pulp caps
– Apexification
– Haemostatic
– No internal resorption compared to ZOE, ferric
sulphate and CaOH
– Slow setting similar to industrial cement
Desensitising
• Ledermix
– Hypersensitive pulps
– Steroidal antibiotic
– Suppress pulp defenses
– For irreversible pulps to delay pulp therapy.

Cvek pulpotomy 1978– permanent teeth

• Indications – trauma. Alternative to RCT in
young permanent teeth, incomplete apex
• 2mm removal of coronal pulp. Studies show
that inflammation in traumatic exposures does
not extend beyond 2mm

Writing a prescription  - ? MUST be included

AGE etc - Name & address of prescriber
- Name and address of patient
- Date of the prescription
- Dose in word & figure IF CD
- Age & DOB if <12 yrs old
Current No prophylaxis recommended
recommendations BUT…Inform patient to be aware of symptoms/signs
relating to antibiotic aggressive, usually develops insidiously and progresses slowly (ie, over
prophylaxis against SBE weeks to months
whilst having dental *low-grade fever (< 39° C), night sweats, fatigability, malaise, and
treatment Subacute weight loss. Chills and arthralgias may occur.
bacterial endocarditi
 *Retinal emboli can cause round or oval hemorrhagic retinal lesions
with small white centers (Roth's spots)
*Cutaneous manifestations include petechiae (on the upper trunk,
conjunctivae, mucous membranes, and distal extremities), painful
erythematous subcutaneous nodules on the tips of digits (Osler's
nodes), nontender hemorrhagic macules on the palms or soles
(Janeway lesions), and splinter hemorrhages under the nails
Amalgam tattoo  - Reactions between the oral mucosa and components of
metal alloys commonly used in

The intrinsic and extrinsic clotting pathways Thrombokinase factor X

aim to activate which clotting factor? converts prothrombin (factor II) to thrombin

Prothrombin time should be interpreted as what? Time it takes for blood to clot after the addition of
tissue factor
Which anatomical features conform the borders of Anterior digastrics
the anterior triangle of the neck
Which muscular triangle of the neck does the Submandibular with the submandibular and
mylohyoid and hypoglossal nerves lie parotid glands
The anterior jugular vein lies in which muscular Submental with the sub mental lymph nodes
triangle
Which structures mark the boundaries of the Anteriorly - Buccinator
pterygomandibular space Posteriroly - Parotid gland, deep cervical fascia
Superiorly - Lateral pterygoid muscle
                Medially - Medial pterygoid muscle
                Laterally - Ascending ramus
Describe what is meant by the pterygomandibular tendinous thickening of the buccopharyngeal
raphe? fascia, which separates and gives origin to the
buccinator muscle anteriorly and the superior
constrictor of the pharynx posteriorly
Which of the following anatomical complications of Placement of LA within the parotid fascia - within
ID anaesthesia may lead to a patient being unable the parotid fascia lies the VII CN which innervates
to close an eye the orbicular is oculli via it's temporal and
zygomatic branches
Which muscle does the buccal nerve run forward Buccinator
on before piercing to supply the buccal mucous
membrane and skin of the cheek?

Radiology

Radiographic features of chronic apical

periodontitis  Loss of Lamina dura
diffuse periapical radiolucency

changes during healing of

chronic apical periodontitis (0-26 weeks)

Radiographic appearance of As above

pulpitis/periapical periodontitis 

Methods of minimising exposure to E/F speed films

ionising radiation / Management of the 20cm (200mm)FSD for intra-oral films etc
patient receiving radiotherapy Rectangular collimator
Beam-aiming device

Location of the impacted upper canine Upper right

Upper
tooth using the parallax method  occlusal
canine palatally
placed.
Impacted canine – palatal or Canine has
moved upwards
buccal? Tip of canine has towards apex of
moved occlusally on moving Original
position of
incisor

from OPG to occlusal film – canine

relative to
opposite direction to X-ray central
tube. incisor
root Upper left
slightly palatal –
evidence of
relatively more
root resorption
of ULc than URc
OPG

VERTICAL PARALLAX… DPT/OPG and an anterior

occlusal film

HORIZONTAL PARALLAX..two intra-oral films

(peri-apical and/or anterior occlusal)

SLOB
Same – Lingual (tooth magnified/crown
moves with tube = palatal)
Opposite – Buccal (tooth size diminish

Choice of radiographs for investigation of a PA radiograph

suspected periapical lesion 

Radiological features of a reversible No periapical radiolucency or loss of lamina dura

pulpitis 

Interpretation of bitewing radiographs 

/Radiographic recognition of
interproximal caries

Annual limit of effective dose of Classified worker = 20mSv

radiation a dental worker may receive …
IRR99 Non-classified worker = 6mSv
General public = 1mSv

Radiation dosimetry when taking routine Two bitewing using:

intraoral dental radiographs  D speed + round collimator = 0.008
E speed + rectangular collimator = 0.002
F speed + rectangular collimator = 0.0016
*Round collimator reduce dose by ½
Background radiation = 2.6mSv (3.5 USA)
AVERAGE
Periapical or Bitewing = 0.001-0.008
OPG = 0.016-0.026
Cone beam CT = 0.07-0.2mSv

DOSE LIMITS (set by ICRP, and revised under IRR 99) &
ASSOCIATED RISKS
 Classified worker = 20 mSv
 Non-classified worker (most dental staff)= 6
Msv (3/10TH of classified worker)
 General public = 1 mSv
 UK background radiation (annual) = 2.6mSv
vs 3.5 mSv in USA
 A intraoral film = 16hrs of background
radiation
 A OPG = 2dys of background radiation
 Risk of developing malignancy from a PA film
= 1 per 2 million – 1 per 20 million
(depending on film speed/type; collimation)
 Risk of developing malignancy from an OPG
= 0.21 – 1.9 per million
 Rectangular collimation = 50% dose
reduction
STOCHASTIC EFFECTS – are random – can be divided
into somatic and genetic
DETERMINISTIC EFFECTS – are only somatic
PROCESSING
1. Developing(alkali soln)– sensitised silver
halide crystals are chemically reduced to
black metallic silver – 5 min @ 20oC – the
higher the temp the faster the process
2. Washing – remove excess developer
3. Fixation – unsensitised silver halide crystals
are removed – transparent part of the film
revealed
4. Washing – excess fixative removed & and
film dried
 Film too dark – left in dev. Too long (more
silver deposited) / thin pt
 Film too pale – underexposed /
underdeveloped (developer contaminated by
fixative or too dilute)
 A blurred film – pt moved / film bent during
exposure
 Foggy film – film out-of-date
 PERSONNEL (IRR 1999)
1. Radiation protection supervisor (RPS) -
oversee work & ensure local rules are
followed – Dentist or a senior member of
staff
2. Radiation protection advisor (RPA) –
expert in radiation protection – advice on
compliance with Regulations, & aspects of
radiation protection

IR[ME]R 00 – ionising radiation Medical Exposure

regulation 2000
1. Legal person – the employer – must provide
a framework of written procedures.
2. Diagnostic reference levels (DRLs) – 2.3
mGy for an adult molar& 60 mGy for a OPG
3. Referrer – qualified healthcare professional
(dentist or doctor)
4. Practitioner – take responsibility for
exposer/justificatin (dentist/doctor)
5. Operator – assist with practical aspects
(dentist/nurse/hygienist – all trained
appropriately)

Estimation of the age of a patient from a

DPT showing a mixed dentition 

AGE 8

AGE 9
 Age 14..with a compound odontoma

Age 14.5...with impacted canines

Age 19

Age 19..with a cemento-ossifying fibroma

(painless)

Radiology
Radiographic features of
chronic apical periodontitis  Loss of Lamina dura
diffuse periapicalradiolucency

changes
during healing of chronic apical
periodontitis (0-26 weeks)

Radiographic appearance of As above

pulpitis/periapical
periodontitis 

Methods of minimising E/F speed films

exposure to ionising 20cm FSD etc
radiation / Management of Rectangular collimator
the patient receiving
Beam-aiming device
radiotherapy

Location of the impacted 2 x Rads taken at different Horizontalangles. The more

upper canine tooth using distant object appears to travel in the same direction,
the parallax method  closer object moves in opposite ditrection.

 SLOB (Same Lingual Buccal Opposite)

 BOPS (Buccal Opposite Palatal Same)
Choice of radiographs for PA!!
investigation of a suspected Lateral oblique IF: intraoral views are unobtainable due to
periapicallesion  gagging; if the patient is unconscious; if the pt has severe trismus

Radiological features of a There are no radiographic features of a reversible pulpitis

reversible pulpitis  Periapical tissues and lamina dura are normal

Radiological investigation of Ameloblastoma

hard tissue swellings of the
mandible  Definition: An aggressive odontogenic epithelium
neoplasm that is locally invasive.
Radiological investigation of
Radiographic Features:
hard tissue swellings of the
mandible  Location: Posterior mandible and ramus (most common)
but can occur anywhere in the maxilla or mandible.

Edge: Well-defined to well-localized.

Shape: Round to no identifiable shape.

Internal: Radiolucent (unilocular or multilocular).  When
multilocular it is said to have a ‘honeycomb’ or ‘soap
bubble’ appearance.

Other: Tendency to cause resorption of the adjacent

teeth and expansion of jaw.

Number: Single.

Posterior mandible

Soap bubble
appearance

Expansion of
mandible
Keratocysticodontogenic tumor

Definition: An odontogenic epithelium neoplasm with a thin keratinized

lining.  This entity was previously named odontogenickeratocyst (OKC).

Radiographic Features:

Location: Posterior mandible and ramus (most common) but can occur
anywhere in the maxilla or mandible.

Edge: Well-defined to well-localized.

Shape: Round to no identifiable shape.

Internal: Radiolucent (unilocular or multilocular).

Other: Tendency to grow along the jaw with minimal expansion.

Number: Single.  If multiple, an underlying syndrome should be

considered (basal cell nevus syndrome/Gorlin-Goltz syndrome).

Keratocysticodontogenic tumor – right posterior mandible

Keratocysticodontogenic tumor – anterior mandible

Dentigerous Cyst

Definition: A cyst that forms around the crown of an

unerupted tooth.  This is most commonly associated with
third molars and maxillary canines.  A hyperplastic follicle
has a very similar appearance to a dentigerous cyst.  A
hyperplastic follicle is an enlarged follicle with less than 5
mm of space from the enamel to the edge of the lesion. 
Once the lesion edge is more than 5 mm from the
enamel, it is classified as a dentigerous cyst.

Radiographic Features:

Location: Around the crown of a tooth.

Edge: Well-defined. Corticated.

Shape: Round to ovoid.

Internal: Radiolucent, unilocular.

Other: The border of the cyst is continuous at the

cemento-enamel junction of the unerupted tooth.  As it
grows, it will displace the associated tooth apically. It may
displace or resorb adjacent teeth as it enlarges.

Number: Typically single, but may be multiple (rare).

Dentigerous cyst

Dentigerous cyst

Dentigerous cyst/Hyperplastic follicle

 (this is a borderline case – maxillary left third molar)

Interpretation of 2 x Rads taken at different Horizontalangles. The more

radiographic features found distant object appears to travel in the same direction,
in association with an closer object moves in opposite ditrection.
unerupted upper canine
tooth    SLOB (Same Lingual Buccal Opposite)
 BOPS (Buccal Opposite Palatal Same)

Interpretation of bitewing Radiographs are useful in the detection of caries because

radiographs  /Radiographic of the nature of the disease process.   Demineralization
recognition of interproximal and destruction of hard tooth structures result in a loss of
caries tooth density in the area of the lesion.  The decreased
density allows a greater penetration of x-rays in the
carious area, and as a result, the carious lesion appears
as a radiolucency on a dental radiograph (see red
arrows).  Radiolucent structures permit the passage of the
x-ray beam and appear dark or black on a dental
radiograph.

The degree of
radiolucency seen on a
dental radiograph is
determined by the
extent and severity of
the destruction seen as
a result of the caries
process.

Caries is always farther advanced clinically than what is

seen on a dental radiograph.

The bite-wing radiograph, a radiograph that shows the

crowns of both the upper and lower teeth on the same
film, is the radiograph of choice for the evaluation of
dental caries.  A periapical radiograph utilizing the
paralleling technique can also be used to detect
interproximal caries.

Annual limit of effective 1 mSv for the general public

dose of radiation a dental 6mSv for non classified workers (Dentists)
worker may receive  20mSv for classified workers (Annual Dose)
 Radiation dosimetry when 0.001-0.008 mSv – Intraoral
taking routine intraoral 0.016-0.026 mSv - Extraoral
dental radiographs 

Estimation of the age of a

patient from a DPT showing
a mixed dentition 

Radiology of the mixed

dentition 

Dental issues in the Xexrostomia/sjogrens / BRONJ

radiotherapy patient 

TSL

Managemen Class V Composite restorations if moisture control obtainable

t of non- Failing this GIC / Compomer
carious
tooth
surface loss
at the labial
cervical
margins of
the
maxillary
anterior
teeth 
Smith and
Knight wear
index 

Each
surface of
each tooth
is given a
score
between 0
and 4
according
to its
appearance
.

B = buccal
or labial
L = lingual
or palatal
O=
occlusal
I = incisal
C = cervical
Monitoring
of tooth
surface loss
Materials

Impressions

Choice of impression materials 

Silicone impression Addition silicone

materials.
Examples include Xantropen and Extrude. 4 types are available – light medium
Addition cured heavy and putty.
silicone impression
These materials are often termed vinyl polysiloxanes. Supplied in 2 pastes or in a
materials 
gun and cartridge form as light, medium, heavy and very heavy bodied. One paste
contains a polydimethylsiloxane (silicone pre polymer) polymer in which some
Silicone impression
methyl groups are replaced by hydrogen. The other paste contains a silicone pre-
materials 
polymer in which some methyl groups are replaced by vinyl groups, this paste also
contains a Chloroplatinic acid catalyst. On mixing, in equal proportions, crosslinking
occurs to form a silicone rubber. Setting occurs in about 6-8 minutes. Setting
Reaction:

o Platinum-catalyzed addition reaction cross-linking 2 types of siloxane

pre-polymer. This reaction does not produce by-products
(occasionally release hydrogen)
Condensation silicone

Used for crown and bridge work mainly, but also for partial dentures, implants and
overdentures. Used in stock trays or special trays. One or two stage impression
stage. Although dimensionally stable the impression should be cast within 24
hours. Supplied as a paste and liquid or two pastes, in light, medium, heavy or very
heavy bodied (putty).

BASE PASTE: liquid Silicone pre-polymer with terminal hydroxy groups, Filler eg.
silica

CATALYST PASTE: Crosslinking agent (organohydrogensiloxane), Activator (dibutyl-

tin dilaurate)

On mixing the two pastes react, cross linking occurs and setting takes about 7
minutes. The setting reaction is a condensation reaction. Hydrogen gas is evolved
 on setting which leads to surface pitting, and a roughened surface to the resulting
model.

Impression Alginate
materials for Learn Ortho
orthodontic study
models 

Impression
materials for
orthodontic
impressions 

Impression
materials for
orthodontic study
models 

Properties of Polyethers
polyether
impression Used for crown and bridge work, partial dentures, implants and overdentures.
materials  Mixed in a 1:1 ratio until homogeneous colour, the amount of catalyst used can be
used to control the setting time. Used in special or stock trays with an adhesive. A
Properties of one or two stage technique can be used. Although dimensionally stable the
polyether impression should be cast within 24 hours. Examples include impregum.
impression
Based on imine chemistry and are supplied in two pastes.
materials 
BASE PASTE: Polyether and Filler- Imine-terminated prepolymer and Inert filler
(silica) with Plasticizer

CATALYST PASTE: Sulphonic acid ester (enhances further polymerisation and

crosslinking), Inert oils and plasticizer.

When mixed the polymer and sulphonic acid ester react to form a stiff polether
rubber. Setting time occurs in about 6 minutes. Usually only comes in one viscosity
- regular bodied, but can also come as light + heavy bodied (Diulent). Heat and
moisture speed up the setting reaction.

Setting reactions of Hydrocolloids

key impression
materials used in A colloid is a state of matter in which individual particles of one
fixed substance, are uniformly distributed in a dispersion medium of
prosthodontics  another substance. When the dispersion medium is water it is
termed a hydrocolloid. The colloid is relatively fluid when the
solute particles present are dispersed throughout the liquid. This is
called a sol. Alternatively, the particles can become attached to
each other, forming a loose network which restricts movement of
the solute molecules. The colloid becomes viscous and jelly like,
and is called a gel. Some colloids have the ability to change
reversibly from the sol state to the gel state. A sol can be
converted into a gel in one of two ways :

1. Reduction in temperature, reversible because sol is formed

again on heating (eg agar).

2. Chemical reaction which is irreversible (eg alginates). A gel can

lose (syneresis which results in shrinkage) or take up (imbibition
which results in expansion) water or other fluids.

Hydrocolloids are placed in the mouth in the sol state when it can
record sufficient detail, then removed when it has reached the gel
state. Hydrocolloid materials especially the alginates, may display
a lack of incompatibility with some makes of dental stones. The
resultant model may show reduced surface hardness and possibly
surface irregularities and roughness.

Agar

Agar (colloid), Borax (strengthen gel), Potassium Sulphate, Water

(dispersion medium).

Alginate

On mixing the powder with water a sol is formed, a chemical

reaction takes place and a gel is formed.

The powder contains Alginate salt (e.g. sodium alginate), Calcium

salt (e.g. calcium sulphate) and Trisodium phosphate. The setting
reaction is as follows:

On mixing the powder with the water:

SODIUM ALGINATE + SODIUM SULPHATE

-- CALCIUM SULPHATE + CALCIUM ALGINATE

The above reaction occurs too quickly often during mixing or

loading of the impression tray. It can be slowed down by adding
trisodium phosphate to the powder. This reacts with the calcium
sulphate to produce calcium phosphate, preventing the calcium
sulphate reacting with the sodium alginate to form a gel. This
second reaction occurs in preference to the first reaction until the
trisodium phosphate is used up, then the alginate will set as a gel.
There is a well-defined working time during which there is no
 viscosity change.

Properties of
impression
materials; long
term stability 

Setting reactions of Polysulfide Impression Material

elastomeric  Chemical makeup
impression • Base: Mercaptan polysulfide.
materials • Cross-linking agent: Sulfur and/or lead peroxide.
• Catalysts: Copper hydroxides, zinc peroxide, organic
hydroperoxide.
• Fillers: Zinc sulfate, lithopone, or calcium sulfate
dihydrate.

Polyether Impression Material
 Chemical makeup
• Base: Polyether
• Cross-linking agent: Sulfate
• Catalysts: Glycol-based plasticizers
• Filler: Silica

Silicone Impression Material

 Condensation-cured - Chemical makeup
• Base: Poly dimethyl siloxane
• Cross-linking agent: Alkyl ortho silicate or organo
hydrogen siloxane
• Catalyst: Organo tin compounds
• Filler: Silica
•
Polyvinyl Siloxane Impression Material
 Additional-cured - Chemical makeup
• Base: Silicone polym
• Catalyst: Chloroplatinic acid
 • Filler: Silica
 For dimensional stability, this is the best impression
material.
 Pouring of the model can be delayed up to 7 to 10 days.
 Stiffness of the material makes removal of the tray difficult.
 Material dispensed using auto-mixing unit and mixing tips.

Restorative

The 'etch and rinse' Bonding to Tooth structure

bonding technique 
Enamel: demineralising the enamel surface is crucial to produce
The 'etch and rinse' micromechanical bonds
bonding technique 
Dentine: need to consider a smear layer, the pulp and hydrophobic
Micromechanical bonding bonding materials applied to a hydrophobic tooth structure.
and resin based materials 
Smear layer = 0.5-2.0 microns thick, debris left over from cutting
tooth structure during cavity prep. It will be thicker when using a
coarser bur.

Most modern primers are made of hydrophilic primers which

contain more monomer for effective bond strengths. Two strategies
are available:

 Etch and rinse (total etch) = removes smear layer

by acid etching tooth surface. Opens dentine
tubules, smear free layer, deep mineralised zone
of collagen fibres is produced by applying 37.5%
phosphoric acid (total etch conditioner). The
hydrophilic primer penetrates deep producing
prominent tags within the dentine, do not over
dry or tags will be destroyed. Eg: SE Bond (with
or without rubber dam)
 Self-etch = partial dissolution of smear layer, still
penetrating into the dentine but primer only
penetrates 1 micron deep. Smear layer is
modified and conditioning leaves the tooth
mildly acidic. The tubules will be filled with
adhesive but not as thick as with total etch. Eg:
Optibond (only with rubber dam).

Composites and related Composites

restorative materials 
Types we use on clinic include: core composites = supercure, used
as temporary restorative or core build up material. Other types =
filtek supreme, definitive restorative. Compomer = dyract,
temporary or restorative material. Resin based composite: contain
an organic resin matrix, inorganic filler and coupling agent.
Composites can be classified as traditional, micro-filled resins,
hybrid or blended or small particle hybrids. Prior to applying
composite the tooth must be etched using 37.5 phosphoric acid,
primed and bonded.

 Organic resin binds individual filler particles, a

fluid monomer and rigid polymer. Resin is
usually BisGMA.
 Monomers can be small (MMA) or large (bis-
GMA).
 Materials will shrink upon polymerisation either
way at a rate of 2%, shrinking away from the
margins causing microleakage. A high filler load
is required to balance this. Place in increments to
create shrinkage towards cavity walls.
 Inorganic filler is the chemically inactive
component, gives hardness and strength and
controls the aesthetics of the material. Fillers
include strontium, barium, quartz or silica glass.
Increasing the filler size increases the hardness.
 Coupling agent (a polymer acid) = gamma MPTS
binds the filler to resin. This increases the wear
resistance.
 3% shrinkage on polymerisation so be sure to
pack composites in layers of 2mm and then light
cure.
 Composites are brittle and weak in thin sections

ANTERIOR COMPOSITE

Composites can be classified as traditional, micro-filled resins,

hybrid or blended or small particle hybrids. Prior to applying
composite the tooth must be etched using 37.5 phosphoric acid,
primed and bonded.

COMPOSITION:

 Polymer resin matrix with filler particles, based on bis-

GMA resin. A range of filler particles, inc quartz, silica,
barium, strontium, zinc glasses and zirconia silica. The
greater the filler content the better the physical
property.
 Materials will shrink upon polymerisation either way
at a rate of 2%, shrinking away from the margins
causing microleakage. A high filler load is required to
balance this. Place in increments to create shrinkage
 towards cavity walls.
 Inorganic filler is the chemically inactive component,
gives hardness and strength and controls the
aesthetics of the material. Fillers include strontium,
barium, quartz or silica glass. Increasing the filler
size increases the hardness.
 Coupling agent (a polymer acid) = gamma MPTS
binds the filler to resin. This increases the wear
resistance.
USES: Aesthetically pleasing. Restorations where caries
does not extend more than 1/3rd occlusal surface.

ADVANTAGES: Good Aesthetics, They are more strong and

durable. They bond to the tooth structure well and support
the remaining tooth to help prevent breakage.

DISADVANTAGES: Polymerisation of 7% and contraction 4-

7 MPa. This can cause cracking or flexure of tooth
substance. This can lead to a gap between restoration and
tooth, microleakage,caries and sensitivity. Co-efficient of
thermal expansion two to six fold higher than that of the
tooth.

POSTERIOR COMPOSITE

COMPOSITION:

 Hybrid Composite is most suited for posterior

restorations, which is a microfilled form of composite
 The material consists of three components: resin
matrix (organic content), fillers (inorganic part) and
coupling agents.
 The resin matrix consists mostly of Bis-GMA
(bisphenol-Aglycidyldimethacrylate).
 Fillers are made of quartz, ceramic and or silica.
 With increasing filler content the polymerisation
shrinkage, the linear expansion coefficient and water
absorption are reduced.
PROPERTIES: Polymerisation shrinkage, wear, water
absorption,

USES: Preventive resin restorations, choice for conservative

restoration of carious lesions of fissures in posterior teeth.
Large initial lesions- treatment of extensive primary carious
lesions, aesthetic restorations, conservative restorations in
the ‘aesthetic zone’, cosmetic reasons

ADVANTAGES: Composites have a wide range of shades

,tints, opacity which are aesthetically pleasing. Primary
choice of material for restorations of anterior teeth.
 DISADVANTAGES: Stability of colour is good, extrinsic
staining may occur over time due to surface deterioration.

Polymerisation contraction of 2%-7% as they set. Sufficient

force may be applied to the cusps of the tooth and be
pulled inwards where microcracks develop leading to
weakening of the cusps and lead to failure under functional
loading. They are contraindicated if poor isolation cannot be
guaranteed, use of rubber dam is imperative. The technique
cannot be rushed. Post op complications may occur is the
restoration is not adequately bonded and polymerised.

Which monomer is commonly Bis-GMA

found in modern composite
materials?

What is the function of the Binds individual filler particles

organic resin in resin based
composites?

The most important feature of Helps reduce polymerization shrinkage

the glass/silica inorganic filler
is to do what

The coupling agent binds the Gamma-MPTS

resin to the filler to create
strong mechanical properties
but what is the shortened
version of the most common
agent?

Which methacrylate monomer Urethane dimethacrylate (UDMA)

is most commonly used in
compomer materials?

Which classification of Microfilled resins

composite involves a 2 stage
process where polymerised
particles of resin are added to
the material acting as large
particle filler?

Explain the function of the water from the oral environment causes the release of H+ ions
carboxyl groups incorporated causing an acid attack to act on the fluoro-alumino-silicate glass
into the resin of a compomer? releasing fluoride ions
 How you best describe a A composite is a filled resin and a bonding material is an
composite and a bonding unfilled resin
material

Which monomer is commonly Bis-GMA

found in modern composite
materials?

What is the function of the Binds individual filler particles

organic resin in resin based
composites?

The most important feature of Helps reduce polymerization shrinkage

the glass/silica inorganic filler
is to do what?

The coupling agent binds the Gamma-MPTS

resin to the filler to create
strong mechanical properties
but what is the shortened
version of the most common
agent?

Which methacrylate monomer Urethane dimethacrylate (UDMA)

is most commonly used in
compomer materials?

Reactions between the oral Amalgam: Although genuine cases of amalgam allergy
mucosa and components of exist, these are rarer than the tabloid press would
metal alloys commonly used suggest. For proven cases resin composite or cast
in restorative dentistry  restorations should be used.

Reactions between the oral Nickel: Constituent of some alloys can cause contact
mucosa and components of eczema. Sensitive patients often have a history of allergy
metal alloys commonly used to jewellery or watch casings. Alternative alloys are
in restorative dentistry  available.

Not metals but useful nevertheless

Acrylic monomer(Methylmethacrylate) Can cause an

allergic reaction and should be considered in a patient
complaining of a 'burning mouth'. The concentration of
monomer is ⇑ in poorly cured acrylic and greater in self-
than heat-cure. Extended curing, e.g. 24 h, may ⇓
concentration of monomer to an acceptable level; if not
a cobalt chrome or SS denture base will be required.

Epimine: In polyether impression material.

 If an allergy is suspected, refer to a dermatologist!

Directly toxic

Beryllium, present in some nickel alloys, is known to be

a carcinogen. Provided the alloy is not ground any risks
are confined to the production laboratory. Beryllium-free
alloys are becoming ⇑ available.

Common Dental Allergies  Resin composites: could cause lichenoid reactions in the
oral mucosa. May be related to allergy to formaldehyde
formed in resin restorations.
 Polyether impression materials: problem was historic as
now have been re-formulated.
 Eugenol: mixed with ZO to form ZOE and has number of
uses in dentistry.
 Acrylic resins: reported to induce HS when used as
denture base (methylmethacrylate).
 Amalgam restorations: rare, but allergy to mercury and
copper in amalgams has been reported causing oral and
mucosal vesicle and ulcer formation. Amalgams may be an
aetiological factor in some of the mucosal changes as with
oral lichen planus.
 Gold alloys: reported cases very low. Probably due to other
base metals used in gold alloys.
 Nickel-titanium alloys: can cause allergic reactions.
 Antibiotics (Penicillin):Allergy to Penicillin and
cephalosporin (b-lactams) is the most common drug
allergy (usually following parenteral administration).
Allergic reactions can range rash and uticariato hives 
life-threatening anaphylactic response. Erythromycin is
alternative.
 Allergy to NSAIDs.
 Local and Topical Anaesthetics:Some individuals are
allergic to benzocaine.
 Adrenaline in LA: although not a true allergy often LA is
deposited in bloodstream and can increase heart rate and
cause breathlessness. This is often mistaken for allergy.
Esters more common than amides.
 Toothpaste and chewing gums: containing cinnamon
cause plasma cell gingivitis or inflammation of other parts
of the oral mucosa Gingivitis, chelitis has been seen in
patients using tartar control toothpaste containing
cinnamonaldehyde and pyrophosphates.
 Topical fluoride (duraphat): known to cause contact
allergies.
 SLS containing toothpaste: rare, but can cause irritation of
the soft tissues of the mouth.
 Latex: historically found in gloves and rubber dam.

Dealing with concerns about Reassure!!

amalgam as a restorative
material
Given the available scientific information and considering the
demonstrated benefits of dental amalgams, unless new
scientific research dictates otherwise, there currently appears
to be no justification for discon- tinuing the use of dental
amalgam.

DENTAL AMALGAM: UPDATE ON SAFETY CONCERNS

Clinical properties of  High compressive strength 500MPa

amalgam   High wear resistance
 Low corrosion (oxidation of the metal alloy which
results in ‘crusting’ causing amalgam to break
apart therefore void formation)
 Low Creep (The movement of amalgam under
loading)
 High fracture resistance
 Conducts electricity
 Conducts heat.
 Similar coefficient of expansion to the tooth
Advantages of contemporary Quicker set to full strength than low Cu (after 1hr
copper amalgams  320MPa out of 500Mpa which is the max strength.)

Cements

Handling of zinc phosphate require mechanical retention+ mild pulp irritant

cemen

Zinc oxide and eugenol (IRM, require mechanical retention

Kalzinol, Sedanol)

Zinc polycarboxalate cement (Poly binds to the tooth chemically, ie does not require mechanical
F) retention + adheres directly to enamel and dentine

CaOH lining Butylene Glycol Disalicylate

Management options when

recementing of an indirect
restoration 

Properties of 10-
methacryloxydecyledihydrogen
phosphate based luting
materials (e.g
Panavia F) 

Biological properties of calcium Regenerative/medicamentBactericidal (due to

hydroxide high pH - 12.5) Dentatures bacterial endotoxin /
Denatures organic tissue / Stimulates calcified
 tissue formation (due to tissue necrosis) / Long
lasting / Irritant if extrude

Lichenoid tissue reactions to Amalgams 60-70% Gold not sure 

common dental materials

Beryllium as a health hazard in Base metal alloys are composed of metallic elements
the dental laboratory  other than gold, silver, platinum, palladium, ruthenium,
iridium, rhodium, and osmium.

Beryllium is added to some base metal alloys for use in

crowns, bridges and partial denture frameworks.
Incorporation of beryllium into the base metal alloy
formulation facilitates castability (lowering the melting
temperature and surface tension) and increases the
porcelain metal bond strength.Beryllium also allows the
alloys to be electrolyticallyetchable for bonding veneers
in conjunction with resin-bonded restorations.

Exposure to beryllium vapor or particles is associated

with a number of diseases:

contact dermatitis

chronic granulomatous lung disease,(AKA chronic

beryllium disease (CBD).

In addition, beryllium and some beryllium compounds

in vapor and particulate form have been shown to be
carcinogenic based on human epidemiological and
animal experimental models. Tumors linked to
beryllium include lung carcinoma and osteosarcoma.

Potential hazards or risks from exposure to beryllium

result from melting, grinding, polishing and finishing
procedures. The risk is greatest during the casting
process in the absence of an adequate exhaust and
filtration system.

According to the Occupational Safety and Health

Administration (OSHA) the current Permissible
Exposure Limits (PELs) for beryllium allow exposure to
 2 micrograms per cubic meter of air (2 µg/m3) as an 8-
hour time-weighted average (TWA), between 5 µg/m3
and 25 µg/m3 exposure for up to 30 minutes at a time,
and 25 µg/m3 as a maximum peak limit that can never
be exceeded. However, some recent studies and
reports have questioned whether the current 2 µg/m3
PEL for beryllium in the workplace is adequate to
prevent the occurrence of CBD among exposed
workers. A recommendation of 0.1 µg/m3 for the 8-
hour TWA has been made based on a study of
unaffected populations near a beryllium plant.

In a recent Hazard Information Bulletin entitled

Preventing Adverse Health Effects from Exposure to
Beryllium in Dental Laboratories ("OSHA
Bulletin"),OSHA expressed concern that cases of CBD
are continuing to occur among dental laboratory
technicians and cautioned the nation's dental
laboratories and lab technicians to be alert to the risk
of developing CBD from exposure to dust from
beryllium.

Use of metal shimstock  Articulating paper 8-12 micrometres. Shimstock foil

0.06 micrometres. Used for Dahls

Ferric sulphate (15.5%) – haemostasis through the formatin of metal-protein clot

Ethics and Law/consent

Negligence

Fraser (Gillick) In general, in English Law a minor is a person less than 18

competence  years old. However the Family Law Reform Act 1969 states:

Consent; Gillick "The consent of a minor who has attained the age of sixteen
competence  years to any surgical, medical or dental treatment which, in
the absence of consent, would constitute a trespass to his
person, should be as effective as it would be if he were of full
age; and where a minor has by virtue of this section given an
Consent in children 
effective consent to any treatment it shall not be necessary
to obtain any consent for it from his parent or guardian".

Consent for treatment in It is probably the case that for a person between 16 and 18
an 8 year old child  years old consent may be obtained either from the parent or
from the person themselves.

Adults, defined as people over the age of 18, are usually

regarded as competent to decide their own treatment. The
 Family Law Reform Act 1969 also gives the right to consent
to treatment to anyone aged 16 to 18.

Note though that consent to medical treatment can be given

by a child under the age of 16 if s/he is 'Gillick competent'
HOWEVER they cannot reject treatment under 18

16 is the age of acceptance and 18 is the age of

rejection

children under the age of 16 can consent to medical

treatment if they have sufficient maturity and
judgement to enable them fully to understand what is
proposed. This was clarified in England and Wales by
the House of Lords in the case of Gillickvs West
Norfolk and Wisbech AHA & DHSS in 1985

Power of attorney Someone else can make decisions on your behalf if they have
an ‘unending power of attorney’ and if there is a consent
issue, the court of law can override treatment e.g. if
someone has dementia.

Practice management; NO INFO WHATSOEVER unless Power of Attorney is in

confidentiality issues  place!!!

Practice management;
confidentiality issues 

Patient confidentiality

Responsibilities relating
to confidentiality in a
teenage minor 

Raising concerns about 8.1.1 of Standards for the Dental Team states that you must
aspects of a colleagues raise any concern that patients might be at risk due to the
clinical performance health, behaviour or professional performance of a colleague.
which affects patient It also makes clear that you must raise a concern even if you
care  are not in a position to control or influence your working
environment and your duty to raise concerns overrides any
personal and professional loyalties or concerns you might
have.

8.2.3 states that, where possible, you should raise your

concern with your employer or manager. We would
encourage you to raise the issue with your practice principal
first, however 8.2.5 makes clear that if you think that the
public and patients need to be protected from a dental
professional registered with us, you must refer your concern
 to us. You may find this is appropriate when:

taking action at a local level is not practical;

e.g if the locum and the practice principal are good friends

action at a local level has failed;

e.g. where the practice principal has ignored your concerns

the problem is so severe that the GDC clearly needs to be

involved (for example issues of indecency, violence,
dishonesty, serious crime or illegal practice);
e.g the explicit videos involve children

there is genuine fear of victimisation or deliberate

concealment;
e.g. you are being bullied by the locum into not telling
anyone what he has been doing

you believe a registrant may not be fit to practise because of

their health, performance or conduct

Knowledge of child  Triangle of safety – injuries in this triangle

protection protocols for  Is injury commensurate to the reported cause
raising a concern   Frenulum tears
Q6) All professionals involved with children need to be alert to the
possibility of NAI or neglect. General consideration regarding NAI when
observing a child patient. Orofacial trauma occurs in at least 50% of children
diagnosed with physical abuse. Bruising in babies or children who are not
independently mobile are a cause for concern. Any bruises with sharp
borders whether it be by biting, pinching, slapping are always indicative of
physical abuse. Watch for burns/ bite marks. A frenum tear in a very young
non-ambulatory patient (less than 1 year) should arouse suspicion.

Accidental injuries – If a child has fallen over then they will tend to be
injured on bony prominences. Such as the forhead or cheekbone. Accidental
lacerations on face are consistent with history i.e. fell of a bike – these are
often associated with other injuries effecting knees/ elbows.

Neglect is the persistent failure to meet a child’s basic physical and/or

psychological needs, likely to result in the serious impairment of the child’s
health or development. Once a child is born, neglect may involve a parent or
carer failing to provide adequate food and clothing, shelter (including
exclusion from home or abandonment), failing to protect a child from
physical and emotional harm or danger, failure to ensure adequate
supervision (including the use of inadequate care-takers) or the failure to
ensure access to appropriate medical care or treatment. Failure to take a
child for appropriate health care when required and necessary dental care
(to make sure child is free from infection / pain) is neglectful. In infancy,
neglected children are often recognised by their poor physical state,
failure to thrive and delay in achieving developmental milestones such as
walking. Older children may have behavioural problems, difficulty forming
 relationships and emotional problems. A neglected child may present to
the dentist with unmet dental needs and may subsequently fail repeated
appointments. Child may present with inappropriate clothing, cold injury,
sunburn, may have attention seeking behaviour.

7)Safeguarding children is not just about referring them when you

have concerns but is about changing the environment to ensure that risks to
children’s welfare are minimised. History and examination - A full dental
examination should be carried out, noting any bruising. It is important also
to note the general appearance of the child, their state of hygiene, whether
they appear to be growing well or are “failing to thrive” and interaction with
their parents or others. Look particularly for signs of “frozen watchfulness”
where the child seems to take in everything going on, but in a detached,
wary or fearful manner. Colleagues to consult - discuss this with an
appropriate colleague or someone else you can trust (seek advice from a
more experienced dentist). Informing the child and parents - inform them
of your intention to refer and seek their consent. There are certain
situations where you should not include parents such as, where discussion
might put the child at greater risk, where sexual or multiple abuse is
suspected, where parents or carers are being violent or abusive etc. Making
a referral - If, having discussed it with an appropriate colleague, you remain
concerned, then you should make a referral to your local social services.
Referrals should be made by telephone & followed up with letter. Your
letter should clearly document the facts of the case and include an explicit
statement of why you are concerned. The telephone discussion should be
recorded, documenting what was said, what decisions were made and plan
of. Follow up on referrel are dentist responsibility.

Consent to treatment - TEACHER – duty of care ends when child arrive at

issues in underage surgery..i.e teacher cannot give consent (Odell case 26)
children

Study design
Bias in clinical trials The predicted difference on average between the
measurement and the true value. Bias is also known as
accuracy.

Confidence intervals  95% confident that a particular number will fall in a

range therefore the chances of something being out of
it wll be really low. Therefore it is insignificant.

Factors causing bias in An error that is not determined by chance but is

epidemiological data; introduced by an inaccuracy in the system. Systematic
systematiic error - errors are predictable and expected.

Evidence based Dentistry; Population

interpretation of data  Intervention
Comparison
Evidence Based Medicine - Outcome
design of research strategies 

Sensitivity and Specificity  Sensitivity

If a person has a disease, how often will the test be
positive (true positive rate)?
Put another way, if the test is highly sensitive and the
test result is negative you can be nearly certain that
they don’t have disease.
A Sensitive test helps rule out disease (when the result
is negative). Sensitivity rule out or "Snout"
Sensitivity= true positives/(true positive + false
negative)
Specificity
If a person does not have the disease how often will
the test be negative (true negative rate)?
In other terms, if the test result for a highly specific
test is positive you can be nearly certain that they
actually have the disease.
A very specific test rules in disease with a high degree
of confidence Specificity rule in or "Spin".
Specificity=true negatives/(true negative + false
positives)

Study design in Epidemiology Epidemiology Study Design – Explains everything nice

and Public Health  and simply but is a bit wordy!

Understanding and usage of The relationship between something that happens or

the epidemiological term exists and the thing that causes it!
'causality' 
AKA: The idea that something can cause another thing
to happen or exist

Interpretation of Epidemiology paper – This paper has everything in it

epidemiological data 

Epidemiological study design;

strengths and weaknesses of
case-controlled studies 

Epidemiological principles;
factors contributing to
reliability and validity 

Other

Metamerism  The visual effect in which a color appears

differently under different light sources.

Different pigments in a material will absorb light at

various wavelengths to differing degrees. This property
explains why two pigments may appear identical under
a specific light source, but appear different in another
type of light source. It is for this reason that it may be
impossible to match tooth and shade guide for all light
sources since the dentine pigments within the tooth are
different from the metallic oxide pigments used in
porcelain.

Metamerism will also mean that a crown which is a

perfect match in daylight may not be a perfect match
under other lighting conditions.

EPT and pacemakers  PDS PPROTOCOL

EPT and pacemakers  The following dental equipment should NOT be used on
patients fitted with a pacemaker.
Electric pulp testing (EPT) and
o The Digitest Pulp Vitality Tester
pacemakers 
o The Cavitron SPS Ultrasonic Scaler

o The Ray-Pex 5 Apex locator

o SybronEndo Apex locator

UK 'State of the Nations Dental

Health' survey 

Preventive dentistry  The process by which the Dentist and

Hygienist/Therapist work in tandem for the prevention
of disease. It encompasses:
  Patient education
 Fluorides
 Dental sealants
 Proper nutrition
 Plaque-control program
 Optimum oral health can become a reality.

Causes of tooth discolouration  Extrinsic discoloration (Staining of

enamel):-
Coffee / Wine / Cola / Tea
As a result of Tannins
Intrinsic discoloration (Staining of the
Dentine)
 Fluorosis
 Tetracycline staining
 Trauma
 Dentinogenesisimperfecta (Grey/Amber/Purple
discolorations.)
Age-related discoloration — This is a
combination of extrinsic and intrinsic
factors. Dentine naturally yellows over
time. The enamel gets thinner with age,
which allows the dentin to show through.

Obligations and responsibilities Know the limit of the Dental chair.

when managing a very obese
patient  x 3 Devonport has a limit of 20 Stone or 127Kg

Practice management; Community care

retention of records 
11 years (adults)
To the age of 25 years (children)
Hospital care

▪ 8 years (adults) 
To 25 years or 8 years post death (children)

Treatment planning for a

missing upper central incisor 

Role of the dental therapist -  Paeds Restorations

what they are and are not  Paeds XLA
permitted to do   IDB and Infiltrations
 Radiographs ( if prescribed by a Dentist)
 Permanent restorations
Role of the dental therapist -
what they are and are not
permitted to do 
The role of the dental
therapist; what they may or
may not do 

Awareness of treatments to be
carried out during domiciliary
visits and those which require
a surgery 

Consequences of drink driving  Standards 9.1 in Standards for the Dental Team makes
clear that you must ensure  that your conduct, both at
work and in your personal like justifies patients’ trust in
you and the public’s trust in the dental profession. We
consider receiving a conviction or caution to be a
breach of that standard.

9.3.1 in Standards for the Dental Team states that you

must inform the GDC immediately if you are subject to
any criminal proceedings anywhere in the world. Our
guidance on reporting criminal proceedings provides
more detail on what we expect you to tell us about. You
must notify us if you have been convicted of a criminal
offence.

The caseworkers in our fitness to practise team will

consider whether you should be referred to the
Investigating Committee for your conviction.

The police have a duty to tell us if you are convicted or

cautioned for an offence and if you do not inform us
about a conviction and the police do, our fitness to
practise team would consider your failure to inform us
about your conviction as well as the conviction itself.

You should also check whether you are under a duty to

tell your employer.

The Professional Conduct Committee

The Professional Conduct Committee (PCC), a statutory

committee of the Council, is one of three practice
committees. The PCC considers whether an allegation
referred to it amounts to misconduct and if this
misconduct amounts to an impairment of the
registrant’s fitness to practise.

After consideration of the allegations referred to

 it the PCC may:

Conclude that the registrant’s Fitness to Practise is

not impaired and close the case
Issue a reprimand
Impose conditions for up to 36 months (immediate
conditions can be applied if required)
Suspend the registrant for up to 12 months (with or
without a review) (immediate suspension if
required)
Erase the registrant from the Register
The PCC also has the right to refer the case back to the
Investigating Committee, any other practice
committees or the Interim Orders Committee.

Role of professionals Hygienist and therapist. IDB without a dentist present

complementary to dentistry 

Referral in general dental Urgent referral if present for 3 weeks or more

practice 

PCDs  ???

Gemination  Two teeth from one tooth germ

Tooth Morphology  - CUSP OF additionalcusp at the mesiopalatal line angle of

CARABELLI maxillary first molars. 60% Of Europeans have it.