Previous OSCE Stations Flashcards

Question

Pain History - SOCRATES - Write up notes - Give provisional diagnosis - Irreversible pulpitis

Answer 1

Introduce self & designation (1 mark) ● Ask about presenting complaint/reason for attendance (1 mark) ● Ask when pain began/how long pt has had pain (2 marks) ● Ask about changes over time (2 marks) ● Ask about site of pain (2 marks) ● Ask about character of pain now - offer prompt: aching/throbbing etc. (2 marks) ● Ask about stimulants - offer prompt: hot, cold etc. (2 marks) ● Ask about relieving factors - offer prompt: cold, analgesics etc. (2 marks) ● Ask about duration of pain - offer prompt: minutes, longer, constant etc. (2 marks) ● Ask if kept awake (2 marks) ● Provisional diagnosis: Irreversible pulpitis (4 marks) ● Note taking: legible, well ordered, complete (4 marks) ● Actor marks: clear communication, showed empathy (4 marks)

Answer 2

Back cap checked : Gripped and turned anti-clockwise ● Bur security checked : Suitable force applied to remove bur ● Tension applied to handpiece when fitted to coupling : Assesses if handpiece is attached safely ● Bur rotated laterally with fingers : Attempts to spin bur, rolls along finger ● Attempts to move bur laterally : Pushes bur from side to side a few times ● Handpiece sound tested when running : Runs for 5 secs or more, views bur movement

Answer 3

Explain nature of injury in simple terms ○ Enamel dentine pulp fracture or complicated pulp fracture ● Explain treatment : PULPOTOMY (open apex) ○ As this is a large exposure the tx of choice is called a pulpotomy ○ Explain partial removal of pulp ○ Explain that aim is to keep undamaged pulp tissue alive ○ Explain that this is so the tooth stays alive and continues to grow ● Baseline sensibility tests ○ Tests required to see how the nerve in the injured and adjacent teeth respond ○ Tests required as baseline reading for long term monitoring ● LA required ○ Parent informed that LA is required ○ Required to keep patient numb and comfortable ○ Describe that LA involves injection in the gum ● Dental Dam ○ What this is - rubber sheet over tooth acts like mask ○ Why dam is placed - moisture control, protects airway ● Drilling/use of handpiece ○ Drill will be used to remove some pulp tissue ○ Aim is to leave only good tissue ● Dressing ○ Indicate that the tooth will be dressed; Setting CaOH, MTA ● Composite restoration ○ Indicate that a white filling will be placed to regain aesthetics ● Actor marks: Describing tx in an understandable manner, supportive and empathetic regarding injury

Answer 4

Pt details correctly entered on to form ○ Sticker (CHI number, Hosp. Number, Name, Sex, Address, D.O.B) ○ + Hospital department, Date, Time, Consultant, Requested by, Phone no. ● Clinical details entered on to form ○ Pain, swelling etc ○ Other relevant information - MH: nil of note ○ Provisional diagnosis - dentoalveolar abscess ● Specimen details including site ○ Type of sample - pus aspirate ○ Details of site - buccal mucosa of 26 ● Investigation ○ Culture & sensitivity testing: bacterial/fungal ○ PRC and viral load: virus ○ Histopathology: tissue biopsies ● Wearing appropriate PPE when handling specimen ○ Examination gloves worn when handling specimen ● Removal of needle ○ Needle safely removed. (needle removed from syringe with sheath intact) ● Disposal of needle in yellow sharps bin ● Sealing syringe for transport ○ Red cap placed onto syringe hub ● LABEL SYRINGE with pt details & placed in plastic bag attached to request form ○ Fully labelled syringe in sealed bag with red hub cap in place & needle removed

Answer 5

Overview of marks: 1. Student listens and is empathetic 2. Asks patient what patient is expecting from appointment 3. Asks permission to continue findings 4. Break news slowly in chunks 5. Avoids jargon, or explains if used 6. Allows patient time to take in information and gives chance to ask questions 7. Repeats the news 8. Summarises what they’ve said 9. Gives patient information on plan moving forward 10. Actor asked if they understood, been shown empathy ● Setting: ○ Sitting down at same level as them ○ Did they bring someone with them? ○ How have they been since you last saw them? ● Perceptions: ○ What does the patient understand has happened up until now? ■ ‘Are you aware of what we’re here to discuss today?’ ■ ‘Do you know what the purpose of your biopsy was?’ ■ ‘Could you explain to me your understanding of things up till now?’ ● Information: ○ Inform patient that you have the results of the biopsy ○ Ask them if they would like you to go through them...they’ll say yes ● Knowledge ○ Give a warning shot ■ ‘I wish I had better news’ ■ ‘I’m afraid the news are not good’ …. pause for a bit ○ Give them the knowledge of what you know ■ ‘The test we have done has shown some abnormalities in the cells’ ...pause… ■ ‘Mrs Smith I’m afraid to say that you have mouth cancer’ ...then big pause… ○ Let it sink in and let them dictate the pace of the conversation from here ■ They might want to know loads of info really quickly or they might be in shock ■ Give them chance to ask questions ● Empathy: ○ Words to the effect of ■ ‘I am deeply sorry to break this to you’ ■ ‘I understand you must have lots and lots of questions...do you have anything that comes to mind?’ ■ ‘Perhaps you would like to bring your husband in with you?’ ● Summary and close: ○ Repeat news ○ Summarise what you’ve told them and the plan for going forward ■ ‘The good news in all of this is that we’ve acted quickly and will be able to move forward with treatment as soon as possible’ ■ ‘I’ll be speaking to the surgeons today and they’ll be seeing you in the coming week to discuss treatment’ ○ Offer them a follow-up appointment or phone number for any questions ○ Give written material if available

Answer 6

Ask for: otherwise you won't get it ○ PA radiograph (2 marks) ○ Sensibility testing (2 marks) EPT 35 & 36 respond positively PA radiograph shows periodontal/periapical pathology Swelling (2 marks) ● Pocket with pus (2 marks) ● Bone loss from radiograph (2 marks) ● Diagnosis - Periodontal abscess (2 marks) ● Treatment ○ Irrigate through pocket (2 marks) ○ Debridement (2 marks) ○ Hot salty mouthwash (2 marks) ● No antibiotics, since it’s a localised infection (2 marks) ● Actor marks: Empathy (1 mark), Communication (1 mark), Understanding (1 mark)

Answer 7

Reassure the patient ○ Fluoride varnish is placed on the tooth and is minimally invasive ○ Promotes remineralisation (hardening of tooth) and prevents demineralisation (softening of tooth) ○ It involves dry the teeth and painting a gel on to the tooth ● Contraindicated in: ○ Severe uncontrolled asthma (hospitalised in the last 12 months) ○ Allergy to colophony (sticking plasters) ■ We can use a colophony free version if needed ● Instructions afterwards ○ Don’t eat/drink for 1 hour ○ Soft diet for the rest of the day ■ No dark coloured foods ○ Avoid fluoride supplements today ● Fluoride toxicity: ○ Very small risk and technically relevant if small child consumes a quantity of toothpaste ○ 5mg/kg: milk ○ 5-15mg/kg: oral calcium gluconate, milk and possible referral ○ >15mg/kg: hospital referral for IV calcium gluconate

Answer 8

Accept and Monitor ● Intercept with a URA – procline uppers ○ notice pt’s age in scenario – this might not be possible ● Growth Modification: with functional appliance (reverse twin block) or (RME + protraction headgear) ○ notice pt’s age in scenario – this might not be possible ● Camouflage with fixed appliances ○ Accept underlying skeletal classification problem, move teeth with fixed ortho to hide it ■ procline uppers and retrocline lowers ■ Risks of ortho: decal, root resorption, relapse, gingival recession ○ Usually together with XLA U5s & L4s (most likely lowers to reduce necessary tipping) ● Orthognathic surgery with combined orthodontics ○ Surgical manipulation of the mandible and/or maxilla to produce optimal aesthetics/function ○ Multidisciplinary team – careful planning ■ Orthodontist, maxillofacial surgeon, clinical psychologist etc ○ Pre-surgical orthodontics – 12-18 months ■ arch alignment, arch coordination, de-compensation ○ Post-surgical orthodontics – 12 months ○ TOTAL TIME = 36 months

Answer 9

Correct choice of instruments - Kilner Needle Holders and Gillies Toothed Tissue Forceps (2 marks) ● Mount the needle 1/3 from end (2 marks) ● Correct grasp of needle holder (2 marks) - Hold the needle holders in your dominant hand by placing the thumb and ring finger into the rings and the index finger on the hinge of the blade ● Correct hold for tissue forceps (2 marks) - Hold in pen grip ● Atraumatic handling of flap of tissue with tissue forceps (2 marks) ● Insert the needle at right angles to the wound edge and perpendicular to the surface (2 marks) ● Insert the needle at appropriate distance from wound edge (~2-5mm) (2 marks) ● Pass the needle through flap and retrieve it with an instrument **not fingers** (2 marks) ● Remount needle correctly as above without use of fingers (2 marks) ● Take a full bite on 2nd side and retrieve it with an instrument – again, not fingers (2 marks) ○ Attempt to re-insert at the same depth in the opposite side of the wound and emerge out of the tissue the same distance from the wound edge as the insertion ● Demonstrate adequate pronation and supination of hand – you seriously get points for this… (2 marks) ● Needle secure during tying of knot (2 marks) ○ Needle placed to side and not flying around/ or thread gathered and needle held secured/ or needle clipped ● 1st throw – two turns, grasp suture at free end, approximate edges (2 marks) ● 2nd throw – one turn in opposite direction, grasp suture at free end and tighten (2 marks) ● 3rd throw – in opposite direction again (no extra marks) ● Cut suture to length suitable for wound site and material used (2 marks) ● Knot to side of the wound (2 marks) ● Final apposition of wound (2 marks) ○ Ensure wound ends close together but no tension on wound + secure knot ● Needle disposed of safely when finished – if not, clip it! (2 marks)

Answer 10

Chronic OAF, patients may complain of: ○ Fluids from nose ○ Speech and singing of nasal quality ○ Problems playing wind instruments ○ Problems smoking or using the straw ○ Bad taste/odour, halitosis, pus discharge ○ Pain/sinusitis type symptom ● ‘An OAC is an acute communication of maxillary air sinus with the oral cavity’ ● ‘In your case the communication hasn’t closed over and instead has healed by epithelialising forming a sinus and a permanent communication of the air sinus and the mouth’ ● ‘This is something we want to manage as it makes you more prone to developing sinus infections’ ● OAF Management ○ Excise sinus tract/fistula – removing epithelium ○ + buccal advancement flap ○ Antibiotics ■ Amoxicillin, 500mg, 7 days, send - 21 capsules, take 1 capsule 3 times daily ■ Doxycycline 100mg, 7 days, send - 8 capsules, take 1 capsule daily (take 2 on day 1) ○ Post-operative instructions: ■ Refrain from blowing nose or stifling a sneeze by pinching the nose ■ Steam or menthol inhalations ■ Avoid using a straw ■ Refrain from smoking

Answer 11

Reasoning: ○ Relines: when fitting surface inadequate but denture otherwise okay ■ Ie occlusal planes, OVD, profile are acceptable but fitting surface underextended, not supportive/stable or retentive ○ Rebase: when you want to keep occlusal surface, but change fitting and polished surface ● Method: ○ Check all the occlusal relationships are acceptable and appropriate ○ Remove undercuts from dentures fitting surface using acrylic bur ○ Adjust border for under/over extension with green stick ○ Apply adhesive to fitting surface of the denture to be refined ○ Insert impression material (light body PVS) into the fitting surface and seat the denture ○ Functional impression: ask the patient to bite together so the impression is taken in OVD ○ Take a lower impression with denture in situ (gold standard but may not be required) ○ Take a bite registration if OVD is not obvious ○ When set remove the impression and send the denture for reline ■ Please pour impression in 100% dental stone using denture impression provided. Please mount upper to cast and create a self cure PMMA reline to change the impression surface.

Answer 12

ntroduce self & designation (2 marks) ● Take history: ○ No. of days symptoms? (1 mark) ○ Does the child have a fever? (1 mark) ○ Child less active than normal? (1 mark) ○ Analgesia used? (1 mark) ○ Did it work? (1 mark) ■ PHG Signs: lymphadenopathy, malaise, pyrexia, erythematous gingivae, ulceration ■ PHG Symptoms: sore mouth and throat, fever, enlarged lymph nodes ● Diagnosis from photograph: ○ Primary herpetic gingivostomatitis - explanation in lay persons terms (2 marks) ○ Contagious primary infection caused by herpes simplex virus (1 mark) ○ Self limiting and will disappear in 7-10 days (1 mark) ○ High carriage rate in population, common (1 mark) ■ Most often occurs in young children and is usually the first exposure a child has to herpes virus (which is also responsible for cold sores & fever blisters) ○ Most initial infections are subclinical but can present as this florid infection (3 marks) ■ Explain in lay persons terms - usually no symptoms ■ Often will present with blisters on the tongue, cheeks, gums, lips & roof of the mouth. After the blisters pop, ulcers will form. ■ Other symptoms to watch out for are high fever, difficulty swallowing, drooling and swelling. ■ Also, because the sores make it difficult to eat & drink, dehydration can occur. ○ Child may or may not develop cold sores in future (1 mark) ● Management: ○ Push fluid intake (1 mark) ○ Analgesia to control fever/pain (2 marks) ○ Bed rest, take it easy (1 mark) ○ Clean teeth with damp cotton roll or cotton cloth to rub around gums (1 mark) ○ Can use dilute CHX to swab gums (1 mark) ○ As child has had problems for 3 days and is otherwise fit and healthy antiviral medication (Aciclovir) is not recommended is not recommended (2 marks) ● Actor marks: empathetic, supportive and understanding (2 marks) ● Prescription: (if necessary - ie severe or immunocompromised) - NB if under 2ys half dose (100mg): ○ Aciclovir 200mg tablets - 5 day regime, Send: 25 tablets, Label: take 1 tablet 5 times daily ● Refer immunocompromised patients to hospital

Answer 13

Pre-cementation checks ○ Is it the restoration as asked for? ○ Check on the cast ■ Rocking, M/D contact points, marginal integrity, aesthetics ■ Check contact points on adjacent teeth on cast to ensure not damaged ● Can be damaged when prepped tooth is sawn off the cast to invest ■ Occlusal interference on excursions ■ No natural teeth contacting (checked with shimstock 8μm) ■ Inadequate reduction DL cusp ○ Remove crown from cast ■ Check if the natural teeth occlude properly now ■ Check if tooth is under-prepped ■ Measure crown thickness using calipers ● Minimum 0.5mm circumferential ● Minimum 1.5mm for functional cusps (1.0mm for non-functional) ● Management ○ Check amount of interference by dropping incisal pin and calculate the difference ■ If do-able to reduce crown without making it too thin then adjust and cement, otherwise... ○ Re-do prep and send back to lab ■ Follow crown prep principles: Ideal taper 6o, retentive grooves/slots, bevel functional cusps, two plane buccal reduction, smooth prep margin at gingival margin ● Avoiding fault in future ○ Measure temp crown thickness before cementing ○ Use sectioned putty index when prepping

Answer 14

Take concerns seriously, answer questions as able: ○ ‘Hello there, what seems to be the problem?’ ○ ‘Can i offer some assistance?’ ● Acknowledge anger ‘I can see that you’re upset and I am sorry that you feel this way.’ ○ This does not accept blame. DO NOT ACCEPT BLAME ● Try to offer practical help: ○ Offer investigation with receptionist and provide feedback to the patient ○ If you can offer another appointment - ‘Do you still have time for us to see you?’ ○ ‘What would like to do, we can work around you?’ ● Making an apology: ○ Be honest ○ Acknowledge the offence ○ Explain how it happened ○ Express remorse: deep guilt, express it! (I am so sorry!) ○ Ensure amends: ‘Is there anything we can do?’ ● If formal complaint requested, advise on NHS complaints procedure ○ Then, if required: a local resolution (payout) ○ If satisfactory: complaint closed ○ If unsatisfactory: healthcare commission or health service ombudsman ● The NHS complaints procedure 1. Acknowledge the complaint and provide the patient with the practice complaint procedure. 2. Inform the dental defence organization if you require advice. 3. Inform the patient of timescales and stages involved. 4. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3 working days maximum but ideally within 24 hours. 5. Early Resolution 5 working days: For issues that are straightforward and easily resolved, requiring little or no investigation. 6. Investigation 20 working days: For issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’. 7. Independent External Review Ombudsman: For issues that have not been resolved.

Answer 15

Correct drug - Detailed action (detailed) - Description of emergency (signs/symptoms) ● Hypoglycaemia ○ Medication: Glucagon → increases the concentration of glucose in the blood by promoting gluconeogenesis and glycogenolysis to convert glycogen to glucose. ○ Type 1 Diabetic Hypoglycaemic coma – normal = 5-7mmol, unconscious <3mmol ○ Assess ABCDE ○ Signs: pale, shaky, sweaty, clammy, dizzy, hungry, confusion, blurred vision, loss of consciousness ■ they must mention loss of consciousness as it defines Tx: ○ If conscious and cooperative → administer oral glucose 10-20g or sugary drink ○ If unconscious/uncooperative → 1mg IM glucagon injection and oral glucose when regain consciousness. ○ After they regain consciousness (15 mins – 2nd dose if not) supply oral glucose/sugary drink as they would have depleted their glycogen stores - they will be unwilling to drink this... ○ IM injection and technique ■ Inject diluting solution in vial with glucagon powder ■ Swirl to mix - don’t shake (will foam up) ■ Syringe solution back into syringe ■ Use Z-track technique to inject into thigh or bicep ● Spread skin, advance needle in skin 90o, aspirate, inject 30s, pull out, release tension - thigh, hip, deltoid, buttock. ● Say ‘I would normally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time’ ○ Reassess ABCDE – assess effect of medication, more oral glucose required? ● Epilepsy ○ Medication: Midazolam → a short-acting benzodiazepine → enhances the effect of the neurotransmitter GABA on the GABA receptors resulting in neural inhibition ○ Signs: loss of consciousness, uncontrollable muscle spasms, drooling, tonic (falls rigid), clonic (sharp jerky movements), hypotension, hypoxia, loss of airway tone ○ Assess ABCDE ○ Do not try to restrain convulsive movements - ensure the patient is not at risk from injury. ○ Secure airway ○ Administration: ■ Administer 100% oxygen, 15L/min flow rate ■ If the fit is repeated or prolonged (>5min): give Midazolam 2ml oromucosal solution, 5mg/ml topically into buccal cavity (10mg) - repeat after 5 minutes if not worked ● Check expiry date and the form of midazolam is compatible with buccal administration, choose appropriate dosage of midazolam by age (different tubes of midazolam with different dosage available) ○ If subsided: recovery position and check airway ○ Refer to hospital if: first seizure, seizure is atypical, injury was caused or difficult to monitor patient

Answer 16

Tooth trial: Check denture extension, support, retention (trial denture will be looser than the actual one), stability, occlusion (balanced occlusion and articulation), speech, aesthetics (tooth mould, shade, gingivae position). Mark post dam on cast.

Answer 17

Problem list - Smoker + Alcohol + Acid Erosion/NCTSL + Perio disease + Impacted 8’s. ● Immediate ○ Pain (Pericoronitis? Toothache? Perio abscess? PAP?) ● Initial ○ HPT: ■ Diet advice: including erosion ■ Consider medical referral if GI intrinsic acid ■ Smoking cessation, alcohol advice ■ Supragingival scaling, RSD ○ Removal of non-symptomatic teeth of poor prognosis: Impacted 8’s ■ Inform of risks: pain, swelling, bleeding, bruising, infection, dry socket, IDN damage leading to numbness/altered sensation that can be temporary/permanent ○ NCTSL management ■ Find cause: Diet? Alcohol? Medications? MH? Habit? Parafunction? ● Tx: diet diary, study casts, photos, DBA, GI, composite ■ Fluoride – toothpaste, mouthwash ■ Dietary advice: change habits - don’t swill drink around mouth, use straws, watch ‘healthy eating’ acids (5-a-day), avoid sports gels/drinks - milk/water instead, chew gum, cheese ■ Desensitising agents – stannous fluoride, potassium nitrate - for symptomatic relief ○ Caries management ○ Endodontic treatment: temporary restorations ● Re-evaluation ○ Perio: 6-8 weeks post completion ○ NCTSL (pics, casts) ● Re-constructive ○ Filling spaces: Dentures, Bridgework, Implant? ● Maintenance ○ Perio, NCTSL

Answer 18

● Introduce yourself and ask the nurse if it is ok to sit down with you - ‘Do you have a minute to talk’ ● Facts: ○ Facts of the situation, what, when, where, how? ○ Ask the individual for their account of the situation ○ ‘Unfortunately, there were remarks said publicly and a talk about posting on social media. I was wondering if you knew anything about this?’ - allow the nurse to reply ○ ‘Is it ok if I hear your side of the story?’ ● Issues: ○ What is the issue here? ○ Explain the issue to the individual and why it is bad. ○ Quote GDC standards - i.e breach of confidentiality, brings profession into disrepute ○ ‘I know it may have been misjudged. But unfortunately, it is not acceptable to say things publicly about patients or post things on social media.’ ○ ‘As the GDC standards state, it is our obligation to have pt best interests and to protect their information. Speaking in the public can breach confidentiality. The patients are recognisable from the posts and this is not protecting them. For example, if it was someone speaking/posting about your family member, how would you feel?’ ○ ‘It is also not providing the public with confidence in you, us and the profession as a whole. The practice could be in question and the GDC could be informed of this in the future.’ ● Options: ○ If involves patient, what options are there to manage this event (short/medium/long term). ○ What is in the patient's best interest? ○ ‘There are a few options to rectify this:’ ■ ‘If there is a social media post – delete it and any photographs immediately’ ■ ‘Apologise to the patient’ if still around... ● If not, the practice can contact patient to ideally attend for a formal apology ● Now: ○ What issues do you need to deal with right now? ○ ‘Inform the nurse that this shouldn’t happen again.’ ● Ask/Advise: ○ Ask the individual if they would be willing to undertake training or education on this matter ■ ‘It would be acceptable if we had training on this in the future and have meetings about social media to increase awareness’ ■ ‘Would you be willing to have training on this?’ ○ If problem repeats: ■ Get advice from someone more senior (defence union, VT trainer) how to manage this. ● Record: document conversation 155. Recurrent Aphthous Stomatitis - Recurrent Minor Ulcers (6 mins)

Answer 19

Build-up and Diagnosis: ○ ‘Are you aware of what we’re here to discuss today?’ ○ ‘You were here a few weeks ago complaining of painful ulceration...etc and we took some bloods to see if we could identify what is causing your symptoms.’ ○ ‘Would you like for me to talk through our findings?’ ○ ‘Let me start by saying there is nothing sinister going on here…’ ○ ‘But your bloods showed that you have developed a type of anaemia called microcytic anaemia caused by an iron deficiency in your blood’ ● Description of disease: ○ ‘Iron deficiency anaemia is a condition where a lack of iron in the body leads to a reduction in the number of red blood cells.’ ○ ‘Iron is used to produce red blood cells, which help store and carry oxygen in the blood.’ ○ ‘If you have fewer red blood cells than is normal, your organs and tissues won't get as much oxygen as they usually would.’ ○ ‘Many people with iron deficiency anaemia only have a few symptoms.’ ○ ‘Most common symptoms are tiredness and lack of energy (lethargy), shortness of breath, noticeable heartbeats (heart palpitations) and a paler complexion’ ○ ‘In addition, In some cases, including yours, people develop minor ulceration in the mouth’ ● Aetiology: ○ ‘There are many things that can lead to a lack of iron in the body.’ ○ ‘Sometimes it can simply be explained by a lack of iron in the diet.’ ○ ‘However there are other common causes like heavy menstruation (if woman) or bleeding in the stomach and intestines which can be caused by a stomach ulcer or taking NSAIDs.’ (or stomach/bowel cancer but don’t say this) ● Management: ○ ‘Iron deficiency can easily be managed with iron supplements and an increase of iron in the diet.’ ○ ‘This would also resolve the minor ulceration in your mouth which tend to go away in 1-2 weeks without scarring.’ ○ ‘Your GP should be able to prescribe you iron supplements in tablets to be taken twice daily and might chose to investigate you further to determine if there is an underlying condition.’ ○ ‘My advice in the meantime is to try to increase the iron in your diet, avoid spicy foods like curries and if your mouth is very sore (can’t eat etc) I can prescribe a numbing m/w to allow you to be more comfortable’ ■ Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using 15ml every 1.5 hours as required ● Can be diluted 1:1 with water if stinging - Spit out after rinsing - not more >7 days ● Diet advice: ○ Dark-green leafy vegetables, such as watercress and curly kale, iron-fortified cereals or bread, brown rice, pulses and beans, nuts and seeds, meat, fish, tofu, eggs, dried fruit (prunes/raisins) ○ Vit C rich foods/drinks help body absorb Fe ○ Tea, coffee and calcium (found in dairy products like milk) make it harder to absorb iron ■ Only in large quantities ● Summary ○ Reassure patient - common condition ○ Ulcers go away in up to 2 weeks without scarring ○ We know what the cause is and we can manage it ○ Any questions? ● Actor marks communication and simple language

Answer 20

Causes of retained ULA/Unerupted 21 ○ Trauma to A - causing damage to the 1 ■ Complications: Ankylosis, arrested tooth (21) formation, dilaceration, displacement ○ Lack of permanent successor/Hypodontia ○ Ectopic tooth germ ○ Crowding ○ Supernumerary: tuberculate most common ● Signs: ○ Discolouration of A, retained A ○ Radiographic ○ Lateral erupted before central ● Investigations: ○ Radiographic localisation for ortho treatment ■ Another PA or anterior occlusal, or alternatively OPT and occlusal, CBCT for 3D view ● Management: ○ Always palpate: usually U1 is buccal and central (high) ○ Options: ■ Leave and monitor - inform of possible cyst or resorption ■ Extract retained A (leave U1) and space maintenance (warn of cyst formation risk) ■ Surgical removal of both teeth and space maintenance ■ Refer for orthodontic opinion/Tx - Inform of possible ortho tx benefits/risks ■ Auto-transplantation ○ Other options: ■ Extract retained A and hope spontaneous eruption (very unlikely since dilacerated) ■ Expose (closed or open) +/- bonding/traction (won’t work if dilacerated)

Answer 21

Brief history: ○ Take pain history ■ How long for? Any analgesia (calpol)? How much analgesia? - within limits ○ Feeding bottle to bed? ○ What is in the feeding bottle? ● Look at pics carefully to identify pattern of decay ○ Pattern is usually upper incisors, D’s and lower canines (lower incisors protected by tongue) ● Advice: ○ Feeder cup replacing bottle from 6 months ○ No feeding at night (lactose in milk - decreased salivary flow and held in mouth) ○ No on-demand breastfeeding ○ No sweetened milk, soy milk (unless medically advised) ○ Milk and water only between mealtimes ○ Sugarfree variations of drinks/foods/medicine (e.g. sugar-free calpol) ○ Safe snacks include, cheese, breadsticks, fruit, plain crisps ○ Toothbrushing: ■ Assist the child until 7yo ■ Brush in the morning and last thing at night ■ No food/ drink except water after brushing ■ Spit don't rinse ● Management: ○ Extraction of carious teeth under GA: as in pain (discuss GA risk and benefit) ○ GIC remaining teeth and review: if no pain (acclimatisation) ○ Fluoride (supplements + varnish) ● Extra points for empathy

Answer 22

Process ○ Discussion of GA risks/benefits and all other alternative options ○ Referral to hospital for specialist to assess - if any other teeth of poor prognosis they will be added to this plan to avoid future GA ○ GA will involve day in hospital - need to monitor for full recovery ○ Need of chaperone throughout. ● Risks ○ Very common minor risks: ■ Headache, nausea, vomiting, drowsiness ■ Sore throat or sore nose/nose bleed from intubation ○ Risks from treatment: ■ Pain, bleeding, swelling, bruising, infection, loss of space, stitches ○ Rare major risks: ■ Brain damage ■ Death (say as follows): ● 3 in a million. Need a machine to breathe during op and there is a very small risk that you will not be able to breathe independently again on waking - ie never waking again. ○ Upset when coming round - can make underlying anxiety worse ○ Malignant hyperpyrexia (v. rare - important to ask for FH) ● Conditions requiring special care (can be contraindications) ○ Sickle cell disease (or any hypoxia) ○ Diabetes - can’t fast in same way ○ Down’s syndrome ○ Malignant hyperpyrexia ○ CF or Severe asthma ○ Bleeding disorders ○ Cardiac or Renal conditions ○ Epilepsy ○ Long QT syndrome ● Referral ○ 1. Patient name ○ 2. Patient address ○ 3. Patient/Parent contact numbers (landline and mobile) ○ 4. Patient medical history ○ 5. Patient GP details ○ 6. Parental responsibility ○ 7. Justification for GA ○ 8. Proposed treatment plan ○ 9. Previous treatment details ■ Letter must include: ■ Recent radiographs or if not available an explanation of why (e.g. pt uncooperative) ● Assessment appointment: ○ For treatment planning ONLY and plan may change with specialist opinion ○ **Informed consent - MUST be written ○ GA process, side effects and complications ○ Adult escort with no other children ○ Pre-operative fasting ○ Post-operative arrangements ○ Post-operative care and pain control

Answer 23

Kennedy classification ○ I: Bilateral free-end saddles ○ II: Unilateral free-end saddles ○ III: Unilateral bounded saddles ○ IV: anterior bounded saddle only ■ Any additional saddles: modifications (except class IV) e.g. class I modification 1 has a bilateral free-end saddles and an anterior saddle ● Craddock classification ○ Class I: tooth ■ Bounded saddles <4 teeth, occlusal and cingulum rests ○ Class II: mucosa ■ Free end saddles: RPI systems, utilised when no suitable teeth available ○ Class III: tooth and mucosa ■ Bounded saddles >4 teeth ● Support ○ Rests: (NB: can prepare rest seats) ○ Immediately adjacent to bounded saddles ○ Mesially to free end saddles ○ Consider opposing arch: is there space for this? ● Retention ○ Clasps: (direct) (NB: composite resin can be added) ■ Use three clasps as far away from each other as possible ■ Types: ● Occlusally approaching: three-armed clasp (retentive arm, reciprocal arm and occlusal rest), ring clasp and ● Gingivally approaching: I-bar, T clasps ○ Other: guide planes (how its seated), soft tissue undercuts, precision attachments ○ Indirect: ■ To place components so as to resist ‘rocking of denture around direct retainers ■ Not needed if three clasps present: provide stability in free end saddles and very long bounded saddles ■ If only two clasps: Place a supporting element to the opposite side of the clasp axis than the origin of the displacing force (90o to the clasp axis and as far away as possible) ● Connector ○ Upper: ■ Plates: Palatal plate, anterior plate, mid-palatal plate, horseshoe plate ■ Bars: Posterior bar, Horseshoe bar, anterior and posterior bar (ring) ○ Lower: ■ Bars: Lingual bar (8mm space = 3mm ging, 4mm bar, 1mm depth FOM), lingual bar w/ dental bar, dental bar, sublingual bar, labial bar ■ Plate: lingual plate

Answer 24

Explain to pt: pulp exposed and requires pulp cap (explain what is) ○ Likely no actor so no need ○ Address the need: vital therapy and risk of possible death of pulp which requires RCT ● Tooth must be asymptomatic, vital, no history of pulpitis (e.g. prolonged pain, toothache) ○ Pulp exposure must be small and surrounding dentine must be relatively hard - otherwise extripate ● Dam should have been on before the pulp was exposed - saliva contamination must be avoided. ● Haemorrhage from exposed pulp - copious irrigation with sterile saline (arrest bleeding with saline) ● Cavity irrigated with chlorhexidine (0.2%) (Clean with CHX, after bleeding arrested) ● Cavity is blotted dry using sterile cotton wool pledgets. (Do not air dry) ● Exposed pulp covered with hard-setting calcium hydroxide cement (Dycal or Life) ● RMGI lining placed (Vitrebond) and the restoration completed as planned. ● Continuing vitality monitored: if symptomatic RCT required.

Answer 25

Ideally prior discussion with patient that if carious pulp exposure then RCT or XLA will be required ○ + Dam has been placed ● Extirpation - Pulpectomy ○ Remove as much pulp tissue as possible with sterile excavator and file/barbed broach ● Odontopaste dressing if tooth vital, Ultracal if non-vital. ○ Odontopaste/Ledermix (antibiotic/steroid agent) as palliative agent in anticipation of RCT/XLA ● Cotton wool roll + GIC restoration

Answer 26

Cleanse cavity with 0.2% w/w chlorhexidine. ● Stained firm dentine is left in situ and covered with a setting calcium hydroxide cement (Dycal or Life). ● A stronger lining material is placed (RMGIC – Vitrebond) to protect the Ca(OH)2 and the tooth is restored with a provisional restoration (GI or RMGI). ● The tooth must be vital, asymptomatic and have no history of previous pulpitis. ● The tooth is monitored for 3 months and if vital and asymptomatic, the provisional restoration should be removed, stained dentine carefully excavated and definitive restoration placed. ● If there have been any pulpal symptoms, then RCT should be undertaken.

Answer 27

Diagnosis: ○ ‘Mrs Smith, you have a very common condition, in fact around 75% of the population get it at one point in their life. .... It is called temporomandibular disorder, or TMD …’ ● Explanation: ○ ‘The jaw joint sits in base of skull and muscles control opening and closing. Now, like any muscle in the body, if overworked they get tired e.g. if you climb a mountain legs are sore for next few days.’ ○ ‘However, as your jaw joint gets used all day everyday like for speaking and eating it never gets a rest. Muscles become inflamed and sore.’ ○ ‘The fact that you’re sore in the morning also tells us that you clench or grind your teeth at night as well which puts more stress on those muscles and exacerbates the problem even more’ ○ ‘The clicking by your ear is caused when the disc between your jaw and the skull gets trapped in front of the jaw bones and snaps in place’ ○ Could draw a wee diagram to show disc and explain that when muscles not in harmony the disc is pulled at wrong time to create clicking noise or disc trapped in front of jaw bones crushing the tissue that can cause pain. ● Management: ○ Reassurance! - “The way we manage this is very simple’ ○ ‘It involves resting the joints’ ■ soft foods/cut in small pieces, chewing on both sides, avoid chewy foods/gum, avoid wide opening, avoid stifling yawns, avoid grinding during day, avoid habits (biting nails) ○ Conservative advice including analgesia (paracetamol/ibuprofen) and heat packs. ○ Evidence to show yoga helps and general stress reduction is beneficial. ○ Make splint to break nocturnal habits ● Summary ○ Reassurance - common condition with simple conservative management ○ Important to reduce stress ○ Inform that other symptoms like tongue scalloping and linea alba are caused by the clenching and also go away on management of condition. ○ Ask if any questions ○ Actor marks for communication, simplicity of language and empathy.

Answer 28

Overview of marks: 1. Student listens and is empathetic 2. Asks patient what patient is expecting outlook to be or what they want from appointment 3. Asks permission to continue findings 4. Break news slowly in chunks 5. Avoids jargon, or explains if used 6. Allows patient time to take in information and gives chance to ask questions 7. Repeats the news 8. Summarises what they’ve said 9. Gives patient replacement options 10. Actor asked if they understood, been shown empathy ● Setting: ○ Sitting down at same level as them ○ Try to make them as comfortable as possible ● Perceptions: ○ What does the patient understand has happened up until now? ■ ‘Are you aware of what might be wrong?’ ○ What is patient expecting from appointment? ● Information: ○ Inform patient that you would like to discuss the prognosis of the tooth ○ Ask them if they would like to discuss that...they’ll say yes ● Knowledge ○ Give a warning shot ■ ‘I wish I had better news’ ■ ‘I’m afraid the news are not good’ …. pause for a bit ○ Give them the knowledge of what you know ■ ‘Your tooth is unrestorable and requires to be extracted’ …big pause… ○ Let it sink in and let them dictate the pace of the conversation from here ■ They might want to know loads of info really quickly or they might be in shock ■ Give them chance to ask questions ● Empathy: ○ Words to the effect of ■ ‘I am deeply sorry to break this to you’ ■ ‘I understand this must be hard for you’ ● Summary and close: ○ Repeat the news ○ Summarise what you’ve told them and the plan for going forward ■ ‘We will aim to restore this tooth as soon as possible for you’ ■ Immediate options: ● Immediate denture in the short term then extraction ● Bridge using their own sectioned crown if available ● Direct polycarbonate crown bridge ■ Permanent replacement options: ● Bridge, Denture, Implant (need 3 months for bone around XLA socket to stabilise) ■ Do NOT mention unrealistic interventions - assess by case ○ Ask of any questions they might have ○ Ensure the patient has a clear plan of what will happen next and your roles ○ Offer them a follow-up appointment or phone number for any questions

Answer 29

Anterior flange missing: ○ Remove undercuts, build flange with greenstick and reline ○ Rebase if not possible or remake if necessary ● Midline Diastema: ○ If want to keep physical aspects of denture, but change aesthetic only ■ Replica (2 stage putty around denture, vaseline to separate) ■ Wax replica used for functional impression + jaw registration ■ Ask lab to close diastema for tooth trial stage ○ Remake if other problems ● Underextended posteriorly at tuberosities: ○ Reline: if functionally good and only problem ○ Remake: if everything bad ● Locked occlusion: ○ Remake with replica technique and use cuspless teeth ● Base plate too thin: ○ Rebase thicker or Rebase using high impact resin. Or remake ● Tori: ○ Relieve clinically if only problem or ask for tin-foil relief ○ If too thin or other problems: rebase or remake and ensure lab waxes undercuts ● Tooth position wrong: ○ Remake ● Occlusal table too long - ie too many posterior teeth over the tuberosities: ○ Remove posterior teeth/ grind down - or remake

Answer 30

Reline: Replacement of a denture fitting surface ○ Note of Caution: relining is satisfactory for a mandibular denture but will increase the thickness of of an upper denture - making it heavier and less retentive. ○ The amount of thickness is directly related to the choice of impression material. The more viscous the impression material the greater the thickness of the reline. Use low viscosity - light body PVS ● Rebase: Replacement of the whole denture base ● So reline mandibular dentures and rebase maxillary dentures. ● Adjust the peripheral borders of the denture as necessary, to correct over (trim the denture) or under extension (add greenstick tracing compound). impression material e.g. zinc

Answer 31

Problems with denture ○ Impression surface: ■ Cause: poor impression (lack of post dam, poor adhesion to tray), damage to cast ■ Solutions: reline/rebase, remake, add post dam using reline ○ Occlusal surface: ■ Cause: premature occlusal contact, centric occlusion/relation not coincident, high lower occlusal plane restricting the tongue, locked occlusion ■ Solutions: cuspless teeth, selective grinding, re-recording centric occlusion, remake ○ Polished surface: ■ Cause: Overextension, underextended (depth &/or width), not in neutral zone ■ Solutions: remove overextension (esp. lingual lower, use pressure indicating paste, allow fraenal relief and flange), add greenstick to underextension and reline, remake if extensive ● Problems with denture wearer: ○ Poor neuromuscular control e.g. stroke, Parkinson’s ○ Unstable foundations ■ Anterior flabby ridge ● Solution: perforated trays + light bodied PVS impression (Or special tray with surgical window and take a wash and cut it out + light bodied PVS) ■ Atrophic lower ridge: ● Solution: admix technique (3 parts imp compound, 7 greenstick) ■ High fraenal attachments ● Solution: provide relief ■ Palatine tori: ● Solution: relief of area on cast before processing ○ Xerostomia

Answer 32

Fracture prone features: ○ Thin, under-extended and or absent flanges (open-faced) ○ Previous repairs ○ Stress concentrators - eg. a large fraenal notch, midline diastema, foreign particles ○ Poor fit ○ Lack of adequate relief ○ Tooth wear ● Prevention: ○ Inclusion of a metal palate ○ Use of an alternative denture base material such as a high impact acrylic resin for thin underextended flanges or open faced denture ● Fracture repair: ○ For simple midline fracture, two fragments are secured in position with sticky wax and additional reinforcement e.g. wooden sticks across the line of fracture. Sent to the lab - light cured PMMA is normally used because of its easier processing technique but it is weaker than heat cured PMMA. ○ If denture fractured into multiple fragments, it may be necessary to reposition the larger of the fragments intraorally and to take an in situ overall impression in alginate. If not possible – remake. ○ For repair of fractured or missing teeth, an impression of the opposing dentition and/or the denture is required to ascertain the correct occlusal relationship.

Answer 33

Diagnosis ○ ‘Mr Smith I’m afraid you’re suffering from a condition called acute necrotising ulcerative gingivitis, or ANUG...’ ○ ‘This is a rare condition presenting as an acute form of gum disease’ ○ ‘This means that the gum disease develops much faster and more severely than normal’ ● Aetiology ○ ‘It can be caused by a variety of reasons but it tends to cluster in people who are stressed, smokers and poorly nourished’ ■ poor OHI, stress, smoking, immunocompromisation, malnourished ○ ‘It can be made worse by high plaque levels due to poor brushing’ ● Symptoms ○ ‘Common symptoms include bleeding/painful gums, painful ulcers, receding gums in between your teeth, bad breath, a metallic taste in your mouth, excess saliva in the mouth and difficulty speaking or swallowing’ ○ ‘The disease can also extend away from the mouth and can cause systemic symptoms like swollen lymph nodes or a high temperature (fever)’ ● Management ○ Reassurance as it can be managed by local measures ■ OHI ■ NsHPT inc RSD (under LA) ■ M/W: CHX 0.2% or hydrogen peroxide, 6% ○ Smoking cessation!! ○ Stress reduction ○ As systemic: lymphadenopathy: ■ Antibiotic prescription - 3 days ● Metronidazole (400mg, Take 1 capsule 3 times per day, for 3 days) ○ No alcohol - vomiting, nausea ● Amoxicillin (500mg, Take 1 capsule 3 times per day for 3 days) - check for allergy ○ Recommend optimal analgesia ○ Advise register with GDP ○ Review within 10 day ○ Referral if no changes on review

Answer 34

Talk about getting them dentally fit, improving their oral hygiene & looking after their oral health. ○ Chemotherapy puts a toll on the entire body, including the mouth ■ ‘Chemotherapy knocks out your immune system, putting you at risk of getting infections’ ■ ‘We want to limit/reduce/remove sources of potential future infection from your mouth before you start’ ○ GDP attempt to reduce complications in chemotherapy regimen ■ Avoid unscheduled interruption of chemotherapy regimen ■ Remove potential sources of infection ■ Avoid exacerbation of mucositis ■ Minimise effects of vomiting (acid erosion) to dentition ○ Finally, plan prevention and rehabilitation ● Tx to be carried out: ○ Full mouth scaling ○ Remove any dubious prognosis teeth or areas of possible infection ■ Normally XLA need ~10 days to heal ■ Should not be done during chemo due to high risk of infection ■ If done after chemo - again higher risk of infection, slower healing, MRONJ ○ Impression for soft splint ○ Smooth down sharp teeth ● Pre-Treatment Prevention: ○ Oral Hygiene ■ x2 brushing daily at least 2 mins time at a time ■ prescribe 2800ppm duraphat (0.619%) ■ interdental cleaning - specifically instruct how to use ○ Fluoride therapy: ■ fluoride varnish, Duraphat toothpaste, trays to fill at night ○ Diet advice ■ avoid spicy and hot foods, avoid fizzy drink, fruit juices, acidic fruit ○ Smoking and alcohol advise if relevant to SH ● Mid-Treatment Management: ○ Minimal role unless emergency +/- manage pathology ➢ Mucositis ■ Inflammation and ulceration, severe pain requiring analgesia, impact on eating and OH ■ Management: ● General: Avoid smoking, spirits, spicy foods, tea, coffee, non-prescription medicine ● Topical: oral cooling prior therapy – ice, topical lignocaine, saline, sodium bicarbonate, benzydamine hydrochloride, gelclair, caphasol, tea tree oil m/w ➢ Candidosis: Pseudomembranous candidosis (Thrush) - Antifungals ➢ Herpes Simplex reactivation ● Post-treatment Palliative Care: ○ Maintenance of oral and dental health ○ Prevention: diet, OH, fluoride ○ Monitoring: increased frequency check-ups, pros maintenance ➢ Altered taste ➢ Trismus - if radiotherapy was to H&N ➢ Periodontal disease ➢ MRONJ ■ Only if cancer therapy consisted of anti-resorptive or anti- angiogenic drugs ■ Risk = 3% after XLA, = 1% spontaneous ● (compared to 0.1% in non-cancer patients on anti-resorptives/anti-angiogenics) ➢ Dry mouth ■ Decreased salivary flow: 50-60% in first week, further 20% in next 5-6 weeks ■ Change in saliva consistency and character: increased viscosity, decreased pH ■ Change in taste perception ■ Recovery over period of years, will not return to normal ■ Associated problems: dysphagia, dysarthria, dyspepsia, quality of life ■ Increased risk of: caries, perio, candidiasis, sialadenitis, prosthodontics difficulties

Answer 35

Suture - as before. Pt details correctly entered on to form ○ Sticker (CHI number, Hosp. Number, Name, Sex, Address, D.O.B) ○ + Hospital department, Date, Time, Consultant, Requested by, Phone no. ● Clinical details entered on to form ○ Pain etc ○ Other relevant information - present for 6 months with gradual increase in size, MH: nil of note ○ Provisional diagnosis - fibro-epithelial polyp ● Specimen details including site ○ Type of sample - excisional biopsy ○ Details of site - excised lump from left dorsum of tongue ● Investigation ○ Culture & sensitivity testing: bacterial/fungal ○ PCR and viral load: virus ○ Histopathology: tissue biopsies ● Wearing appropriate PPE when handling specimen ○ Examination gloves worn when handling specimen ○ Place sample in path pot without touching formalin ● Sealing path pot for transport ○ Cap tightened ● LABEL POT with pt details & place in plastic bag attached to request form

Answer 36

Place separators between medial and distal contacts ○ Floss 2 pieces of floss through the orthodontic separator ○ Pull tight and move down between contacts of the tooth (not subgingival) ● Leave in place for 2-7 days ● Remove with a BLUNT probe ● Sit child upright ● Place gauze swab to protect the airway ● Choose the crown: aim to fit smallest size of crown that will seat (use sticky stick) ● Select one that covers all the cusps and approaches the contact points with slight springiness ○ Do not fully seat the crown! ● Dry the crown, fill with GIC (Aquacem) ● Dry the tooth ○ If cavity large: place some GIC in the cavity ● Place the crown over the tooth ● Seat the crown with finger pressure - first method ● Child can seat the crown by biting on it over gauze - second method ● Remove excess cement with CWR ● Get pt to bite down for 2-3mins or finger pressure ● Make sure all excess cement has been removed ● Floss between contacts Part 2: Child starts choking on hall crown (mannequin) - deal with the emergency appropriately. ● ABCDE ● ‘Are you choking?’ ‘Can you cough for me?’ ● 5 back slaps between shoulder blades ○ Child can be lying on thigh or across knees ● 5 abdominal thrusts between belly button and sternum ● Continually check for object dislodging ● Re-evaluate ABCDE ● BLS if still not resolved ● Call 999 and refer to hospital to check for rib fracture

Answer 37

Problems ○ Increased OJ (1 mark) ○ Increased OB (1 mark) ○ Peg Lateral (1 mark) ○ Ectopic Canine (4 marks) ● Dental Health Implication ○ Risk of trauma from OJ (1 mark) ○ Risk of trauma from OB (1 mark) ○ Risk of root resorption (1 mark) ○ Risk of cyst formation (1 mark) ● Position determination from radiographs provided - detailed use of parallax and explanation (4 marks) ○ Parallax – OPT and oblique occlusal radiograph views - had to explain how you get your answer ■ Vertical parallax - SLOB ■ Explanation: The tube head shifted up from OPT to oblique occlusal, the canine moved together with the tubehead compared to the incisor. According to SLOB rule, the canine is palatal to the incisor.

Answer 38

Examiner asks: What kind of articulator are these casts mounted on? ○ Average value (1 mark) ■ Also: simple hinge, semi adjustable and fully adjustable ● Upper design (2 marks) & Lower design (2 marks) ○ Design correctly and neatly copied. ○ Rests, major connectors, saddle areas and clasps all drawn correctly onto prescription ● Lab prescription supplied ○ Position of all 8 occlusal rest seats identified (4 marks) ○ 4 I-bars correctly identified (2 marks) ○ 2 occlusally approaching and 2 ring clasps identified (2 marks) ○ Mid palatal strap and lingual bar (2 marks) ● Area providing reciprocation ○ Reciprocation is provided by any part of the denture that is directly opposite a clasp arm. ○ Resist lateral movement of teeth from forces of clasps/retentive component during insertion. ○ Should indicate all 8 areas (2 marks) ● Indicate what bracing is and what parts of denture provide bracing ○ Bracing is the resistance to lateral movements (1 mark) ○ Correctly identify elements that provide resistance to lateral movement (1 mark)

Answer 39

Identify dangers and how to rectify ○ Bracket table: LA needle unsheathed, scalpel, tooth in forceps, endo files ○ Surgery: Sharp box on floor, gloves in sink, blood spillage ● Know waste streams ○ Black: household waste - packaging, hand towels ○ Orange: low risk clinical waste ■ Swabs, dressings and other non-sharp clinical waste e.g. dam, micro brush ○ Yellow: high risk clinical waste (we don't have this on clinic) ■ Body parts including teeth ○ Red: Specialist, hazardous waste ■ Dispose of amalgam in white box with red lid. ■ Spill/leak proof. Mercury vapour suppressant in lid. ■ Amalgam waste, amalgam capsules, amalgam filled teeth ○ Blue: Sharps including vials with medication or pharmaceuticals remaining ○ Dispose of sharps in sharps bin (orange stream): 3As, 2Ns ■ Always dispose of sharps in the sharps box immediately after use ■ Always keep out of reach of children and non-authorised personnel ■ Always close sharps box between use using temporary closing mechanism ■ Never retrieve anything from sharps box ■ Never fill more than ¾ full ● Place sharps box at waist height on a flat surface - sharp box on floor here! ● Blood spillage and how to deal with it ○ Stop what we are doing ○ Apply appropriate PPE ○ Cover spill with disposable paper towels ○ Apply sodium hypochlorite/sodium dichloroisocyanurate – liquid/powder/granules (10,000ppm) ○ Leave for 3-5 minutes, use scoop to take up the gross contamination and put into orange waste ○ Clean with water and general purpose neutral detergent disinfectant wipes

Answer 40

Possible causes of white patch: ○ Hereditary, Keratosis (Smoking, Traumatic), Lichenoid, Lupus, Pseudomembranous or Chronic Hyperplastic Candidiasis (not in this site), Carcinoma/SCC ● Discussing the lesion ○ ‘The lesion on the FOM has a number of possible causes. Some of these are harmless and benign. However, some causes could be more serious and possibly cancerous.’ ○ ‘As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’ ○ ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’ ● Information on what to expect at OM: ○ Biopsy ■ LA injection around the site of the sample ■ Taking a small amount of tissue to send to the lab for analysis ■ Sutures will be placed to close up the wound ○ Post-op advice ■ It will be sore for a week after the procedure, similar to having an ulcer ● Risks: pain, swelling, bleeding, bruising, infection, numbness/altered sensation ■ Sutures will dissolve and come out on their own in around 2-4 weeks ■ Advice will be provided - salt water mouthwashes, softer diet, limit smoking etc ■ Review appointment to be booked to discuss findings ● Management of Risk factors ○ Smoking cessation advice ○ Reduce alcohol consumption ■ Don’t mention 14 units - Consider the lesion as a wake-up call to quit ● Urgent cancer referral guidelines: ○ Persistent unexplained head and neck lumps for >3 weeks ○ Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks ○ All red or speckled patches of the oral mucosa persisting for >3 weeks ○ Persistent hoarseness lasting for >3 weeks (request chest x-ray at the same time) ○ Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks ○ Persistent pain in the throat lasting for >3 weeks

Answer 41

Aciclovir only prescribed: Immunocompromised or severe infection in the non-immunocompromised ● Primary response to herpes simplex virus ○ Sore mouth and throat, enlarged lymph nodes ○ Also: period of malaise and fever (!!systemic symptoms!!) ○ Happens once (or twice – two types), self-limiting 7-10 days ○ Fluid intake, bed rest, analgesia/antipyretic, CHX, nutritious diet ● Aciclovir prescription: ○ 200mg tablets or oral suspension (200mg/5ml or 100mg/5ml) ○ Send: 25 tablets ○ Label: 1 tablet 5 times daily ■ [5x200mg for >2yo, 5x100mg for <2yo]

Answer 42

Diagnosis: Fractured right/left mandibular fracture ● Initial General History ○ Headache? ○ Any loss of consciousness? ○ Nausea or vomiting? ○ Numbness of face? ○ Police involvement? ○ Examine and record injuries elsewhere ● E/O: ○ Pain ○ Lacerations ○ Bleeding ○ Swelling ○ Facial asymmetry ○ Palpation of mandible bilaterally (condyle, ramus, body, symphysis) ○ Limitation of mandibular movement? (Reduced interincisal opening) ○ Mandibular deviation on opening and lateral movement? ○ Tenderness of TMJ? ○ Examination of sensation of lower lip/chin region ■ Areas supplied by mental nerve (mandibular division of trigeminal nerve) ● I/O: ○ Lacerations (esp. gingivae) ○ Bruising/swelling/haematoma ○ Occlusal derangement and step deformities ○ Loose or broken teeth ○ Anaesthesia/Paraesthesia of teeth in lower jaw on side of fracture ○ AOB – due to bilateral ramus/sub-condylar fracture ● Classifications ○ Soft tissue involvement: simple, compound, comminuted ■ Fractures involving teeth always expose the periodontium so are always compound ● High risk for infection - need for antibiotics ○ Number: single, double, multiple ○ Site: condylar, subcondylar, body, coronoid, angle, ramus, parasymphyseal, symphyseal, alveolar ○ Side: unilateral/bilateral ○ Displacement: displaced, undisplaced ○ Direction: favourable, unfavourable ○ Specific: greenstick (children’s bones bend), pathological ● Factors influencing displacement of mandibular fractures ○ Pull of attached muscle ○ Angulation & direction of fracture line ○ Opposing occlusion ○ Magnitude of force ○ Mechanism & direction of injury ○ Intact soft tissue ● Further investigations: ○ TWO Radiographs: OPT + PA mandible ○ CBCT most commonly used now ● Identification of relevant radiographic findings ○ Fractures - most possibly more than one ■ Previously parasymphyseal fracture and bilateral condylar fractures ■ Always compare right side from left ● Management: ○ Urgent phone to an OMFS unit or A&E dept for advice and URGENT referral ■ Might not see it urgently if undisplaced ■ Can ask you to prescribe pain relief and antibiotics ○ Surgical management: ORIF (if symptomatic or displaced) ○ Conservative management if undisplaced, asymptomatic or >1-month-old

Answer 43

Decal - has the shape of backet ○ Weakens the enamel to caries ○ Unsightly staining ● Pt selection ○ High risk if caries history evidence of decal, NCTSL ● Oral Hygiene   ○ Toothbrushing + single tufted TB for brackets ○ Inter-dental brushes and superfloss ○ O.H.I. should include ■ minimum twice per day VERY thoroughly ● Dry toothpaste, methodical: work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 minutes, spit don’t rinse ■ brushing after meals  as brackets trap food/plaque ■ disclosing tablets to identify missed areas ● Diet advice ○ Limit sugar amount and frequency ○ Avoid snacks between meals – limit sugar intake to <3 times daily ○ Avoid hard/hot foods, fizzy drinks, sports drinks, sticky sweets, chewing gum ○ Ideal drinks are water or milk, crackers, cheese, fruit is acceptable snack but be careful of fat in cheese and natural sugar/acid in fruit ○ Watch out for hidden sugars in foods such as tomato soup and ketchup. ○ Rinse mouth after eating ● Fluoride ○ Toothpaste  ■ Duraphat  – 2800 ppm (0.619%)  – 5000 ppm  (1.2%) ■ Twice daily, ordinary toothpaste at other times ■ Warn re overdose and children ○ Mouthwash  ■ Daily 0.05% fluoride mouthwash (225ppm) ■ Use IN-BETWEEN brushing, NOT after ○ F Varnish ■ Proflurid (22600ppm) - not duraphat ■ Every 4 months ● *This is for prevention - F varnish isn't used for tx of decal as it seals it in ● Prescriptions: ○ Sodium Fluoride Toothpaste 0.619% (2800ppm) ■ Send: 75ml ■ Label: brush teeth for 1 minute after meals using 1cm before spitting out, twice daily ○ Sodium Fluoride Toothpaste 1.1% (5000ppm) ■ Send: 51g ■ Label: brush teeth for 3 minute after meal using 2cm, before spitting, 3x daily

Answer 44

Gold standard: Cuspal coverage onlay ○ Gold, composite, porcelain, zirconia ■ Reduces risk of tooth fracture/catastrophic failure ■ Less microbial leakage/better seal ● Full coverage: MCC, GSC, all ceramic, all zirconia ○ If less tooth structure remains - in order to cover and protect ● Direct restoration: composite or amalgam ○ If only occlusal cavity present ○ Not as favourable: more leakage, more likely to fracture ○ Attempt to extend cavity just past the cusps to provide cuspal coverage. ● Core build up if necessary: ○ Gold standard: Composite core ○ Explain to pt the tooth has been hollowed out need to put filling material to fill up the space and retain the crown ○ Nayyar core - not favourable ○ Metal cast post if necessary - not favourable

Answer 45

Caries risk assessment: 7 things ○ clinical evidence, diet, MH, SH, saliva, plaque control, fluoride exposure ● Prevention: 8 things ○ radiographs, diet advice, tooth brushing instruction, strength of fluoride in toothpaste, fluoride supplement, fluoride varnish, fissure sealant, sugar free medicine ● Prevention - high risk: ○ Toothbrushing advice: ■ Assist child with brushing until able to brush independently (7yrs) ■ x2 daily with fluoride toothpaste ■ Demonstrate on child 6 monthly, get parent to demonstrate in front of you ■ Methodical approach: ● work from upper right clockwise to lower right, brush 1 tooth at a time, angling brush at 45 degrees between gum and tooth, brush in short scrubbing motion for a minimum of 2 minutes, spit don’t rinse ○ Diet advice ■ Avoid sugar snacks/drinks ■ Snack on healthier foods: carrot sticks, breadsticks, fruit in moderation ■ Milk and water only (between meals) ■ If nursing bottle: no bottle to bed at night, no soy milk or sweetened milk, no on demand breastfeeding ■ Do not eat or drink after brushing teeth at night ○ Fluoride: ■ Varnish: x4 yearly to children >2yrs (5%, 22600ppm) ■ Toothpaste: x2 daily - 1450 ppm (smear < 3yo pea > 3yo) ● >10yrs: 2800ppm, >16yrs: 5000ppm ● Avoid rinsing mouth, drinking or eating for 30 mins after use ● Advice that this TP is a medicine and should only be used prescribe ■ Mouthwash: x1 daily for >6yo - (0.05%) ● Preferentially at different time from brushing ● Avoid rinsing mouth, drinking or eating for 15 mins after use

Answer 46

When to use each cement: ○ Aquacem (GIC) → Metal post, MCC, Gold restorations, Zirconia restorations ○ Panavia (Anaerobic cure comp) → Adhesive bridge (RBB) ○ Nexus NX3 (Dual cure comp) → Fibre post, Composite/porcelain restorations, Veneers ● Pre-cementation checks ○ Check on the cast ■ Is the restoration as asked for ■ Rocking, M/D contact points, marginal integrity, aesthetics ■ Check contact points on adjacent teeth on cast to ensure not damaged ● Can be damaged when prepped tooth is sawn off the cast to invest ■ Occlusal interference on excursions ■ Natural teeth contacting (check with shimstock 8μm) ○ Remove crown from cast ■ Check if occlusion correct and still the same ■ Check crown thickness using calipers ○ Crown placed in patient with airway protection ■ Check all the above ■ Patient happy with appearance ● Post-cementation checks ○ Excess cement removed ○ No space around margins ○ Interproximal contact point exists and is clear ○ Occlusion checked with articulating paper (in excursion as well) ○ Restoration clensible ○ Confirm patient happy with aesthetics and feel

Answer 47

Fill in details: ○ Patient detail sticker on all three sheets: (Name, Age, CHI, Sex, DOB), Any photos or SH ○ Practitioner details/Practice detail/no ○ Date and time of recording impression, date and time of completed required lab work ○ Plan: stage of Tx (prep or fit), present (work), other lab work ● Instructions ○ Please pour up impressions with 100% improved stone, mount on DENAR II semi-adjustable articulator using facebow/wax bite etc provided. ○ Construct a metal ceramic (NiCr) conventional mesial cantilever bridge to replace tooth XX. Use XX as abutment and XX as pontic. ○ Shade XX. Staining and special effects, Surface features and finish. ○ Ridge-lap pontic (depends on tooth to be replaced) ■ Ridge lap: posteriors, ■ Modified ridge lap: upper anteriors ■ Dome shape: posteriors, lower anteriors ○ Please construct in canine guidance and ensure pontic is free of excursive movements. ○ Please return bridge with cast. ● Signature

Answer 48

Introduce self and designation ● Reassure father everything will be ok ● Knee-to-knee examination ○ Explain to the parent what you intend to do ○ Sit across from the parent with your knees touching theirs ○ Bring your knees together and ask the parent to do the same ○ Ask the parent to sit the child with their legs round the parents waist ○ Lower the child down into your knees and ask the parent to hold the child’s arms ● Trauma stamp: ○ Colour, EPT, EC, TTP/percussive note, mobility, displacement, radiograph, sinus ● Subluxation signs: ○ TTP, mobile, bleeding from gum, no displacement ● Explain nature of injury in simple terms ○ Subluxation of the upper central baby teeth ○ This is an injury to the supporting structures of the tooth ● Explain treatment: JUST OBSERVATION ○ No treatment required ○ Only that can be done today is clean tooth with saline or CHX wipe with gauze due to age. ● Explain home care: ○ Instruct soft food for 1 week ○ Important to keep the area clean and plaque free for good healing ■ OHI - Brush with a soft brush after every meal ■ CHX 0.2% with cotton swab to area x2 per day for 1 week ● Explain possible complications to primary tooth: ○ Pain, swelling, dark discolouration, increased mobility, delayed exfoliation, infection ■ Child may not complain of pain, however, infection may be present and parent should watch for signs of swelling on the gums and bring the child in for treatment. ● Explain possible complications to permanent tooth: ○ Premature or delayed eruption, enamel hypoplasia/ hypomineralization, crown/root dilaceration, failure to erupt, failure to form, odontome formation ● Follow up: 1wk and 6-8wks ● Actor marks for describing tx in an understandable manner, supportive and empathetic regarding injury

Answer 49

Correct drug - Detailed action (detailed) - Description of emergency (signs/symptoms) ● Asthma ○ Medication: Salbutamol → Short acting selective beta2-agonist, relaxes smooth muscles in the bronchi causing bronchodilation. ○ Assess ABCDE ○ Signs: airway constriction/bronchoconstriction, fast breathing, wheeze, gasping, clutching chest, blushing, tachycardia - probably regular ○ Call ambulance – location, number, describe Pt condition ○ Administration: ■ Salbutamol inhaler - 100μg per actuation ■ Shake, press, inhale, hold 10 sec asthma attack, COPD, choking, OR ■ 4 actuations in large volume spacer 20 secs inhalation and then put on O2 ● repeat as required ○ Reassess ABCDE ○ Administer 100% oxygen, 15L/min flow rate ● Anaphylaxis ○ Medication: Adrenaline → powerful vasoconstrictor, bronchodilator & increases contractility of myocardium ○ Assess ABCDE ○ Signs: airway constriction/bronchoconstriction, fast irregular breathing, stridor, blushing, tachycardia but weak pulse, urticaria, angioedema. ○ Anaphylactic shock = inability to perfuse organs ○ Secure airway ○ Call ambulance – location, number, describe Pt condition ○ Administration: ■ Adrenaline ½ of a 1ml ampule 1:1000 = 500μg IM injection ● *Aspirate as can generate arrhythmias ● Use Z-track technique to inject into thigh or bicep ○ Spread skin, advance needle in skin 90o, aspirate, inject 30s, pull out, release tension - thigh, hip, deltoid, buttock. ○ Say ‘I would normally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time’ ○ Reassess ABCDE ○ Administer 100% oxygen, 15L/min flow rate ● Differentiator between them - similar symptoms ○ Check medical history or series of events leading to the episode ○ Asthma only has respiratory symptoms and those caused by the hypoxia (e.g. tachycardia) ○ Anaphylaxis is systemic presenting with a weaker pulse, urticaria (hives on skin) and angioedema (swollen face) 35

Answer 50

The treatment is to have the lower L/R third molar removed surgically under local anaesthetic’ ● ‘You will be awake throughout the procedure’ ● ‘You will be numbed up firstly by an injection in the back of your jaw which will numb that side of your jaw all the way down to your chin. You will not be able to feel anything sharp while we take the tooth out but you will still be able to perceive pressure.’ ● ‘The procedure will involve making a cut and raising a bit of your gum, removing bone around the tooth, and possibly sectioning the tooth and removing it piece by piece. This will involve drilling, similar to the one used for fillings. Then we will clean the area with salty water and place some sutures to close up the wound. Once again, you will be numb in the area of treatment during this procedure and will hear sounds of the tooth coming up as well as pressure but no sharpness or pain’ ● Complications: pain, swelling, bleeding, bruising, infection, dry socket (failed clot/exposed bone), jaw stiffness, damage to adjacent tooth ● Also: temporary/permanent numbness, prolonged nerve pain, tingling due to damage to the nerve. ○ ‘This is a sensory nerve and any nerve damage will have no effect on your appearance or the way your mouth or jaw moves. This is something only you will be aware of.’ ○ Risks: 10% temporary, <1% permanent ○ If roots involved with IDN then nerve damage risks increase to 20% temporary and 2% permanent. ○ If IDN involvement: Coronectomy ‘involving the same procedure as above up to the sectioning of the tooth however only the the crown of the tooth is removed leaving the roots in place to avoid risking nerve damage - this cannot be done if the tooth is carious. If the roots become mobile they will have to be removed as well’ ● ‘If you have this procedure performed under local anaesthetic we advise that you refrain from fasting. It is not required to bring someone with you and you will be more than capable of driving yourself home if required however it is advised that you take the rest of the day off from work.’ ● Ask if they have any questions.

Answer 51

Type N – non-vacuum, passive air removal, unwrapped solid products, non-hollow, non-lumened ● Type B – vacuum, active air removal, packaged instruments, lumened, hollow cannulated or porous ● Cycle: ○ Stages: air removal, sterilising, drying, cooling ○ Parameters: 134-137 degrees, 2-2.3bar for a minimum holding time of 3 minutes ○ Type of water used: reverse osmosis/ distilled/ sterile/ de-ionised ● Steriliser tests: ○ Daily: wipe clean, change water, Automatic Control Test (ACT), Steam Penetration Test (Bowie-Dick/Helix) ○ Weekly: ACT, Steam Penetration Test, Vacuum Leak Test, Automatic Air Detector Function Test ○ Quarterly: Validation Report (taking loads of data for effectiveness of steriliser) ○ Yearly: Annual Report – by insurance company for safety (e.g. check pressure release valves) ● Instruments found on top of steriliser ○ Should be set out non-overlapping with hinged instruments open ○ Check for recent print-out from steriliser ○ Check if colour change of packaged instruments ■ Instrument packaging: Brown to Pink ■ Helix/Bowie Dick: Yellow to Blue ○ If unsure, take tray of instruments back to beginning - cleaning in AWD or manual cleaning.

Answer 52

Take concerns seriously, answer questions as able: ○ ‘Hello there, what seems to be the problem?’ ○ ‘Can I offer some assistance?’ ● Acknowledge anger ‘I can see that you’re upset and I am sorry that you feel this way.’ ○ This does not accept blame. DO NOT ACCEPT BLAME ● Try to offer practical help: ○ Offer to take over the treatment over your colleague ○ Offer investigation with colleague and provide feedback to the patient ○ ‘Would you like me to recement the crown?’ ○ ‘What would like to do, we can work around you?’ ● Making an apology: ○ Be honest ○ Acknowledge the offence ○ Explain how it happened ○ Ensure amends: ‘Is there anything we can do?’ ● If formal complaint requested, advise on NHS complaints procedure ○ Then, if required: a local resolution (payout) ○ If satisfactory: complaint closed ○ If unsatisfactory: healthcare commission or health service ombudsman ● The NHS complaints procedure a. Acknowledge the complaint and provide the patient with the practice complaint procedure. b. Inform the dental defence organization if you require advice. c. Inform the patient of timescales and stages involved. d. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3 working days maximum but ideally within 24 hours. e. Early Resolution 5 working days: For issues that are straightforward and easily resolved, requiring little or no investigation. f. Investigation 20 working days: For issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’. g. Independent External Review Ombudsman: For issues that have not been resolved.

Answer 53

LN Palpation: ○ preauricular, parotid, submandibular, submental ○ occipital, posterior auricular, jugulo-digastric, jugulo-omohyoid, deep cervical, supraclavicular ● Take a brief history ○ Noticed lesion? How long for? Painful? Pain/Problems eating or swallowing? Hoarseness of voice? ○ Relevant MH? Smoker? Alcohol? Regular attender? Daily mouthwash use (alcohol)? ● Discussing the lesion ○ ‘The lesion on the FOM has a number of possible causes. Some of these are harmless and benign. However, some causes could be more serious and possibly cancerous.’ ○ ‘As the site is a high risk for oral cancer, and you have other risk factors, it would be appropriate to refer you on to have this looked at.’ ○ ‘In order to be sure I will make an urgent referral to OM/Macfac dept where they will take a biopsy of the white patch so that a laboratory can tell us what it is’ ● Information on what to expect at OM: ○ Biopsy ■ LA injection around the site of the sample ■ Taking a small amount of tissue to send to the lab for analysis ■ Sutures will be placed to close up the wound ○ Lymph node biopsy - Fine needle aspirate? ○ Post-op advice ■ It will be sore for a week after the procedure, similar to having an ulcer ● Risks: pain, swelling, bleeding, bruising, infection, numbness/altered sensation ■ Sutures will dissolve and come out on their own in around 2-4 weeks ■ Advice will be provided - salt water mouthwashes, softer diet, limit smoking etc ■ Review appointment to be booked to discuss findings ● Management of Risk factors ○ Smoking cessation advice ○ Reduce alcohol consumption ■ Don’t mention 14 units - Consider the lesion as a wake-up call to quit ● Urgent cancer referral guidelines: ○ Persistent unexplained head and neck lumps for >3 weeks ○ Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks ○ All red or speckled patches of the oral mucosa persisting for >3 weeks ○ Persistent hoarseness lasting for >3 weeks (request chest x-ray at the same time) ○ Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks ○ Persistent pain in the throat lasting for >3 weeks

Answer 54

Go through OPT in systematic manner: ● Demographics ○ type of X-ray, age, date etc ● Quality ○ Diagnostically acceptable? If not - why not? ● Dentition ○ Teeth: erupted/unerupted, permanent/primary/mixed, missing/supernumerary, impacted, ectopic ○ Restorations: heavily/moderate/mild restored, overhangs, fractures, poor margins ○ Trauma ● Disease: ○ Caries: primary/secondary, supra/sub-gingival, periapical pathology ○ Perio: periodontal bone levels, localised/generalised, supra/sub-gingival calculus ○ Endo: well/poorly compacted, material, ?mm from apex/to apex, separated instruments etc ○ TMJ ○ Other pathology: cysts ● Diagnosis

Answer 55

Amoxicillin prescription ○ Metronidazole is the most common antibiotic, but it’s contraindicated due to an alcohol problem. ○ Still get a mark for prescribing metronidazole but have to mention alcoholism on prescription for pharmacist. ● Prescription: ■ Amoxicillin Capsules, 500mg ■ SEND: 9 capsules ■ LABEL: 1 capsule 3 times daily for 3 days ○ Patient’s name - correct place (2 marks) ○ Patient’s address, postcode - in full (2 marks) ○ Patient’s CHI - correct area (2 marks) ○ Number of days treatment - correct number of days - 3 (2 marks) ○ Acceptable drug and formulation - amoxicillin, 500mg capsules (1 mark) ○ Correct drug dose - 500mg (2 marks) ○ Correct frequency - 3x a day (2 marks) ○ Correct duration of treatment - three days (2 marks) ○ Total number of capsules - 9 (2 marks) ○ Prescription signed and dated - correct area (2 marks) ○ Written in indelible ink - pen used (2 marks)

Answer 56

Bleeding: ○ If bleeding does occur, arrest with wet gauze using firm pressure for 20 minutes, if unable to arrest, contact the emergency number provided ○ If it doesn’t stop bleeding, phone emergency contact first ○ If continues to bleed/out of hours go to A&E ● Rinsing: ○ Do not rinse the area, for the first 24 hrs ○ After 24hrs you should rinse mouth with warm saline/salt water gently 3-4 times day ● Care: ○ Do not bite lip, cheek or tongue while numb ○ Do not disturb socket with finger, tongue or toothbrush, avoid probing the site ○ Brushing other teeth as normal, avoid that area ○ Inform the patient that they may experience swelling and bruising - should peak at 48hrs, if increasing after this, contact the GDP ○ Avoid hot and hard foods ○ Avoid excessive exercise ○ Eat soft foods on opposite side to extraction for a few days ○ Avoid/Cut down smoking over the next few days/week ○ Avoid alcohol for as long as possible (24 hours) ○ Gentle rinsing after the first day with warm salty water ○ Swelling: peaks at 48 hours, resolves in around 7 days. ■ Can use ice pack today when you go home (5 mins on, 5 minutes off for an hour) ○ If sutures: dissolve on their own in about 2-4 weeks ● Pain : ○ Expect some pain at first ○ Painkillers before analgesia wears off fully ○ Take normal painkillers: Ibuprofen and Paracetamol ○ If pain worsens after 2-3 days return to the practice: possible infection or dry socket ○ Take analgesia as for a headache for 1-3 days after the op and begin before LA wears off ● Provide emergency contact number

Answer 57

Leave/monitor ○ Risk of infection/abscess/tooth breakdown/catastrophic root fracture ● Remove crown and remove caries - restore with new crown if restorable: ○ Adv: removes risk of post removal ○ Dis: not actually resolving the problem of no endo (risk of periapical infection) ● Remove post core and replace + RCT. ○ Risk of removing post and core: root fracture, core/post fracture ○ RCT - involves cleaning out the tooth and filling it to prevent infection ■ Needs a series of appointments ● Explain risk of tooth being unrestorable requiring XLA ○ Options for replacement ■ Leave space ■ Restore with bridge ■ Restore with denture ■ Restore with implant

Answer 58

ABCDE ● Are you choking? ● 5 back slaps between shoulder blades ● 5 abdominal thrusts between belly button and sternum ● Continually check for object dislodging ● Re-evaluate ABCDE ● BLS if still not resolved ● Call 999 to check for rib fracture

Answer 59

Explain treatment required ○ Caries management ■ List carious teeth ● Sed/GA referral vs GDP management ■ Start working with least invasive restorations - fissure sealant to then LA procedures ○ Prevention: ■ Assign caries risk ■ 8 things: radiographs, diet advice, tooth-brushing instruction,F toothpaste, F supplements, F varnish, sugar free medicine, fissure sealant ● Mucocele: ○ Leave and review vs referral for surgical removal ○ Explain the procedure: LA around site of swelling, cut in gum and removal in its entirety, sutures ○ Risks: pain, swelling, bleeding, bruising, infection, numbness, sutures ● Hypodontia: ○ Potential problems: space, drifting, overeruption, aesthetics, functional problems ○ Space maintenance: URA ○ Referral to orthodontist at 6-7yrs ○ Tx options in future: ■ Nothing ■ Restorative only: composite, veneers, RBB, RPD ■ Ortho only ■ Restorative + ortho: space closure and reshape teeth to camouflage ● Deal with complaint: ○ ‘I can’t give comment because I don’t know the full story’ ○ ‘I can only offer you this treatment at this present time’ ○ ‘Whatever was offered previously, will not change what treatment is required now’ ○ Tell mum if she is intended to complain, she can go back to the practice, they will have a standard complaint procedure = only if the patient asks (do not offer!) ○ ‘It will be unhelpful for me to be involved in this matter as I don’t know the background behind treatment that was or wasn’t done and would be unfair for me to speculate on it

Answer 60

Wear appropriate PPE ● Dispose all sharps, then clinical wastes and domestic wastes ● Wipe down bay in prep for next patient ● Start from the top: dental light - control surfaces, full length of all cables. ● Then change to new wipes: dental chair, spittoon. ● New wipes again: bench top surfaces, computer keyboard and mouse.

Answer 61

Establish what patient knows about the biopsy and possible implications. ● Break the news of diagnosis – ‘epithelial dysplasia which has a potential to be cancerous.’ ● Stress to the patient: ‘This is not cancerous YET but there is evidence of a tissue change.’ ● Ensure they understand: ‘This diagnosis implies there is a HIGHER risk for a transformation to malignancy.’ ● ‘The good news is that the risk can be reduced by removing the factors that can cause cancer’ ● Alcohol advice - mentioning what unit of alcohol is and weekly intake guidelines and dental effects ○ FRAMES Counselling approach ■ Short, non-judgemental, motivational ■ F – feedback - given to patient about behaviour ■ R – responsibility - for change is placed on patient ■ A – advice - how to do that change, given by practitioner ■ M – menu of options - self-directed change options and treatments offered ■ E – empathetic - warmth, respect and understanding ■ S – self-efficacy - is engendered to encourage change ○ 4A’s 1R ■ Ask: How much do you drink/units? What kind? Eye-opener? Family concerns? ■ Advise: Effects on general and dental health ● Stress that alcohol increases the risk of oral cancer! ● Oral effects: fungal, caries, dry mouth, perio, poor wound healing, dental erosion, bruxism ○ *increased bleeding – reduced clotting ● General effects: increased risk of stroke, cardiac disease, liver disease ■ Assess: whether the pt is willing to reduce drinking, inform them that this if fundamental to prevent oral cancer ■ Refer: Alcoholics Anonymous ■ Guidelines - Maximum 14 units per week with at least 2-3 drink free days ● *In your case you should consider cutting alcohol out completely due to it being a risk factor for your dysphasia turning to cancer ● Eye contact, open body language - Actor marks non-judgemental tone and clear advice

Answer 62

Introduce self and designation ● State separated instrument and explain ○ Calmly explain to the patient that there is a file separated in to the canal of the tooth. ○ Explain that thin metal files are used in order clear out the pulp tissue and shape the canal. ○ Sometimes they can separate in tight or curved areas leaving the metal tip lodged in the canal. ● Possible consequences ● Possible treatments ○ Do what you're comfortable with and what you're prepared for based on your illumination, magnification, access to instruments and time. ○ ‘I’ve tried to remove the file and failed and you will arrange a referral to see a specialist.’ ○ Do nothing - dress and monitor. ○ Attempt removal with tweezers if they can see the separated file. ○ Dislodge and remove the broken file with an ultrasonic instrument. ○ Bypass the fragment by watch-winding a small file alongside the instrument and EDTA to soften the dentine. ○ If they remove it: complete RCT as normal. ○ If not possible to bypass or remove the fragment - accept and obturate to file - better outcomes with a protaper file separating at the apex as you're finishing your apical prep (as you know it's clean) ○ Retrograde RCT - apicectomy/peri-radicular surgery ○ XLA as last resort ● Ask if they have any questions ● Check understanding and confirm an option ● Actor marks: professionalism, simple language, enough info provided to gain consent

Answer 63

Component faults: ○ Z-spring encased in acrylic, UR6 adam’s clasp arrowhead fault, UL6 adam’s clasp flyover fault ● Prescription faults: ○ Southend clasp included meaning appliance won’t work, Adam’s clasp on ULC not ULD, FABP instead of PBP. ● How would you rectify these errors? ○ Re-make appliance by taking new impressions ● Activating palatal finger spring: ○ Using spring former pliers – 1-2mm activation ● Fitting a URA ○ Check that the appliance if for the correct patient ○ Check the appliance matches prescription ○ Run finger over all surfaces to check for protruding wires and sharp acrylic ○ Check wirework integrity (if overworked) ○ Fit the appliance ○ Check for any blanching or trauma ○ Check posterior retention ■ Flyovers (first as influence the arrowheads) ■ Arrowheads ○ Check anterior retention ○ Activate appliance - to produce 1mm movement per month: spring formers ○ Demonstrate to patient about insertion and removal ○ Ask patient to demonstrate insertion and removal ○ Review: 4-6 weekly ● Instructions to patient ○ Will feel big and bulky ○ Likely to impinge on speech ■ Start reading a book aloud to prevent this by speeding up adjustment of Teeth ○ May have ‘mild discomfort’ - particularly on teeth being moved - but this is a sign that the appliance is working ○ Initial increase in saliva – 24-48 hours ○ Wear 24 hours/day including meal times ○ Can remove the appliance to clean with a soft brush after each meal or when taking part in active/ contact sport – store in a safe place ○ Avoid hard and sticky foods ○ Be cautious with hot food and drinks as base plate acts as an insulator ○ Non- compliance will lengthen treatment ○ Give an emergency contact number – do not wait till next appt. if there is a problem

Answer 64

Black Safety Plus Handle: For LA injection 2. Mouth Mirror: Soft tissue retraction, indirect vision 3. Straight Probe: Test for LA before XLA, test surface 4. Collage Tweezers: Handle cotton pledget (with cross pattern), remove sequestrae 5. Swann Morton Scalpel Handle with no15 Blade: Incision to raise a flap or biopsy 6. ‘S’ Shaped Cheek Retractor: Retract the cheek, retract soft tissue 7. Howarth Periosteal Elevator: Raise mucoperiosteal flaps, flap retraction 8. Howarth Periosteal Elevator: As above 9. Ash Periosteal Elevator: Elevate soft tissue flaps, flap retraction 10. Couplands Osteo Chisel No1: Elevate root and tooth, create space for insertion of forceps 11. Couplands Osteo Chisel No2: As above 12. Couplands Osteo Chisel No3: As above 13. Warwick James Elevator Right: Elevator for removing teeth and roots, especially upper 8s 14. Warwick James Elevator Straight: As above 15. Warwick James Elevator Left: As above 16. Cryers Elevator Right: Elevator used to elevate roots and remove interradicular bone 17. Cryers Elevator Left: As above 18. Curved Mosquito Forceps: Picking up sequestrate or fractured instruments or posts, artery clips 19. Bone Rongeurs: Also known as bone nibblers, used to trim bone, remove spicules and septae 20. Rake Retractor: Flap deflection, scratchin your back 21. Bone File: Smooth down rough bit of bone by pull stroke 22. Victoria Curette: Remove granuloma or cyst from periapical tissue, remove granulation tissue from socket 23. Mitchells’ Osteo Trimmer: Removing sharp bone spicules, exposing canines, apicectomy 24. Straight Spencer Wells Forceps: Picking up teeth, removing sharp bone spicules 25. Alice Tissue Forceps: Used to hold soft tissues, can be used to pick up teeth 26. Kilner Needle Holders: Holding needle for suturing 27. Fickling Forceps: As above forceps 28. Gillies Needle Holders: Holding needle for suturing 29. Gillies Toothed Tissue Forceps: Manipulation of suture 30. Curved Iris Scissors: Cutting suture 31. Lack’s Tongue Depressor: Depressing tongue, retracting tissue 32. Towel Clips: Clipping things on tray table

Answer 65

OFG: Oral granulomatous inflammation causing problems ○ blocks lymphatic channels causing swelling ● Autoimmune – Type IV hypersensitivity to additives ○ (benzoates, cinnamonaldehyde, sorbic acid, chocolate) ● Symptoms: lip swelling/cracked, angular cheilitis, buccal cobblestoning, ulceration, lymphoedema, gingivitis ● History: take full system’s history including info like weight loss and bowel problems ● Diagnosis: Patch testing for 20mins ● Management: dietary avoidance, antibiotics (macrolides), tacrolimus ointment to lip, steroids, azathioprine ● Patient mentions bowel problems = potential for Crohn's ○ Inflammatory disease that can affect ANY part of the GI tract ○ Patchy lesions in colon – causing perforation, stricture, obstruction and increased cancer risk ○ Refer patient to GP to investigate.

Answer 66

Injection in parotid gland → Facial nerve ● Diagnosis: Test branches of facial nerve ● Symptoms: ○ generalized weakness of the ipsilateral side of the face, inability to close the eyelids, obliteration of the nasolabial fold, drooping of the corner of the mouth, deviation of the mouth toward the unaffected side. ● Confirmation: ○ Temporal branch affected - *if stroke patient can still wrinkle forehead* ● Management: ○ Reassurance ○ Cover eye with pad until blink reflex returns - an eye patch should be applied, especially during night time, while artificial tears can be used during the day (+ sunglasses) to prevent exposure keratitis

Answer 67

Edentulous trays (blue) - shallower ● Primary imp material for lower edentulous: alginate, impression compound ● Stand at 7 o’clock for lower impressions ● Please pour casts in 50/50 dental stone/plaster and construct lower special tray in light cured PMMA with 1-2mm spacer (1mm for PVS, 3mm for alginate)- non-perforated, finger-rests and intra-oral handle. Please return trays with casts

Answer 68

Staining: ○ Causes: ■ MIH, fluorosis, decal, tetracycline, trauma, dentinogenesis/amelogenesis imperfecta ○ Treatment: ■ Microabrasion: easy to be done, effective, removal of tooth structure, use of acid ■ Vital external bleaching: may not work, gingival irritation, sensitivity, will not bleach restoration, relapse, overbleach ■ Localised composite addition: add bulk to tooth, may not mask totally ■ Comp/porcelain veneer: good aesthetic, tooth prep needed, need to wait until 18 for stable gingival level ■ MCC: destructive ● Missing teeth: ○ Causes: ■ Hypodontia, trauma causing arrested tooth formation, ectopic, dilaceration, supernumerary ○ Treatment: ■ RBB, Essix retainer, RPD, Implant if above 18y/o, Ortho space closure

Answer 69

Faults with metal framework casting ○ These could include: ■ Errors in casting: CoCr bubbles making surface rough - due to air bubbles trapped on wax pattern investing ■ Errors in design: too close to gingival margin, undercuts not blocked out ● Faults with prescription between drawing and writing: ○ Support: rests are missing, no posterior stop (i.e. posterior of free end saddle ends further anteriorly than desirable) ○ Retention: ring clasp around the wrong way (are there ineffective clasps? check the cast for survey lines) ○ Connector: sublingual bar instead of lingual bar on prescription (sublingual bar looks almost identical to lingual bar. The sublingual bar actually lays on the floor of mouth and there is no 1mm from the functional depth as is with the lingual bar. ○ Also check for: indirect retention, appropriate reciprocation for clasps ● No labial relief as asked

Answer 70

All burs given - Remember PPE ● Points for seating position ● Not really marked on pt management - clinicians not really watching whilst you prepare the tooth ● x2 putty index ○ 1 for provisional (do not section) ○ 1 for reduction determination (section along long axis) ● Using a chamfer bur ○ Create 3 notches on buccal surface, each just below 0.5mm in to tooth tissue. Ensure the tooth is cut in two planes as for crown prep ○ Connect the notches with the chamfer bur ● Reduce the incisal edge, ideally around 1mm (0.75-1.5mm) ● Bevel the incisal edge (3 different planes total) ● Use a smooth composite finishing rugby ball bur to finish

Answer 71

Missing teeth - identify the causes ● Gingival margin - from the ACJ, recession ● Probing depths - indicator of tx difficulty ● Loss of attachment - indicator of severity of disease ● Bleeding on probing - indicator of disease activity ● Furcation - involvement indicator of tx difficulty ● Mobility - gives rise to symptom, poorer prognosis ● Reasons for failure ○ Smoking ○ Patient not compliant: OH is poor ○ Inability for patient to practice OH effectively ■ Hard to reach areas - furcations, lone standing teeth ■ Poor manual dexterity - dementia/parkinsons/age ○ Systemic factors: stress, diabetes, pregnancy, malnutrition/poor diet ○ Difficulty accessing for debridement/Inadequate debridement (time constraint, pt cannot tolerate) ○ Iatrogenic factors: overhangs, poor margins

Answer 72

ARR: the difference in risk between the groups ● RR: the ratio of the risk in each group ● NNT: the number of patients you would need to treat to prevent one patient from developing the risk ● 95% CI: 95 times out of 100 the CI will contain the TRUE value in the entire population ○ Can be determined for both ARR and RR ● Null hypothesis (true or rejected) ○ = The intervention works only as well as the control ● FOR ARR – IF CONFIDENCE INTERVAL RANGE OVERLAPS 0 = NULL HYPOTHESIS ○ i.e. if the risk reduction with intervention was 0 then the intervention is the same as the control ● FOR RR – IF CONFIDENCE INTERVAL RANGE OVERLAPS 1 = NULL HYPOTHESIS ○ i.e. if the ratio with of intervention risk over the control risk was 1 then the intervention and control risk are the same ● YOU CAN ALSO COMMENT ON THE BROADNESS OF THE CI RANGE ○ A narrow range means the study is more representative of the true population results compared to a broad range ● What type of study? ○ Randomised controlled trial: prospective ○ Cohort study: prospective ○ Case-control: retrospective ○ Cross-sectional survey: one single point of time ● Criteria for good randomised controlled trial ○ Blinding, inclusion/exclusion criteria, randomisation, control, all subjects accounted for at the end?

Answer 73

Overfilled, underfilled, poorly compacted, accessory canals missed, missed canal, inadequately prepared, extrusion of debris, perforation, RCF of incorrect shape, vertical root fracture, endo file fracture, blockage/ obstruction of canal, poor coronal seal - failed restoration ● Tx options: ○ Leave and monitor: no active tx, but may infection including abscess may flare up later ○ Retreatment: no surgery needed, but chances of success decreased, if post core present, removing may cause vertical root fracture ○ Periradicular surgery: if retreatment not possible, surgery more difficult to tolerate, invasive, time consuming, expensive, nerve damage, reduced support, scarring ○ XLA: tooth loss, need replacement or non-functional and p

Answer 74

History: ○ How dry mouth is affecting the pt? Need water to swallow/ affect speech, uncomfortable? ○ What medications pt is taking (amitriptyline)? Alcohol? Smoking? ○ Medical history - diabetes/epilepsy/anxiety/stroke/sjogren's/CF/HIV ● Usual features/symptoms: ○ Swallowing difficulty, clicking speech, discomfort, altered taste, cervical caries, halitosis, candidiasis ● Management ○ Treat cause: Hydration, Chew gum, Modify drugs, Control diabetes/somatoform disorder, reduce caffeine, Stop smoking/alcohol ○ Prevent diseases: Caries (High F- toothpaste), Candida / Angular cheilitis (CHX) ○ Saliva substitutes: Spray/Lozenges: Saliva Orthana - Stimulants: Pilocarpine ● Contact medical practitioner to query if changing medication is possible

Answer 75

‘So you’ve got these white patches around your mouth’ ● ‘Lichen planus can present anywhere on the skin but in some cases it present in the mouth and it is one of the most common conditions they get to see in the oral medicine department.’ ● ‘The whiteness arises from extra keratin deposition. Keratin is a protein that is present all around your skin and the body can be stimulated to make more by several factors like friction (e.g. causing calluses in the case of skin).’ ● ‘Lichen planus is kind of an allergic reaction to something and in most cases we don't really know what causes it. Most common culprits are reactions to medications or metal in silver fillings.’ ● ‘Lichen planus has a small chance to develop into something sinister like a mouth cancer in 1% of cases in 10 years in an average case. It's important to note though that it's a spectrum disease which ranges from simple asymptomatic white patches to more sinister erosive sore ulcerated areas. Depending on what area of the spectrum you're on the risk of malignancy can be higher or lower.’ ● ‘This is not something we can treat other than if possible remove the causing factor if we know it but we can manage the symptoms.’ ● ‘Mostly start by avoiding SLS toothpaste or MW and other allergens like benzoates. Chlorhexidine can sometimes be helpful and soreness can be managed with Difflam. In later stages medicines like corticosteroids (local and then systemic) can be used to. In the mouth it can usually take 3-5 years to resolve (skin it's ~18 months) and in the meantime we would like to keep an eye on it by taking some pictures and reviewing you every 4-6 months (if sinister type then by OM dept, if common type then by GDP) in order to monitor any changes.’ ● ‘Any questions?

Answer 76

Normal O2sat = 97-100, Alarm at 90, Hypoxic at 85 ● If dropping: stimulate patient - ask to breathe ● If alarm: ○ supplemental oxygen: nasal cannulation 2L/min ○ reverse with flumazenil (500mg/5ml) ● Contraindications for IV Sedation: ○ severe COPD, hepatic insufficiency, pregnancy and lactation, hypothyroidism, myasthenia gravis ● Contraindications for Inhalation Sedation: ○ common cold, tonsillitis, nasal blockage, severe COPD, MS, pregnancy (1st trimester), claustrophobia (fear of the mask) ● Minimum O2 delivery = 30% (max N2O = 70%)

Answer 77

CN 1 (Olfactory) - Can patient smell as normal? ● CN 2, 3, 4, 6 (Optical, Oculomotor, Trochlear, Abducens) - Test visual acuity and eye movement. ● CN 5 (Trigeminal) - Any abnormal sensation at each branch? Can patient clench jaw? Corneal reflex ● CN 7 (Facial) - Facial muscles tests (puff out cheeks, pout, wrinkle forehead, raise eyebrows) ● CN8 (Vestibulocochlear) - Can patient hear normally? Block one ear and check for differences) ● CN 9, 10 (Glossopharyngeal and Vagus) - Deviation of uvula on saying ah, gag reflex ● CN 11 (Accessory) - Can patient shrug their shoulders? ● CN 12 (Hypoglossal) - Can patient protrude tongue? Is there deviation on protrusion? Is there asymmetry?

Answer 78

Pain history ○ Site - may migrate from one site to another, can cross anatomical boundaries ○ Onset - often chronic, patient may relate it to a specific episode of treatment ○ Character - varied, often a continuous sharp ache, can be throbbing ○ Radiation - often radiates across anatomical boundaries ○ Associations - no local signs of inflammation ○ Timing - generally continuous ○ E/R factors - associated with stimuli that usually do not elicit pain, analgesia generally not effective ○ Severity - very severe ● Special Investigations ○ Radiographs for caries ○ Sensibility tests ○ Mobility ○ Perio disease ○ Tooth Slooth

Answer 79

Procedure (multiple appts) ○ LA - topical gel, CWR, injection + LA risks (perm/temp nerve damage, altered sensations, numbness, lasts for hours, increased HR) - aids pt makes procedure comfortable ○ Rubber dam (nitrile/latex sheet) - isolation, moisture control, airway protection, prevents NaOCL incident - clamp can fracture, mouth open throughout procedure. Test CHX. ○ Radiographs are required pre, during, post tx ○ Access - drills to remove nerve, high/slow speed ○ Files - series of files to clean and shape canal ○ Irrigation - NaOCl (bleach) throughout + EDTA ○ Canal dried with paper points ○ Intracanal medicament - resolves infection/symptoms ○ Obturation - GP root canal filling, coated in sealer, packed with accessory points, burnt off ○ Lining material placed - to seal canal ○ Restoration - temp/permanent, ideally indirect restoration (extra appts + expense) ○ R/V appt needed ● Prognosis ○ Be specific for case - good/poor/limited ○ Orthograde RCT - not guaranteed, but predictable and usually successful ○ - Up to 90% over 10 years for teeth with irreversible pulpitis. ○ - Up to 80% over 10 years for teeth with necrosis. ● Alternatives ○ No treatment ○ Extraction ○ Retrograde RCT ● Risks ○ Instrument separation, failure to negotiate canals to working length, hypochlorite accident, material extrusion, post-op pain, post-op swelling, need for pain control, perforation and root fracture. ○ Failure to resolve symptoms. Expensive. ● Benefits ○ Resolution of infection +/-symptoms, retain tooth, no loss of bone, abutment potential, don’t require replacement for missing tooth, best aesthetics

Answer 80

Extra oral signs: ○ Bruising of face - punch, slap, pinch ○ Bruising of ears - pinch, pull ○ Abrasions and lacerations ○ Burns and bites ○ Neck - choke or cord marks ○ Eye injuries ○ Hair pulling ○ Fractures (nose>mandible>zygoma) ● Intra oral signs ○ Contusions ○ Bruises ○ Abrasions and lacerations ○ Burns ○ Tooth trauma ○ Frenal injuries ● Index of Suspicion ○ Delay in seeking help ○ Story vague, lacking in detail, vary with each telling and person to person ○ Account not compatible with injury ○ Parents mood abnormal. Preoccupied. ○ Parents behaviour gives cause for concern ○ Child’s appearance and interaction with parents is abnormal ○ Child may say something contradictory ○ History of previous injury ○ History of violence within the family ● Taking action ○ Provide any urgent dental treatment ○ Tell parent: unless this will put child at risk. ■ Explain your concerns honestly, inform them of your intention to refer ■ “These types of injuries have to be reported” ○ Seek parents consent to share info ○ Record incident and conversation ○ Refer to social services/police - b be specific about reasons ○ Confirm referral acted upon ○ Arrange dental follow up ○ Be prepared for reporting in case of court ○ Always discuss with colleague

Answer 81

Iatrogenic faults: ○ RCT: fractured file, perforated file, ledging, GP overfill/underfill, extruded sealer, missed canal ○ Restorations: overhangs, fractured, poor margins, post w/o RCT, perforated post ○ External inflammatory/surface/ replacement, internal inflammatory, cervical root resorption? ● Developmental: ○ Cysts: dentigerous, radicular, erupted, keratocyst ○ Unerupted/ectopic/impacted teeth ○ Dentinogenesis Imperfecta (amber radiolucency, bulbus crown, abscess, pulpal obliteration) ○ TMD ● Trauma ○ Bone fracture, Tooth fracture, Displacement 6

Answer 82

Formulations and max doses: ○ Lidocaine 2% 1:80000 adrenaline: 4.5mg/kg ○ Articaine 4% 1:100000 adrenaline: 5mg/kg ○ Prilocaine 3% w/ 0.03IU/ml felypressin: 6.6mg/kg ● Assembly: ○ Remember to check expiry date and that bung is on the right way round ● Side effects: ○ Allergic reaction (rash, tingling, breathing problems) ○ Seizure, cardiac arrest ○ Nausea, vomiting, dizziness, headache, blurred vision ○ Twitching muscles ○ Nerve damage, continuing numbness, weakness or pins and needles ○ Haematoma ○ Tachycardia ● Checking anaesthesia: ○ Question patient ○ Check by percussion to tooth ○ Probe to gingivae/palate

Answer 83

Equipment: ○ Fox’s Occlusal Plane Guide - Use: to set occlusal plane ○ Willis Gauge - Use: measuring occlusal vertical dimension (OVD, FWS, RVD) ● Lines/Features: ○ High Smile Line ■ Why: Allows waxing of teeth in correct height and alignment (not showing too much gum) ■ How: Getting the patient to smile and marking lip level ○ Centre Line/Midline ■ Why: To orientate central incisors making the block symmetrical ■ How: Using nose septum or using existing lower/upper anteriors ○ Canine Line ■ Why: To set canine position - Also provide size measurements for tooth selection ■ How: Measured using vertical line from inner canthus of the eye ● Reference lines: ○ Used to ensure anterior and posterior occlusal plane is level ■ Ala-Tragus line ■ Interpupillary line

Answer 84

4 criteria!! NEWS assessment (National Early Warning Score) ○ Temperature <36oC or >38oC ○ White Blood Cell count <4 or >11 thousand per mm3 ○ Pulse over 90bpm (tachycardia) ○ Respiratory rate over 20bpm (tachypnoea) ● 2 out of 4 required for definition of sepsis syndrome – Requires URGENT referral ● Always refer URGENTLY if: ○ Spread of infection to pharyngeal or submandibular space ○ Systemic manifestations AND immunocompromised ○ Trouble swallowing or breathing ○ Rapidly progressing infection ● Antibiotics for dental abscess if systemic manifestations OR immunocompromised ○ Always try local measures first - drain by extraction, through canal or by soft tissue incision ○ Amoxicillin: 500mg tablet x3 daily for 5 days (could also prescribe pen v) ○ Metronidazole: 400mg tablet x3 daily for 5 days

Answer 85

Ask ○ About abuse - in private setting without family members ○ Use non-judgemental language ○ ‘Is everything OK at home?’ ○ ‘I’ve noticed you’ve got some bruises on your neck, is everything OK? Has someone hurt you?’ ○ ‘I’m worried that you don’t seem your usual self, is everything OK?’ ○ ‘Do you feel safe?’ ● Validate ○ Provide validating messages that take the blame away from the victim ○ A way of showing your patient that you are concerned about them ○ Removes the blame, shows that you believe them, shows that you are taking this seriously ○ ‘You do not deserve to be hurt or hit no matter what happened’ ○ ‘I am concerned about your safety’ ○ You should still do this even if your patient denies abuse, it may provide some relief or comfort ○ Helps the victim to start to realise the seriousness of their situation ● Document ○ Be specific and detailed ○ Use the patient’s own words ○ Name, location, witnesses that the patient mentioned ○ Describe injuries in as much detail as possible - Take photographs if able ● Refer ○ To appropriate services ○ Even if they don't seem keen, still offer as they may go away and think about it ○ Do not attempt to deal with problem yourself - Patient is the one needing to take action, not you ○ The core Scottish organisation is the Scottish Domestic Abuse Helpline – 0800 027 1234 ● Communication ○ Introduce self ○ Use the domestic abuse pamphlet ○ Use the ‘secret’ lip balm or pen etc

Answer 86

Fungal infection of the cheek side of the mouth ● Potentially malignant, can progress to oral cancer ● Risk factors: OH, steroid inhaler, diet diabetes, deficiency, dry mouth, antibiotic, immunosuppression ● Management: ○ Incisional biopsy - Referral to OM ○ OHI, reduce carbohydrate intake, rinse mouth after inhaler ○ Correct deficiency, control diabetes, stop smoking, correct denture fault ○ Systemic antifungal - review after 7 days ■ Fluconazole 50mg ■ Send: 7 tablets ■ Label: 1 tablet to be taken once per day for 7 days

Answer 87

A – Active component (moves the teeth, 0.5mm) ● R – Retention (holds the brace in, 0.7mm in permanent, 0.6mm in deciduous) ● A – Anchorage (resists unwanted tooth movement) ● B – Baseplate (plus any modifications) ○ Provides anchorage, retention, connector ○ Self-cure PMMA over Heat-cure PMMA ■ Advantages: quicker and easier fabrication - 14mins vs 14hrs ■ Disadvantages: residual monomer can be an irritant ○ Knife edge acrylic ■ Stops the tongue playing with the URA causing ulcers from trauma ● Overbite ○ Please construct a URA to reduce overbite ○ A: ○ R: 16/26 Adams clasps 0.7 H.S.S.W ○ 11/21 Southend clasp 0.7 H.S.S. ○ A: ○ B: Self-cure PMMA / FABP OJ+3mm ● Overjet ○ Please construct a URA to reduce overjet and continue to reduce overbite ○ A: 22,21/11,12 Robert’s retractor 0.5 H.S.S.W + 0.5mm I.D tubing ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 3/3 Mesial stops ○ A: (not ideal – will keep an eye on it) ○ B: Self-cure PMMA / FABP OJ+3mm ● Retracting Canines ○ Please construct a URA to retract canines ○ A: 13/23 Palatal finger spring + Guard 0.5 H.S.S.W ○ R: 16/26 Adams Clasps 0.7 H.S.S.W + 11/21 Southend Clasp 0.7 H.S.S.W ○ A: ○ B: Self-cure PMMA ● Retracting Buccally Placed Canines ○ Please construct a URA to retract buccally placed canines ○ A: 13/23 Buccal canine retractor 0.5 H.S.S.W + 0.5mm I.D. tubing ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 11/21 Southend clasp 0.7mm H.S.S.W ○ A: ○ B: Self-cure PMMA ● Anterior Crossbite ○ Please construct a URA to correct anterior crossbite ○ A: Z-spring 0.5 H.S.S.W ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W ○ A: ○ B: Self-cure PMMA / Posterior Bite Plane ● Posterior Crossbite ○ Please construct a URA to expand the upper arch ○ A: Midline palatal screw ○ R: 16/26 Adams clasps 0.7 H.S.S.W + 14/24 Adams clasps 0.7 H.S.S.W ○ A: Reciprocal Anchorage ○ B: Self-cure PMMA / Posterior bite plane

Answer 88

Introduce self & designation (1 mark) ● Gather info about patient's coagulation status: ○ Why are they on rivoroxiban? Are they on it for a limited time? When did they last take it? Do they have any other relevant medical complications? Any anti-platelets? ● Detailed and valid explanation as to why the tooth cannot be extracted today (4 marks) ○ No jargon! ○ ‘Due to high risk bleeding which is a result of the rivoroxiban and the potential for this extraction to become a surgical intervention which may need a flap to be raised it is advised that we do not carry out this extraction at this appointment. ● Reference to relevant guidelines (1 mark) ○ SDCEP: States that in order to perform a safe extraction for a patient on rivoroxiban the patient must miss the morning dose, they would be able to commence DOAC 4 hours after haemostasis has been achieved ● Convincing patient and NOT proceeding with extraction (4 marks) ● Deal with patient’s pain (4 marks) ○ Acknowledge the pt is in pain and discuss dealing with the pain ■ analgesia +/- pulp extirpation/sedative dressing ● Ask if the pt understands the explanation and if they have any questions (2 marks) ● Engaging with patient/eye contact/good communication (2 marks) ● Actor marks: communication, empathy, simple language (2 marks)

Answer 89

● Know waste streams ○ Black: household waste - packaging, hand towels ○ Orange: low risk clinical waste ■ Swabs, dressings and other non-sharp clinical waste e.g. dam, micro brush ○ Yellow: high risk clinical waste (we don't have this on clinic) ■ Body parts including teeth ○ Red: Specialist, hazardous waste ■ Dispose of amalgam in white box with red lid. ■ Spill/leak proof. Mercury vapour suppressant in lid. ■ Amalgam waste, amalgam capsules, amalgam filled teeth ○ Blue: Sharps including vials with medication or pharmaceuticals remaining ○ Dispose of sharps in sharps bin (orange stream): 3As, 2Ns ■ Always dispose of sharps in the sharps box immediately after use ■ Always keep out of reach of children and non-authorised personnel ■ Always close sharps box between use using temporary closing mechanism ■ Never retrieve anything from sharps box ■ Never fill more than ¾ full ● Place sharps box at waist height on a flat surface - sharp box on floor here! ● Blood spillage and how to deal with it ○ Stop what we are doing ○ Apply appropriate PPE ○ Cover spill with disposable paper towels ○ Apply sodium hypochlorite/sodium dichloroisocyanurate – liquid/powder/granules (10,000ppm) ○ Leave for 3-5 minutes, use scoop to take up the gross contamination and put into orange waste ○ Clean with water and general purpose neutral detergent disinfectant wipes

Answer 90

Take concerns seriously, answer questions as able: ○ ‘Hello there, what seems to be the problem?’ ○ ‘Can i offer some assistance?’ ● Acknowledge anger ‘I can see that you’re upset and I am sorry that you feel this way.’ ○ This does not accept blame. DO NOT ACCEPT BLAME ● Try to offer practical help: ○ Offer investigation with post/previous dentist? ● Making an apology: ○ Be honest ○ Acknowledge the offence ○ Explain how it happened ○ Express remorse: deep guilt, express it! (I am so sorry!) ○ Ensure amends: ‘Is there anything we can do?’ ● If formal complaint requested, advise on NHS complaints procedure ○ Then, if required: a local resolution (payout) ○ If satisfactory: complaint closed ○ If unsatisfactory: healthcare commission or health service ombudsman ● The NHS complaints procedure 1. Acknowledge the complaint and provide the patient with the practice complaint procedure. 2. Inform the dental defence organization if you require advice. 3. Inform the patient of timescales and stages involved. 4. Acknowledge the complaint in writing, by email or by telephone as soon as you receive it – 3 working days maximum but ideally within 24 hours. 5. Early Resolution 5 working days: For issues that are straightforward and easily resolved, requiring little or no investigation. 6. Investigation 20 working days: For issues that have not been resolved at the early resolution stage or that are complex, serious or ‘high risk’. 7. Independent External Review Ombudsman: For issues that have not been resolved.

Answer 91

Ask ○ About abuse - in private setting without family members ○ Use non-judgemental language ○ ‘Is everything OK at home?’ ○ ‘I’ve noticed you’ve got some bruises on your face, is everything OK? Has someone hurt you?’ ○ ‘I’m worried that you don’t seem your usual self, is everything OK?’ ○ ‘Do you feel safe?’ ● Validate ○ Provide validating messages that take the blame away from the victim ○ A way of showing your patient that you are concerned about them ○ Removes the blame, shows that you believe them, shows that you are taking this seriously ○ ‘You do not deserve to be hurt or hit no matter what happened’ ○ ‘I am concerned about your safety’ ○ You should still do this even if your patient denies abuse, it may provide some relief or comfort ○ Helps the victim to start to realise the seriousness of their situation ● Document ○ Be specific and detailed ○ Use the patient’s own words ○ Name, location, witnesses that the patient mentioned ○ Describe injuries in as much detail as possible - Take photographs if able ● Refer ○ To appropriate services ○ Even if they don't seem keen, still offer as they may go away and think about it ○ Do not attempt to deal with problem yourself - Patient is the one needing to take action, not you ○ The core Scottish organisation is the Scottish Domestic Abuse Helpline – 0800 027 1234 ● Communication ○ Introduce self ○ Use the domestic abuse pamphlet ○ Use the ‘secret’ lip balm or pen etc

Answer 92

- Skeletal classification - Class II - maxilla more than 2-3mm in front of the mandible; increased OJ, ANB>4 degrees - Incisor classification - Class II Div 1 - lower incisor edge lies posterior to the cingulum plateau of the upper central incisors. The upper central incisors are proclined or of average inclination and there is an increased OJ - Dental factors of class II div 1 malocclusion Increased OJ - incisors proclined or of average inclination Variable OB Can have good alignment, crowding or spacing in dentition Habitually parted lips may lead to drying of the gingivae and exacerbation of any pre-existing gingivitis Reasons for tx: - Concerns regarding aesthetics - Concerns regarding dental health - Prominent incisors are at risk of trauma especially w incompetent lips - OJ > 9mm - 2x likely to suffer trauma - IOTN 5A Management: - Accept and monitor - when there is a mildly increased OJ and if pt isnt concerned, can give advice and use of mouth guard for trauma protection - Attempt growth modification Headgear - try and restrain growth of maxilla horizontally and/or vertically Functional appliance - (twin bloc, medium opening activator) - utilise, eliminate or guide the forces of muscle function, tooth eruption and growth to correct malocclusion. These should be used during growth and coincide with pubertal growth spurt. URA - Limited role unless there is very mild class II, when OJ is due to inclination of incisors and favourable OB Only can be given after specialist assessment Orthodontic camouflage with fixed appliance - accept underlying skeletal discrepancy and camoflague the incisal relationship to class I Orthognathic surgery - Should be carried out when growth is complete and only when there is severe A/P skeletal discrepancy or vertical direction Usually involved mandibular surgery but may include maxilla Fixed appliances will be required before, during and after surgery

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