SCENARIO BASED QUESTION : ODELL CASES

 CASES NO. 1 A HIGH CARIES RATE

Complaint : lost filling on lower right tooth with sharp edge irritating tongue

Intraoral Exm: Mandibular right 1st molar - probing depth 3mm

- grossly carious
- sinus discharge buccally

Vitality test: 1st molar FAILS to respond

Radiographic investigation : - Bitewings (to detect approximal/occlusal surface)

- PA
- Panoramic radiograph ( general survey )
Explain the Xray below :

PA : - caries on lower right 1st molar extends to pulp.

- molar drifted mesially & tilted
- peri-apical radiolucency under both roots, continuing in PDL & loss of
lamina dura

BITEWING: - occlusal caries in all molars except max 1st molar (right)
-
Diagnosis : Nonvital lower 1st molar with Periapical Abscess

Sequence of Treatment phase:

1. Immediate phase : Caries removal, access cavity prep, irrigation, temp restoration
2. Stabilizing caries : Removal of all caries in other teeth & temp restoration
3. Preventive measure: Deit analysis, oral hygiene & fluoride Rx
4. Premanent restoration : Depending on all found during temp restoration.

Temporary restoration option: ZOE paste, ZOcement, Polycarboxylate cement, GIC

Dietary advice: reduced amt of sugar, restrict intake of sugar to mealtime,

QUESTIONS:
1. Which are the predominant form of caries in Adolescents ? – Qcclusal lesion
2. Why does occlusal caries go undetected ? – Firstly : starts in fissure & obscured by sound superficial enamel.
Secondly : lesion cavitates late
3. How to confirm the tooth involving sinus ? – Guttapercha point inserted in sinus before xray
4. What should be the first line of treatment in this case ? – caries removal, access cavity prep, drainage , irrigate &
temp restoration.
5. Reasons for gross breakdown of the tooth ? – marginal leakage, undermining marginal ridge, mesial cusp
collapse or failure to remove all carious material.
6. What is the most imp preventive procedure in this case? - Dietary analysis
7. How to evaluate Pt’s diet ? – enquiry into lifestyle & enquiry into diet components.
8. What are the causes of high carise susceptibility ? - sugar containing food n drinks, frequency, sugar attacks,
consistency & hidden sugars
 ODELL CASE NO - 2

A 45-year-old healthy African man presents with an enlarged jaw. The patient’s main
complaint is that his lower back teeth on the right side are loose and that his jaw on the right
feels enlarged.

• The patient has been aware of the teeth slowly becoming looser over the previous 6
months.
• They seem to be ‘moving’and are now at a different height from his front teeth
making eating difficult.
• He is also concerned that his jaw is enlarged and there seems to be reduced space for
his tongue.
• He has recently had the lower second molar on the right extracted. It was also loose
but extraction does not seem to have cured the swelling. Although not in pain, he has
finally decided to seek treatment.

1. The following lesions may appear radiographically as multilocular radiolucencies

EXCEPT
A. Ameloblastoma
B. Odontogenic myxoma
C. Radicular cyst
D. Odontogenic keratocyst
2. What other diagnostic investigation would you carry out for this patient?

A .CT Scan
B .MRI
C .Lateral cephalogram
D .PA view

3. What is the diagnosis according to clinical features and radiograph provided?

A. Dentigerous cyst
B. Unicystic Ameloblastoma
C. Multicystic Ameloblastoma
D. AOT

4. If the patient with Ameloblastoma had diapetes type 1, What will be the difficulty in
the management
A. Poor healing
B. Infection
C. To control his glucose level before the surgery.
D. Intraoperative fracture

5. The most appropriate treatment for a unicystic ameloblastoma of the posterior

mandible in an 18 year old patient is
A. Root canal therapy.
B. Hemi-mandibulectomy.
C. Block resection.
D. Curettage.
E. Radiotherapy.

6. Tissue from multilocular radiolucent area of the posterior mandible histologically

shows follicular areas lined with columnar cells resembling the enamel organ, the
diagnosis is
A. Neurofibroma
B. Ameloblastoma
C. Central fibroma
D. Lat periodontal cyst
E. Dentigerous cyst
Odell-Case 3

An unpleasant
Surprise
A 30-year-old lady develops acute
shortness of breath following
administration of amoxicillin.
What would you do?

History
- The patient complains that she feels unwell, hot and breathless.
- The patient has an appointment for routine dental treatment
involving scaling and a restoration under local anaesthesia and
antibiotic prophylaxis. She took a 3 g oral dose of amoxicillin
45 minutes ago.
- She is well controlled asthmatic taking salbutamol on occasions.
- She also suffers from eczema, as do her mother and her two
children, and uses a topical steroid cream as required.
- The patient has had antibiotic cover before and refuses treatment
without.
- She has had previous courses of penicillin from her general
medical practitioner for chest infections.

Questions
1- What is the likely diagnosis?
A. Herpes Zoster
B. Lichenoid Reaction
C. Penicillin hypersensitivity
D. Latex allergy
E. Allergy to salbutamol
2- What is the incidence of penicillin allergic reaction (urticaria) in
population?
A. 5%
B. 15%
C. 25%
D. 50%
E. Very rare

3- The reaction that happened to this patient is:

A. IgE mediated
B. IgA mediated
C. T-cell mediated
D. Non-specific histamine release
E. Cytotoxic

4- In this patient, it’s considered hypersensitivity:

A. Type I
B. Type II
C. Type III
D. Type IV
E. Non-specific immune reaction

5- Penicillin anaphylaxis may be fatal:

A. In 5% of cases and death usually occur within 15 minutes
B. In 5% of cases and death usually occur after few days
C. In 10% of cases and death usually occur within 15 minutes
D. In 10% of cases and death usually after few days
E. Rarely
6- Signs and Symptoms of immediate onset allergic reaction include
all the following except:
A. Rash
B. Swelling of lips
C. Hypertension
D. Cyanosis
E. Small airway obstruction

7- What is the first line of treatment would you perform for this
patient?
A. Give Adrenaline 0.5 ml of 1:1000 solution IV or IM
B. Give Adrenaline 300 micrograms IM via autoinjectors
C. Give Chlorphenamine 10 mg IV and Hydrocortisone 100-200 mg
IV or IM
D. B and C only
E. (A or B) + C

8- What would be your treatment if medical or paramedical help is

likely to arrive late?
A. Give Adrenaline 0.5 ml of 1:1000 solution IV or IM
B. Give Adrenaline 300 micrograms IM via autoinjectors
C. Give Chlorphenamine 10 mg IV and Hydrocortisone 100-200 mg
IV or IM
D. B and C only
E. (A or B) + C
9- What would be your treatment if the patient does not develop
brochospasm?
A. Give Adrenaline 0.5 ml of 1:1000 solution IV or IM
B. Give Adrenaline 300 micrograms IM via autoinjectors
C. Give Chlorphenamine 10 mg IV and Hydrocortisone 100-200 mg
IV or IM
D. Give oral Antihistamincs
E. None of the above
10- Why was this patient at high risk of anaphylaxis?
A. History of asthma
B. Family history of eczema
C. Female anxious patient
D. A and B
E. All of the above

11- If you discovered that you had just administered a penicillin

orally to a patient known to be allergic to penicillins, what
would you do?
A. Follow-up is only required if only one dose orally was given
B. Give Adrenaline immediately
C. Give Chlorphenamine and steroid immediately
D. Wait until symptoms or signs develops then take action
E. B and C

12- Regarding Antibiotic Prophylaxis, which of the following

conditions does not require antibiotic prophylaxis?
A. Recent valve replacement
B. Rheumatic fever in Indigenous Australians
C. Tetrology of Fallot
D. Repaired septal defect
E. Previous history of bacterial endocarditis

13- What would be your action if a patient - who was used to take
antibiotic prophylaxis for lifetime dental procedures – insists to
take prophylactic antibiotic, although her medical condition is not
covered in the new guidelines?
A. Give her antibiotic as she is insisting
B. Inform her about the adverse effects of antibiotics and refuse
giving her
C. Consult her medical practitioner and consider giving her antibiotic
14- Which of the following dental procedures does not require
antibiotic prophylaxis?
A. Extraction of loose tooth
B. Sub-gingival scaling
C. Replanting avulsed tooth
D. Inferior alveolar nerve block
E. Implant placement

References:
1- Odell Clinical problem solving 3rd edition
2- Theraputic Guidelines 2012 Version 2
3- Management of medically compromised patients 8th edition
J.W.Little

Answers:
1- C
2- A
3- A
4- A
5- C
6- C
7- B
8- D
9- D
10- D
11- C
12- D
13- C
14- D
Gingival recession
A 30-year-old woman has gingival recession.

• She is a fit and healthy individual and is not a smoker.

• The patient has a normal tooth brushing habit.A lower incisor is missing,
the patient had undergone extraction of the incisor but had not worn an
appliance.

On performing the clinical examination you find that

• All probing depths are 1–2 mm with no bleeding.
• The width of keratinized gingiva varies with the degree of recession.
• No teeth have increased mobility and no possible occlusal factors are
present.
• There is no reason to suspect loss of vitality and all teeth respond to
testing.
History of complaint
She remembers noticing the recession for at least the previous
5 years. She thinks it has worsened over the last 12
months. There has recently been some sensitivity to hot and
cold and gingival soreness, most noticeably on tooth brushing
or eating ice cream.

Questions:

1. What is the likely diagnosis?

a. LAP (localized aggressive periodontitis)

b. Gingival hyperplasia

c. Gingival recession

d. Abrasion

2. what is probable etiology of the condition?

a. post orthodontic treatment

b. trauma due gingival cord

c. tooth brush trauma

d. parafunctional habit ( impinging gingival with tongue,finger nail, pencil ,etc)

3. what is the most common cause of hot/cold sensitivity ?

a. exposed dentinal tubles in recessed gingiva

b. root caries

c. erosion

d. none of the above

4. how is gingival recession measured?

a. From CEJ to free marginal gingiva

b. From gingival margin to junctional epithelium

c. From margin to depth of sulcus

d.From CEJ to mucogingival junction

5. how to measure total width of attached gingiva?

a. from CEJ to mucogingival junction

b. from free gingival margin to mucogingival junction minus pocket depth

c. A+B

6. Radiograph to assess gingival condition?

a.bitwing xray

b. pantogram

c. ConeCT

d.periapical xrays

e. none of the above

7. what is/are treatment of gingival recession?

a. mucogingival surgery ( pedicle ,coronal positioned grafts )

b. free gingival graft

c. acrylic stent or veneer

d. all of the above

Answers:

1.c 2.c 3.a

4.a 5.b 6.e 7.d

Some past paper ques :

Examination reveals area of gingival recession, exposed wide area of dental

roots. Which is the procedure of choice to obtain coverage of the root surface.

A. Free gingival autograft

B. Sub - epithelial tissue graft

C. Apically position graft (B)

D. Free gingival graft

E. Modified wide flap

Ques : Areas of isolated gingival recession are most frequently seen on teeth that are

A. non vital.

B. moderately mobile. (D)

C. ankylosed.

D. labially prominent in the arch

QUES : Which ttt is considered the gold standard for gingival recession:

A. Free gingival graft

B. Connective tissue graft

C. Lateral pedicle flap (B)

D. Double papilla flap

E. Coronally repositioned flap

QUES : A narrow triangular-shaped gingival recessionover the root of a tooth is

called a

A. festoon.

B. cleft. (B)

C. crater.

D. fenestration.
E. dehiscencE
 Case No 5 – Missing Incisor

A 9-year-old boy is referred to you in the orthodontic department with an unerupted

upper left central incisor. What is the cause and how may it be treated?
History of complaint:
The upper permanent central incisor on the opposite side erupted normally at 7 years
of age.

History of trauma few time back,with no considerable loss of tooth.

Medical history:
The patient has suffered from asthma since he was 4 years old. This is controlled using
salbutamol (Ventolin).

The patient is in the early mixed dentition stage and the teeth present are:

No upper left central incisor is present, but there is a pale swelling high in the upper
labial sulcus above the edentulous space and the upper left B. There has been some
loss of space in the region of the absent upper central incisor. There is a tendency to
an anterior open bite which is slightly more pronounced on the right.
Q-1 what could be the most probable cause out of following?
a. Scaring following extraction.
b. Developmental cause.
c. Avulsion.
d. Dilaceration following trauma.
e. None of the above.
Q-2 What all radiographs would be required?
i. OPG.
ii. Periapical radiograph of concerned area.
iii. Lateral view.
iv. Bitewing radiograph.
v. Occlusal radiograph of maxilla.
a. I and ii.
b. I,ii and iii.
c. iii and iv.
d. I,ii,iii and v.
Q-3 What could be the reason for anterior open bite?
a. Tongue thrusting.
b. Trauma.
c. Digit sucking.
d. Asthma.
e. None of the above.
Q-4 What could be the likely cause of lower centre line shift?
a. Trauma.
b. Early exfoliation of lower left C.
c. Thumb sucking.
Radiographs.
Q-5 What is your final diagnosis after viewing radiograph?
a. Supernumerary teeth.
b. Intrusion.
c. Dilaceration of CI.
d. Cyst
e. None of the above.
Q-6 What would be the best possible treatment?
a. Localized surgical exposure of crown followed by orthodontic traction.
b. Extraction followed by permanent restorstion.
c. Extraction followed by single tooth implant.
Q-7 Statement 1 To achieve lost space both upper Cs should be extracted and upper
left B to encourage eruption of permanent lateral incisor.
Statement 2 Followed by surgical exposure and orthodontic of upper left 1.
a. Both statements are true.
b. Both statements are false.
c. First statement is true, second is false.
d. First statement is false and second is true.
Q-8 What would be the choice of appliance?
a. Removable ortho.appliance
b. Fixed ortho.appliance
Q-9 Suitable appliance would have?
a. Fingure spring on upper right CI and left LI and cribs on 6D I 6D
b. Fingure spring on upper right CI and left LI alone
 c. Fingure spring on upper right CI and left LI, cribs on 6D I 6D and buccal arm on
upper left CI.

Q-10 What further treatment is required at this stage?

a. Orthodontic treatment to correct malocclusion.
b. Wait and observe till permanent dentition is developed fully.
Q-11 Prevalence of childhood (0-14 years) asthma in Australia?
a. More in boys.
b. More in girls.
c. Equal in both.
Q-12 Prevalence of asthma in 15 years or above age in Australia?
a. More in boys.
b. More in girls.
c. Equal in both.
Q-13 Is Nitrous Oxide contraindicated in asthmatic children.
a. True.
b. False.
Q-14 Adrenaline containing L.A. should be avoided due to potential adrenergic effects
in asthmatic children if injected IV?
A. True.
B. False.
Answers:

1 D
2 D
3 D
4 B
5 C
6 A
7 A
8 A
9 C
10 B
11 A
12 B
13 B
14 A
1|Page

Cracked Tooth Syndrome

Odell Case 11
(This one I have summarized all the important points you need to know about it, rather than presenting it in a
question format. Hope you will find it useful)

 Cameron suggested the term ‘‘cracked tooth syndrome’’ (commonly

abbreviated to CTS) for the collective signs and symptoms associated with
cracked teeth
 The use of the term ‘‘syndrome’’ is particularly misleading because a
syndrome is defined as ‘‘a number of symptoms occurring together and
characterizing a specific disease’’.
 Clearly, a crack in a tooth is not a disease and therefore the term syndrome is
inappropriate (cracks should be thought of as a cause of disease rather than
being considered as a syndrome a disease in itself. The noting of the presence
of a crack should be considered as a clinical finding or observation, and not a
diagnosis. Cracks should be considered as a potential pathway of entry for
bacteria into the tooth)
 The most commonly affected teeth are the mandibular molars, Mandibular
second molars were more likely to be involved than first molars
 Cracked tooth syndrome is likely to occur three times more commonly in a
tooth which has been weakened by restoration of one or both marginal ridges,
than a tooth which only has an occlusal restoration.
 Conservation of tooth structure in cav i t y preparations is important in the
prevention of CTS

Dr. Eshan Verma

2|Page

Terminology:
Enamel crazing (or enamel infraction) – small cracks on the surface of teeth;
hence craze lines in teeth involve only the enamel and there are no pulp symptoms.
No treatment is required but enamel crazes have the potential to progress to become
cracks in the tooth and should therefore be monitored.

Crack – a crack is a defect where there is a break between two parts but without
separation of the fragments; hence, a crack in a tooth involves the dentine and the
enamel and ⁄or cementum. A crack may extend into the pulp space in some cases. A
crack may or may not cause pulp diseases (inflammation and eventually necrosis and
infection) and periradicular diseases, depending on whether bacteria can penetrate
the tooth via the crack to reach the pulp space. Cracks do not require treatment unless
they are causing pulp and⁄ or periradicular diseases. However, all cracks have the
potential to progress to become a fracture of the tooth and therefore they should be
monitored if not treated immediately to help prevent or manage pulp and⁄or
periradicular disease. Cracks that are causing pulp and periradicular diseases require
treatment, the nature of which varies considerably depending on the position,
direction and extent of the crack.

Fracture – a fracture is a defect where there is a break between two parts and the
fragments have separated; hence, a fracture of a tooth involves the dentine and either
only the enamel or cementum, or both of these tissues. A fracture may or may not
extend into the pulp space. A fracture may or may not cause pulp diseases
(inflammation and eventually necrosis and infection) and periradicular diseases,
depending on whether bacteria can penetrate the tooth via the fracture to reach the
pulp space. The treatment required for fractures varies considerably depending on
the position, direction and extent of the fracture

Dr. Eshan Verma

3|Page

Cavity size and its relation

to direction of crack and
symptoms (Fig 1)
Clinical observation of fractured
teeth shows that most fractures
tend to occur in a direction near
parallel to the forces on the
cuspal incline.

The extent of the crack in a

mesio-distal is more common
than a bucco- lingual direction

Larger restorations-the crack

tends to be more superficial and
may produce less severe
symptoms, or there may be no symptoms at all.

Teeth with smaller restorations- cracks will be much deeper and closer to the pulp
and may produce more severe symptoms.
Wedging forces placed on both buccal and lingual cuspal inclines- the resultant
crack may occur in the midline of the tooth and propagate towards the pulp,
especially in unrestored teeth

Clinical Symptoms:
 Pain on biting on a particular tooth, often occurring with foods that have small,
discrete, harder particles in them.
 Patients may also complain of sensitivity to cold, sweet or hot, depending on
how far the crack has propagated into the tooth. (with cold being the most
common, then sweet)

Dr. Eshan Verma

4|Page

Diagnosis
Detailed history (any of above mentioned symptoms)

Clinical Examination

 The crack may be visible in the enamel at the marginal ridge or propagating from the
external line angle of the restoration
 Intraorally a Tooth Slooth (fig 2) or
a Fracfinder can be used on each
individual cusp and the patient
asked to bite, thus allowing the
placement or selective pressure on
one cusp. If there is pain on biting
or release of biting pressure, it is
indicativethat this cusp is cracked.

 the use of magnifying lenses with

transilluminating light in a
darkened room (before and after
the removal of restoration)
 Removal of the restoration may
show the extent of the crack in a
mesio-distal or a bucco- lingual
(less common) direction, but will
not give an indication of its apical
direction
 The use of a dye, for example,
methylene blue, which can be
sealed into the cavity with a zinc
oxide eugenol dressing can aid in diagnosis.
 The use of rubber dam enhances the probability of visualizing these cracks, by isolating
the tooth with a contrasting colour, keeping the area free of saliva and removing peripheral
distractions
 Perfrom Vitality test and radiographs to confirm the diagnosis of pulp⁄root canal status and
periradicular status and to identify the tooth involved

Dr. Eshan Verma

5|Page

Treatment Plan:
The cause of the disease should also be determined during the clinical examination for the proper
treatment plan.

Treatment protocol is summarized in fig 3

Dr. Eshan Verma

6|Page

 The most common mode of

treatment is the overlaying of the
offending cusp with amalgam.
The existing restoration is
removed and light pressure is
placed on the cracked cusp. If it
is too weak, it will fracture at the
site of the crack and can be
restored in a conventional
manner. If it resists this pressure,
the cracked cusp is reduced by 2 mm (for adequate bulk of amalgam), with a
small amalgam pin or cleat for retention to tie the two sides of the crack
together, and overlaid with amalgam. This protects the cusp from further
loading and prevents crack propagation. (Fig 4)

 Gold and porcelain inlays may also

be used in a similar way to tie the
cusps together.(fig 5)

Dr. Eshan Verma

7|Page

 Stainless steel orthodontic band can be

cemented around the cracked tooth,
binding the cusps together (Fig. 6).
This has the advantage of allowing
time to see if the symptoms are
reversible. The patient is told to use the
tooth normally, and if after review in 2-
4 weeks the symptoms have subsided,
the tooth can be restored more
confidently with an overlay restoration

Symptoms and Hydrodynamic theory:

The hydrodynamic theory is based on the concept that rapid movement of dentinal
fluid in the dentinal tubules causes pain. This movement stimulates mechano-
receptors in close proximity to the odontoblast cell body, which then activate A-delta
nerve fibres (faster myelinated fibres), resulting in a short sharp pain.

The pain is produced with movement of dentinal fluid when the crack is opened by
pressure on the cusp, and it also explains the short sharp pain as the fluid moves back
on releasing the pressure.

Seventy to eighty per cent of nerve fibres entering the pulp are non-myelinated fibres,
known as C- fibres. These fibres are slow-conducting and produce a dull, poorly
localized sensation and are activated by inflammation, heat and mechanical
deformation. The pain is a dull, poorly localized ache which increases after a hot
drink. These fibres are usually activated by stimuli which cause actual damage to the
pulp.

 If a tooth with CTS is exhibiting this type of pain, urgent treatment is required
to tie the cusps together (for example, an orthodontic band) and a sedative
dressing is required (ZOE to seal the cavity and hopefully maintain the vitality
of the pulp)

Dr. Eshan Verma

8|Page

References:

 Odell Case 11
 Homewood CI: Cracked tooth syndrome – Incidence, clinical findings and
treatment, Australian Dental Journal 1998;43:4
 Abbott P, Leow N: Predictable management of cracked teeth with reversible
pulpitis, Australian Dental Journal 2009; 54: 306–315

Dr. Eshan Verma

 Odell case 12: A DEFECTIVE DENTURE BASE

SUMMARY

The acrylic denture base and cobalt–chromium casting shown both have defects caused by similar
mechanisms. Can you identify the problem and its causes, which are different in the two examples

The heat-processed ‘acrylic’, poly(methylmethacrylate) denture base

Table 12.1 Types of porosity

Defect Manifestation Cause

Contraction porosity Porosity throughout the Insufficient material packed

Gaseous porosity
Granular porosity
This denture has suffered from gaseous porosity and the appearances are typical but more extensive
than usually seen.
denture. The denture may
be the incorrect shape.
Porosity in a localized area of
the denture base, particularly in during processing.
the thicker parts. Each defect is
round and sharply defined.
Porosity appears in thin
sections of the denture,
which often have a ‘white
and frosty’ appearance.
into the flask, or inadequate
flasking pressure. Correct use
of the trial packing stage should
eliminate this.
Vaporization of monomer
Incorrect polymer: monomer
ratio when producing the
dough, or failing to pack the
flask at the dough stage.
Table 12.2 Common defects in cobalt–chromium castings
Defect Cause
Porosity : spherical voids Investment too thick
Gases dissolve in the alloy and
form bubbles on cooling
Porosity: irregular voids Casting shrinkage
Turbulent flow of the alloy
Incomplete cast: rounded Back pressure of air in the
margins mould
Incomplete cast: short casting Insufficient alloy
Mould too cold when cast
Insufficient casting force
Fins Investment cracking
Rough surface Investment breakdown
Air bubbles on wax pattern
Distortion Stress relief of the wax pattern
Cast too small Insufficient investment
expansion
Cast too large Too much investment
expansion
Fig. 12.2 The cobalt–chromium partial denture casting.
Use the correct powder: liquid
ratio
Do not overheat the alloy
Ensure sprues are of the correct
diameter
Ensure sprues are in the correct
position
Use a porous investment or
include vents
Use sufficient alloy
Ensure the correct operating
temperature
Ensure the machine is correctly
set up
Use the correct investment
and do not heat too rapidly
Use the correct investment and
do not overheat
Use a wetting agent
Warm the wax thoroughly
before making the pattern
Use the correct operating
temperature
Use the correct investment for
the alloy, and the correct
operating temperature
I searched fr qs on this case, found 2 qs in Boucher's

Ques 1. What r d causes of porosity?

Ans- Packing wth acrylic mix that has too much monomer in it, under packing, curing too fast,
excessive thickness of acrylic.

Ques 2. Why is porosity sometimes found in thick sections of the denture only?

Ans-The rapid curing of of acrylic or d heat formed during polymerisation process is not dissipated
rapidly enough. This results in small voids frm d entrapped monomer.

Ques 3. Self made q:

After curing d technician informs u dat there r porosities on d external surface of d denture base.
What wl u do?

A tell d technician to polish it and then u insert d denture in d patient's mouth.

B tell d technician to construct record bases on d master cast and then repeat the Jaw relation, try
in.

C tell d technician to repeat the packing and curing.

Ques 4. Self made q:

What wl u do in case of internal porosities in d denture base?

A Make a new denture

B Gve the same denture to the patient.

CASE 13 Cardiac Arrest and BLS

A 55-year-old male patient suddenly collapses in your general dental

practice.The patient attended routine dental appointment to receive some
simple restorative work done under LA.He is a regular attender but dislikes
injections.About 20 mins after the administration of LA the pt.complains of a
pain in the chest and suddenly becomes anxious.He is breatheless.When
your nurse asks the patient if he is OK there is no response !!!!!

MEDICAL HISTORY
Well controlled insulin-dependent diabetic
Hypertensive on medication (enalapril 20 mg daily)
Obese
Smokes(20 cigarettes/day)
Social drinker

1.What would you do immediately

A) Shout and arousal
B) Call for help
C) Check if he is conscious
D) A and C

2.Which of the following are causes for sudden loss of consciousness??

A) Vasovagal attack(faint)
B) Hypoglycemia
C)Cardiac arrest
D) Steroid crisis
E) All of the above

3.Following are premonitory symptoms of vasovagal attack except

A) cold clammy skin
B)Pallor
C)Initially bradycardia and low pulse volume followed by tachycardia and
a full pulse
D)Slow recovery on placing supine or slightly head down(max. inclination
is 10o)
4. Signs of cardiac arrest includes
A) Absence of central pulse
B)Chest pain radiating to neck arm and jaws
C)Unconscious
D)Absence of breathing or abnormal breathing pattern(infrequent noisy
gasps)
E)All of the above

5.Risk factors for cardiac arrest includes

A) History of angina
B) Coronary arterial disease
C) Diabetes
D) Hypertension
E) High alcohol intake
F) All of the above

6.Techniques included in Advanced Life Support(ALS) are

A) ECG assessment
B) Defibrillation
C)The administration of drugs
D)All of the above

7.Dentures should be removed during BLS

A) True
B) False

8.How long should you continue to provide BLS?

Continue with BLS until the victim shows signs of life or until the team
gets physically exhausted and is unable to carry on the support.

ANSWERS
1) D
2) E
3) D
4) E
5) F
6) D
7) B dentures are removed only if they are loose or broken. Well-fitting
dentures usually facilitate a good oral seal during expired air(mouth -
to -mouth)ventilation
 Some useful points
1. Aim of basic life support is to protect the brain from irreversible hypoxic
damage.
2. Irreversible hypoxic damage develops within 3-4 minutes of cardiac
arrest in a previously healthy and well-oxygenated individual.
3. BLS delays the rate of deterioration of cerebral function and maximizes
the chances of ALS being successful.
4. Effective BLS should be followed by prompt ALS and hospital admission
which greatly increases the chance of survival.
5. Most common cause of failure or difficulty with BLS is airway obstruction
due to fall back of the relaxed tongue. It is overcome by measures that pull
the tongue forward such as head tilt (neck lift),chin lift and jaw thrust. Blood
vomit or foreign materials (including poorly fitting or broken dentures) may
also obstruct the airway.
6. Even with prompt ALS support from a specialized team the chance of
death are greater than 50%
7. If both ALS and BLS are delayed less than 2% of patients will live.

The current 2005 Resuscitation Council

guidelines for the management of respiratory and/or cardiac
arrest in an adult are:
1. Check the area for danger to yourself and victim
2. Assess responsiveness by shaking shoulders and
shouting
3. Shout for help (do not call 999 yet)
4. Open the airway (tilt head and lift chin or jaw thrust)
5. Check mouth for vomit / debris and remove with finger
scoops
6. Assess breathing – listen and feel for breathing while
observing chest movements. Take no more than 10
seconds
7. If breathing is abnormal (infrequent noisy gasps) or
absent, call emergency service on 999. You may have to
leave the victim to do this
8. Perform 30 chest compressions of 4–5cm each over the
centre of the sternum at 100 per minute
9. Give 2 ventilations
10. Continue compressions (30) and ventilations (2) until
help arrives, the victim shows signs of life or until you
are physically exhausted and unable to carry on.
Dry socket SBQ
What investigations would you carry out?

What is a dry socket?

Infection
Pieces of extracted teeth
Dislodged clot due to granulation tissue
Dislodged clot due clotting factor deficiency

How would you treat this patient?

Analgesics
Disinfection of socket
Local analgesia
Stabilization of clot
B,c,d

Which can not cause dry socket?

Surgical or traumatic extraction

Mandibular extraction, especially third molar
Female patient, especially if on contraceptive medication
Patient who smokes
Infection or recent infection at site
Periodontal disease or acute necrotizing ulcerative gingivitis elsewhere in the mouth
Local bone disease or sclerosis reducing blood supply for clot formation, as in
Paget’s disease, cemento-osseous dysplasia or after radiotherapy
Excessive use of local anaesthetic; vasoconstrictor in excess around the socket
may prevent formation of blood clot
History of previous dry socket
Young adult to middle-aged patient
None of the above

All of the following are cardinal signs of a localized osteitis (dry socket)

EXCEPT one. Which one is the EXCEPTION?

• throbbing pain (often radiating)

• bilateral lymphadenopathy
• fetid odor
• bad taste
• poorly healed extraction site

Immediate of dry socket treatment is

Avoid osteomyelitis
Control Pain
A 42-year-old man presents with pain following extraction of an upper
first molar. The patient is suffering dull throbbing pain in his upper jaw
and face on the left side only. Pressure below his eye is painful and all his
upper teeth on the left are tender on biting. He has a nasal discharge and
blocked nose on the left. The patient is heavy smoker ,otherwise he is healthy

Qs:.

1-Most likely cause of pain:

a.Osteomylitis
b.Dry socket
c.Sinusitis
d.Secondary metastsis
e.Fractured root fragment

2- Dry socket develops in around……..post extraction:

a. 10%
b. 30%
c. 40%
d. 5%
3- The followings are susceptible to develop this condition except:
a. Hypercementosed upper molars
b.Diabetic patients
c.Complicated extraction
d. Proximity of roots to maxillary sinus
e. Osteoporosis

4- The best radiograph which should be taken to reveal the propapble diagnosis:
a. SMV
b. Periapical
c. Bitewing
d. occlusal
e. Occiptomental

5- Management should be:

a. Immediate surgical closure
b. Antibiotics and nasal degcongestants
c. Referral to ENT surgeon
d.Excision of the fistula and surgical closure

CDEED
SUMMARY
A 38-year-old woman with mouth ulcers has noticed
a recent exacerbation in their severity. the patient complains of mouth ulcers which
have been troubling her recently ………
HISTORY OF COMPLAINT;;;;

Suffered form occasional mouth ulcers usually small one at time over period more
than 20 years old .recently they seem to have become wores and she now has several
(recurrent)

A***What are common causes of recurrent oral ulceration ::

1-recurrent aphthous stometitis
2-erythema multiform
3-occasional cases of traumatic ulceration
4- ulcer associated with gastrointestinal diseas
5- all of above
B***what it is the most important way to differtial form these condition in the point
A
1-histary
2-blood test
3-biopsy
4-all of above
EXAMNATION ,,,,,according to pic. What do u see ???

There is an obvious ulcer on the anterior buccal mucosa. It is

shallow, a few millimetres in diameter and has a slightly
irregular but well-defined margin. The surrounding mucosa
appears normal with only a narrow rim of erythema around
the ulcer. There is a temporary restoration in the upper right
first premolar and the ulcer would lie in approximately this
 ………
region at rest
now according to pic and history of patient what most likely digionsis
1- traumatic ulceration
2- RAS minor type
3- -erythema multiform
4- Non of above

the ulcer in this patient where most likely affected

1-keratinized mucosa
2- non keratinized mucosa

If u know the diameter of the ulcer are 3-5 mm which type can u expected
1- minor type
2-herpetiform type
3- major type ulcer

Frequacy of attacks of ulcer depended :

1-duration of ulcer
2-number of ulcer
3-severity of attacks

All type of ulcer preceded vesicles

1-true
2-false

The following should trigger a search for underlying predisposing causes :-

1-onset after the second decade
2-increas in ulcer size,duration,symptoms or severity
3-marked periulcer erythema
4-all of above
5- 1&3

TREATEMENT OF RAS ;-
1-non-prescription treatement :-reassurance is an important part of treatement
probably the best option for occasional ulcer and a simple advices may help to
make ulcer bearable avoid spicy foods or acidic fruit ect ,,,
2- prescription treatement include ;
A- anti-inflammatory (analgesic mouthwash)ex-benzdamine
B-anti-septic mouthwash ex-chlorhexidine
3-steroid ex-hydocotison .thalidomide
An 8 year old girl fractured her upper right permanent central
incisor. Two hours prior to presentation, she fell hitting her mouth at
school. One tooth appears to be broken. The child has asthma but
otherwise healthy. The mother of the child stated that the broken
tooth had not appeared normal and may have been decayed.

Extra orally there is swelling of the upper lip but no external abrasion or
laceration.

Intra orally gingival tissues labial to upper right permanent central incisor are
erythematous and swollen. Crown of the tooth appears to be missing and less
than 1mm of tooth visible above the level of gingiva.

d/d – intruded incisor or, crown has been fractured at the level of the gingiva.

IOPA confirms intrusive luxation.

1. What are the radiolucent areas on the crown of intruded tooth.

a. Caries
b. Internal resorption
c. Enamel hypoplasia
d. Artifact
 2. Intruded teeth with open apices have the potential to re erupt. In
case of failure to re erupt how long should you wait before surgical
intervention.
a. One week
b. Two weeks
c. Four weeks
d. Eight weeks

3. Following trauma to tooth, the next day there was no response to

pulp tests. you should
A. Review again later
B. Start endodontic treatment
C. Extraction of tooth

4. What is the main purpose of performing pulp test on a recently

traumatised tooth

a. Obtain baseline response

b. Obtain accurate indication about pulp vitality

5. What treatment should be rendered in this particular case.

a. Surgical repositioning followed by splinting
b. Orthodontic extrusion followed by endodontic treatment.

6. 8 years old child who has sustained a fracture of maxillary permanent

central incisor in which 2mm of the pulp is exposed, presents for
treatment three hours after injury. Which of the following should be
considered
A. Remove the surface 1-2 mm of pulp tissue and place calcium
hydroxide
B. Place calcium hydroxide directly on the exposed pulp
 C. Pulpotomy using formocresol
D. Pulpectomy and immediate root filling
E. Pulpectomy and apexification

7. A healthy 6 year old child presents with carious maxillary second primary
molar with a necrotic pulp. Which treatment would be preferred

a.Extraction

b.Indirect pulp treatment

c.Pulpotomy

d.Pulpectomy

e.Antibiotic coverage

8. A child has sustained a traumatic exposure of primary central incisor,

he presents to you for treatment two days after the injury. Which of
the following should be considered
a. Pulpotomy and Ca(OH)2
b. Pulpotomy and formocresol
c. Direct pulp capping
d. Pulpectomy (RCT)

Answers:

1. C
2. A
3. A
4. A
5. B
6. A
7. D
8. D
Case-22, Hypoglycemia
Case: A 55 year old man collapses in your dental surgery. What is
the cause and what would you do
MCQs:
1. Blood sugar levels are regulated by Insulin, its antagonist is
secreted by:
a) Alpha cells b) Beta cells
c) Delta Cells d) None of the above
2. Hypoglycemia can be precipitated by:
a) Insulin overdose b) Missing meals
c) Both a and b d) none
3. The diagnostic test done to monitor long standing cases of
Diabetes Mellitus is:
a) FBS b) RBS
c) HbA1C d) Asking the patient
4. If a person complains of confusion, sweating, tachycardia,
weakness, vertigo during the dental procedure, with a history of
D.M, you should suspect:
a)Hyperglycemia
b) Hypoglycemia
c) Diabetic Ketoacidosis
d) Ignore the symptoms and continue with your procedure
5. The first thing you should do, when you suspect a
hypoglycemic shock in an unconscious patient is:
a) Reassure the patient that this is temporary and the condition
will revert back
b) Cease the dental treatment and assess Vitals, Call 000
c) Quickly Give 20 grams Glucose orally
d) Call emergency services and start with CPR
e)To confirm diagnosis go for a Dip-stick test
6. The first sign of chronic Diabetes Mellitus is:
a)Nephropathy
b)Neuropathy
c)Retinopathy
d)All of the above
7. The patient becomes unconscious with cold clammy skin,
pallor, initial bradycardia and low volume pulse, the best
management would include
a) IV glucose stat
b)CPR
c) Supine position with slightly head down(10®)
d) Injection Hydrocortisone Stat I.V.
8. Management of hypoglycaemia included:
a) Injection 1mg glucagon i.m.
b) Inj. 20 IU Insulin I.M
c) Vigorously shaking the patient
d) 50 ml 50% Glucose I.V
e) 100 ml 20% glucose I.V
f) Restart with the treatment once the patient has recovered
A) a,b and f
B) a, c,d, and e
C) a,d,e
d) a,b, d, and e
9. The duration of action of Glucagon in blood is for:
a) 1 hour
a)1/2 hour
c)1/4 hour
d)1/8 hour
10. The main disadvantage of IV injection of 50% glucose is:
a) Its Thick consistency
b) Inability to cannulate
c) Its a Painful injection
d) May lead to thrombophlebitis
e) all of the above
11. A hypoglycaemic episode can precipitate in a NIDDM patient
(T/F)
12. Lignocaine is contraindicated in patients taking Sulfonylurea
(T/F)?
13. Adrenalin used as a vasoconstrictor in LA sensitises Cardiac
muscles to arrhythmias in an uncontrolled Diabetic patient. (T/F)
14. The rate of oxygen give to a hypoglycaemic patient is:
a)4L/min
b)5L/min
c)6L/min
d) 8L/min
15. Xerostomia precipitated in a Diabetic Patient can be attributed
to Polyuria. (T/F)
16. Oral Hypoglycemia can never be associated with Lichenoid
Reactions (T/F)
17. A very rare complication effect of Oral hypoglycaemia
includes:
a)Peripheral Neuropathy
b) Peripheral mononeuropathy in oro-pharangeal region
c) cataract
d) Polyarteritis
Case: 23

1. 78 year old female, lost a tooth spontaneously while eating. She has been taking
alendronate for osteoporosis for the last five years. No pain , no bleeding in the exposed
bone area. No pus discharging, no pocket depth exceeds 3 mm, no halitosis.

What is the diagnosis?

a..Alveolar Osteitis

b.Bisphosphonate related osteonecrosis

c.Osteopenia

d.Chronic osteomyelitis

2. 68 years old, female patient taking alendronate, for which disease from the following?

a.Osteoporosis
b.Osteopetrosis
c.osteomyelitis
d.osteopenia

3. Which of the following bisphosphonate has the highest potency for developing
osteonecrosis?
a.Etidronate
b.alendronate
c.Zoledronate
d.tildronate

4. What is the safe period after starting oral and intravenous bisphosphonates regimen?
a. 1 year and 6 months respectively
b. 3 years and 6 months respectively
c. 2 years and 4 months respectively
d. 1 year and 3 months respectively

5. What investigation would be most beneficial in making the decision of whether or not to
extract any teeth in this patient?
a.OPG
b.CTscan
c.MRI
d.serum CTX-1 level

6. The CTX concentration came 65pg/l , what do you do?

 a. Proceed without any worry
b. Consider drug holiday where the bisphosphonate is ceased temporarily
c. Permanent cessation of bisphosphonate after consulting patient’s GP
d. Refer to specialist

7.How long will it take to heal the bone after cessation of the bisphosphonate?

a.6-12 months

b. 12-24 months

c. 3-6 months

d.8 weeks

8.BRONJ is suspected if an area of exposed bone persist in a patient taking bisphosphonate for more
than:

a. 3 months

b. 2 months

c.6 months

d. one year

9.true or false:

Nitrogen containing bisphosphonates are more potent than non nitrogen containing
bisphosphonates.

10.which of the following can be prescribe as an alternative to bisphosphonate?

a. Risedronate

b.strontium ranalate

c.teraparatide

d. b or c.

11. Antibiotic prophylaxis is necessary in the treatment of osteonecrosis when-

a. Antibiotic prophylaxis is of no value in treating osteonecrosis

b. always use antibiotic prophylaxis as an adjunct when treating osteonecrosis

c. the patient is medically compromised, eg, diabetic patient or taking corticosteroid)

d. the bone is infected by oral flora

A 67-year-old lady is referred to your general dental practice complaining that
her denture has never ‘seemed right’ from the day it was fitted.

Case history
Complaint:

1. Small filling recently lost from one of the upper canine roots (root-treated) below her
overdenture

2. Dissatisfied primarily with her upper complete overdenture

3. Uncomfortable to wear for long, so removes in afternoon

History of complaint:

wore an acrylic upper partial denture successfully until 6 months ago

Provided with upper over dentures on two retained upper canine roots 3 months ago (due to
failure of treatments and consequently, loss of teeth)

Satisfied with fit and retention (no ovement while eating

Medical History

Myocardial infarction (low aspirin-75 mg/day)

Statin for raised serum cholesterol

Extra oral: slightly open lip posture at rest

Intra oral: slight redness of palate under denture bearing area, no BOP around canine

roots, denture clean without defects

From the patient’s history, what do you think could be the reason for the chief
complaint?

1. Poor adaptation- No (no problem of displacement during eating, speaking, facial

movements)
2. Over extended- No (same as above)
3. Teeth outside occlusion zone- No (same as above)
4. Occlusion discrepancies- MOST LIKELY (inability to tolerate, upper denture occluding
against lower natural teeth)

What features you will stress upon for denture review?

1. Check posterior border extension (correctly extended, not displaced on lateral

excursion)
2. Retention (stable and retentive)
3. Vertical dimension at occlusion
4. Vertical dimension at rest
5. Appearance

a. 1,3
b. 1,2,3
c. 2,4,5
d. 3,4
e. All

Rest vertical dimension with the upper prosthesis

removed. Vertical dimension with the upper overdenture in place
Which of the following method will you use to accurately measure VDO?

1. Dividers/calipers method – (accurate; measures lower facial ht. at rest and dentures in
occlusion; problem: markers fixed to skin, may move during muscle movement, fixed
support can alter freeway space)
2. Willis bite gauge method- (accurate; measures lower facial ht. at rest and dentures in
occlusion; fixed support can alter freeway space)
3. Closed speaking space method- (pt. adapts to both increase/decrease occlusal ht; adjunct )

What can be the diagnosis?

1. Error in retruded position – No (no history of pain on the ridge and eating)
2. Error in VDO
3. Denture related stomatitis- secondary finding but not the diagnosis (asymptomatic, not
noticed by patient usually)
4. Difficulty in adaptation- no (3 months sufficient time usually)
5. Problem with patient expectations- no (pt. did not mention anything about appearance-
based on pt. chief complaint)
6. Hypersensitivity to acrylic- no (inflammation of just denture bearing area not whole mouth)
7. Psychogenic reasons- no ( nothing in history)

What all findings support your diagnosis?

1. Open lip posture

2. Increased VDO
3. History of few hours of tolerance
4. Increased VDR
5. 1, 2 and 3

What is your primary concern for the patient while starting with treatment plan?

1. Re-restore canine roots- (replace to prevent caries)

2. Denture stomatits- (first, to improve support for new prosthesis)
3. Impression for new denture
4. Refer to oral pathologist
5. Send the patient home because you are too tired ;)
In case of associated erythamatous candidiasis, how will you manage?

1. Antifungal therapy
2. Denture hygiene
3. Ceasing night wear
4. Amphotericin 10 mg lozenges 4 times daily only if indicated
5. 2 only
6. 2,3 and 4
7. 1,2 and 4
 CASE 25
IMPACTED 3 MOLAR
COMPLAINT:
A 24-year-old gentleman is referred to you in your
oral surgery-orientated practice for a second opinion
on the need to remove his lower third molar teeth. Is
this the correct decision, and if it is, how should it be
achieved?
HISTORY- PATIENT HAS PREVIOUS TWO EPISODES OF
PERICORONITIS. The first was relatively mild but the
second, about 3 months ago, was associated with
inability to open the mouth and slight facial swelling and
required a course of oral antibiotics.
Q1. WHAT RADIOGRAPHS WILL YOU
NEED THE MOST TO ASSESS THE
IMPACTED TOOTH?
A.CBCT
B. PERIAPICAL
C. OPG
D. OCCLUSAL VIW

Q2.MANDIBULAR IMPACTED THIRD

MOLARS AFFECTS _____ % OF PEOPLE
AGED 20-30 YRS??
A. 25%
B. 40%
C. 65%
D. 75%
Q3. ON THE BASIS OF WINTER LINES
WHICH ONE TELLS ABOUT THE BONE
REMOVAL REQUIRED AROUND THE
CROWN
A. BLUE
B. GREEN
C. AMBER
D. WHITE
E. RED

Q4WHAT IS THE RISK FOR TEMPORARY N

PERMANENT DAMAGE TO LINGUAL N
INFERIOR ALVEOLAR NERVE AFTER
EXTRACTION?
A. 5%, 3%
B. 2%, 1%
C. 3%,0.5%
D. 2%, 0.5%

Q5MOST DIFFICULT IMPACTION IN

UPPER N LOWER ARCH ARE??
A. HORIZONTAL N MESIOANGULAR
B. VERTICAL N HORIZONTAL
C. MESIOANGULAR N DISTOANGULAR
D. MESIONGULAR N TORSOVERSION
Q6THE ANGLE OF IMPACTION IS
DECIDED ON THE BASIS OF WHICH
WINTERS LINE
A. WHITE
B. RED
C. AMBER
D. BLUE

Q7 WINTERS LINE ARE APPLIED TO

A. PERIAPICAL, BISECTING TECHNIQUE
B. PERIAPICAL.PARALLEL TECHNIQUE
C. LATERAL OBLIQUE
D. PANAROMIC TOMOGRAM
Q8.HOW WILL U CLASSIFY D GIVEN CASE
???

A. Class 1, position C, vertical

B. Class 1, position C, horizontal.
C. Class 2, position B, mesioangular.
D. Class 1, position B, mesioangular.
ANSWERS
1B
2D
3C
4D
5C
6A
7B
8C
 Odell case no. 28
A very painful mouth
A 20-year-old man presents
to you in your general dental
practice, feeling ill and with a
very sore mouth.
Intraorally there are a few
well defined and rounded
ulcers are on labial mucosa.
Cervical lymph nodes that
are slightly tender.

Case history
Complaint:
Patient complains of pain which is preventing eating and hampering drinking.

History of complaint:
1. He first noticed feeling unwell 4 days previously and thought he had
‘flu.
2. He was slightly feverish and developed a headache.
3. His mouth was sore but it was not until about 1 day later that it
became very painful.
 4. He has had no similar attacks before.

Medical history : pt is fit and well.

Extra oral: enlarged cervical lymph nodes that are slightly tender,
mobile but soft or firm rather than hard.

Intra oral: ulcers affect much of the oral mucosa, including the gingiva, palate
and tongue, and that they extend back into the oropharynx.

QUESTIONS:

1. Based upon pts' brief history and presentation, what is the

differential diagnosis?
I. primary herpetic gingivostomatitis
II. Apthous ulcer.
III. Erythema multiform
IV. Ulcer due to gastrointestinal diseases.
V. Fordyce’s granules.
a. i,ii,iii
b. i & iii
c. ii & iv
d. iv only
e. all of above

2. What is the difference between primary herpetic

gingivostomatitis and erythema multiform?
a. Site specificity
b. Characteristics of presentation.
 c. Patient’s history
d. Type of mucosa & periodicity.

3. Ulcer may be confined to gingiva in acute necrotizing ulcerative

gingivitis.
In this case ulceration is very extensive.
a. Both sentences are TRUE & RELATED.
b. Both sentences are TRUE & NOT RELATED.
c. Both sentences are NEITHER TRUE NOR RELATED.
d. Both sentences are FALSE BUT RELATED.

4. What investigation might you consider needed for this case?

a. Smear for light microscopy.
b. Biopsy
c. Swab for viral antigen
d. Viral antibody titre level.
e. All of above.

5. What is true about viral antibody titre level in following

sentences?
a. High titre of anti viral IgM indicates acute infection.
b. The test is very long and not used frequently.
c. Low stable titre of anti viral IgG indicates previous
infection.
d. A and c.

6. Which therapeutic agent is absolutely contraindicated in the

treatment of herpes simplex?
a. Vitamin c
b. Acetylsalicylic acid.
c. Antibiotics
d. Corticosteroids.
e. Local anesthetics.
7. What is the appropriate treatment for this clinical entity?
a. Rest
b. Sedative antihistamine
c. Proper fluid intake
d. Acyclovir 200mg 5times /day.
e. Chlorhexidine mouthwash.

I. A,b,c,d
II. A,c,d,e
III. A,b,c,e
IV. B,c,d,e.
V. All of above.

ANSWERS :-
1. B
2. D
3. B
4. E
5. D
6. D
7. III
case no. 31- occupational injury and prevention
History: While transferring the luxator to the table after use, you drop it on your foot
and it caused injury. Your injury is a deep injury by a sharp instrument covered with
blood and therefore there is a risk of transmission of HIV.

MCQs.

1. What would be the immediate measure after such sharp injury?

a. call emergency help and wait for the help to arrive
b. use potent antiseptics like ethyl alcohol directly on the injury that can kill most virus
including HIV
c. bleed the site and wash it with soap and water without scrubbing and no antiseptics
d. bleed the area and scrub thoroughly with soap and apply antiseptic solution

2. if patient's HIV status is unknown but high risk patient, what is recommended
protocol for administration of post exposure prophylaxis (anti-retroviral drugs)
following a sharp injury?
a. you may wait for 1-2 days till the HIV status of the patient becomes clear
b. Don't wait beyond 1 hour and take PEP
c. Don't take PEP till the HIV status of the patient becomes clear, as antiretroviral drugs
have major side effects
d. take immediately PEP for all cases, as you cannot rely on laboratory testing

3. What is the risk of developing HIV infection following a sharps injury?

a.50 in 1000
b. 20 in 1000
c. 1 in 1000
d. 3 in 1000

4. following a needle stick injury from HIV patient,

a. doctor should obtain PEP immediately
b. PEP is mostly Unnecessary
c. Formal assessment of HIV risk of patient is necessary to consider PEP
d. apply ethyl alcohol and do nothing

5. chances of transmission of HIV is highest when

a. patient is symptomatic
b. patient saliva is tested HIV positive
c. early infection stage of HIV
d. patient is from African countries where HIV rate is highest

6. in which circumstances use of PEP is not indicated

a. unknown HIV status of the patient
b. if the doctor is pregnant, she should not take PEP due to high side effects
c. when patient is tested HIV negative but he's homosexual
d. patient is recently infected and still asymptomatic

7. What is the risk of transmission of hepatitis B by this injury?

a. higher than HIV even in immunized individuals
b. very low if individual is immunized
c. high if antibody titre is 100mlU/ml
d. high only if at least 2 ml blood is transferred

8. what should be done if patient is HBc positive?

a. take PEP against HBc if risk is high
b. consider PEP only if patient is acute HBc positive
c. HBc is non infective so no risk at all
d. PEP is not available against HBc so treat acute infection if it occurs

9.which of the following is true regarding hepatitis B infection?

a. All types of hepatitis B antigens have similar infectivity
b. HBe antigen is having higher transmission rates than HBs
c. HBs antigen has higher transmission rate than HBe
d. Risk is highest in HBc positive individuals

answers:
1- c
2- b
3-d
4-b
5-a
6-c
7-b
8-d
9-b
previous MCQS from exam papers
45. A patient with no positive history came along for scaling. The moment you
pick
up the scaler you punch your finger, what should you do?
A. Complete the procedure as nothing has happened
B. Check patient’s blood for Hepatitis B antibody HBsAb
C. Check patient’s blood for Hepatitis B antigen HBsAg
D. Check dentist’s blood for Hepatitis B antibody HBsAb and HIV antigen HIVAg
E. Check dentist’s blood for Hepatitis B antigen HBsAg and HIV antibody HIVAb
F. Dentist should go and take a HBsAb vaccine

25. Which of the following is TRUE in regard to high risk patient?

A. 0.1ml of blood from Hepatitis B carrier is less infective than 0.1ml of blood from HIV
patient
B. 0.1ml of blood from Hepatitis B carrier is more infective than 0.1ml of blood from HIV
patient
C. Level of virus are similar in the blood and saliva of HIV patient
D. Level of virus in the saliva is not significant for Hepatitis B patient
E. The presence of Hepatitis B core Antigen in the blood means that active disease is not
present
39. In regard to HIV infection, which of the following is the earliest finding?
A. Kaposi sarcoma on the palate
B. Reduced haemoglobin
C. Infection with pneumocystic carinii
D. Reduction in white cells count
E. B cell lymphoma

42. Which one of the following is true about oral hairy leukoplakia?
A. Associated with HIV virus infection and is commonly seen on the dorsal of the tongue
B. Associated with HIV virus infection and is commonly seen on the lateral side of the
tongue
C. Usually caused by Candida species
D. Always associated with trauma to the lateral side of the tongue
E. Always associated with pernicious anaemia

612. What is INCORRECT in HIV associated periodontitis:**

A. Picture of ANUG superimposed with RPP
B. Spontaneous bleeding interproximal
C. Depression of T4/T8 lymphocytes
D. Deep Perio-pockets usually seen in advanced periodontitis
1043. Which of the following IS NOT RECOGNISED on HIV patients:
A. Squamous cell carcinoma
B. HIV gingivitis
C. Osteosarcoma
D. External lymphoma
E. Kaposi sarcoma
1044. The MOST primary treatment of ANUG in HIV patient is:
A. Prescribe antibiotics
B. Debridement and antimicrobial rinses
C. Gingivoplasty
D. Flap surgery
11. the initial therapy in HIV patients is,
A. Debridement and antimicrobial mouth rinses
B. Root planing and surgical approach

840. Which of the following does not carry a risk of infection from hepatitis B
patient:
A. HBs Ag antigens
B. HBs Ag
C. HBe Ag

443. What is to be done with instruments after surgically treating a patient with
confirmed diagnosis of hepatitis B,**
A. Soak them in hypochlorite solution “Milton”
B. Sterilize, scrub and sterilize
C. Handle them with two pairs of household rubber gloves
D. Scrub them with iodine surgical solution

answers- refer 1000 mcq key

Case number 33:- First Permanent Molars.

A seven year old girl and her mother attend your practice.

P/C-

Mother reports that the child suffers intermittent spontaneous discomforts from upper left tooth.

History of complaint-

Vague symptoms. Patient had complained of pain 3 or four times over last month. No history of
sleepless nights or swellings. No relevant medical history.

Dental history-

Regular patient since 3 year of age. Restorations in first primary molars. New carious lesions at each
recall visit, despite intensive preventive advice and diet analysis.

O/E-

Child points to sound upper left primary canine on being asked about the source of pain. 6.4 ditched
amalgam restoration on the palatal aspect. 6.5 Sound amalgam restoration possible caries in an
occlusive pit. 2.6 Erupting eighth colossal surface not fully though mucosa. A small occlusal cavity in the
confluence of the mesial fissures. Plaque or food debris in the fissures.

MCQs

1. Features suggesting necrotic pulp

a. Extension of caries or fracture into the pulp
b. Poorly localized pain
c. Pus from gingival margin or a sinus
d. A and C
e. All of the above
2. Ligkely diagnosis based on the information so far obtained
a. Pulp necrosis
b. Reversible pulpitis
c. Irreverible pulpitis
3. Preferred further investigations
1. Vitality test
2. Bite wing radiograph
3. IOPA
 4. OPG
a. 1,2,3
b. 2,3
c. 1,4
d. All of the above
4. Occult or hidden caries
a. More prevalent before wide spread use of fluorides
b. More prevalent after wide spread use of fluorides
c. Radiographs are required for the diagnosis of the lesion
d. B and c
5. Use of fluoride toothpaste or fluorides
a. Makes enamel resistant to smooth surface caries
b. Has major effect in the prevention of progression dentine caries
c. Very effective against fissure caries
6. Based on the radio graph what further investigation would you carry out
a. Blood test
b. Lateral ceph
c. Cavity preparation test
d. Radio isotopes scan
7. On opening the cavity the underlying coronal denting has been almost completely destroyed by
caries. Why did the child not experienced severe symptoms of irreversible pulpitis
a. Multirooted teeth
b. Poor blood supply to the teeth
c. Closed apices
8. Your treatment of choice
a. RCT
b. Apexification
c. Apexogenesis
d. Extraction
9. Which specialist opinion will you require for this case
a. Pedodontist
b. Orthodontist
c. Oral surgeon
d. None
10. Space closure after permanent first molar extraction
1. More by mesial movement of posterior teeth
2. More by distal movement of anterior teeth and thereby correction of crowding
3. Rapidly in lower arch
4. Is frequently incomplete in the lower arch unless much of the space can be occupied by
distal movement of a crowded second pre molar
a. 1,2,3
b. 1,4
 c. 2,3,4
d. 2,3
11. Ideal time for extraction first permanent molar
a. Stage of dental development rather than chronological age is important
b. Crucial factor is the stage of development of second molar
c. Permanent second molar should have crown formation and mineralization of 1/3 of the root
completed
d. Appearance of inter radicular crescent of bone in the second molar
e. Approximate age of 9.5 years
f. All the above

Answers:-

1. D
2. B
3. B
4. D
5. A
6. C
7. A
8. D
9. B
10. B
11. F
 Sample Odell Case 34: A sore mouth
A 55-year-old gentleman presents to you in general practice complaining of an
extremely sore mouth and the recent appearance of white patches on his cheeks.
He thinks he may be allergic to his dentures. The patient was fitted with a new set
of complete dentures 3 weeks ago and since then his mouth has become
progressively more sore. In recent days he has noticed the appearance of white
patches on his cheeks. He had not noticed these before. One year ago the patient
was diagnosed as a noninsulin-dependent diabetic and he has a history of peptic
ulceration. Current medications are “metformin” and “ranitidine”. He is otherwise
fit and well.

***The patient’s right and left buccal mucosa on presentation.

Q1. According to history and clinical presentation, the lesion might be:
a. Candidal Leukoplakia
b. Erosive lichen planus
c. Lupus erythematosus
d. Lichenoid drug reaction

Q.2. In this case which of the following will be useful for diagnosis?
a. Incisional biopsy
b. Microbiological test
c. Serological test
d. None of the above
e. All of the above
Q.3. Adequate biopsy should include all of the following, Except:
a. Margins of suspicious areas
b. Sloughs and necrotic areas
c. Margins from normal tissue
d. Extension of 2-4mm deep in the lesion with vertical edges.

Q.4. Which of the following is Untrue about oral lichen planus?

a. Commonly occurs on the buccal mucosa
b. May be symptomatic
c. Wickham’s striae disappears on stretching
d. Risk of malignant transformation
e. Commonly affects children and young age
f. B and D
g. C and E

Q.5. The following is untrue about Lupus Erythematosus, Except:

a. Discoid type may affect organs other than skin and oral mucosa
b. Acute SLE oral lesions oftenly responds to topical corticosteroids
c. Both DLE and SLE serologic test shows positive Antinuclear Antibodies
and Anti-DNA antibodies
d. Oral lesions of SLE are similar to those of DLE

Q.6. Which statement/s not true:

a. Gingival lichen planus is the most difficult to treat
b. Liquifactive degeneration of basal cell layer is a demarcation in lupus and
not in lichen
c. T-cell lymphocytes shows predominant infiltration at epithelio-
mesenchymal junction of lichen
d. Betamethasone diporopionate (0.05%) topical ointment used until
symptoms resolves.
e. A and C
f. B and D

Q.7. Malignant transformation rate of oral lichen planus is:

a. 1 – 4 %
b. 20 – 25 %
c. 50 – 70 %
Q.8. Lichenoid drug reaction could be caused by Except:
a. Beta-blockers
b. NSAIDs
c. Paracetamols
d. Amalgam restorations
e. Oral hypoglycemic

Q.9. “Oral lesions’ onset and nature” of lichenoid drug reaction does not
differ from that of lichen planus.
● T/F

Q.10. Denture wearers should always be suspected for elevated salivary

candida count.
● T/F

Q.11. Proper ttt for this case is:

a. Stop, reduce the dose of the drug or change it if possible
b. Change denture material
c. Corticosteroid therapy according to lesion extent plus antiseptic mouth rinse
d. Nystatin topically or Amphotericine lozenges 4/day
e. A,C and D
f. B,C and D
g. C and D only

Q.12. Patient should expect a quick resolve of the lesions and symptoms.
● T/F

蜉
 ANSWERS

1. D
2. E
3. B
4. E
5. D
6. F topical steroids not to be used continuously more than 3 weeks
without specialist advice (TG pg 75)
7. A
8. C
9. FALSE
10. TRUE
11. E
12. FALSE

REFERENCES:
1. THERAPEUTIC GUIDELINE 2012
2. CAWSON- ESSENTIALS OF ORAL PATHOLOGY AND
ORAL MEDECINE – 8TH ED.
3. REGEZI- CLINICAL PATHOLOGIC CORRELATIONS-
4TH ED.
4. ODELL- CLINICAL PROBLEM SOLVING- 3RD ED.
5. PUB-MED

THANK YOU

蜉
Case 35.A failed bridge

40 yr old,upper left missing incisor replaced by spring cantilever which decemnted 1st time 2
yrs ago n then again yesterday.it was lost due to bicycle trauma when he was 16.left lat incisor
congenitally absent n abutment is 1st n 2nd premolar.first premolar root treated wd post

1.select which are most appropriate treatment option?

a.a new spring cantilever

b.an adgessive bridge

c.a single tooth implant

d.spoon denture

e every denture

2.parts of implant

1.fixure

2.abutment

3.crown

4.key

5.pontic

6.retainer

a.1,4,3 b.1,2,3 c:1,5,2 d:4,5,6

3.which radiograph technique most useful fr recording bone height n width

a.opg b.periapical c.mri d.bitewing

4.what is the minimum height n width of bone required to place implant.

a.6mm n 4mm b.15mm n 6mm c.10mm n 4mm d.10mm n 6mm

5.ideal time for osseointegration

a 3-6 months b 3-9months c.1-2 months d.place immediately no waiting period

6.signs of failure of implant.select which are

1.mobilty

2.no periapical radiolucency

3 peri implant radiolucency

4 bone loss less than .2mm per yr

5.bone loss more than .2mm per yr

7.most suitable material fr implant

a cobalt chromium

b.titanium

c.hydroxyappatite

d.gold

8.surface of implant before placment should b smooth or rough?

Case 36

Skateboarding accident

6 yr old boy in mixed dentition stage complains of front loose teeth.he has abrasions on nose,
upper lip,petechial brusing on left side neck n bruising on right inner ear.upper labial frenum
torn n upper left central incisor lat displaced.

child is anxious n reluctant in answering any ques

theres delay in seeking dental treatment

1.what investigations are taken

a.periapical view

b.opg ( a)

c.mri

d.visual examination only

Diagnosis shows that upper right primary incisor is sublaxated while left central incisor is lat
laxated.permanent incisors are distant frn primary tooth

2.treatment options

a.extraction of left primary incisor n splinting of right central incisor

b.analgesics n oral hygiene instructions n follow up

c.splinting of teeth (b)

d.extraction of both teeth

3. Recommended analgesic

a.ibuprefen

b.codeine (c)

c.paracetamol suspension

d.ibuprefin plus paracetamol

The vague history,delay in dental treatment,child behaviour,marks on neck n ear are suggestive
of child abuse
4.why are neck n ear considered safe in accident

a.beacause they are strongly protected by fascia

b.they lie un triangle of safety *b)

c.pt cant fall on his neck

5.what else should the dentist do

a.do nothing only provide dental treatment

b.call child care department (c)

c.discuss the case wd senior collegue first n then make refreal

detal neglect is considered child abuse when

.repeated missed appointments

.failure to completevplanned treatment

.repeatedly returning in pain

.requiring ga fr extraction
 An Adverse Reaction
A 38-year-old lady becomes unwell during routine
dental treatment in your general dental practice.
What would you do? What is the cause?
Complaint
The patient is to have a crown preparation performed on
her lower second molar and a very small amalgam
placed in an upper premolar on the same side. You have
given an infiltration of 1.0 ml lidocaine (lignocaine) 2%
with adrenaline (epinephrine) 1:80 000 (12.5g/ml) and
used a further 2-ml cartridge to give an inferior dental
and lingual nerve block. Having finished injecting you
turn away to prepare some instruments.Almost
immediately the patient says she feels ill. She is clearly
apprehensive and is holding her chest complaining of
palpitations
A.which position will you make her lie
1.on her left 2.supine 3.upright
B.If no improvement what will u check
1.pallor 2.b.p and pulse 3.urticaria 4.all of the
above
C.What is the main reason for vasovagal attack?
D.What are the main signs and symptoms of
myocardial infarct ?

Important points
1.Intravascular injection is most common after
inferior dental blocks and posterior superior dental
blocks because of the high vascularity of the
injection site.
2.. Anxiety can itself produce a significant level of
adrenaline but levels rise more slowly and the
patient would have to be very nervous, positively
phobic, to generate endogenous adrenaline to the
levels found in intravascular injection of local
anaesthetic.
3.Thus, 2% lidocaine in a 2.2 ml cartridge is
equivalent to 44 mg of drug. With a maximum safe
dose of 4.4 mg/kg, a single cartridge could be
administered for every 10 kg of body weight. A 70
kg male would have a maximum safe dose of 7
cartridges and a 20 kg child a maximum safe dose
of 2 catridges..
4.Only a handful of cases of genuine lidocaine
(lignocaine) hypersensitivity are recorded. A
minority of older patients give a convincing history
of local anaesthetic allergy, in some cases backed
up by hospital investigations. This is because older
preparations contained preservatives such as
benzoates to which hypersensitivity was possible.
The worst offending preservatives are no longer
used, though very occasionally a reaction to
sodium metabisulphite preservative is recorded

5.Latex hypersensitivity is increasing in prevalence

and is commoner in atopic patients and those who
have come into contact with latex repeatedly, such
as health care workers, those with spina bifida or
those who are subjected to multiple surgical
procedures. Rubber dam, gloves and even traces
of rubber from local anaesthetic cartridges or drug
vials can trigger reactions. Other less obvious
items in the dental surgery which may contain
latex are face masks with elastic components,
amalgam carriers, plastic syringes, aspirator
tubes, orthodontic elastics and emergency
equipment such as ventilating bags and
sphygmomanometer cuffs. These usually cause
type 1 reactions such as urticaria, asthma or
anaphylactic shock

1.What are the alternatives for latex free gloves?

Neoprene and nitrile gloves
2.Fellypresin is similar to which hormone?
Oxytocin
3.Which is the longest acting LA?
Bupivacaine .That is why bupivacaine with
adrenaline is given to patients with trigeminal
neuralgia and patient gets relief for about 14 days
4.What dose of prilocaine will cause
methaemoglobinaemia?
More than 600mg.
1.)Aspiration is carried out prior to a local
anaesthetic injection in order to reduce the
A. toxicity of local anaesthetic.
B. toxicity of vasoconstrictor.
C. possibility of intravascular
administration.
D. possibility of paraesthesi
2)The use of aspirating syringes for the
administration of local anesthetics is
recommended because
1. the effectiveness of local anesthesia is
increased.
2. aspiration of blood is proof that the needle
is in an intravascular location.
3. their use removes the hazard of rapid
injection and provides a distinct saving of
time.
4. their use reduces the frequency of
accidental intravenous injection.
A. (1) and (2)
B. (1) and (3)
C. (2) and (4)
D. All of the above
4)A patient who is jaundiced because of liver disease
has an increased risk of
A. postextraction bleeding.
B. cardiac arrest.
C. postoperative infection.
D. anaphylactic shock.
E. pulmonary embolism
Ques : What is the most adverse reaction to lignocaine
1.drug interaction with the patient s medicine s
2.injecting into vein
3.hypersensitivity
4.toxicity

Ques : in case of injecting with lignocaine and procaine

what are the chances of nerve damage with procaine...
A.same b.less c.twice

Ques :
10) When using Articaine (versus Lignocaine) risk of
parasthesia during IAN block a. is increased by 5%b. is
increased by 100%c. is increased by 200%d. Same

Ques : Angioneurotic edema is mostly occurs with

which of the following local anasthetics?
Articaine
Lignocaine
Prilocaine
Mepivicaine
Bupvicaine

Ques : Question: Which local anaesthetic agent

contains both Ester & Amide groups in its chemical
structure ?
1. Articaine
2. Prilocaine ( articaine)
3. Tetracaine
4. Lignocaine
Case 43

BRIDGE DESIGN
A 28 years old patient comes to your dental surgery, her upper left 2nd premolar (25) is missing
which was extracted due to failed RCT 2 years ago. She wants to get the space filled and is visible
during speech. Her four first premolars were extracted for orthodontic treatment in her teens and the
spaces were closed successfully.
There is mesio-occlusal restoration in 26, 23 and 26 are vertically aligned due to orthodontic
treatment. The first molar and the incisor teeth are in Class I occlusion, with canine guidance in left
lateral excursion.

1. If the edentulous ridge was extensively resorbed what option would be feasible for restoration
a. RPD-flange useful
b. Elongate Pontic
c. Ridge augmentation
d. All of the above

2. Advantage of Conventional Bridge over Minimal Preparation Bridge

a. More expensive
b. Conservative of tooth tissue
c. Lifespan approaching 10 years
d. No coverage of the palate required

3. Average time required for Implant retained crown preparation

a. 7-9 months
b. 6-9 months
c. 10 months
d. 4-6 months

4. Minimum height (h) and width (w) of bone required to accommodate 4mm diameter implant is

a. 10 mm h, 6 mm w
b. 15mm h, 7 mm w
c. 10mm h, 5 mm w
d. 15mm h, 4 mm w

5. Degree of vertical alignment of the potential abutment teeth is necessary

a. to eliminate undercut
b. allows bridge to be the made in lab.
c. A and B
d. none of the above

6. Abutment teeth that can affect a retentive bridge preparation

a. Extensively restored teeth
b. Insufficient crown length
c. post crowns
d. Recession
e. All of the above

7. Minimum 7mm mesiodistal space between the adjacent teeth and 7mm interocclusal space for
standard implants placement is needed? (True/False)

8.Which prosthesis is desirable for replacing missing teeth on both sides of the arch?
a. Fixed partial denture
b. RPD

9. In this case, patient desires a fixed prosthesis, what investigations would be necessary before
designing a bridge
a. OPG radiographs,
b. Vitality test of 23 and 26
c. Blood test
10. Which is an ideal conservative replacement for this Patient
a. conventional preparation bridge
b. Mucosa supported acrylic denture
c. minimal preparation bridge
d. Metal based tooth supported design

11. Patient has Class I occlusion, it essential to mount the study models with the use of facebow?
(True or false)

12. In the upper anterior region a simple cantilever design is more dependable than lower anterior
region because
a. Surface area of enamel on the incisors is insufficient
b. Surface area of enamel on the incisors is sufficient
c. Design is not dependent on the surface area of the enamel

13. For this patient simple cantilever design was chosen, using 26 as a retainer, which has a MO
restoration, how can the rigidity and bonding of this retainer be maximized?
a. Minimum 1 mm retainer thickness
b. Incorporating the cavity into the design
c. Not removing the restoration
d. Removing the existing restoration
d. a, b and c
e. a, b and d

14. Metal should be wrapped around the abutment tooth

a. close to the contact point
b. should not be wrapped
c. As far as possible from the contact point

15. The cantilever pontic should have maximal occlusogingival height to ensure a rigid prosthesis?
(True/False)
Ans.
1d 8b 15 True
2c 9b
3b 10 c
4a 11 False
5c 12 b
6e 13 e
7 True 14 c

 
ODELL CASE NUMBER 44 : scenario

60 year old man presents to you in your general dental practice requiring dental extraction. He is
taking oral anticoagulants. How will you deal with his extraction?

Additional information :

a. Broken down upper molar – tender on biting , patient points directly to the tooth and
requests extraction
b. Several episodes of pain on the above root filled and heavily restored and crowned tooth.
The crown has been lost
c. Medical history – rhematic fever as a child and cardiac valve damage, heart valve
replacement 7 years ago
d. Medication history – patient on 9mg warfarin and 2 tablets of co-amilofruse daily.
e. INR range of the patient – 3.5-4.5
f. INR checked ten days ago – 3.9

Section 1 questions :

1.INR measures which of the following :

a) Partial prothromboplastin time

b) Prothrombin time
c) Both a and b

2.Which clotting factors does warfarin interfere with

a. 3,7,9,10
b. 2,, 5, 9,10
c. 2,7,9,10
d. 2,5,11,12
e. 2,3,7,10

3.Is this patient at risk for infective endocarditis:

a. Probably, if the patient is under the care of an inexperienced dentist

b. Definitely, patients with prosthetic heart valve replacement are always at high risk
c. Not all, his surgery was performed 7 years ago and the window period of risk has ended
and he is under the care of a an experienced dental practitioner
d. None of the above, the risk of infective endocarditis does not apply to this patient.

4.If you were the dentist handling this case, which of the following investigations would you want
to do first:

a) Take a panoramic radiograph to check all the teeth of the patient

b) Testing the Vitality of this tooth only
c) Testing the vitality of this tooth, adjacent teeth in the arch
d) Take a periapical radiograph to find out the extent of caries, previous root filling status
and difficulty of extraction

5.In this case, is it important to gauge the difficulty of extraction prior to the procedure itself :

a) Yes, to assess if there s a risk of prolonged bleeding

b) No, all extractions are difficult and time required to do them is not an important factor
On the radiograph you see that the permanent molar is extensively carious, has silver point only
in one canal which extends beyond the root apex by 2mm and the over filled root lies very close
to the antrum. But there’s no apical radiolucency .The adjacent second premolar has also been
root treated though the root filing stops just at the anatomical apex. Though there’s a small apical
radiolucency associated with the second premolar root and coronal caries is also evident:

6.What would be your clinical diagnosis of this cases:

a) The pain is due to secondary caries and periapical periodontitis in relation to the second
premolar
b) The pain is due to the periapical periodontitis of the first permanent molar
c) Since there’s no apical radiolucency associated with the first molar tooth, it is definitely
not the cause of patient’s problem
d) The pain is referred pain from somewhere else in the arch
e) The pain is cardiogenic in nature

7.What would be your treatment in this case:

a) Do root canal treatment on the first premolar, and repeat root canal treatment on both
second premolar and first molar since all teeth can be saved.
b) Extract the first premolar , the second premolar and the first molar, since all the teeth
seem to be the cause of the problem and are non restorable
c) Extract the second premolar since it is the main cause of the problem and has associated
apical radiolucency
d) Extract the first permanent molar since the patient has directly pointed out to it as the
offending tooth and this tooth is the only tooth that seems non restorable in your clinical
judgement

8.What is the primary cause of complication in this case :

a) Infection
b) Anticoagulation
 c) History of hypertension
d) There’s no complication that can be anticipated at this stage to occur before, during or
after any dental intervention

9.Would you prescribe antibiotics for this patient :

a) Yes, most definitely

b) No, not all
c) Only if the patient requests an antibiotic

10.INR measured anytime before the extraction procedure holds valid as long as it was done
within the last 7 days of the procedure because the range of INR to be between 2.5-4.0 is very
important for extraction to proceed further :

a) Statement 1 is true but statement 2 is false

b) Statement 2 is true but statement 1 is false
c) Both the statements are true
d) Both the statements are false

11.You plan to extract the first molar as desired by the patient. You decide to get the patient’s
INR checked on the very day of the surgery, and found that it was 4.8. you would :

a) Go ahead as planned
b) Ask the patient to come again tomorrow and then will extract the tooth
c) Not extract the tooth, control the pain with analgesics temporarily and Refer the patient
back to his consulting GP

12.After a visit to his GP, the patient returns on the 6th day with clear go ahead from the GP for
the extraction. You plan the extraction for the next day and again check the INR which is 3.9
now. During the day of the surgery you would :

a. Administer antibiotic prophylaxis , if required

b. Ensure you have 4.8% tranxemic acid mouthwash
c. Extract the tooth, place a local hemostatic agent, place a suture and pack the socket with
a gauze filled with 4.8% tranxemic acid mouthwash
d. Instruct the patient to use the tranxemic acid mouthwash at home – 10 ml for 2min ,4
times a day for 5 days after the procedure
I. C&D
II. A&C
III. B,C,D
IV. A,B,C,D

Section 2: questions discussed in the group :

1.What is your management with a patient who is taking Warfarin and will be submitted to dental
treatment?
a) Cease the warfarin & do local measures
b) Maintain the warfarin routine & Local measures
c)Stop the warfarin for 3 days & apply local measures
d)Stop the warfarin permanently, that will take care of the bleeding

2.Patient on anti-coagulant therapy requires an extraction to be performed. Which of the

following is NOT true:**
.a. Post operative bleeding can be reduced somehow by using tranexemic acid
.b. Prothrombin values of at least 2.5 is required to perform extraction
.c. It takes at least 8 hours for heparin to take affects
. d. Heparin should be administered sub-cutaneous
3.Patient on anti-coagulant therapy requires an extraction to be performed.
Which of the following is NOT true:
A. Minor bleedings bleeding can be reduced somehow by using tranexamic acid
B. Prothrombin value above 2.5 is required to perform extraction
C. It takes up to 12 hours for Vitamin K reverse effects of warfarin
D. Heparin can be administered sub-cutaneous and acts rapidly
4.Regarding Warfarin drug interactions, all the following increase Warfarin action except:
A. Tetracyline
B. Metronidazole
C. NSAIDs
D. Carbamazepine
E. Azole Antifungals
5.Before performing surgery on a patient who is taking warfarin, which of the following should
be evaluated?
A. Bleeding time.
B. Clotting time.
C. Prothrombin time.
D. Coagulation time.
6.Patient with prosthetic heart valves, with INR value of 3.0; requires surgery, what is the your
management
A. Give Amoxicillin or Vancomycin and suture carefully
B. Stop warfarin, start heparin, carefully suture and give Amoxicillin or Vancomycin
C. Stop warfarin, carefully suture and give Amoxicillin or Vancomycin

7. Dental implants are CONTRAINDICATED in patients who

1. are over age 80.
2. have unrepaired cleft palates.
3. are taking anticoagulants.
4. have uncontrolled diabetes mellitus.
A. (1) (2) (3)
B. (1) and (3)
C. (2) and (4)
D. (4) only
E. All of the above

8.Regarding paracetamol drug interaction with Warfarin:

A. There's no drug interaction
B. Drug interaction may occur if paracetamol dose exceeds 2 g per day
C. Drug interaction may occur if paracetamol dose exceeds 3.5 g per day
D. Drug interaction may occur if paracetamol dose exceeds 3.5 g per week
9.What is the most probable danger if you stop warfarin in a patient suffering from Atrial
Fibrillation.
A. CVA,
B. MI,
C. thromboembolism of vessels
11. Which of the following would you NOT prescribe for a patient receiving Warfarin?
1. Acetylsalicylic acid.
2. Metronidazole.
3. Erythromycin.
4. Codeine.
A. (1) (2) (3)
B. (1) and (3)
C. (2) and (4)
D. (4) only
E. All of the above

Scenario 1 :- A patient aged 50, reports to your clinic for extraction of lower molar . He has
been on warfarin since 10 years now. You have to perform a minor oral surgery.
1. The most important factor to be considered before doing the extraction.
a. Administer antibiotics
b. Cease warfarin 24 hours before the procedure
c. Check pulse and blood pressure
d. Take a detailed medical history and consult the GP
2. Blood test for INR should be undertaken
a. 24 hours prior to the surgery
b. 48 hours prior to the surgery
c. 72 hours prior to the surgery
d. On the day of the surgery
3. If the INR is between 2 to4 ,
a. Proceed with the surgery alone
b. Proceed with surgery using antibiotics and tranexemic acid mouthwash
c. Proceed with surgery using tranexemic acid mouthwash (4.8%)
d. Refer to patient’s GP
4. INR values above 4.5 increase the risk of
a. Thromboembolism
b. Heammorhage
c. Stroke
d. All of the above
5. Action of warfarin is to
a. Increase the production of vitamin K in the body
b. Decrease the production of vitamin K in the body
c. No effect on vitamin K
Scenario 2: A 64-year-old patient who is receiving warfarin as part of the management of
his atrial fibrillation tells you that one of his lower right back teeth was restored three
years ago by a dentist who has since retired from your practice. The tooth is now
occasionally sensitive to hot and cold. The clinical notes confirm the history
and indicate that the tooth was restored using a resin composite material. (from ADC
handbook )
You obtain the attached periapical radiograph.

Q 1 In addition to testing the pulp vitality with either cold or an electric pulp tester, which of
the following clinical tests or procedures would be the most appropriate to assist in
making a diagnosis?
A Orthopantomogram
B Bite-wing radiograph
C Percussion
D Crack testing
E INR
Q 2 In case like this Class II composite restorations of posterior teeth are more likely to fail
due to recurrent caries if
A the material is placed in increments because of the risk of leakage between
the increments.
B a glass-ionomer lining is used because of the risk that the lining will leach out
over time.
C occlusal loads are applied to the marginal ridge due to flexure of the
material.
D the curing time is extended due to greater shrinkage of the material.
E the gingival margin is on dentine because bonding under these
conditions is unpredictable.
Q 3 Given the history and the radiographic evidence, would you expect the “sensitivity” to
hot and cold that the patient reports to be
A sharp, occurring once or twice per week and only with ice-cream and hot
coffee?
B sharp and relieved on removal of the hot or cold stimulus?
C dull and lingering for 1-2 minutes?
D always present but worse after a hot or cold stimulus?
E worse in the morning
Q 4 If you decided to extract the tooth and in planning for the procedure you find that that
the patient’s INR is 2.4, would you:
A Proceed with the extraction and provide appropriate post-operative
instructions.
B Proceed with the extraction and suggest that the patient stop theirwarfarin
for 3 days
C Suggest that the patient stop their warfarin and commence taking 125mg
aspirin before returning in 3 days to have the tooth removed.
D Consult the patient’s cardiologist to discuss stopping their warfarintreatment.
E Refer to patient to a consultant Oral and Maxillofacial Surgeon who is best
placed to manage complex surgical problems such as this.
Q 5 After removal of the 46, which of the following prosthodontic options would be most
appropriate?
A Immediate placement and immediate restoration with a dental implant.
B Replacement with an immediate removable partial denture.
C Replacement with a removable partial denture after the extraction site has
healed.
D Replacement with a fixed bridge.
E No replacement until the patient has had an opportunity to assess their
functional and aesthetic concerns

Answers to section 1 Answers to section 2

1. B 1 B
2. C 2 C
3 B 3 D
4 C 4 D
5 A 5 C
6 B 6 A
7 D 7 D
8 B 8 D
9 A 9 A
10. B 10 A
11. C
12 IV

Answers to scenario 1 Answers to scenario 2

1. D C
2. A E
3 C C
4 D A
5. B E
Case 47

1. Hx : 52 yr pt. pain since 8 monnths , on hot n cold , lasts fr a few secs , sharp . but now dull
n throbbing, on hot and cold , and lasts for hours , waking up since last 2-3 days , relieved a
bit by PCM . tooth is not tender to bite on.
Poor oral hygiene , multiple restorations , gingivitis around post teeth.
Lower elft first molar : pfm crown with defective margin n distal caries. Molar 2 has a disto
occlusal composite restor , poor occlusal contour , lasrge distal ledge . read p/a radio table
(findings)
2. What is ur diagnosis ? a. Rev pulpitis b. Irrever pulpitis c. Irreversible pulpitis with acute
periapical abscess (b)
3. Apices of lower molars lie close to : a. Buccal cortex b. Lingual cortex (b)
4. Tests of vitality measure pulp vitality ..true /false? (f)
5. False positive EPT : a. Multirooted teeth b. Poor contact between electrode n tooth c.
Advanced age d. High pain threshold (a)
6. What should be the emergency t/t in this case? (open n dress)
7. If there was no p/a r/lucency when u started doing rct , but after rct , and before obturation
, u see a r/lucency , what could be the reason ? (b)
a. It is a cyst that has developed recently
b. This is a granuloma which might have developed coz canals were left open
c. This is a cyst that could not be identified earlier
d. This is a granuloma that was present earlier but could not be identified
8. Apical contriction is located at ............... short of r/graphic apex (1.5-2 mm boucher , odell
1-2 mm)
9. Apical constriction is often visible on a p/a film ..t/f ? ( f)
 ODELL CASE NO – 50

A 15-year-old boy presents to you in general dental practice requesting closure of the spaces
between his upper front teeth. The patient does not wish to have gaps between his upper front
teeth. His permanent teeth erupted at a normal age with large spaces between them. The
primary predecessors had all been present and were exfoliated normally. None of the
permanent teeth has been extracted. The patient is fit and well. The patient’s mother had a
number of teeth missing. They had been replaced with a partial denture at an early age.

Study models taken at the presentation:

1. The tooth MOST often congenitally missing is the

A. mandibular first premolar
B. mandibular lateral incisor
C. maxillary third molar
D. maxillary lateral incisor
E. maxillary canine
2. If the treatment is going to be done, who should sign the consent?

A. parent/Guardian and Dentist

B. Parent/ Guardian only
C. Parent/Guardian and Child
D. Parent/Guardian, Child and Dentist
E. Child only

3. What other radiographs will be needed apart from OPG to determine the missing
teeth in this situation?

A. Peri apical only

B. Anterior maxillary occlusal

C. Cross sectional Maxillary occlusal

D. Lateral Maxillary occlusal

E. Anterior maxillary occlusal and Peri apical

4. What is the vertical angulation used for the lateral maxillary occlusal projection?

A. 0 degrees

B. +45

C. +60

D. +65

E. –55

5. Patient’s main concern is his appearance and he is happy to commit to long and
complex treatment: what is the best treatment option?

A. Space closure with composite restorations

B. Orthodontic space closure and reshaping canine and first premolar into lateral incisor and
canine respectively
C. Fixed bridge from 14 to 24

D. Create space for the lateral incisors by orthodontic treatment followed by provision of
lateral incisor with a prosthesis.

E. Reducing the spaces by fabricating Individual crowns which are wider.

6. What is the best treatment option to replace the lateral incisors?

A. Implant retained crown

B. Conventional fixed bridge from canine to canine

C. Minimum preparation cantilever bridge with Central Incisors

D. Minimum preparation cantilever bridge with Canines

E. Minimum preparation fixed-fixed bridge from Canine to canine.

ANSWERS:

1. C
2. C
3. B
4. C
5. D
6. E
Case 64

PAIN IN THE NECK-SIALOLITH

Pain during

Mealtimes

Area-

Angle of the jaw in submandibular region

How did it occur-

Started during a meal 4 months ago

Description of Pain –

Painful because of inflammation

INTERPRETATION

Mealtime Syndrome with classical signs of inflammation

Specific Questions

Ask for abnormality of salivary flow ,Foul Odour

EXAMINATION

Size-Small/Big
Lymphadenopathy –Absent

Swelling –Movable Firm and Tender

Intraoral Examination

Bimanual Palpation is important to stabilize the gland

Expression of saliva-Massaging the duct

Observe saliva -Clear/Cloudy

Possible Causes

INTRADUCTAL /EXTRADUCTAL

Sialolithiasis/mucous Plug/Stricture

Extraductal –Trauma /Pressure from Neoplasm

Intermittent swelling with wind instrument players force air back into the gland

Sjogren’s Syndrome

Drug Induced

INVESTIGATIONS

1. Plain Radiograph- True Occlusal/Lateral view of Upper Neck/Oblique Lateral /Panoramic for
submandibular

Cheek blown out for Parotid in PA view

More useful for Submandibular because 60-70% of calculi are radioopaque,less value in Parotid only 20-
40% calculi are Radioopaque

2. Sialogram-Done by injecting contrast media into the duct usually contain IODINE
Contraindicated in Iodine Hypersensitivity

3. Ultrasound-Noninvasive ,Quick

Shows gland Parenchyma and stones over 2mm

Not good for duct architecture

4. Computerised Tomography

Detecting small calculi, (Hard Tissue)10 times more sensitive than Plain radiograph not for assessing
fine detail of duct
 5. Magnetic Resonance Imaging
Excellent soft tissue contrast-Good for detecting Neoplasms

6. Radioisotope Scan

Indicates salivary gland activity not for detecting stones –XEROSTOMIA

7. Salivary Endoscopy

New technique Endoscopes 0.7-1.3mm diameter passed through ducts-DIRECT VISION

Where are Sialoliths most common –Submandibular Glands (Due to Tortuous course)

Treatment

Extracorpeal Lithotripsy –Ultrasonic Waves –Shatter the stone -used for 7mm –effective 1/3rd
Cases
Radiographically guided –Basket extraction-Balloon Catheter -10mm –stone should be mobile
75% cases
Endoscopy-Ultrafine Endoscopes-Time Consuming –Risk of perforating
Intraoral Surgery-95% success rate –Complication damage to Lingual Nerve

Complications

Fistula Formation
Frey’s Syndrome
Nerve Palsy-
Facial Nerve & Hypoglosslal nerve

MCQ’S

1. What is the appearance of duct on Sialogram-String Of Sausages or string of beads

2. Submandibular gland is a Serous Gland

3. Sialoliths are more common in Submandibular Gland

4. Ct scans are good to show gland parenchyma but MRI shows Calcifications TRUE /FALSE

5. Which nerve is not likely to be damaged during operation of gland

 Lingual Nerve
Hypoglossal Nerve
Facial Nerve
Vagus Nerve

Research on FACEBOOK FORUM

March 2005
16. Which is the LEAST likely to cause Xerostomia
A. Sjögren's syndrome
B. Emotional reaction
C. Antidepressant drugs
D. Submandibular sialolith

ADC 2001
Intermittent painful swelling in the submandibular region that increases atmealtime is indicative of
A. a ranula.
B. a blockage of Wharton's duct.
C. Ludwig's angina.
D. a blockage of Stensen's duct.
E. an epidemic parotitis.

A 25 yr old lady comes to your clinic, she complains of swelling of her face in the morning after meals.
She is in the police academy and had a fracture few years ago but there are no radiographic signs of
fracture.
a,What is ur diagnosis?
b,What radiographs would you suggest for this patient?
c,Give differential diagnosis for the swelling.

908. A patient states that for ALMOST a year now, she has had a rubbery, firm, painless nodule within
the substance of parotid gland. This MOST likely is:
A. Mucocele
B. Lymph node
C. Benign mixed tumour
D. Squamous cell carcinoma
E. Sialolith with encapsulations
 AN ENDODONTIC PROBLEM

SUMMARY A 60-year-old female patient has pain from a root-

treated tooth. What will you do?

Complaint-

1. Discomfort from a lower left back tooth.

2. RCT 2 years ago and pain on biting since then.
3. Fractured instrument in one of the root canal.
4. The filling was lost from the tooth about 4 months ago.

Examination –

1. Rct treated- 37
2. Large distal cavity with caries.
3. Exposed gutta purcha root filling in pulp chamber.
4. Tender to percussion
5. 38- large poorly contoured amalgam.

Ques1 : what are the reasons for the failure?

A. Fractured instrument
B. No apical seal
C. Loss of restoration (E)
 D. Microleakage
E. All of the above

Ques 2 : when should be the retreatment considered after loss of

coronal seal?

A. 2 weeks
B. 1 month
C. 2 month ( 3 months or more)
D. 3 months
E. Immediately

Ques 3: for what thing would you look in the radiograph?

A. Nature and quality of treatment.

B. Any missed root canal.
C. Estimated working length
D. Root morphology (E)
E. All of the above

Pre operative radiograph

Ques 4 : What are the radiographic faults?

A. The film is placed too far anteriorly

B. Distal cone cut
 C. Tube head positioned too far anteriorly
D. Superimposition of mesial canals (c)
E. All of the above

Ques 5 : you will relocate the fractured instrument by taking a

radiograph with

A. Same vertical angulation

B. Different vertical angulation ( a and d)
C. Same horizontal angulation
D. Different horizontal angulation

Second radiograph

Ques 6 : what all instruments can fracture in a root canal?

A. Barbed broach
B. Stainless steel hand and rotary files (D)
C. Gates glidden drill
D. All
Ques 7 : how will you remove the instrument?

A. Ultrasonic scaler tip

B. Hedstrom file
C. Instrument removal system
D. Masseran kit (D)
E. Any of the above

Ques 8 : how easy the removal will be, depends on?

A. Location within root canal

B. Type of instrument
C. Width and length of fragment (e)
D. Anatomy of canal
E. All of the above

Ques 9 : what options are available if broken instrument cannot be

removed?

A. Obdurate wih the instrument in the canal

B. Re treatment
C. Resection or hemisection of that root
D. Peri radicular surgery (f)
E. Extraction
F. All

Post operative radiograph of the

completed RCT prior to final
restoration
Ques 10 : The instrument most easily broken in the root canal is a

A. barbed broach.

B. reamer. (A)

C. file.

D. rat tail file.

E. Hedstrom file.