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Short answers

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

SAQs, March 2006

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

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

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

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

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

SAQs, March 2005

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

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

3: complications of surgical extraction of upper 6

4: saliva and its role in dental caries and erosion

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

lymphadenopathy and fever...

Discuss your clinical examination, differential diagnosis and quick accounton treatment of the diseases u have mentioned in the differential diagnosis.

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SAQs, March 2000

1. From the medical history you find the patient is on Tricyclic Anti-depression medication.How would you manage this patient?

Complete building the medical and the dental history to reach a

proper diagnosis and find the aetiology of the chief complaint so I canstart assessing the case by evaluating the available information; theoverall case assessment is an essential step that allows theconsiderations of treatment options and a provisional treatment planto be formulated.

Consult the patients GP for any precautions should be taking or anymodification to the treatment should be followed.

Resolution of any acute problems and stabilisation or elimination ofactive disease.

If it is not possible to get in contact with the GP refer to the MIMs toget more information about the drug to find out what I can or I can not

prescribe Assessing and managing accordingly any emergencies situations

that exist, acute pain, bleeding swellingetc Eliminating any acute problems or active diseases I will assess the

periodontal tissues and elimination of any active diseases,regeneration of the periodontal attachment loos and stabilisation ofgingival contours would be my next step in managing the patient.

Reassessment of the periodontal situation by assessing the patientocclusal stability and plan for any restorative or prostheticmanagement.

Finally and it is an important part is the patient consultation to present

and discuss the treatment plan and give the alternative options,obtaining a patient consent/s, arrange for appointments and financialconsiderations

Reconfirm the definitive treatment plan and make sure the patientsexpectations are what the result would be.

Tricyclic has a side affects on the oral cavity by causing dry mouth;and systemically it causes blurred vision, constipation, and difficultyin urination; postural hypotension; tachycardia, increased sensitivityto the sun; weight gain; sedation (sleepiness); increased sweating.Some of these side effects will disappear with the passage of time orwith a decrease in the dosage.

Bear in mind all this information should be recorded appropriately forfuture follow up and to adhere to the Australian Dental Board policies.

2. A 23 year-old female comes to you with Gingival abscess in the rightupper central incisor region which she had a blow to 10 days ago; sincethen the tooth is a bit loose, now she is complaining of pain andtenderness started two days ago.What is your management?

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Gathering general information including but not limited to name, age,sex, previous major operations, any medication is taken at the timeshe is presentedetc. mostly this is prepared and universal for allpatients.

Building the medical and the dental history to help building a properdiagnosis and find the aetiology of the chief complaint so I can startassessing the case by evaluating the available information; theoverall case assessment is an essential step that allows the

considerations of treatment options and a provisional treatment planto be formulated.

Clinical examination in both directions Extra and intra. Extraexamination includes the general morphology, skeletal base, skincolour and lesions, eyes, lymph nodes, lip, breathing, TMJ andmasticatory muscles. Intra orally starts with soft tissues and oralmucosa and muscles followed by the dental examination byexamining the teeth and focusing on the tissues, bone and teeth nextto tenderness and the blow area; and look for any attrition, abrasion,erosion, or hypominerlization on the tooth surface or any abnormalityin the gingivae or hard tissues Faceting, fracture or caries of the

enamel then examine the periodontal tissues and record any toothmobility or badly restored teeth.

Check the occlusal view if possible and the result of the blow on theocclusal harmony and the other tissues.

Order any special tests required and in this case a periapical to startwith seems to be essential.

Assess the case and advise for a rigid splint or extraction and fixedprothesis lateretc and this is completely demandant on theoutcome of the assessment.

Transfer the treatment options to the patient in a simple languageand this stage should include the approximate cost and any need for

future follow up.

3. A 13 year old patient has rampant caries and gingival swelling.What are the causes? How to prevent them? What is your management?

Most probable cause of the rampant caries is the frequent intake of sugar, thenthe oral hygiene methods that have been adapted by the patient. But we mustbe able to visualize adequately a childs teeth and mouth and have access to a

reliable historian for non-clinical data elements.

Prevention programme starts with assessing all 3 components of caries risk-clinical conditions, environmental characteristics, and general health conditions;a complete analysing of the diet regime; then build a new diet system preventsless frequent take of carbohydrates and in sever cases could include changingsugar to carbohydrate free substitute. Endorsing a good oral hygiene plan thatsuits the patient and the advice for a regular topical fluoride application is asimportant as the diet. Systemic fluoride may be applicable depends on the caseand the water fluoridation program in the area.

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The management includes, Gathering general information including but not limited to name, age,

sex, previous major operations, any medication is taken at the timeshe is presentedetc. mostly this is prepared and universal for allpatients.

Building the medical and the dental history to reach a properdiagnosis and find the aetiology of the chief complaint so I can startassessing the case by evaluating the available information; the

overall case assessment is an essential step that allows theconsiderations of treatment options and a provisional treatment planto be formulated.

Clinical examination in both directions Extra and intra. Extraexamination includes the general morphology, skeletal base, skincolour and lesions, eyes, lymph nodes, lip, breathing, TMJ andmasticatory muscles. Intra orally starts with soft tissues and oralmucosa and muscles followed by the dental examination byexamining the teeth and focusing on the tissues, bone and teeth nextto tenderness; look for any attrition, abrasion, erosion,hypominerlization or any abnormality in the gingivae or hard tissues

Faceting, fracture or caries of the enamel then examine theperiodontal tissues and record any tooth mobility or badly restoredteeth.

Check the occlusal view if possible and the result of the blow on theocclusal harmony and the other tissues.

Assess the case and treat according to the diagnosis outcome;bearing in mind that the target is to treat the acute problems ormanage any source of pain then reserve as much as possible of thechild teeth tissues.

4. Patient with chronic periodontic disease.

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

The overall clinical factors are: Patient age: for two patients with comparable level of the remaining

connective tissues attachment and alveolar bone, the prognosis isbetter in the older of two. For the younger patient, the prognosis isnot as good because of the short time frame in which the periodontaldestruction has occurred. In some cases this is maybe because theyounger patient suffers from an aggressive type of periodontitis.

Disease severity: Studies have demonstrated that a patients history

of previous periodontal disease may be indicative of theirsusceptibility for future periodontal break down. Prognosis isadversely affected if the base of the pocket is close to the root apex.

Also the height of the remaining bone, all these should be weighedagainst the benefits that would accrue to the adjacent teeth if thetooth under consideration were extracted.

Plaque control: bacterial plaque is the primary etiological factorassociated with periodontal disease. Therefore effective removal ofplaque on daily basis by patient is critical to the success of theperiodontal therapy and to the prognosis.

Patient complaisance/ cooperation: the prognosis for patients with

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gingival and periodontal disease is critically dependant on thepatients attitude and desire to retain natural teeth, and willingnessand ability to maintain good oral hygiene. Without these, treatmentcan not succeed.

There are systemic and environmental factors such as: Smoking: Epidemiologic evidence suggests that smoking may be

the most important environmental risk factor impacting the

development and progression of periodontal disease. Therefore itshould be made clear to the patient that a direct relationship existbetween smoking and the prevalence and incidence ofperiodontitis. Also patient should be informed about the effects ofsmoking on the healing process.

Systemic disease /condition: the patients systemic backgroundaffects overall prognosis in several ways. For example, studieshave shown that the severity of periodontitis is significantly higherin patients with type I and II diabetes than in those withoutdiabetes. Patients with diabetes or with newly diagnosed diabetesshould be informed about the impact of diabetic control on the

development and progression of periodontal disease. Genetic factors: periodontal diseases represent a complex

interaction between microbial challenge and the hosts responseto that challenge, both of which may be influenced byenvironmental factors such as smoking. There also is evidencethat genetic factors may play an important role in determining thenature of the host response.

Stress: physical and emotional stress, as well as substanceabuse, may alter the patients ability to respond to the periodontaltreatment performed.

The Local Factors:

Plaque /calculus: the microbial challenge presented by bacterial plaque andcalculus is the most important local factor in periodontal diseases. Thereforein most cases, having a good prognosis is dependent on the ability of thepatient and the clinician to remove these etiologic factors

Subgingival restorations: may contribute to increased plaque accumulation,increased inflammation and increased bone loss when compared withsupragingival margins.

Anatomic factors: may predispose the periodontium to disease, andtherefore affect the prognosis, include short, tapered roots with large

crowns, cervical enamel projections (CEPs) and enamel pearls,intermediate bifurcation ridges, root concavities, and developmentalgrooves.

Tooth mobility: the principle causes of tooth mobility are the loss of alveolarbone , inflammatory changes in the periodontal ligament, and trauma fromocclusion. However, tooth mobility resulting from loss of alveolar bone is notlikely to be corrected.

Prosthetic / restorative factors: the overall prognosis requires a generalconsideration of bone level and attachment level to establish whetherenough teeth can be saved either to provide a functional and aestheticdentition or to serve as abutments for useful prosthetic replacement of the

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missing teeth.Caries, non vital teeth , and root resorption: for teeth mutilated with extensivecaries, the feasibility of adequate restoration and endodontic therapy should beconsidered before undertaking periodontal treatment.

5. Class two amalgam restoration on a molar.What factors do you consider when preparing a good proximal contactarea?

The extent of the cavitation of the proximal enamel will dictate the classificationand, ultimately, the outline form of the cavity. There is no need to removesound enamel, particularly from the gingival floor, just because it is underminedfollowing removal of caries. The enamel at the gingival is not under occlusalload and can be retained, thus keeping the restoration margin out of thegingival crevice, in case we are going to use the lamination sandwichtechnique. If not ditches and grooves are the best methods of developingretention; pronounced groove along the gingival floor of the mesial proximal boxof 2mm depth provides a good positive retention. The main retentive form in theproximal box should be placed within the dentine at the gingival floor as well as

in the facial and lingual walls. Now if the separate sections of the restorationare individually self retentive, there will be no failure at the narrow isthmus that

joins the occlusal extension to the proximal box and there is no need to widen itin this case. Other wise extending it just over the contact area with the adjacentteeth is indicated and bevelling the step as well to strengthen the amalgam inthis area and extra retention will be gained.

SAQs, 1999

1. List the factors that determine the prognosis of an avulsed,traumatised upper central incisor.

The single most important factor determining the prognosis of areplanted tooth is viability of the periodontal membrane left on theroot prior to replantation.

If the root surface is left dry, approximately 50% of the periodontalligament cells are dead after 30 minutes; after 60 minutes, almost nocells are viable. Replantation of such tooth results in extensivepulpally-derived inflammatory resorption, or ankylosis. The criticaltime of dry storage seems to be between 18 and 30 minutes

A storage media must be of correct osmolality and PH. Saliva allowsstorage for 2 hours. Normal saline solution allows the same time,while milk on the other hand allows up to 6 hours.

Mechanical damage happens as a result of the process of avulsionand replantation; the damage is seen on both cells and tissues.These areas of damage appear as surface resorption defects.

Socket: curettage of the socket wall and the presence or removal of ablood clot had a little influence on the healing pattern of the replantedteeth. Therefore this need not be done unless the clot preventsproper seating of the tooth. However, alveolar bone should bemoulded back into position following replantation, this aids in bonehealing and allows good adaptation of soft tissues.

Splinting: minimal splinting and non-rigid splints permit physiologicaljiggling movement of the tooth which result in lower incidence of

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ankylosis. Care must be taken in the placement of the splints, keep itsimple and avoid gingival tissues. Studies have shown that normaland hard diet resulted in significantly less ankylosis and a higherincidence of normal periodontal ligament compared with soft diet.

Antibiotics: High dose of a broad spectrum antibiotic is recommendedfollowed by at least two weeks of oral administration. Intrapulpalapplication of antibiotic is indicated if bacterial invasion of the pulpoccurs prior to systemic antibiotic.

Endodontic treatment: teeth with immature apices should bemonitored clinically and radiographically since revascularisation ofthe pulp is possible. Teeth with mature apices rarely < 1% regainvascularity and so necrosis and infection would follow, so anendodontic treatment is advised as soon as possible. Extra oralendodontics should not be perform prior to replantation as theexcessive handling of the tooth will increase the risk of additionaldamage to the periodontal membrane. And the filling material mayincrease the risk of inflammatory resorption.

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

Amalgam- Sandwich Technique- Composite- Pins-

3. An insulin dependent 45 year old male needs a full clearance and fullupper and lower dentures. Discuss how you would manage this case.

Medical considerations.

Take a thorough medical history for all patients diagnosed with diabetes.

Ascertain the identity of the physician treating the patient and the date of the lastvisit.Obtain information concerning the type of diabetes, the severity and control of thediabetes, and the presence of cardiovascular or neurologic complications.Refer any patient with the cardinal symptoms of diabetes or findings that suggestdiabetes (headache, dry mouth, irritability, repeated skin infection, blurred vision,paresthesias, progressive periodontal disease, multiple periodontal abscesses) toa physician for diagnosis and treatment.Diabetic patients who are receiving good medical management without seriouscomplications such as renal disease, hypertension, or coronary atheroscleroticheart disease, can receive any indicated dental treatment.

Those with serious medical complications may require an altered plan of dentaltreatment. When the severity and degree of control of diabetes are not known,treatment should be limited to palliation.

Food intake and appointment scheduling. To preventing insulin shock fromoccurring:

Verify that the patient has taken medication as usual.Verify that the patient has had adequate intake of food.Schedule appointments in the morning, since this is a time of high glucose and

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low-insulin activity. Afternoon appointments are a time of low-glucose and high-insulin activity which may predispose the patient to a hypoglycemic reaction.Instruct patients to tell the dentist if at any time during the appointment they feelsymptoms of an insulin reaction occurring. A source of sugar, such as orange juice,must be available in the dental office should the symptoms of an insulin reactionoccur.Oral surgery concerns.

It is important that the total caloric content and the protein/carbohydrate/fat ratio ofthe patient's diet remain the same so control of the disease and proper bloodglucose balance are maintained.IDDM diabetics who are going to receive periodontal or oral surgery proceduresmay be placed on prophylactic antibiotic therapy during the postoperative period toavoid infection.Consultation with a patient's physician before conducting extensive periodontal ororal surgery is advisable. The physician may, in fact, recommend that the patientbe treated in a hospital environment where infection, bleeding, and dysglycemiacan be better managed.Dangers of acute oral infection. Any diabetic patient with acute dental or oral

infection presents a problem in management. This problem is even more difficultfor patients who take high insulin dosage and those who have IDDM. The infectionwill often cause loss of control of the diabetic condition, and as a result theinfection is not handled by the body's defenses as well as it would be in anondiabetic patient. The patient's physician should become a partner in treatmentduring this period.

Oral complications. The oral complications of uncontrolled diabetes mellitus mayinclude:

Xerostomia,

Infection,Poor healing,Increased incidence and severity of periodontal disease, andBurning mouth syndrome.Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, orpain in the oral region.Oral findings in patients with uncontrolled diabetes are thought to be related toexcessive loss of fluids through urination, altered response to infection,microvascular changes, and possibly increased glucose concentrations in saliva.

Early diagnosis and treatment of the diabetic state may allow for regression of

these symptoms, but in long-standing cases the changes may be irreversible.

Potential Drug Interaction. While patients with well-controlled diabetes can begiven general anesthetics, management with local anesthetics is preferable.General anesthetics should be used with caution because they can producehyperglycemia.

4. Your dental nurse has suffered a needle stick. What is yourmanagement for the case?

IMMEDIATELY WASH THE INJURY WITH SOAP AND WATER If splashed with a bodily fluid, thoroughly irrigate the affected area

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Cover the injured area with a bandage for protectionThere is no need to apply agents such as bleach to the injury

Risk assessmentReport the incident to the practice principal/manager following first aid Document as much of the following as possible to determine risk:1. How did the injury occur?2. What type of injury is it, and what is the extent of the injury?

3. What was the source of the sharp or bodily fluid?4. How much of the source material came into contact with the affected person?5. Was any protective clothing being used? After initial risk assessment, seek further management and treatmentIf appropriate, post-exposure treatment should be implemented as soon aspossible

Injury management:

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

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

SAQs, Sep. 1999

The compulsory question:what factors will you discuss with a patient forwhom an impacted lower third molar is to be removed under localanaesthic before the surgery?

I will explain for the patient first about in a basic word about the differencebetween Partial Bony impaction and complete bony impaction and thecomplications of both of them.1. Complete Bony Impaction when the wisdom teeth are completely covered inbone. When the tooth is completely covered with bone it will remain completelycovered with its "developmental sack" in which all teeth develop. Later in life,this sack may undergo changes and enlarge and develop into a cyst. This cystwill enlarge at the expense of the bone of the jaw. These cysts should beremoved and examined by a pathologist.2. Partial Bony Impaction when the teeth begin to erupt but are not able toerupt completely. In this situation, the upper third molars usually are positionedtowards the cheek while the lower third molars usually lean forward with onlypart of the crown sticking through the gum. This situation can to decay and gumdisease around the second molar directly in front of it.

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The most common complication of the partial bony impaction is that the flap ofgum tissue which partially covers the erupting third molar creates a pocketwhere bacteria that are present in the mouth can grow and cause an infectionknown as pericoronitis. The swelling and infection can become very serious.The treatment for pericoronitis is extraction of the third molar tooth.

Then I will discuss the risks and complications involved in the removal of thirdmolars which are:

PAINSurgical removal of the third molars can lead to some discomfort and pain. Thisis usually treated with pain medication.INFECTIONBecause of the large number of bacteria present in the mouth post surgicalinfection is always possible. Patients are usually placed on prophylacticantibiotics to prevent infections from developing.SWELLINGFollowing surgery patients may experience swelling and bruising. Thesesymptoms vary between patients.

BLEEDINGSome post surgical bleeding is considered normal. This is usually minimal andis easily controlled with the pressure of biting on gauze.

Inform the patient that third molars can be removed with local anaesthesiaalone but many people prefer I.V. sedation during surgery.

Finally there are some risks/complications that are unique to the removal ofthird molars.

The upper third molars have roots which often are separated from the maxillarysinuses by only a very thin layer of bone. Occasionally, a small communicationis established between the sinus and the oral cavity when one of the upper thirdmolars is removed. If this is the case, the normal procedure is for the area to besutured closed, the patient to be informed of the finding, appropriate antibioticsand decongestants to be prescribed, the patient to be instructed to avoidValsalva manoeuvres (tasks which build up pressure in the sinus like noseblowing and bearing down forcefully) and the patient reappointed for follow-up.Most often this results in an uneventful healing period with no further treatmentbeing required. Occasionally, the area will heal open rather than closed inwhich case an additional small surgical procedure will be required to close the

communication.

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

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

Choose two of the following four questions:1. What are the factors that will reduce the radiation exposure of patient,describe how each factor affects the reduction of patient exposure.

The largest single contributor of man-made radiation exposure to the populationis medical and dental diagnostic radiology. In total, such radiations account formore than 90% of the total man-made radiation dose to the general population.It is generally agreed by experts in the scientific community that radiationexposure to patients from medical and dental radiographic sources can bereduced substantially with no decrease in the value of diagnostic informationderived.

The risk to the individual patient from a single dental radiographic examinationis very low. However, the risk to a population is increased by increasing thefrequency of radiographic examinations and by increasing the number of

persons undergoing such examinations. For this reason, every effort should bemade to reduce the number of radiograms and the number of personsexamined radio-graphically, as well as to reduce the dose involved in aparticular examination.

To accomplish this reduction, it is essential that patients not be subjected tounnecessary radiological examinations and, when a radiological examination isrequired, it is essential that patients be protected from excessive radiationexposure during the examination.

The recommendations outlined below are directed toward the dentist and the

operator of dental X-ray equipment. These recommendations are intended toprovide guidelines for the elimination of unnecessary radiological examinationsand for reducing doses to patients. Also, included are recommended upperlimits on patient doses for certain common dental radiographic examinations.

9.1 Guidelines for the Prescription of Dental Radiographic ExaminationsThe dental practitioner is in the unique position to reduce unnecessary radiationexposure to the patient by eliminating examinations which are not clinically

justified. The dental practitioner can achieve this by adhering to following basicrecommendations.

A radiographic examination should be for the purpose of obtainingdiagnostic information about the patient to aid in a clinical evaluationof the patient and treatment when warranted.

Routine or screening examinations, in which there is no prior clinicalevaluation of the patient, should not be prescribed. It is considered abad practice to radiograph patients unnecessarily, as in a standardsurvey, and this is especially deplored when done on children. It isalso considered bad practice to take radiograms before a clinicalexamination by the dentist. These two practices constitute the largestpotential abuse of radiology in dentistry.

It should be determined whether there have been any previous

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radiographic examinations which would make further examinationunnecessary or allow for an abbreviated radiographic examination.

When a patient is transferred from one practitioner to another, anyrelevant radiograms should accompany the patient or should berequested from the previous dentist.

The number of radiographic views required in an examination shouldbe kept to the minimum practical, consistent with the clinicalobjectives of the examination.

In prescribing radiographic examinations of pregnant or possiblypregnant women, full consideration should be taken of theconsequences of foetal irradiation. The developing foetus is sensitiveto radiation damage that can result in congenital defects. In dentalradiology, good radiation protection practice reduces the foetal doseto an acceptable minimum and dose levels which do not constitute asignificant hazard. It should be emphasized that precautions toreduce radiation exposure to the patient should be taken all the timebecause a woman of child bearing capacity may be unaware of herpregnancy.

Repeat radiographic examinations should not be prescribed simply

because a radiogram may not be of the "best" diagnostic quality, butdoes provide the desired information.

A patient's clinical records should include details of all radiographicexaminations carried out.

9.2 Guidelines for Protecting the Patient During RadiographicExaminations

It is possible to obtain a series of diagnostically acceptableradiograms and have the patient dose vary widely because ofdifferences in the choice of loading factors and film speeds. It is theresponsibility of the operator and dental practitioner to be aware ofthis and to know how to carry out a prescribed examination with the

lowest practical dose to the patient. The recommendations that followare intended to provide guidance to the operator and dentalpractitioner in exercising responsibility towards reduction of radiationexposure to the patient.

The operator must not perform any radiographic examinations notprescribed by the dental practitioner responsible for the patient.

The dose to the patient must be kept to the lowest practical value,consistent with clinical objectives. To achieve this, techniquesappropriate to the equipment available should be used. It isrecommended the X-ray loading factors charts be established when

using X-ray units which do not have preprogrammed anatomicalfeature settings. The loading factors chart must be established afteroptimizing the film processing procedure.

Fluoroscopy must not be used in dental examinations. Dental radiography must not be carried out at X-ray tube voltages

below 50 kilovolts (peak) and should not be carried out at X-ray tubevoltages below 60 kilovolts (peak).

Dental X-ray equipment should be well maintained and itsperformance checked routinely. Accurate calibration of the equipmentshould also be carried out on a regular basis.

The quality of radiograms should be monitored routinely, through a

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Quality Assurance program, to ensure that they satisfy diagnosticrequirements with minimal radiation exposure to the patient.

The patient must be provided with a shielded apron, for gonadprotection, and a thyroid shield, especially during occlusalradiographic examinations of the maxilla. The use of a thyroid shieldis especially important in children. The shielded apron and thyroidshield should have a lead equivalence of at least 0.25mmof lead. Inpanoramic radiography, since the radiation is also not adequate and

dual (front and back) lead aprons should be worn. The primary X-ray beam must be collimated to irradiate the minimum

area necessary for the examination. The primary X-ray beam should be aligned and the patient's head

positioned in such a way that the beam is not directed at the patient'sgonads and is not unnecessarily irradiating the patient's body.

The fastest film or film-screen combination consistent with therequirements of the examination should be used. The film processingtechnique should ensure optimum development and should be inaccordance with the recommendations given in section 6.1. Sightdeveloping must not be done.

Dental X-ray films must be examined with a viewbox specificallydesigned for this purpose.

While recommended dose limits have been defined for radiationworkers and the general population, no specific permissible levelshave been recommended, to date, for patients undergoing diagnosticradiographic procedures. For patients, the risk involved in theradiographic examination must always be weighed against therequirement for accurate diagnosis. Information from the DentalExposure Normalization Technique (D.E.N.T.) program is used toprovide realistic sets of limits. These recommended upper and lowerlimits are presented in Table 4. Any patient skin dose greater than

the upper limit presented is an indication of poor film processingtechniques or sub-standard equipment performance. The lower limitsindicate the point where any gain in dose reduction may be reflectedby a loss of diagnostic quality of the film.

http://www.hc-sc.gc.ca/hecs-sesc/ccrpb/publication/99ehd177/chapter9.htm

2. 11 years child has a class II division I malocclusion; he is a thumbsucker; discuss the causes and how you would manage the case

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

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

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Unknown Dates:

1. Patient in dental surgery got unconscious, breathless and decrease ofpulse rate; how would you manage this condition and what is yourdiagnosis?

The unconsciousness is caused by Cerebral Hypoxia, my diagnosis is Syncope

and/ or Physical Shock.The management,

Lower head slightly and elevate legs and arms / for pregnant women,roll on left side/

Administer Oxygen at 10L flow/minute Administer spirits of ammonia Apply cold compresses to forehead Keep monitoring and recording vital signs

To manage the slow pulse, Administer 0.4 mg atropine IV to increase heart rate

Repeat up to 1.2 mg, then consider use of additional vasopressors/epinephrine 0.3-0.5 mg SC or IM, IV with ACLS training/

If there is no pulse start CPR and treat as Cardiac arrest accordingly.

2. 8 years old patient shows with small occlusal carious lesions on 46, what isyour management?

3. 20 years old patient comes with a fracture in the middle third of the root of21, what sort of management you would suggest?

4. 46 years old attends your clinic complaining of pain in TMJ area withclicking during the opening of his mouth; how would you manage this case?

5. 30 years patient attends your clinic seeking a bleaching to his teeth after hehas read about a new way of getting white teeth in a magazine; what wouldyou do?

Emergency TreatmentsUnconsciousness

1. Lower the head slightly and elevate legs and arms ( for pregnant women,roll on left side)

2. Administer O2 at 10L. Flow/min

3. Administer spirits of ammonia4. Apply cold compresses to forehead5. Monitor and record vital signs6. Reassure patient- in case of low blood pressure,a. Lower head and raise arms and legsb. Start 5% dextrose and lactated Ringers IVc. Administer vasopressor drug (epinephrine 0.3-0.5 mg SC or IM, IV with

ACLS training- Slow Pulse less than 60 beats per minute:a. Administer 0.4 mg atropine IV to increase the heart rate

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b. Repeat up to 1.2 mg, then consider use of additional vasopressors

Cardiac Arrest

1. Airway- lift chin, clear airway if necessary, and observe for breathing2. Breathing- inflate lungs with mouth to mouth resuscitation, give 2 initial

quick breaths, and perform endotracheal intubation and positive pressure

Oxygen3. Circulation- check carotid pulse; if pulse is absent, compress sternum 2 t o3finger widths above xiphoid process.

a. One operator: 15 compressions, 2 inflations-rate of 80compressions/min

b. Two operators:15 compressions, 2 inflations-rate of80compressions/min-continue resuscitation until spontaneous pulse return

4. Drugs IV- start 5% dextrose lactated ringers with ( ACLS training)

a. Epinephrine 0.5-1.0 ml 1:1000, repeat every 5 minutes prnb. Sodium bicarbonate 1m Eq/kg initially and initial dose every 10 minutes untilcirculation is restored (or as governed by arterial blood gas measurement)c. Atropine sulfate indicated if pulse is less than 60/min and systolic bloodpressure below 90- initial dose of 0.5mg, repeat every 5 minutes but not toexceed 2.0 mg total dose5. Other drugs used cardiac arrest (with ACLS training)

a. Lidocaine (anti-arrhymic agent)b. Calcium chloride (increase in myocardial contractility)c. Morphine sulphate (for pain relief)

Monitor and record vital signs, drug administrations, and patient response.Ambulance, emergency room, and medical assistance should be called.

Diabetic coma

1. Place patient in supine position2. Administer Oxygen3. If patient is conscious, give patient a high sugar-containing drink as Glucolaor orange juice

4. If patient is unconscious, a glucose paste can be applied to the buccalmucosa. A dentist with ACLS training can start an IV 5% dextrose and run IV asfast as possible5. Monitor and record vital signs6. Activate EMS system by calling 0007. Transport patient to emergency room if some improvement is not fairlyrapid. And if in doubt treat as an insulin shock.

- Response to treatment,a. Insulin shock rapid improvement following carbohydrate administration.b. Diabetic coma, no improvement after carbohydrate administration and slow

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improvement (6-12 hours) after insulin administration.

Acute Adrenal Insufficiency

Conscious,

1. Position patient semi-reclining

2. Monitor and record vital signs3. Administer Oxygen4. Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV5. May have to transfer to hospital for lack of fluids

Unconscious

1. Position patient supine2. Monitor and record vital signs3. Administer Oxygen4. Call 0005. Reviews patient history6. Administer steroids hydrocortisone 100mg, or dexamethasone 4 mg IV7. Administer vasopressor (epinephrine 0.5ml)8. Rapid transfer of patient to hospital.